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Cultural Psychiatry (Advances in Psychosomatic Medicine, Vol. 33)

Richard Balon, MD

Wayne State University, Detroit, Michigan, USA

Edited by R. D. Alarcón. Basel, Switzerland: S. Karger; 2013; ISBN 978-3-318-02394-7; pp 133; $59 (hardcover).

The impact of culture on mental illness is well known, especially to those who are practicing psychiatry in ethnically diverse areas. The observation and study of various expressions of mental illness in different ethnic groups or cultures has been part of what is called cultural psychiatry. The concept of cultural psychiatry has been developing over a long time. For many years and for most psychiatrists cultural psychiatry mainly represented the host of culture-bound syndromes, possible differences in metabolism of some medications among ethnic groups, and maybe an acknowledgement that some Japanese patients somatize a lot when depressed.

However, as the editor of this volume, Renato Alarcón, writes, cultural psychiatry is much more than that. Citing the work of the Group for the Advancement of Psychiatry, he states that, “The most accepted definition of cultural psychiatry considers it as the discipline that deals with the description, assessment and management of all psychiatric conditions to the extent that they reflect and are subjected to the patterning influence of cultural factors and variables as broad as ethnicity, race and identity or as focused as language, religion, gender and sexual orientation, educations, traditions and beliefs, sociodemographic status, dietetic modalities or financial philosophies” (p 3). (My question here is: Then, what is not cultural psychiatry?) Cultural psychiatry clearly seems to be coming of age. Dr. Alarcón gathered an international group of authors who together produced this slim volume. Although I am going to refer to their works as chapters, this is more a collection of review articles than a tightly edited book with bona fide chapters.

In the first chapter, “Cultural psychiatry: a general perspective,” Dr. Alarcón reviews the basic concepts of cultural psychiatry, its definition, issues of culture and the etiopathogenesis of mental illness, the impact of culture on clinical presentations, culture and psychiatric diagnosis, culture and psychiatric treatment, and culture and prevention in mental health. He notes that “culture plays a decisive role in different facets of the clinical presentations of psychiatric entities. The concept of pathoplasty, unfairly neglected in current psychopathological language, conveys the rich connection between culture and the expression of psychiatric symptoms, the way they are described, experienced, and reported by patients belonging to different cultures” (p 5). An interesting notion for those enchanted by culture-bound syndromes: they will be less semiautonomous and, considering their similarity with diagnoses present in existing nomenclatures, they will be included more often under those diagnoses or as “variations of well-established entities (eg, anxiety, panic disorder, obsessive-compulsive disorder, conversion disorder), or their description will be tightly elaborated upon. The following treatise, “Culture and psychiatric diagnosis” by Roberto Lewis-Fernández and Neil Krishan Aggarwal, mostly discusses the challenges of including cultural issues into DSM-5, the principles guiding revisions in culture and diagnosis for DSM-5, and reviews the introductory chapter on cultural aspects of psychiatric diagnosis (conceptual aspects; Outline for Cultural Formulation and Cultural Formulation Interview, Glossary of Cultural Concepts of Distress rather than the previous Glossary of Culture-Bound Syndromes). The authors emphasize that, “In order to maximize the validity and usefulness of diagnosis, these cultural/contextual elements [culture, social structures, local material environment, individual circumstances] need to be included in the design and implementation of nosological systems” (p 16). This chapter covers an important topic, yet it is a bit disappointing with its lack of specificity and concrete descriptions that would be useful in clinical practice.

The next chapter, “Trends in cultural psychiatry in the United Kingdom” by Kamaldeep Bhui, is again a surprisingly nonspecific and unfocused review, this time on trends in cultural psychiatry in the United Kingdom. The author writes that the emergence of cultural psychiatry in the United Kingdom is centered around issues of race and religion, “the two most conspicuous ways of classifying the patient to be different from the professional” (p 32). Interestingly, in the United Kingdom there have been fears about overstating or emphasizing differences that can become politically and socially divisive, as exemplified by recent debates about multiculturalism being responsible for terrorism (p 32). The author also mentions the different influences between cultural psychiatry in the United States and Canada on the one hand (mostly influenced by anthropology), and the United Kingdom on the other hand (where anthropology has been a rather “critical friend” of sociology, psychology, history, health services research, and public health sciences). The fourth chapter, “Opening up mental health service delivery to cultural diversity: current situation, development and examples from three Northern European countries” by Sofie Bäärnhielm, Cecilie Jávo, and Mike-Oliver Mösko, presents current examples from Germany, Norway, and Sweden on opening up mental health care services to the cultural diversity of their populations. Many of us probably still have problems conceptualizing Scandinavian countries such as Norway and Sweden as multicultural, but the authors make a solid argument that these countries are becoming more diverse with a recent influx of immigrants from all over the world. However, the most interesting and revealing piece of information for me was the fact that in Norway “people suffering from chronic psychiatric illness are exempt from any healthcare costs. Psychiatric services are decentralized in order to be available to all citizens and geographic regions” (p 47).

