A biocultural approach to psychiatric illnesses.

RATIONALE: As a species, humans are vulnerable to numerous mental disorders, including depression and schizophrenia. This susceptibility may be due to the evolution of our large, complex brains, or perhaps because these illnesses counterintuitively confer some adaptive advantage. Additionally, cultural and biological factors may contribute to susceptibility and variation in mental illness experience and expression. Taking a holistic perspective could strengthen our understanding of these illnesses in diverse cultural contexts. OBJECTIVES: This paper reviews some of these potential factors and contextualizes mental disorders within a biocultural framework. RESULTS: There is growing evidence that suggests cultural norms may influence inflammation, neurotransmitters, and neurobiology, as well as the illness experience. Specific examples include variation in schizophrenia delusions between countries, differences in links between inflammation and emotion between the United States and Japan, and differences in brain activity between Caucasian and Asian participants indicating that cultural values may moderate cognitive processes related to social cognition and interoception. CONCLUSIONS: Research agendas that are grounded in an appreciation of biocultural diversity as it relates to psychiatric illness represent key areas for truly interdisciplinary research that can result in culturally sensitive treatments and highlight possible biological variation affecting medical treatment.

Population-based differences in immune system response contribute to an increased risk of schizophrenia in African migrants?

Among the highest incidences of schizophrenia is the one documented in second-generation migrants of African descent in the Western countries. Interestingly, people of African and European ancestry demonstrate significant genetic-based differences in immune system regulation and response. As a result, the pro-inflammatory phenotype is more pronounced in people of African descent than it is in Europeans. At the same time, the role of the immune system in the etiology of schizophrenia is gaining increased recognition. Here, we propose that the population-specific genetic variation within the immune system interacts with unfavourable environments to contribute to a higher risk of schizophrenia in people of African ancestry. Our hypothesis is supported by recent findings from two separate fields of research-population genetics and psychoneuroimmunology. Moreover, we highlight the need to include African populations in genetic studies of schizophrenia.

Antipsychotic medications and stroke in schizophrenia: A case-crossover study.

BACKGROUND: The association between antipsychotic use and the risk of stroke in schizophrenic patients is controversial. We sought to study the association in a nationwide cohort with schizophrenia. METHODS: Using a retrospective cohort of patients with schizophrenia (N = 31,976) derived from the Taiwan National Health Insurance Research Database, 802 new-onset cases of stroke were identified within 10 years of follow-up (from 2000 through 2010). We designed a case-crossover study using 14-day windows to explore the risk factors of stroke and the association between antipsychotic drugs and the risk of stroke. We analyzed the risks of individual antipsychotics on various subgroups of stroke including ischemic, hemorrhagic, and other strokes, and the risks based on the antipsychotic receptor-binding profile of each drug. RESULTS: Use of any second-generation antipsychotic was associated with an increased risk of stroke (adjusted risk ratio = 1.45, P = .009) within 14 days while the use of any first-generation antipsychotic was not. Intriguingly, the use of any second-generation antipsychotic was associated with ischemic stroke but not hemorrhagic stroke. The antipsychotic receptor-binding profile analysis showed that the antihistamine 1 receptor was significantly associated with ischemic stroke (adjusted risk ratio = 1.72, P = .037), and the sensitivity analysis based on the 7-day window of exposure validated the association (adjusted risk ratio = 1.87, P = .015). CONCLUSIONS: Use of second-generation antipsychotic drugs appeared to be associated with an increased risk of ischemic stroke in the patients studied, possibly mediated by high affinity for histamine-1 receptor blockade. Further research regarding the underlying biological mechanism and drug safety is suggested.

Do they see dead people? Cultural factors and sensitivity in screening for schizophrenia spectrum disorders.

