Ethnicity and psychopharmacology

The Genetics of Response to and Side Effects of Lithium Treatment in Bipolar Disorder: Future Research Perspectives

Although the mood stabilizer lithium is a first-line treatment in bipolar disorder, a substantial number of patients do not benefit from it and experience side effects. No clinical tool is available for predicting lithium response or the occurrence of side effects in everyday clinical practice. Multiple genetic research efforts have been performed in this field because lithium response and side effects are considered to be multifactorial endophenotypes. Available results from linkage and segregation, candidate-gene, and genome-wide association studies indicate a role of genetic factors in determining response and side effects. For example, candidate-gene studies often report GSK3β, brain-derived neurotrophic factor, and SLC6A4 as being involved in lithium response, and the latest genome-wide association study found a genome-wide significant association of treatment response with a locus on chromosome 21 coding for two long non-coding RNAs. Although research results are promising, they are limited mainly by a lack of replicability and, despite the collaboration of consortia, insufficient sample sizes. The need for larger sample sizes and "multi-omics" approaches is apparent, and such approaches are crucial for choosing the best treatment options for patients with bipolar disorder. In this article, we delineate the mechanisms of action of lithium and summarize the results of genetic research on lithium response and side effects.

The side effect profile of Clozapine in real world data of three large mental health hospitals

OBJECTIVE

Mining the data contained within Electronic Health Records (EHRs) can potentially generate a greater understanding of medication effects in the real world, complementing what we know from Randomised control trials (RCTs). We Propose a text mining approach to detect adverse events and medication episodes from the clinical text to enhance our understanding of adverse effects related to Clozapine, the most effective antipsychotic drug for the management of treatment-resistant schizophrenia, but underutilised due to concerns over its side effects.

MATERIAL AND METHODS

We used data from de-identified EHRs of three mental health trusts in the UK (>50 million documents, over 500,000 patients, 2835 of which were prescribed Clozapine). We explored the prevalence of 33 adverse effects by age, gender, ethnicity, smoking status and admission type three months before and after the patients started Clozapine treatment. Where possible, we compared the prevalence of adverse effects with those reported in the Side Effects Resource (SIDER).

RESULTS

Sedation, fatigue, agitation, dizziness, hypersalivation, weight gain, tachycardia, headache, constipation and confusion were amongst the highest recorded Clozapine adverse effect in the three months following the start of treatment. Higher percentages of all adverse effects were found in the first month of Clozapine therapy. Using a significance level of (p< 0.05) our chi-square tests show a significant association between most of the ADRs and smoking status and hospital admission, and some in gender, ethnicity and age groups in all trusts hospitals. Later we combined the data from the three trusts hospitals to estimate the average effect of ADRs in each monthly interval. In gender and ethnicity, the results show significant association in 7 out of 33 ADRs, smoking status shows significant association in 21 out of 33 ADRs and hospital admission shows the significant association in 30 out of 33 ADRs.

CONCLUSION

A better understanding of how drugs work in the real world can complement clinical trials.

Mental health interventions for traumatized asylum seekers and refugees: What do we know about their efficacy?

BACKGROUND

The prevalence of trauma-related problems among refugees and asylum seekers is extremely high due to adverse experiences associated with forced migration. Although the literature presents a considerable number of guidelines and theoretical frameworks for working with traumatized refugees and asylum seekers, the efficacy, feasibility and applicability of these interventions have little empirical evidence.

AIMS

The purpose of this article is to critically review the literature to provide a rationale for developing culturally sensitive, evidence-based interventions for refugees and asylum seekers.

METHODS

A literature review integrating research findings on interventions designed especially for traumatized asylum seekers and refugees was conducted. Retained studies had to use some quantitative measurements of post-traumatic stress and to have pre- and post-measurements to evaluate the efficacy of the intervention. Studies included in this review cover a wide variety of interventions, including trauma-focused interventions, group therapy, multidisciplinary interventions and pharmacological treatments.

