Cultural psychiatry and psychopharmacology.
Article Type: Report
Subject: Mental illness (Care and treatment)
Mental illness (Risk factors)
Mental illness (Demographic aspects)
Ethnic groups (Psychological aspects)
Psychopharmacology (Usage)
Authors: Bhagar, Harpriya "Sonya" A.
Mensah, Jason
Pub Date: 06/22/2009
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2009 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Summer, 2009 Source Volume: 12 Source Issue: 2
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 218313993
Full Text: ABSTRACT

America is undergoing rapid changes in the ethnic demographics of its constituents, with reports stating that by 2050, ethnic minorities will make up more than 50 percent of the population (US Census Bureau 2008). Current statistics report that over one in four Americans will suffer from a mental disorder in any given year (NIMH 2009). The effect of this necessitates that cultural competence in relating to patient care must now become a mandate for health care workers, especially those that work in mental health fields. Approaching the challenge in achieving the goal of relating to diverse ethnic groups is by nature multidisciplinary and complex. One o(the issues arising in the implementation of cultural psychiatry is the pharmacotherapy of psychiatric illnesses.

**********

[ILLUSTRATION OMITTED]

America is undergoing rapid changes in the ethnic demographics of its constituents, with reports stating that by 2050, ethnic minorities will make up more than 50 percent of the population (U.S. Census Bureau, 2008). Current statistics report that over one in four Americans will suffer from a mental disorder in any given year (NIMH, 2009). The effect of this necessitates that cultural competence in relating to patient care must now become a mandate for health care workers, especially those that work in mental health fields. Approaching the challenge in achieving the goal of relating to diverse ethnic groups is by nature multidisciplinary and complex. One of the issues arising in the implementation of cultural psychiatry is the pharmacotherapy of psychiatric illnesses.

Prior to making pharmacological treatment decisions, proper assessment and diagnosis is necessary. A tool pertinent for formulating appropriate psychiatric diagnoses for members of diverse ethnic groups is the "Outline for Cultural Formulation" in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR). The outline consists of five domains: 1) cultural identity of the individual, 2) cultural explanation of the individual's illness, 3) cultural factors related to psychosocial environment and levels of functioning, 4) cultural elements of the relationship between the individual and the clinician, and 5) the overall cultural assessment for diagnosis and care (DSM-IV-TR, 2000). A more in-depth discussion regarding the use of Cultural Formulation is beyond the scope of this article. The Clinical Manual of Cultural Psychiatry by Dr. Russell Lim is an excellent resource for interested readers.

Ethnic variations in psychiatric symptomatology are aspects of cross-cultural assessment of which one should be aware. A common difference is that non-Western patients tend to report more somatic symptoms than emotional and psychological pain (Mumford, 1995). Some strategies in addressing this issue are to inquire from the patient the meaning of the somatic symptoms and to discuss stressors such as work, familial relations, and challenges adapting to a new environment/culture. In addition, gathering information from family and friends close to the patient regarding the patient's behavior at baseline and any recent changes from baseline (Purnell, 2008). Emphasis on appropriate diagnosis is of paramount importance due to the danger of ineffectual or possible toxic consequences of misdiagnosis when treating with psychotropic medication.

Ethnopsychopharmacology--psychopharmacology among diverse ethnic groups--has shown that the effects of psychotropic medication vary in their metabolism among ethnic groups. The majority of psychotropic medications are metabolized by the cytochrome P450 (CYP450) enzymes. Among these enzymes are multiple variations, some of which have been identified and cloned (Lim, 2006). Based upon genetic features of their CYP450 enzymes, patients can be grouped into one of four groups: poor metabolizers (PM), intermediate metabolizers (IM), extensive metabolizers (EM), and ultra rapid metabolizers (UM) (Lin, Smith, & Ortiz, 2001). Features of PMs and IMs can lead to higher than normally expected drug levels, and often patients in these classes can show a therapeutic response with smaller than normal doses or develop severe side effects due to being over-medicated. Patients that are EMs and UMs tend to vary from having expected to minimal drug levels that correspond with expected to minimal response to medication (Lira, 2006).

Furthermore, other confounding factors that affect metabolism of psychotropics can be differences in diet and the use of alternative healing practices such as herbal medicinals and other lifestyle factors (Pi & Simpson, 2005). Documented dietary habits such as cruciferous vegetables (e.g., cabbage and sprouts) and charbroiled meat (which can produce aromatic hydrocarbons) have shown to influence the activity of CYP450 enzymes (Lin, Smith, & Ortiz, 2001). Of note, some studies have shown differences in the effects of macronutrients such as high-protein versus low-protein diets. Studies suggest slower CYP450 metabolism in patients with low protein diets; however, after adapting more Western dietary habits, their metabolic profiles for these drugs became indistinguishable from those of native Westerners (Lin, Smith, & Ortiz, 2001).

The use of herbal remedies is another factor to address, particularly when at least one-third of current pharmaceuticals are based on herbal remedies (Lim, 2006). Unfortunately, data reporting of herb-drug interactions is scarce. Some herbs can lead to induction or inhibition of metabolizing enzymes ( Lin, Smith, & Ortiz, 2001), which can either diminish therapeutic effects or cause unwanted side effects. A useful source regarding herbal medicinals and possible interactions with psychotropics is the pharmacist-based Web site, www.naturaldatabase.com.

