Download Cultural Barriers to Adequate Detection and Management of Major

Culturally Sensitive Interviews
with the use of the
Engagement Interview Protocol (EIP)
Albert Yeung, M.D., Sc.D.
MGH Depression Clinical and Research Program
Harvard Medical School
Albert Yeung, M.D. - Disclosures
• Dr. Yeung and/or the Depression Clinical and
Research Program of Massachusetts General
Hospital have received or are receiving research
support from Abbott, Alkermes, Aspect Medical
Systems, AstraZeneca, Bristol-Myers Squibb,
Cephalon, Eli Lilly, Forest Laboratories,
GlaxoSmithKline, Johnson & Johnson, Lichtwer
Pharma GmbH, Lorex Pharmaceuticals,
Novartis, Organon, Pamlab, Pfizer, Pharmavite,
Roche, Sanofi-Synthelabo, Solvay, and Wyeth.
U.S. Population Projections
2008
2050
Non-Hispanic whites
60%
46%
Hispanics
15%
30%
African Americans
14%
15%
Asian Americans
5%
9%
Based on U.S. Census (2000)
Disparities and Depression (I)
• Disproportionate burden of mental illnesses shouldered by
blacks, Latinos, American Indians, Alaska Natives,
Asian-Americans and Pacific Islanders (AAPI)
• Only 1/20 Latino immigrants with a mental disorder seeks
treatment from a qualified professional
• Only 17% of afflicted AAPI sought care
• Only one mental health professional for 1,000 American
Indians or Alaska Natives (vs 1 per 578 for Whites)
Satcher D. Supplement to Surgeon General’s Report 2001
Disparities and Depression (II)
• Prevalence of mental disorders for racial and ethnic
minorities in the United States is similar to that for whites
• Minorities have less access to, and availability of, mental
health services. Minorities in treatment often receive a
poorer quality of mental health care
• General barriers: cost, lack of availability of services,
societal stigma toward mental illness
• Barriers for minorities: mistrust and fear of treatment,
racism and discrimination, cultural stigmas against mental
illness, and differences in language and communication
(Satcher D. Supplement to Surgeon General’s Report 2001)
Culture and Depression (I)
• People from each culture have their own
“explanatory model” of illness1
• In many non-European cultures, equivalent
concepts of depressive disorders are not found2
1
Kleinman(1982); 2 Marsella (1985) In Depression & Culture
Culture and Depression (II)
 Holistic vs dichotomized mind/body approach1
 Psychiatric nosology emphasizes mood s/s
 Eastern medicine’s disease classification does
not separate mood symptoms from physical
symptoms
 Mood symptoms are not the “idioms of
distress” among many Asian Americans2
1 Lin
K.M. Psych Serv 1999.
1982.
2
Kleinman A. Culture, Med & Pscyh
Barriers for Asian Americans in Accessing
Mental Health Services
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•
•
•
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Cultural barriers
Many Asian Americans are unfamiliar with
definitions of psychiatric disorders
Language barriers
Issues of use of interpreters
Issues with translation of terminologies
Traditional roles of psychiatrists in many
Asian countries
Yeung & Kung. Psychiatric News 21 (1): 34-36, 2004
Under-recognition of Depression in
US Hispanics in Family Practice
• Cause of Under-recognition: language differences, health
literacy barriers, somatic presentations, and use of cultural
idioms of distress
• Hispanic patients are often agreeable to treatment, tend to
prefer psychotherapy or combined counseling and
medication
• Recent studies have found that both psychological and
pharmacological treatment are efficacious in this minority
group
Lewis-Fernandez R et al. JABFP 18: 282-96, 2005
Under-recognition of MDD in
African Americans (AA)
• AAs with MDD are under-diagnosed
• AAs seem to have more severe episodes of depression
compared to Caucasians
• AAs with MDD often present with somatic symptoms,
leading physicians to miss a MDD diagnosis
• Depression is often seen as a “personal weakness” by AA
• AAs and other ethnic groups differ in the rate they
metabolize SSRIs, while clinical trials recruit mainly
Caucasians
Bailey RK et al. J National Med Asso 101:1084-1089, 2009
Relationship between Somatic Symptoms
and Depression
• Examined data from the World Health Organization’s
study of psychological problems in primary care
• Involved 15 centers in 14 countries on 5 continents
• The range of patients with depression who reported only
somatic symptoms was 45 to 95 percent
• The frequencies of psychological and physical symptoms
of depression were similar among centers
• In part, presentation of somatic symptoms may reflect
characteristics of physicians and health care system, as
