Culturally Sensitive Interviews with the use of the

Engagement Interview Protocol (EIP)

Albert Yeung, M.D., Sc.D.

MGH Depression Clinical and Research Program

Harvard Medical School

Albert Yeung, M.D. - Disclosures

• Dr. Yeung and/or the Depression Clinical and Research Program of Massachusetts General Hospital have received or are receiving research support from Abbott, Alkermes, Aspect Medical Systems, AstraZeneca, Bristol-Myers Squibb, Cephalon, Eli Lilly, Forest Laboratories, GlaxoSmithKline, Johnson & Johnson, Lichtwer Pharma GmbH, Lorex Pharmaceuticals, Novartis, Organon, Pamlab, Pfizer, Pharmavite, Roche, Sanofi-Synthelabo, Solvay, and Wyeth.

U.S. Population Projections

2008 2050

Non-Hispanic whites 60% 46%

Hispanics 15% 30%

African Americans 14% 15%

Asian Americans 5% 9%

Based on U.S. Census (2000)

Disparities and Depression (I)

• Disproportionate burden of mental illnesses shouldered by blacks, Latinos, American Indians, Alaska Natives,

Asian-Americans and Pacific Islanders (AAPI)• Only 1/20 Latino immigrants with a mental disorder seeks

treatment from a qualified professional• Only 17% of afflicted AAPI sought care• Only one mental health professional for 1,000 American Indians

or Alaska Natives (vs 1 per 578 for Whites)

Satcher D. Supplement to Surgeon General’s Report 2001

Disparities and Depression (II)

• Prevalence of mental disorders for racial and ethnic minorities in the United States is similar to that for whites

• Minorities have less access to, and availability of, mental health services. Minorities in treatment often receive a poorer quality of mental health care

• General barriers: cost, lack of availability of services, societal stigma toward mental illness

• Barriers for minorities: mistrust and fear of treatment, racism and discrimination, cultural stigmas against mental illness, and differences in language and communication

(Satcher D. Supplement to Surgeon General’s Report 2001)

Culture and Depression (I)

• People from each culture have their own “explanatory model” of illness1

• In many non-European cultures, equivalent concepts of depressive disorders are not found2

1 Kleinman(1982); 2 Marsella (1985) In Depression & Culture

Culture and Depression (II)

Holistic vs dichotomized mind/body approach1

Psychiatric nosology emphasizes mood s/s Eastern medicine’s disease classification does

not separate mood symptoms from physical symptoms

Mood symptoms are not the “idioms of distress” among many Asian Americans2

1 Lin K.M. Psych Serv 1999. 2 Kleinman A. Culture, Med & Pscyh 1982.

Barriers for Asian Americans in Accessing Mental Health Services

Cultural barriers• Many Asian Americans are unfamiliar with

definitions of psychiatric disorders• Language barriers• Issues of use of interpreters• Issues with translation of terminologies• Traditional roles of psychiatrists in many

Asian countries

Yeung & Kung. Psychiatric News 21 (1): 34-36, 2004

Under-recognition of Depression in US Hispanics in Family Practice

• Cause of Under-recognition: language differences, health literacy barriers, somatic presentations, and use of cultural idioms of distress

• Hispanic patients are often agreeable to treatment, tend to prefer psychotherapy or combined counseling and medication

• Recent studies have found that both psychological and pharmacological treatment are efficacious in this minority group

Lewis-Fernandez R et al. JABFP 18: 282-96, 2005

Under-recognition of MDD in African Americans (AA)

• AAs with MDD are under-diagnosed• AAs seem to have more severe episodes of depression

compared to Caucasians• AAs with MDD often present with somatic symptoms,

leading physicians to miss a MDD diagnosis• Depression is often seen as a “personal weakness” by AA• AAs and other ethnic groups differ in the rate they

metabolize SSRIs, while clinical trials recruit mainly Caucasians

Bailey RK et al. J National Med Asso 101:1084-1089, 2009

Relationship between Somatic Symptoms and Depression

• Examined data from the World Health Organization’s study of psychological problems in primary care

• Involved 15 centers in 14 countries on 5 continents• The range of patients with depression who reported only

somatic symptoms was 45 to 95 percent• The frequencies of psychological and physical symptoms

of depression were similar among centers• In part, presentation of somatic symptoms may reflect

characteristics of physicians and health care system, as well as cultural differences among patients

