Never before in the history of the United States have culture, race, and ethnicity been so relevant. The steady increase in the immigration process toward the United States that has occurred since World War II has been a major factor in this regard. However, the main factor during the past decade has been the exceptional population growth of the ethnic minority groups who reside in this country.
Between 1990 and 2000. the US Census1 depicted that Hispanic Americans sustained a 58% growth rate. Asian Americans and Pacific Islanders a 50% growth rate. Native Americans a 17% growth rate, and African Americans a 16% growth rate. In comparison, the Caucasian population has grown at a rate of only 3%. Currently. 12.5% of the US population, or 35.3 million people, are Hispanic; 12. 1% (33.9 million) are African American (black); 3.7% (10.5 million) arc Asian or Pacific Islander; and 0.7% (2.1 million) are Native American.
In other words, the United States has already become a pluralistic and multiethnic society, which has permeated all aspects of life and society, including medicine and psychiatry. In this context, cross-cultural psychiatry has witnessed, from a clinical and scientific point of view, an unusual steady growth during the past 2 to 3 decades.2,3
In this article, the most relevant psychiatric aspects within the context of culture, race, and ethnicity are addressed. Emphasis is also given to the most salient and relevant clinical psychiatric issues pertaining to cross-cultural psychiatry. Additionally, the link between theoretical models and evidence-based clinical applications is emphasized. The objective is to offer psychiatric practitioners an up-to-date review of what is relevant in their daily clinical practices with respect to the psychiatric aspects of culture, race, and ethnicity.
UNDERSTANDING CULTURE, RACE, AND ETHNICITY
Busy psychiatric practitioners do not know well how to differentiate between culture, race, and ethnicity. In this context, they frequently tend to exchange these terms when assessing, diagnosing, and treating psychiatric patients, especially among patients from different minority backgrounds. This situation becomes even more relevant when psychiatric practitioners and patients are from different cultural, racial, and ethnic backgrounds. It is therefore important to clearly understand the definition, conceptualization, and clinical meaning of each of these fnree terms.
Culture is defined as a set of meanings, values, everyday practices, behavioral norms, and beliefs used by members of a particular group in society as a way of conceptualizing their unique views of the world, as well as when interacting with their environments. In this context, culture encompasses language, nonverbal expressions, social relationships, manifestations of emotions, religious beliefs and practices, and socioeconomic ideologies. Additionally, culture, in this realm, is not perceived as static but rather as constantly changing and adapting from generation to generation.4-6
Race is a concept under which human beings historically and traditionally chose to group themselves. This decision was primarily based on their common physiognomy. In this context, physical, biological, and genetic connotations are fully integrated in the definition.4, Although the validity of this definition has occasionally been questioned, its conceptualization has remained quite strong throughout the world.7
Ethnicity is defined as a subjective sense of belonging to a given group of people who share a common origin as well as a common matrix of cultural beliefs and practices. In this context, ethnicity becomes an integral component of one's sense of identity; therefore, it is an important source of clinical and psychosocial manifestations related to the individual's self-image and. thus, to each person's intrapsychic life.4,5
The Meaning of Identity
Central to the clinical understanding of psychiatric patients from a cultural point of view, and also taking into consideration race and ethnicity, the clear conceptualization of identity is of paramount relevance. Additionally, the conceptualization of the "cultural formulation" as delineated in the Diagnostic and Statistical Manual of Mental Health Disorders, fourth edition (DSM-IV)* fully relies on the clear understanding of identity. In this context, the patient's ethnic and cultural backgrounds must be fully taken into consideration when assessing, diagnosing, and treating psychiatric patients - or any patients, for that matter.
In this regard, DSM-IV offers an excellent outline to be understood and followed by psychiatric practitioners.
Cultural identity of the patient. Attention to the patient's ethnic and cultural background is very important, and, in the case of immigrants or ethnic minorities, the degree of their involvement with both the culture of origin and the host (majority) culture is also very relevant.
Cultural explanations of the patient's illness. In this respect, specific idioms of distress or ways of manifesting symptoms need to be noted. Examples of these may include religious explanations of the potential etiology of the illness, specific and unique somatic manifestations, or culture-bound syndromes.
Cultural factors related to psychosocial environment and levels of functioning. In this regard, the cultural manifestations or interpretations of stressors, as well as available network systems of support, must be addressed.
