Eugenio M. Rothe, MD

Supportive psychotherapy occurs in almost every doctor-patient encounter and is the psychotherapy provided to the vast majority of patients who are seen in psychiatric clinics and mental health centers. Yet very few scholarly articles are written that help explain its principles or how it works.

In the late 19th century, Freud began to develop the techniques of psychoanalysis, which served as a foundation for all the other psychotherapeutic modalities. Most of Freud’s patients were members of the upper classes of Viennese society and had significant ego strengths, and their problems were mainly intra-psychic. In contrast, many of the patients seen by psychiatrists and residents today suffer from extra-psychic problems, such as poverty, social and political oppression, and abuses of power in relationships that threaten to overwhelm their coping capacities. For these patients, supportive therapy is the treatment of choice.

Supportive psychotherapy is a dyadic treatment that uses direct measures to ameliorate symptoms and to maintain, restore, or improve self-esteem, ego functions, and adaptive skills. It was developed in the early 20th century, and its objectives are more limited than those of the psychodynamic therapies. This therapeutic modality focuses especially on developing adaptive capacities that take into account the patient’s limitations, including:

• Personality issues, such as deficits in character structure and defense mechanisms

• Native ability (eg, impaired reality testing, decreased cognitive functioning, lower IQ, learning disabilities)

• Problems associated with life circumstances (eg, lower levels of education, low socioeconomic status, limited social support systems, problems related to migration)

The connection between mental illness and poverty

There is a 2-way connection between mental illness and poverty. Poverty increases the risk of mental illness, and mental illness is often a person’s path into poverty. In 1965, the sociologist Oscar Lewis published the controversial document “The Culture of Poverty,” in which he argued that to adapt to their environment, people who live in poverty for a long time develop a series of coping mechanisms that become engrained and paralyzing and that affect the individual, the family, the slum community, and the community in relation to society.

Supportive therapy can serve as the first bridge out of social isolation and marginalization, since the 2 most important elements of supportive therapy are the 

, which allays anxiety, helps support the patient’s healthy defenses, and enhances adaptive skills; and 

. This style avoids analytic abstinence and engages the patient in a collaborative discussion that decreases the power differential.

Supportive therapy is also the treatment of choice in individuals with severe personality disorders, at least in the initial phases of treatment. Many individuals with personality disorders resent and fear the power differential that results from a more analytic stance, given that many of them have experienced abuses of power in early life. If the power differential is not addressed early in the treatment, it can destroy the therapeutic relationship.

Most psychotherapies rely on the therapeutic alliance, but in supportive psychotherapy it is considered the most important element. When practicing supportive psychotherapy, one must negotiate a therapeutic alliance that preserves the authority, voice, and agency of the patient and ensures that he or she is active in the treatment. In patients who have chronic disorders, unsatisfactory living conditions, and little hope for change in their lives, the therapist represents a figure of 

, a contact with the outside world, and a representative of the broader world. Supportive psychotherapy stands in contrast to expressive therapies that seek to accomplish personality change through analysis of the relationship; exploration of previously unrecognized feelings, thoughts, needs, and conflicts; and development of insight. Supportive therapy includes some of these elements, so the therapist must move through a “psychotherapeutic continuum” (

The therapist takes into account the patient’s cognitive abilities, reality testing, thought process, capacity to organize behavior, affect regulation, and capacity to relate to others in order to determine the patient’s location on the continuum. Purely supportive interventions are chosen for patients with disorganized behavior, thought disorder or cognitive impairment, limited intelligence, and lower levels of education and socialization and for patients with personality disorders. With less impaired patients, expressive therapies are used. It is important for the therapist to be hopeful that the impaired patient can eventually move across to more psychodynamic supportive therapy and beyond.

Affect regulation is one of the most important goals of supportive psychotherapy. More regressed patients commonly have difficulties with affect regulation, which produces a state in which the patient cannot attend or think and which interferes with the capacity to self-reflect. The therapist must attend to the patient’s physical comfort in therapy and try to avoid interruptions and phone calls during the sessions; establish conditions of emotional safety, such as addressing issues of substance abuse, self-harm, and domestic abuse; and avoid an interrogation stance.

In contrast to more psychodynamic-oriented therapies, one must be careful not to be incisive when practicing supportive therapy with more vulnerable or regressed patients. Clarifications, interpretations, and confrontations may embarrass the patient, increase the patient’s anxiety to a level that he or she is incapable of modulating, and may reawaken memories of abuse. These interventions are more appropriate for treating patients with neurotic defenses that are analyzed and examined and the conflicts underlying the defenses identified.

 is fostered by conveying to the patient acceptance, interest, respect, and admiration for his or her accomplishments, thus supporting the patient’s self-esteem. Conscious problems are addressed, and defenses are questioned only when they are maladaptive. The patient is treated with honesty and respect.