Simon GE et al. NEJM, 341:1329-35, 1999

Cultural Variations in the Clinical Interpretation of Depression and Anxiety

• Somatic symptoms serve as cultural idioms of distress in many ethnocultural groups

• Misinterpreted of somatic complaints by clinicians may lead to unnecessary diagnostic procedures or inappropriate treatment

• Clinicians must learn to decode the meaning of somatic and dissociative symptoms, which are…part of a language of distress with interpersonal and wider social meanings

Kirmayer LJ J Clin Psychiatry 62 (suppl 13), 22-28, 2001

The Explanatory Model Interview Cataloguefor Studying Illness Beliefs

a) Patterns of Distress (presentation, labeling)

b) Perceived causes of illness

(medical / biological / psychosocial /supernatural / traditional)

c) Help seeking patterns

Weiss M. Soc Sci Med 27, No.1:5-16,1988

Chief complaints of Chinese-Americans with Major Depressive Disorder (N=29)______________________________________________Chief complaints (%) N (%)______________________________________________Physical symptoms 12 (42)Depressive neurovegetative s/s 10 (34)Depressive psychological s/s 4 (14) Irritability, Rumination, Poor memoryNervousness 2 (7)Depressed Mood 0 (0)No complaints 1 (3.5)______________________________________________

Yeung et al., J Nerv & Ment Dis 192 (4): 324-327, 2004

Labels used by Chinese-Americans Patients with Major Depressive Disorder to Describe their Illness (N=29)_____________________________________________________Name of the illness N (%)_____________________________________________________“Don’t know” 16 (55)“Not an illness” 5 (17)Medical Illnesses 5 (17)

“hypertension” 1 “cold” 2 “poor health” 1 “injured arm” 1

“Post Traumatic Stress Syndrome” 1 (3.5)“Craziness” 2 ( 7)__________________________________________________________________

Yeung et al., J Nerv & Ment Dis 192 (4): 324-327 2004

Causes of Illness Perceived by Chinese-Americans with Major Depressive Disorder (N=29)

Methods Frequency (%)____________________________________________Stress and/or psychological factors 27 (93)Magico-Religious-Supernatural 13 (45)Medical Problems 5 (17)Traditional beliefs 4 (14)Hereditary 4 (14)Toxicity 3 (11)Ingestion 2 ( 2 )Sex 0 ( 0 )______________________________________________

Yeung et al., J Nerv & Ment Dis 192 (4): 324-327, 2004

Methods of Help-Seeking by Depressed Chinese-Americans Patients (N=29)

______________________________________________

Methods Frequency(%)______________________________________________

General Hospital 20 (69)Lay Help 18 (62)Alternative Treatment by Providers 16 (55)Spiritual Treatment 4 (14)Alternative Treatment by Self 3 (11)Mental Health Professionals 1 (4)______________________________________________

Yeung et al., J Nerv & Ment Dis 192 (4): 324-327, 2004

Challenges in Discussing with Culturally Diverse Populations about Psychiatric Illness

Many of them do not share the mind/body dualism, the basic assumptions of the diagnostic criteria in modern psychiatry, and

Many of the labels of mental illnesses are not in the patient’s lexicon, or these labels carry strong stigma that deter patients from accepting or adhering to treatment

Interview with Cultural Sensitivity

■ It requires knowledge of one’s own cultural, the patients’ culture, the ways they might interact

■ To develop co-constructed illness-narratives with patients

■ To reframe communications into more culturally resonant forms, by contextualizing depressive symptoms into patient’s physical health and social system

■ Use terminology that avoid unintended stigma

■ To involve patient’s families whenever possible

Yeung & Kam. Transcult Psychiatry 45(4):531-5

Cultural Formulation

A format for semi-structured evaluation of every patient’s cultural background, which includes:

A) the cultural identity of the patient

B) cultural explanations of the individual’s illness

C) cultural factors related to psychosocial environment and functioning,

D) cultural elements of the relationship between the individual and the clinician, and

E) an overall assessment of diagnosis and care

 Lewis-Fernandex & Naelys. Psychiatric Quarterly 2002; 73 (4): 271-295

Engagement Interview Protocol (EIP)

I. History of Illness

Elicit patient’s narratives &

explanatory model of illness

II. Psychosocial History

III. Mental Status Examination

IV. Multi-axial Diagnoses

V. Culturally Sensitive Communication of Diagnosis

VI. The Customized Approach to Treatment Negotiation

Yeung et al. International Journal of Culture and Mental Health (in press)

