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Clinical Aspects of Culture in the Practice of Psychiatry: Assessment and Treatment of Culturally Diverse Patients

Authors: Russell F Lim, MD ; Francis Lu, MDFaculty and Disclosures


Over 100 sessions on cultural issues were included at the 158th Annual Meeting of the American Psychiatric Association, held in Atlanta, Georgia, in May 2005. Ethnicities and underrepresented groups addressed included Asians, African Americans, Hispanics, Native Americans, Arab Americans, women, gays, lesbians, transgenders, and bisexuals. This article focuses on sessions pertaining to assessment and treatment, and includes clinical aspects of somatization and ethnopsychopharmacology, as well as the effects of culture and spirituality on assessment. The following article will summarize the main points of the presentations and present some clinical pearls that will be useful in delivering culturally competent care.

Somatization and Stigmatization

A workshop on somatization and stigma in Asian Americans (AA) and Pacific Islanders (PI) dealt with the diversity in their ethnicities and in their historical experiences in the United States, and how that affects their assessment and treatment.[1] Asian immigrants now account for about 4% of the US population and are the fastest-growing racial group. It is projected that by the year 2020, the combined AA/PI population will reach approximately 20 million, or about 6% of the total US population.

Recognition of mental illness in Asians is challenging in the primary care setting. Due to the various cultural backgrounds and perceptions of psychiatric illness, access, diagnosis, and treatment are especially challenging in this population.

Sabina Lim, MD,[1] a fourth-year resident at Yale, spoke about how somatization is the primary means of experiencing and expressing emotion for Asian-American patients. In contrast to the Western mind-body dichotomy, Asian culture considers the mind and body as a whole, which has led to somatic presentations of mental illness. This disease presentation and the stigma of mental illness among Asians delay access to appropriate care. Somatization is defined as psychological and interpersonal distress communicated in the form of medically unexplained symptoms, which should not to be confused with the symptoms of somatoform disorders which suggest a medical condition, but are not fully explained by a medical condition. Patients who are unable to express their distress in words will use somatic symptoms to express their pain. Somatization is commonly seen in most patients from non-Western countries, not just in Asian Americans. Dr. Lim also spoke of how the stigma of mental illness results not only in shame in the individual, but also as shame in the entire family, which causes avoidance of mental health services outside of the family. Other barriers are beliefs that mental illness can be viewed as a sign of weakness, or a lack of self-control, as the suppression of negative affect is valued among Asian Americans. The view that the mind and body are connected also contributes to the reluctance to seek treatment.

Dr. Lim went on to show that somatic complaints are more common in Chinese Americans than white patients, so much so that 29% of Chinese Americans meet criteria for somatoform disorder, compared with 9% of whites, and both had concurrent psychiatric disorders such as major depressive disorder (71% and 63%, respectively).[2] The most common complaints are shown in Table 1. There are other culture-bound syndromes or local specific patterns of symptoms that we should be aware of, such as neurasthenia, a syndrome of physical and emotional weakness, shin-byung, a syndrome of anxiety and weakness, and hwa-byung, or "anger sickness" (see Table 2).

Table 1. Typical Somatic Symptoms[2]

HEENT: lump/heaviness in throat, blurry vision
Cardiac: chest pain, shortness of breath
GI: nausea, vomiting, difficulty swallowing, chronic indigestion/upset stomach/dyspepsia
MS: nonspecific aches/tightness/pains, generalized fatigue
Neuro: headaches, dizziness, vertigo, fainting, seizures, paresthesias

Table 2. Asian Culture Bound Syndromes[2]