Other important techniques used in supportive psychotherapy include behavior goal setting, encouragement, positive reinforcement, shaping behavior, and modeling. Children respond to the influence of their parents by imitating them and gradually by internalizing aspects of the parents by the process of identification. They later identify with other important figures in their lives. Some key aspects of these identifications include the development of a stable sense of self; a capacity to modulate anxiety so that it does not lead to defensive distortions of reality; a benevolent conscience that allows for a reasonable pursuit of pleasure without unreasonable guilt; and a capacity to love without fearing a loss of the self in experiences of fusion, or of excessive anxiety in the face of separations. For change to take place in therapy, interpretive work needs to occur with the patient’s increasing capacity for self-reflection, but modeling by the therapist provides some of the first and most fundamental building blocks for change.

Supportive therapy may include educating the patient and family members about the illness and about the patient’s potential and limitations, establishing realistic goals, addressing issues in the life of the patient that will reduce stress and anxiety, and helping the patient and the family improve their adaptive skills. It may also include limit setting and appropriate reward and punishment with children, and helping the patient, the family, and others involved to understand the patient’s functional and cognitive limitations.

It is important to take into account barriers to treatment such as economic, geographic, cultural, and stigma-related issues; distrust; and past persecutory experiences. 

 are the characteristic way in which members of different cultures describe what is wrong and which may differ from the expressions found in mainstream American culture. It is also very important to explore the patient’s history for adverse life events and to listen to the metaphors or therapeutic stories for adverse previous personal and medical experiences. In many cases, the patient’s “life-meaning story” is closely related to previous traumas that account for treatment resistance. In some cases, the patient fears a repetition of these traumas, such as in the case of psychiatric hospitalization, which may elicit fears of oppression, abuse, and incarceration.

I am grateful to David Lopez, MD, and Jennifer Downey, MD, of the 

American Academy of Psychoanalysis and Dynamic Psychiatry

 (AAPDP) for their invitation to write this article and for their review of the article. The AAPDP is the affiliate society of the American Psychiatric Association dedicated to all aspects of psychodynamic psychiatry. Its mission is to promote psychodynamic understanding when evaluating and treating patients in clinical practice, medical education, and residency training.

• Applebaum AH. Supportive psychotherapy. 

• Dohrenwend BP, Levav I, Shrou PE, et al. Socioeconomic status and psychiatric disorders: the causation- selection issue. 

• Lewis O. Culture of poverty. In: Moynihan DP, ed. 

On Understanding Poverty: Perspectives From the Social Sciences

• Pumariega A, Rothe EM, Mian A, et al. Practice parameters for cultural competence in child psychiatric practice. 

• Rothe EM. A psychotherapy model for treating child and adolescent refugees caught in the midst of catastrophic situations. 

. Arlington, VA: American Psychiatric Press; 2004. 

Dr. Rothe is Professor of Psychiatry and Public Health at the Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, and Immediate Past Chair of Scientific Programs, American Academy of Psychoanalysis and Dynamic Psychiatry.

Dr. Rothe reports no conflicts of interest concerning the subject matter of this article.

Articles

Supportive psychotherapy can serve as the first bridge out of social isolation and marginalization and addresses personality issues, such as deficits in character structure and defense mechanisms.

Supportive Psychotherapy in Everyday Clinical Practice: It’s Like Riding a Bicycle

The American Academy of Psychoanalysis and Dynamic Psychiatry (

 (APA), will celebrate its 59th annual meeting on May14 to 16, 2015, at the 

 Hotel in Toronto. The mission of the AAPDP is to maintain psychotherapy as a fundamental part of the psychiatric profession and to integrate psychodynamic theory, neuroscience, and the humanities into the daily practice of psychiatry.

This year’s meeting offers a rich and varied program. In the opening plenary, Richard Brockman, MD, will revisit William Shakespeare in “Othello: Shame, Rage and Neurobiology,” reminding psychiatrists that much can be learned and rediscovered from the works of literature and the arts, especially in view of the recent scientific advances that help to further integrate psychodynamic theory and neurobiology.

The first day of the meeting will include a series of symposia and workshops that focus on new approaches to the construction of 

 assessments and formulations, treatment plans, the integration of psychodynamic concepts into psychopharmacology, and the therapeutic use of dreams. These interactive presentations are specifically designed to help clinicians address the practical, everyday realities faced by today’s psychiatrists.