EIP (I):Elicit patient’s illness narratives

It is important to listen to the patients’ narratives, to understand the framework, conception, and the language they use to describe their illness

Patient’s narratives of his/her illness can be used as a platform to develop co-constructed illness narratives with patients, and to aid this process by reframing different elements of the clinical process into more cultural resonant forms

Yeung & Kam. Transcult Psychiatry 45(4):531-552

EIP (II): Explore patient’s Illness Beliefs

1. What do you call your problem?2. What has caused it?3. Why do you think it started when it did?4. What does it do to you?5. How severe is it?6. What do you fear most about it?7. What are the chief problems it has caused you?8. What kind of treatment do you think you should receive? What are the most important results you hope to receive from

the treatment?

Kleinman(1982) Patients and Healers

EIP (III): Culturally Sensitive Communication of psychiatric disorders

Elicit patient’s illness beliefs Acceptance of multiple explanatory models Clarify meanings of diagnostic labels Flexibility of terminology Connecting patient’s illness explanatory model

with Western psychiatric diagnosis

Staging of disclosure

EIP (IV): Customized Treatment Negotiation

Provide rationale for use of medication Disclose side effects and offer reassurance Elicit patient’s resistance to medications Discuss alternative treatment options Negotiate to reach consensus on treatment

Vignette # 1. The depressed patient who focused on anxiety symptoms

A 21 y/o single Chinese male who emigrated to the U.S. two years ago. He was a restaurant worker, and had borrowed a huge sum of money to be smuggled into the U.S. While he was preoccupied with anxiety symptoms, he reported having depressed mood, insomnia, irritability, ↓ interests, & ↓concentrating

Patient’s explanatory model of his illness experience:1. “ What do you call it?” “worries”2. “What caused it?” “stress from adjusting to life here and language problems”3. “When started?” “two years ago after I came to the U.S.”4. “What does it do to you?”“cannot concentrate at work”5. How severe is it? “pretty severe”; “it has lasted for a long time”6. “What do you fear most?” “That I might become impulsive and even hurt myself”7. “Chief problems?” “too much worries”8. “What treatment?” “try to stay in touch with my family” “most important results” “to get better”

Vignette # 1. The depressed patient who focused on anxiety symptoms

Culturally Sensitive Disclosure of Diagnosis: We adopted his explanatory model and used his own words in suggesting that it was likely that his symptoms were due to “pressure” in his life as a recent immigrant. We asked him if he had heard of depression (yi yu zheng) and whether he might be suffering from depression. He replied that he was not familiar with the term and he was not sure if he had the illness. We informed him that while it may be too early to conclude, it was possible that he actually had depression

Customized Approach to Treatment Negotiation: He was informed that there are medications available to reduce his worries as well as his other related symptoms including insomnia, irritability, and loss of interest, and that he should expect to “get better” in several weeks. The patient agreed to try the medications and see if they could help him

Vignette # 2. The depressed patient who attributed her symptoms to psychosocial problemsA 29-year-old divorced Chinese female who emigrated to the U.S. four years ago, and she lived with her 9-year-old son. She was laid off from her job three months ago, which had caused significant financial hardship. The patient and her son shared an apartment with roommates, and complained the lack of privacy. She reported that she had been suffering from sadness, insomnia, ↓ interest, irritability, guilt, and ↓ concentrating. She had not received any treatment for these symptoms

Patient’s explanatory model of his illness experience:1. “What do you call it?” “don’t know”2. “What has caused it” “financial pressure and crowded living condition”

3.“When did it start?” “since I was laid off several months ago”4.“What does it do to you?” “don’t feel well”5.“How severe is it?” “moderately severe”6.“What do you fear most?” “the influence on my son’s emotion”7.“Chief problems?” “sadness, being irritable”8.“What treatment?” “to improve in our living conditions” “most important results”

Vignette # 2. The depressed patient who attributed her symptoms to psychosocial problems

Culturally Sensitive Disclosure of Diagnosis: The patient was aware of her own mood and depressive symptoms, although she attributed them to her financial and living condition rather than a mental condition. We agreed with her interpretation of the importance of her psychosocial stress or “pressure” (in her own words) on the development of her symptoms. When we asked her if she considered herself having depression, she replied, “possible”

.

