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TRANSCULTURAL ISSUES IN THE DIAGNOSIS AND TREATMENT OF DEPRESSION

TRANSCULTURAL ISSUES IN THE DIAGNOSIS AND TREATMENT OF DEPRESSION Learning Objectives By the end of this presentation, participants will be able to: Define the terms culture, cultural competence , cultural identity , cultural humility , and transcultural psychiatry

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TRANSCULTURAL ISSUES IN THE DIAGNOSIS AND TREATMENT OF DEPRESSION

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  1. TRANSCULTURAL ISSUES IN THE DIAGNOSIS AND TREATMENT OF DEPRESSION

  2. Learning Objectives • By the end of this presentation, participants will be able to: • Define the terms culture, cultural competence, cultural identity, cultural humility, and transcultural psychiatry • Identify cultural influences on the patient-provider relationship • Recognize the roles of culture, race, and ethnicity in the detection, diagnosis, and treatment of depressive disorders • Discuss current efforts directed at improving cultural competence at organizational and individual levels of health care

  3. Introduction Culture “A shared set of beliefs, norms, or values that will influence the meaning given to life events and experiences” Schraufnagel TJ. Gen Hosp Psychiatry. 2006;28(1):27.

  4. Essential Components of Culture • Culture: • Is learned • Refers to a system of meanings • Acts as a shaping template • Is taught and reproduced • Exists in a constant state of change • Includes patterns of both subjective and objective components of human behavior Adapted from: Gaw AC. Concise Guide to Cross-Cultural Psychiatry. Washington DC: American Psychiatric Publishing; 2001.

  5. Aspects of Cultural Identity Adapted from: Ton H, Lim RF. The assessment of culturally diverse individuals. In: Lim RF (ed). Clinical Manual of Psychiatry. Arlington, VA: American Psychiatric Publishing; 2006:10.

  6. Introduction Transcultural Psychiatry A cross-cultural approach to mental health problems that recognizes the relevance of social, cultural, and ethnic factors to the etiology and treatment of disease. World Psychiatric Association, 1998. http://www.mentalhealth.com/newslet/tp9801.html.

  7. Historical Overview of Transcultural Psychiatry • The concept of cultural psychiatry dates back approximately 200 years1 • In the 1800s, anthropologists took an ethnocentric approach to psychiatry2 • Cultural inquiry was focused on non-Western, isolated cultural groups1,2 • Prince RH, Okpaku SO, Merkel L. Transcultural psychiatry: A note on origins and definitions. In: Okpaku, SO (ed). Clinical Methods in Transcultural Psychiatry. Washington, DC: American Psychiatric Press; 1998:3. • Ton H, Lim RF. The assessment of culturally diverse individuals. In Lim, RF (ed). Clinical Manual of Psychiatry. Arlington, VA: American Psychiatric Publishing; 2006:5.

  8. Historical Overview of Transcultural Psychiatry (cont) • Late 1900s: Modern psychiatry criticized for not focusing on relativity of cultural society1 • “Culture” begins to replace terms such as “savage tribes, primitive, civilized” in psychiatric publications2 • DSM-IV considers integrating cultural factors into the diagnosis and evaluation of mental disorders1 • Ton H, Lim RF. The assessment of culturally diverse individuals. In Lim RF (ed). Clinical Manual of Psychiatry. Arlington, VA: American Psychiatric Publishing; 2006:5. • Prince RH, Okpaku SO, Merkel L. Transcultural psychiatry: A note on origins and definitions. In: Okpaku SO (ed). Clinical Methods in Transcultural Psychiatry. Washington, DC: American Psychiatric Press; 1998:4.

  9. Historical Overview of Transcultural Psychiatry (cont) • 1955: • Transcultural psychiatry established as a distinct discipline by E.D. Wittkower • Section of Transcultural Studies, McGill University, Montreal • Journal: Transcultural Psychiatric Research Review Prince RH, Okpaku SO, Merkel L. Transcultural psychiatry: A note on origins and definitions. In: Okpaku SO (ed). Clinical Methods in Transcultural Psychiatry. Washington, DC: American Psychiatric Press; 1998:3.

  10. Introduction—Current Demographics U.S. Census 2000: Racial/Ethnic Groups % % % % % % US Census Bureau: Census 2000.

  11. Common Cultural Themes • Each patient is unique: • Each patient is a member of one or more cultural, racial, or ethnic groups • Treatment needs to be individualized for each person • Each cultural or ethnic group shares beliefs that characterize illness and determine acceptable treatment; however, there may be variations in these beliefs within each group • When formulating a treatment plan, consider individual characteristics such as: • Education • Nationality • Faith • Level of acculturation Juckett G. Am Fam Physician. 2005;72(11):2267.