RESULTS

The majority of studies with traumatized refugees and asylum seekers reported positive outcomes of the intervention in reducing trauma-related symptoms. There is evidence to support the suitability of cognitive-behavioral therapy (CBT) and narrative exposure therapy (NET) in certain populations of refugees. Other intervention studies are limited by methodological considerations, such as lack of randomization, absence of control group and small samples.

CONCLUSIONS

This review has again highlighted the shortage of guiding frameworks available to investigators and clinicians who are interested in tailoring interventions to work with refugees and asylum seekers. Theoretical, ethical and methodological considerations for future research are discussed.

Psychological characteristics of early remitters in patients with panic disorder

We aimed to examine whether anxiety sensitivity and agoraphobic fear could affect the time taken to remission after 24 weeks of open-label escitalopram treatment of patients with panic disorder (PD). We recruited 158 patients, and 101 patients completed the study. Clinical severity and psychological characteristics were assessed at baseline and 4, 12, and 24 weeks after the treatment, using the Clinical Global Impression-Severity (CGI-S), the Hamilton Rating Scales for Anxiety and Depression, the Anxiety Sensitivity Index-Revised (ASI-R), the Albany Panic and Phobia Questionnaire (APPQ), and the Panic Disorder Severity Scale (PDSS). Remission was defined as the absence of full panic attacks and PDSS scores of 7 or less. Completing patients were stratified according to the time taken to remit: early (n=20) and late (n=58) remission and non-remission groups (n=23). There were no significant differences among the three groups at baseline on the CGI-S and the PDSS mean scores. However, early remitters had significantly lower scores than late remitters and non-remitters on the ASI-R and APPQ. In conclusion, anxiety sensitivity and agoraphobic fear can affect the time to remission after pharmacotherapy, and clinicians should consider the psychological characteristics of PD patients in order to achieve an optimal response to pharmacotherapy.

Effective therapeutic dosage of antipsychotic medications in patients with psychotic symptoms: Is there a racial difference?

Background

Genetic make up had been known to influence pharmacokinetics and pharmacodynamics of psychotropic medications. Time separation in evolutionary trend in Africans, Orientals and Caucasians had been thought a possible explanation for the observed racial variation in activities of Cytochrome P 450 (CYP 450) enzymes, which are responsible for metabolism of psychotropic and other medications in human. Past studies on pharmacokinetics and pharmacodynamics of antipsychotic medications and socio-cultural factors influencing response to antipsychotic medications had consistently giving an inkling of possible racial difference in symptoms response to antipsychotic medications. Another growing body of evidence subscribing to possible racial difference in psychotic symptoms response to antipsychotic medications is the observed variation in antipsychotic medications prescription pattern and dosage across races and regions. Empirical observation had shown that dosage prescription pattern of antipsychotic medications in most Sub-Saharan African countries deviates from the standard prescription guidelines published for use in western parts of the world. Studies coming from the United States (U.S) had consistently reported a higher dosage of antipsychotic medications prescription for African-American patients compared to their Caucasian counterparts. Research on East Asia Psychotropic Prescription (REAP) study had also identified high dosage antipsychotic medications prescription pattern well above the recommended dose of 1,000 mg Chlorpromazine equivalent per day as common practices in some East Asian countries.

Presentation of the Hypothesis

The pertinent question is why the apparent differences in dosage prescription practices across races and regions? The possibility of racial differences in psychotic symptoms response to antipsychotic medications rather than clinicians' prescription attitudes was entertained.

Testing the Hypothesis

Future carefully controlled studies might be needed to test the proposed hypothesis of racial differences in psychotic symptoms response to antipsychotic medications.

Implication of the Hypothesis

There might be actual racial influence on psychotic symptoms response to antipsychotic medications. If future carefully controlled studies uphold the hypothesis of racial differences in psychotic symptoms response to antipsychotic medications, there might be need to draw up new treatment or prescription guidelines that would put into consideration variations in genetic make up and consequent racial differences in psychotic symptoms response to antipsychotic medications.

Long-term efficacy and safety of zonisamide monotherapy in epilepsy patients

BACKGROUND AND PURPOSE

Zonisamide (ZNS) is a useful antiepileptic drug with a broad therapeutic spectrum. However, there is limited information on the long-term use of ZNS as a monotherapy. This study investigated the long-term effects of ZNS as a monotherapy for the treatment of epilepsy.