Neurasthenia (shenjang shuairuo)
  • "Lack of nerve strength"/"neurological weakness"/"exhaustion of the nervous system"
  • Chinese syndrome characterized by mental and physical fatigue, poor concentration, poor memory, and dizziness. Physical symptoms such as changes in appetite and sleep, headaches, sexual dysfunction.
  • Korean syndrome characterized by anxiety and physical complaints, such as weakness, dizziness, poor appetite, insomnia. Dissociation may present. Attributed to possession by ancestral spirits.
  • Most common in middle-aged Korean women ("anger sickness")
  • Sense of epigastric/upper abdominal mass/heaviness, shortness of breath, indigestion, fatigue, flushing, palpitations, vomiting, cold hands or feet, dysphoria, panic
  • Thought to be due to suppression of anger, disappointment, grudges, and unfulfilled expectations

The Diagnostic Approach to Treatment

The diagnostic approach to treatment is a careful medical work-up to rule out any organic causes, such as a comprehensive metabolic panel, thyroid function tests, EKG, EEG, and/or cranial imaging. The clinician needs to ask the patient about the use of herbal medications, because alternative healing methods are widely practiced and available through Oriental medicine doctors, acupuncturists, herbalists, bone setters, psychic healers, and spiritual mediums. Patients often consult alternative healers first and may continue seeing them, even while in mental health treatment, so it is important to ask specifically about these practices. Eisenberg and colleagues[3] found that 42% of all patients surveyed in the United States used some form of complementary or alternative medical treatment.

In addition, it is important not to neglect asking patients about stressors in their lives, even though they many not make the connection between physical complaints and stress . Common stressors include a failure to live up to the expectations of self and family, or threats to competence, such as failure in school or work, familial conflict, recent immigration, or poor acculturation. These all can result in guilt, shame, isolation, and a decrease in functioning. Patients may also downplay the importance of their symptoms, stating that they are commonplace, and do not require treatment. Asian-American patients will also underreport symptoms of suicidal ideation or actual suicide attempts, although other ethnicities may be reluctant to report as well.

It is important to ask for a cultural consultation to determine the normality of symptoms or beliefs. An interpreter trained in mental health who speaks the patient's preferred language is very helpful. Generalizations about culture are meant to provide a starting point for clinicians, and are not meant to invoke cultural stereotypes or reduce pathology to a cultural phenomenon. In addition, clinicians of the same ethnicity may have difficulty with overidentifying with their clients and should be aware of major blind spots in their history taking due to assumptions that are not checked out thoroughly with the patient.

Mona H. Gill, MD,[4] Assistant Clinical Professor at the University of California, Davis, spoke about treatment approaches. She stated that although patients focus on physical symptoms, they are often fully aware of emotional/social stressors. Patients tend to present symptoms according to what they perceive as "appropriate" for a visit to the doctor. Thus, a somatic presentation may predominate during their first mental health visit. It is critical to ask patients about psychosocial stressors, keeping in mind that the mind/body dualism is not present in Asians.

Nonpharmocologic Treatment

Dr. Gill discussed the usefulness of psychosocial treatments. Contrary to earlier beliefs, Asian patients are often receptive and are likely to benefit from psychotherapy that concentrates on the instillation of hope, the fostering of trust, and the construction of "explanatory models" that make sense to the patient and focus on recovery. An orientation phase may be necessary where the purpose and ground rules of psychotherapy are discussed. It is also important to define the problem. A problem-focused family-therapy approach appears to be very effective. In most instances, family members ask for help when difficulties are encountered with one member, the identified patient. Dr. Gill suggested that psychiatrists use a family psychoeducational approach, such as education about illness, training in clearer communication, problem-solving, and behavior management strategies. A family approach involves building alliances with family members who have power. There are 2 types of power: "role prescribed power" and "psychological power." Any treatment will not be effective without the involvement of the identified family leader. In general, family therapy is helpful in patients from most non-Western countries.

In family therapy the therapist may have to take a more authoritative or active stance to gain credibility. This may be done by providing structure, giving advice, and acting as an advocate. The therapeutic models that serve family therapy best are generally more structured: behavioral, such as progressive muscle relaxation, systematic desensitization and behavioral modification, cognitive therapy, psychosocial rehabilitation, or interpersonal therapy that focuses on roles and social relations. Finally, culturally sensitive programs in the community can be effective, such as a Hmong depression group. The group reduces shame and isolation, and fosters more willingness in patients to divulge feelings after trust with the group has developed. In addition, Asian American patients are more used to a group situation because of emphasis on the family unit in Asian families.

