TRANSCULTURAL ISSUES IN THE DIAGNOSIS AND TREATMENT OF DEPRESSION

1
TRANSCULTURAL ISSUES IN THE DIAGNOSIS AND
TREATMENT OF DEPRESSION
2
Learning Objectives

• By the end of this presentation, participants
  will be able to
• Define the terms culture, cultural competence,
  cultural identity, cultural humility, and
  transcultural psychiatry
• Identify cultural influences on the
  patient-provider relationship
• Recognize the roles of culture, race, and
  ethnicity in the detection, diagnosis, and
  treatment of depressive disorders
• Discuss current efforts directed at improving
  cultural competence at organizational and
  individual levels of health care

3
Introduction

• Culture
• A shared set of beliefs, norms, or values that
  will influence the meaning given to life events
  and experiences

Schraufnagel TJ. Gen Hosp Psychiatry.
200628(1)27.
4
Essential Components of Culture

• Culture
• Is learned
• Refers to a system of meanings
• Acts as a shaping template
• Is taught and reproduced
• Exists in a constant state of change
• Includes patterns of both subjective and
  objective components of human behavior

Adapted from Gaw AC. Concise Guide to
Cross-Cultural Psychiatry. Washington DC
American Psychiatric Publishing 2001.
5
Aspects of Cultural Identity
Adapted from Ton H, Lim RF. The assessment of
culturally diverse individuals. In Lim RF
(ed). Clinical Manual of Psychiatry. Arlington,
VA American Psychiatric Publishing 200610.
6
Introduction

• Transcultural Psychiatry
• A cross-cultural approach to mental health
  problems that recognizes the relevance of social,
  cultural, and ethnic factors to the etiology and
  treatment of disease.

World Psychiatric Association, 1998.
http//www.mentalhealth.com/newslet/tp9801.html.
7
Historical Overview of Transcultural Psychiatry

• The concept of cultural psychiatry dates back
  approximately 200 years1
• In the 1800s, anthropologists took an
  ethnocentric approach to psychiatry2
• Cultural inquiry was focused on non-Western,
  isolated cultural groups1,2

• Prince RH, Okpaku SO, Merkel L. Transcultural
  psychiatry A note on origins and definitions.
  In Okpaku, SO (ed). Clinical Methods in
  Transcultural Psychiatry. Washington, DC
  American Psychiatric Press 19983.
• Ton H, Lim RF. The assessment of culturally
  diverse individuals. In Lim, RF (ed). Clinical
  Manual of Psychiatry. Arlington, VA American
  Psychiatric Publishing 20065.

8
Historical Overview of Transcultural Psychiatry
(cont)

• Late 1900s Modern psychiatry criticized for not
  focusing on relativity of cultural society1
• Culture begins to replace terms such as savage
  tribes, primitive, civilized in psychiatric
  publications2
• DSM-IV considers integrating cultural factors
  into the diagnosis and evaluation of mental
  disorders1

• Ton H, Lim RF. The assessment of culturally
  diverse individuals. In Lim RF (ed). Clinical
  Manual of Psychiatry. Arlington, VA American
  Psychiatric Publishing 20065.
• Prince RH, Okpaku SO, Merkel L. Transcultural
  psychiatry A note on origins and definitions.
  In Okpaku SO (ed). Clinical Methods in
  Transcultural Psychiatry. Washington, DC
  American Psychiatric Press 19984.