METHODS

We retrospectively analyzed the records of epilepsy patients treated with ZNS monotherapy at our clinic. We identified outcomes for patients treated with ZNS monotherapy for a minimum of 6 months. Efficacy was quantified as the percentage change in seizure frequency, and safety was assessed by the frequency and types of adverse events.

RESULTS

Sixty patients who received ZNS for a minimum of 6 months were included. The mean duration of treatment was 19.8 months (range, 6-37 months), and the mean ZNS dosage was 255 mg/day (range, 100-500 mg/day). Twenty-seven patients (45%) were seizure-free, and an additional 20 patients (33%) had above 50% seizure frequency reduction at the last follow-up visit. Partial seizures with or without secondary generalization and generalized seizures were well controlled by ZNS, whereas complex partial seizures were not. Forty-eight patients (80%) reported mild-to-moderate adverse events, including memory loss (35%), attention deficit (27%), and weight loss (20%).

CONCLUSIONS

Long-term ZNS monotherapy is effective at treating a broad spectrum of seizure disorders, except complex partial seizures. However, a specific adverse event, such as cognitive impairment, is common and long-lasting.

Ethnopharmacology: understanding how ethnicity can affect drug response is essential to providing culturally competent care

Ethnopharmacologic research has revealed that ethnicity significantly affects drug response. Genetic or cultural factors, or both, may influence a given drug's pharmacokinetics (its absorption, metabolism, distribution, and elimination) and pharmacodynamics (its mechanism of action and effects at the target site), as well as patient adherence and education. In addition, the tremendous variation within each of the broader racial and ethnic categories defined by the U.S. Census Bureau (categories often used by researchers) must be considered. Nurses need to become knowledgeable about drugs that are likely to elicit varied responses in people with different ethnic backgrounds, as well as the potential for adverse effects. The existing ethnopharmacologic research focuses primarily on psychotropic and antihypertensive agents, as does this article. Cultural assessment of every patient is vital; thus Leininger's Sunrise Model and Giger and Davidhizar's Transcultural Assessment Models are briefly described as well.

Cognitive Effects of Low-dose Topiramate Compared with Oxcarbazepine in Epilepsy Patients

Background and Purpose

Low-dose topiramate (TPM) monotherapy has recently been found effective for seizure control in newly diagnosed epilepsy. In higher dosages, TPM has been associated with relatively high rates of adverse cognitive effects; similar side effects have been seen after rapid titration or polytherapy. However, its cognitive effects during low-dose monotherapy have not been established. We evaluated the cognitive effects of low-dose TPM compared with oxcarbazepine (OXC), a drug that does not appear to affect cognitive function.

Methods

Cognitive tests and subjective complaints of 30 patients with low-dose TPM monotherapy (50-200 mg/day) were retrospectively compared with those of 30 patients with OXC monotherapy at 1 year of medication. The two groups did not differ with respect to epilepsy-relevant variables, nor on baseline neuropsychological tests.

Results

The TPM group showed a significant difference in the performance of delayed word recall (P<0.05), backward digit span (P<0.01), and verbal fluency (P<0.05) compared with the OXC group. The TPM group showed worse performances of digit span and verbal fluency. The OXC group showed better performances of delayed word recall. The incidence of cognitive complaints was higher in the TPM group (50%) than in the OXC group (20%) (P<0.05). These cognitive effects shown in the TPM group were dose-related. The cognitive dysfunction was trivial with patients taking 50 mg/day TPM.

Conclusions

Even at low-dose, TPM has a negative effect on working memory and verbal fluency compared with OXC. It can be demonstrated at 1 year of treatment.