OBJECTIVE: Schizophrenia spectrum disorders (SSDs), are diagnosed more frequently among African-Americans (AAs) than Caucasians. It has been suggested that cultural differences in symptom presentation and endorsement (including reporting spiritual/religious experiences) may influence this disparity. The current study investigated the relationship between endorsement of spiritual auditory and visual hallucinations and subsequent diagnosis of SSD among AA patients. DESIGN: Participants (N = 471 AAs) completed the Mini International Neuropsychiatric Interview-Plus (MINI-Plus) Screening Interview as part of their intake to a HIV outpatient clinic. Endorsement of auditory or visual (A/V) hallucinations was explored with the MINI-Plus Psychotic Disorder Module and questions regarding the content of the unusual experience. RESULTS: Logistic regression indicated that endorsement of A/V hallucinations significantly predicted a SSD (OR = 41.6, 95% CI 13.7-126.0, p < .001). However, when hallucinations were spiritual in nature, odds of an SSD fell dramatically (OR = 0.22, 95% CI 0.07-0.64, p < .001). CONCLUSIONS: The current study indicates that not all visual and auditory hallucinations are symptomatic of a psychotic disorder in AA patients. Many of these experiences may be related to spirituality. Clinicians assessing AA patients need to query content of, meaning attributed to, and distress associated with A/V unusual experiences.

Schizophrenia: Impact of psychopathology, faith healers and psycho-education on adherence to medications.

BACKGROUND: Many patients suffering from psychosis are nonadherent to their medications. Nonadherence can range from treatment refusal to irregular use or partial change in daily medication doses. AIM: To investigate whether symptom dimensions, post-discharge care plans and being involved with faith healer affect the adherence to treatment in patients with schizophrenia. METHOD: A total of 121 patients with schizophrenia were examined 6 weeks post-discharge from the inpatient unit and assessed for full, partial or nonadherence to medication. RESULTS: There was a significant association between family involvement and partial adherence and between community team involvement post-discharge and full adherence to medications. Psycho-education was a predictor for adherence to medications, persecutory delusions and lack of insight predicted partial adherence, while being involved with faith healers predicted nonadherence. CONCLUSION: Adherence to medications and socio-demographic variables are independent. This study demonstrated that nonadherence or partial adherence to medications is associated with lack of insight and persecutory delusions. Psycho-education could improve the adherence to medication compliances.

A large single ethnicity study of prepulse inhibition in schizophrenia: Separate analysis by sex focusing on effect of symptoms.

Deficits in sensorimotor gating, as measured with prepulse inhibition (PPI), have been considered an endophenotype of schizophrenia. However, the question remains whether these deficits are related to current symptoms. This single site study aimed to explore clinical features related to the modulation of startle reflex in a large sample of Japanese patients with schizophrenia (DSM-IV). The subjects comprised 181 patients and 250 healthy controls matched for age and sex. Schizophrenia symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Startle reflex to acoustic stimuli was recorded using a startle stimulus of 115 dB and a prepulse of four different conditions (intensity: 86 dB or 90 dB; lead interval: 60 ms or 120 ms). Patients exhibited significantly reduced startle magnitude (p < 0.001), habituation (p = 0.001), and PPI (90 dB, 60 ms, p = 0.016; 90 dB, 120 ms, p = 0.001) compared with controls. Patients of both sexes exhibited significantly lower habituation and PPI (90 dB, 120 ms) compared with the same sex controls. We could not detect a significant correlation with any clinical variable in the entire patients, however, when men and women were examined separately, there was a negative correlation with the PANSS cognitive domain (ρ = -0.33, p = 0.008) in men, but not in women. Moreover, when patients were subdivided into four clusters, two clusters with high positive symptoms showed significant PPI deficits in men. Our results suggest that sensorimotor gating is impaired in schizophrenia of both sexes, and PPI deficits may be related to thought disturbance and disorganization in male patients with schizophrenia.

Serum trace element differences between Schizophrenia patients and controls in the Han Chinese population.

Little is known about the trace element profile differences between Schizophrenia patients and healthy controls; previous studies about the association of certain elements with Schizophrenia have obtained conflicting results. To identify these differences in the Han Chinese population, inductively coupled plasma-mass spectrometry was used to quantify the levels of 35 elements in the sera of 111 Schizophrenia patients and 110 healthy participants, which consisted of a training (61/61 for cases/controls included) and a test group including remaining participants. An orthogonal projection to latent structures model was constructed from the training group (R(2)Y = 0.465, Q(2)cum = 0.343) had a sensitivity of 76.0% and a specificity of 71.4% in the test group. Single element analysis indicated that the concentrations of cesium, zinc, and selenium were significantly reduced in patients with Schizophrenia in both the training and test groups. The meta-analysis including 522 cases and 360 controls supported that Zinc was significantly associated with Schizophrenia (standardized mean difference [SMD], -0.81; 95% confidence intervals [CI], -1.46 to -0.16, P = 0.01) in the random-effect model. Information theory analysis indicated that Zinc could play roles independently in Schizophrenia. These results suggest clear element profile differences between patients with Schizophrenia and healthy controls, and reduced Zn level is confirmed in the Schizophrenia patients.