9
Historical Overview of Transcultural Psychiatry
(cont)

• 1955
• Transcultural psychiatry established as a
  distinct discipline by E.D. Wittkower
• Section of Transcultural Studies, McGill
  University, Montreal
• Journal Transcultural Psychiatric Research Review

Prince RH, Okpaku SO, Merkel L. Transcultural
psychiatry A note on origins and definitions.
In Okpaku SO (ed). Clinical Methods in
Transcultural Psychiatry. Washington, DC
American Psychiatric Press 19983.
10
IntroductionCurrent Demographics
U.S. Census 2000 Racial/Ethnic Groups






US Census Bureau Census 2000.
11
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Common Cultural Themes

• Each patient is unique
• Each patient is a member of one or more cultural,
  racial, or ethnic groups
• Treatment needs to be individualized for each
  person
• Each cultural or ethnic group shares beliefs that
  characterize illness and determine acceptable
  treatment however, there may be variations in
  these beliefs within each group
• When formulating a treatment plan, consider
  individual characteristics such as
• Education
• Nationality
• Faith
• Level of acculturation

Juckett G. Am Fam Physician. 200572(11)2267.
13
Common Cultural Themes (cont)

• Trust and respect1
• Establish trust through time, patience, and small
  talk2
• Be aware of cultural differences such as
• Establishing eye contact1,2 avoided out of
  respect in several cultures
• Opposite-sex touching between health care
  provider and patient2 may be forbidden in
  certain groups (eg, Orthodox Jews and some
  Islamic sects)
• Need for explanations of what will be done2
• Preferences for natural medicines1,2

• Burroughs VJ. National Pharmaceutical Council,
  2002.
• http//www.npcnow.org/resources/PDFs/CulturalFI
  NAL.pdf.
• 2.Juckett G. Am Fam Physician. 200572(11)2267.

14
Common Cultural Themes (cont)

• Health beliefs and practices
• Traditional healing is common1
• 38 of Native American patients consulted with a
  healer 61 rated the advice higher than that
  of their physician
• Latino healing traditions and Chinese medicine
  may often characterize diseases as hot or
  cold and manage them with alternative, herbal,
  or home remedies2
• Physicians should take advantage of opportunities
  to communicate with local medicine people eg,
  Latino folk healers (curanderos)
• Fatalism or an attitude of passive acceptance may
  be encountered1
• Mistrust of Western medicine, physicians, and
  hospitals exists1

• Burroughs VJ. National Pharmaceutical Council,
  2002. http//www.npcnow.org/resources/PDFs/Cultura
  lFINAL.pdf.
• Juckett G. Am Fam Physician. 200672(11)2267.

15
Common Cultural Themes (cont)

• Family values
• Family members opinions about illness and
  treatment may be held in high esteem
• An older family member may make health care
  decisions for the family
• The family support system can greatly influence
  the patients response to medication and
  therefore, clinical outcomes

• Burroughs VJ. National Pharmaceutical Council,
  2002. http//www.npcnow.org/resources/PDFs/Cultura
  lFINAL.pdf.

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17
Cultural Influences on the PatientProvider
Relationship

• The culture of the clinician and the larger
  health care system govern the societal
  response to a patient with mental
  illness and influence many aspects of the
  delivery of care, including diagnosis,
  treatments, and the organization and
  reimbursement of services.
• US Dept of Health and Human
  Services, 2001.

US Dept of Health and Human Services. Executive
Summary. In Mental Health Culture, Race, and
EthnicityA Supplement to Mental Health A Report
of the Surgeon General. Rockville, MD 2001.
18
The Role of Myth and Stereotype
Cultural Influences on the PatientProvider
Relationship (cont)
Stereotypical and/or Prejudicial Physician
Behavior
Misdiagnoses and Misplaced Interventions

• Poor Outcomes
• Poor Patient Care
• Missed Opportunities

Misinterpretation of Ambiguous/ Unfamiliar Behavio
r
Whaley AL. Am J Orthopsychiatry. 199868(1)47.
19
Cultural Influences on the Patient Provider
Relationship (cont)

• Interethnic transference1,2
• The patients response to an ethnoculturally
  different physician
• Interethnic effects of transference1,2
• Overcompliance or over-friendliness
• Denial of ethnocultural factors
• Mistrust
• Hostility
• Ambivalence

• Comas-Diaz L, Jacobsen FM. Am J Orthopsychiatry.
  199161(3)392.
• Ton H, Lim RF. The assessment of culturally
  diverse individuals. In Lim RF (ed). Clinical
  Manual of Psychiatry. Arlington, VA American
  Psychiatric Publishing 200619.

