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Culture and Mental Illness

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Shankar Vedantam
Washington Post staff writer
Tuesday, June 28, 2005; 12:00 PM

What role does culture play in diagnosing and treating mental illness? In many poorer nations, social networks are a critical part of healing and recovery as patients continue to participate in society rather than becoming isolated, as is often the case in more developed nations. In the United States, some racial groups are more frequently diagnosed with schizophrenia than others, suggesting some sort of bias in the detection of such illnesses. This new information suggests a powerful link between societal factors and the diagnosis, treatment and outcome of mental illness.

Washington Post staff writer Shankar Vedantam, who covers health and science, was online Tuesday, June 28 at Noon ET to discuss his three part series on culture and mental illness. Read more: Patients' Diversity Is Often Discounted.

Social Network's Healing Power Is Borne Out in Poorer Nations.

Racial Disparities Found in Pinpointing Mental Illness.

A transcript follows.

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Shankar Vedantam: Welcome to the online chat to discuss my series of articles about how culture influences the diagnosis, treatment and outcome of mental illness. There is a lot of ground to cover, but we'll try to get to as much of it as possible. In the meantime, keep the questions coming!

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Washington, D.C.: That anecdote of the woman hearing voices at Cambridge Hospital is certainly provocative. Help us understand the point a little better. Is it that in Latino communities, there is no such thing as psychosis based on hearing voices, but if the same patient wandered back into mainstream medicine, he/she would in effect become psychotic-meaning there is a hermeneutics of psychosis?

Shankar Vedantam: You raise an excellent question. For readers who don't remember the specific excerpt from Sunday's story, let me add it here and then address the question.

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.

I think it would be a huge mistake to suggest that there is no such thing as psychosis among Latinos from the Caribbean. Rather, the point of the story is that by focusing only on her symptoms, doctors were misled. The same symptoms, in other words, can mean different things, depending on the context. The goal of people like Dr Lewis-Fernandez is to have doctors focus on the context as well as the symptoms, to ask, for instance, how the patient interprets the symptoms herself, and to ask how the culture from which the patient comes thinks about such symptoms. Many advocates of cultural competence talk about how the culture influences "idioms of distress" -- the ways in which patients express symptoms. Arthur Kleinman, the Harvard psychiatrist, told me that during his research in China after the Cultural Revolution, patients with what we would now call depression mainly complained about dizziness, exhaustion and sleeplessness -- symptoms associated with what was then known as neuresthenia. "Depression was a highly stigmatized mental illness, neuresthenia was thought of as a physical condition and didn't have any disgrace or humiliation," Kleinman told me. But as China has globalized, this has changed. Now depression is a very common diagnosis.

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Washington, D.C.: This was a great article. You make it very clear that race matters, that it is a blind spot that affects the diagnosis or misdiagnosis of mental illness. However, the article does not address the likely cause of this blind spot. Proponents of political correctness and multiculturalism have long asserted that race is just a "social construct" that has no biological meaning. They have said the same about sex (remember the brouhaha over Harvard President Larry Summers?). The recent FDA approval of a drug to treat heart ailments in African-Americans, and this article illustrating differences among the races in mental health issues, all lead to the same conclusion: race is a biological fact, and it impacts health decisions.

The question is this: Will the medical world be willing to confront embedded preconceptions about race, and to endorse medical approaches that take it into account as a relevant biological fact?

Shankar Vedantam: Thanks very much. I think there is a confusion of terms here. Scientists are questioning the validity of race as a biological construct. That has very little to do with whether race as validity as a SOCIAL construct. Modern genetics is showing us that so-called biological differences between groups of people are either trivial or non-existent at the level of our DNA. Of course, that says nothing about whether people can be biased, or whether race plays a role in things such as psychiatric diagnosis. The third installment of my series, published today, shows that race does seem to matter in diagnosing schizophrenia in the United States.

Zeber, who studies quality, cost and access issues for the U.S. Department of Veterans Affairs, found that differences in wealth, drug addiction and other variables could not explain the disparity in diagnoses: "The only factor that was truly important was race."

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Miami, Fla.: Mr. Vedantam,

I enjoyed your series and found it somewhat vindicating. Keep up the excellent work and keep it coming.

Shankar Vedantam: Thanks very much by the kind words.

