Cultural Variables in Psychiatry

Several recent national reports indicate that people from racial and ethnic minority groups in the United States face severe difficulties accessing mental health care services. When they do obtain services, they often face further challenging obstacles in obtaining adequate care. At the 2001 fall component meetings of the American Psychiatric Association, then-U.S. Surgeon General David Satcher, M.D., presented his newly published report "Mental Health: Culture, Race, and Ethnicity." The report pointed out that there are significant disparities in the availability and access to mental health care services disproportionately affecting racial and cultural minority populations. In order to respond to the report and to provide guidance to the Board and Assembly, the then-President of the APA, Richard K. Harding, M.D., appointed a Steering Committee to Reduce Disparities in Access to Psychiatric Care. The Steering Committee's report will soon be published.

In the meantime, President Bush's New Freedom Commission on Mental Health has published its own recommendations for steps that can be taken at national, state and local levels to improve access to mental health care services and supports for all people afflicted with psychiatric disorders. Recognizing the severity of these discrepancies, the Accreditation Council for Graduate Medical Education (ACGME) established new training standards for all residency programs that include cultural competency. It is obvious that the major factors involved in creating and perpetuating disparities that Satcher, the New Freedom Commission and many other sources have recognized involve the consequences of national economic and social forces such as poverty, discrimination, violence and crime.

Psychiatrists might wonder what we as professionals can do about this other than be politically involved, responsible citizens. Until political solutions are eventually found, the Group for the Advancement of Psychiatry (GAP) Committee on Cultural Psychiatry believes that there are many clinical interventions that psychiatrists can adapt to their practices that enhance outcomes in mental health care to minority patients.To begin with, psychiatrists should become familiar with the Cultural Formulation (Appendix I) in the DSM-IV-TR, which recommends that the clinician assess the patient's self-perception of their ethnic identity. This is an important procedure in the diagnostic process and is also helpful in designing the treatment and management interactions that follow. The first step is to ask the patient about cultural and religious backgrounds. People who live in multicultural societies may have several ethnic traditions from which much of their identity is derived. Although patients may be able to articulate some cultural influences with full awareness, others may be so automatic and taken for granted that they are discovered only by studied self-reflection and inference. Giving the patient the opportunity to reflect on personal cultural identification may allow for expressions that affirm the self and inform the clinician.

Despite the lack of precision and clarity with respect to race, the subject has assumed particular significance in the United States with linkage of stereotyped concepts and stigmata. The potentially problematic interaction between different racial groups is a significant element in practically every facet of life. In psychiatric practice, race can have significant consequences for the diagnostic process for treatment decisions. Studies have found that whites and Asians more often received the diagnoses of major affective disorders than African-Americans or Hispanics and that African-Americans and Asians received the diagnoses of schizophrenia and other psychoses more often than whites. These studies concluded that biases in diagnosis may be related to factors of race and ethnicity (Flaskerud and Hu, 1992).

The DSM-IV-TR also discusses gender in the context of culture as a variable in the prevalence and the clinical presentation of disorders preceding the consideration of diagnosis. Although gender as a cultural variable may determine the epidemiological prevalence of certain diagnostic categories, there are also differences in prevalence in clinical samples. This may be the result of culturally determined gender differences in acknowledgment or denial of symptoms, in differential treatment-seeking behaviors, or biases in diagnosing. For example, whereas Hispanic men have somewhat higher rates of alcohol abuse and dependence than white or African-American men, Hispanic women have lower rates of these disorders than women from any other ethnic group.

It is important to be aware of issues that are culturally significant in patients' psychology and how these issues influence their concepts of self and their relationships with others. Despite individual endowments, capacities or achievements, women in Western countries are more motivated by emotional connectedness and relationships than are men (Comas-D'az and Greene, 1994). As Clower (1991) and others have suggested, the vicissitudes in the psychological development of females lead to some very positive capabilities: flexibility in adaptive regression, identification, empathy, affiliation and close intimacy. On the other hand, females may have liabilities: low self-esteem, inhibition of independence and self-assertion, and a proclivity to endure less than satisfying relationships.

As is the case with gender, age interacts with the other components of cultural identity to influence developmental issues, as well as psychiatric assessment and treatment. The APA Task Force on Ethnic Minority Elderly has presented specific outlines for clinical care of the elderly from ethnic minority groups. In all groups, elderly people feel the impact of immigration more keenly than other age groups and are handicapped by a lesser ability to acculturate and a higher risk of culture shock (Sakauye, 1992). Elderly people are also more likely to manifest culture-bound syndromes, which create difficulties in diagnosis. Also confounding the diagnostic process is the fact that many speak only their native languages. Ethnic minority elderly people may also feel displaced in Western societies, in which aged people may be abandoned or placed in nursing homes.