  12. Common Cultural Themes (cont) • Trust and respect1 • Establish trust through time, patience, and small talk2 • Be aware of cultural differences such as: • Establishing eye contact1,2 —avoided out of respect in several cultures • Opposite-sex touching between health care provider and patient2 —may be forbidden in certain groups (eg, Orthodox Jews and some Islamic sects) • Need for explanations of what will be done2 • Preferences for “natural” medicines1,2 • Burroughs VJ. National Pharmaceutical Council, 2002. • http://www.npcnow.org/resources/PDFs/CulturalFINAL.pdf. • 2.Juckett G. Am Fam Physician. 2005;72(11):2267.

  13. Common Cultural Themes (cont) • Health beliefs and practices • Traditional healing is common1 • 38% of Native American patients consulted with a healer; 61% rated the advice higher than that of their physician • Latino healing traditions and Chinese medicine may often characterize diseases as “hot” or “cold” and manage them with alternative, herbal, or home remedies2 • Physicians should take advantage of opportunities to communicate with local medicine people [eg, Latino folk healers (curanderos)] • Fatalism or an attitude of passive acceptance may be encountered1 • Mistrust of Western medicine, physicians, and hospitals exists1 • Burroughs VJ. National Pharmaceutical Council, 2002. http://www.npcnow.org/resources/PDFs/CulturalFINAL.pdf. • Juckett G. Am Fam Physician. 2006;72(11):2267.

  14. Common Cultural Themes (cont) • Family values • Family members’ opinions about illness and treatment may be held in high esteem • An older family member may make health care decisions for the family • The family support system can greatly influence the patient’s response to medication and therefore, clinical outcomes • Burroughs VJ. National Pharmaceutical Council, 2002. http://www.npcnow.org/resources/PDFs/CulturalFINAL.pdf.

  15. Cultural Influences on the Patient–Provider Relationship • “The culture of the clinician and the larger health care system govern the societal response to a patient with mental illness [and influence] many aspects of the delivery of care, including diagnosis, treatments, and the organization and reimbursement of services.” —US Dept of Health and Human Services, 2001. US Dept of Health and Human Services. Executive Summary. In: Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD; 2001.

  16. The Role of Myth and Stereotype Cultural Influences on the Patient–Provider Relationship (cont) Stereotypical and/or Prejudicial Physician Behavior Misdiagnoses and Misplaced Interventions • Poor Outcomes • Poor Patient Care • Missed Opportunities Misinterpretation of Ambiguous/ Unfamiliar Behavior Whaley AL. Am J Orthopsychiatry. 1998;68(1):47.

  17. Cultural Influences on the Patient– Provider Relationship (cont) • Interethnic transference1,2: • The patient’s response to an ethnoculturally different physician • Interethnic effects of transference1,2: • Overcompliance or over-friendliness • Denial of ethnocultural factors • Mistrust • Hostility • Ambivalence • Comas-Diaz L, Jacobsen FM. Am J Orthopsychiatry. 1991;61(3):392. • Ton H, Lim RF. The assessment of culturally diverse individuals. In: Lim RF (ed). Clinical Manual of Psychiatry. Arlington, VA: American Psychiatric Publishing; 2006:19.

  18. Cultural Influences on the Patient– Provider Relationship (cont) • Interethnic countertransference1,2: • The nontherapeutic manner of an ethnoculturally different clinician in response to a patient • Interethnic effects of countertransference1,2: • Denial of ethnocultural factors • Clinical anthropologist syndrome • Guilt or pity • Aggression • Ambivalence • Comas-Diaz L, Jacobsen FM. Am J Orthopsychiatry. 1991;61(3):392. • Ton H, Lim RF. The assessment of culturally diverse individuals. In: Lim RF (ed). Clinical Manual of Psychiatry. Arlington, VA: American Psychiatric Publishing; 2006:20.

  19. Screening and Diagnosing Depression—The Role of Culture • Cultural explanatory models of illness • Define culturally acceptable symptoms of illness • “Idioms of distress” • Help define behavior the sick individual must assume Ton H, Lim RF. The assessment of culturally diverse individuals. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: American Psychiatric Publishing. 2006:14.