Customized Approach to Treatment Negotiation: We acknowledged that improving her housing condition was important, and we suggested that she look into applying to state-subsidized housing. In addition, we pointed out that the treatment of depression would help her to feel less stressed and irritable so that she can be a good mother. Also, her mood and other symptoms may improve with treatment and she would be able to function and interview for new jobs. We offered her treatment options including medications and therapy, and patient agreed to see a therapist

Vignette # 3. The depressed patient who focused on her somatic symptoms

A 63-year-old widowed Chinese female who emigrated to the U.S. in 2003. She lived alone in elderly housing, and provided childcare to her grandchildren several days a week. She felt that she had difficulty adjusting to life in the U.S. and felt socially isolated and lonely. She complained about insomnia, headaches, depressed mood, ↓interest, feelings of guilt, fatigue, ↓concentration, irritability, and passive SI. She wants to fix her sleep problem

Patient’s explanatory model of his illness experience:1. “What do you call it?” “insomnia and fatigue” 2. “What has caused it?” “adjustment problems in the U.S.” 3. “When did it start?” “in 2003” 4. “What do it do to you?” “When I cannot sleep, I feel tired and have headaches” 5. How severe is it? “sleep problem is pretty severe’ 6. “What do you fear most?” “cannot sleep at night” 7. “Chief problems?” “sleep problems” 8. “What treatment?” “medication may help” “most important results” “to sleep well”

Vignette # 3. The depressed patient who focused on her somatic symptoms

Culturally Sensitive Disclosure of Diagnosis: The patient focused strongly on her somatic symptoms, including insomnia, headaches, and fatigue. She labeled her problem “insomnia”.. When asked, patient replied that she had sort of heard of depression, but did not think she suffered from depression. We explained that in the West, depression refers to a cluster of symptoms including sadness, insomnia, loss of interest, guilt feelings, fatigue, difficulty concentrating, irritability and SI, similar to many of the symptoms that she reported

.

Customized Approach to Treatment Negotiation: She had considered taking medications for sleep, but like many Chinese, “sleeping pills” have strong negative connotations. We reassured her that we were not planning to use “sleeping pills.” Rather, we planned to use medications to treat her insomnia, mood symptoms which does not have addictive potential. The patient was receptive to the recommendation and accepted an antidepressant despite denying that she had a depressive disorder

Vignette # 4. The depressed patients who considered herself as having poor health with unidentified causes

A 51-year-old widowed Chinese female who emigrated to the U.S. in 2006. She was a housewife in China and worked as a home aide for the elderly in the U.S. She reported having language barriers, financial problems, and was socially isolated. She complained of insomnia, ↓interest, irritability, excessive worries, difficulty concentrating, and multiple physical symptoms. Her primary care physician did not find any specific illness after repeated examinations and laboratory tests

Patient’s explanatory model of his illness experience:1. “What do you call it?” “don’t know”, “it could be poor health”2. “What has caused it?” “not sure”3. “When did it start?” “when I emigrated to the U.S.”4. “What does it do to you?” “poor health”5. How severe is it? “moderately severe” “it has lasted for 3 years”6. “What do you fear most?” “I may have an unidentified illness”7. “Chief problems?” “not feeling well”8. “What treatment?” “not sure” “most important results” “I want to feel better”

Vignette # 4. The depressed patients who considered herself as having poor health with unidentified causes

Culturally Sensitive Disclosure of Diagnosis: The patient was aware that she had multiple physical and emotional symptoms. She, like many Chinese immigrants with traditional illness beliefs, was unfamiliar with the concept of depression and attributed her symptoms to “poor health”. During the interview, she was asked if she held strong opinions against being diagnosed with depression. She did not offer a direct answer, but remained skeptical that she had depression

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Customized Approach to Treatment Negotiation: Treatment negotiation focused on symptom reduction. The patient was encouraged to consider medication treatment and self-management measures such as exercise, relaxation techniques, problem-solving skills, and positive thinking for relief of symptoms. Although many patients are unfamiliar with depression or wary of the diagnosis, they are willing to accept medications including antidepressants if reassured that these are safe medications that may reduce or even eliminate their symptoms

Conclusion

Cultural barriers contribute to treatment disparities of MDD among minority patients

Clinicians need to explore patient’s illness beliefs and what they hope to obtain from treatment

Incorporating culture in diagnostic interviews allows the clinician to communicate the illness using language, concepts, and framework that the patient can understand, and to successfully negotiate treatment strategy meaningful to the patient