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New York, N.Y.: Dear Shankar,

Thanks so much for a fascinating series of articles. Could you describe how you became involved in researching the topic? And do you have any anecdotes or stories from India that you could share here that didn't make it into the articles?

Cheers from NYC.

Shankar Vedantam: I'm afraid I don't have any eureka moment that prompted me to begin examining this issue. I have been writing about human behavior for the Post for several years and, in the course of my reporting, came across the people who I describe in the stories.

Reporting the schizophrenia story in India was really eye-opening. One thing that I didn't quite manage to get to in the series was the fact that there seems to be so little fear of patients with schizophrenia in India, as opposed to the United States, where the culture seems regularly suggests that people experiencing delusions/hallucinations are dangerous. I just didn't get the notion in India that patients with schizophrenia are out of control and dangerous -- and I suspect this is an important reason patients seem more integrated into Indian society, especially in rural areas. There is certainly far less stigma associated with serious mental illness in India. When I asked patients for permission to sit in on their conversations with doctors, most looked at me as if they didn't know what I was talking about.

It is difficult to generalize about a country as vast as India, of course. There is more stigma in urban areas rather than rural areas. New York University clinical professor of psychiatry Martin Gittelman said something that I thought was very insightful: "Urban Shanghai may look closer to urban New York than to rural China."

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Charlottesville, Va.: Mr. Vedantam,

If schizophrenia remains more intense in those not integrated into societal networks, would it not be possible that even forms of adjustment disorders, everyday neuroses, and so on, be also exacerbated by the impoverished social networks and therefore isolation in the industrialized world? The inverse relationship between productivity and social networks is very worrisome indeed.

Shankar Vedantam: This is an interesting question and an interesting hypothesis. I would be cautious about extrapolating too much from the what the data show, however, and the WHO studies were limited to schizophrenia. Is it possible that the same benefits occur with other illnesses? It is possible, but I think it would need to be demonstrated through studies before we can make such an assertion confidently. (It is possible that such studies have indeed been conducted -- if anyone knows about them, please drop me a line and I will post it.)

There are of course a variety of other sources of evidence that speak more generally about the benefits of community and the psychological and physical costs of stress. But in terms of extrapolating such results to the outcome of other serious mental disorders, we ought to keep in mind the difference between data and intuition. There is a reason why studies like the WHO trials are so rare: They are expensive and time consuming and very difficult to do.

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Arlington, Va.: In the field of social work, which often overlaps in the mental health community with psychology, the National Association of Social Workers publishes standards for cultural competence. It's very important for the clinician to examine his or her own personal beliefs about different cultures, learn about the culture of your client, understand communication styles within that culture that will help you deliver your services to the client, and empower your client in a world that can be oppressive to other cultures. The path to cultural competence is never complete--you as a clinician are always learning, always putting the client first, and always adopting a friendly "not-knowing" stance to reduce any cross cultural misunderstandings. I'm entering my second year of my graduate social work education (MSW) and am glad to see that The Post is recognizing race is an issue, as is culture. To read the NASW standards for cultural competence, go to NASW Thanks for such a great article!

Shankar Vedantam: Thanks very much for the note and the link.

The sense that I got from many of the advocates for cultural competence is that the hardest step for many is to acknowledge that race/ethnicity/culture may actually play a role in diagnosis and treatment. Francis Lu, a psychiatrist at the University of California at San Francisco and an advocate for cultural competence, said, "Bias is a very real issue. We don't talk about it -- it's upsetting. We see ourselves as unbiased and rational and scientific."

And here's another excerpt from the last part of the series:

Advocates for cultural competence say both clinicians and patients are unwilling to acknowledge that race might matter: "In a cross-cultural situation, race or ethnicity is the white elephant in the room," said Lillian Comas-Diaz, a psychotherapist in Washington, who added that she always brings up the subject with patients as a way to get hidden issues into the open -- and increase trust.

"I say, 'You happen to be Pakistani, and I am not -- how do you feel about that?' Sometimes they say, 'Oh, it's not important,' but when certain things happen [later] in therapy, people remember you opened the door and they come inside," she said.

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Etlan, Va.: This was one of the best pieces of reporting I've seen in the 40 years I've been reading The Post. That's a compliment by the way. You simply brought up (and I compliment your editors for giving this front page status) an issue that is vitally important but has never gotten the light of day in the media.

I haven't finished all your articles so maybe you mention it but I've read before that one of the main reasons for the continued, almost total reliance on drugs for treatment is the insurance connection. IOW it is a lot easier to get coverage for drugs than for talk therapy.

