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LETTER |
Correspondence: Requests for reprints should be sent to Leopoldo J. Cabassa, MSW, Center for Mental Health Services Research, George Warren Brown School of Social Work, Washington University, Campus Box 1196, One Brookings Drive, St Louis, MO 63130 (e-mail: ljc1{at}gwbmail.wustl.edu).
Snowden’s article in the February issue of the Journal presents a comprehensive review of the literature regarding the role that practitioners’ bias plays in the development of racial and ethnic disparities in the current mental health system.1 Missing from this review is the growing literature that directly examines the role that culture plays in the expression, presentation, and course of mental illnesses.2–4 The integration of this body of work into the current discussion of mental health disparities in service use and quality of care can help clarify and expand our understanding of the sociocultural processes that create these inequities.
For instance, Good, in a critical review of the literature on cultural issues related to diagnosis and comorbidity,5 specifies 3 key areas of research that can help address the gaps identified by Snowden. First, supplement experimental studies that identify factors related to clinician bias with ethnographic studies to elucidate how local cultural and institutional contexts influence illness narratives. Such studies could directly examine how the context in which clinician-client interactions occur influences diagnostic and treatment decisions. Second, pay attention to how presentation of symptoms and expression of disorders vary across cultures. There is a rich literature in cross-cultural psychiatry that examines how illnesses are organized and expressed in local idioms and how these organizations and expressions may affect help-seeking behaviors and service use.3,4,6 Third, test the validity of diagnostic categories across patient populations. Literature dealing with this issue has revealed how different ethnic groups present different symptoms for the same disorder7 or present culturally bound clusters of symptoms.8
A multidisciplinary approach that combines epidemiological, clinical, and anthropological data can produce a better empirical base for determining the roots of mental health disparities and can inform the translation of this knowledge into practice to eliminate inequities in service use and quality of care.
References
1. Snowden LR. Bias in mental health assessment and intervention: theory and evidence. Am J Public Health.2003;93:239–243.
2. Fabrega H. The role of culture in a theory of psychiatric illness. Soc Sci Med.1992;35:91–103.
3. Kleinman A. Rethinking Psychiatry: From Cultural Category to Personal Experience. New York, NY: Free Press; 1988.
4. Lewis-Fernandez R, Kleinman A. (1995). Cultural psychiatry: theoretical, clinical and research issues. Psychiatr Clin North Am.1995;18:433–447.[ISI][Medline]
5. Good BJ. Culture, diagnosis and comorbidity. Cult Med Psychiatry.1993;16:427–446.
6. Lopez SR, Guarnaccia PJ. Cultural psychopathology: uncovering the social world of mental illness. Annu Rev Psychol.2000;51:571–598.[ISI][Medline]
7. Brekke JS, Barrio C. Cross-ethnic symptom differences in schizophrenia: the influence of culture and minority status. Schizophr Bull.1997;23:305–316.
8. Guarnaccia PJ, Good BJ, Kleinman A. A critical review of epidemiological studies of Puerto Rican mental health. Am J Psychiatry.1990;147:1449–1456.
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