  20. Screening and Diagnosing Depression—The Role of Culture • Types of models include: • Religious/Spiritual: Illness is punishment; atonement is necessary • Magical: Witchcraft, or sorcery causes illness; counteract with spell • Moral: Illness due to character flaw (eg, lazy, selfish); must improve • Medical: eg, Western allopathic medicine, Ayurvedic medicine, Chinese medicine Ton H, Lim RF. The assessment of culturally diverse individuals. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: American Psychiatric Publishing. 2006:14.

  21. Screening and Diagnosing Depression—The Role of Culture (cont) • Somatization • Expressing psychological distress through bodily symptoms • Common in all cultural groups and societies • Culture specific with varying modicums of style • Depression can be displayed as low energy, insomnia, and physical pain, while mood symptoms are minimized • Can indicate • Physical or mental illness • Interpersonal conflict or positioning • Cultural idiom of distress • Metaphors for experience or emotion Kirmayer LJ, Dao THT, Smith A. Somatization and psychologization: Understanding cultural idioms of distress. In: Okpaku SO (ed). Clinical Methods in Transcultural Psychiatry. Washington, DC: American Psychiatric Press; 1998:233.

  22. Screening and Diagnosing Depression—Refugees and Immigrants • Refugees and immigrants include: • People who abandon their homes and communities • Due to war, political violence, and other threats • People displaced outside their country of residence • Internally displaced persons • Asylum seekers • Stateless persons • Recently returned refugees • This population was >42 million at the end of 2004 Porter M. JAMA. 2005;294:602.

  23. Screening and Diagnosing Depression—Refugees and Immigrants (cont) • Increased risks for psychological stress and mental illness: • History of political or religious persecution (including experiencing violence, imprisonment, or war) • Foreign language, custom, and acculturation stress • Social isolation and rejection/lack of social support • Racism and prejudice • Difficulty securing employment and housing • Limited health care access • Unattended chronic illness • Minority status Jablensky A. J Refugee Studies. 1992;5:172.

  24. Screening and Diagnosing Depression—Refugees and Immigrants (cont) Merriam-Webster Online. 2006. http://www.m-w.com/

  25. Screening and Diagnosing Depression—Refugees and Immigrants (cont) Khoa LX. J Refugee Resettlement. 1981;1:48.

  26. Screening and Diagnosing Depression—Assessment Across Cultures Checklist for Cultural Sensitivity and Awareness • Identify Communication Method • Identify Language Barriers • Identify Cultural Background • Identify Patient’s Comprehension Level • Identify Religious/Spiritual Beliefs • Identify Culture-specific Diet Considerations • Identify Any Health Care Provider Bias • Does Patient Trust Caregivers? • Does Patient Understand the Recovery Process? • Assess with Cultural Sensitivity Cultural Sensitivity and Awareness Checklist Seibert PS. J Med Ethics. 2002;28:143.

  27. Treatment of Depression—The Role of Culture • DSM-IV-TR: • Addresses disparities regarding cultural validity of psychiatric illnesses in the DSM-III • Appendix 1: Outline for cultural formulation • Cultural identity of the individual • Cultural explanations of the individual’s illness • Cultural factors related to psychosocial environment and levels of functioning • Cultural elements of the relationship between the individual and the clinician • Overall cultural assessment for diagnosis and care • Glossary of culture-bound syndromes American Psychiatric Association. DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

  28. Treatment of Depression—The Role of Culture (cont) • Culturally appropriate treatment plan • Individualized treatment for each patient1 • Thorough assessment of each patient’s demographics and characteristics (eg, race/culture/ethnicity, faith, level of acculturation, education)1 • Awareness of differences in cultural expressions of, and attitudes toward, disease1 • Consultation with family and cultural consultants1 • Medication management requires: • Adjustment based on ethnicity and response1 • A “start low, go slow” treatment approach2 • Lim RF. Conclusions: Applying the DSM-IV-TR outline for cultural formulation. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: American Psychiatric Publishing, Inc.; 2006:237. • Smith, MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: AP Publishing, Inc.; 2006:207.

  29. Treatment of Depression—Effective Communication • Have patients repeat instructions in their own words instead of asking, “Do you understand?” • Patients may agree or smile through embarrassment or respect even when they don’t understand • An interpreter may be needed • In some cultures, negative prognoses are communicated to the family first • Inform families of the standard US practice of disclosing information to patients first, and then ask them which they would prefer Juckett G. J Fam Physician. 2005;72(11):2267.

  30. Treatment of Depression—Effective Communication (cont) • Be aware of different perceptions of: • Time management—relaxed or punctual • Personal space • Gestures • Pointing may be considered insulting or rude • For many Asians, exposing the sole of the foot or touching the head are considered taboo Juckett G. J Fam Physician. 2005;72(11):2267.

