Intended for healthcare professionals

Rapid response to:


Mental healthcare in low and middle income countries

BMJ 2014; 349 doi: (Published 25 November 2014) Cite this as: BMJ 2014;349:g7086

Rapid Response:

Drake and colleagues (2014) make an excellent case for culturally adapted, relevant services and interventions for mental illness in low and middle income countries. Cognitive behaviour therapy (CBT) is now recognised as a key evidence-based therapy that is widely used across the globe for various illnesses (Hoffman et al. 2012). However the concepts and constructs used in therapy have been criticised as being rooted in Western cultures and not consistent with cultural beliefs elsewhere. Cultural relevance is essential (Rathod et al, 2008) and practice needs to be adapted to fit a variety of cultural backgrounds (Rathod, 2014). Adapting an intervention carries inherent challenges and risks like presuming global understanding from knowledge of the culture or subculture – stereotyping - when the intervention should allow latitude and flexibility for an assessment of every individual's personal values. Cultural adaptation also inevitably modifies evidence based treatments and the dilemma exists as to when fidelity to the core intervention is lost and when adaptation compromises the effectiveness of an intervention.

We found that outcomes were significantly worse in African Caribbean and Black African groups participating in a large randomised controlled trial of CBT for psychosis (Rathod et al. 2005) and this led to qualitative (Rathod et al. 2010) and quantitative (Rathod et al, 2013) research. Experiences of patients, clinicians and lay members from minority cultural communities were used to adapting CBT using a framework proposed by Tseng et al. (2005). Trials of adapted therapies have been performed with positive results in psychosis and depression in the UK, United States, Pakistan and China and this is expanding to other countries (Rathod et al, 2015). Such work now needs replicating, developing and implementing.


Drake, R. et al. (2014). Mental healthcare in low and middle income countries. British Medical Journal; 349:g7086.
Hofmann, S., Asnaani, A., Vonk, I., Sawyer, .A. and Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy Research, 36(5): 427–440.
Rathod, S., Kingdon, D., Smith, P. and Turkington, D. (2005). Insight into schizophrenia: the effects of cognitive behavioral therapy on the components of insight and association with sociodemographics – data on a previously published randomised controlled trial. Schizophrenia Research, 74: 211–219.
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Rathod, S., Phiri, P., Kingdon, D., Gobbi, M. (2010). Developing Culturally sensitive Cognitive behaviour therapy for Psychosis for Ethnic minority patients by Exploration and Incorporation of Service Users’ and Health Professionals' Views and Opinions. Journal of behavioural and Cognitive Psychotherapies, 38; 511-33.
Rathod, S. (2014). Developing Culturally adapted cognitive behaviour therapy for mental disorders. Social Psychiatry today; Official newspaper of the World Association of Social Psychiatry and Royal College of Psychiatrists Jubilee Congress 2014; page 3.
Rathod S., Phiri, P., Harris, S., Underwood, C., Thagadur, M., Padmanabi, U., & Kingdon D. (2013). Cognitive behaviour therapy for psychosis can be adapted for minority
ethnic groups: A randomised controlled trial. Schizophrenia Research, 143(2–3), 319–326.
Tseng, W. S. (1999). Culture and psychotherapy: Review and practical guidelines. Transcultural Psychiatry, 36, 131–179.
Rathod, S., Kingdon, D., Pinninti, N., Turkington, D., Phiri, P. (2015). Cultural adaptation of CBT for serious mental illness – A guide for training and practice. Wiley.

Competing interests: No competing interests

02 December 2014
Shanaya Rathod
Consultant Psychiatrist
David Kingdon