20
Cultural Influences on the Patient Provider
Relationship (cont)

• Interethnic countertransference1,2
• The nontherapeutic manner of an ethnoculturally
  different clinician in response to a patient
• Interethnic effects of countertransference1,2
• Denial of ethnocultural factors
• Clinical anthropologist syndrome
• Guilt or pity
• Aggression
• Ambivalence

• Comas-Diaz L, Jacobsen FM. Am J Orthopsychiatry.
  199161(3)392.
• Ton H, Lim RF. The assessment of culturally
  diverse individuals. In Lim RF (ed). Clinical
  Manual of Psychiatry. Arlington, VA American
  Psychiatric Publishing 200620.

21
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22
Screening and Diagnosing DepressionThe Role of
Culture

• Cultural explanatory models of illness
• Define culturally acceptable symptoms of illness
• Idioms of distress
• Help define behavior the sick individual must
  assume

Ton H, Lim RF. The assessment of culturally
diverse individuals. In Lim RF (ed). Clinical
Manual of Cultural Psychiatry. Arlington, VA
American Psychiatric Publishing. 200614.
23
Screening and Diagnosing DepressionThe Role of
Culture

• Types of models include
• Religious/Spiritual Illness is punishment
  atonement is necessary
• Magical Witchcraft, or sorcery causes illness
  counteract with spell
• Moral Illness due to character flaw (eg, lazy,
  selfish) must improve
• Medical eg, Western allopathic medicine,
  Ayurvedic medicine, Chinese medicine

Ton H, Lim RF. The assessment of culturally
diverse individuals. In Lim RF (ed). Clinical
Manual of Cultural Psychiatry. Arlington, VA
American Psychiatric Publishing. 200614.
24
Screening and Diagnosing DepressionThe Role of
Culture (cont)

• Somatization
• Expressing psychological distress through bodily
  symptoms
• Common in all cultural groups and societies
• Culture specific with varying modicums of style
• Depression can be displayed as low energy,
  insomnia, and physical pain, while mood symptoms
  are minimized
• Can indicate
• Physical or mental illness
• Interpersonal conflict or positioning
• Cultural idiom of distress
• Metaphors for experience or emotion

Kirmayer LJ, Dao THT, Smith A. Somatization and
psychologization Understanding cultural idioms
of distress. In Okpaku SO (ed). Clinical Methods
in Transcultural Psychiatry. Washington, DC
American Psychiatric Press 1998233.
25
Screening and Diagnosing DepressionRefugees and
Immigrants

• Refugees and immigrants include
• People who abandon their homes and communities
• Due to war, political violence, and other threats
• People displaced outside their country of
  residence
• Internally displaced persons
• Asylum seekers
• Stateless persons
• Recently returned refugees
• This population was gt42 million at the end of 2004

Porter M. JAMA. 2005294602.
26
Screening and Diagnosing DepressionRefugees and
Immigrants (cont)

• Increased risks for psychological stress and
  mental illness
• History of political or religious persecution
  (including experiencing violence, imprisonment,
  or war)
• Foreign language, custom, and acculturation
  stress
• Social isolation and rejection/lack of social
  support
• Racism and prejudice
• Difficulty securing employment and housing
• Limited health care access
• Unattended chronic illness
• Minority status

Jablensky A. J Refugee Studies. 19925172.
27
Screening and Diagnosing DepressionRefugees and
Immigrants (cont)
Merriam-Webster Online. 2006. http//www.m-w.com/
28
Screening and Diagnosing DepressionRefugees and
Immigrants (cont)
Khoa LX. J Refugee Resettlement. 1981148.
29
Screening and Diagnosing DepressionAssessment
Across Cultures
Checklist for Cultural Sensitivity and Awareness

