Kenneth Sakauye, MD

The cultural aspects of treating patients are similar for all age-groups, but certain themes have greater relevance with the elderly. “Cultural issues” is a complex construct that often seems vague and indirect. Culture is different from race. Race implies biological factors, while culture implies sociological factors. Racial differences may be seen in genetic variations, such as hepatic enzyme polymorphisms, that might account for pharmacokinetic differences or different disease rates.

Culture, on the other hand, describes aspects of beliefs, attitudes, language, preferences, and actions that are passed down from generation to generation. Race is often used as a proxy for culture (stereotyping), and vice versa, but there is a difference. The introduction in DSM-5 states:

Mental disorders are defined in relation to cultural, social, and familial norms and values. Culture provides interpretive frameworks that shape the experience and expression of the symptoms, signs, and behaviors that are criteria for diagnosis.

DSM-5 highlights the need to be aware of cultural differences because they might lead to misdiagnosis, poor treatment adherence, and problems establishing a treatment alliance, mismatch of services, and family issues that may differ from “mainstream psychiatry” (

DSM-5 reflects a major change in the view of cultural issues from be-ing a rare occurrence, to being viewed as a pervasive influence on diagnosis and treatment. As a reminder, DSM-IV only mentioned culture in the last Appendix of the text as rare culture-bound syndromes. In DSM-5, the Cultural Formulation Interview was added to suggest that the way of obtaining cultural information was not through a symptom checklist approach that some physicians use, but rather through:

• Subjective expressions of how a patient might perceive the problem and its cause

• What others in the patient’s social network think

• What type of help is thought to be useful

• What developmental influences the person is aware of (cultural awareness)

• The patient’s comfort with the provider and the provider’s ideas

The Interview is reproduced in full in DSM-5 and is available at no cost online at 

http://www.psychiatry.org/practice/dsm/dsm5/online- assessment-measures#Cultural

Cultural competency training is now mandated in training programs by the ABPN (American Board of Psychiatry and Neurology), AAMC (Association of American Medi- cal Colleges), and hospitals under JCAHO (Joint Commission on Accreditation of Hospitals); in the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS), training standards are evolving.

Although everyone has a cultural heritage, culture has more relevance in treatment when there is a significant difference in the cultural background of the physician and the patient. Ethnic minority elderly are more likely to be “different,” since many are foreign-born, are non–English-speaking, and have traditional values and histories that the physician does not understand. American-born minority elderly are more likely to be poorly educated and poorly assimilated, such as African American elderly who faced Jim Crow laws and severe prejudice until the civil rights movement began in the 1960s. These differences often make the mentally ill minority elderly especially likely to avoid treatment or resist engagement.

A heuristic technique to foresee potential cultural problems is to anticipate possible issues by time from immigration and degree of assimilation of the patient (

 Cultural issues differ for foreign-born versus American-born, immigrants versus refugees, new immigrants versus long-term residents, and assimilated versus culturally isolated individuals. New immigrants’ issues are dominated by language barriers and culture shock (ie, lifestyle differences-norms and attitudes). Older immigrants have learned to cope and may even be less angered by racism because they do not internalize the criticisms.

An example is seen in rates of depressive symptoms among ethnic groups across the life span. A study from the UK showed that the prevalence of depressive symptoms in South Asian and black Caribbean participants was twice that in white Europeans.

 Although the study included all ages, culture shock and adjustment difficulties have always been expected to be greater for the elderly, who may have more health comorbidities and coping limitations than younger immigrants. This is similar to relocation trauma often observed in nursing home residents, which is attributable to heightened difficulty in adjusting to radical environmental change.

An NIMH-sponsored epidemiological catchment area study showed that recent immigrants had a higher rate of mental illness than American-born elderly, although the rates were lower in immigrants who had lived in the US for more than 20 years.

 Some signs of cultural problems are excessive silence during the interview, difficulty of the therapist in understanding the nature of the problem, hostility, nonadherence with medications, differences in primary language spoken, or idiosyncratic behaviors or expressions.

Misdiagnosis versus missed diagnosis of dementia

Brief cognitive screening instruments, such as the Mini Mental State Examination, and neuropsychological tests may be biased by language barriers and education as well as by perceived discrimination that could affect test performance.

 Reliability of screening may be improved by use of validated language translations of mental status examinations, such as the Montreal Cognitive Assessment, or less language-dependent short instruments, such as the Mini-Cog.

 Both should be coupled with a functional activities assessment, such as an instrumental activities of daily living assessment, to improve sensitivity of a dementia diagnosis.

Nursing home utilization and aggression management

The much lower utilization of nursing homes by minority elderly compared with white elderly is no longer true. Minority populations now utilize nursing homes at about the same rate. The reason for the earlier disparity seems to be a much more complicated social issue that includes barriers to access or lack of affordable facilities.