Also any comment on Tom Cruise and his recent statements about chemical imbalances and mental illness?

Shankar Vedantam: Thanks for the very kind words. I'll be sure to take your note with me when I sit down with my editor for my annual performance review!

Sunday's article described several reasons behind the rise of the biomedical model of psychiatry -- the role of insurance companies (and the lack of mental health parity) are clearly important reasons. The desire of psychiatrists to integrate their field with the rest of medicine also played an important role in the development of the Diagnostic and Statistical Manual of disorders.

Here are a couple of excerpts from Sunday's story that discusses these issues:

Drugs were shown to help patients with various symptoms, yielding hard data that most talk therapies and social interventions could not readily produce. Neuroscientists showed that many mental disorders had genetic components.

Insurance companies found that paying for pills was cheaper and simpler than paying therapists to address the interpersonal causes of suffering -- especially because general physicians could write most of the prescriptions. Patient advocates realized that defining mental illnesses as brain diseases reduced the stigma attached to depression and psychoses -- a patient could hardly be blamed for having an organic disease.

And here's the other excerpt:

Through much of the 20th century, the long shadow of Sigmund Freud hung over psychiatry. Just as doctors today talk about serotonin and brain structures such as the amygdala, doctors at mid-century evaluated patients through the lens of Freudian concepts such as transference and repression. Without common definitions of the symptoms they encountered, psychiatrists often disagreed over what ailed their patients. Show a patient to 10 psychiatrists, the joke went, and you would get 10 diagnoses.

In response, Columbia's Robert Spitzer led efforts to update American psychiatry's manual of mental disorders in 1980 and again in 1987. Experts drew up lists of specific symptoms associated with particular mental disorders -- and gave the field a common lexicon. The "Diagnostic and Statistical Manual of Mental Disorders," commonly known as DSM, became the bible of the medical model of psychiatry.

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Washington, D.C.: The article on how social connections aid people with schizophrenia was fascinating. My younger brother came down with schizophrenia in his early twenties, and I have often thought how lucky we were that he was living in my parent's hometown at the time, and that his instinct in the early stages was to come back to my parents house rather than isolating himself. His life now is very much like what is described in the article on India-- he works a job and leads a fairly normal life, but with constant vigilance from family.

Everyday as I pass any number of mentally ill homeless people on my way to work in D.C., I am very thankful that my brother came home to his family so that we could take care of him.

Shankar Vedantam: Thank you for sharing that story.

There are many families, of course, who are unable to provide the sort of assistance that your family has provided. Many are completely overwhelmed with various issues, and unable to come up with the emotional, physical and financial resources to accomplish what you have been able to do for your brother. In many parts of India, especially in rural areas, extended families are the norm, and often have more emotional resources than nuclear families in urban areas.

I want to be sure that I am not romanticizing one system over another. There are numerous reasons why someone may not prefer to live in an extended family -- as my story yesterday noted, there are many unequal and unfair family arrangements that may be to the benefit of patients but to the detriment of other family members.

The point of my story, ultimately, is not to ask how to turn nuclear families into extended families or the United States into India. That would be absurd. But there may be things each system can learn from what is best about other systems. Here's an excerpt from Monday's story:

Norman Sartorius, the former head of WHO's mental health program, spearheaded the schizophrenia studies. He says there is much the United States and Europe could learn from villages such as Raipur Rani.

In an interview at his home in Geneva, he said Western countries could financially help families take care of their relatives, which would save money on hospitalization and incarceration. Caregivers might be given time off from jobs. And doctors could enlist recreational and religious groups to replace the social networks that patients lose.

"Social factors play a major and important role in the outcome of disease," Sartorius said. "Very few solutions are medical in medicine."

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Largo, Md.: Thanks for your informative analysis. As a professional black woman of a certain age, I cannot tell you how psychotherapy aided me over a period of years. I learned how to tell when I was "going down into the hole," and how to avoid despairing and frightening immobilization. Clinical depression is rampant in ALL strata of the so-called black community, and common to both men and women of all ages. I am just as concerned about Latinos, but have no knowledge. Thank you again.

Shankar Vedantam: Thank you very much for your note.

