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MGH Depression Clinical and Research Program Harvard Medical School

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1 MGH Depression Clinical and Research Program Harvard Medical School
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

2 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. 2006 NCDEU Annual Meeting (STARD)


4 U.S. Population Projections
2008 2050 Non-Hispanic whites 60% 46% Hispanics 15% 30% African Americans 14% Asian Americans 5% 9% Based on U.S. Census (2000) 4

5 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

6 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) Jones at the Centers for Disease Control and Prevention proposed a theoretical framework of racism: which operates at three distinct levels: institutionalized policies and practices that maintain racial disadvantage treatment (e.g. employment, housing, health care, education…) , individual racial discrimination and biased (racial profiling, lower education expectation for minority students, unequal medical treatment), and internalized cognitive processes (introjection of racial stereotypes by the minority group members to have self-doubt, lower school performance, substance abuse, dropouts etc)

7 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

8 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 Kleinman A. Culture, Med & Pscyh 1982. 8

9 Barriers for Asian Americans in Accessing Mental Health Services
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

10 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: , 2005

11 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: , 2009

12 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: , 1999

13 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

14 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

15 Chief complaints of Chinese-Americans with Major Depressive Disorder (N=29)
______________________________________________ Chief complaints (%) N (%) Physical symptoms (42) Depressive neurovegetative s/s 10 (34) Depressive psychological s/s (14) Irritability, Rumination, Poor memory Nervousness (7) Depressed Mood (0) No complaints (3.5) Yeung et al., J Nerv & Ment Dis 192 (4): , 2004 Yet, in stage I which used BDI for depression screening, more than 90% reported having depressed mood. Also, when asked directly, all patients were able to describe and endorse enough criteria to warrant a DSM-IV MDD diagnosis.

16 Labels used by Chinese-Americans Patients with Major Depressive Disorder to Describe their Illness (N=29) _____________________________________________________ Name of the illness N (%) “Don’t know” (55) “Not an illness” (17) Medical Illnesses (17) “hypertension” 1 “cold” “poor health” 1 “injured arm” 1 “Post Traumatic Stress Syndrome” 1 (3.5) “Craziness” ( 7) __________________________________________________________________ Yeung et al., J Nerv & Ment Dis 192 (4):

17 Causes of Illness Perceived by Chinese-Americans with Major Depressive Disorder (N=29)
Methods Frequency (%) ____________________________________________ Stress and/or psychological factors (93) Magico-Religious-Supernatural (45) Medical Problems (17) Traditional beliefs (14) Hereditary (14) Toxicity (11) Ingestion ( 2 ) Sex ( 0 ) ______________________________________________ Yeung et al., J Nerv & Ment Dis 192 (4): , 2004

18 Methods of Help-Seeking by Depressed Chinese-Americans Patients (N=29)
______________________________________________ Methods Frequency(%) General Hospital (69) Lay Help (62) Alternative Treatment by Providers (55) Spiritual Treatment (14) Alternative Treatment by Self (11) Mental Health Professionals (4) Yeung et al., J Nerv & Ment Dis 192 (4): , 2004

19 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

20 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

21 Cultural Formulation A format for semi-structured evaluation of every patient’s cultural background, which includes: the cultural identity of the patient cultural explanations of the individual’s illness cultural factors related to psychosocial environment and functioning, cultural elements of the relationship between the individual and the clinician, and an overall assessment of diagnosis and care  Lewis-Fernandex & Naelys. Psychiatric Quarterly 2002; 73 (4): 21

22 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 The Customized Approach to Treatment Negotiation Yeung et al. International Journal of Culture and Mental Health (in press)

23 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):

24 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

25 EIP (III): Culturally Sensitive Communication of psychiatric disorders
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 Whatever explanations are given for the illness, the clinician should consider them seriously,. These explanations are meaningful to the patients, and should be used as the platform from which to discuss the rationale and anticipated outcomes of available treatment.

26 EIP (IV): Customized Treatment Negotiation
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

27 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”

28 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

29 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” “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”

30 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

31 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 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” “What has caused it?” “adjustment problems in the U.S.” “When did it start?” “in 2003” “What do it do to you?” “When I cannot sleep, I feel tired and have headaches” How severe is it? “sleep problem is pretty severe’ “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”

32 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

33 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 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”

34 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, problem-solving 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

35 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

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