Not long ago, David Henderson, M.D., an associate professor of psychiatry at Harvard University, treated a Japanese student from the Massachusetts Institute of Technology (MIT) for depression.
Yet after he gave the student a prescription for an antidepressant, the student did not return for a follow-up visit. Concerned about the student, Henderson contacted the dean at MIT. The reason the student failed to come for the follow-up, it turned out, was that he had decided that he was not very depressed because he had been given only one prescription, not multiple ones, which would have been the case in Japan.
In other words, no matter how much psychiatrists know about cultural differences among patients, there is still more to learn, Henderson indicated in a symposium at APA's 2006 annual meeting in Toronto in May.
“It makes our lives as clinicians challenging, that's for sure,” symposium discussant Gregory Fricchione, M.D., declared. Fricchione is director of the Division of International Psychiatry at Massachusetts General Hospital.
To speed psychiatrists on their journey of learning more about cultural differences among patients, speakers presented some valuable insights gleaned either from their personal experiences or from studies that they had conducted. For example:
Keeping appointments. Patients from a Hispanic background may arrive early or late for appointments because Hispanics sometimes have a different conception of time than many non-Hispanic Americans do, David Mischoulon, M.D., Ph.D., reported. Mischoulon, an assistant professor of psychiatry at Harvard University, is originally from Argentina.
Depression. When depressed Chinese-American patients visit clinicians, they tend to talk about physical symptoms, not their depression, Albert yeung, M.D., Sc.D., an assistant professor of psychiatry at Harvard University, noted. The reason, he said, is that they do not seem to realize what the illness of depression is, but if you ask them directly whether they are sad, they will acknowledge it.
Culture-bound syndromes. Indian men sometimes believe that they are losing semen in urine, but actually they are anxious and depressed, said Rajesh Parikh, M.D. Parikh is a consultant neuropsychiatrist at the Jaslok Hospital and Research Center in Bombay. Hispanic patients sometimes experience an “attack of nerves,” Mischoulon noted. It is similar to a panic attack, but often involves fainting or shouting. Some two-thirds of individuals who experience this syndrome are anxious or depressed, studies have shown.
Psychotic symptoms. Psychotic symptoms expressed by Hispanic patients may differ from those often seen in Americans patients of other ethnic backgrounds, Mischoulon said. For example, their auditory hallucinations may consist of hearing a knocking at the door, a doorbell ringing, or children's voices calling one's name. visual hallucinations might consist of “black” thoughts flying across one's vision.
The symposium speakers also suggested ways of deploying patients' cultural beliefs and expectations to bolster the therapeutic process. Among them:
Involving the family. With patients from India, it is crucial to involve family members in treatment, Parikh asserted, because family in their culture is very important. The same is the case with Hispanic patients, Mischoulon stressed. Also, bringing in family members can give a clinician more perspective on a patient's issues, he said.
Relaxing boundaries. Many Hispanic patients expect clinicians to divulge a lot of personal information about themselves, which American psychiatrists usually do not do, said Mischoulon. Thus, providing a little personal information might further therapy with Hispanic patients.
Countering fatalistic beliefs. When Hispanic patients resist treatment because they hold fatalistic beliefs such as “the good Lord willing” or “Que sera, sera” (what will be, will be), Mischoulon might admonish them to “do the necessary leg-work to help God.”
Enlisting native healers. For some Hispanic patients, for example, it may help to enlist the assistance of traditional healers, Mischoulon asserted. The reason is that patients may respect the psychiatrist for being open to their ways.
These “practical tips for harnessing an individual's cultural beliefs, support systems, et cetera, toward treatment” were some of the symposium highlights, co-chair Shamsah Sonawalla, M.D., an assistant professor of psychiatry at Harvard University, told Psychiatric News.
“The most impressive notion [of the symposium],” Fricchione believes, “was that modern psychiatry in the United States must become more sophisticated in its evaluation and management of diverse populations that increasingly seek treatment in our centers. This is because, while there are certainly psychiatric conditions that all groups share, with common symptom clusters and treatment responses, there are also important differences that will impact on patient access, compliance, and response to treatment.” ▪
Shamsah Sonawalla M.D., chaired the symposium on ethnic and cultural aspects of mood and anxiety disorders.