• Identify Communication Method
• Identify Language Barriers
• Identify Cultural Background
• Identify Patients Comprehension Level
• Identify Religious/Spiritual Beliefs
• Identify Culture-specific Diet Considerations
• Identify Any Health Care Provider Bias
• Does Patient Trust Caregivers?
• Does Patient Understand the Recovery Process?
• Assess with Cultural Sensitivity

Cultural Sensitivity and Awareness Checklist
Seibert PS. J Med Ethics. 200228143.
30
Treatment of DepressionThe Role of Culture

• DSM-IV-TR
• Addresses disparities regarding cultural validity
  of psychiatric illnesses in the DSM-III
• Appendix 1 Outline for cultural formulation
• Cultural identity of the individual
• Cultural explanations of the individuals illness
• Cultural factors related to psychosocial
  environment and levels of functioning
• Cultural elements of the relationship between the
  individual and the clinician
• Overall cultural assessment for diagnosis and
  care
• Glossary of culture-bound syndromes

American Psychiatric Association. DSM-IV-TR.
Washington, DC American Psychiatric Association
2000.
31
Treatment of DepressionThe Role of Culture (cont)

• Culturally appropriate treatment plan
• Individualized treatment for each patient1
• Thorough assessment of each patients
  demographics and characteristics (eg,
  race/culture/ethnicity, faith, level of
  acculturation, education)1
• Awareness of differences in cultural expressions
  of, and attitudes toward, disease1
• Consultation with family and cultural
  consultants1
• Medication management requires
• Adjustment based on ethnicity and response1
• A start low, go slow treatment approach2

• Lim RF. Conclusions Applying the DSM-IV-TR
  outline for cultural formulation. In Lim RF
  (ed). Clinical Manual of Cultural Psychiatry.
  Arlington, VA American Psychiatric Publishing,
  Inc. 2006237.
• Smith, MW. Ethnopsychopharmacology. In Lim RF
  (ed). Clinical Manual of Cultural Psychiatry.
  Arlington, VA AP Publishing, Inc. 2006207.

32
Treatment of DepressionEffective Communication

• Have patients repeat instructions in their own
  words instead of asking, Do you understand?
• Patients may agree or smile through embarrassment
  or respect even when they dont understand
• An interpreter may be needed
• In some cultures, negative prognoses are
  communicated to the family first
• Inform families of the standard US practice of
  disclosing information to patients first, and
  then ask them which they would prefer

Juckett G. J Fam Physician. 200572(11)2267.
33
Treatment of DepressionEffective Communication
(cont)

• Be aware of different perceptions of
• Time managementrelaxed or punctual
• Personal space
• Gestures
• Pointing may be considered insulting or rude
• For many Asians, exposing the sole of the foot or
  touching the head are considered taboo

Juckett G. J Fam Physician. 200572(11)2267.
34
Treatment of DepressionPsychotherapy and
Counseling

• Minority individuals may not participate in
  therapy because of stigma surrounding its use
• Discouragements to using mental health services
  may also include
• Lack of counselors trained in culturally
  sensitive therapy models
• Lack of bilingual counselors
• Lack of counselors with similar ethnic/racial
  backgrounds
• Lack of cultural sensitivity

Kearney LK. The Counseling Mental Health Center
2003 Research Consortium. http//www.utexas.edu/st
udent/cmhc/research/rescon.html
35
Treatment of DepressionPsychotherapy and
Counseling (cont)

• Whites have been shown to attend mental health
  therapy sessions significantly more often than
  African American, Asian American, and Hispanic
  individuals1
• However, another study demonstrated that, among
  the Asian population, East Asians used these
  services more than whites, African Americans,
  Latinos, Native Americans, and other Asian
  populations2
• More research is needed regarding mental health
  therapy use and outcomes among racial and ethnic
  minorities1

• Kearney LK. The Counseling Mental Health Center
  2003 Research Consortium. http//www.utexas.edu/st
  udent/cmhc/research/rescon.html
• Barreto RM. Psychiatric Services. 200556746.