Immigrant status is also a significant stressor for those of all ages and a major consideration in the diagnostic and treatment process. The story of the patient's exodus should include: country of origin, position in the family, education, employment status, level of support, political issues, and experiences of war and traumatic events (Lee, 1990). By definition, immigrants leave their countries voluntarily (and often easily), whereas refugees are either forced out or flee surreptitiously. Both may experience trauma and losses. Clinicians should also discuss the extent of the patient's loss of family members, relatives and friends; property, financial resources, business and career; and support of the cultural milieu, community and religion.

The DSM-IV-TR Cultural Formulation also included the patient's "explanatory model of illness" (Kleinman, 1988). The explanatory model may consist of cultural notions of etiology, timing, mode of onset, pathophysiology, natural history, severity and appropriate treatments. Psychological causation is an example of the explanatory model in the Western patient, whereas a broken taboo may be the explanation used by some traditional Native Americans, who may believe that a spirit calls to them or travels to the afterworld.

Clinicians can elicit the explanatory model by asking the patient: "What has happened?" "Why?" and "Why now?" The clinician should also ask: "What will happen if nothing is done?" and "What effect will the experience have on others?" Finally, the clinician should ask, "What can be done about it?" in order to lay the foundation of a therapeutic plan that considers culture.

These cultural considerations often include religious and spiritual beliefs, which profoundly influence mental status as well as psychiatric assessment and treatment (Lukoff et al., 1993, 1992a, 1992b; Matthews et al., 1993). "Religious or Spiritual Problem" is included in DSM-IV-TR's nonillness category ("Additional Conditions That May Be a Focus of Clinical Attention"). It is important for the clinician to acknowledge and work with a patient's religious beliefs as potential sources of support, rather than only as manifestations of psychopathology. Griffith and Young (1988) and Burton (1992) are among the many who have examined the interactions between religion and family as resources that could be assessed and used therapeutically.

Socioeconomic status also influences mental health diagnosis and care. Economically disadvantaged people experience a reduction in effective coping, which leads to a sense of helplessness and powerlessness and psychopathology rates higher than rates found in the highest socioeconomic groups (Dohrenwend et al., 1980; Fried, 1982). Research has also found that anxiety disorders are more often diagnosed in children of middle-class parents than in children of blue-collar parents and that middle-class children are more likely to be treated with psychotherapy than children of blue-collar parents. Psychosis or personality disorders are more often diagnosed in children of lower-class parents than in children of middle-class parents. Many studies have found that those in most need received the least service (Langner et al., 1974; Ruiz et al., 1995).

Diet and medicinal herbs may also affect treatment considerations. Diet can have dramatic effects on the pharmacology of both psychotropic and non-psychotropic medications by changing their absorption, metabolism, distribution and elimination. Ethno-culturally determined pharmacological influences can occur as a result of differences in food composition, preparation and even the circadian timing of feeding. Studies in England, for example, have found that Sudanese and Asian-Indian immigrants who maintain their native vegetarian diets tend to have different cytochrome P450 enzyme activity profiles from immigrants who adopt the mainstream British meat-eating diet (Jacobsen, 1994).

Throughout much of Latin America, the hot and cold theory dictates that foods culturally characterized as hot should not be consumed concurrently with foods characterized as cold, thereby leading to variations in food intake that may alter pharmacologic activity. An example is found in the Mediterranean diet containing fava beans. Fava beans have a high content of the neurotransmitter dopamine and can cause severe hypertensive reactions in individuals taking monoamine oxidase inhibitors (MAOIs).

Grapefruit juice has been found to inhibit the cytochrome P450 3A4 isozyme, which is responsible for metabolizing a number of psychotropics, including sertraline (Zoloft), nefazodone (Serzone), trazodone (Desyrel), fluoxetine (Prozac), buspirone (BuSpar) and numerous benzodiazepines (as well as many non-psychotropic medications). Consuming grapefruit juice can cause dramatic elevations in the blood levels of these drugs.

There are many other useful cultural considerations that the GAP Committee on Cultural Psychiatry has reviewed and summarized in their book Cultural Assessment in Clinical Practice (2002; American Psychiatric Publishing, Inc.). The case vignettes and the clinical orientation of this book should enable psychiatric residents and psychiatrists in practice to achieve a level of cultural competence in issues affecting their ethnic and racial minority patients' lives and disorders.