They also aim at helping psychiatrists maintain their understanding of the patient as “a real person,” putting in place treatment plans that incorporate psychopharmacology and psychodynamics. The hope is that psychiatrists will develop stronger 

 that help to improve treatment adherence and treatment outcomes and avoid the reductionistic approaches that are often imposed by third-party payers.

In the humanistic tradition that characterizes the meetings of the AAPDP, Chuck Joy, MD, will share his poetry in the interactive workshop titled, “A Psychiatrist-Poet Invites You to Explore What His Poetry Evokes in You.” Later, Gregory Mahr, MD and Dennis Kuo, MD will explore the relationship between “Music, Mind, and Brain.”

Other presentations will focus on the relationship between the therapeutic alliance and somatization; 

; the therapist’s capacity of self-regulation when treating severely regressed patients; and unique 

 to the treatment of trauma in diverse patient populations, such as war veterans, victims of torture, and AIDS patients.

Two plenary addresses will feature, Graeme Taylor, MD, who will discuss, “Patients With a Paucity of Inner Experiences: Insights from Neuroscience and Empirical Research,” and Andrew Gerber, MD, PhD, who will talk about “The Essential Role of Neuroscience Research and the Future of Psychoanalysis.”

The second day of the meeting will include presentations on dealing with the death of a parent as a college student; violations in the treatment alliance; how metaphor creates an environment for change in psychotherapy; the Superego seen from the point of view of neurobiology; memory reconsolidation in psychotherapy; and the contributions of the Babylonian Talmud to the understanding of dreams, among others.

The presidential address will be given by Elizabeth Auchincloss, MD, who will discuss “New Developments in the Therapeutic Alliance and Its Implications for the Future of Psychotherapy and Psychoanalysis.” The meeting will include presentations; paper sessions; and a luncheon for residents and medical students, who are invited to attend the meeting free of charge upon presenting a valid ID.

The AAPDP invites all psychiatrists, residents, and medical students interested in psychodynamic therapy to register and attend this stimulating and exciting meeting, which takes place immediately before the APA, by logging on to 

Dr Rothe is Chair of Scientific Programs for the American Academy of Psychoanalysis and Dynamic Psychiatry.

The American Academy of Psychoanalysis and Dynamic Psychiatry meeting will include a series of symposia and workshops that focus on new approaches to psychotherapy.

Psychodynamic Psychiatrists to Meet in Toronto Alongside the APA

San Francisco will host the 57th annual meeting of the 

American Academy of Psychoanalysis and Dynamic Psychiatry (AAPDP)

, which will take place concurrently with the American Psychiatric Association (APA) annual meeting from May 16 to 18, 2013. The chosen location will be at the Westin St. Francis Hotel at 335 Powell Street with easy access to many of the city’s main attractions.

The AAPDP welcomes all psychiatrists interested in psychotherapy and psychodynamics and has as its mission keeping psychodynamic therapy as an integral part of the psychiatric profession. This year’s meeting will highlight the topic of Suicide and the Opening Speaker will be Mardi Horowitz, MD, who will present on 

The Keynote Address will be given by APA President, 

Wisdom: From Psychology to Neuroscience. 

The Friday morning program will consist of 2 symposia-

On the Nature of the Clinical Applications of Psychodynamics 

Transcultural and Intergenerational Aspects of Suicide

. These will befollowed by a resident’s workshop sponsored by the New York Medical College Psychoanalytic Institute and titled

, Clinical Dilemmas and Therapeutic Issues.

 It will feature a rich and diverse collection of their own clinical experiences presented by residents and discussed by the masters.

Friday’s noon workshops will address the paradoxes of, 

Suicide as Impact of Trauma and Trauma as Impact of Suicide, 

Relational Suicide Assessment With Particular Attention to Medical Students. 

The afternoon will start with a presentation of a 90-minute documentary film titled 

 followed by an interview with the documentary author-filmmaker Michael Stutz, conducted by AAPDP President, Michael Blumenfield, MD, followed by a question and answer session with the audience.

Psychodynamic Psychotherapy With Persons that have Medical Illnesses,

States of Mind Preceding Near Lethal Suicide Attempts.

 Workshops will continue on Saturday and will address such tiles as: 

Trauma and Identity in a Psychological Autopsy

 and other symposia addressing novel approaches of the psychodynamic treatment of PTSD, countertransference issues in suicide, treatment of the suicidal adolescent, the psychodynamics of physician-assisted suicide, suicide issues in the military, the therapeutic use of dreams, Jungian perspectives on suicide, a pharmacology peer supervision workshop, and a workshop for residents and medical students.

