Introduction

Cultural sensitivity remains a crucial aspect of diagnosing and treating psychiatric patients. There are many culture-specific syndromes and pharmacologic considerations that the diligent physician or provider should be aware of when encountering patients from different backgrounds. Not addressing cultural concerns when assessing patients may lead to unnecessary or even incorrect treatment modalities. Educating patients and their families regarding mental health diagnoses and treatments is vital, as it ensures proper management of the patient’s symptoms. Patients and families from different cultures may never have been exposed to mental health treatment or may not believe in such treatment. Open discussions need to be held to cultivate an understanding of the patient’s mental health concerns and ensure the development of good rapport with patients and families.[1][2][3][4][5]

Function

With rapid changes in the ethnic diversities and multicultural and linguistic groups in the population, clinicians need to develop awareness and knowledge about different attitudes and beliefs that can influence their psychological thought processes. In assessing a patient who speaks a language other than English and may hold beliefs different from the mainstream culture, every clinician has to be knowledgeable about the complex processes that facilitate adjustment and conflict resolution among members of that culture. Every cultural group defines a spectrum of "normal behaviors" within their ethnic or cultural group. They also have various thresholds of tolerance as well as identification of "abnormal behaviors." Behavior that may be unacceptable in one social setting can lead to a diagnosis of a psychiatric disorder by a clinician who is raised and trained in a different society. However, the same behavior in other subcultures or ethnic groups can indicate a normal adaptive response to a stressful situation. In understanding a patient's cultural identity, the clinician should note the patient's age, sex, race, ethnicity, language, sexual orientation, socioeconomic class, education level, and religious and spiritual beliefs. For immigrants and ethnic minorities, it is crucial to understand the degree of acculturation and capacity to adapt to the host culture.[6][7][8][9] Many studies have demonstrated a strong association between religion/spirituality and depression. In general, faith in God is associated with a decreased risk of suicide.

Issues of Concern

Varying Backgrounds

Some of the psychopharmacological considerations for patients of varying backgrounds are listed below.

Black patients

Black patients tend to receive more diagnoses of schizophrenia compared to other populations. When presenting with an affective disorder, clinicians often misdiagnose a patient in this group as having schizophrenia. Black patients also receive higher doses of antipsychotic medications and can be more sensitive to the effects of these medications. They are also less likely to receive second-generation antipsychotics and have twice the likelihood of tardive dyskinesia compared to White patients.[10]

Hispanic patients

Hispanic patients tend to focus more on somatic complaints when depressed compared to other populations. They also require half of the dose of antidepressants compared with White patients in treatment. The Hispanic population is also more prone to experiencing anticholinergic side effects of psychopharmacological agents.[11]

Asian patients

Like Hispanic patients, Asian patients will often deny depressed mood but present with more somatic rather than psychological complaints. Asian patients are also at higher risk of extrapyramidal side effects of psychotropic medications. Research has shown plasma haloperidol levels to be 52% higher in Chinese patients than in other patient populations.[12]

White patients

White patients have lower serum haloperidol and prolactin levels than Asian patients.

Studies have found a correlation between a genetic marker, the human leukocyte antigen HLA-B*1502, and Stevens-Johnson syndrome induced by carbamazepine in certain groups of the Chinese population.

Alcohol Metabolism

Alcohol metabolism differs in cultures. Eighty percent of Asians, particularly women and 50% of Native Americans, exhibited a flushing response to alcohol, which is explained by the genetic polymorphism of the isoenzymes alcohol dehydrogenase and aldehyde dehydrogenase. These enzymes are critical for the metabolism of alcohol.[13]

Cytochrome P450

The cytochrome P450 enzyme system plays a key role in the metabolism of psychotropic and nonpsychotropic drugs. Genetic defects in the isoenzymes of this system are present in certain ethnic groups that can put them at risk of being poor metabolizers and thus make them more vulnerable to the toxic effects of drugs.

Clinical Significance

Lewis-Fernández first introduced the notion of "cultural syndromes" in the latest published Diagnostic and Statistical Manual of Mental Disorders (DSM) as 1 of 3 concepts that replaced the "culture-bound syndromes" concept. Lewis-Fernández wrote that cultural syndromes are "clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts." He led the development of the DSM-5 Cultural Formulation Interview, a standardized method for cultural assessment in mental health practice.

Cultural Syndromes

The following are a few cultural syndromes to be aware of in practice:

Hwa-Byung

Hwa-Byung is an example of a cultural syndrome specific to Koreans and Korean immigrants. The incidence of comorbid depression, anxiety, and conversion disorder is high in middle-class, middle-aged Korean women. The symptoms of Hwa-Byung are primarily physical, presenting with palpitations, insomnia, and headaches. Psychological symptoms may include, but are not limited to, heightened startle response, sad or depressed mood, and guilt or hopelessness. The syndrome is translated into English as "anger syndrome" and explained as the suppression of anger.