Cultural elements of the relationship between the patient and the psychiatric practitioner. For example, differences in cultural and social status between the patient and the clinician need to be noted. Specific attention to the potential effect of these differences on the diagnosis made and the treatment selected is also crucial in this regard. Likewise, language differences or differences in the patterns of communication are also relevant and thus need to be addressed. Attention to the existence of potential cultural scotomas and overidentification or rejection of patients on the part of the clinician are also essential.
Overall cultural assessment for diagnosis and care. This implies that the cultural formulation will require a thoughtful discussion as to how the different cultural, racial, and ethnic considerations will specifically influence the diagnoses and treatment plans for each patient. Examples include the assessment of potential transferential and countertransferential situations to be expected and how they should be addressed, as well as the potential barriers related to the lack of cultural competence on the part of the psychiatric practitioners, and how these barriers should be dealt with and resolved.
Fortunately, today's busy psychiatric practitioners have good resources in the medical literature to address key issues such as the understanding of ethnic identity among patients, issues pertaining to racial identity, applications of culturally sensitive psychotherapy approaches, empirical issues pertaining to psychodynamic processes within the context of culture, transference and countertransference situations within the context of cross-cultural psychiatry, and other clinically relevant topics.3,9,10
Central to the subject of idioms of distress is the understanding of the unique manifestations of symptoms or clusters of symptoms among different cultural, racial, and ethnic groups. In this context, two culturally-related terminologies, ernie and etic, need to be understood and recognized. Both of them are at the core of the understanding of culture-bound syndromes.
As used in cross-cultural psychiatry, ernie denotes a conceptually narrow view, by persons of a given ethnic, racial or cultural group, of a phenomenon that occurs within the boundaries of that group.4 For example, a given symptom such as hallucinatory experiences may be explained by cultural, racial, or ethnic groups as caused by religious factors. This is the case among some Puerto Ricans who are followers of the Pentecostal religion. Ignoring the role of ernie factors in the clinical setting might result in noncompliance with treatment, inability to develop the therapeutic alliance, and even the rejection of services.11,12
The term etic denotes a traditional and universal approach to the conceptualization, understanding, and perception of symptom manifestation.4 At times, however, it is quite difficult to explain a given clinical phenomena as being ernie or etic, particularly when addressing clinical manifestations that occur in a given cultural, racial, or ethnic group when the clinicians are from a different cultural, racial, or ethnic origin. For the benefit of the psychiatric practitioners, a few examples of culture-based syndromes may be useful, particularly those that are frequently observed among ethnic minority groups who reside in the United States.
Epidemiologically, this culturebound syndrome is observed among African American populations from the Southern part of the United Stales and the Caribbean, including the US Virgin Islands and Puerto Rico.13 Etiopathologically, this syndrome is viewed as a response to a traumatic event, fear of what may happen, or rook work. Symptomatologically, this syndrome is manifested by a seizure-like affliction or sudden collapse, sometimes proceeded by dizziness or "swimming" in the head. While the eyes of the person who suffers from this syndrome are opened, the person claims that he or she cannot see anything. During the presence of the syndrome, the person is unable to move but can hear and is aware of his or her environment.
Pharmacologic Agents Metabolized in the Cytochrome P450 (CYP) System15
Differentially, posttraumatic stress disorder, anxiety disorders, somatoform disorders, dissociative disorders, malingering, epilepsy, and narcolepsy should be taken into consideration. Therapeutically, praying, herbal baths, herbal cleansing, and other types of folk healing practices have shown beneficial results.13
'Ataque de Nervios' (Puerto Rican Syndrome)
Epidemiologically, this syndrome has been observed among those of Puerto Rican descent, both from Puerto Rico and from the US mainland, as well as those of Dominican and Cuban decent.14 It is more frequently observed among women than men, particularly women older than 40. Etiopathologically, it is felt to be due to aggressive and Iibidal conflicts. Sy mptomatologically, it is manifested by seizure-like movements without loss of sphincter control, trembling, semiconscious states, stupor, feelings of loosing control, shouting and crying, combative behavior, and dizziness.
Differentially, epilepsy, panic attacks, anxiety disorders, amnestic disorders, somatoform disorders, and depressive disorders should be taken into consideration. Therapeutically, emotional support, understanding, counseling, supportive psychotherapy, and folk healing practices have been shown to be beneficial.14
Evil Eye ('Mal de Ojo')
Epidemiologically, this syndrome commonly has been observed among US groups that originate from the Mediterranean basin, including those of Italian, Greek, or Spanish descent.14 Children, adolescents, and women are more frequently vulnerable to this syndrome. Etiopatologically, it is fell this syndrome is due to intense looks at the person who develops the syndrome; beauty or ugliness are felt to be associated with these intense looks. Women and strangers are usually blamed for the intense looks. Symptomatologically, persons who suffer from this syndrome complaint of headaches, fitful sleep, weeping, fever, coughing, vomiting, and diarrhea.