The meeting will also feature a live interview with one of the masters of the AAPDP covering the life and work of Leah Davison, MD. The meeting will conclude with the Presidential address given by former APA president Herb Pardes, MD, who will discuss 

Psychodynamics in a Turbulent World of Health Reform

The American Academy of Psychoanalysis and Dynamic Psychiatry welcomes all psychiatrists interested in psychotherapy and psychodynamics and has as its mission keeping psychodynamic therapy as an integral part of the psychiatric profession.

Psychodynamic Psychiatrists to Meet Alongside the APA in San Francisco

Philadelphia will host this year’s annual 56th Annual Meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry (

), which will take place from May 3 to 5, 2012. The chosen location will be at the Loews Philadelphia Hotel at 1200 Market Street, with easy access to many of the city’s main attractions.

In what now has become a tradition and a statement about our strong ties with the American Psychiatric Association (APA), the Opening Speaker will be APA President John Oldham, MD, who will inform us about “Personality Disorders and DSM-5.” Thanks to the efforts of co-chairs Eugene Della Badia, DO, and Kimberly Best, MD, the meeting will highlight a Plenary Session with Henri Parens, MD, a child survivor of the holocaust and Professor of Psychiatry at Jefferson Medical College, who will present autobiographical material and discuss the topic of “Resiliency.” The Keynote Address will be delivered by Salman Akhtar, MD, also a Professor at Jefferson, who will present on “Psychoanalytic Perspectives on Human Goodness: Theory and Technique.”

The Friday program will begin with two concurrent panels: the first will be chaired by Andres Pumariega, MD, Chairman of Psychiatry at the Cooper Medical School in Camden, New Jersey, and will focus on “Psychotherapy Approaches with Children and Families of Underprivileged and Culturally Diverse Backgrounds.” The concurrent panel “New Frontiers in Psychodynamic Psychiatry,” will be chaired by Gail Berry, MD, with Gerald P. Perman, MD, as discussant. This will be a rich and diverse collection of presentations covering applied psychodynamics, politics and neuroscience.

Friday’s noon workshops will consist of Cesar Alfonso, MD, and Silvia Olarte, MD’s “The Psychiatrist as Internist of the Mind,” concurrently with Crittenden Brookes, MD, PhD, and Clay Whitehead, MD’s ongoing and exciting discussion group, “Theoretical Models of Psychotherapy.” The afternoon will offer a series of very exciting consecutive presentations, all in the same room, in order to allow the members to interact as a group and be able to attend all the presentations without having to make difficult choices. The session will start out with Erminia Scarcella, MD’s “The Red Book of C.J. Jun,” and Sheila Hafter-Gray, MD, as discussant, followed by Samuel Slipp, MD, who will present on “How Freud’s Fight Against Anti-semitism Split the Psychoanalytic Movement.” Later, Buddy Glucksman, MD, and Milton Kramer, MD, will present on “Initial and Manifest Dream Reports of Patients in Psychodynamically-Oriented Psychotherapy,” ending with Greg Mahr, MD, of Michigan, who will present on “The Overdiagnosis of Bipolar Disorder: Countertransference Aspects.”

The Saturday morning program will begin with two concurrent panels. One will focus on the “The Interface between Psychodynamics and Biologic Psychiatry,” including topics such as evidence-based findings on adherence to medication, splitting treatment with psychologists and social workers, and the use of MRI’s and genetic testing in psychodynamic psychiatry. The other panel will focus on “Child and Adolescent Psychiatry,” and it will cover such topics as psychodynamic reactions to foster care; psychotherapy with persons who are adopted; childhood precursors to personality disorders; and an international perspective on attachment. The noon program will present attendees with two consecutive and very difficult choices. The first two workshops will focus on “Neurodynamics and Psychodynamics of Narrative,” by Richard Brockman, MD, and “Transcultural and Psychodynamic Psychiatry in the Era of Globalization” chaired by Cesar Alfonso, MD, and Antonio Bullon, MD. These are followed by another very difficult choice for the attendees: “Narratives and Brain Processing” with Andrei Novac, MD, and Barton Blinder, MD, of Newport Beach, California, concurrently with a workshop titled: “Interfacing with the Academy Journal: Psychodynamic Psychiatry,” which will introduce members to the new Academy Journal, including instructions and coaching on how to publish articles in the journal. This workshop will be chaired by Richard Friedman, MD; Jennifer Downey, MD; Cesar Alfonso, MD; and Joseph Silvio, MD. In the meantime, that same day at noon, Kim Best will be chairing the “Residents Luncheon” in which psychiatry resident Heather Forouhar-Graff, MD, will present “The Nocebo Effect: Reviewing the Literature from a Medical Student’s Perspective.”

