Cultural Issues in Treating Geriatric Patients With Mental Illness

TABLE Cultural differences that affect care

Figure. Impact of ethnicity on mental health care

The cultural aspects of treating patients are similar for all age-groups, but certain themes have greater relevance with the elderly. “Cultural issues” is a complex construct that often seems vague and indirect. Culture is different from race. Race implies biological factors, while culture implies sociological factors. Racial differences may be seen in genetic variations, such as hepatic enzyme polymorphisms, that might account for pharmacokinetic differences or different disease rates.

Culture, on the other hand, describes aspects of beliefs, attitudes, language, preferences, and actions that are passed down from generation to generation. Race is often used as a proxy for culture (stereotyping), and vice versa, but there is a difference. The introduction in DSM-5 states:

Mental disorders are defined in relation to cultural, social, and familial norms and values. Culture provides interpretive frameworks that shape the experience and expression of the symptoms, signs, and behaviors that are criteria for diagnosis.

DSM-5 highlights the need to be aware of cultural differences because they might lead to misdiagnosis, poor treatment adherence, and problems establishing a treatment alliance, mismatch of services, and family issues that may differ from “mainstream psychiatry” (Table).

Cultural influences defined

DSM-5 reflects a major change in the view of cultural issues from be-ing a rare occurrence, to being viewed as a pervasive influence on diagnosis and treatment. As a reminder, DSM-IV only mentioned culture in the last Appendix of the text as rare culture-bound syndromes. In DSM-5, the Cultural Formulation Interview was added to suggest that the way of obtaining cultural information was not through a symptom checklist approach that some physicians use, but rather through:

• Subjective expressions of how a patient might perceive the problem and its cause

• What others in the patient’s social network think

• What type of help is thought to be useful

• What developmental influences the person is aware of (cultural awareness)

• The patient’s comfort with the provider and the provider’s ideas

The Interview is reproduced in full in DSM-5 and is available at no cost online at http://www.psychiatry.org/practice/dsm/dsm5/online- assessment-measures#Cultural.

Cultural competency training is now mandated in training programs by the ABPN (American Board of Psychiatry and Neurology), AAMC (Association of American Medi- cal Colleges), and hospitals under JCAHO (Joint Commission on Accreditation of Hospitals); in the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS), training standards are evolving.¹

Identification of cultural themes

Although everyone has a cultural heritage, culture has more relevance in treatment when there is a significant difference in the cultural background of the physician and the patient. Ethnic minority elderly are more likely to be “different,” since many are foreign-born, are non–English-speaking, and have traditional values and histories that the physician does not understand. American-born minority elderly are more likely to be poorly educated and poorly assimilated, such as African American elderly who faced Jim Crow laws and severe prejudice until the civil rights movement began in the 1960s. These differences often make the mentally ill minority elderly especially likely to avoid treatment or resist engagement.

A heuristic technique to foresee potential cultural problems is to anticipate possible issues by time from immigration and degree of assimilation of the patient (Figure).² Cultural issues differ for foreign-born versus American-born, immigrants versus refugees, new immigrants versus long-term residents, and assimilated versus culturally isolated individuals. New immigrants’ issues are dominated by language barriers and culture shock (ie, lifestyle differences-norms and attitudes). Older immigrants have learned to cope and may even be less angered by racism because they do not internalize the criticisms.

An example is seen in rates of depressive symptoms among ethnic groups across the life span. A study from the UK showed that the prevalence of depressive symptoms in South Asian and black Caribbean participants was twice that in white Europeans.³ Although the study included all ages, culture shock and adjustment difficulties have always been expected to be greater for the elderly, who may have more health comorbidities and coping limitations than younger immigrants. This is similar to relocation trauma often observed in nursing home residents, which is attributable to heightened difficulty in adjusting to radical environmental change.

An NIMH-sponsored epidemiological catchment area study showed that recent immigrants had a higher rate of mental illness than American-born elderly, although the rates were lower in immigrants who had lived in the US for more than 20 years.⁴ Some signs of cultural problems are excessive silence during the interview, difficulty of the therapist in understanding the nature of the problem, hostility, nonadherence with medications, differences in primary language spoken, or idiosyncratic behaviors or expressions.