  31. Treatment of Depression—Psychotherapy and Counseling • Minority individuals may not participate in therapy because of stigma surrounding its use • Discouragements to using mental health services may also include: • Lack of counselors trained in culturally sensitive therapy models • Lack of bilingual counselors • Lack of counselors with similar ethnic/racial backgrounds • Lack of cultural sensitivity Kearney LK. The Counseling & Mental Health Center 2003 Research Consortium. http://www.utexas.edu/student/cmhc/research/rescon.html

  32. Treatment of Depression—Psychotherapy and Counseling (cont) • Whites have been shown to attend mental health therapy sessions significantly more often than African American, Asian American, and Hispanic individuals1 • However, another study demonstrated that, among the Asian population, East Asians used these services more than whites, African Americans, Latinos, Native Americans, and other Asian populations2 • More research is needed regarding mental health therapy use and outcomes among racial and ethnic minorities1 • Kearney LK. The Counseling & Mental Health Center 2003 Research Consortium. http://www.utexas.edu/student/cmhc/research/rescon.html • Barreto RM. Psychiatric Services. 2005;56:746.

  33. Age Gender Diet Herbal supplements Exercise Smoking Alcohol Caffeine Genetics Culture Comorbid disease Other medications Adherence/compliance Patient–physician relationship Social supports Treatment of Depression—Ethnopsychopharmacology • Factors influencing drug metabolism and response to medication: Smith, MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: AP Publishing, Inc.; 2006:207.

  34. Treatment of Depression—Ethnopsychopharmacology (cont) • Treatment responses vary among individuals of different racial and ethnic origin1-5 • Genetic polymorphisms and differing rates of polymorphism among different ethnic groups exist in drug-metabolizing enzymes, targets, and pathways1,3-5 • Optimal drug concentrations may vary between individuals or racial/ethnic groups1-5 • African Americans may require lower doses of tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs).2 • Asians often respond to doses of psychotropics lower than the recommended doses, and may experience side effects at the “normal” doses.5 • Smith, MW. Ethnopsychopharmacology. In: Lim RF (ed). Clin Manual of Cultural Psychiatry. AP Publishing, Inc.; 2006:207. • Varner RV, Ruiz P, Small DR. Psychiatr Q. 1998;69(2):117. • Bondy B. Dialogues Clin Neurosci. 2005;7:223. • Shimoda K. J Clin Pharmacol. 1999:19(5):393. • Lin KM. Psychiatr Serv. 1999;50:774.

  35. Treatment of Depression—Ethnopsychopharmacology (cont) • Cytochrome P450 (CYP450) drug- metabolizing enzymes: • >20 human CYP450 enzymes identified1 • Metabolize antidepressants, antipsychotics, and benzodiazepines1,2 • Most relevant to psychiatric treatment include1,2: • CYP2D6 • CYP3A4 • CYP1A2 • CYP2C19 • Smith, MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: AP Publishing, Inc.; 2006:207. • Bondy B. Dialogues Clin Neurosci. 2005;7:223.

  36. Treatment of Depression—Ethnopsychopharmacology (cont) SNRIs = serotonin-norepinephrine reuptake inhibitors; SSRIs = selective serotonin reuptake inhibitors; TCAs = tricyclic antidepressants Adapted from: Smith MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: AP Publishing, Inc.; 2006:207.

  37. Treatment of Depression—Ethnopsychopharmacology (cont) • CYP2D6 enzyme • Major metabolic pathway for many psychotropics1 • Highly polymorphic: >70 known mutations1 • Polymorphisms have a strong effect on treatment responses1,2 • Co-administration of certain antidepressants, antipsychotics, antihistamines, and other drugs can inhibit metabolism3,4 • Malhotra AK. Am J Psychiatry. 2004;161:780. • Smith, MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: AP Publishing; 2006:207. • Brosen K. Clin Pharmacokinet. 1995;29(suppl)1:20. • Hamelin BA. Drug Metab Dispos. 1998;26:536.

  38. Treatment of Depression—Ethnopsychopharmacology (cont) • CYP2D6 enzyme (cont) • Individuals with CYP2D6 polymorphisms sort into 1 of 4 groups: • Poor metabolizer (PM): inactive form (slower metabolism of drug) • Intermediate metabolizer (IM): less active form • Extensive metabolizer (EM): no mutation (aka, “normal”) • Ultrarapid metabolizer (UM): multiple copies of the gene (accelerated drug metabolism) Smith, MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: AP Publishing; 2006:207.