36
Treatment of DepressionEthnopsychopharmacology

• Factors influencing drug metabolism and response
  to medication

• Age
• Gender
• Diet
• Herbal supplements
• Exercise
• Smoking
• Alcohol
• Caffeine

• Genetics
• Culture
• Comorbid disease
• Other medications
• Adherence/compliance
• Patientphysician relationship
• Social supports

Smith, MW. Ethnopsychopharmacology. In Lim RF
(ed). Clinical Manual of Cultural Psychiatry.
Arlington, VA AP Publishing, Inc. 2006207.
37
Treatment of DepressionEthnopsychopharmacology
(cont)

• Treatment responses vary among individuals of
  different racial and ethnic origin1-5
• Genetic polymorphisms and differing rates of
  polymorphism among different ethnic groups exist
  in drug-metabolizing enzymes, targets, and
  pathways1,3-5
• Optimal drug concentrations may vary between
  individuals or racial/ethnic groups1-5
• African Americans may require lower doses of
  tricyclic antidepressants (TCAs) and selective
  serotonin reuptake inhibitors (SSRIs).2
• Asians often respond to doses of psychotropics
  lower than the recommended doses, and may
  experience side effects at the normal doses.5

• Smith, MW. Ethnopsychopharmacology. In Lim RF
  (ed). Clin Manual of Cultural Psychiatry. AP
  Publishing, Inc. 2006207.
• Varner RV, Ruiz P, Small DR. Psychiatr Q.
  199869(2)117.
• Bondy B. Dialogues Clin Neurosci. 20057223.
• Shimoda K. J Clin Pharmacol. 199919(5)393.
• Lin KM. Psychiatr Serv. 199950774.

38
Treatment of DepressionEthnopsychopharmacology
(cont)

• Cytochrome P450 (CYP450) drug- metabolizing
  enzymes
• gt20 human CYP450 enzymes identified1
• Metabolize antidepressants, antipsychotics, and
  benzodiazepines1,2
• Most relevant to psychiatric treatment
  include1,2
• CYP2D6
• CYP3A4
• CYP1A2
• CYP2C19

• Smith, MW. Ethnopsychopharmacology. In Lim RF
  (ed). Clinical Manual of Cultural Psychiatry.
  Arlington, VA AP Publishing, Inc. 2006207.
• Bondy B. Dialogues Clin Neurosci. 20057223.

39
Treatment of DepressionEthnopsychopharmacology
(cont)
SNRIs serotonin-norepinephrine reuptake
inhibitors SSRIs selective serotonin reuptake
inhibitors TCAs tricyclic antidepressants
Adapted from Smith MW. Ethnopsychopharmacology.
In Lim RF (ed). Clinical Manual of Cultural
Psychiatry. Arlington, VA AP Publishing, Inc.
2006207.
40
Treatment of DepressionEthnopsychopharmacology
(cont)

• CYP2D6 enzyme
• Major metabolic pathway for many psychotropics1
• Highly polymorphic gt70 known mutations1
• Polymorphisms have a strong effect on treatment
  responses1,2
• Co-administration of certain antidepressants,
  antipsychotics, antihistamines, and other drugs
  can inhibit metabolism3,4

• Malhotra AK. Am J Psychiatry. 2004161780.
• Smith, MW. Ethnopsychopharmacology. In Lim RF
  (ed). Clinical Manual of Cultural Psychiatry.
  Arlington, VA AP Publishing 2006207.
• Brosen K. Clin Pharmacokinet. 199529(suppl)120.
• Hamelin BA. Drug Metab Dispos. 199826536.