Cognitive effects of low-dose topiramate monotherapy in epilepsy patients: A 1-year follow-up

The present study was conducted to evaluate the long-term effects of low-dose topiramate (TPM) monotherapy on the cognitive function of epilepsy patients. Forty-seven epilepsy patients received TPM, with target doses of 50, 75, and 100 mg/day. Cognitive tests were performed twice, at baseline and 1 year after starting medication. Thirty-six patients completed the follow-up neuropsychological tests. After a year of treatment, 16 patients (44%) complained of cognitive problems. Although it improved seizure frequency and EEG abnormalities, TPM had significantly negative effects on the digit span and verbal fluency tests. These cognitive effects were dose-related and significantly improved after withdrawal from TPM and substitution with older antiepileptic drugs. In conclusion, even at a low dose, TPM has long-term, negative effects on working memory and verbal fluency.

Ethnopharmacology

Ethnopharmacologic research has revealed that ethnicity significantly affects drug response. Genetic or cultural factors, or both, may influence a given drug's pharmacokinetics (its absorption, metabolism, distribution, and elimination) and pharmacodynamics (its mechanism of action and effects at the target site), as well as patient adherence and education. In addition, the tremendous variation within each of the broader racial and ethnic categories defined by the U.S. Census Bureau (categories often used by researchers) must be considered. Nurses need to become knowledgeable about drugs that are likely to elicit varied responses in people with different ethnic backgrounds, as well as the potential for adverse effects. The existing ethnopharmacologic research focuses primarily on psychotropic and anti-hypertensive agents, as does this article. Cultural assessment of every patient is vital; thus Leininger's Sunrise Model and Giger and Davidhizar's Transcultural Assessment Models are briefly described as well.

CYP2D6 allele frequency in European Caucasians, Asians, Africans and their descendants

Over 40 cytochrome P450 (CYP) 2D6 allelic variants have been discovered thus far. The alleles may be classified on the basis of the level of activity for which they encode CYP2D6 enzymes, into functional, non-functional and reduced function groups. CYP2D6 allele frequency is known to vary amongst racial/ethnic groups. Generally, for European Caucasians and their descendants, the functional group of alleles are predominant, with a frequency of 71%. Non-functional alleles represent 26% of the variability, mainly CYP2D6*4. In Asians and their close descendants, functional alleles represent only ~ 50% of the frequency of CYP2D6 alleles. Asians and Pacific Islanders have a high frequency (median = 41%) of a reduced function allele, CYP2D6*10, contributing to the population shift to the right of metabolic rates indicating slower metabolism. Information concerning Amerindians from North (Canada), Central and South America indicate comparatively low frequencies of CYP2D6*10, perhaps a "founders" effect. The frequency of functional alleles in Africans and African Americans is also about 50%. Both Africans and African Americans have reduced function alleles representing 35% of allele variation, mainly CYP2D6*17. African Americans, however, have more than twice the median frequency of nonfunctional alleles compared with Africans (14.5% vs 6.3%). Non-functional and reduced function alleles represent about 50% of allele frequency in Black populations but a much greater variety than carried in Asians. Since alleles which encode for no or reduced functioning clearly affect metabolic activity of drugs mediated by CYP2D6, studies are needed in populations in which these alleles play a major role in order to assure optimal dosing recommendations are based on empirical pharmacogenetics.

Culture and history in psychiatric diagnosis and practice

A brief review of the history of Western psychiatry underscores how happenings in Anglo European societies during the early modern and modern era impacted on regional populations in the midst of profound demographic, social and political economic change. Such factors along with cultural conventions created an amalgam of behavior problems: social responses to these under the aegis administrative bodies gave rise to the discipline and profession of psychiatry. Central tenets that we take for granted as facts about psychiatric disorders (e.g., their manifestations, natural history, diagnosis) were shaped by historical and cultural influences. Psychiatry may outline a science of the psyche and its disturbances but it also reflects a cultural interpretation about personal experience, responsibility, social behavior, and the requirements for social order. The cultural character of the psychiatric enterprise itself, just as much as the characteristics of its disorders, constitute the subject matter of cultural psychiatry. Events during the late eighteenth and nineteenth centuries in Anglo European societies gave rise to psychiatry. First, there took place the differentiation of psychiatric disorders from the pool of human social and behavior problems. Second, and in relation to this, a segment of the medical profession was accorded (or appropriated) a social mandate and acquired an obligation to treat victims of mental disorders. The historical sociology of psychiatry constitutes one aspect of cultural psychiatry. The second covers developments during the latter part of the twentieth century. At this juncture, psychiatry became the target of labeling theorists in sociology, cultural relativists in anthropology, antipsychiatrists from within the discipline itself, and revisionist and critical historians of psychiatry. An outgrowth of this is the perspective that underscores the important role played by values, ideas, and world-views in how individuals experience and carry out their lives, phenomena that are critical to the expression, interpretation, diagnosis, and treatment of psychiatric disorders. That the science and practice of modern psychiatry incorporate an ethnocentric, Anglo European bias or slant on psychopathology is an integral assumption of cultural psychiatry. By describing how other non-Western systems of psychiatry have operated, for example, their theories and practices, one gains a further appreciation of the important role of culture in shaping Western psychiatry. This is taken up in an article by Fàbrega elsewhere in this issue where concepts and practices of traditional Chinese and Indian medicine that pertain to mental health and illness are reviewed.