Using cultural competence principles will help these strategies work better. An ethnically sensitive therapist doesn't have to be from the same background as the client, but must be open to incorporating both native and Western treatment interventions. The culturally effective therapist mobilizes family strengths, and enlists the support of the extended family and community network to empower the client. Finally, ethnically sensitive providers continually engage in self-awareness about cultural differences.


When choosing a medication for Asian patients, the following points are important. Data from the last 2 decades show different effects from pharmacotherapy in different ethnic groups, and Asian patients often respond to substantially lower doses of psychotropics. Specific mutations of certain cytochrome P450 enzymes lead to poor or slow metabolism. Dr. Gill's recommendation was to start with half the recommended dose of antidepressant or neuroleptic medication, understanding that some patients may need regular or "higher" doses. Lifestyle considerations such as alcohol and caffeine consumption, smoking, and dietary factors may also have an effect on the effectiveness of a medication.

Belief Systems

Nang Du, MD,[5] Clinical Professor of Psychiatry at the University of California, San Francisco (UCSF), spoke about the importance of understanding Asian patients' beliefs, such as beliefs in animism, Buddhism, Taoism, Confucianism, naturalistic ideas, and Ayurveda, which vary widely from one culture to another. Patients believing in animism feel that human beings, animals, and inanimate objects are endowed with souls or spirits. Mental illness is considered as an affliction caused by loss of one's soul or possession by evil or vengeful spirits. Followers of Buddhism feel that human life is full of sorrow. Suffering from sorrow comes from chains of causation due to family's deeds, one's own karma, expectation, or desires. Mental illness is considered as a suffering caused by misdeeds of self or ancestors, or by too much desire or ambition. Taoists feel that the body is a microcosm of the universe governed by the balance of 2 principal forces: Yin, representing female, softness, darkness, and coldness; and Yang, representing male, strength, lightness, and heat. An imbalance of Yin and Yang causes illnesses, according to believers. Adherents of Confucianism are taught a civil code of conduct which emphasizes reciprocity, benevolence, filial piety, respect of authority, self-development, and scholarship. Patients believing in naturalism feel that health is the balance and harmony between human body and natural forces, so that changes in the weather or physical conditions can cause physical or mental illnesses. Some South Asians believe in Tridosha in Ayurveda, which asserts the existence of 3 vital forces, Vita (space and air), Pitta (fire and water), and Kapha (water and earth). The basic principles of each of these belief systems can easily affect a patient's understanding of physical symptomology.

Because mental illness is often seen as a character weakness, the disorganized, disruptive, impolite behaviors of a mentally ill patient bring shame to the family. Some Asians feel that shameful flaws are passed on genetically from one generation to another, so that the mental illness of one person will put all siblings and relatives at risk for developing mental problems. These beliefs about heredity will also affect a patient's therapy.

Dr. Du also described several traditional healing methods which patients could be using, such as traditional medicine based on Yin-Yang, Hot-Cold theory, or Ayurveda theory. Patients believing in these particular practices look for special diets and herbs to correct imbalances between the opposing qualities featured by these systems. Other practices of herbal medicine include acupuncture, coining, cupping, moxibustion, meditation, yoga, and qi-gong. Finally, some patients believe that a shamanistic ceremony will help them to find out the causes of illness, and then asking for forgiveness from spirits, chasing evil spirits way, or calling one's soul back will result in a resolution of symptoms. Buddhists believe that prayer or charity works to resolve bad karma.

Dr. Du went on to say that to get Asian Americans into treatment the therapist must understand the barriers to diagnosis and the origins of the stigma of mental illness. One barrier to diagnosis is the insidious onset and incremental progressive nature of mental illnesses compared with physical illnesses, which make it hard to identify. A second barrier is the "conspiracy of silence" in the family and the lack of knowledge of mental illnesses. The final barrier is structural and includes the lack of access to care due to language differences, cultural sensitivity training of mental health personnel, and cultural-oriented services.