Saturday afternoon will consist of a three-hour panel, concurrently with three successive paper sessions on education, taking place in the adjacent room. The panel, “Update in HIV and AIDS Psychiatry,” will be chaired by Mary Ann Cohen, MD, and will encompass 5 distinguished presenters who will provide a comprehensive and up-to-date focus on these conditions. In the other room, Joseph Silvio, MD, and Peter Collori, MD, will present on “Rediscovering Psychodynamics in Modern Residency Programs: Experiential Training for PGY-I and Beyond,” followed another presentation focusing on psychiatric education titled, “Experientally Engaging Psychiatric Trainees in Reflection, Psychotherapy and Organizational Dynamics Using Balint Style Group Facilitation: The Dudley Model,” by Faisal Shafi Shaikh, MRCPsych, of the United Kingdom. The Faculty of the Psychoanalytic Institute of New York Medical College will sponsor the 3rd and final presentation of the afternoon titled, “Dilemmas in Clinical Practice,” and consisting of work with patients done by residents and with contributions by Scott Schwartz, MD. A rich discussion by Doug Ingram, MD; Joe Silvio, MD; Sherry Katz-Bearnot, MD; Buddy Glucksman, MD; and Silvia Olarte, MD, will follow.

The closing of the meeting will take place with the Presidential Address. Academy President Cesar Alfonso, MD, has chosen Debra Katz, MD, of the University of Kentucky, to deliver the presentation titled, “Inspiring Interest in Psychodynamic Psychiatry and Psychoanalysis: National Survey Data and Implications for the Future.”

There is a term in Latin that is used in judicial circles to define a situation that is so clear and of such common agreement, that it requires no argument. It’s “Res Ipsa Loquitur,”meaning: “the thing speaks for itself.” This is the most fitting description of the level of quality of our upcoming annual meeting. We hope to see you all in Philadelphia. Registration and contact information at 

Philadelphia will host this year’s annual meeting that will take place from May 3 to 5, 2012. The chosen location will be at the Loews Philadelphia Hotel at 1200 Market Street, with easy access to many of the city’s main attractions.

AAPDP Annual Meeting Offers a Rich and Exciting Program

A few years ago, the eminent professor of psychiatry, Dr Ronald Pies, wrote a commentary for 

 titled, “Are We Misreading the Signs in Psychiatry?”

 In that article, Dr Pies discussed the need for the comprehensive evaluation of patients in order to arrive at the correct diagnosis. We want to take from his premise that this concept should be expanded to include that among patients presenting with substance abuse as a primary diagnosis, other co-existing Axis I diagnoses should be considered. 

The recent passing of the famous British singer Amy Winehouse highlights once again the question: Is substance abuse a form of self-medication in some of the most well-known cases of public self-destruction? A 

 reads:“Amy Winehouse Died from Alcohol Withdrawal, Says Family.” Several London newspapers previously speculated about a heroin overdose. Whatever the cause of death, the demise of Amy Winehouse again sparks the debate about public figures who die from “yet another addiction,” leaving open the possibility that other co-existing Axis I diagnoses are being ignored and untreated.

As psychiatrists, we are well aware of the co-morbidity of substance abuse with major mental illness. Long before Mickey Mantle declared that he always needed several shots of liquor to face the press (social anxiety?), we have been aware that Vincent Van Gogh, Charles Dickens, Lord Byron, Salvador Dali, Sylvia Plath, and many other famous artists have struggled with mental illness and co-existing substance abuse disorders.

We have also seen the other side of the coin, for example, when clear cut alcohol or opiate abusers present with racing thoughts and irritable mood upon interrupting the abuse of their substance of choice and a diagnosis of bipolar disorder is made, only to discover later that such presentation was part of the withdrawal syndrome.

We venture to speculate that we, as psychiatrists, are not the ones misreading the signs, but that it is the media who miss the signs and misinform the public. It is our responsibility as psychiatrists to educate the media and the public in general about the danger of oversimplification and of the possibility that behind egregious and self-destructive substance abuse, there is often a co-existing psychiatric diagnosis.

1. Pies R. Are we misreading the signs in psychiatry? 

 2006;23(2):15-16.
2. Nudd T. Amy Winehouse died from alcohol withdrawal, says family. 

 Available at: http://www.people.com/people/article/0,,20513558,00.html. Accessed August 15, 2011.

It is our responsibility as psychiatrists to educate the media and the public in general.

Are the Media and the Public Still Missing the Clues?

Why Are Vampires So Popular in Our Culture?