Lifestyle factors need to be considered as well. Some of these can range from ritual substance use--which can serve as the practicing of one's faith--to family]cultural beliefs regarding Western medications. In addressing these issues, it is not only important for clinicians to listen with sensitivity and understanding to develop rapport, but it is also important for clinicians to formulate a treatment plan that is culturally relevant to meet the needs of the patient.

Clinically, once a patient is prescribed psychotropic medications, the monitoring of adherence and side effects can often be challenging. For example, patients can regularly attend appointments and report everything is fine, while in reality they are not taking the medication or are silently suffering from side effects of medications (Thompson, 2005). The reason for this often lies in the difficulties of educating patients regarding the medication. A useful strategy when using psychopharmacologic therapy with patients from diverse backgrounds is to apply the following (Lim, 2006):

* Start at a low dosage and titrate upward slowly

* Inquire about diet and lifestyle factors

* Obtain baseline laboratory studies (complete blood count, complete metabolic panel, lipid profile, thyroid hormone panel, etc.)

* When possible, check plasma levels of medication

* Recruit family to monitor patient for medication adherence and/or side-effects

* Promote education regarding medication and treatment plan

* Use different formulations if necessary (liquid, quick dissolve, or depot)

Overall, the field of ethnopsychopharmacology has made significant progress over the last couple of decades. Yet, further research is necessary to refine psychopharmacologic therapy to meet the unique needs of an increasingly diverse American population.

This article is approved by the following for continuing education credit:. The American Psychotherapy Association provides this continuing education credit for Diplomates.

After studying this article, participants should be better able to do the following:

1. List the ways in which psychiatric symptoms present differently among various ethnocultural groups.

2. List the differences that culture, genetics, and lifestyle play in treatment planning and pharmacologic management of psychiatric disorders.

KEY WORDS: cultural psychiatry, psychopharmacology

TARGET AUDIENCE: physicians

PROGRAM LEVEL: Basic

DISCLOSURE: The author has nothing to disclose.

PREREQUISITES: None

Earn CE Credit

Take CE tests for free online at www. americanpsychotherapy.com or see the questions for this article on page 53.

POST CE TEST QUESTIONS (Answer the following questions after reading the article, pages 51-52)

1. Which section of the DSM IV-TR addresses specific cultural issues in diagnosis?

a) Decision Trees for Differential Diagnosis

b) Highlights of Changes in DSM-IV Text Revision

c) Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes

d) DSM-IV Classification

2. Somatic symptoms of psychiatric disorders are more common in which of the following groups?

a) Westerners

b) Non-Westerners

c) Americans

d) Non-Americans

3. Family involvement is not important in pharmacologic management in psychiatric disorders.

a) True

b) False

4. Which of the following diets have slower CYP450 metabolism?

a) Low protein rich diets

b) High fat diets

c) Protein rich diets

d) None of the above

5. In any given year, what percentage of the American population will suffer from a mental disorder?

a) 50%

b) 12%

c) 5%

d) 25%

6. Which of the following types of metabolizer will have the greatest risk of suffering from medication side effects due to being overmedicated?

a} Extensive metabolizers

b) Ultra rapid metabolizers

c) Poor metabolizers

d) None of the above

7. What is Ethnopsychopharmacology?

a) Psychopharmacology from multiple ethnic groups

b) Psychopharmacology for minorities only

c) herbal medicinal treatments of psychiatric disorders

d) Psychopharmacology among diverse ethnic groups

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.-TR). Washington, DC: American Psychiatric Association.

Lim, R. F. (Ed.). (2006). The assessment of culturally diverse individuals. Clinical Manual of Cultural Psychiatry (pp. 3-31). Arlington, VA: American Psychiatric Publishing Incorporated.

Lin, K. M., Smith, M. W., & Ortiz, V. (2001). Culture and psychopharmacology. Psychiatric Clinics of North America, 24, 523-538.

Mumford, D. B. (1995). Cultural issues in assessment and treatment. Current Opinion in Psychiatry. 8(2), 134-137.

NIMH. (2008). The numbers count." Mental heath disorders in America. Retrieved January 31, 2009, from http://www.nimh.nih.gov/health/publications/ the-numbers-count-mental-disorders-in-america.shtml

Paulanka, P. J., & Purnell, L.D. (Eds.). (2008). Transcultural Health Care: A culturally competent Approach (3rd ed). Philadelphia: EA. Davis Company.

Pi, E. H., & Simpson, G.M. (2005). Cross-cultural psychopharmacology: A current clinical perspective. Psychiatric Services, 56, 31-33.

Thompson, J. W. (2005). Cultural competence in clinical psychopharmacology. Journal of Clinical Psychiatry 66(6), 799.

U.S. Census Bureau. (2008). 2008 National population projections. Retrieved January 31, 2009, from http://www.census.gov/Press-Release/www/releases/ archives/population/012496.html

By Harpriya A. (Sonya) Bhagar, MBBS, and Jason Mensah, DO

Harpriya A. (Sonya) Bhagar, MBBS, is an assistant professor of clinical psychiatry at Indiana University School of Medicine. She can be reached at hbhagar@iupui.edu.

Dr. Jason Mensah is currently a third-year general psychiatry resident at Indiana University. He received his Osteopathic Medical degree from Nova Southeastern College of Osteopathic Medicine. Dr. Mensah's interests are cultural psychiatry and integrative treatments of psychiatric disorders. The author has no disclosures. Dr. Mensah can be contacted at jmensah@iupui.edu.
Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.