David Henderson, M.D., tells listeners at the APA annual meeting how to
adapt approaches to the treatment of racial or ethnic minorities to that of
all patients. Henderson was awarded the 2007 Solomon Carter Fuller Award at
Credit: David Hathcox
The path to treating patients in Boston has led David Henderson, M.D., far
Two years after completing his residency in 1992, it dawned on Henderson
that he was struggling to treat a group of patients from a broad spectrum of
racial, ethnic, and cultural backgrounds. He realized that the American
psychiatric model had its limitations when he prepared to treat patients who
were not white or male.
"I realized I had been trained to treat about 1 percent of the
world's population," he told an audience at APA's annual meeting in San
Diego in accepting the 2007 Solomon Carter Fuller Award, given each year in
memory of the first black psychiatrist in the United States. The award honors
an African-American citizen "who has pioneered in an area that has
significantly benefited the quality of life for black people."
Henderson is associate professor of psychiatry at Harvard Medical School
and director of the Schizophrenia, Diabetes, and Weight Reduction Research
Program at Massachusetts General Hospital. He also studies the impact of
trauma in areas of mass violence and develops programs to assist vulnerable
populations, including projects in Rwanda, Cambodia, East Timor, Bosnia, New
York City, and Louisiana.
Henderson's mentor at Harvard, Chester Pierce, M.D., told him he needed an
international experience. Henderson found that experience—and began to
understand his dilemma and its solution—in Africa.
In January 1995, he stepped off the plane at a bullet-pocked airport in
Rwanda shortly after the genocide that devastated the country. He asked
himself: "Did I really need to come here to treat a diverse,
international population in the United States?"
The answer, he soon learned, was "yes."
People of non-European ancestry now make up 35 percent of the U.S.
population, and that figure is predicted to increase to 45 percent by 2025.
Race and ethnicity affect how these minorities are diagnosed and treated, he
said. They are, for example, more likely than white people to be diagnosed
with schizophrenia than affective disorders. African Americans often are
prescribed higher doses and are more likely to be secured or restrained when
hospitalized. Physicians must recognize these patterns, which stem from lack
of knowledge or from individual and institutional biases, he said.
"So you have to start addressing this population," he said."
They will be your patients, and you have to understand what their lives
Next, he went to Cambodia. Henderson had treated Cambodians in Boston but
couldn't grasp what they had gone through until he visited the country in June
Psychiatry didn't exist in Cambodia, he said. His job was to train primary
His first shock came when he went from having access to a hundred drugs to
having just five available. "This was a humbling experience for a
psychopharmacologist," he said.
Talking to patients provided another lesson in cultural anthropology. As
part of a routine psychiatric workup, he might ask patients if they heard
voices when nobody was in the room. They invariably said, "yes."
Still guided by his American training, Henderson concluded this was a symptom
Puzzled by the consistent responses, he posed the question to the Cambodian
doctors he worked with. They, too, said, they heard voices. Finally he asked
the minister of health if he heard voices when he was alone. The minister also
"I decided then that everybody in Cambodia was psychotic,"
Henderson said, recalling how his cultural blinders affected his thinking.
The minister of health finally took pity on the poor foreigner.
"Let's take a minute to help Dr. David, because he is not in touch
with his ancestors," said the minister.
"That opened my eyes in a humbling kind of way," said
Culture isn't just some nebulous background from which patients emerge when
it's time to visit the doctor, he found. Culture affects patients' willingness
to seek treatment, how they manifest and communicate symptoms, how they cope
with illness, and what range of family and community support they receive.
Getting a positive response to, "Do you walk down the street and feel
people are out to get you?" may not indicate paranoia to someone who
lives in a poor, violent neighborhood.
If human differences represent the contributions of common ancestry,
genetics certainly plays a role. There are gender and ethnic differences in
how drugs are metabolized, thanks to differences in cytochrome P450 enzymes.
Women metabolize drugs using the CYP1A2 enzyme more slowly than men, for
example, and CYP2D6 has more nonfunctioning alleles in populations of
Africans, African Americans, and Asians, and so their effects may be
clinically relevant, he noted.
"PDR dosages are based on extensive metabolizers, but there are also
slow metabolizers, who metabolize at half the rate of high
metabolizers," said Henderson. These patients reach toxic levels
quickly, he said. They complain of side effects "too soon."
Clinicians see them as "bad" patients, as complainers. But there
are also "super metabolizers"—like 29 percent of
Ethiopians—who never achieve therapeutic blood levels of medications.
Psychiatrists relying on U.S. data based on white populations may label these
patients "treatment resistant."
More research needs to be done to better understand the effects of drugs on
racial and ethnic groups, said Henderson, which is why Congress required that
sufficient numbers of minority populations be included in Phase III clinical
trials to provide statistically valid analyses of any differences.
Adequate numbers of minorities would allow researchers to test hypotheses
observed in prior research (such as differences in drug metabolism), generate
new hypotheses about the roles of race and ethnicity, and ensure an equitable
distribution of the risks and benefits of research participation.
Despite the Congressional mandate, he said, "most studies fall short
in recruiting minority subjects, yet nothing happens to the
researchers." The Food and Drug Administration, National Institutes of
Health, and National Institute of Mental Health "must get serious about
this and make further funding conditional on compliance."
His travels and his treatment of ethnically diverse populations have taught
Henderson that ethnic data need to be integrated into all textbooks, training,
and practice. The lessons he learned apply to treating all patients, not just
members of minority groups.
"You can't know every culture but you have to be aware," he
said. "I have to change my practice for everybody."
That may mean starting drugs at lower doses than recommended by
manufacturers and working the dosage up gradually.
He cited the case of an African-American woman who went off her medications
after discharge, complaining about side effects. Henderson knew within 10
minutes of examining her chart that all the drugs she had been prescribed were
metabolized by the CYP2D6 enzyme and that her side effects came from her being
a slow metabolizer. He prescribed a drug not metabolized by CYP2D6, and she
responded well, but she had cost the system $100,000 in the interim.
"So this information has to be integrated into clinical
practice," he said. "It's not that brilliant. It's just
straightforward, basic knowledge." ▪