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Washington, D.C.: Thank you for your excellent series; I realize you had a lot of ground to cover, but I feel that you mis-characterized psychiatry in the U.S. as wholly based on the "medical model" for treating schizophrenia. Since the late 60's there has been a great deal of effort devoted to the "recovery model" for maintaining people with this disorder in the community, living normal lives, with supports from clinical teams as needed (see the Wisconsin Assertive Community Treatment model by Stein and Test, for example) to compensate for the absence of extended families in our culture. Supported employment, assistance in maintaining apartments, social clubs, etc. are all part of the effort to make recovery, or minimal need for hospitalization, the norm. Of course, budget problems have slowed the momentum, but this approach is well-established and not to recognize it is a disservice to readers. (On the other hand, its proponents do sometimes promise better outcomes than they can deliver).

Shankar Vedantam: Thank you for your comment. I broadly agree with you.

The focus of my story -- and this is a newspaper, with space restrictions and other limitations -- was to focus on what is by many accounts the dominant system of care. But your points are well taken, and thank you for making them.

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Springfield, Ill.: Mr. Vedantam, you are to be commended for the humanistic perspective you placed on mental illness, which is still very stigmatized in our society.

Would you suggest that the treatment of mental illness is not just a matter of competence as much a parallel to how medicine has been "fast tracked" and economized in our society?

Shankar Vedantam: Thanks very much for your comment. There are clearly a number of reasons as to why medicine in particular countries takes particular forms. I think most people would agree that economic forces play a role in the shapes that medicine takes in particular settings.

As a science reporter, I have long been baffled at why so little money in most countries is spent on prevention, and so much is spent on care, which is frequently more expensive and less effective. The field of mental health is starting to grapple with the idea of prevention. I personally think this is a very important area of research.

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Charlottesville, Va.: In schizophrenia and other severe forms of mental illness, there is normally an acute reaction to failing to accomplish the tasks of developmental stages. I was interested in Devi in your second article, who married and had 5 children despite her illness. If we think of social networks as good at providing developmental assistance--could the developmental assistance which the culture provides then serve to reduce the instances of failure of developmental accomplishments and therefore confine and diminish the illness of schizophrenia?

Shankar Vedantam: You are asking me a question that is well beyond my competence to answer.

Devi's doctors believe that the fact she had such an active family and village life clearly contributed to her recovery. William Carpenter, the Maryland psychiatrist who helped conduct part of the WHO study in the Washington area, talked about the difference between ego-centric and socio-centric cultures.

In countries such as India, he said, if you were 40 and had schizophrenia, you were still with your family, not homeless or in jail. Especially in rural areas, you can still work -- because your social and occupational niche will adjust to your mental needs. "In an ego centric culture there's a greater chance you will drop through the cracks," he said. "In a socio-centric culture you will continue to have a niche."

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Reston, Va.: Do demographics play a role in diagnosis?. The bulge in Blacks and Hispanics (teens,young adults) are at the ages that schizophrenia and other severe mental illness' begin to manifest themselves.

Shankar Vedantam: I'm not sure I completely understand your question.

Schizophrenia is a disorder that typically strikes people just as they are emerging into adulthood, often in college or in their early 20's. An earlier description of the illness called it dementia praecox -- which is roughly translated as youthful dementia.

This is something that makes the disorder especially cruel. Having one's life stolen away at any stage is painful, but it is especially difficult to see young people vanish away into inner worlds during what ought to be the best years of their lives.

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Washington, D.C.: Throughout the article, you make reference to studies that show actual incidence of schizophrenia is equal among races, though diagnosis is not. How were said studies measuring incidence of the disease independent of diagnoses?

The thrust of the article was that blacks and Hispanics are overdiagnosed as schizophrenic; what evidence (other than individual anecdotes) lead Zeber to this conclusion rather than suspecting whites are underdiagnosed?

Shankar Vedantam: An excellent question -- I am sorry to be getting to it so late in the discussion.

The reason that experts believe the rate of schizophrenia is the same across different groups (both inside and outside the United States) is because the rates seem identical when experts conduct standardized structured interviews among different groups. That is different than what happens in clinical settings, where individual clinicians might offer diagnosis and care in slightly different ways.

By the way, the WHO studies on schizophrenia were originally designed to merely answer the question whether the disorder existed in all countries and, if so, whether it could be diagnosed using standardized criteria. The difference in outcome was discovered only later in the study, after it was established that the disorder exists everywhere and can be reliably diagnosed.

