1. The Influence of Culture in Emergency Psychiatry

2. Dr. Dionne Hart

3. A Griot

4. Presentation Outline Defining Cultural Psychiatry Defining Cultural Psychiatry Describe Cultural Formulation Describe Cultural Formulation Clinical Applications Clinical Applications Case Example Case Example Suggest a modified version of the Cultural Formulation for emergency room setting Suggest a modified version of the Cultural Formulation for emergency room setting

5. Physicians Competency Survey mailed to 3500 residents in their final year of training in emergency medicine, family practice, internal medicine, OB/GYN, pediatrics, psychiatry, or general surgery at US academic health centers. Survey mailed to 3500 residents in their final year of training in emergency medicine, family practice, internal medicine, OB/GYN, pediatrics, psychiatry, or general surgery at US academic health centers. Cross-cultural care was perceived to be important, there was little time allotted during residency to address cultural issues, and there was little training, for evaluation, or role modeling. Cross-cultural care was perceived to be important, there was little time allotted during residency to address cultural issues, and there was little training, for evaluation, or role modeling. JAMA September 7, 2005-Volume 294, No.9 JAMA September 7, 2005-Volume 294, No.9

6. Introduction to Cultural Psychiatry Culture defined as a set of beliefs, traditions, customs, and habits that provide a social and historical background to a persons identity and behavior. Culture defined as a set of beliefs, traditions, customs, and habits that provide a social and historical background to a persons identity and behavior. Kleinman A. Writing at the Margins: Discourse Between Anthropology and Medicine. Berkeley, Calif: University of California Press; 1996. Kleinman A. Writing at the Margins: Discourse Between Anthropology and Medicine. Berkeley, Calif: University of California Press; 1996. Hsu SL. Individual Reconsidered: A Face in Psychological Anthropology. Knoxville, Tenn: University of Tennessee Press; 1983 Hsu SL. Individual Reconsidered: A Face in Psychological Anthropology. Knoxville, Tenn: University of Tennessee Press; 1983

10. Modified Cultural Formulation Elicit first language, place of birth, self- defined ethnicity, and identification with specific cultural groups Elicit first language, place of birth, self- defined ethnicity, and identification with specific cultural groups Define all terms used by you and the patient. Develop a shared understanding of the problem. Define all terms used by you and the patient. Develop a shared understanding of the problem. Be sensitive to religious and social taboos within the patients culture. Be sensitive to religious and social taboos within the patients culture. Do not ask children to interpret. Avoid relatives interpreting unless in an emergency. Do not ask children to interpret. Avoid relatives interpreting unless in an emergency. Involve independent advocates with the patients agreement. Involve independent advocates with the patients agreement.

11. Case Example 19 year old Somalian male brought to the ED by his parents, who speak limited English. The patient sits is a corner responding to internal stimuli. 19 year old Somalian male brought to the ED by his parents, who speak limited English. The patient sits is a corner responding to internal stimuli.

12. An interpreter is utilized. Interpret is unable to understand the patient as his speech is illogical and nonsensical. An interpreter is utilized. Interpret is unable to understand the patient as his speech is illogical and nonsensical. Parents deny prior medical or psychiatric disorders. Parents deny prior medical or psychiatric disorders. The psychiatrist asked if the patient utilized illicit drugs. Interpreter refuses. He is Muslim and does not use Western drugs. The psychiatrist asked if the patient utilized illicit drugs. Interpreter refuses. He is Muslim and does not use Western drugs.

13. Impasse Need more medical information Need more medical information Unable to communicate directly with patient or parents Unable to communicate directly with patient or parents Interpreter is impeding evaluation process. Interpreter is impeding evaluation process. Parents now wish to take the patient home although he remains agitated and psychotic. Parents now wish to take the patient home although he remains agitated and psychotic.

14. Safety First Patient placed on a seventy-two hour hold despite parents wishes. Patient placed on a seventy-two hour hold despite parents wishes. No beds are available in the state of Minnesota No beds are available in the state of Minnesota He is treated emergently with IM Zyprexa, Benadryl, and Ativan. He is treated emergently with IM Zyprexa, Benadryl, and Ativan.

15. Generose via Emergency Treatment Units South Hall

16. Hennepin County Acute Psychiatry Services

17. Observation Period Roommates visit patient. Roommates visit patient. Roommates reluctantly report the patient ingested khat for the first time at a party two days ago. After a couple hours, the patient was found sitting in a darkened room agitated and grasping items in the air. Roommates reluctantly report the patient ingested khat for the first time at a party two days ago. After a couple hours, the patient was found sitting in a darkened room agitated and grasping items in the air. Afraid they transported the patient to his parents home. Afraid they transported the patient to his parents home.

18. Khat A shrub that originated in Ethiopia then spread to other countries A shrub that originated in Ethiopia then spread to other countries Amphetamine-like properties Amphetamine-like properties Stimulant which may lead to a psychotic or manic episode Stimulant which may lead to a psychotic or manic episode

19. Areas of Use

20. ??? Rochester, MN

21. Clinical Applications Diagnostic Considerations Recognize neuropsychiatric manifestations of disorders endemic in ethnic populations Recognize neuropsychiatric manifestations of disorders endemic in ethnic populations Differences in diagnosis and treatment of affective and thought disorders Differences in diagnosis and treatment of affective and thought disorders Identify disorders which may be related to diet, social, or religious practices Identify disorders which may be related to diet, social, or religious practices

22. Clinical Applications: Evaluation Considerations Develop an alliance Develop an alliance Recognize possible barriers to treatment Recognize possible barriers to treatment Promote treatment compliance Promote treatment compliance

23. Use of Interpreters Interpreters should have professional knowledge, judgment, and experience beyond familiarity with the languages involved. Interpreters should have professional knowledge, judgment, and experience beyond familiarity with the languages involved. Remain neutral. Remain neutral. Strictly translate questions and responses. Strictly translate questions and responses. If possible matching sex and approximate age. If possible matching sex and approximate age. Avoid use of family members or friends, particularly children. Avoid use of family members or friends, particularly children.

24. Key Questions What do you call your problem? What do you call your problem? What are your thoughts on what is the cause of your problem? What are your thoughts on what is the cause of your problem? What are the implications of this illness for your life? What are the implications of this illness for your life? What are you expecting is the appropriate treatment? What are you expecting is the appropriate treatment? What are your concerns for your prognosis? What are your concerns for your prognosis?