In practice settings around the world, it is not uncommon for psychiatrists
to prescribe Asian patients low doses of psychotropic medication with the
understanding that Asians metabolize these medications at slower rates than
patients of other ethnicities.
As a result of this practice, however, these patients may not be receiving
adequate treatment, said James Chou, M.D., an associate professor of
psychiatry at New York University School of Medicine.
Chou appeared at the meeting "Overcoming Stigma in Asian American
Mental Health," with Ramaswamy Viswanathan, M.D., to discuss issues
related to the psychiatric treatment of Asians. The meeting was held last
month in New York.
While it is true that some people of Asian descent, as well as those from
other ethnic groups, may not metabolize psychotropic medications at the same
rate as Caucasians, there is no basis for automatically prescribing half the
recommended dosage to a patient because he or she is Asian, Chou said."
You have to base the drug dosage on individual response and avoid
generalizations based on
James Chou, M.D.: The practice of prescribing reduced doses of
medication to Asian patients may be leading to inadequate treatment of their
Chou explained that people belonging to certain ethnic groups produce
lesser amounts of enzymes, such as CYP2D6, which break down toxins in the
body. This can result in higher blood levels of certain psychotropic
medications and more side effects for the patient.
However, he cautioned, practitioners can't judge how quickly a patient will
metabolize the medications based solely on the color of their skin or the
country in which they were born.
A number of studies from the 1970s through the 1990s show that Asians
receive lower doses of benzodiazepines, mood stabilizers, and antipsychotic
medications than do white Americans, Chou said.
For instance, Teruo Okuma, M.D., and other researchers found that
therapeutic dosages of chlorpromazine and lithium were different in Japan from
those in Western countries in the early 1980s, with Japanese patients
receiving lower dosages.
Ching-Piao Chien, M.D., reported in 1993 that Asian and Hispanic immigrants
who had been in the United States less than five years received lower dosages
of medication than those who had been in the country longer than five
Chou reviewed several studies investigating Asian patients' responses to a
number of psychotropic medications but warned that in the majority of the
studies small sample sizes mitigated the impact of any conclusions.
For instance, Keh-Ming Lin, M.D., M.P.H., and colleagues found in 1989 that
when they administered fixed doses of haloperidol to 13 Caucasian and 16 Asian
patients with schizophrenia, the Asian patients had a 10 percent to 15 percent
higher mean serum haloperidol concentration and higher rating for
extrapyramidal symptoms than did white patients.
When a larger group of Taiwanese patients and Caucasian patients were
administered fixed doses of clozapine, researchers found that serum levels of
the drug were 30 percent to 50 percent higher in the Asian patients, Chou
Metabolism varies from drug to drug, he added. "Asians have reduced
metabolism of haloperidol, risperidone, and clozapine, but not of
olanzapine," Chou said.
In a small, unpublished study of olanzapine, Chou cited, Asians and
Caucasians metabolize the drug at similar rates.
Chou concluded that the literature on psychopharmacology for Asians is"
weak," and although there is evidence that Asian patients do
metabolize some medications more slowly than Caucasian patients, he advised
psychiatrists to "dose based on the response of the individual
Medications are only part of the treatment for Asians with mental illness,
of course. Psychotherapy may be an important part of the recovery process for
many Asian patients, and psychiatrists and mental health professionals should
be mindful of certain elements of Asian culture when conducting psychotherapy,
according to Ramaswamy Viswanathan, M.D., an associate professor of psychiatry
at the State University of New York, Downstate Medical Center.
Viswanathan emphasized that clinicians should also be attentive to
individual and subcultural differences when working with Asian patients.
While American society tends to stress the value of freedom and
individuality, Asian society "stresses conformity and obedience to
authority," he said.
The value of privacy is critical in American society, but in Asian
communities, "your family knows everything about you, and even your
neighbors know a lot about you," he said.
In Western societies, it may be acceptable to express negative emotions,
but this is not so in Asian culture. Talking about negative emotions "is
a disgrace to the patient and family" he noted. "Somatization of
illnesses such as depression is much more acceptable."
Viswanathan also noted that "an Asian patient's first mental health
visit is likely to be initiated by a family member, and the majority of Asian
patients are accompanied by one or more family members."
When this happens in his practice, Viswanathan said he gently suggests to
the family members that he needs to be alone with the patient "to give
the patient a chance to express things they don't want to express in front of
the family," he said.
He also noted that Asian patients are receptive to problem-focused
cognitive-behavioral interventions "because the principles are similar
to Eastern philosophy, and relaxation is similar to meditation."
He added that "interpersonal therapy, which emphasizes roles and
social relations, may also resonate with Asian traditions." ▪