 A new issue is a higher reported prevalence of dementia-related behaviors in ethnic minority groups and a much higher incidence of restraint use.

 Although the reasons for the disparity are not clear, it is often presumed that staff appraisal of the problem and environmental strains on the patient are the major reasons for the differences, rather than higher rates of psychosis or unprovoked aggressive drive.

Older observational studies demonstrated that certain behaviors are more likely to be viewed as aggressive or pathological in minority patients than are the same behaviors in other patients. For example, a Hispanic man was referred for aggression when he was the only Spanish-speaking resident in a facility without any Spanish-speaking staff. He showed no evidence of psychosis or depression when he was evaluated with the help of translators. Complaints of agitation stopped when the patient was engaged in activities and a means of better communication was implemented. Closer attention must be paid to potential precipitants of behaviors and envi- ronmental interventions, instead of medication for management.

Paranoia versus hypervigilance: long-term effects of prejudice

Real or perceived racism is almost a ubiquitous minority experience, which has an influence on behaviors and attitudes, even if it is not experienced on a daily basis. Most people learn ways to minimize exposure to threat. Social structures are established to help maintain group identity and support. The large body of literature on mental health care disparities demonstrates that real or perceived interpersonal racism occurs in health care settings as well.

 It also acknowledges that minority groups are disproportionately underrepresented in the proportion of patients seeking treatment. A common experience for elderly African Americans, especially in the South, has been segregated care and fear of mistreatment in new settings.

One of my early experiences with this was an elderly black depressed woman who was admitted to a predominantly white hospital unit. She initially had an abject fear of being experimented on or killed. In a short time, she was reassured and it became clear that she was not psychotic. Suspiciousness and feelings of mistreatment or being experimented on are not necessarily delusional beliefs.

Moreover, it should not be assumed that minority elderly persons have a cultural preference to different treatment because they hesitate to ask for medical/psychiatric care. Gitlin and colleagues

 studied the beliefs of older African Americans. The goal was to find out what these elderly patients knew about depressive symptoms and their preferred treatment approaches. No ethnic differences were seen in endorsement of medications and behavioral activation (a form of cognitive-behavioral therapy), and some patients also endorsed faith-based strategies.

A major question that has been asked about culturally appropriate services is whether different treatment approaches should be used. Same-language therapists seem to be essential, but there are no studies or even case reports on providing psychotherapy when there are communication barriers.

 reported that of the 82,000 studies that focused on depression outcomes in minority populations, only 19 included older adults. Other than language adaptation, most studies did not explicitly mention the cultural adaptations made for diagnosis or treatment. Other articles on psychotherapy with minorities of all ages often point to therapist differences in outcomes-outcomes are better with some therapists. Their approaches have not yet been manualized in a way that can be easily taught.

A basic approach that should be taken with minority elderly as well other age-groups was summarized by Kobylarz and colleagues

 as the mnemonic ETHNIC(S): Explanation (what do you think you have?); Treatment (what have you tried?); Healers (who have you sought help from?); Negotiate (how do you think I can help?); Intervention (this is what I think needs to be done); Collaborate (how can we work together on this?); and Spirituality (role of religion for the patient).

A Treatment Improvement Protocol: Improving Cultural Competence

 Competencies of individual staff are specific to the racial and cultural groups served in terms of cultural awareness, cultural knowledge, cultural knowledge of behavioral health (cultural lens for worldview), and culturally specific interventions (

). In this protocol, a culturally responsive program:

• Emphasizes flexible attitudes from the counselors: cultural knowledge, valuing traditional values, sensitivity to potential beliefs or attitudes that increase antagonism to traditional psychiatric help

• Establishes credibility of the professional in the initial meeting with the family

• Provides services in the patient’s primary language

• Conducts culturally specific assessments of trauma that the patient’s ethnic group commonly faces, community and extended family supports, immigration history, if appropriate

• Considers more family involvement, including home visits when appropriate

• Provides concrete services when needed

• Allows cultural healing practices and integrates them into treatment when possible (eg, acupuncture, mediation, detoxification practices, religious customs) and considers patient’s values (eg, acknowledge the patient’s wishes and limitations)

• Explains key principles and expectations of therapy, including family roles if family therapy is needed, and negotiates

Dr Sakauye is Emeritus Professor of Psychiatry at the University of Tennessee Health Science Center in Memphis. He reports no conflicts of interest concerning the subject matter of this article.

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https://www. thinkculturalhealth.hhs.gov/pdfs/EnhancedNational CLASStandards.pdf

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Comprehensive Textbook of Geriatric Psychiatry

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. Revised ed. New York: New York University Press; 1978.