Explanatory models of psychosis amongst British South Asians.

PURPOSE: A strong interest in the understanding, exploring, and extracting explanatory models of psychosis has recently arisen. Explanatory models (EMs) offer justifications and propose explanations when coping with and treating illnesses. Therefore, they may be important predictors of clinical outcome. Explanatory models of psychosis have been explored in many non-Western countries. However, very little research has examined EMs of psychosis in the UK. We therefore, aimed to elicit and describe explanatory models of psychosis amongst British South Asians, using both quantitative and qualitative methods. METHOD: EMs of psychosis were examined using the Short Explanatory Model Interview (SEMI) in a cross-sectional sample of 45 patients. RESULTS: Most patients (55.5%) attributed their illness to supernatural causes. Few patients cited a biological (4.4%) cause. Majority of patients held dual EMs of psychosis (77.7%), combining prescribed medication and seeing a traditional healer as a treatment method. Duration of Untreated Psychosis (DUP) was not significantly associated with EMs of psychosis. CONCLUSION: The results suggest that patients hold multi-explanatory models in order to make sense of their illness and these stem from deep rooted traditional beliefs. This highlights the importance of educational intervention, culturally adapted psychological interventions and possibly working together with traditional healers in the UK to provide a positive support system. Further work is required in order to fully understand the relationship between EMs of psychosis and DUP.

[Mental Health Care Utilization of First Generation Vietnamese Migrants in Germany]. / Inanspruchnahme ambulanter psychiatrischer Versorgung bei vietnamesischen Migranten der ersten Generation in Deutschland.

OBJECTIVE: Vietnamese migrants underutilize and are a "hard to reach group" within the existing mental health care system in Germany. METHODS: We analyzed migration related and clinical data for all first-time Vietnamese migrants seeking psychiatric help, within the first 30 months of a newly established outpatient clinic, offering culture-sensitive psychiatric treatment in native Vietnamese language. RESULTS: Most first time patients were female, first generation Vietnamese migrants with poor German language skills. Only 1 /3 of all patients had a psychiatric history, while this number was higher in patients with schizophrenia. Over time, more first time patients with depression were seeking psychiatric care, accompanied with an increase of non-professional referrals within the Vietnamese communities. CONCLUSION: This first study on mental health care utilization in Vietnamese migrants in Germany points towards the fact that "migrants" cannot be considered as a homogeneous group. Mental health care utilization must be evaluated for specific migrant groups, and can be initially improved if offered in native language and when it is referred to by members of migrant communities.

Idiom of distress or delusional state? Cultural clash as the cause of misdiagnosis: a case report.

The Beta Israel (House of Israel) represent a total number of more than 100,000 individuals. Ethiopian Jewish culture is based on a tribal cultural model. With their arrival in Israel, many difficulties surfaced. Ethiopian Jews had to deal with cultural choices that challenged their traditions. It has been suggested that the trauma of their journey coupled to the difficulties of the adaptation process to Israeli society, ( the culture shock), was directly responsible for psychopathology found among this population. It also appeared that culture plays a central role in the construction of the clinical picture, blurring at times the boundary between expressions of distress and pathology. It became increasingly difficult to draw the line between culturally normative behavior and psychopathology. The following case report underlines the importance of socio cultural considerations in both staff and patients, and illustrates the dangers of misdiagnosis due to patient therapeutic team cultural clash. A 41 year old woman of Ethiopian origin was hospitalized for suspected schizophrenia. Because of the striking contrast between the patients behavior, responses and so called psychotic content, possible misunderstanding based on cultural differences was considered by the clinical management team. This case underlines the dangers of the psychiatric diagnostic process, emphasizes the important role of sociocultural backgrounds of both staff and patients in patient management and encourages the consideration of cultural factors in all patient evaluations.

