The Influence of Culture in The Influence of Culture in Emergency PsychiatryEmergency Psychiatry

The Influence of Culture in The Influence of Culture in Emergency PsychiatryEmergency Psychiatry

Dr. Dionne HartDr. Dionne Hart

A GriotA Griot

Presentation OutlinePresentation Outline

Defining Cultural PsychiatryDefining Cultural Psychiatry Describe Cultural FormulationDescribe Cultural Formulation Clinical ApplicationsClinical Applications Case ExampleCase Example Suggest a modified version of the Cultural Suggest a modified version of the Cultural

Formulation for emergency room settingFormulation for emergency room setting

Physicians’ CompetencyPhysicians’ Competency

Survey mailed to 3500 residents in their final year Survey mailed to 3500 residents in their final year of training in emergency medicine, family practice, of training in emergency medicine, family practice, internal medicine, OB/GYN, pediatrics, psychiatry, internal medicine, OB/GYN, pediatrics, psychiatry, or general surgery at US academic health centers.or general surgery at US academic health centers.

Cross-cultural care was perceived to be important, Cross-cultural care was perceived to be important, there was little time allotted during residency to there was little time allotted during residency to address cultural issues, and there was little address cultural issues, and there was little training, for evaluation, or role modeling.training, for evaluation, or role modeling.

JAMA September 7, 2005-Volume 294, No.9JAMA September 7, 2005-Volume 294, No.9

Introduction to Cultural Introduction to Cultural PsychiatryPsychiatry

Culture defined as a set of Culture defined as a set of beliefs, traditions, customs, beliefs, traditions, customs, and habits that provide a and habits that provide a social and historical social and historical background to a person’s background to a person’s identity and behavior.identity and behavior.

Kleinman A. Writing at the Margins: Discourse Between Kleinman A. Writing at the Margins: Discourse Between Anthropology and Medicine. Berkeley, Calif: University of Anthropology and Medicine. Berkeley, Calif: University of California Press; 1996.California Press; 1996.

Hsu SL. Individual Reconsidered: A Face in Psychological Hsu SL. Individual Reconsidered: A Face in Psychological Anthropology. Knoxville, Tenn: University of Tennessee Anthropology. Knoxville, Tenn: University of Tennessee Press; 1983Press; 1983

Modified Cultural FormulationModified Cultural Formulation

Elicit first language, Elicit first language, place of birth, self-place of birth, self-defined ethnicity, and defined ethnicity, and identification with identification with specific cultural groupsspecific cultural groups

Define all terms used by Define all terms used by you and the patient. you and the patient. Develop a shared Develop a shared understanding of the understanding of the problem.problem.

Be sensitive to religious Be sensitive to religious and social taboos within and social taboos within the patient’s culture.the patient’s culture.

Do not ask children to Do not ask children to interpret. Avoid interpret. Avoid relatives interpreting relatives interpreting unless in an emergency.unless in an emergency.

Involve independent Involve independent advocates with the advocates with the patient’s agreement.patient’s agreement.

Case ExampleCase Example

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

An interpreter is utilized. Interpret is unable to An interpreter is utilized. Interpret is unable to understand the patient as his speech is illogical understand the patient as his speech is illogical and nonsensical.and nonsensical.

Parents deny prior medical or psychiatric Parents deny prior medical or psychiatric disorders. disorders.

The psychiatrist asked if the patient utilized The psychiatrist asked if the patient utilized illicit drugs. Interpreter refuses. “He is illicit drugs. Interpreter refuses. “He is Muslim and does not use Western drugs.”Muslim and does not use Western drugs.”

ImpasseImpasse

Need more medical informationNeed more medical information Unable to communicate directly with patient Unable to communicate directly with patient

or parentsor parents Interpreter is impeding evaluation process.Interpreter is impeding evaluation process. Parents now wish to take the patient home Parents now wish to take the patient home

although he remains agitated and psychotic.although he remains agitated and psychotic.

Safety FirstSafety First

Patient placed on a seventy-two hour hold Patient placed on a seventy-two hour hold despite parents’ wishes.despite parents’ wishes.

No beds are available in the state of MinnesotaNo beds are available in the state of Minnesota He is treated emergently with IM Zyprexa, He is treated emergently with IM Zyprexa,

Benadryl, and Ativan.Benadryl, and Ativan.

Generose via Emergency Generose via Emergency Treatment Unit’s South HallTreatment Unit’s South Hall

Hennepin County Hennepin County Acute Psychiatry ServicesAcute Psychiatry Services

Observation PeriodObservation Period

Roommates visit patient.Roommates visit patient. Roommates reluctantly report the patient Roommates reluctantly report the patient

ingested khat for the first time at a party two ingested khat for the first time at a party two days ago. After a couple hours, the patient days ago. After a couple hours, the patient was found sitting in a darkened room agitated was found sitting in a darkened room agitated and grasping items in the air. and grasping items in the air.

Afraid they transported the patient to his Afraid they transported the patient to his parents’ home.parents’ home.

KhatKhat

A shrub that originated A shrub that originated in Ethiopia then spread in Ethiopia then spread to other countriesto other countries

Amphetamine-like Amphetamine-like propertiesproperties

Stimulant which may Stimulant which may lead to a psychotic or lead to a psychotic or manic episodemanic episode

Areas of UseAreas of Use

??? Rochester, MN??? Rochester, MN

Clinical ApplicationsClinical ApplicationsDiagnostic ConsiderationsDiagnostic Considerations

Recognize neuropsychiatric manifestations of Recognize neuropsychiatric manifestations of disorders endemic in ethnic populationsdisorders endemic in ethnic populations

Differences in diagnosis and treatment of Differences in diagnosis and treatment of affective and thought disordersaffective and thought disorders

Identify disorders which may be related to Identify disorders which may be related to diet, social, or religious practicesdiet, social, or religious practices

Clinical Applications:Clinical Applications:Evaluation ConsiderationsEvaluation Considerations

Develop an allianceDevelop an alliance Recognize possible Recognize possible

barriers to treatmentbarriers to treatment

Promote treatment Promote treatment compliancecompliance

Use of InterpretersUse of Interpreters

Interpreters should have professional Interpreters should have professional knowledge, judgment, and experience beyond knowledge, judgment, and experience beyond familiarity with the languages involved.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, Avoid use of family members or friends,

particularly children.particularly children.

Key QuestionsKey Questions What do you call your What do you call your

problem?problem? What are your thoughts What are your thoughts

on what is the cause of on what is the cause of your problem?your problem?

What are the What are the implications of this implications of this illness for your life?illness for your life?

What are you expecting What are you expecting is the appropriate is the appropriate treatment?treatment?

What are your concerns What are your concerns for your prognosis?for your prognosis?