Differentially, somatoform disorders and organ i c -related conditions should be considered. Therapeutically, mixing water and one hen's egg and placing the mixture at the end of the bed where the patient sleeps has been shown to be beneficial.14
Piblokto (Arctic Hysteria)
Epidemiologically, this syndrome commonly is found among Native Americans from the Arctic region, particularly among women.13 Etiopathologically, this syndrome is felt to be caused by psychological stress. Symptomatologically, this syndrome is manifested by tremors, anxiety, crying spells, screaming, tearing of clothes, imitation of animal screaming, running into snow or water, depression, and suicidal or homicidal tendencies. The episode usually lasts about 1 to 2 hours and is followed by amnesia about the event.
Differentially, brief psychotic disorder, dissociative disorders, conversion disorder, anxiety disorders, and depressive disorders should be taken into consideration. Therapeutically, seclusion, restraint, psychopharmacotherapy, hospitalization, and psychotherapy have been found to be beneficial, depending on the severity of the cases.13
Epidemiologically, this syndrome is observed among Japanese populations and those of Japanese descent.13 Adolescents who are shy and overprotected are found to be more vulnerable for this syndrome. Etiopathologically, it is felt that excessive concentration or attention provokes this syndrome. Symptomatologically, those affected manifest fear of meeting another person's eyes, fear of not being perfect enough, and fear of fainting: they also experience palpitations, show anxiety, and fear flushing (erythrophobia) or having unpleasant odors when meeting people.
Differentially, anxiety disorders need to be considered. Therapeutically, "Mori ta" therapy has proven to be beneficial in persons suffering from this syndrome. "Morita" therapy consists of helping patients to liberate themselves from self-preoccupation and over-intellectualization, thus helping patients to accept things as they are.13
CULTURE, RACE, ETHNICITY, AND PSYCHOPHARMACOLOGY
Culture, race, and ethnicity may affect psychopharmacologic agents in many ways. A number of factors may have a direct or indirect effect on the psychopharmacologic treaünent of psychiatric disorders and conditions, and of non-psychiatric illnesses and conditions as well.15 These factors may include age-related behavior, sex-related behavior, personality characteristics, diet, adherence to treatment, placebo effect, exercise, use of herbal-related remedies, disease perception and treatment, and use of social support systems, as well as use and abuse of caffeine, nicotine, alcohol and drugs.
During the past 2 to 3 decades, the research efforts and advances in the area of psychopharmacology in relation to culture, race, and ethnicity have been both pioneering and highly successful. These research efforts and advances have focused primarily on three major research areas: pharmacogenetics, pharmacokinetics, and pharmacodynamics. However, nonbiologic factors have been the focus of research as well.15
Ethnic Variations in CYP Metabolization15
Ethnic Variations in Medication Doses and Side Effects (Compared with Caucasians in the United States)15
Pharmacogenetic research efforts focus on the genetic and environmental factors that control and influence the functions of drug-metabolizing enzymes. For example, the genetic polymorphism of the cytochrome P450 (CYP) system has demonstrated that some individuals are poor metabolizers, while others are extensive metabolizers.15 In this respect, certain ethnic groups, such as US immigrants from East Asian countries (eg, China. Korea), lack the enzyme aldehyde dehydrogenase (ALDH). This results in accumulation of acetaldehyde in the body, thus leading to facial flushing when drinking alcohol. Many Native Americans also lack this enzyme.15
Pharmacokinetic research efforts focus on the fate and distribution of drugs in the body. These processes have a direct effect on the absorption, distribution, metabolization and biotransformation, and excretion of psychopharmacologic agents.15 Pharmacodynamic research efforts focus on how psychopharmacologic agents affect the body, usually by interacting with receptors that bind with endogenous and exogenous substances.1 3
Psychopharmacologic agents that are metabolized by the CYP system are shown in Sidebar I (see page 529), and ethnic variations in CYP metabolization are shown in Sidebar 2.15
Although more research needs to be done, research efforts to date demonstrate multiple ethnic variations in dosing and side effects from different medications when compared with Caucasian populations in the United States.15 These differences are outlined in Sidebar 3. Additional research is welcome in this important area for the field.