Misdiagnosis versus missed diagnosis of dementia

Brief cognitive screening instruments, such as the Mini Mental State Examination, and neuropsychological tests may be biased by language barriers and education as well as by perceived discrimination that could affect test performance.^5,6 Reliability of screening may be improved by use of validated language translations of mental status examinations, such as the Montreal Cognitive Assessment, or less language-dependent short instruments, such as the Mini-Cog.^6,7 Both should be coupled with a functional activities assessment, such as an instrumental activities of daily living assessment, to improve sensitivity of a dementia diagnosis.⁸

Nursing home utilization and aggression management

The much lower utilization of nursing homes by minority elderly compared with white elderly is no longer true. Minority populations now utilize nursing homes at about the same rate. The reason for the earlier disparity seems to be a much more complicated social issue that includes barriers to access or lack of affordable facilities.⁹ A new issue is a higher reported prevalence of dementia-related behaviors in ethnic minority groups and a much higher incidence of restraint use.^10-12 Although the reasons for the disparity are not clear, it is often presumed that staff appraisal of the problem and environmental strains on the patient are the major reasons for the differences, rather than higher rates of psychosis or unprovoked aggressive drive.

Older observational studies demonstrated that certain behaviors are more likely to be viewed as aggressive or pathological in minority patients than are the same behaviors in other patients. For example, a Hispanic man was referred for aggression when he was the only Spanish-speaking resident in a facility without any Spanish-speaking staff. He showed no evidence of psychosis or depression when he was evaluated with the help of translators. Complaints of agitation stopped when the patient was engaged in activities and a means of better communication was implemented. Closer attention must be paid to potential precipitants of behaviors and envi- ronmental interventions, instead of medication for management.

Paranoia versus hypervigilance: long-term effects of prejudice

Real or perceived racism is almost a ubiquitous minority experience, which has an influence on behaviors and attitudes, even if it is not experienced on a daily basis. Most people learn ways to minimize exposure to threat. Social structures are established to help maintain group identity and support. The large body of literature on mental health care disparities demonstrates that real or perceived interpersonal racism occurs in health care settings as well.¹³ It also acknowledges that minority groups are disproportionately underrepresented in the proportion of patients seeking treatment. A common experience for elderly African Americans, especially in the South, has been segregated care and fear of mistreatment in new settings.

One of my early experiences with this was an elderly black depressed woman who was admitted to a predominantly white hospital unit. She initially had an abject fear of being experimented on or killed. In a short time, she was reassured and it became clear that she was not psychotic. Suspiciousness and feelings of mistreatment or being experimented on are not necessarily delusional beliefs.

Moreover, it should not be assumed that minority elderly persons have a cultural preference to different treatment because they hesitate to ask for medical/psychiatric care. Gitlin and colleagues¹⁴ studied the beliefs of older African Americans. The goal was to find out what these elderly patients knew about depressive symptoms and their preferred treatment approaches. No ethnic differences were seen in endorsement of medications and behavioral activation (a form of cognitive-behavioral therapy), and some patients also endorsed faith-based strategies.

Psychotherapy

A major question that has been asked about culturally appropriate services is whether different treatment approaches should be used. Same-language therapists seem to be essential, but there are no studies or even case reports on providing psychotherapy when there are communication barriers.

In a 2012 review, Fuentes and Aranda¹⁵ reported that of the 82,000 studies that focused on depression outcomes in minority populations, only 19 included older adults. Other than language adaptation, most studies did not explicitly mention the cultural adaptations made for diagnosis or treatment. Other articles on psychotherapy with minorities of all ages often point to therapist differences in outcomes-outcomes are better with some therapists. Their approaches have not yet been manualized in a way that can be easily taught.

Interventions

A basic approach that should be taken with minority elderly as well other age-groups was summarized by Kobylarz and colleagues¹⁶ as the mnemonic ETHNIC(S): Explanation (what do you think you have?); Treatment (what have you tried?); Healers (who have you sought help from?); Negotiate (how do you think I can help?); Intervention (this is what I think needs to be done); Collaborate (how can we work together on this?); and Spirituality (role of religion for the patient).