The fifth chapter, “Cultural psychiatry in the French-speaking world” by Joseph Westermeyer, is clearly disappointing. It includes some interesting—and mostly historical—information, but one becomes discouraged by the lack of editing and attention to detail. Examples are the listing of “Haiti, French Guinea, and other Caribbean entities…” (p 56)—there is no French Guinea, there is a French Guyana, though. The main point of the following chapter, “Transcultural aspects of somatic symptoms in the context of depressive disorders” by Issa Bagayogo, Alejandro Interian, and Javier Escobar, is that “culture—the set of values, attitudes, beliefs, and expectations shared by a group of people—may ultimately influence the formation and presentation of symptoms in response to distress” (p 65). The authors review the relationship between depression and somatization and conclude that somatic symptoms are commonly represented within depression across racial and ethnic groups. Interestingly, greater pain complaints were reported among Latinos and African Americans even after adjusting for depression severity (p 70). The authors conclude that there is a greater tendency for Latino, black, and Asian persons with depression to emphasize somatic symptoms in their clinical presentations.

The seventh chapter, “Culture and demoralization in psychotherapy” by John de Figueiredo and Sara Gostoli, first reviews 3 concepts: a) demoralization by Jerome Frank, b) sentiments by Alexander H. Leighton, and c) meaningful connections by Karl Jaspers. The text then discusses the clinical applications of these concepts into psychotherapeutic approaches (eg, cultural considerations in areas such as the relationship between the demoralized person and the psychotherapist; setting for the healing; rationale leading to a ritual or procedure; and ritual or procedure itself). The next chapter, “Ethnopsychopharmacology and pharmacogenomics” by Hernan Silva, defines ethnopsychopharmacology as the study of how culture and genetic differences of natural social groupings determine and influence the response to psychotropic medications (p 89). The pharmacogenomic part of the chapter reviews cytochrome P 450 2D6 and the serotonin transporter polymorphism, and their relation to culture and ethnicity.

The ninth chapter, “Cultural psychiatry: research strategies and future directions” by Laurence Kirmayer and Lauren Ban, provides a review of methodological strategies in cross-cultural research. It discusses issues such as universality of categories and constructs, clinical bias, reification of culture, limited evidence base, focus on pathology, and focus on the individual in regards to strategies, methods, and implications. In the section on global mental health, stigma, and mental health literacy the authors propose using mental health literacy packages in developing countries (mine: Why not the developed countries, too?). The chapter also touches on issues such as cultural competence, safety, and efficacy; ecosocial models of mental illness and wellness; cognition and emotion as situated, embodied, and enacted; cultural constructions of self and personhood; and cultural concepts of mental disorder and psychological essentialism. The following chapter, “Bioethical dimensions of cultural psychosomatics: the need for an ethical research approach” by Fernando Lolas, emphasizes that “Bioethics has established itself as an indispensable ancillary discourse in psychiatric practice and research,” (p 121) and that “The psychosomatic approach and the problem of diagnosis will continue to be at the center of a humane care based on research and science” (p 121). Enough of the truisms! The last chapter, “Epilogue” by Renato Alarcón, basically is a summary of the book with some expansion to other areas. While discussing teaching of cultural psychiatry, the author writes that “the general goals of teaching of core cultural competencies include the conduction of a well-organized clinical interview, professionalism, empathy and genuine human understanding of the patient and his/her family, the achievement of a meaningful initial diagnosis, the setting up of comprehensive tests aimed at further diagnostic precision, familiarization with institutional rules of clinical documentation, initiation and conduction of appropriately comprehensive treatment plans, as well as establishment of adequate follow-up procedures. More specific cultural components have to do with exhaustive exploration of cultural variables, the use of the Cultural Formulation Interview in search of the patient’s cultural identity, recognition of racial/ethnic, social and cultural similarities and differences, elements of a possible migration history, information about family history, structural hierarchies, coping mechanisms, etc., identification of cultural risk and protective factors, cultural aspects of the primary psychopathologies (ie, impact on severity), cultural correlates of psychometric and other tests, inclusion of adequate cultural documentation, pharmacological and pharmacogenomic clarifications, fostering of truly multidisciplinary team-based approach, and recognition of the sociocultural implications of the case in the context of public mental health policies and procedures” (p 129).

Although at times interesting, this book probably is not what a busy clinician interested in cultural issues would expect. The focus of this book is limited in both the material covered and the audience. One wishes for a broader coverage of as many cultures as possible and as many specifics as possible. The writing is eloquent, yet almost apologetic at times. The editing (or copy editing) could have been tighter—the reviews do not flow well from one to another. It is all more about perspectives, concepts, and constructs than about clinical applicability. Yet it is an interesting read about an area of psychiatry that has been coming of age and has received inadequate coverage for a long time.