well as cultural differences among patients
Simon GE et al. NEJM, 341:1329-35, 1999
Cultural Variations in the Clinical Interpretation
of Depression and Anxiety
• Somatic symptoms serve as cultural idioms of distress in
many ethnocultural groups
• Misinterpreted of somatic complaints by clinicians may
lead to unnecessary diagnostic procedures or
inappropriate treatment
• Clinicians must learn to decode the meaning of somatic
and dissociative symptoms, which are…part of a language
of distress with interpersonal and wider social meanings
Kirmayer LJ J Clin Psychiatry 62 (suppl 13), 22-28, 2001
The Explanatory Model Interview Catalogue
for Studying Illness Beliefs
a) Patterns of Distress (presentation, labeling)
b) Perceived causes of illness
(medical / biological / psychosocial /
supernatural / traditional)
c) Help seeking patterns
Weiss M. Soc Sci Med 27, No.1:5-16,1988
Chief complaints of Chinese-Americans with
Major Depressive Disorder (N=29)
______________________________________________
Chief complaints (%)
N (%)
______________________________________________
Physical symptoms
12 (42)
Depressive neurovegetative s/s
10 (34)
Depressive psychological s/s
4 (14)
Irritability, Rumination,
Poor memory
Nervousness
2 (7)
Depressed Mood
0 (0)
No complaints
1 (3.5)
______________________________________________
Yeung et al., J Nerv & Ment Dis 192 (4): 324-327, 2004
Labels used by Chinese-Americans Patients with Major
Depressive Disorder to Describe their Illness (N=29)
_____________________________________________________
Name of the illness
N (%)
_____________________________________________________
“Don’t know”
16 (55)
“Not an illness”
5 (17)
Medical Illnesses
5 (17)
“hypertension”
1
“cold”
2
“poor health”
1
“injured arm”
1
“Post Traumatic Stress Syndrome”
1 (3.5)
“Craziness”
2 ( 7)
__________________________________________________________________
Yeung et al., J Nerv & Ment Dis 192 (4): 324-327 2004
Causes of Illness Perceived by Chinese-Americans
with Major Depressive Disorder (N=29)
Methods
Frequency (%)
____________________________________________
Stress and/or psychological factors
27 (93)
Magico-Religious-Supernatural
13 (45)
Medical Problems
5 (17)
Traditional beliefs
4 (14)
Hereditary
4 (14)
Toxicity
3 (11)
Ingestion
2 (2)
Sex
0 (0)
______________________________________________
Yeung et al., J Nerv & Ment Dis 192 (4): 324-327, 2004
Methods of Help-Seeking by Depressed
Chinese-Americans Patients (N=29)
______________________________________________
Methods
Frequency(%)
______________________________________________
General Hospital
20 (69)
Lay Help
18 (62)
Alternative Treatment by Providers
16 (55)
Spiritual Treatment
4 (14)
Alternative Treatment by Self
3 (11)
Mental Health Professionals
1 (4)
______________________________________________
Yeung et al., J Nerv & Ment Dis 192 (4): 324-327, 2004
Challenges in Discussing with Culturally Diverse
Populations about Psychiatric Illness
Many of them do not share the mind/body dualism, the
basic assumptions of the diagnostic criteria in modern
psychiatry, and
Many of the labels of mental illnesses are not in the
patient’s lexicon, or these labels carry strong stigma that
deter patients from accepting or adhering to treatment
Interview with Cultural Sensitivity
■ It requires knowledge of one’s own cultural, the patients’
culture, the ways they might interact
■ To develop co-constructed illness-narratives with patients
■ To reframe communications into more culturally resonant
forms, by contextualizing depressive symptoms into
patient’s physical health and social system
■ Use terminology that avoid unintended stigma
■ To involve patient’s families whenever possible
Yeung & Kam. Transcult Psychiatry 45(4):531-5
Cultural Formulation
A format for semi-structured evaluation of every patient’s
cultural background, which includes:
A) the cultural identity of the patient
B) cultural explanations of the individual’s illness
C) cultural factors related to psychosocial environment and
functioning,
D) cultural elements of the relationship between the
individual and the clinician, and
E) an overall assessment of diagnosis and care
Lewis-Fernandex & Naelys. Psychiatric Quarterly 2002; 73 (4): 271-295
Engagement Interview Protocol (EIP)
I. History of Illness
Elicit patient’s narratives &
explanatory model of illness
II. Psychosocial History
III. Mental Status Examination
IV. Multi-axial Diagnoses
V. Culturally Sensitive Communication of Diagnosis
VI. The Customized Approach to Treatment Negotiation
Yeung et al. International Journal of Culture and Mental Health (in press)