Biological constraint, cultural variety, and psychological structures

Although biological processes bias humans to develop particular cognitive, affective, and behavioral forms, the cultural context of growth shapes these forms in particular ways. Psychologists have been indifferent to the nature of the mental structures that mediate the varied psychological functions that are the usual target of inquiry. This paper argues that schemata for perceptual events, motor programs, and semantic networks are distinct, although interdependent, forms that rest on different neurophysiologies. The biological constraints are weakest on the semantic networks that are influenced by the history, economy, religion, geography, and social structure of the society. These factors influence how cultures classify names for emotions, categories of self-membership, and popular metaphors for human nature. One class of schemata is derived from changes in body tone. Temperamental variation in the susceptibility to changes in body tone has relevance for understanding personality and a vulnerability to anxiety disorders.

Antipsychotic-Induced movement disorders in the elderly: epidemiology and treatment recommendations

We reviewed the epidemiological aspects of antipsychotic-induced movement disorders as they pertain to older patients. The incidence and prevalence of drug-induced parkinsonism and tardive dyskinesia (TD) are significantly greater in the older patient than in the younger patient whereas akathisia seems to occur evenly across the age spectrum and dystonia is uncommon among older patients. The literature on risk factors associated with treatment-emergent movement disorders is highly variable. Treatment practices vary across the age range and the interaction between age and antipsychotic dosage confounds our understanding of the relative importance of treatment-related risk factors. However, there is general agreement that pre-existing extrapyramidal signs (EPS) increase the vulnerability of the patient to developing significant drug-induced movement disorders. Elderly patients with dementia are at greater risk than patients without dementia for persistent drug-induced EPS. Management of drug-induced movement disorders in the older patient requires careful consideration of the contraindications imposed by such agents as anticholinergics and beta-blockers. At present, well-controlled double-blind studies of second-generation antipsychotics such as clozapine, risperidone. olanzapine or quetiapine for reducing the risk of treatment-emergent movement disorders in the elderly have not been published. However, open-label studies of atypical antipsychotics demonstrate a markedly lower incidence of both EPS and TD compared with conventional antipsychotic treatment in the elderly. There is emerging literature in support of atypical antipsychotics for the treatment of existing drug-induced movement disorders. More controversial is the use of adjunctive antioxidants in newly treated patients who are vulnerable to drug-induced movement disorders. While the evidence is mixed in support of antioxidants for the treatment of TD, the possibility remains that prophylactic use of antioxidants may help reduce the incidence of TD. The development of a drug-induced movement disorder often reduces the quality of life in an elderly patient. Effective pharmacological management requires cooperation from the patient and family, which can be fostered early in the patient's care through proper informed consent. The risks and benefits of antipsychotic treatment in the elderly patient need to be communicated to the patient and family. At the present time, there is no consistently effective treatment for patients with TD once it develops. Therefore, attention should focus on its prevention and close monitoring.

Single dose pharmacokinetic study of lithium in Taiwanese/Chinese bipolar patients

OBJECTIVE

The purpose of this study is to investigate the single dose pharmacokinetics of lithium in Taiwanese/Chinese bipolar patients for future interracial comparisons.

