Clinical Topics in Cultural Psychiatry

The preface of this book opens with the following statement: “Culture is what makes us who we are.” It would be accurate to describe this statement as the foundation on which the book is compiled. The volume consists of 29 chapters, several of which were originally published, between 1997 and 2005, as reviews in the Advances in Psychiatric Treatment, as part of a series on culture in psychiatric illness. In this volume, each review has been updated to reflect changes and new findings since the original publication, and the editors have added additional chapters to reflect newer topics that were not part of the original series of review articles. This results in some inconsistency of organization across chapters and repetition of some themes. While this may otherwise have been a drawback, here, the format chosen by the editors is a strength, since it allows each chapter to be a stand-alone discussion of a topic, without requiring cross-reference across chapters.

Writing on culture is difficult, since this is a term of enormous depth and breadth and much of the writing on this topic tends to inadvertently simplify (and sometimes oversimplify) concepts. In my view, the greatest achievement of this book may be its avoidance of this pitfall. The editorial approach is expansive rather than restrictive, and as a result, the book incorporates several topics that have not traditionally been a part of discussions on culture and mental health (for example, globalization, migration, racism, and poverty and their interaction with and effect on mental illness).

The book is organized into the following three sections: Theoretical and General Issues, Specific Mental Health Conditions Across Cultures, and Management Issues in the Cultural Context. In the first section, the chapter on “Globalization, Psychiatry and Human Rights,” by Brendan Kelly, opens with a discussion on economic theories and socioeconomic equality. The chapter includes a discussion of human rights and large-scale social change and how these may influence mental illness at the population level. The chapter on “Racism, Racial Life Events and Mental Health,” by Bhugra and Ayonrinde, makes a case for accumulated racial life experiences as an often unrecognized etiological factor in medical illnesses, such as hypertension and several psychiatric conditions. The authors acknowledge a shortage of data related to racism and racial life events, but based on the limited existing evidence, they suggest that racism may serve as a chronic stressor in some groups of individuals and affect clinical presentation. The authors, however, rightly warn against overgeneralization and interpretation of such findings, since the data are relatively unclear.

The second section, entitled Specific Mental Conditions Across Cultures, is largely based on extensive reviews of epidemiological literature from around the world. A noteworthy inclusion in this section is the topic “Mental Health of the Aging Immigrant Population,” by Livingston, Sembhi, and Bhattacharya. The issue of aging and culture has not been discussed extensively in psychiatry. Most studies in this area focus on ethnic and racial differences in epidemiology of diseases in older persons (e.g., dementias, depression). The chapter summarizes this body of literature but ultimately makes clear that even the existing literature, which is mainly limited to migrant populations in the United States, may not apply to other parts of the world. One hopes that this work provides the impetus for further research in this area.

The chapter “Culture and Liaison Psychiatry,” by Gopinath Ranjith, stands out for its creative use of clinical vignettes that raise critical clinical questions. In one vignette, the author describes the case of a woman from India who was seen in an intensive care unit in a hospital in the United Kingdom after an overdose of medication in response to family pressure to return to India to get married. The psychiatrist assessed the woman, and after determining that there was no ongoing suicidal ideation recommended discharge from the hospital and referral to a psychologist for problem solving therapy. However, 2 weeks after the evaluation, the psychiatrist received a note from the psychologist stating that an attempt was made to contact the patient in order to commence therapy, only to learn that the patient had in fact returned to India. The psychiatrist was left wondering whether a major cultural stressor had been ignored. This vignette warns against a common error of omission in psychiatric assessment—not just in consult liaison, but also in emergency, inpatient, and outpatient settings. Culture affects the manifestation and severity of most social stressors, and this in turn influences outcomes. In the vignette, the eventual outcome is not presented, but the reader is left with a clear sense that by ignoring the cultural element to the patient's stress, the psychiatrist may have missed an opportunity to actually help the patient beyond just assessing her symptoms. Even if the patient is from a culture that is unfamiliar, any psychiatrist is well served by simply inquiring about the patient's background and attempting to place psychiatric symptoms within cultural context.

The final section addresses Management Issues in the Cultural Context. Much of this section consists of chapters reviewing ethnic differences in response to psychotropic medication and psychotherapy among patients from different cultures. Two chapters are noteworthy in this section because they are of immediate use to clinicians and they are likely to make valuable teaching examples. In the chapter “Interpreter-Mediated Psychiatric Interviews,” Farooq and Fear discuss issues associated with translation in psychiatry. The use of interpreters does not receive adequate attention in training or practice. Too frequently, clinicians resort to using patients' family members or associates as interpreters. I can recount several instances from my own experience where the family members add their own subjective opinions to what the patient is saying, thus biasing the interview and clinical impressions. The authors caution against such common errors and provide simple tips on conducting interviews using an interpreter. Important suggestions include requesting verbatim translations, speaking directly to the patient and not the interpreter, and seeking the impression of the interpreter afterward about the normality of the conversation. In the chapter “Cross-Cultural Psychiatric Assessment,” Bhugra and Bhui provide a systematic guide to clinical evaluation of culture-related clinical information. The authors note the importance of assessing migration status and conditions of migration, acculturation (including language fluency, employment, and use of leisure time), and patients' own explanatory models for their symptoms. Incorporating these elements into a psychiatric assessment has benefits for patients as well as clinicians. Patients are more likely to develop a positive rapport with a clinician who demonstrates perceptive insight into patients' experiences with migration and acculturation and seeks to understand how patients understand their symptoms. This can lead to better clinical information and reflect in the overall quality of care.

The overwhelming majority of contributing authors to this book are from the United Kingdom, and most discussions are based on the British perspective. However, American readers will note that much of the literature reviewed is from the United States and culture-related issues in the United Kingdom are more similar than different from those in the United States (though undoubtedly, some differences exist). Overall, this book stands out for its broad scope; sophisticated approach to the topic of culture; integration of ideas from diverse fields such as economics, anthropology, and social psychology; and its synthesis of diverse bodies of literature within psychiatry to provide informed clinical recommendations. I expect that this book will be of great value and interest to mental health practitioners across levels of experience and expertise, especially to those working among culturally diverse populations.