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Patients' Diversity Is Often Discounted
· A host of small studies suggests that the effects of psychiatric drugs vary widely across different ethnic groups. There are even differences in the effect with dummy pills.
Keh-Ming Lin, a psychiatrist who formerly headed the UCLA center, said that because psychiatric drugs affect behavior and change how people feel, their effects are powerfully modified by patients' beliefs.
The effects of such drugs "are not solely determined by their pharmacological properties," wrote Lin and colleagues in a book, "Psychopharmacology and Psychobiology of Ethnicity." "The prescription and use of medication is enmeshed in a process replete with social and symbolic meanings and implications."
Psychiatric diagnoses are similarly influenced by culture, said Maria Oquendo, a psychiatrist at Columbia University. Women from different cultures, for instance, face very different norms about what constitutes an ideal body weight -- and this influences the course of certain disorders: "We consider anorexia nervosa to have biological underpinnings and, therefore, universal, but in less industrialized cultures, anorexia is vanishingly rare. Culture informs our decisions on what we consider normal."
"If we understand that our definition of pathological isn't pathological in other countries, we can make better decisions on when to treat, especially with medications," she added.
Advocates for culture's role in psychiatry describe many case studies to illustrate their argument: Roberto Lewis-Fernandez was a young doctor in training in Massachusetts when he encountered a patient who was 49 and suicidal at Cambridge Hospital. The Puerto Rican woman begged for help in resolving a conflict with her son, but the Harvard University-affiliated psychiatrists focused on one set of symptoms -- she was hearing voices, seeing darting shadows and sensing invisible presences.
They diagnosed her as depressed and psychotic, or out of touch with reality, and medicated her. She was discharged. Soon after, the woman had an argument with her son and nearly killed herself by overdosing on the medication.
For Lewis-Fernandez, who is Puerto Rican, the suicide attempt confirmed his fears that his superiors had misjudged the situation. For months, as top psychiatrists ordered him to keep increasing the potency of her drugs, he had told himself that hearing voices, seeing shadows and sensing presences is considered normal in some Latino communities. But he dared not challenge the wisdom of the medical model.
"I wasn't sure if she was psychotic, but I treated her as if she was," he said about the case, which he wrote up in a medical journal. "I gave her the medicines."
When the hospital's outpatient unit evaluated the woman anew, doctors there came up with a different diagnosis. They concluded that her symptoms were not abnormal in the context of her culture -- they were expressions of distress, not illness. Lewis-Fernandez helped her reconcile with her son. She still heard voices and saw shadows, but now, as before, they did not bother her.
Unlike anti-psychiatry groups that wish to do away altogether with drugs and doctors, advocates for cultural competence argue only against one-size-fits-all thinking. Genetic vulnerabilities and brain chemistry are undoubtedly important, said Lewis-Fernandez, but his patient was badly served because doctors assumed all her problems could be reduced to brain chemistry.
"Sure, after a certain amount of suffering for a certain amount of time, your brain reacts," he said. "The idea of mainstream psychiatry is that the pill will correct the chemical imbalance in the brain. Yes, but the imbalance keeps happening because of the situation she is in, and the pill can't correct the situation."