METHOD

Eight bipolar patients took 900 mg of lithium carbonate after overnight fasting. Blood samples of 5 mL were taken after 15 min, 30 min, 45 min, 1 h, 2 h, 3 h, 4 h, 7 h, 9 h, 15 h, 25 h and 31 h after dosing. The computer programs CSTRIP and PCNONLIN were used for pharmacokinetic analysis.

RESULTS

The pharmacokinetic parameters obtained were as follows: Cmax, 0.970 +/- 0.170 (SD) mmol/L; Tmax, 1.59 +/- 0.78 h; AUC31 h = 548.9 +/- 135.4 mmol x m/L; AUC to infinity = 722.6 +/- 262.7 mmol x m/L; beta-half-life = 16.3 +/- 7.18 h; kappa-half-life = 0.613 +/- 0.442 h; Cl(oral) = 1.13 +/- 0.39 mL/min/kg; Vd/F = 1.43 +/- 0.387 L/kg. Most of the pharmacokinetic parameters were within the ranges reported in investigations of Caucasian subjects.

CONCLUSIONS

This study showed that racial differences in lithium pharmacokinetics might not exist. We suggest that methodological designs, including method of blood sampling, measurement of lithium, and pharmacokinetic and statistical calculations, be standardised if future cross-ethnic comparisons are to be conducted.

Black and white patients response to antidepressant treatment for major depression

Differences in response to psychopharmacologic agents according to race has so far primarily focused on investigations related to the response of Asian-American patients to neuroleptics and lithium. In this article, we present evidence which depicts that black patients need lower doses of tricyclic antidepressants (TCAs) than white patients to attain a similar response in the treatment of major depression. Likewise, we also advance that black patients might need lower doses of selective serotonin re-uptake inhibitor antidepressants (SSRIs) than white patients to attain a similar response in the treatment of major depression. Further studies are suggested to confirm these findings.

Ethnicity and antipsychotic response

OBJECTIVE

To review the data generated by studies examining interethnic/racial differences in response to antipsychotics.

DATA SOURCES

A MEDLINE search (1966-1996) identified all articles examining differences in antipsychotic response among Caucasians, Asians, Hispanics, and African-Americans, as well as articles evaluating postulated mechanisms for these differences.

STUDY SELECTION

All abstracts, studies, and review articles were evaluated.

DATA SYNTHESIS

Ethnic/racial differences in response to antipsychotic medications have been reported and may be due to genetics, kinetic variations, dietary or environmental factors, or variations in the prescribing practices of clinicians. Studies suggest that Asians may respond to lower doses of antipsychotics due to pharmacokinetic and pharmacodynamic differences. Research relevant to African-Americans is limited, but some studies suggest that differences in this group may be due to clinician biases and prescribing practices, rather than to pharmacokinetic or pharmacodynamic variability.

CONCLUSIONS

Future research directed at validating the hypotheses that different ethnic/racial groups show variations in response to antipsychotics should focus on homogeneous ethnic groups, use recent advances in pharmacogenetic testing, and control for such variables as observer bias, gender, disease chronicity, dietary and environmental factors, and exposure to enzyme-inducing and -inhibiting agents. Clinicians should be aware that potential interethnic/racial differences in pharmacodynamics and pharmacokinetics may exist that can alter response to antipsychotics.

The pharmacokinetics and pharmacodynamics of adinazolam: multi-ethnic comparisons