41
Treatment of DepressionEthnopsychopharmacology
(cont)

• CYP2D6 enzyme (cont)
• Individuals with CYP2D6 polymorphisms sort into 1
  of 4 groups
• Poor metabolizer (PM) inactive form (slower
  metabolism of drug)
• Intermediate metabolizer (IM) less active form
• Extensive metabolizer (EM) no mutation (aka,
  normal)
• Ultrarapid metabolizer (UM) multiple copies of
  the gene (accelerated drug metabolism)

Smith, MW. Ethnopsychopharmacology. In Lim RF
(ed). Clinical Manual of Cultural Psychiatry.
Arlington, VA AP Publishing 2006207.
42
Treatment of DepressionEthnopsychopharmacology
(cont)

• CYP2D6 enzyme (cont)
• Polymorphisms can alter drug efficacy, side
  effects, and plasma levels1,2
• Poor metabolizersIncreased risk of side effects
  may require lower doses3
• Ultrarapid metabolizersRisk subtherapeutic
  treatment with normal-range dosing, and/or side
  effects due to increased concentrations of
  metabolites3

• Smith MW. Ethnopsychopharmacology. In Lim RF
  (ed). Clinical Manual of Cultural Psychiatry.
  Arlington, VA AP Publishing 2006207.
• Bondy B. Dialogues Clin Neurosci. 20057223.
• Bernard S. Oncologist. 200611126.

43
Treatment of DepressionEthnopsychopharmacology
(cont)

• CYP2D6 enzyme (cont)
• Patients with decreased CYP2D6 activity have
  increased adverse effects, increased hospital
  stays, and increased costs
• Annual cost 5,000 more for poor metabolizers or
  ultrarapid metabolizers than for patients with
  normal activity

Reyes C. National Alliance for Hispanic Health,
2004.
44
Treatment of DepressionEthnopsychopharmacology
(cont)
Adapted from Bernard S. Oncologist. 200611126.
45
Treatment of DepressionEthnopsychopharmacology
(cont)

• CYP3A4
• Multiple drug-drug, diet-drug and herb-drug
  interactions1
• Observed ethnic differences in enzyme activity
• Citrus fruits and corn (common in the Mexican
  diet) are inhibitors and can slow down drug
  metabolism by CYP3A4, increasing risks of adverse
  effects from increased serum drug levels2
• Additional inhibitors1,3 include grapefruit
  juice, and various antidepressants (including
  some SSRIs and TCAs)

• Smith MW. Ethnopsychopharmacology. In Lim RF
  (ed). Clinical Manual of Cultural Psychiatry.
  Arlington, VA AP Publishing 2006207.
• Reyes C. National Alliance for Hispanic Health,
  2004.
• Bondy B. Dialogues Clin Neurosci. 20057223.

46
Treatment of DepressionEthnopsychopharmacology
(cont)

• CYP1A2
• Marked interindividual variability in metabolism
  rate because of multiple factors (eg, dietary
  habits, smoking)
• Polymorphism in activity identified in 32 of
  whites data not yet available for other
  racial/ethnic groups
• Activity is induced by cruciferous vegetables
  (eg, broccoli), cigarette smoking, heterocyclic
  amines of char-broiled meat, and high-protein
  diets

Smith MW. Ethnopsychopharmacology. In Lim RF
(ed). Clinical Manual of Cultural Psychiatry.
Arlington, VA AP Publishing 2006207.
47
Treatment of DepressionEthnopsychopharmacology
(cont)

• CYP2C19
• Responsible for metabolism of 3 common
  SSRIscitalopram, escitalopram, and sertraline1
• Intermediate metabolizer phenotype (less active
  form) may indicate dosage adjustments to lower
  levels2
• 18.5 of African Americans
• 15.717.6 of Asians
• 2.9 of whites

• Smith MW. Ethnopsychopharmacology. In Lim RF
  (ed). Clinical Manual of Cultural Psychiatry.
  Arlington, VA AP Publishing 2006207.
• Burroughs VJ. J Nat Med Assoc. 200294(10
  suppl)1.