[Etiological illness concepts in patients suffering from schizophrenia from Austria and Pakistan with special consideration of the gender aspect]. / Krankheitsmodelle bei PatientInnen mit Schizophrenie in Pakistan und in Österreich unter besonderer Berücksichtigung von Genderaspekten.

OBJECTIVE: Etiological illness concepts of patients with schizophrenia are an important factor for the drug compliance as well as for a successful psychotherapeutic approach. These cognitive representations are influenced by issues like the illness, culture, gender, and age. The aim of this study was the elaboration of the interaction of these factors with special consideration of the gender aspect. METHOD: The notions about the reasons of illness were explored by means of a 41-item standardized self-rating instrument in 240 patients suffering from schizophrenia from Pakistan and Austria. RESULTS: Only in the scale "conflicts" the mean values for Austrian women were statistically significant higher than for their male counterparts. In Pakistani patients we found no significant differences, patients with an early age at onset of illness more frequently reported a magic-religious explanatory model in both cultures. Austrian patients with a longer duration of illness believed more often that the outbreak of the illness was caused by negligent behaviour. CONCLUSION: While gender has important effects on course and outcome of schizophrenia, the influence on etiological illness concepts is rather weak. Two reasons can be postulated: (a) The acquirement of knowledge about the development of mental disorders is culture-specific, but not gender-specific, (b) psychotic disorders are even out originally existing gender differences.

[Mental health beliefs between culture and subjective illness experience]. / Subjektive Krankheitsmodelle zwischen spezifischer Krankheitserfahrung und Kultur.

OBJECTIVE: Subjective health beliefs are representations about pathogenesis, course and treatment options of psychic as well as somatic illnesses. They are important for a psychotherapeutic interaction as well as for a stable drug adherence. However, it remains unclear whether these representations are primarily affected by the cultural background or by an individual's specific illness experiences, a question of increasing importance in our era of globalized migration. METHOD: The study sample consisted of 203 Austrians (125 with schizophrenia, 78 with obsessivecompulsive disorder) and 190 Pakistanis (120 with schizophrenia, 70 with obsessive-compulsive disorder). All patients completed the "Causal Explanations of Mental Disorders" (CEMD), a 41-item self-rating questionnaire. RESULTS: Pakistani patients reported magic-religious oriented mental health beliefs more frequently. In contrast, Austrians' beliefs are more often in line with the bio-psychosocial explanations of Western medicine. Concerning mental health beliefs the cultural background seems to be more important than the subjective experience with a distinctive mental disorder. CONCLUSIONS: Although the subjective experience is of importance for the shape of illnessspecific cognitions, mental health beliefs are primarily caused by the patients' socio-cultural origin. It is a challenge for psychiatry to improve the co-operation with culture-anthropology and other social sciences.

Effect of aripiprazole, risperidone, and olanzapine on the acoustic startle response in Japanese chronic schizophrenia.

BACKGROUND: Studies have also shown that differences in the kind of the antipsychotics influenced disruption of the sensorimotor gating system, including prepulse inhibition (PPI), acoustic startle reflex (ASR), and habituation (HAB). We investigated the influence on startle response in chronic schizophrenia in 20 patients with schizophrenia taking risperidone, 21 patients with schizophrenia taking olanzapine, and 20 patients with schizophrenia taking aripiprazole. METHOD: The patients who participated in this study were on maintenance therapy with only one antipsychotic drug for 4 months. We performed the test for the association between all PPI measures (ASR, HAB, and PPI at prepulse sound pressure intensities of 82, 86, and 90 dB) and each the risperidene, olanzapine, and aripiprazole groups, with analysis of covariance (ANCOVA; using age, duration of illness, and daily dose of the antipsychotic as covariates). Also, when significant difference was detected in ANCOVA, the differences of PPI measures between every pairs of two drug groups were tested as a post hoc analysis with the use of t test and Bonferroni's correction of multiple tests. RESULT: We found that PPI90 showed significant differences with ANCOVA among patients with schizophrenia taking each of the antipsychotics. When we performed a post hoc analysis for PPI90, the value was higher in the aripiprazole group than in the olanzapine group and higher in the risperidone group than in the olanzapine group. CONCLUSION: Aripiprazole and risperidone may improve PPI90. ASR, HAB, PPI82, and PPI86 were no different among the Japanese schizophrenic patient groups with different antipsychotics.

