Tomado del Washington Post
Â Shankar VedantamWashington Post staff writer
Tuesday, June 28, 2005; 12:00 PM What role does culture play in diagnosing and treating mental illness? In many poorer nations, social networks are a critical part of healing and recovery as patients continue to participate in society rather than becoming isolated, as is often the case in more developed nations. In the United States, some racial groups are more frequently diagnosed with schizophrenia than others, suggesting some sort of bias in the detection of such illnesses. This new information suggests a powerful link between societal factors and the diagnosis, treatment and outcome of mental illness.Washington Post staff writer Shankar Vedantam, who covers health and science, was online Tuesday, June 28 at Noon ET to discuss his three part series on culture and mental illness. Read more: Patients’ Diversity Is Often Discounted.Shankar Vedantam: Welcome to the online chat to discuss my series of articles about how culture influences the diagnosis, treatment and outcome of mental illness. There is a lot of ground to cover, but we’ll try to get to as much of it as possible. In the meantime, keep the questions coming!_______________________Washington, D.C.: That anecdote of the woman hearing voices at Cambridge Hospital is certainly provocative. Help us understand the point a little better. Is it that in Latino communities, there is no such thing as psychosis based on hearing voices, but if the same patient wandered back into mainstream medicine, he/she would in effect become psychotic-meaning there is a hermeneutics of psychosis?Shankar Vedantam: You raise an excellent question. For readers who don’t remember the specific excerpt from Sunday’s story, let me add it here and then address the question.Roberto Lewis-Fernandez was a young doctor in training in Massachusetts when he encountered a patient who was 49 and suicidal at Cambridge Hospital. The Puerto Rican woman begged for help in resolving a conflict with her son, but the Harvard University-affiliated psychiatrists focused on one set of symptoms — she was hearing voices, seeing darting shadows and sensing invisible presences.They diagnosed her as depressed and psychotic, or out of touch with reality, and medicated her. She was discharged. Soon after, the woman had an argument with her son and nearly killed herself by overdosing on the medication.For Lewis-Fernandez, who is Puerto Rican, the suicide attempt confirmed his fears that his superiors had misjudged the situation. For months, as top psychiatrists ordered him to keep increasing the potency of her drugs, he had told himself that hearing voices, seeing shadows and sensing presences is considered normal in some Latino communities. But he dared not challenge the wisdom of the medical model.“I wasn’t sure if she was psychotic, but I treated her as if she was,” he said about the case, which he wrote up in a medical journal. “I gave her the medicines.”When the hospital’s outpatient unit evaluated the woman anew, doctors there came up with a different diagnosis. They concluded that her symptoms were not abnormal in the context of her culture — they were expressions of distress, not illness. Lewis-Fernandez helped her reconcile with her son. She still heard voices and saw shadows, but now, as before, they did not bother her.I think it would be a huge mistake to suggest that there is no such thing as psychosis among Latinos from the Caribbean. Rather, the point of the story is that by focusing only on her symptoms, doctors were misled. The same symptoms, in other words, can mean different things, depending on the context. The goal of people like Dr Lewis-Fernandez is to have doctors focus on the context as well as the symptoms, to ask, for instance, how the patient interprets the symptoms herself, and to ask how the culture from which the patient comes thinks about such symptoms. Many advocates of cultural competence talk about how the culture influences “idioms of distress” — the ways in which patients express symptoms. Arthur Kleinman, the Harvard psychiatrist, told me that during his research in China after the Cultural Revolution, patients with what we would now call depression mainly complained about dizziness, exhaustion and sleeplessness — symptoms associated with what was then known as neuresthenia. “Depression was a highly stigmatized mental illness, neuresthenia was thought of as a physical condition and didn’t have any disgrace or humiliation,” Kleinman told me. But as China has globalized, this has changed. Now depression is a very common diagnosis.