48
Treatment of DepressionEthnopsychopharmacology
(cont)

• Implications for the Future
• Knowledge of variation in treatment response
  should alert the physician to the need for
  individualized therapy
• Formularies and protocols should include optimal
  therapies for patients of all races and
  ethnicities
• Drugs in the same class may differ in clinical
  effect caution is needed with drug substitution
  for an equivalent in programs whose goal is
  cost containment
• Pharmaceutical companies should include
  representative numbers of racial and ethnic
  groups in drug metabolism studies and clinical
  trials

Burroughs VJ. J Nat Med Assoc. 200294(10
suppl)1.
49
Treatment of DepressionEthnopsychopharmacology
(cont)

• Successful and safe drug prescribing for ethnic
  and minority patients includes
• Start low, move slow Initiate with minimal
  dosing and evaluate the response
• Take into consideration the patients ethnic
  background and enzyme activity levels
• Ask about supplemental herbs, diet, and smoking
• Check plasma levels when
• Patients have strong side effects while on low
  doses of antidepressants
• Patients do not improve while on higher doses of
  antidepressants
• Involve the family or support system in treatment

Smith MW. Ethnopsychopharmacology. In Lim RF
(ed). Clinical Manual of Cultural Psychiatry.
Arlington, VA AP Publishing, Inc. 2006228.
50
Treatment of DepressionApproaches to
Psychotherapy

• Key applications for transcultural psychotherapy
• Understand the patients social and cultural
  background
• Determine if the patients behavior is within his
  or her own societal and cultural norms
• Analyze the situation in a culture-specific
  fashion
• Identify available strategies in managing the
  patients behavioral issues

Siegfried J. Commonsense reasoning in the
transcultural psychotherapy process. In Okpaku
SO (ed). Clinical Methods in Transcultural
Psychiatry. Washington, DC American Psychiatric
Press 1998279.
51
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52
Institute of Medicine 2005 ReportImproving the
Quality of Healthcare for Mental and
Substance-Use Conditions

• IOMs comprehensive strategy to reduce gaps in
  care includes
• A system in which patient preferences, needs, and
  values prevail
• Coordinated care by multiple providers
• An infrastructure which produces scientific
  evidence and promotes its application to patient
  care

Institute of Medicine. Improving the Quality of
Health Care for Mental and Substance-Use
Conditions Quality Chasm Series. 2005.
53
Institute of Medicine 2005 ReportImproving the
Quality of Healthcare for Mental and
Substance-Use Conditions (cont)

• IOMs comprehensive strategy to reduce gaps in
  care includes (cont)
• Delivery of high-quality health care, supported
  by
• Health care workforce education, training, and
  capacity to deliver
• Government programs, employers, and other group
  purchasers
• Research funds supporting studies with direct
  clinical/policy impact and/or therapeutic
  advances
• Emerging information technology related to health
  care benefits

Institute of Medicine. Improving the Quality of
Health Care for Mental and Substance-Use
Conditions Quality Chasm Series. 2005.
54
Overcoming BarriersCLAS Standards

• Culturally and Linguistically Appropriate
  Services (CLAS)
• Released in 2000 from the Office of Minority
  Health (OMH)
• Recommended national standards for adoption
  and/or adaptation by health care organizations in
  order to offer culturally and linguistically
  accessible health care
• Consist of 14 standards

US Dept. of Health and Human Services, 2000.
http//www.omhrc.gov/assets/pdf/checked/finalrepor
t.pdf
55
Overcoming BarriersCLAS Standards (cont)

• Standards 13, 813
• Guidelines recommended by OMH for adoption as
  mandates by federal, state, and national
  accrediting agencies
• Focus Culturally compatible care, diverse
  staffing, formulation of a strategic plan,
  institution of competence-related measures,
  community involvement, and needs assessment
• Standards 47
• Federal mandates for recipients of federal
  funding
• Focus Language access and language resource
  availability
• Standard 14
• Recommendation suggested for voluntary adoption
  by health care organizations
• Focus Public availability of information about
  progress and implementation of CLAS standards