Treatments for Hwa-Byung vary widely. While some Korean families may be open to the concept of family therapy to benefit the family as a whole, other families may decline family therapy as they identify women as the primary source of the problem in the family. Korean women often have difficulties verbalizing their distress and directly confronting their spouses and children in therapy. Family therapy in the United States commonly engages families in discussing their interpersonal conflicts and family dynamics in a session. However, this is often not acceptable in Korean culture. A family therapist working with this culture must be aware that when there is significant tension and stress among family members in a session, it may be necessary to incorporate individual sessions into the treatment. The wife may feel more comfortable discussing personal issues about relationships in a separate session's non-threatening and confidential environment. In joint sessions, the therapist must focus on teaching concrete skills rather than discussing the wife's concerns.

The development of Hwa-Byung may be related to the chronic stress involved with interpersonal family conflicts. However, other social issues like poverty, lack of trust in relationships, and discrimination against women can be an added source of stress. It also merits noting that the syndrome often manifests with physical symptoms rather than psychological symptoms. Thus, a clinician should integrate psychotherapy into treatment early on and not just depend on medications to treat the physical symptoms.

Amok

Amok is another example of a culture-bound syndrome. This condition is a dissociative episode characterized by depression followed by outbursts of violence, aggression, and homicidal behavior. This syndrome tends to be caused by a perceived threat to the individual and is accompanied by persecutory ideas. After a stressful stimulus occurs, there is a period of social withdrawal and brooding followed by aimless wandering; this can then transition to a sudden and extremely violent homicidal tendency. Verbalizations may be frenzied and may represent internal conflict. Cessation may occur spontaneously but usually results from being overpowered or killed. Psychosis or depression may occur after the episode. Amok is prevalent only among males from Malaysia, Laos, Philippines, and Polynesia.

Ataque de nervios

Ataque de nervios is a condition reported primarily among Latinos from the Caribbean and Latin America. The most common symptoms include uncontrollable shouting, crying, and verbal or physical aggression. Dissociative experiences, in addition to seizure-like or fainting episodes, can be present. A general feature of ataque de nervios is feeling out of control. This condition most commonly occurs as a response to a stressful event related to the family. The initiation of the episode is immediate upon exposure to the stimulus. An intense affective storm is followed by bodily sensations (trembling, chest tightness) as well as swearing, yelling, and possible attempts to harm oneself or others. Partial or total amnesia frequently follows the attack and may include alterations of consciousness. Psychotherapy has proven to be helpful, and medication can be indicated to address underlying symptoms of anxiety or depression.

Dhat 

Dhat is a folk term used to describe severe anxiety and hypochondriacal concerns with the discharge of semen that contributes to feelings of weakness and exhaustion in the male population in rural India.

Koro

Koro is a syndrome that exists in some East Asian cultures; this syndrome presents with intense anxiety related to fears that the genitalia will recede into the body and cause death.

Susto

Susto is an illness prevalent among Latinos in the United States that correlates with a scary event that causes the soul to leave the body and leads to unhappiness and sickness. Patients may often present with neurovegetative symptoms of disturbances in sleep, appetite, and multiple somatic complaints.[14][15][16]

Other Issues

To develop a better understanding of the treatment of cultural issues, 4 principles should be considered:

• The importance of avoiding stereotypes about individuals and groups
• Learning how to ask the right questions (for example, improving the clinician's skills for active listening and eliciting culturally relevant information)
• Improving cultural competence in a way that is coextensive with the trainee's emerging clinical skills in other areas
• Improving the clinician's insight and acceptance of cultural competence is integral to every patient's assessment and clinical care

Cultural sensitivity remains vital in accurately diagnosing and treating patients from different backgrounds and ethnicities. Cultural influences are linked to healthcare disparities and providers' attitudes in clinical encounters. The entire healthcare team must learn the importance of appropriate responses to a patient's concerns that involve cultural differences. Studying one's implicit assumptions regarding reactions toward a patient's culture can help eliminate bias and improve healthcare delivery. Delicately eliciting cultural information is also necessary to help enhance rapport with the patient and family.

Enhancing Healthcare Team Outcomes

Treatment of a cultural syndrome is a diagnostic challenge for any clinician. Gathering a detailed history and understanding the patient and the family's views and opinions about the presenting problems assists in developing insight into the dynamics of the patient's world and helps the clinician develop a treatment plan that is acceptable and conducive to the patient's well-being. This approach also facilitates better patient and clinician communication and improves treatment outcomes.

Irrespective of their particular role in the health care team, each member must be aware of these cultural differences when caring for with patients and report to the team leader as concerns arise. As one member of the team learns about a cultural norm that applies to a patient, they should document it for the benefit of other members; this prevents wasted time for each team member to have to find out the same information and also can avoid indelicate situations that may occur as each provider interacts with the patient for the first time. Clinicians (MDs, DOs, NPs, PAs), nurses, pharmacists, and other healthcare team personnel are all responsible for understanding and respecting these cultural differences and sharing them with other providers. This collaborative communication will streamline the healthcare delivery process and better drive optimal outcomes for patients with cultural diversity concerns.