MIND AND CULTURE: Psychiatry's Missing Diagnosis
Patients' Diversity Is Often Discounted
Sunday, June 26, 2005
First of three parts
When UCLA researchers reviewed the best available studies of psychiatric drugs for depression, bipolar disorder, schizophrenia and attention deficit disorder, they found that the trials had involved 9,327 patients over the years. When the team looked to see how many patients were Native Americans, the answer was . . .
"I don't know of a single trial in the last 10 to 15 years that has been published regarding the efficacy of a pharmacological agent in treating a serious mental disorder in American Indians," said Spero Manson, a psychiatrist who heads the American Indian and Alaska Native Programs at the University of Colorado Health Sciences Center in Aurora. "It is stunning."
Native Americans are not the only group for whom psychiatrists write prescriptions with fingers crossed, the researchers at the University of California at Los Angeles found as they reviewed the data for a U.S. surgeon general's report: Of 3,980 patients in antidepressant studies, only two were Hispanic. Of 2,865 schizophrenia patients, three were Asian. Among 825 patients in bipolar disorder or manic depression studies, there were no Hispanics or Asians. Blacks were better represented, but even their numbers in any one study were too small to tell doctors anything meaningful.
In all, just 8 percent of the patients studied were minorities.
It is but one example of a larger pattern: Scientists have broadly played down the role of cultural factors in the diagnosis, treatment and outcome of mental disorders. In part, this is because modern psychiatry is based on the idea that mental illnesses are primarily organic disorders of the brain. This medicalized approach suggests that the symptoms, course and treatment of disorders ought to be the same whether patients are from the Caribbean, Canada or Cambodia.
This model has produced striking successes. Neuroscientists have uncovered key details about how the brain functions and malfunctions, and drug companies have found many effective medications. More patients than ever before have received treatments that have been proven to work.
As the population of the United States grows ever more diverse, however, this approach is facing challenges from within the profession's own ranks. A growing number of advocates for "cultural competence," many of whom are minorities themselves, warn that doctors are harming patients by ignoring evidence about the effects of ethnicity, sex, religious beliefs, social class and national origin on mental health and mental illness.
"The [drug] companies are thinking about the average Caucasian, male patient," said psychiatrist Michael Smith, at UCLA's Research Center on the Psychobiology of Ethnicity, who bemoaned the vacuum of information about drug metabolism and side effects among various groups. Some minorities' distrust of drug trials further compounds the problem, he and other researchers said.
"This thing called psychiatry -- it is a European-American invention, and it largely has no respect for nonwhite philosophies of mental health and how people function," agreed Carl Bell, a psychiatrist at the University of Illinois at Chicago.
"A lot of minority groups perceive psychiatric interventions as an ideological approach that discounts their own cultures," added Marcello Maviglia, a psychiatrist who has worked extensively with Native American patients in New Mexico. "A lot of people wouldn't be able to verbalize this, but patients know when you are discounting them, their traditions."