The DSM-IV-TR Cultural Formulation

To address the issue of stigma, Dr. Du suggested using the DSM IV-TR Cultural Formulation,[6] which focuses on the patient's cultural identity, cultural explanation of the individual's illness, including the predominant idioms of distress, any local illness category used to identify the condition, perceived causes or explanatory modules to explain the illness, and, finally, any preferences or experiences with professional or popular sources of care. The DSM-IV-TR Cultural Formulation also includes the cultural factors related to psychosocial environment and levels of functioning, cultural elements of the relationship between the individual and the therapist and the overall cultural assessment for diagnosis and care (Table 3).[6]

Table 3. The DSM-IV-TR Outline for Cultural Formulation[6]

A. Cultural identity of the individual
B. Cultural explanations of the individual's illness
C. Cultural factors related to psychosocial environment and functioning
D. Cultural elements of the relationship between the individual and the clinician
E. Overall cultural assessment for diagnosis and care

Dr. Du presented 3 approaches for overcoming the stigma of mental illness: the biological, the psychological, and the social. For the biological, physiologic explanations of mental illness help to dispel guilt and shame. Psychopharmacologic education is critical for compliance, which includes the proper dosage of the medication, time duration for maximal effectiveness, and side effects. Culturally appropriate use of psychotropic medication involves starting with low dosages and being vigilant for side effects. The psychological approach involves the application of the DSM IV-TR Cultural Formulation in assessment, including the use of the patient's explanatory model to understand and engage clients, as well as the incorporation of traditional beliefs in explanation and psychoeducation. Finally, there must be negotiation to compromise between the patient's belief models and the therapist's clinical models to achieve common treatment goals. The social approach includes the involvement of family supports and spiritual authority or shaman in treatment as allies in therapy and treatment. Sites of worship, such as temples, should be employed as a spiritual therapeutic environment to dispel stigma. Another approach is to combine medical and psychiatric ambulatory services.

Dr. Du concluded with a model for interactions with patients of all cultural backgrounds, called the LEARN model, which uses the word "learn" as an acronym for a technique[7] (Table 4).

Table 4. Guidelines for Health Practitioners -- LEARN[7]

L isten with sympathy and understanding to the patient's perception of the problems
E xplain your perception of the problems
A cknowledge and discuss the differences and similarity
R ecommend treatment
N egotiate agreement

Later, in that same workshop, Dr. Nalini Juthani,[8] Professor of Clinical Psychiatry at the Albert Einstein College of Medicine, talked about patterns of behavior in her second-generation South Asian patients. A family friend usually makes the referral, and the patient is often not willing to see a psychiatrist. Dr. Juthani has the patient call, and then the patient comes with the family group to identify the family leader. Dr. Juthani sees the patient alone first, then together with the group. The evaluation usually takes hours, and since she could not bill for the entire time, she adapted by charging by the hour. Since family members each wanted their 5 minutes, they would have to pay for the privilege. The therapist is seen more as a guru or expert, rather than a consultant. Dr. Juthani stressed that agreement to meet with a therapist does not mean adherence to treatment recommendations; only adherence means acceptance of treatment. There is strong pressure from parents for the patient to go to temple, for example, rather than to accept therapeutic treatment. In addition, parents often will not allow their children, who are often the patient, to speak for themselves.

Finally, Dr. Michele Riba,[9] Professor of Psychiatry at the University of Michigan, spoke of the importance of doing a full organic work-up on patients with unexplainable symptoms. She recalled a case of a young monolingual Vietnamese patient who talked to himself and responded to internal stimuli. A consultation with the neurology department revealed an unresectable meningioma. This case was a cautionary tale in being careful not to neglect an organic work-up in a culturally different patient. She described a good cultural history as detective work, and stated that we need to acknowledge our biases and engagement with the patient with compassion. Dr. Riba suggested that clinicians need to connect with the patient's humanness, suffering, and symptoms. She acknowledged that DSM-IV-TR is an oversimplification and encouraged psychiatrists to go beyond its limitations.