That unusual topic was addressed by Dr Eugenio Rothe at a symposium at the recent 

. We’ve invited Dr Rothe to talk briefly about the appeal of vampires and what their popularity reveals about the human psyche. Dr Rothe is Professor of Psychiatry and Public Health at the Herbert Wertheim College of Medicine, Florida International University, and Chair of the Scientific Programs, of the 

Podcasts

That unusual topic was addressed by Dr Eugenio Rothe at a symposium at the recent APA meeting in Honolulu.

The cultural and demographic profile of the United States is undergoing a rapid transformation. In many areas of the country, there is no longer an ethnic majority but a multiplicity of racial and cultural groups. These changes can be attributed to 3 principal factors

:

• The aging and lower fertility rates of the European origin population.
• The significant increase of immigration from developing countries, especially from Latin American and Asia.
• The higher fertility rates of the non-European minority groups. 



Risk factors for depressive disorders in minority youth


The most recent studies reveal that minority children and adolescents are at a higher risk for depression than white youth. This is particularly true for Hispanic, non-Hispanic black, and American Indian youths.

Suicide rates, which have been traditionally lower among minority youth, are now equal to or surpass those of white youth. Hispanic, non-Hispanic black, and American Indian youth have a higher suicide risk than youth from the mainstream culture. 

The stresses of living in poverty are frequently accompanied by variables such as discrimination, gender role pressures, losses related to immigration, and ongoing frustration and deficient support systems, which abound in this population.

 Conflict also plays an important role in depression and often evolves into a vicious cycle in which irritability-a common feature of child and adolescent depression-increases interpersonal tensions and may cause parents, teachers, and friends to distance themselves from the depressed person. This, in turn, increases feelings of abandonment and lack of support.


Minority and immigrant children and adolescents face a number of barriers to effective mental health care. These include population barriers (socioeconomic disparities, stigma, poor health education, and lack of legal immigration status), provider factors (deficits in cross-cultural knowledge and skills and attitudinal sensitivity), and systemic factors (location of services and organizations, and lack of culturally competent services and practitioners).

Minority youth often reside in neighborhoods where services are unavailable, or they lack the public or private insurance necessary to obtain mental health services. Recent studies show that Hispanic families underuse mental health services because of language and cultural barriers,

 non-Hispanic black families underuse health services because of distrust,

 while Asian Americans avoid or delay seeking care because of the stigma that is associated with mental illness.


Diagnosing depression in minority and immigrant youths can be challenging to unfamiliar clinicians. There is significant evidence that psychiatric disorders are frequently misdiagnosed among culturally diverse youth. Various studies have found an overdiagnosis of conduct disorder and an underdiagnosis of depressive disorders in minority youths.

 Misdiagnosis largely originates from difficulties that clinicians may have in addressing cultural differences, including cognitive biases stemming from stereotyping, lack of systematic assessment, and lack of contextualization of information obtained in diagnostic assessments.

 Most care for depression is provided by primary care physicians who may have relatively little experience with depression in children and adolescents and have added disincentives, such as decreased reimbursement for identifying a mental health versus a somatic health problem.



Children and adolescents from minority populations may demonstrate different symptoms than white American youths. Somatization and anger, for example, are symptoms more frequently associated with depression in minority youths.

 The degree of emotional reactivity can also vary: Asian Americans who are depressed show heightened reactivity compared with white Americans who show less reactivity when depressed.

 Diagnosis is more challenging with depressed minority children and adolescents because of frequent comorbidities. For example, stresses associated with immigration, acculturation stress, discrimination, and community violence contribute not only to depression but also to anxiety, disruptive behavioral symptoms, substance abuse, and posttraumatic stress disorder (PTSD).

 argues that culture shapes the way individuals not only express but also understand the symptoms of illness. There are significant differences in how the various ethnic groups understand depression, which can influence help-seeking behaviors and invoke spiritual, supernatural, sociological, and interpersonal explanatory models. For example, non-Hispanic blacks often conceptualize depressive symptoms as part of their experience of sociopolitical oppression.

 Stigma also constitutes a major barrier to seeking mental health services in general, and cultural beliefs play a large role in the perpetuation of stigma. Many cultures have major negative associations with any type of mental health assistance, often equating this with serious psychopathology and social undesirability. The fear of double-stigmatization (being culturally different as well as "crazy") presents major barriers to accessing services.

 developed the exploratory model, which methodically elicits the symptoms that are more salient and worrisome to the patient. This model helps reveal patterns of distress; explores perceived causes and attributions; identifies preferences in help-seeking behavior; helps uncover perceptions of stigma; and ultimately explores the discrepancies that may exist between the patient's understanding of the condition and the clinician's proposed etiology, diagnosis, and treatment plan. This model leads to higher levels of treatment adherence. Values are also intimately associated with levels of acculturation, generational differences, and educational and socioeconomic variables.