Knowledge and preferences regarding schizophrenia among Chinese-speaking Australians in Melbourne, Australia.

OBJECTIVE: The aim of this study was to better understand the knowledge of schizophrenia, preferences regarding professional help, medication and treatment methods among Australians of a Chinese-speaking background. METHODS: A cluster convenience sampling method was adopted in which subjects were taken from the four main areas in cosmopolitan Melbourne where most Chinese people live. A total of 200 Chinese-speaking Australians participated in the study. They were presented with a vignette describing an individual with schizophrenia and were then asked questions to assess their understanding of schizophrenia and their preferences regarding professional help, medication and treatment methods. A comparative approach was used to compare our findings with those of a previous study on the mental health literacy of Australian and Japanese adults. RESULTS: Compared with the Australian and Japanese samples, a much lower percentage of Chinese-speaking Australians (15.5%) was able to identify the vignette as a case of schizophrenia/psychosis. A higher percentage of the Chinese-speaking Australians believed that professionals, and particularly counselling professionals, could be helpful for the person in the vignette. A higher percentage of the Chinese-speaking Australian and Japanese samples believed that close family members could be helpful, and expressed more uncertainty about the usefulness or harmfulness of certain medications than the Australian sample. A higher percentage of the Chinese-speaking Australians than the Australian and Japanese samples endorsed inpatient treatment for the person in the vignette. About 22, 17, 19 and 28% of the Chinese-speaking Australian participants, respectively, rated 'traditional Chinese medical doctors', 'Chinese herbal medications', 'taking Chinese nutritional foods/supplements' and 'qiqong' as helpful. Many perceived 'changing fungshui' and 'traditional Chinese prayer' to be harmful. CONCLUSIONS: Campaigns to increase the schizophrenia literacy of Chinese-speaking Australians are needed and must take into consideration the aforementioned socially and culturally driven beliefs so that culturally relevant education programmes can be developed.

Ethnic diversity and pathways to care for a first episode of psychosis in Ontario.

OBJECTIVE: To examine ethnic variations in the pathways to care for persons accessing early intervention (EI) services in Ontario. METHOD: The pathways to care and the duration of untreated psychosis were assessed for first-episode psychosis patients who entered specialized EI services in Ontario. The sample was assigned to the following ethnic classifications: the White (Caucasian), Black (African descent), and Asian (ancestry from the continent) groups, plus all the "other ethnicities" group. RESULTS: There were 200 participants: 78% were male; 61% from the White, 15% Black, 13% Asian, and 11% were from the other ethnicities group. At the first point of contact, more participants used nonmedical contacts (12%), such as clergy and naturopathic healers, than psychologists (8%) or psychiatrists (7%). There were no ethnic differences for duration of untreated psychosis (median 22 weeks) or for initiation of help seeking by family/friends (53%), police (15%), or self (33%). After adjusting for relevant clinical and demographic factors, the Asian and other ethnicities groups were 4 and 3 times (respectively) more likely than the White or Black groups (P = .017) to use emergency room services as the first point of contact in the pathways to care. Participants from the Asian group experienced less involuntary hospitalizations (P = .023) than all the other groups. Yet overall, there were many more similarities than significant differences in the pathways to care. CONCLUSION: EI services should monitor the pathways to care for young people of diverse ethnic backgrounds to address any disparities in accessing care.

Personal experience of schizophrenia and the role of Danwei: a case study in 1990s Beijing.

Danwei as a cornerstone of Chinese urban society has received great research attention. The relationship between the Danwei and psychiatric patients, however, remains unclear. This article aims to shed light on the subject with an integrated micro-macro approach. It introduces a historical understanding of mental health in urban China under the "economic state in transition" framework. A detailed case study in clinical sociology is provided to reveal the many social factors affecting the experience of a schizophrenic patient and his significant others. A changing role of the Danwei is hypothesized and validated with qualitative data. The Danwei was shown to have changed significantly before the mid-1990s, yet it still played a major role in urban workers' lives, including those of psychiatric patients, and even more so in people's expectations. This lends support to the need for a more responsive public policy to address various social issues brought about by economic reform, with the learning of worldwide experiences including "community care," "social support" and "social rehabilitation." Implications for social research, policymaking and professional practice are discussed.

