Immigrant status is also a significant stressor for those of all ages and a major consideration in the diagnostic and treatment process. The story of the patient's exodus should include: country of origin, position in the family, education, employment status, level of support, political issues, and experiences of war and traumatic events (Lee, 1990). By definition, immigrants leave their countries voluntarily (and often easily), whereas refugees are either forced out or flee surreptitiously. Both may experience trauma and losses. Clinicians should also discuss the extent of the patient's loss of family members, relatives and friends; property, financial resources, business and career; and support of the cultural milieu, community and religion.
The DSM-IV-TR Cultural Formulation also included the patient's "explanatory model of illness" (Kleinman, 1988). The explanatory model may consist of cultural notions of etiology, timing, mode of onset, pathophysiology, natural history, severity and appropriate treatments. Psychological causation is an example of the explanatory model in the Western patient, whereas a broken taboo may be the explanation used by some traditional Native Americans, who may believe that a spirit calls to them or travels to the afterworld.
Clinicians can elicit the explanatory model by asking the patient: "What has happened?" "Why?" and "Why now?" The clinician should also ask: "What will happen if nothing is done?" and "What effect will the experience have on others?" Finally, the clinician should ask, "What can be done about it?" in order to lay the foundation of a therapeutic plan that considers culture.
These cultural considerations often include religious and spiritual beliefs, which profoundly influence mental status as well as psychiatric assessment and treatment (Lukoff et al., 1993, 1992a, 1992b; Matthews et al., 1993). "Religious or Spiritual Problem" is included in DSM-IV-TR's nonillness category ("Additional Conditions That May Be a Focus of Clinical Attention"). It is important for the clinician to acknowledge and work with a patient's religious beliefs as potential sources of support, rather than only as manifestations of psychopathology. Griffith and Young (1988) and Burton (1992) are among the many who have examined the interactions between religion and family as resources that could be assessed and used therapeutically.
Socioeconomic status also influences mental health diagnosis and care. Economically disadvantaged people experience a reduction in effective coping, which leads to a sense of helplessness and powerlessness and psychopathology rates higher than rates found in the highest socioeconomic groups (Dohrenwend et al., 1980; Fried, 1982). Research has also found that anxiety disorders are more often diagnosed in children of middle-class parents than in children of blue-collar parents and that middle-class children are more likely to be treated with psychotherapy than children of blue-collar parents. Psychosis or personality disorders are more often diagnosed in children of lower-class parents than in children of middle-class parents. Many studies have found that those in most need received the least service (Langner et al., 1974; Ruiz et al., 1995).
Diet and medicinal herbs may also affect treatment considerations. Diet can have dramatic effects on the pharmacology of both psychotropic and non-psychotropic medications by changing their absorption, metabolism, distribution and elimination. Ethno-culturally determined pharmacological influences can occur as a result of differences in food composition, preparation and even the circadian timing of feeding. Studies in England, for example, have found that Sudanese and Asian-Indian immigrants who maintain their native vegetarian diets tend to have different cytochrome P450 enzyme activity profiles from immigrants who adopt the mainstream British meat-eating diet (Jacobsen, 1994).
Throughout much of Latin America, the hot and cold theory dictates that foods culturally characterized as hot should not be consumed concurrently with foods characterized as cold, thereby leading to variations in food intake that may alter pharmacologic activity. An example is found in the Mediterranean diet containing fava beans. Fava beans have a high content of the neurotransmitter dopamine and can cause severe hypertensive reactions in individuals taking monoamine oxidase inhibitors (MAOIs).
Grapefruit juice has been found to inhibit the cytochrome P450 3A4 isozyme, which is responsible for metabolizing a number of psychotropics, including sertraline (Zoloft), nefazodone (Serzone), trazodone (Desyrel), fluoxetine (Prozac), buspirone (BuSpar) and numerous benzodiazepines (as well as many non-psychotropic medications). Consuming grapefruit juice can cause dramatic elevations in the blood levels of these drugs.