In a symposium on ethnopsychopharmacology, Dr. Albert Yeung,[10] Assistant Professor at Harvard, spoke on how depression is seen differently in Chinese Americans, and he suggested ways of approaching the diagnosis and treatment of depression in this population. He and Dr. Du agree that the stigma of mental illness is a major barrier to an Asian American's acceptance of psychiatric help, and he recommended the use of Arthur Kleinman's 8 questions[11] (Table 5) to elaborate part B of the DSM-IV-TR Cultural Formulation, followed by a careful disclosure of the patient's psychiatric disorder, and then negotiation with the patient to reduce the stigma of mental illness. Kleinman's questions help us to see the illness from the patient's point of view, and elaborates its name, cause, timing, effects, severity, fears, how it affects the patient, and what treatment that they expect. The manner in which the illness is disclosed is crucial to the patient's acceptance of the diagnosis. As clinicians, we need to clarify the meanings of our diagnostic labels to clients, and try to state them in terms of the patient's illness beliefs. Negotiation of treatment involves describing a rationale for the use of medications and a careful discussion of side effects. It is important to help clients state their resistance to taking medications and show them their options. Clinicians also need to explain the importance of the proper dose and to convey hope and optimism. Dr. Yeung's approach is applicable to other minority groups as well (Tables 5-7).

Table 5. Arthur Kleinman's 8 Questions[10,11]

1. What do you call your problem?
2. What has caused it?
3. Why do you think it started when it did?
4. What does it do to you?
5. How severe is it?
6. What do you fear most about it?
7. What are the chief problems it has caused you?
8. What kind of treatment do you think you should receive?

Table 6. Disclosure of Psychiatric Disorders[10]

Clarify meanings of diagnostic labels
Elicit patient's illness beliefs
Acceptance of multiple explanatory models
Flexibility of terminology
Staging of disclosure

Table 7. Customized Approach in Treatment Negotiation[10]

Provide rationale for use of medication
Disclose side effects and offer reassurance
Elicit patient's resistance to medications
Discuss alternative treatment options
Negotiate to reach consensus on treatment
Explain importance of taking prescribed dose
Convey hope and optimism

Cultural Considerations for Hispanic Patients

David Mischoulon, MD, PhD,[12] Assistant Clinical Professor of Psychiatry at Harvard spoke of how best to approach Hispanic patients, and described cultural factors that affect assessment and treatment, including language, family dynamics, and health beliefs. He also emphasized the importance of having an interpreter trained in mental health who is familiar with the patient's cultural background to ensure proper interpretation. He stated that Hispanic patients tend to reject the notion of mental illness, and see depression as a sign of weakness or madness. Like Asian clients, they tend to somatize, and show a preference for native healers, such as spiritual healers (espriritistas, curanderos, folk healers). A spiritist would diagnose a specific problem, align with the patient, try to identify ego strengths, and access good protective spirits. Curanderos may use specific medicines and recipes to relieve symptoms.

Hispanic patients also have different expectations of the clinician from their Western counterparts; they feel that the clinician should behave in a more familiar manner (personalismo) with the patient and family, particularly once trust (confianza) has been established. In addition, the patient's sense of time is different, resulting in the patient being late or early for appointments. There are also cultural values and gender roles that will affect the patient-clinician dyad. Hispanic patients commonly feel that whatever will happen is predetermined, and in the hands of a higher entity (si dios quire, what God wants; or que sera sera, what will be, will be). Men are familiar with machismo, or the expectation that men are strong and loving providers for their families. Women would be familiar with marianismo, the belief that women are spiritually superior to men, and defer their own need for the children and family. Thus, they are idealized and known for their self-denial, which may result in depression. As seen in Asian patients, the family is the primary source of support, and for the treatment to succeed, the family needs to be involved as part of the treatment team.