RACIAL AND ETHNIC DISPARITIES
Recently, the US Surgeon General made public a supplemental report titled "Mental Health: Culture. Race, and Ethnicity."16 This report highlights a series of clinical and programmatic findings that have major connotations for the mental healthcare of the racial and ethnic minority groups who reside in the United States. The main findings in these respects, among others, include:
* Minorities have less access to, and availability of, mental health services.
* Minorities are less likely to receive needed mental health services.
* Minorities in treatment often receive a poorer quality of mental healthcare.
* Minorities are underrepresented in mental health research.
* Disparities impose a greater disability burden on minorities.
* Culture counts - culture and society play pivotal roles in mental health, mental illness, and mental healthcare.
* The cultures of racial and ethnic minorities influence many aspects of mental illness, including how patients from a given culture communicate and manifest their symptoms, their style of coping, their family and community supports, and their willingness to seek treatment.
* Cultural and social factors contribute to the causation of mental illness, yet that contribution varies by disorder. Mental illness is considered the product of a complex interaction among biological, psychological, social, and cultural factors. The role of any of these major factors can be stronger or weaker, depending on the specific disorder.
* Ethnic and racial minorities in the United States face a social and economic environment of inequality that includes greater exposure to racism, discrimination, violence, and poverty.
* Racism and discrimination are stressful events that adversily affect health and mental health.
* Mistrust of mental health services is an important reason deterring minorities from seeking treatment.
* Reducing or eliminating these disparities requires a steadfast commitment by all sectors of American society.
This supplement report, as part of its vision for the future, made six specific recommendations: continue to expand the science base, improve access to treatment, reduce barriers to mental healthcare, improve quality of mental health services, support capacity development, and promote mental health. It is hoped that government at the federal, state, and local levels, as well as society at large will work hard to meet these relevant and much-needed recommendations.
The role of culture, race, and ethnicity has become a major priority and relevance in psychiatric practice. The influx of migrants from all parts of the world toward the United States during the past 4 to 5 decades, coupled with the high population growth on the part of the ethnic minority groups who reside in this country, have converted this into a pluralistic and multiethnic society.
It is, therefore, critical to recognize and conceptualize the roles of culture, race, and ethnicity within the context of psychiatric practice. In this regard, it is also relevant to understand the meaning of identity from a clinical point of view. Additionally, the proper identification of the idioms of distress as exemplified by the culture-bound syndromes are significant. Equally important is for clinicians to be aware and well informed about the effects of culture, race, and ethnicity on psychopharmacologic choices and outcome in the treatment of psychiatric disorders and conditions.
Finally, it is crucial that clinicians remain cognizant of racial and ethnic disparities in the current healthcare and mental healthcare system in the United States. It is also important to make every effort to resolve these disparities as soon as possible. It is hoped that this article will be of benefit for psychiatric practitioners in their quest to improve their capacity to diagnose and treat psychiatric disorders and conditions, within the context of cultural competence, among the racial and ethnic minority groups who reside in the United States.
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7. Lock M. The concept of race: an ideological construct. Transcultural Psychiatric Research Review. 1993:30(3):203-227.
8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington. DC: American Psychiatric Publishing; 1994.
9. Ruiz P Assessing, diagnosing and treating culturally diverse individuals: a Hispanic perspective. PsychiatrQ. 1995;66(4):329-341.
10. Foulks EF. Cultural issues. In: Hersen M. Sledge W, eds. Encyclopedia of Psychotherapy. San Diego. CA: Academic Press: 2002:603-613.
11. Ruiz P. Ruiz PP. Treatment compliance among Hispanics. Journal of Operational Psychiatry. 1983:14(2):112-114.
12. Ruiz P. The role of culture in psychiatric care. Am J Psychiatry. 1 998: 115(2): 1763-1765.
13. GawA. Culture. Ethnicity and Mental Illness. Washington. DC: American Psychiatric Publishing: 1993.
14. Ruiz P Cultural barriers to effective medical care among Hispanic-American patients. Annu Rev Med. 1985:36:63-71.
15. Ruiz P Ethnicity and Psychopharmacology. Washington. DC: American Psychiatric Publishing; 2000.
16. US Department of Health and Human Services. Mental Health: Culture, Race, and Ethnicity - A Supplement to Mental Health: Report of the Surgeon General. Rockville. MD: US Department of Health and Human Services. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; 2001.
Pharmacologic Agents Metabolized in the Cytochrome P450 (CYP) System15
Ethnic Variations in CYP Metabolization15
Ethnic Variations in Medication Doses and Side Effects (Compared with Caucasians in the United States)15