The pharmacokinetics and pharmacodynamics of adinazolam and N-demethyladinazolam (NDMAD), its major active metabolite, were compared in 39 healthy male volunteers (13 Asian, 12 Caucasian and 14 African-American). In a four-way, double-blind crossover design, subjects were administered (1) 30 mg oral adinazolam mesylate SR tablets, (2) 10 mg parenteral (i.v.) adinazolam mesylate, (3) 30 mg i.v. NDMAD and (4) placebo. Venous blood samples were collected at specific time intervals after drug administration and assayed for adinazolam and NDMAD concentrations. Sedation was rated at the time of each blood draw according to the Nurse-Rated Sedation Scale, and the digit-symbol substitution test was administered to evaluate psychomotor performance. After i.v. administration of adinazolam, Asians manifested significantly higher Cmax, larger AUC and lower CL of both adinazolam and NDMAD than their Caucasian and African-American counterparts. Likewise, after i.v. NDMAD Asians had significantly higher NDMAD Cmax and AUC than Caucasians and African-Americans. Most of these differences remained statistically significant after controlling for body surface area. With PO adinazolam, Asians also manifested substantially higher Cmax, larger AUC and lower CL for both adinazolam and NDMAD; however, with the exception of Cmax, these differences did not reach statistical significance. These results are in accordance with previous observations for ethnic-related differences in drug pharmacokinetics. In contrast, pharmacodynamic differences were not noted among the three study groups.

Race, quality of care, and antipsychotic prescribing practices in psychiatric emergency services

OBJECTIVE

The study examined whether the prescription practices of clinicians in psychiatric emergency services differed for African-American patients. Prescription of antipsychotic medications and its relation to quality of care was a particular focus.

METHODS

Data from 442 independently observed evaluations of patients in psychiatric emergency services were examined using multivariate analyses. The observations were made during a five-year period at four urban general hospitals in California.

RESULTS

Clinicians in the four emergency services, most of whom were Caucasian, prescribed more psychiatric medications to African Americans than to other patients and devoted significantly less time to their evaluations. African Americans received more oral doses and more injections of antipsychotic medications, and the mean 24-hour dosage of antipsychotics (1,321 milligrams) was significantly higher than for other patients (825 milligrams). The tendency to overmedicate African-American patients was lower when clinicians' efforts to engage the patients in treatment were rated higher.

CONCLUSIONS

The results highlight the importance of efforts to engage African Americans in the treatment process and the need for clinical skills and training to help bridge cultural distances.

Cultural challenges to the psychiatric enterprise

Two challenges to psychiatry emanating from the study of cultural differences in mental illness are reviewed. The first challenge, conducted under the banner of cultural relativism, appeared to undermine the validity of psychiatric disorders. The misconceptions of this challenge, as embodied in the excesses of the labeling theory of sociology, were associated with the writings of antipsychiatrists and rejection of the community mental health movement. The result of all this was a devaluation of insights inherent in the cultural perspective. The second challenge draws emphasis to the pervasive role played by cultural differences in every facet of the psychiatric enterprise. Its relevance and contributions are briefly summarized. The study of the cultural sciences as they pertain to psychiatry offers a necessary corrective to the increasing impersonality and reductionism that is coming to characterize the neurobiologic approach.

Transcultural Psychiatric Nursing: Diagnostic and Treatment Issues

1. Psychiatric nurses are exposed to individuals and families experiencing culture-bound illnesses in which symptomatology closely mimics psychiatric problems. 2. Because of the great potential of misdiagnosis among culturally diverse groups as having a mental illness, a cultural assessment must be done. 3. The culturally competent model of care is a conceptual model of nursing care that views cultural awareness, knowledge, skill, and encounters as components of cultural competence. Cultural competence is viewed as a process in which the psychiatric nurse strives to effectively work with individuals and families from culturally diverse backgrounds.

Side effects of chronic lithium therapy in Hong Kong Chinese: an ethnopsychiatric perspective

A biocultural study of the side effects of chronic lithium treatment among 70 Hong Kong Chinese psychiatric patients, using a self-report 33-item checklist and semi-structured interviews, revealed an imperfect correspondence between biomedically prescribed and culturally endorsed psychotropic side effects. Although polydipsia and polyuria (47%) were the biomedically most 'real' side effects, they were not usually regarded as bothersome or translated into metaphors to express undesirable side effects. Complaints such as tiredness (38%), drowsiness (36%) and poor memory (31%) were also common but their frequency was significantly lower than that of normal control subjects. The item 'loss of creativity' had no conceptual equivalent in Chinese and was usually misinterpreted. As no patient was aware that lithium was a metal, the side effect 'metallic taste' was variously labelled. Contrary to Western findings, complaints of 'missing of highs', loss of assertiveness and fear of weight gain were rarely encountered. Active elicitation was required for indigenous complaints, with 38% of patients considering lithium to cause mild "hotness." This was readily neutralized by drinking more water which had a "cooling" effect. Expectedly, concurrent neuroleptics and antidepressants amplified most lithium side effects. This study affirms Western data on the biomedically universalizable effects of chronic lithium treatment, but also supports the thesis that culturally constituted cognitive styles affect patients' recognition, labelling, experiencing and reporting the total drug effect. Further, it demonstrates that the lived experience and clinical negotiation of lithium associated side effects reproduce, authenticate, and at times critique, core cultural and moral premises of Western and Chinese societies.

