Addressing cultural and linguistic barriers in primary care psychiatry

INTRODUCTION

Common mental disorders (CMDs) affect 17%–46% of patients in India and globally.^[1,2] They are often underrecognized and inadequately treated in primary care due to a lack of psychiatric training, limited knowledge, and the absence of a standardized psychiatry curriculum for primary care doctors (PCDs).^[3-5] To address this “functional treatment gap”, the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, developed the Primary Care Psychiatry Program (PCPP), a digitally-enabled initiative providing specialized training for PCDs. Its flagship Diploma in Primary Care Psychiatry (DPCP), a one-year course, has successfully graduated five batches in Bihar and Uttarakhand, with two more batches currently underway in Karnataka.^[6]

The specialist-based diagnosis and treatment strategies in standard psychiatric curricula are often perceived by PCDs as redundant, complex, and difficult to implement in busy clinical settings.^[7,8] To address these challenges, the clinical schedules for primary care psychiatry (CSP) were developed as an all-in-one, integrated tool. It enables PCDs to provide safe and effective first-line pharmacotherapy for common psychiatric disorders, facilitating rapid screening through a culturally appropriate questionnaire without prioritizing specific conditions.^[9]

The CSP Version 2.4 is an integrated tool designed for PCDs to identify and manage six highly prevalent psychiatric disorders – tobacco addiction, alcohol-related disorders, psychotic disorders, somatization disorders, anxiety disorders, and depressive disorders (TAP SAD). It includes a culturally tailored 21-question screener, a transdiagnostic classification system, simplified diagnostic criteria, management protocols, and referral guidelines. Disorders are classified into CMDs, severe mental disorders, and substance use disorders, with diagnostic hints to guide users. The CSP emphasizes pragmatic approaches suited to busy clinics, requiring brief training for PCDs and providing clear management pathways, including medications, counseling, and follow-up strategies. It addresses the significant treatment gap in CMDs while enabling effective first-line care for psychiatric disorders in primary care settings.^[6,9-11]

The CSP demonstrates a high sensitivity of 91% for detecting psychiatric conditions, with a specificity of 68% and a positive predictive value of 69%. While it effectively identifies psychiatric disorders, its specificity and positive predictive value are comparatively lower. Successful administration of the CSP requires practical clinical training with a strong translational component.^[10,12]

It is important to highlight that while certain scales are designed to screen for specific disorders, the CSP is intended for rapid screening of a broader range of highly prevalent psychiatric disorders within a primary care setting. This distinction highlights the CSP’s broader applicability in primary care compared to condition-specific tools.^[10,13-15]

As global efforts to standardize health status measures intensify, clinicians and medical researchers increasingly encounter the challenge of validating composite measurement tools when used across different cultural contexts. It is essential to establish standardized procedures for adapting and validating these tools, such as health-related quality of life measures, which are often originally developed within specific cultural frameworks, typically Anglo-Saxon.^[16] Although the CSP was designed specifically for the Indian population, the use of English in these measures has proven to be unintuitive for many PCDs. The difficulty PCDs faced in translating questions from English to Kannada undermined one of the core objectives of the CSP screener – reducing the time required for screening. As PCDs struggled to convey the questions clearly, the screening process became longer and less efficient, defeating the purpose of a quick and streamlined assessment tool. The language barrier not only impacted efficiency but also compromised the effectiveness of the screener in its intended role of facilitating rapid psychiatric evaluations, necessitating careful consideration of linguistic and cultural adaptations to ensure their effectiveness.^[17,18]

This study aimed to translate and validate the language equivalence of the Kannada version of the CSP screener for use in primary care.

MATERIALS AND METHODS

RESULTS

Figures 1a and b present the average scores assigned by raters to each of the 19 questions in the screener. All questions, with the exception of Question 18, received an average score above 9. The overall average rating across all items was >9 out of 10, indicating that the Kannada version adequately conveys the meaning of the original English version. In addition, the consistency observed between the translated Kannada version and the back-translated English version supports the face validity of the adaptation. 19 items on the tool were scored by five individual raters, of which 24% of the resulting scores achieved perfect marks, whereas only 21% of the scores fell below 9.

Close

Figure 1:

(a and b) Average scores by different raters.

Export to PPT

DISCUSSION

The Kannada adaptation of the CSP screener demonstrated a high level of equivalence with the original English version, achieving an overall average score of 9.4 on a 10-point scale. This strong score reflects the robustness of the translation process and indicates that the Kannada version retains the integrity and key features of the original tool, whose psychometric properties have already been rigorously validated.^[10] Furthermore, field testing to evaluate the reliability between the two versions would be beneficial in ensuring accurate diagnoses, even though diagnostic accuracy is implied from previous studies.

However, a minor inconsistency was noted in Question 18, where the translated version required further elaboration in Kannada to fully convey the intended clinical nuance. This highlights a common challenge in adapting clinical tools across languages, where certain questions may require contextual adjustments to maintain clarity and clinical relevance. Despite this, the adaptation process ensured that the overall meaning and diagnostic utility were preserved, underscoring the cultural sensitivity embedded in the translation.

Efforts were made to identify studies on the language adaptation of screening tools in primary care psychiatry; however, no relevant studies were found. This represents a clear limitation in our current findings.

The validated Kannada version of the CSP screener provides a streamlined tool for conducting psychiatric assessments, making it easier and faster for PCD to identify and manage mental health conditions. Its cultural adaptation ensures that it is well-suited for use within Kannada-speaking populations, allowing for more accurate diagnosis and tailored treatment recommendations. Developing the Kannada version not only has the potential to improve early detection of psychiatric disorders, enhance patient outcomes, and reduce the treatment gap in primary care settings across Kannada-speaking regions but also opens avenues for integrating mental health care into outreach programs, unorganized workplaces, and vulnerable populations.

CONCLUSION

The Kannada version of the CSP screener closely matched the original English version. Field testing in real-world settings is recommended to further assess its reliability. The methodology used in this study can serve as a framework for translating and adapting the CSP screener into other regional languages, broadening its application and improving access to mental health care across diverse linguistic groups.