Dr. Mischoulon also spoke of Hispanic culture-bound syndromes (Table 8), such as ataque de nervios, which is an episode of shouting uncontrollably and fainting; nervios, an instability of mood; and susto, or soul loss. Psychotic symptoms present differently in Hispanic patients compared with other populations, and may include an odd visual or auditory hallucination. Finally, Dr. Mischoulon talked about ethnopsychopharmacology and how to use the available data in a clinical situation. Most of the data involves cytochrome p450 and genetic polymorphisms (such as seen in 1A2, 3A4. 2D6 variants), interacting with environmental factors, that result in different rates of metabolism of psychotropic medications. These medications include tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine reuptake inhibitors, and antipsychotics. There are 4 groups of metabolizers: (1) the poor metabolizers (PM), which are seen in 2% to 10% of Hispanics and less than 1% of Asians; (2) the slow metabolizers, of which there are several varieties, including the J mutation which is seen in 47% to 70% of Asians, 23% in whites, and 11.6% in Spaniards, and the Z mutation which is seen in 40% of African blacks, but in only 15% to 26% of African Americans; (3) the intermediate to extensive metabolizers which are found in Mexican Hispanics with the J+L mutation; and (4) the superextensive metabolizers (SEM) , which have the L mutation seen in 7% of Spaniards; 19% of Saudis, and 29% of Ethiopians. Thus, what we see are slow metabolizers in Caribbean Hispanics because of the J+Z mutation, and intermediate to extensive metabolizers in Mexican Hispanics with the J+L mutation. The enzyme 1A2 metabolizes TCAs, SSRIs, neuroleptics and 3A4, a major metabolic enzyme that metabolizes most types of antidepressants, benzodiazepines, mood stabilizers, and neuroleptics. The clinician should also attend to dietary considerations, since elements in particular foods may interact with metabolizers. For example, 1A2 activity is increased by cyclic aromatic hydrocarbons (smoking, grilled meat) and indoles (cabbage, brussels sprouts), whereas activity in 3A4 is decreased by corn (flavonoids) and grapefruit (narangin). In addition, drug effects can be altered by other drugs. For example, SSRIs may increase TCAD levels via competition for 2D6, EM may convert to PM by competitive inhibition, protease inhibitors may inhibit cytochrome p450 enzymes, while rifampin may induce them. Dr. Mischoulon concluded by asserting that although ethnopsychopharmacology is important, clinicians should have a holistic strategy that includes supportive psychotherapy, including engagement of alternative healers chosen by the patient, which shows respect for other treatment approaches and validates the patient's cultural beliefs. The patient needs to feel comfortable discussing treatment and concerns. These principles could be applied to other minority patients as well.

Table 8. Hispanic-Specific Syndromes[12]

Ataque de nervios (attack of nerves)
Similar to panic attack but often exhibiting more violent behavior, and may occur without fear or apprehension, often precipitated by an upsetting event
Shouting uncontrollably, trembling, palpitations, heat in chest rising to head, fainting, seizure-like episodes
Two thirds may have depressive or anxiety disorder
Generally treated symptomatically; no solid data on optimal treatment
Nervios (nerves)
More generalized state compared with ataque
Analogous with GAD
Emotional upset, somatic distress, social isolation, restlessness, feeling out of control, mood/affective instability
External stressors are a major factor
Susto (fright)
A sudden fright or trauma, causing the soul or spirit to leave the body, making one vulnerable to various ills
Anxiety, irritability, anorexia, insomnia, trembling, sweating, tachycardia, diarrhea, depression, vomiting
Spiritists may be very helpful here
Atypical psychotic symptoms
Psychotic symptoms described by Hispanic patients often present differently from those seen in other populations
May include atypical auditory and visual hallucinations in the context of an otherwise unremarkable mental status exam
Symptoms include a knocking at door, doorbell ringing, shadows, spots, children's voices calling name
Seldom part of chief complaint