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 Barnes LL, Lewis TT, Begeny CT, et al. Perceived discrimination and cognition in older African Americans. 

 Montreal Cognitive Assessment (MoCA). http://www.mocatest.org. Accessed May 7, 2015.

 Mini-Cog. http://www.alz.org/documents_ custom/minicog.pdf. Accessed May 7, 2015.

 Tappan RM, Rosselli M, Engstrom G. Use of the MC-FAQ and MMSE-FAQ in cognitive screening of older African Americans, Hispanic Americans, and European Americans. 

 Srinivasan S, Sakauye K. Cultural influences in the clinician-elderly patient relationship. 

 Sink KM, Covinsky KE, Newcomer R, Yaffe K. Ethnic differences in the prevalence and pattern of dementia-related behaviors. 

 Cassie KM, Cassie W. Racial disparities in the use of physical restraints in US nursing homes. 

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. Rockville, MD; 2001. http://www.ncbi.nlm.nih.gov/pubmed/20669516. Accessed May 7, 2015.

 Gitlin LN, Chernett NL, Dennis MP, Hauck WW. Identification of and beliefs about depressive symptoms and preferred treatment approaches among community-living older African Americans. 

 Fuentes D, Aranda MP. Depression interventions among racial and ethnic minority older adults: a systematic review across 20 years. 

 Kobylarz FA, Heath JM, Like RC. The ETHNIC(S) mnemonic: a clinical tool for ethnogeriatric education. 

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Articles

The cultural aspects of treating patients are similar for all age-groups, but certain themes have greater relevance with the elderly. 

Cultural Issues in Treating Geriatric Patients With Mental Illness

Different psychiatric themes and problems in treatment present themselves for U.S.-born versus immigrant minority patients. Language barriers, culture-bound syndromes, and differences in customs and culture are often pronounced for immigrants and the basis for adaptation problems and stress. Problems are often more subtle for U.S. born minorities of color such as African-Americans who have lived in the United States for many generations (American Psychiatric Association Task Force on Ethnic Minority Elderly, 1994). The psychological sequelae of longstanding experiences of prejudice and marginalization may be profound for minority individuals. Ingrained feelings of bitterness and resentment over prejudicial treatment and attitudes may last a lifetime, although, in theory, this is put into perspective as one matures. Internalization of prejudicial views is an issue for minority patients that can be a lifelong influence on self-esteem. This cannot be viewed as a personality disorder in the usual sense, although culturally insensitive therapists might misdiagnose it as such. The phenomenon has several faces. It leads to an "external locus of control" in which things in life are viewed as chance occurrence. It can engender either strong adherence to, or rejection of, social hierarchies. It can affect the treatment alliance, even if the patient's therapist is of the same race. 

"Mrs. H" is a 77-year-old African-American female who resided in a long-term care facility after suffering a cerebrovascular accident five months earlier, leaving her with a left hemiparesis. She also required management of insulin-dependent diabetes mellitus and atrial fibrillation. Mrs. H's primary care physician referred her to the psychiatry department because of a personality change over the past few months, when she became more irritable and withdrawn. She denied depression but several staff members found her unusually tearful and easily insulted. According to Mrs. H, a member of the staff noticed that she rarely smiled and was not herself for several months. She found herself in tears and in nostalgic contemplation more often than not. Mrs. H blamed an initial 26-pound weight loss over the past few months on distaste for food in the facility, but she was not losing further weight. She denied sleep disturbance and showed no suicidal ruminations, delusions or hallucinations. Mrs. H had never been diagnosed with or treated for depression. 

She was taciturn and concrete with doctors, leading many caregivers to think she was mildly demented from her stroke (which later turned out to be false). An attempt to improve the reliability of the evaluation was made by assigning a same-race student doctor to interview her over an extended period of time. It is important to note that the student was a fair-skinned African-American, unlike the patient, who was dark-skinned. The patient did not even begin to talk openly until the fourth visit, when she first began to allude to a lifelong feeling of inferiority. She opened up only after direct inquiry into the impact of race on her life. 

She was intimidated by whites and light-skinned African-Americans, and had felt this way all of her life. She even attributed her tendency to help others as a way of "pleasing people." She grew up in an era when African-Americans were not afforded the same rights and privileges as their white counterparts. She had white neighbors that she could not befriend, although she often wanted to out of curiosity, knowing in her heart that she was "just like them." Mrs. H felt that being African-American hindered her in life--she never felt like she was "good enough." 

Mrs. H's maternal family was lighter than she was, and they would make every attempt to make it painfully obvious that she was the darkest person in the family. Her mother only said negative things to remind her of her shortcomings. She did not feel loved at home, and was "never built up to think that she was somebody." She felt that the white nuns at her parochial school treated her and the other darker-skinned students worse. As a child, she believed that the fair-skinned children were smarter than she was. Mrs. H lived life without many expectations, accepted the way others treated her and internalized their racial negativity. 