EIP (I):Elicit patient’s illness narratives
It is important to listen to the patients’ narratives, to
understand the framework, conception, and the
language they use to describe their illness
Patient’s narratives of his/her illness can be used as a
platform to develop co-constructed illness narratives with
patients, and to aid this process by reframing different
elements of the clinical process into more cultural
resonant forms
Yeung & Kam. Transcult Psychiatry 45(4):531-552
EIP (II): Explore patient’s Illness Beliefs
1. What do you call your problem?
2. What has caused it?
3. Why do you think it started when it did?
4. What does it do to you?
5. How severe is it?
6. What do you fear most about it?
7. What are the chief problems it has caused you?
8. What kind of treatment do you think you should receive?
What are the most important results you hope to receive from
the treatment?
Kleinman(1982) Patients and Healers
EIP (III): Culturally Sensitive Communication
of psychiatric disorders
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Elicit patient’s illness beliefs
Acceptance of multiple explanatory models
Clarify meanings of diagnostic labels
Flexibility of terminology
Connecting patient’s illness explanatory model
with Western psychiatric diagnosis

Staging of disclosure
EIP (IV): Customized Treatment Negotiation
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Provide rationale for use of medication
Disclose side effects and offer reassurance
Elicit patient’s resistance to medications
Discuss alternative treatment options
Negotiate to reach consensus on treatment
Vignette # 1. The depressed patient who focused on anxiety symptoms
A 21 y/o single Chinese male who emigrated to the U.S. two years ago. He was
a restaurant worker, and had borrowed a huge sum of money to be smuggled
into the U.S. While he was preoccupied with anxiety symptoms, he reported
having depressed mood, insomnia, irritability, ↓ interests, & ↓concentrating
Patient’s explanatory model of his illness experience:
1. “ What do you call it?”
“worries”
2. “What caused it?”
“stress from adjusting to life here and language problems”
3. “When started?”
“two years ago after I came to the U.S.”
4. “What does it do to you?”“cannot concentrate at work”
5. How severe is it?
“pretty severe”; “it has lasted for a long time”
6. “What do you fear most?” “That I might become impulsive and even hurt myself”
7. “Chief problems?”
“too much worries”
8. “What treatment?”
“try to stay in touch with my family”
“most important results” “to get better”
Vignette # 1. The depressed patient who focused on anxiety symptoms
Culturally Sensitive Disclosure of Diagnosis: We adopted his explanatory model
and used his own words in suggesting that it was likely that his symptoms were
due to “pressure” in his life as a recent immigrant. We asked him if he had heard
of depression (yi yu zheng) and whether he might be suffering from depression.
He replied that he was not familiar with the term and he was not sure if he had
the illness. We informed him that while it may be too early to conclude, it was
possible that he actually had depression
Customized Approach to Treatment Negotiation: He was informed that there are
medications available to reduce his worries as well as his other related symptoms
including insomnia, irritability, and loss of interest, and that he should expect to
“get better” in several weeks. The patient agreed to try the medications and see
if they could help him
Vignette # 2. The depressed patient who attributed her symptoms to
psychosocial problems
A 29-year-old divorced Chinese female who emigrated to the U.S. four
years ago, and she lived with her 9-year-old son. She was laid off from
her job three months ago, which had caused significant financial
hardship. The patient and her son shared an apartment with roommates,
and complained the lack of privacy. She reported that she had been
suffering from sadness, insomnia, ↓ interest, irritability, guilt, and
↓ concentrating. She had not received any treatment for these symptoms
Patient’s explanatory model of his illness experience:
1. “What do you call it?”
“don’t know”
2. “What has caused it”
“financial pressure and crowded living condition”
3.“When did it start?”
“since I was laid off several months ago”
4.“What does it do to you?” “don’t feel well”
5.“How severe is it?”
“moderately severe”
6.“What do you fear most?” “the influence on my son’s emotion”
7.“Chief problems?”
“sadness, being irritable”
8.“What treatment?”
