Although oversimplifying to some degree, the first phase of cultural psychiatry in the United States can be traced to the period after World War I and through World War II. In this phase, some attention was paid to the mental problems of those who clearly seemed culturally "different," in an ethnic or religious sense, from the usual "Caucasian American." This viewpoint--a remnant of drapetomania--could encompass so-called Negroes, but also newer immigrants like Italians, Greeks and Jews. It was thought that "war neurosis" occurred more in such groups. Italianitis referred to Italians who seemed to have a tendency to develop symptoms of secondary gain after World War I stress, feeling that this wealthy country should provide for them (Benton, 1921). Of course there was little scientific evidence to support this claim. Some attention was also paid to cultural differences in inpatient treatment, such as higher hospitalization rates for Negroes and lower rates for Asian-Americans. A beginning realization that difficulties occurred in providing cross-cultural psychotherapy also emerged.
The next phase began in the 1960s, with the development of government-sponsored community mental health care centers. One of the goals of these centers was to provide better access to care for minorities and the poor. However, many studies indicated that, in fact, minority and refugee patients were accepted into treatment less frequently, had a higher dropout rate and, as a continuation of an earlier trend, received less psychotherapy (Moffic and Kinzie, 1996). When treatment facilities hired more minority staff members, this difference diminished somewhat.
The years following the civil rights and ethnic pride movements of the 1960s saw more use of community education, more bilingual staff, and more collaboration with folk healers and religious leaders--all of which proved helpful in addressing the continuing deficits in the care of patients from poor and minority cultural backgrounds. Special clinics and inpatient units devoted to specific cultural groups have yielded some success and continue to be studied (Mathews et al., 2002).
By the end of the 20th century, cultural psychiatry became broader and more complex. The possibility that drug response could be affected by ethnic or racial biological differences was substantiated by research (Lin et al., 1993). While specific guidelines have been slow to evolve, clinicians were advised to proceed with some caution in cross-cultural prescribing. Beyond ethnic or minority status, culture also came to encompass such factors as religion, age, disability, celebrity, gender, sexual preference and occupation. For example, after the Sept. 11, 2001, bombing, it was striking that New York City firefighters often had a "tough-it-out" ethos that tended to deny symptoms and avoid treatment (Moffic, 2003).
Cultural influences made their way into the DSM-IV. Each diagnostic category has a section titled "Specific Culture, Age, and Gender Features." An appendix has an "Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes." Training programs developed model educational guidelines to teach this new information (LoboPrabhu et al., 2000; Moffic et al., 1988). Culture even found its way into managed care. Although most companies are still owned by white males, cultural competence has made its way into the process of accrediting managed behavioral health care organizations.
The term and goal of cultural competence can be said to characterize the state of cultural psychiatry at the beginning of the 21st century (Lu, 1996). This competence is important at both the system and clinical levels. Various states have even begun to incorporate cultural competence into contracts, such as the New York State Cultural and Linguistic Competence Standard Evaluation.
Although some African-Americans still mistrust white clinicians (possibly a lingering remnant of drapetomania) (Whaley, 2001), gains in cultural competence have been documented. For example, in contrast to prior studies, a recent study at a community mental health care center in New Haven, Conn., did not find any racial or ethnic disparities in the prescription of atypical antipsychotics (Woods et al., 2003). A five-stage model for family intervention for Asian-Americans with schizophrenia was developed and includes preparation, engagement, psychoeducation, therapy and termination (Bae and Kung, 2000). A third example is a new six-step formula to separate out cultural factors in the diagnosis of attention-deficit/hyperactivity disorder, especially in African-American children (Pitts and Wallace, 2003).
Gender issues are also coming to the forefront. Women are now known to have a prevalence of major depressive disorder twice that of men, likely due to both neurobiological and psychosocial factors (Kornstein et al., 2002). So-called atypical vegetative symptoms of the depression are seen more often in women. There are suggestions that estrogen may play a role in the pathophysiology of depression and even possibly the response to serotonergic antidepressants.Future of Cultural Psychiatry