Where Culture and Science Collide: How Ethnic, Social Factors Affect Response to Psychotropic Drugs

To the scientist, the process of the randomized controlled trial can seem straightforward: one group takes the study drug, and the other group takes the placebo. When psychotropic drugs are tested, after 12 to 24 weeks, standard questionnaires are used to gauge how whether the new drug is working.

But as presenters acknowledged during the session, “Psychopharmacology and Ethnicity,” at the 175th Annual Meeting of the American Psychiatric Association in San Francisco, California, it’s not always that simple. A dose that works for one ethnic group may not be powerful enough for another population, due to genetics, diet, or both. Especially with mental health conditions, the placebo effect is constant challenge—even the color of the pill can evoke different responses in different groups.

Dinesh Bhugra, MBBS, PhD, a professor of Mental Health and Cultural Diversity at King’s College, London, said the role of cultural psychiatry is understanding how these factors affect a patient’s responses to treatment—both medication and talk therapy. The challenge of culture, he said, is that it affects both the patient and the clinician.

“Can every culture predict behavior? Cultures are heterogeneous. There are strong influences, but individual responses,” he said.

Some countries have what Bhugra called “linear active” cultures—people do one thing at a time and stick to schedules; Germany, Canada, Belgium, and Austria are examples. Patients from these countries are more introverted, private, and focused on their jobs.

Countries like Portugal, northern Italy, and much of Latin America are “multi-active” cultures, where schedules are less important, and “conversations are never left unfinished.” In these countries, patients are more emotional, talkative, and tend to overshare.

Understanding cultural differences can be important in interpreting a patient’s symptoms. “Some cultures have no word for depression,” he said. “This is very important, because culture affects how symptoms are expressed.”

A patient may say, “My heart is sinking,” or “I feel gutted.”

Cultural Clashes and Racism

Bhugra said the wave of immigration in Europe, and the United Kingdom in particular, have elevated issues of the lack of cultural sensitivity and institutional racism among clinicians. It’s not a new problem, but it’s a bigger one now, he said. The treatment is subtle—clinicians don’t listen to patients from other cultures. There’s an attitude of, “I know what’s good for you,” which leads to too much medication being prescribed. Conditions are misdiagnosed, and patients who need talk therapy are put on powerful medications instead.

Wherever this occurs, Bhugra said it calls for self-examination at both the individual and the institutional level. “People take pride in saying, ‘I’m color blind.’ Well, don’t be color blind. Patients don’t all behave in the same way,” he said.

When prescribing medication, it’s essential to understand a patient’s diet, whether he or she smokes or is surrounded by smoking—and especially if patients are using herbal supplements or alternative remedies. More and more, developing countries make use of polypharmacy, which puts therapies in a single tablet, he said.

Some cultures put value on large pills, or taking pills multiple times a day. Bhugra said it’s important to train prescribers—and given staff shortages, family caregivers—to understand that starting with the lowest possible dose is best. Side effects, diet, and tobacco and alcohol use, and their effects, must all be monitored.

But most of all, physicians must listen to their patients. If they experience physical symptoms of their depression, those symptoms are quite real and must be addressed. If it is possible to give patients a choice between a pill or a syrup to improve adherence, physicians should do so.

“One size does not fit all,” he said.

The Placebo Effect

Antonio Ventriglio, MD, PhD, of the University of Foggia, Italy, traced the history of the use of the placebo in medicine, from the first use in 1799, to a controversial paper in 1933 that claimed there was no difference between a placebo and a medication, to its use today in trials.

Over time, research has shown that the placebo effect—the patient responding to a non-therapeutic dose—changes under certain conditions. Ventriglio discussed findings of reactions to “hot” colors versus “cold” colors of pills, how people respond to pills versus capules, and “why some interventions are more effective in some ethnic groups than others.”

“Injections are seen as stronger than tablets. The number of times a patient takes a drug over the period may make them think they are taking more treatment,” he said. And, difference responses based on race and ethnicity have emerged.

“There’s no doubt that discussion of ethnic and racial differences are charged with emotions,” he said. “This is a challenge for the FDA other regulators to include in clinical trials—why some interventions are more effective in some ethnic groups than others.”

For example, he pointed out that Western cultures are skeptical about homeopathic medicine, which is hugely popular in India.

An area that needs more research is different rates of placebo response by ethnic group to psychotropic drugs. “We don’t have enough data on this,” Ventriglio said.

Moderator Stephen Stahl, MD, PhD, called for more work on why rates of placebo response are rising in mental health trials. “Something is happening with the placebo response rate that is chasing big pharma out of psychiatry,” he said.

Small Study Suggests Genetic Differences

Finally, panelist Donatella Marazziti, MD, of the University of Pisa presented findings from a small study that compared differences in 2 key measures that could suggest why Africans with depression have higher rates of non-response to selective serotonin reuptake inhibitors (SSRIs) than whites. The study measured and compared (1) platelet 5-HT transporter (SERT) and (2) plasma oxytocin (OT) levels in groups of Italian men and male immigrants from Senegal living in Italy.

Using blood tests and established assays to measure density of the SERT protein, Marazziti established that SERT is higher in the Senegalese men. This finding would suggest a lower incidence of psychiatric disorders in this ethnic group. At the same time, the plasma OT levels were almost triple in the Senegalese men.

Her finding said, “A single nucleotide polymorphism of the OT receptor gene seems associated with decreased trust, empathy, optimism, and social support-seeking (which are important components of coping with stressors).”

Marazziti noted that the study was small (20 men in each group), and it cannot be said for certain if genetic differences account for the results.