Understanding the differences between the values of traditional societies versus modern societies is an important tool that will help improve communication between the clinician and the patient (

).It is also important to remember that a significant portion of immigrants and members of minority populations in the United States are urban or rural poor and that poverty and educational levels are important variables in determining the patient's understanding of illness and help-seeking behaviors.

Culture-bound syndromes are folk diagnostic categories that supply coherent meanings to certain recurrent and remarkable sets of experiences and observations. These are associated with the matter and forces that constitute the experienced universe and are often related to a particular culture's explanation of disease.

 There are multiplicities of culture-bound syndromes that tend to vary by geographical region.

Hispanic working-class women may sometimes have an attack of nerves that involves sighing or screaming loudly, falling on the floor, and losing consciousness. They often feel disempowered, helpless, and unable to protest or disagree with their husbands, senior family members, or authority figures. Having an "ataque de nervios" achieves the dual purpose of conveying to others that they have had enough, while at the same time arousing feelings of guilt in those thought to be responsible for this outcome. In addition, the ataque de nervios protects them from a direct confrontation, because the phenomenon is understood as being beyond the person's control.

There is a lack of consistency in the terminology of these syndromes, which has hindered efforts at classification. Thus, it may not be practical for clinicians to attempt to familiarize themselves with all of them. Instead, it is important to understand that symptom patterns are often linked and should be understood in their relationship to the particular cultural setting where they occur.



 presents recommendations that can be adapted by clinicians in diagnosing and treating psychiatric disorders in ethnic minority and immigrant patients.




The great advances in the technology of transportation that took place in the 19th and 20th centuries resulted in an increase in migrations worldwide. These migrations, in turn, are responsible for the enormous ethnic diversity that can now be found in countries such as the United States. The survival of any species depends, to a large extent, on its capacity to adapt to new and changing environments. So in nature, genetic polymorphism tends to be the rule rather than the exception. The new fields of ethnobiology and ethnopharmacology are rapidly gaining ground and, since 1999, the Surgeon General of the United States has mandated that ethnicity should be an important part of genetic studies.



Genetic polymorphism postulates that the number of genes controls the metabolism of drugs by affecting drug metabolizing enzymes, receptors, and transporters. Ethnopharmacology places its focus on the interethnic differences in pharmacokinetics and pharmacodynamics. Drugs are usually metabolized in 2 phases. In phase 1, metabolism occurs through the cytochrome P-450 (CYP) enzymes that lead to oxidation of the substrates. In phase 2, metabolism is through conjugation, which is mediated by the transferases. There is evidence of ethnic variations in both phases.



Differences in polymorphism in phase 1 that account for the variations in the CYP chain are responsible for the differences in how members of different ethnic groups metabolize drugs, leading to poor (ie, slow) metabolizers, who have decreased enzyme activity; and extensive metabolizers, who have increased activity, which occurs in ultrarapid metabolizers who have more than one copy of the gene on one or both alleles. Many of the psychotropic drugs are metabolized by CYP 2D6.



Receptors are also sensitive to genetic polymorphism and vary widely across ethnic groups. Enzymes, such as catechol-

-methyltransferase, responsible for metabolizing dopamine and monoamine oxidase, which, in turn, is responsible for metabolizing norepinephrine, are highly polymorphic. Genotyping of CYP 2D6 revealed a particular mutation that is found in approximately 34% of Asians.

 This results in an enzyme with slower metabolic capacities than in white persons.The signal transduction cascade, composed of G-proteins, ion channels, second messengers, and protein kinases, is much less understood.



Another important consideration is that biological systems are dynamic, not static. The expression of genes is also influenced by variables such as environment, age and sex, nutrients, various plants and foods, steroid hormones, and other chemicals. For example, smoking, which is frequent among adolescents and is also highly comorbid with depression, may reduce serum concentrations of psychotropic medications by induction of CYP-1A2. This is a consideration that needs to be taken into account when medication is given to depressed adolescents who are also smokers. Grapefruit juice may increase serum concentrations of nefazodone, antivirals, and alprazolam by inhibiting CYP 3A4 (bioavailability is increased in the gut wall, and clearance is decreased in the liver).

The clinician prescribing psychotropic medications for patients of minority or immigrant backgrounds should first explore the presence of tobacco consumption, use of herbal remedies, and dietary habits of the patient before medicating, since these habits can influence the rate of metabolism of many psychotropic medications.This fact should be taken into account when treating adolescents from the Caribbean, who usually con- sume large amounts of citrus fruits. A high-protein diet, found among adolescents who practice athletic sports, accelerates the metabolism of certain CYP enzymes, and a diet high in carbohydrates, found in adolescents who may be sedentary and overweight, decreases the metabolism of certain CYP enzymes.