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Chester, VA: Mr. Vedantam,

Your series is indeed very interesting. I have read the 2nd and 3rd parts. I have yet to read the first one. I am following the on line discussion, which I find extremely elucidating.

Here is my question:

If everyone regardless of race is prone to be diagnosed with schizophrenia under certain conditions, wouldn't this show that social and economic factors could, under certain circumstances, trump racial factors?

I would like to know where you draw the line between race and culture. The headline of your series speaks on culture, yet the content of your series emphasizes on race? From what I infer, it is not precisely race what matters, but culture, economics, health disparities, and social marginalization. I don't think this factors cause schizophrenia. In other words schizophrenia is a medical condition some times aggravated by social and economic condition.

How do you relate medical treatment to (for) the poor to the 'race' factor?

Thank you for your reply.

Shankar Vedantam: Thanks very much.

I'm not sure what you mean by saying that everyone can be diagnosed with schizophrenia. If you mean are all groups prone to schizophrenia, then sure, the answer is yes.

Race and ethnicity are aspects of culture. The Monday installment of the series, for instance, focuses not on race/ethnicity but on socio-economics -- patients in poor countries, independent of ethnicity, appear to have better outcomes of schizophrenia than patients in wealthy countries.

And yes, I would absolutely agree that different cultures do not seem more or less likely to cause schizophrenia. As I have said repeatedly, the prevalence of the disorder appears to be similar among all groups. It is the outcome of the disorder that seems to be influenced by culture.

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Arlington, Va.: Thank you so much for highlighting the bias that can be so often detrimental to culturally and racially diverse clients. As a social worker working in a community mental health center I see the push to medicate instead of actually looking at the "person-in-environment" factors (social supports, culture, race, discrimination, class, etc) that are all interconnected and affect a person. From your research and experience do you believe the DSM is a useful tool in treating culturally/racially diverse clients?

Shankar Vedantam: Thanks for the question. One must be careful not to throw the baby out with the bath water -- virtually every expert that I quote in the series who advocates cultural competence would agree that the DSM has great value. The manual itself has attempted to address issues of culture -- although many of the advocates for cultural competence that I spoke with suggest that more is needed.

Many if not all the psychiatrists I quote use the manual to diagnose patients, and many believe medications are an integral part of treatment. In contrast with anti-psychiatry critics, all the people in my stories who have advocated a a critique of psychiatry are ardently pro-psychiatry. All are enthusiastic about research being done on brain chemistry and genetic vulnerabilities.

Here's Roberto Lewis-Fernandez from Sunday's story:

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."

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Philadelphia, Pa.: I have a Ph.D. in clinical psychology and am a schizophrenia researcher. I feel that oftentimes, mental health professionals are characterized as short-sighted and inexorably married to the medical model. I would like to think that most of us think of psychopathology in terms of an interaction between biological factors (genes, neurotransmitters) and the environment (stress, etc.), but unfortunately, I don't think we are portrayed that way.

That being said, I would like to say that in my training, issues of diversity were emphasized continuously, whether in a research or clinical context. On internship, several 4-hour seminars were dedicated solely to issues of diversity. At times during training, the issues did seem to be given lip-service, but the message that I got was: Race, ethnicity, sex, and socio-economic status MATTER. I think it is important for the general public to know this.

Shankar Vedantam: Thanks for your comment -- I very much appreciate your weighing in.

I think there is no doubt that many of the best minds in mental health agree that there are psycho-social aspects to diagnosis and care. However, for a variety of reasons (many of which have nothing to do with science or medicine), those aspects of care do not seem to get equal billing in actual care. As I write in Sunday's story and Monday's story, the challenge lies in integrating those ideas in practice, especially when many of those aspects of care lie outside the bounds of traditional medicine.

Finding patients with schizophrenia housing, employment, and social connections are as essential to care as diagnosis and writing prescriptions, said Benedetto Saraceno, the head of WHO's mental health program. It is one thing to agree with him, but I think it is obvious that implementing that idea can be remarkably difficult.

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Washington, D.C.: Mr. Vedantam:

Very interesting piece.

My question is on a related topic that I'm sure you know about - Tom Cruise and his attack on psychiatry. I am a white woman who has suffered from depression in the past. I am now recovering, but I chose talk therapy over drugs, which were strongly prescribed. Do you think there will be any fall out, since Tom Cruise is a well-known and -respected (at least until now) actor and an effect on the stigmatization of mental illness and its various forms of treatment? I didn't need drugs, but I know there are people out there who do, and I would hate to think that they don't get the help they need because they will be seen as weak.