She found compensatory relationships in a maternal aunt, her husband and the extended support network through the church. Although she grew up in a devoutly Baptist family, she could not gather enough courage or confidence to participate in church functions. Having a child forced her to get involved and become active in the community and their local church; church became central to her. She became a deaconess and used the church for support. These experiences were not only reinforcing to her worth as a person, being a good mother and spouse, but she found herself becoming active in areas that she would have normally shied away from. 

Her present depression was a result of cumulative losses: the death of her husband and son two years earlier and the loss of her part-time work after a car accident in which she also lost her car. Shortly after, she noticed that she became more forgetful, more conscious of her health and developed a fear of falling. She became more helpless after her stroke and placement into the nursing home.

Although Mrs. H undeniably suffers from depression, many cultural features influence the working alliance and presentation of elderly African-American patients and other minority patients. Regarding the interview process, it is important to realize that patients often do not view current symptoms as depression. Excess physical disability from depression is often attributed to health problems. This lack of insight becomes a major problem in establishing compliance with medical treatment for depression. 

It is important to realize that latent cultural issues (e.g., skin color, feelings of inferiority) do not surface immediately. Issues like those described in this case emerge only after a relationship is established, rarely on the first session, and often must be interpreted or confronted directly. 

Extended family networks are clearly important when family size is small or when the immediate family is not cohesive, or lacks money or resources, as may occur in poor minority families. Compensatory relationships may be one key to successful aging. This is probably the reason why Vaillant and Mukamal (2001) found no correlation between successful aging and warmth of parental experiences, contrary to the stereotype. In this case, compensatory positive relationships can come from extended family or especially the church for African-Americans. Both lead to growth and development. 

Social supports and a sense of mastery over one's situation are often viewed as major buffers against stress. Although universal issues, this seems especially important for minority individuals. Kleinman (1988), in his landmark book, summarized life event changes perceived as stressful in the presence of inadequate social support and ineffective coping responses casually contributing to the onset of  medical and mental disorders. In the case of Mrs. H, her cumulative losses all proved catastrophic, especially in the absence of social supports. 

The underlying thread in this and many other minority cases is that low self-esteem caused by racism, not a personality disorder, influences treatment. "Disconfirming cultural labels foster ruinous cycles of generalized hopelessness that undermine one's identity," Kleinman (1988) wrote. It is clear that this concept about color and the unconscious devaluation of darker skin exists even within a minority community. If being poor makes one second class, being a minority makes one third class, being dark-skinned and a woman may make one feel below third class. Stigmatizing labels induce feelings of guilt, worthlessness and negative self-identity conducing to despair (Dressler, 1985). Cultural labels act as self-fulfilling prophecy in mental disease. African-Americans are recognized by their physical features and are treated accordingly (U.S. Department of Health and Human Services, 2001). 

How does one understand why people like Mrs. H do not attribute or link their low self-esteem directly to racism despite the inextricable relationship between the two? The answer is that the personal experiences of the individual seem overshadowed by the collective experience of the race. Patients like Mrs. H take racism for granted and seem unaware of its existence, despite its ever-present status. Sue and Sue (1999) confirmed, "African Americans differ significantly in their family and individual experiences." For some, like Mrs. H, the experience as a dark-skinned person of color played a large role in her identity but was perceived as an expectable aspect of being an African-American in the United States. Kleinman (1988) summarized: "Mental illnesses are the outcome of the creation of experience by physical stuff interacting with symbolic meaning  the experience of illness (or distress) is always a culturally shaped phenomenon." 

Non-minority caregivers need to believe that it is not just political correctness to guard against racial stereotyping. Dealing with cultural issues becomes a therapeutic issue that must be discussed openly and uncritically. There is no best way to address it, but it will not become manifest unless confronted gently. One must be more attentive to structural issues in therapy such as scheduling enough time to avoid rushing the patient, avoiding excessively long silences, and providing feedback in the form of repeating how one has understood what was just said. When the patient feels safe to express feelings and believes the therapist genuinely wants to understand, treatment begins. 

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 Kleinman A (1988), Rethinking Psychiatry: From Cultural Category to Personal Experience. New York: Free Press.
 

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 U.S. Department of Health and Human Services (2001), Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General. Washington, D.C: U.S. Department of Health and Human Services.
 

 Vaillant GE, Mukamal K (2001), Successful aging. Am J Psychiatry 158(6):839-847 [see comment].

In what ways does culture impact treatments of depression? This case study follows the progress of "Mrs. H," a 77-year-old African-American female.

Author | Kenneth Sakauye, MD

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