In a workshop on ethnicity and psychopharmacology, William Lawson, MD, PhD, Professor and Chair of Psychiatry at Howard University, spoke about how ethnicity affects treatment choices.[13] Recent reports have shown that ethnic disparities exist in the illness burden of many mental disorders. These disparities are due in large part to disparities in the availability and appropriate use of treatment. African Americans with psychosis often receive excessive treatment. They are at risk for receiving more medications, higher doses of those medications, greater use of antipsychotics irrespective of diagnosis, and less use of antidepressants. This prescribing pattern often occurs despite pharmacokinetic data that indicate that doses should be lower. African Americans often do not receive newer agents. When they are prescribed, they are often combined with older agents, thereby defeating the pharmacologic benefit. Attitudinal factors and stereotypical beliefs are often the reasons for the inappropriate treatment. Emerging metabolic risks of the newer antipsychotics have complicated treatment decisions, but ethnic differences in the risk of some side effects may be overcome by combination therapy. Nevertheless, the lack of minority participation in research and the limited research on complex pharmacotherapy leaves little guidance for someone treating an inner-city population.

In a symposium on ethnopsychopharmacology, Dr. David Henderson,[14] Assistant Professor of Psychiatry at Harvard, spoke about the ethnopsychopharmacologic approach (Table 9) which involves a culturally sensitive assessment, appropriate choice of medications, and careful monitoring. He also suggested the use of the DSM-IV-TR Cultural Formulation for Diagnosis with a careful elicitation of beliefs, expectations, history of help-seeking, nature of the support system, and the use of "alternative" treatment and healing methods. When choosing a medication, the medical history, concurrent medications, diet, and food supplements/herbs all must be taken into account. In addition, to ensure adherence, the patient and patient's family must be involved in treatment decisions. Finally, the patient must be monitored carefully. The physician should proceed slowly, starting with low doses, and increasing gradually. Again, the involvement of family is crucial for compliance with treatment. If side effects become intolerable, the clinician should lower dosages, or choose a drug metabolized through a different route. If there is no response-check compliance, raise dose and monitor levels, add inhibitors, switch drug, or choose an augmentation strategy. He also talked about the nonbiologic factors in treatment, such as misdiagnosis, patient's mistrust of the mental health care system, poor communication between patients and physicians, and the patient's use of traditional and alternative healing methods.

Table 9. An Ethnopsychopharmacologic Approach[14]

Cultural formulation for diagnosis: Careful elicitation of beliefs, expectations, history of help-seeking, nature of the support system, use of "alternative" treatment and healing methods
Choice of Medication
Medical history, concurrent medications, diet, and food supplements/herbs
Involve patient and family in treatment decisions
Monitor Patient
Proceed slowly, involve family
If side effects intolerable: lower dosages, or chose drug metabolized through different route

If no response: check compliance, raise dose and monitor levels, add inhibitors, switch drug, augmentation

Religion in Clinical Practice

In a workshop on improving diagnostic and therapeutic skills, Dr. Francis Sanchez[15] spoke about clinical approaches for Filipino-American patients. He talked about how religion is a significant factor, and how many have a fatalistic and passive attitude towards life. The orientation is group-focused, as opposed to the Western view, which is individually focused. As in other ethnic minority groups, relationships with the family are crucial to engaging patients in treatment. Evaluations will therefore take longer than with other clients.