  39. Treatment of Depression—Ethnopsychopharmacology (cont) • CYP2D6 enzyme (cont) • Polymorphisms can alter drug efficacy, side effects, and plasma levels1,2 • Poor metabolizers—Increased risk of side effects; may require lower doses3 • Ultrarapid metabolizers—Risk subtherapeutic treatment with normal-range dosing, and/or side effects due to increased concentrations of metabolites3 • Smith MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: AP Publishing; 2006:207. • Bondy B. Dialogues Clin Neurosci. 2005;7:223. • Bernard S. Oncologist. 2006;11:126.

  40. Treatment of Depression—Ethnopsychopharmacology (cont) • CYP2D6 enzyme (cont) • Patients with decreased CYP2D6 activity have increased adverse effects, increased hospital stays, and increased costs • Annual cost ~$5,000 more for poor metabolizers or ultrarapid metabolizers than for patients with normal activity Reyes C. National Alliance for Hispanic Health, 2004.

  41. Treatment of Depression—Ethnopsychopharmacology (cont) Adapted from: Bernard S. Oncologist. 2006;11:126.

  42. Treatment of Depression—Ethnopsychopharmacology (cont) • CYP3A4: • Multiple drug-drug, diet-drug and herb-drug interactions1 • Observed ethnic differences in enzyme activity: • Citrus fruits and corn (common in the Mexican diet) are inhibitors and can slow down drug metabolism by CYP3A4, increasing risks of adverse effects from increased serum drug levels2 • Additional inhibitors1,3 include grapefruit juice, and various antidepressants (including some SSRIs and TCAs) • Smith MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: AP Publishing; 2006:207. • Reyes C. National Alliance for Hispanic Health, 2004. • Bondy B. Dialogues Clin Neurosci. 2005;7:223.

  43. Treatment of Depression—Ethnopsychopharmacology (cont) • CYP1A2 • Marked interindividual variability in metabolism rate because of multiple factors (eg, dietary habits, smoking) • Polymorphism in activity identified in 32% of whites; data not yet available for other racial/ethnic groups • Activity is induced by cruciferous vegetables (eg, broccoli), cigarette smoking, heterocyclic amines of char-broiled meat, and high-protein diets Smith MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: AP Publishing; 2006:207.

  44. Treatment of Depression—Ethnopsychopharmacology (cont) • CYP2C19 • Responsible for metabolism of 3 common SSRIs—citalopram, escitalopram, and sertraline1 • Intermediate metabolizer phenotype (less active form) may indicate dosage adjustments to lower levels2: • 18.5% of African Americans • 15.7–17.6% of Asians • 2.9% of whites • Smith MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: AP Publishing; 2006:207. • Burroughs VJ. J Nat Med Assoc. 2002;94(10 suppl):1.

  45. Treatment of Depression—Ethnopsychopharmacology (cont) Implications for the Future • Knowledge of variation in treatment response should alert the physician to the need for individualized therapy • Formularies and protocols should include optimal therapies for patients of all races and ethnicities • Drugs in the same class may differ in clinical effect; caution is needed with drug substitution for an “equivalent” in programs whose goal is cost containment • Pharmaceutical companies should include representative numbers of racial and ethnic groups in drug metabolism studies and clinical trials Burroughs VJ. J Nat Med Assoc. 2002;94(10 suppl):1.

  46. Treatment of Depression—Ethnopsychopharmacology (cont) • Successful and safe drug prescribing for ethnic and minority patients includes: • “Start low, move slow” – Initiate with minimal dosing and evaluate the response • Take into consideration the patient’s ethnic background and enzyme activity levels • Ask about supplemental herbs, diet, and smoking • Check plasma levels when: • Patients have strong side effects while on low doses of antidepressants • Patients do not improve while on higher doses of antidepressants • Involve the family or support system in treatment Smith MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: AP Publishing, Inc.; 2006:228.

  47. Treatment of Depression—Approaches to Psychotherapy • Key applications for transcultural psychotherapy: • Understand the patient’s social and cultural background • Determine if the patient’s behavior is within his or her own societal and cultural norms • Analyze the situation in a culture-specific fashion • Identify available strategies in managing the patient’s behavioral issues Siegfried J. Commonsense reasoning in the transcultural psychotherapy process. In: Okpaku SO (ed). Clinical Methods in Transcultural Psychiatry. Washington, DC: American Psychiatric Press; 1998:279.

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