Thyroid abnormalities during chronic lithium treatment in Hong Kong Chinese: a controlled study

Fifty Chinese psychiatric patients on chronic lithium treatment and the same number of sex- and age-matched control outpatients were assessed by a thyroidologist and underwent laboratory investigations. Lithium patients had a higher rate of goitres (50% vs 10%, P < 0.0001) and a higher mean TSH level (P < 0.005) than controls. Thyroid antibodies were detected in 7 older manic-depressive patients as opposed to 1 control, but not in patients with recurrent unipolar mania. Five patients, but no controls, had single or multiple episodes of hyperthyroidism, which was followed in 2 of them by biochemical hypothyroidism. It is suggested that variations in iodine status, dietary goitrogens, immunogenetic makeup and their complex interactions with chronic lithium treatment may contribute to ethnically different patterns of thyroid abnormalities.

Community mental health services for the underserved: a culturally specific model

Underutilization of community mental health services by minorities has been an ongoing concern in the field of mental health. Many agencies are mainstream and ethnocentric in their services to culturally diverse clients, resulting in color-blind treatment approaches. During the era of civil rights, the concept of difference was used to exclude groups of individuals, families, and communities from access to resources. However, ethnicity does matter and make a difference. This article will address the need for culturally relevant services for African-American clients with the dual diagnosis of substance abuse and mental illness. The intent is to provide mental health care providers with a culturally specific model that will render culturally relevant and culturally competent services to individuals from diverse cultural backgrounds.

Black-white differences in psychopathology in an urban psychiatric population

The study was conducted in a psychiatric setting that services a large metropolitan population. It relied on the semi-structured Initial Evaluation Form which is completed by expert trained clinicians and which is geared to a comprehensive evaluation along the lines stipulated in DSM-III. The symptoms of a large sample of white and black patients are compared. The study relied on an Analysis of Variance (ANOVA) procedure which controlled for age, gender and education and concentrated exclusively on ethnic differences in clinically homogenous subgroups. The sample was partitioned into relatively pure groups of DSM-III diagnoses that are frequent in the population, including schizophrenia, affective and anxiety disorders, dementia, paranoid and manic disorders. Prominent black/white differences in psychopathology were noted, but in only a few instances included items generally thought of as typical of a specific disorder. Some differences appeared to be due to selection factors and others raised the question of alternate expressions of psychopathology among blacks as versus whites. The significance of the results obtained is discussed together with questions requiring further research. Some of the issues involved in the study of black/white differences in psychopathology are critically analyzed.

Comparison of alprazolam plasma levels in normal Asian and Caucasian male volunteers

Single-dose pharmacokinetics of alprazolam was studied in 42 normal male volunteers (14 Caucasians, 14 American-born Asians, and 14 foreign-born Asians), after both oral and parenteral (IV) administration of a small dose (0.5 mg) of the test drug. Asians manifested significantly higher Cmax, larger AUC, slower CL and longer t1/2 under both testing situations. When body surface area was used as a covariate, these cross-ethnic differences remained statistically significant (except Cmax) after oral but not IV drug administration. There were no differences between the two Asian groups in any of these parameters examined in this study. These results confirmed previous observations of ethnic differences in the pharmacokinetic response between Asians and Caucasians and suggested that smaller doses of alprazolam may be required for Asians for similar clinical effects as compared to their Caucasian counterparts.