US Dept. of Health and Human Services, 2000.
http//www.omhrc.gov/assets/pdf/checked/finalrepor
t.pdf
56
State and Federal Requirements for Cultural
Competency Are Increasing

• California As of July 1, 2006,1 licensed
  physicians must include cultural competency and
  linguistics in CME (Assembly Bill 1195)1-3
• New Jersey Physicians must complete cultural
  competency training to obtain a medical license
  from the State Board of Medical Examiners
  (Assembly Bill S144)2
• Washington state By July 1, 2008, educational
  programs for health professionals must integrate
  multicultural health instruction into their basic
  education preparation curriculum
• Other bills have been passed, or are under
  consideration, in various states, including2

• University of California, Davis CME Summary and
  Initiatives for Compliance. http//www.ucdmc.ucdav
  is.edu/cme/resources/ucd_summary.pdf
• Underserved Quality Improvement Organization
  Support Center. CLAS Implementation Guide.
  http//www.qsource.org/uqiosc/CLASGuide.pdf
• Assembly Bill No. 1195. http//www.healthlaw.org/l
  ibrary.cfm?fadownloadresourceID78947appViewfo
  lderprint
• Engrossed Senate Bill 6194. http//www.leg.wa.gov/
  pub/billinfo/2005-06/Pdf/Bills/Session20Law20200
  6/6194.SL.pdf

57
Overcoming BarriersFederal Requirements

• Currently, more than 14 states have Medicaid and
  Medicare contracts with cultural competency
  requirements, as required by the federal
  government1
• JCAHO, the national accrediting body for
  hospitals, is working with the government to
  develop cultural competency mandates
• Helped develop the national Culturally and
  Linguistically Appropriate Services standards
  (CLAS)1
• As of 2006, CLAS standards have been
  crosswalked with JCAHO standards for hospitals,
  ambulatory, behavioral health, long term care,
  and home care2

• U.C. Davis Health System. Cross cultural
  competency program. http//www.ucdmc.ucdavis.edu/h
  r/hrdepts/eod/cross_cultural_competency.html.
• Joint Commission on Accreditation of Healthcare
  Organizations. 2006. http//www.jointcommission.or
  g/NR/rdonlyres/5EABBEC8-F5E2-4810-A16F-E2F148AB517
  0/0/hlc_omh_xwalk.pdf

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59
Final Thoughts

• Cultural competency
• Possessing knowledge, awareness, and respect for
  other cultures.

Juckett G. J Fam Physician. 200572(11)2267.
60
Final ThoughtsCultural Humility
incorporates a lifelong commitment to
self-evaluation and self-critique, to redressing
the power imbalances in the patient-physician
dynamic, and to developing mutually beneficial
and nonpaternalistic clinical and advocacy
partnerships with communities on behalf of
individuals and defined populations. - Tervalon
M. J Health Care Poor Underserved. 19989(2)117.
A respectful attitude toward multicultural
perspectives
does not require mastery of lists of
different or peculiar beliefs and
behaviorsRather, it is a respectful
partnership with each patient through
patient-focused interviewing, exploring
similarities and differences between the
physicians own and each patients priorities,
goals, and capacities. - Hunt LM. Bulletin.
2001241882.
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Final ThoughtsCultural Humility (cont)

• Create an attitude of learning about cultural
  differences in patient encounters
• Acknowledge the presence of differing belief
  systems and cultural values
• Remember that each patient is a unique member of
  one or more cultural, racial, or ethnic groups
• Provide individualized treatment to each patient
• Realize that, while each cultural or ethnic group
  shares beliefs that characterize illness and
  determine acceptable treatment, these beliefs may
  vary within each group
• Avoid stereotyping and overgeneralizations

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