This paper critically reviews the process and outcome of an effort to enhance the cultural validity of DSM-IV and outlines recommendations to improve future diagnostic systems. An ordered presentation of the antecedents and the main phases of this developmental effort is followed by a content analysis of what was proposed and what was actually incorporated, and a conceptual analysis of underlying biases and their implications. The cultural effort for DSM-IV, spearheaded by a scholarly independent NIMH workgroup, resulted in significant innovations including an introductory cultural statement, cultural considerations for the use of diagnostic categories and criteria, a glossary of culture-bound syndromes and idioms of distress, and an outline for a cultural formulation. However, proposals that challenged universalistic nosological assumptions and argued for the contextualization of illness, diagnosis, and care were minimally incorporated and marginally placed. Although a step forward has been taken to introduce cultural elements in DSM-IV much remains to be done. Further culturally informed research is needed to ensure that future diagnostic systems incorporate a genuinely comprehensive framework, responsive to the complexity of health problems in increasingly multicultural societies.

The outline for the Cultural Formulation (CF) introduced in DSM-IV does not present any method for collecting the required cultural information. The absence of specific guidelines and illustrative cases has hampered its wider use. This article offers a practical approach to preparing a Cultural Formulation as a component of culturally competent clinical care. We summarize the rationale for the four sections of the CF, describe the process of conducting culturally focused clinical interviews, and present examples of questions or lines of inquiry that can be used to collect the information needed to construct the CF. An online supplement provides case examples of cultural formulations applied to patients seen in the US.

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Ethnomedicine is an intellectual area which embraces theoretical concerns that are relevant to both the social and biological sciences. The relation which exists between disease, social behavior, and human adaptation constitutes the primary subject matter of ethnomedicine. This relation is examined in terms of man's unique capacities for symbolization and culture. Since ethnomedical generalizations explain how social groups deal with a generic disease, they can be used to examine contemporary problems which involve the organization and practice of medicine as well as problems that stem from relations of the medical system with other subsystems in the group. Recasting contemporary social problems in this way may help to clarify their roots and sources (13,28). In focusing on fundamental properties of disease in man, ethnomedicine can also help to clarify the effects and meanings of disease and thereby make its control more rational. A theory of disease, an ultimate aim of ethnomedical inquiry, will serve as an explanatory device with wide-ranging applications.

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