Mental Health Assessment and Diagnosis of Asian Adults: Challenges • Core Psychiatric “diseases” are the same across humanity. • Presenting Psychiatric “illness” however is Dr Ashok Malur MD shaped by: Consultant Psychiatrist, Auckland District Health –Culture Board. – Ethnicity Honorary Senior Lecturer in Psychiatry, Auckland –Race medical school.

Definitions

• Culture is defined as a common heritage or set of • Culture structures the way people identify beliefs, norms and values which are shared among a what is abnormal and deviant, how illness is large group of people. defined and how and where help is sought. • Ethnicity is a group of people with shared heritage including common history, language and beliefs. This is • Culture also determines what resources are self ascribed and relatively stable. made available to society to cope with • Race is constant and has a social meaning and a distress. Biological concept.

The Clinician/Patient cultural interface • This is more important when the two are from different Culture Can be Pathogenic, cultures.

Pathoselective And • Clinicians need to be 1) Aware of their own culture Pathoprotective!! 2) Aware of the patient’s culture. 3) Aware of their own limitations. Ask for help when in doubt. 4) Be willing to introspect about their own responses at every juncture. 5) Be respectful of patient’s culture and experiences

1 Cultural barriers to care among Assessment Asians • Asians around the world are less likely than white middle class • For the patients that do front up in a mental health people to seek treatment for mental health related problems. service apart from the standard questions in a Reasons: Psychiatric interview, please ask for:

1) Absence of Mind-body dichotomy among non European cultures. 1) Language issues. If there is a problem look 2) Stigma attached with mental health issues in Asian for a trained Interpreter. communities. “The conspiracy of silence” among Asian families. 2) Assess the cultural identity of the person to 3) Language issues leading to avoidance and 4) Cultural differences between clinician and patients evaluate the stage of acculturation of the patient. leading to lack of engagement.

Assessment contd. Be aware that

• The assessment process may extend to more than • Migration History needs to be checked out. 1 session. •Check out for safety issues. • Asians tend to minimise safety problems due • The rapport building could take a long time. This will often need an interaction with the to concern for family dynamics and stigma. extended family and at times community leaders as well. Distress is expressed verbally and non verbally.

Symptom presentation Culture bound syndromes.

• Somatisation; defined as Psychological and • Dhat syndrome; Indian syndrome affecting interpersonal distress communicated in the form of young males who worry that their masculinity medically unexplained symptoms. Very common in most is being lost in nocturnal seminal emissions. non European cultures. • Hwa-byung(Korean) or anger sickness • Culture bound syndromes. Shinbyung (Korean) a thought to be due to suppression of anger, syndrome of anxiety and weakness, attributed to disappointment, grudges, affecting women. possession by ancestral spirits. • Shenjang shuairuo (Chinese) similar to Neurasthenia.

2 Arthur Kleinman’s 8 questions Diagnostic formulation

1) What do you call your problem? • The diagnostic formulation proceeds along 2) What has caused it? with the assessment. 3) Why do you think it started when it did? • Seek information about belief systems. 4) What does it do to you? Religious beliefs e.g., Buddhists, Taoism, 5) How severe is it? Confucianism, Hindu beliefs steeped in 6) What do you fear most about it? Ayurveda. 7) What are the chief problems it has caused you? • Animists and naturalists. 8) What kind of treatment do you think you should receive?

Diagnostic formulation Explanatory models

• Enquire about the use of alternative healing • This can be defined as the explanation the methods. patient and the family and at times the group • 42% of all patients surveyed in the United gives, regarding the aetiology and genesis of States used some form of complementary or the problem under deliberation. alternative medical treatment. • In acculturated Asian people the Bio psychiatric model of depression, a disease model which emphasises the roots of the disorder in anatomy, heredity and disease process is more common.

Explanatory models contd Explanatory models contd

• In traditional Asian societies a “situational • Interestingly Explanatory models for psychotic model” that describes psychological distress in processes among Asian cultures appears to the context of social and interpersonal closely resemble Western concepts. situations may be a more common • However the same is not true for “neurotic explanatory strategy. disorders“. This would explain the resistance • External locus of control explanation; e.g. to accessing health professionals when spirits, ancestral dissatisfaction depressed.

3 The “LEARN” Model The “LEARN” model contd.

• This is an acronym for • This is a model for interactions across all Listen with sympathy and understanding to the cultural backgrounds. patient’s perception of the problem. • This can be applied to the DSM IV TR outline Explain your perception of the problems for Cultural formulation of the diagnosis which Acknowledge and discuss the differences and helps reduce the stigma associated with similarity in perceptions mental health issues, thereby improving Recommend treatment treatment outcomes for traditional societies. Negotiate agreement

In Conclusion, the barriers for the References assessment and diagnosis in Asian • Slide 2; Bhugra D severe mental illness across cultures, patients Acta Pysch.scand, 2006. • Slide 4; Tseng W-T handbook of Cultural psychiatry, • Different perceptions of San Diego academic press 2002 mental health issues among • Slide 5; adapted from Pierre Casse,Training for the Asians Multicultural Manager. • The stigma attached to • Slide 6; Lim S Somatisation and Stigma in Asians. mental illness resulting in the Program abstracts of the American psychiatric “conspiracy of silence” association annual meeting 2005,May 21-26, 2005 • Structural barriers viz: the lack of access to care due to language differences, cultural sensitivity training of mental health clinicians and cultural oriented services

References References

• Slide 10;Hsu LKG, Folstein MF. Somatoform disorders in • Slide 14;Eisenberg DM, Davis RB,Ettner SR .Trends in Caucasian and Chinese Americans. Journal of Nerv Alternative med use in the USA.1990-97.JAMA Mental disorder 1997;185;382-387 1998;280;1569-1575 • Slide12;Kleinman A; Patients and healers in the context • Slide 15;Keyes C, The Interpretive basis. In; Culture of culture, an exploration of the Borderland between and Depression, University of California Press, Berkeley Anthropology, Medicine and Psychiatry. Berkeley. University of California Press, 1987 1985 • Slides 13 and 20;Du N; Somatisation and Stigma in • Slides 16 and 17;Patel V; Explanatory models of mental Asians. Programme and abstracts of the APA 2005 illness in sub-Saharan Africa. Social science medicine annual meeting May 21-26, 2005 40,1995;1291-1298

4 References

• Patel, Pereira, Mann. Somatic and psychological models of common mental disorder in primary care in India. Psychological Med.28, 1998, 135-143 • Slide 18;Berlin EA, Fowkes WC, Western J of Med.1983, 139;924-938

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