Complementary treatment of psychotic and epileptic patients in malaysia.

The objective of this article is to describe and compare the use of traditional/complementary medicine (T/CM) among psychotic (schizophrenia and schizophreniform disorder) and epileptic Malay patients in peninsular Malaysia. There were 60 patients in each group. T/CM consultation was uniformly spread across all levels of education and social status. We could not find a single over-riding factor that influenced the decision to seek T/CM treatment because the decision to seek such treatment was complex and the majority of decisions were made by others. Fifty-three patients (44.2%), consisting of 37 (61.7%) psychotic and 16 (26.7%) epileptic patients had consulted Malay traditional healers (bomoh) and/or homeopathic practitioners in addition to modern treatment; of these, only three had consulted bomoh and homeopathic practitioners at the same time. The use of T/CM was significantly higher in psychotic than in epileptic Malay patients.

The healthcare-seeking behaviour of schizophrenic patients in Cambodia.

AIMS: To understand the patterns of the schizophrenic patients' healthcare-seeking behaviour (HCSB) in the context of a post-conflict country where psychiatric facilities are scarce. METHODS: Cross-sectional survey assessing schizophrenic patients and their caregivers who consulted for the first time in four different outpatient psychiatric departments. RESULTS: One hundred and four schizophrenic patients were selected: 56.7% began the HCSB with traditional medicine; 22.1% with western medicine, psychiatry included, and 20.2% with religious medicine; 77.3% did not begin the HCSB with psychiatry because they did not know it was a mental problem or because they did not know mental health services existed. The patients' education was the only factor that significantly influenced the HCSB. CONCLUSION: In Cambodia, traditional and religious medicine are the first pathway to mental healthcare when patient and caregiver decide to seek help due to psychotic symptoms. The lack of knowledge on mental health and facilities appears the main reason to explain the schizophrenic patients' HCSB. This suggests that the development of psychiatry in Cambodia will be facilitated by a better spreading of knowledge on mental health and will have to take traditional and religious medicine into account.

Perceptions about the cause of schizophrenia and the subsequent help seeking behavior in a Pakistani population - results of a cross-sectional survey.

BACKGROUND: There is a cultural variability around the perception of what causes the syndrome of schizophrenia. Generally patients with schizophrenia are considered dangerous. They are isolated and treatment is delayed. Studies have shown favorable prognosis with good family and social support, early diagnosis and management. Duration of untreated psychosis is a bad prognostic indicator. We aimed to determine the perceptions regarding the etiology of schizophrenia and the subsequent help seeking behavior. METHODS: This cross-sectional study was carried out on a sample of 404 people at the out patient departments of Aga Khan University Hospital Karachi. Data was collected via a self-administered questionnaire. Questions were related to a vignette of a young man displaying schizophrenic behavior. Data was analyzed on SPSS v 14. RESULTS: The mean age of the participants was 31.4 years (range = 18-72) and 77% of them were males. The majorities were graduates (61.9%) and employed (50%). Only 30% of the participants attributed 'mental illness' as the main cause of psychotic symptoms while a large number thought of 'God's will' (32.3%), 'superstitious ideas' (33.1%), 'loneliness' (24.8%) and 'unemployment' (19.3%) as the main cause. Mental illness as the single most important cause was reported by only 22%. As far as management is concerned, only 40% reported psychiatric consultation to be the single most important management step. Other responses included spiritual healing (19.5%) and Sociachanges (10.6) while 14.8% of respondents said that they would do nothing. Gender, age, family system and education level were significantly associated with the beliefs about the cause of schizophrenia (p < 0.05). While these variables plus 'religious inclination' and 'beliefs about cause' were significantly associated with the help seeking behavior of the participants. CONCLUSION: Despite majority of the study population being well educated, only a few recognized schizophrenia as a mental illness and many held superstitious beliefs. A vast majority of Pakistanis have non-biomedical beliefs about the cause of schizophrenia. Their help seeking behavior in this regard is inappropriate and detrimental to the health of schizophrenic patients. Areas for future research have been identified.