Two related Issue Workshops focused on the methods of religious and spiritual assessment in clinical practice. Francis Lu, MD,[16] Professor of Clinical Psychiatry at UCSF, discussed how the DSM-IV TR Outline for Cultural Formulation provides a concise clinical method of cultural assessment, including religious and spiritual issues. First, the clinician needs to understand the person's cultural identity, incorporating many cultural variables including one's religious and spiritual experiences, worldviews, and values. Secondly, the clinician should determine the idioms of distress, explanatory models, and treatment pathways related to the person's cultural identity. Third, the clinician determines the cultural stressors and supports including religious and spiritual ones in the person's life. The work of Ken Pargament, PhD,[17] demonstrates the critical importance of understanding to what extent the person uses positive or negative religious coping styles (eg, "God is forgiving and benevolent" vs "God is punishing me for my sins"), which affect morbidity and mortality. Fourth, clinicians should assess the cultural elements of their relationship with patients by (1) understanding their own cultural identity including their own religious/spiritual beliefs, (2) comparing their cultural identity with that of the patient, and (3) continually assessing how similarities and differences affect rapport, communication, the therapeutic alliance, as well as transference and countertransference. Finally, clinicians should use this information to help with the differential diagnosis and treatment planning. For example, the diagnostic category of "Religious and Spiritual Problem" in the section entitled "Other Conditions That May Be a Focus of Clinical Attention" provides a nonpathological category for distressing experiences including those involving a loss of faith in God. DSM-IV TR instructs us that diagnoses in this section are to be coded on Axis I and that concurrent diagnosis including mental disorders are possible. Treatment planning should then address the issues related to this diagnosis.

Allan M. Josephson, MD, Professor of Psychiatry, University of Louisville, and John R. Peteet, MD, Associate Professor of Psychiatry, Harvard Medical School, presented on the importance of assessing the patient's world view based on their recent book, Handbook of Spirituality and Worldview in Clinical Practice.[18,19] Worldview cognitively helps an individually determine what choices in life are morally correct and provide meaning to life; worldview is directly related to religious perspectives and indirectly related to spirituality. A useful screening tool for worldview in the initial interview is entitled FICA, an acronym which represents elements for assessment (Table 10). Further assessment of worldview may reveal existential and spiritual concerns that affect onset of clinical symptoms, functioning, and outcomes. These existential and spiritual concerns include identity, hope, meaning/purpose, morality, and autonomy/authority. The clinician, depending on the level of expertise with such issues, has 4 possible approaches to patient's concerns involving these worldview issues: (1) Acknowledge the problem, but limit discussion to its psychological dimension; (2) clarify the worldview as well as the psychological aspects of the problem, suggesting resources for dealing with the former, and considering working with an outside resource such as clergy; (3) address the problem using the patient's own philosophy of life; or (4) address the problem using a shared perspective on life. The clinician must be aware of and be able to manage transference and countertransference, as well as the boundary and informed-consent issues that arise in meeting patient needs in this area.

Table 10. FICA Model[18]

Faith and religious/spiritual beliefs
Involvement in the practices associated with a faith or beliefs
Community of support related to a faith or beliefs
Address how these beliefs, practices, and community are to be integrated in health and mental health care

In conclusion, the 158th Annual American Psychiatric Association Meeting was rich in sessions featuring cultural issues. The selected presentations show how we can use the DSM-IV-TR Cultural Formulation, the LEARN model, the FICA model, and Arthur Kleinman's 8 questions to assess and engage patients in a dialogue leading to a compromise between their health beliefs and our treatment recommendations. In addition, we need to be aware of particular issues for Asian, Hispanic, and African-American patients, such as health beliefs, illness models, and diagnostic biases, to diagnose and treat them properly. Finally, we know that different ethnic groups metabolize drugs differently, and that extrinsic factors such as diet and smoking can affect the blood levels of psychotropic medications; the best practice is to start with lower doses and increase cautiously, watching for side effects.


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  4. Gill M. Somatization and stigma in Asians: cultural challenges in practice. Program and abstracts of the American Psychiatric Association 2005 Annual Meeting; May 21-26, 2005; Atlanta, Georgia. Component Workshop 11.
  5. Du N. Somatization and stigma in Asians: cultural challenges in practice. Program and abstracts of the American Psychiatric Association 2005 Annual Meeting; May 21-26, 2005; Atlanta, Georgia. Component Workshop 11.
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