Cultural Psychiatry in an Urban Setting

By Rita Baron-Faust

It may come as no surprise that the stresses of immigration and poverty can determine how and when a person gains access to mental health care. But did you know that a person's racial or cultural background could influence the manifestation of symptoms and affect the outcome of psychotherapy? Or that a patient's race or ethnicity could affect even the metabolism of psychoactive drugs?

NYU School of Medicine has a longstanding commitment to train culturally competent psychiatrists who are sensitive to the challenges of practicing in an urban world. The opportunities to develop such sensitivity are abundant, thanks to the extraordinarily diverse patient populations served by the School's faculty, residents, and students at NYU Hospitals Center and its affiliates, including Bellevue Hospital Center and the Veterans Affairs Medical Center.

Training at NYU stresses cultural sensitivity. Cultural issues are interwoven into the curriculum during the first two years of medical school, and special lecture courses are required for residents in psychiatry, reports Robert Cancro, M.D., the Lucius N. Littauer Professor and Chairman of the Department of Psychiatry at NYU School of Medicine. In addition, an eight-week cultural competency course for psychiatric residents is taught by Ernesto Ferran, Jr., M.D., Clinical Associate Professor of Psychiatry.

"Cultural competency" means understanding how different people frame their conceptions of illness, their symptoms, and their health-seeking behaviors, as well as their response to treatment through cultural paradigms," says Dr. Ferran.

"In different countries and cultures, there are very different views of what mental illness is and isn't, and symptoms may be affected by what is seen as culturally acceptable behavior," Dr. Ferran explains. For example, in a delusional disorder such as schizophrenia, the culture may influence the content of the delusions and/or hallucinations. A case in point, Dr. Ferran says, is that in Haiti and for Haitian immigrants to the U.S. - the notion of seeing people who have died, or hearing their voices, is an accepted part of the culture. "So a Haitian patient who reports hearing and seeing a deceased relative is not necessarily having an hallucinatory episode," Dr. Ferran explains.

In response to such differences, psychiatrists-in-training at NYU learn to temper their diagnoses according to the culture of their patients Psychiatric residents also learn how to deal with the variety of attitudes toward psychiatric treatment held by members of different cultures. In some cultures, for instance, the entire family feels shamed if a member is treated for a psychiatric disorder. This is particularly true for Asian people, says Henry Chung, M.D., Clinical Assistant Professor and Medical Director of the Chinatown Health Clinic. Only if such resistance is understood and acknowledged can it be breached, he emphasizes.

Instruction in the medical management of psychiatric diseases also reflects the department's awareness of ethnic and cultural differences. For instance, explains James Chou, M.D., Assistant Professor of Psychiatry, something as simple as a diet heavy in corn - a staple of the Mexican-American kitchen even in big cities - can affect the processing of some psychiatric medicines. Nor is diet the only factor in which race and ethnicity play a role. Genetically determined differences in liver enzymes hamper the metabolism of tricyclic antidepressants and benzodiazepines in Asians, and slow the clearance of lithium in African-Americans, compared to Caucasians, Dr. Chou explains.

Several studies at NYU and Bellevue have helped to elucidate the differences in therapeutic response based on race and ethnicity. Manuel Trujillo, M.D., Professor of Clinical Psychiatry, reports, "We recently pub-lished a study showing that an antipsychotic, olanzapine, was significantly more effective in our Asian patients. This discovery was the direct result of having a separate population to study in our Asian inpatient unit."

The unit is one of a number of unique programs made possible by an annual grant from the New York City Department of Mental Health to fund a Division of Cultural Psychiatry at Bellevue. "There are at least 180 racial, ethnic, and cultural groups in New York City, and we have cata-logued at least 138 different groupsseen at Bellevue," says Dr. Trujillo.

The $300,000 annual grant funds training programs that interface with NYU affiliates, as well as professorships and clinical programs, including bilingual in- and outpatient clinics for Hispanic, Arabic, and Bangladeshi patients.

The 28-bed Asian inpatient unit, for instance, headed by Angelina de Castro, M.D, Clinical Instructor in Psychiatry, is staffed by a multi-disciplinary team fluent in Mandarin, Cantonese, and other regional dialects, and even offers patients a Chinese menu.

"We are far more effective in treat-ing Chinese patients since we have had this unit. We come up with better treatment plans, and we have better treatment plans, and we have better outcomes, comments Ricardo Castaneda, M.D., Clinical Associate Professor of Psychiatry and Director of Inpatient Psychiatry at Bellevue.

That same philosophy went into establishing Bellevue's outpatient Bilingual Treatment Program (BTP) for Spanish-speaking patients back in 1985. The program was started by Carmen Inoa Vazquez, Ph.D., Clinical Associate Professor of Psychiatry and co-author of The Maria Paradox, a mental health guide for Latinas.

The BTP, headed for the past three years by Yvette Caro, Ph.D., Clinical Assistant Professor of Psychiatry, offers individual and group therapy for depression, anxiety and panic disorders, bereavement, and domestic violence. It also pre-sents workshops on parenting skills, domestic violence, immigration and acculturation issues, and even menopause. Substance abuse, often a product of poverty and stress, is a common health issue in the urban envi-ronment. "In some groups, such as Russians, heavy alcohol use is part of the culture, and helping people acknowledge that they have an illness can be difficult," observes Marc Galanter, M.D., Professor of Psychiatry, who heads the NYU School of Medicine's Division of Alcoholism and Drug Abuse.

Another problem endemic to the urban environment is homelessness, which, Dr. Galanter says, can be considered a culture unto itself. To serve the homeless, there is now a special inpatient unit called "Project Help" at Bellevue that is geared to the unique needs of the homeless.

"We treat the poor, the disadvantaged, minorities, and diverse cultural groups," concludes Dr. Cancro. "If you can bridge cultural gaps to take care of these patients, who are often the sickest and most in distress, you can take care of anyone."

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