“to improve in our living conditions”
“most important results”
Vignette # 2. The depressed patient who attributed her symptoms to
psychosocial problems
Culturally Sensitive Disclosure of Diagnosis: The patient was aware of her own
mood and depressive symptoms, although she attributed them to her financial
and living condition rather than a mental condition. We agreed with her
interpretation of the importance of her psychosocial stress or “pressure” (in her
own words) on the development of her symptoms. When we asked her if she
considered herself having depression, she replied, “possible”
Customized Approach to Treatment Negotiation: We acknowledged that improving
her
. housing condition was important, and we suggested that she look into applying
to state-subsidized housing. In addition, we pointed out that the treatment of
depression would help her to feel less stressed and irritable so that she can be a
good mother. Also, her mood and other symptoms may improve with treatment and
she would be able to function and interview for new jobs. We offered her treatment
options including medications and therapy, and patient agreed to see a therapist
Vignette # 3. The depressed patient who focused on her somatic symptoms
A 63-year-old widowed Chinese female who emigrated to the U.S. in 2003. She
lived alone in elderly housing, and provided childcare to her grandchildren several
days a week. She felt that she had difficulty adjusting to life in the U.S. and felt
socially isolated and lonely. She complained about insomnia, headaches,
depressed mood, ↓interest, feelings of guilt, fatigue, ↓concentration, irritability,
and passive SI. She wants to fix her sleep problem
Patient’s explanatory model of his illness experience:
1. “What do you call it?”
“insomnia and fatigue”
2. “What has caused it?” “adjustment problems in the U.S.”
3. “When did it start?”
“in 2003”
4. “What do it do to you?” “When I cannot sleep, I feel tired and have headaches”
5. How severe is it?
“sleep problem is pretty severe’
6. “What do you fear most?” “cannot sleep at night”
7. “Chief problems?”
“sleep problems”
8. “What treatment?”
“medication may help”
“most important results” “to sleep well”
Vignette # 3. The depressed patient who focused on her somatic symptoms
Culturally Sensitive Disclosure of Diagnosis: The patient focused strongly on her
somatic symptoms, including insomnia, headaches, and fatigue. She labeled her
problem “insomnia”.. When asked, patient replied that she had sort of heard of
depression, but did not think she suffered from depression. We explained that in
the West, depression refers to a cluster of symptoms including sadness,
insomnia, loss of interest, guilt feelings, fatigue, difficulty concentrating, irritability
and SI, similar to many of the symptoms that she reported
Customized Approach to Treatment Negotiation: She had considered taking
medications for sleep, but like many Chinese, “sleeping pills” have strong negative
connotations. We reassured her that we were not planning to use “sleeping pills.”
Rather, we planned to use medications to treat her insomnia, mood symptoms
which
does not have addictive potential. The patient was receptive to the
.
recommendation and accepted an antidepressant despite denying that she had a
depressive disorder
Vignette # 4. The depressed patients who considered herself as having
poor health with unidentified causes
A 51-year-old widowed Chinese female who emigrated to the U.S. in 2006. She
was a housewife in China and worked as a home aide for the elderly in the U.S.
She reported having language barriers, financial problems, and was socially
isolated. She complained of insomnia, ↓interest, irritability, excessive worries,
difficulty concentrating, and multiple physical symptoms. Her primary care
physician did not find any specific illness after repeated examinations and
laboratory tests
Patient’s explanatory model of his illness experience:
1. “What do you call it?”
“don’t know”, “it could be poor health”
2. “What has caused it?”
“not sure”
3. “When did it start?”
“when I emigrated to the U.S.”
4. “What does it do to you?” “poor health”
5. How severe is it?
“moderately severe” “it has lasted for 3 years”
6. “What do you fear most?” “I may have an unidentified illness”
7. “Chief problems?”
“not feeling well”
8. “What treatment?”
“not sure”
“most important results” “I want to feel better”
Vignette # 4. The depressed patients who considered herself as having
poor health with unidentified causes
Culturally Sensitive Disclosure of Diagnosis: The patient was aware that she had
multiple physical and emotional symptoms. She, like many Chinese immigrants
with traditional illness beliefs, was unfamiliar with the concept of depression and
attributed her symptoms to “poor health”. During the interview, she was asked if
she held strong opinions against being diagnosed with depression. She did not
offer a direct answer, but remained skeptical that she had depression
Customized Approach to Treatment Negotiation: Treatment negotiation focused on
symptom
reduction. The patient was encouraged to consider medication treatment
.
and self-management measures such as exercise, relaxation techniques, problemsolving skills, and positive thinking for relief of symptoms. Although many patients
are unfamiliar with depression or wary of the diagnosis, they are willing to accept
medications including antidepressants if reassured that these are safe medications
that may reduce or even eliminate their symptoms
Conclusion
 Cultural barriers contribute to treatment disparities of MDD
among minority patients
 Clinicians need to explore patient’s illness beliefs and what
they hope to obtain from treatment
 Incorporating culture in diagnostic interviews allows the
clinician to communicate the illness using language,
concepts, and framework that the patient can understand,
and to successfully negotiate treatment strategy meaningful
to the patient