It is interesting to note that persons who migrate and leave behind the dietary habits of their country of origin begin to metabolize in a similar fashion as members of the new host country. For this reason, it is important to include in the clinical interview questions about whether the person is foreign-born or first- or second-generation American and how long they have been living in the United States.



Genotyping before medicating seems to be in the not too distant future. However, at present there are large gaps in phenotyping of the 4 major minority populations in the United States: Hispanics, non-Hispanic blacks, Asians, and American Indians.

Experience has shown that the practices of Western medicine have not eclipsed or replaced traditional medicine, but that the 2 are sometimes practiced simultaneously or sequentially among certain cultural groups. For example, a Navajo patient may visit the psychiatrist at the local community mental health center while simultaneously seeking help from a Navajo medicine man. In such cases, communication with the patient about these practices, and sometimes with the non-Western traditional practitioner, becomes important.Traditional remedies sometimes have strong active ingredients, such as atropinic substances that can produce anticholinergic adverse effects and even toxicity. Many patients do not inform their doctor that they are consuming these substances unless they are asked directly.

Hispanics present a challenge to psychopharmacology, since they are usually lumped together in a single ethnic category. Most Hispanics in the United States are a mix of Spaniards, Africans, and American Indians, who have descended from the Asian and Mongol people who crossed the Bering Strait and populated the American continent in pre-Columbian times. The 

 mutation of the CYP 2D6 is found in 47% to 70% of Asians and the 

 mutation is found in 15% to 20% of non-Hispanic blacks. These mutations are responsible for slowing down the metabolism of compounds by CYP 2D6, including antibiotics, some cardiovascular medications, analgesics, and psychotropic medications.

 These factors should be taken into account when prescribing SSRIs for non-Hispanic black adolescents as well as for Puerto Rican and Dominican adolescents who tend to have a large percentage of African ancestry.



Asians are frequent users of traditional medicines and many are slow metabolizers, due to polymorphism of the enzymesCYP 2C19, CYP 2D6, CYP 3A4, and possibly others that are still unknown. For these reasons, they sometimes perceive Western medicines as being too strong and as having too many adverse effects.



There has been little psychopharmacological research done with minority and immigrant youths using double-blind, placebo-controlled trials. The Treatment of Adolescent Depression Study had a 26% minority representation among its participants, and minority status was found not to be a significant moderator of acute outcome.

 However, no separate data analysis on the efficacy of the treatments examined has been published. There are significant problems associated with inclusion of minority samples in research trials and with the identification and diagnoses of depression in minority children, which results in the lower numbers of youths who receive treatment for depression.



Many questions in this field remain unanswered, but what is clear is that ethnopharmacology has already become an important part of the psychiatric treatment paradigm.


There are a number of evidence-based psychotherapeutic interventions that are gaining considerable research support for use with minority and immigrant children and youth. Cognitive-behavioral and interpersonal psychotherapies have some research evidence with Hispanic and non-Hispanic black youths.

 Interpersonal psychotherapy was originally evaluated with a largely Hispanic sample

 and was later shown to be more effective than cognitive-behavioral psychotherapy in a head-to-head trial,

 lending some support to the importance of congruence between cultural values ("personalismo," the closer interpersonal relationships among Hispanics) and the effectiveness of psychotherapeutic interventions. School-based preventive interventions have also been used with minority children and adolescents. A school-based cognitive intervention for depression was found to be effective as long as 2 years ago.

 Effectiveness was also shown using school-based cognitive-behavioral therapy for trauma-related depression or PTSD with Hispanic children and adolescents.



Some therapists have developed interventions that are specific for particular ethnic and racial groups, which have been evaluated for efficacy.

 Group and family psychotherapy, particularly approaches that integrate cultural and ethnic identity themes, psychoeducation, and culturally consonant coping approaches, have also been reported as both well accepted and successful.




Culturally competent clinicians need to be aware and accepting of cultural differences and aware of their own culture and the biases it may create. In order to become more effective and to provide the best level of care for their patients, clinicians need to understand the cultural differences in the ethnic populations they serve and, based on this knowledge, to modify clinical approaches to the needs of their patients and families.

 

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The cultural and demographic profile of the United States is undergoing a rapid transformation. In many areas of the country, there is no longer an ethnic majority but a multiplicity of racial and cultural groups.

Author | Eugenio M. Rothe, MD