This is further amplified in A Treatment Improvement Protocol: Improving Cultural Competence.¹⁷ Competencies of individual staff are specific to the racial and cultural groups served in terms of cultural awareness, cultural knowledge, cultural knowledge of behavioral health (cultural lens for worldview), and culturally specific interventions (Figure). In this protocol, a culturally responsive program:

• Emphasizes flexible attitudes from the counselors: cultural knowledge, valuing traditional values, sensitivity to potential beliefs or attitudes that increase antagonism to traditional psychiatric help

• Establishes credibility of the professional in the initial meeting with the family

• Provides services in the patient’s primary language

• Conducts culturally specific assessments of trauma that the patient’s ethnic group commonly faces, community and extended family supports, immigration history, if appropriate

• Considers more family involvement, including home visits when appropriate

• Provides concrete services when needed

• Allows cultural healing practices and integrates them into treatment when possible (eg, acupuncture, mediation, detoxification practices, religious customs) and considers patient’s values (eg, acknowledge the patient’s wishes and limitations)

• Explains key principles and expectations of therapy, including family roles if family therapy is needed, and negotiates

• Emphasizes relationship building

Disclosures:

Dr Sakauye is Emeritus Professor of Psychiatry at the University of Tennessee Health Science Center in Memphis. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. US Department of Health and Human Services Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. https://www. thinkculturalhealth.hhs.gov/pdfs/EnhancedNational CLASStandards.pdf. Accessed May 7, 2015.

2. Sakauye K. Ethnocultural aspects of aging in mental health. In: Sadavoy J, Jarvik LF, Grossberg GT, Meyers BS, eds. Comprehensive Textbook of Geriatric Psychiatry. 3rd ed. New York: WW Norton; 2004:225-250.

3. Williams ED, Tillin T, Richards M, et al. Depressive symptoms are doubled in older British South Asian and Black Caribbean people compared with Europeans: associations with excess co-morbidity and socioeconomic disadvantage. Psychol Med. 2015 Feb 13:1-11; [Epub ahead of print].

4. Srole L, Langner TS, Michael ST. Mental Health in the Metropolis: The Midtown Manhattan Study. Revised ed. New York: New York University Press; 1978.

5. Stephenson J. Racial barriers may hamper diagnosis, care of patients with Alzheimer disease. JAMA. 2001;286:779-780.

6. Barnes LL, Lewis TT, Begeny CT, et al. Perceived discrimination and cognition in older African Americans. J Int Neuropsychol Soc. 2012;18:856-865.

7. Montreal Cognitive Assessment (MoCA). http://www.mocatest.org. Accessed May 7, 2015.

8. Mini-Cog. http://www.alz.org/documents_ custom/minicog.pdf. Accessed May 7, 2015.

9. Tappan RM, Rosselli M, Engstrom G. Use of the MC-FAQ and MMSE-FAQ in cognitive screening of older African Americans, Hispanic Americans, and European Americans. Am J Geriatr Psychiatry. 2012; 20:955-962.

10. Srinivasan S, Sakauye K. Cultural influences in the clinician-elderly patient relationship. Ann Longterm Care. 2005;13:18-24.

11. Sink KM, Covinsky KE, Newcomer R, Yaffe K. Ethnic differences in the prevalence and pattern of dementia-related behaviors. J Am Geriatr Soc. 2004; 52:1277-1283.

12. Cassie KM, Cassie W. Racial disparities in the use of physical restraints in US nursing homes. Health Soc Work. 2013;38:207-213.

13. US Department of Health and Human Services. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Mental Health: Culture Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD; 2001. http://www.ncbi.nlm.nih.gov/pubmed/20669516. Accessed May 7, 2015.

14. Gitlin LN, Chernett NL, Dennis MP, Hauck WW. Identification of and beliefs about depressive symptoms and preferred treatment approaches among community-living older African Americans. Am J Geriatr Psychiatry. 2012;20:973-984.

15. Fuentes D, Aranda MP. Depression interventions among racial and ethnic minority older adults: a systematic review across 20 years. Am J Geriatr Psychiatry. 2012;20:915-931.

16. Kobylarz FA, Heath JM, Like RC. The ETHNIC(S) mnemonic: a clinical tool for ethnogeriatric education. J Am Geriatr Soc. 2002;50:1582-1589.

17. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. A Treatment Improvement Protocol: Improving Cultural Competence. TIP 59. Rockville, MD: US Dept of Health and Human Services; 2014. HHS publication (SMA) 14-4849.