Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 2
Overview of Cultural Diversity and Mental Health Services
Ethnopsychopharmacology
There is mounting awareness that ethnic and cultural influences can alter an
individual’s responses to medications (pharmacotherapies). The relatively new
field of ethnopsychopharmacology investigates cultural variations and
differences that influence the effectiveness of pharmacotherapies used in the
mental health field. These differences are both genetic and psychosocial in
nature. They range from genetic variations in drug metabolism to cultural
practices that affect diet, medication adherence, placebo effect, and
simultaneous use of traditional and alternative healing methods (Lin et al.,
1997). Just a few examples are provided to illustrate ethnic and racial
differences.
Pharmacotherapies given by mouth usually enter the circulation after absorption
from the stomach. From the circulation they are distributed throughout the body
(including the brain for psychoactive drugs) and then metabolized, usually in
the liver, before they are cleared and eliminated from the body (Brody, 1994).
The rate of metabolism affects the amount of the drug in the circulation. A slow
rate of metabolism leaves more drug in the circulation. Too much drug in the
circulation typically leads to heightened side effects. A fast rate of
metabolism, on the other hand, leaves less drug in the circulation. Too little
drug in the circulation reduces its effectiveness.
There is wide racial and ethnic variation in drug metabolism. This is due to
genetic variations in drug-metabolizing enzymes (which are responsible for
breaking down drugs in the liver). These genetic variations alter the activity
of several drug-metabolizing enzymes. Each drug-metabolizing enzyme normally
breaks down not just one type of pharmacotherapy, but usually several types.
Since most of the ethnic variation comes in the form of inactivation or
reduction in activity in the enzymes, the result is higher amounts of medication
in the blood, triggering untoward side effects.
For example, 33 percent of African Americans and 37 percent of Asians are slow
metabolizers of several antipsychotic medications and antidepressants (such as
tricyclic antidepressants and selective serotonin reuptake inhibitors) (Lin et
al., 1997). This awareness should lead to more cautious prescribing practices,
which usually entail starting patients at lower doses in the beginning of
treatment. Unfortunately, just the opposite typically had been the case with
African American patients and antipsychotic drugs. Clinicians in psychiatric
emergency services prescribed more oral doses and more injections of
antipsychotic medications to African American patients (Segel et al., 1996). The
combination of slow metabolism and overmedication of antipsychotic drugs in
African Americans can yield very uncomfortable extrapyramidal 26 side effects
(Lin et al., 1997). These are the kinds of experiences that likely contribute to
the mistrust of mental health services reported among African Americans (Sussman
et al., 1987).
Psychosocial factors also can play an important role in ethnic variation.
Compliance with dosing may be hindered by communication difficulties; side
effects can be misinterpreted or carry different connotations; some groups may
be more responsive to placebo treatment; and reliance on psychoactive
traditional and alternative healing methods (such as medicinal plants and herbs)
may result in interactions with prescribed pharmacotherapies. The result could
be greater side effects and enhanced or reduced effectiveness of the
pharmacotherapy, depending on the agents involved and their concentrations (Lin
et al., 1997). Greater awareness of ethnopsychopharmacology is expected to
improve treatment effectiveness for racial and ethnic minorities. More research
is needed on this topic across racial and ethnic groups.
20 The term “Latino(a)” refers to all persons of Mexican, Puerto Rican, Cuban, or other Central and South American or Spanish origin (CMHS, 1998).
21 Acculturation refers to the “social distance” separating members of an ethnic or racial group from the wider society in areas of beliefs and values and primary group relations (work, social clubs, family, friends) (Gordon, 1964). Greater acculturation thus reflects greater adoption of mainstream beliefs and practices and entry into primary group relations.
22 Research is emerging on the importance of tailoring services to the special needs of gay, lesbian, and bisexual mental health service users (Cabaj & Stein, 1996).
23 Of the 15 percent of the U.S. population that use mental health services in a given year, about 2.8 percent receive care only from members of the clergy (Larson et al., 1988).
24 In spring 2000, survey field work begins on an NIMH-funded study of the prevalence of mental disorders, mental health symptoms, and related functional impairments in African Americans, Caribbean blacks, and non-Hispanic whites. The study will examine the effects of psychosocial factors and race-associated stress on mental health, and how coping resources and strategies influence that impact. The study will provide a database on mental health, mental disorders, and ethnicity and race. James Jackson, Ph.D., University of Michigan, is principal investigator.
25 African Americans are overrepresented among persons undergoing involuntary civil commitment (Snowden, in press-b).
26 Dystonia (brief or prolonged contraction of muscles), akathisia (an urge to move about constantly), or parkinsonism (tremor and rigidity) (Perry et al., 1997).
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