Thank you.

Shankar Vedantam: Thanks very much for your comment -- you make points well worth noting.

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Washington, D.C.: Your chart on care and remission shows 750,000 people with schizophrenia living independently and 135,000 in jails, 100,000 in shelters. Those proportions are surprising--the later two figures seem low and the first, high. You cite sources ranging from 1992 to 1996 and undated sources. What you do these figures represent? How did you arrive at them?

Shankar Vedantam: We found it remarkably difficult to find data on where the approximately 2.2 million people with schizophrenia in the United States. (That in itself is telling.)

There is excellent data collected by the federal government's Substance Abuse and Mental Health Services Administration about patients receiving care in any given year. However, that data does not account for at least half the people with schizophrenia in the United States. The data we used in the graphic was drawn from the work of psychiatrist E. Fuller Torrey, from his book, Surviving Schizophrenia.

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Washington, D.C.: Tom Cruise's publicity tour for War of the Worlds has allowed him to bring his perceptions of mental illness into the spotlight. How do you think his negative attitude towards psychiatry and psychiatric medications will impact public perception of mental health issues across racial lines?

Shankar Vedantam: Mr Cruise is a celebrity. I cover science. I think readers in general (and especially the ones who wrote in with such smart questions today) can tell the difference.

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Washington, D.C.: I'm doing research on this issue for a Latino civil rights group--can I contact you with specific questions? This series of articles is really helpful. Congratulations!

Shankar Vedantam: Thanks very much. I would be glad to field ideas, suggestions and any other feedback.

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Arlington, VA.: NAMI, The Nation's Voice on Mental Illness, is taking an active role to eliminate mental health care disparities that exist among diverse communities. At our National Convention last week in Austin, we held various tracks specifically relating to mental illness in Latino, African American, and Asian American communities.

To learn more about NAMI's Multicultural Action Center, please visit NAMI

Shankar Vedantam: Thanks for the note and the link.

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Fredericksburg, Va. : How widespread did you find the concept of focus units to deal with racial, ethnic and cultural differences? Were they limited to San Francisco?

Shankar Vedantam: As far as I know, yes. There may well be others, but for the purposes of my story, I focused on the San Francisco hospital. I think it is fair to say that it is unusual -- and no doubt at least partly connected to the enormous diversity of the city of San Francisco.

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Springfield, Ill.: Thank you very much for the excellent series. What do you believe needs to happen in the "helping professions" to realize that we must see individuals contextually versus as symptomatically, and then rushing to treat the symptoms (biological intervention)?

Shankar Vedantam: Thanks very much for the comment.

I think the advocates for cultural competence are trying to do a great deal to increase awareness. But as I have noted repeatedly in this conversation, many of the factors driving care are independent of medicine and individual doctors. Many psychiatrists I have spoken with are frustrated at the system of care in which they find themselves, and often chafe at the fact that they cannot spend as much time with patients as they would like (or the patient needs.) The president's Freedom Commission on mental health has identified numerous areas of the mental health system that appear broken, and has called for systemic changes.

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Alexandria, Va.: I think it would help if insurance companies would cover mental illness the way they cover other illnesses. After all, it's really just a physical part of the brain or hormones that is causing it, right?

If full coverage were offered, more people could get the help they need and it would be a step in the right direction of reducing stigma.

Shankar Vedantam: I think there is no doubt that the reason many practitioners feel hurried and harried is because mental health coverage is not the same as coverage for other issues. Part of the reason, in fact, that many groups have embraced the idea of mental illnesses as brain disorders is because they feel it would encourage companies to provide better coverage to think of mental disorders as being disorders of the brain. I think it would be fair to say that virtually all the advocates for cultural competence that I quote -- many of whom think mental disorders are more than just diseases of the brain -- would agree that better insurance coverage is an integral part of a better system of care.

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Anonymous: From the person doing research on this issue who would like to contact you with specific questions, this is the question. What is your source for the points made in your first article, quoted below? This is fascinating because the same premise that acculturation increases risk holds true for criminality, including gang activity. Also, is the same premise true with regard to alcohol abuse? You mentioned drug abuse, and I'm familiar with that data, but do you have any sources with regard to alcohol abuse among Latinos from a health disparities or acculturation perspectives?

People of Mexican descent born in the United States have twice the risk of disorders such as depression and anxiety, and four times the risk of drug abuse, compared with recent immigrants from Mexico. This finding is part of a growing body of literature that indicates that the newly arrived are more resilient to mental disorders, and that assimilation is associated with higher rates of psychiatric diagnoses.

Shankar Vedantam: This chat has gone on for two hours, and I am not going to be able to get to all the questions. I will try to take a couple more, but then have to give my fingers a rest.

The source for the data you cite are from a 1998 paper published by William Vega and other researchers in the Archives of General Psychiatry titled Lifetime Prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. There is an editorial by Javier Escobar accompanying the paper in the same issue of the journal.

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Ijamsville, Md.: There is a predilection to diagnose -anybody- with a mental illness nowadays, rather than look for other explanations for someone's symptoms. I am a white female and almost 8 years ago, I began experiencing deja vu with an overwhelming sense of fear which would last for a couple minutes. My primary care doctor at the time said I was having panic attacks and put me on Prozac. Later, she referred me to a psychiatrist and therapist, both to whom I related the deja vu with fear episodes I was having. Just this past February, I had a grand mal seizure preceded by a few of those deja vu with fear episodes. It turns out I have epilepsy and the deja vu with fear is a -common- type of partial seizure! Why didn't my former doctors actually -listen- to my description of having deja vu with fear? Why were they so quick to assume I had a mental problem, rather than a neurological one? I don't believe I'm the only one this has happened to.

Shankar Vedantam: Thanks for the comment. (I am going to post a few comments without responses, so they can be part of the conversation, even though I am not going to be able to respond.)

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Silver Spring, Md.: Has anyone ever done a study regarding racial disparities vis a vis successful use of the insanity defense in criminal cases? In nearly 25 years in criminal trial as law clerk and Assistant District Attorney, I rarely saw minorities successfully advance an insanity defense. (compare e.g. Colin Ferguson, the LIRR killer of 6 in NYC vs. the man who murdered the U.S. Capitol police officer a few years back.)

Shankar Vedantam: Interesting question. Don't know the answer.

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Washington, D.C.: What is your opinion of Bebe Moore Campbell's new book about mental illness? I understand she's appearing with Mayor Williams on Wednesday.

Shankar Vedantam: Putting this comment/question out there ...

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Bethesda, Md.: In the first part of your series ("Patients' Diversity is Often Discounted") you note, "Of 3,980 patients in antidepressant studies, only two were Hispanic. Of 2,865 schizophrenia patients, three were Asian. Among 825 patients in bipolar disorder or manic depression studies, there were no Hispanics or Asians." These numbers clearly discount the work being done at the National Institute of Mental Health, where I am a research assistant. Where does the U.S. Surgeon General's Office get their numbers? Since all of the studies at NIMH, and even Howard University, were clearly discounted, isn't it possible that there are a multitude of other research sites covering the issues you address?

Shankar Vedantam: Thanks very much for your question. I am sorry I didn't get a chance to get to it earlier.

The numbers you cite are from a UCLA survey conducted for a surgeon general's report on mental illness. The survey focused on clinical trials for psychiatric medications -- the majority of which, as I am sure you know, are conducted by the pharmaceutical industry.

The National Institutes of Health in particular and the federal government in general have made efforts to increase the participation of minorities in research, as we note in Sunday's paper (in the sidebar.) Many federal grants now require investigators to include minorities.

The system of drug approvals in the United States, however, relies on the pharmaceutical industry to conduct most trials of medications. The UCLA survey was based on an analysis of that data. (I should note that when drug studies have been sponsored by the federal government, they seem to be far more successful in recruiting minorities. In part, this may be because the essential goals of federal and private research are different.)

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Ashburn, Va.: The article says the psychiatrists don't know why the treatment success in America is worse than in third world nations. It seemed pretty obvious to me. The patient in the third world case you described continued to live at home, surrounded by faces she knew, sounds and smells that were familiar to her, food that was what she was used to eating, and general support. In America the patient is either committed in a mental hospital, jailed, or let loose to live on the streets.

Shankar Vedantam: Thanks for the comment

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Shankar Vedantam: Thank you everyone for a very stimulating conversation. You asked great questions. I'm sure some of the best answers will occur to me as I am heading home tonight!

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