Treatment and response

Culture has an important influence on the type of service received. African-Caribbean and African-American patients receive antipsychotic medications in a higher prescribed dose, and more frequent use of injectable preparations is made in this group. (3 ^i3,5.4,5 5 and 57) Asian patients have been reported to receive lower doses.(58,59) Some ethnic minority groups may receive less information about side-effects,(60) which may result in less vigilance with regard to onset of side-effects such as tardive dyskinesia. In the United States and the United Kingdom, ethnic minority patients are less likely to receive psychological treatment. (6 62> In the United

States, African-American children have substantially lower rates of receiving methylphenidate. (6 64> Such differences may be related to differences in explanatory models of African-American parents, and differences in the rate with which African-American parents receive appropriate information about attention deficit-hyperactivity disorder from the doctor.(65)

There are several important considerations with regard to outcome in relation to cultural variables. (66> The first is that services offered may not be equally efficacious for different groups of people. For example, Chinese, Japanese, Filipino, Korean, and Southeast Asian Americans who were treated in the same setting in Los Angeles County showed different outcomes. Filipinos were under-represented in the system, whereas Southeast Asians were over-represented and had higher rates of service utilization. Despite this, Southeast Asians showed less improvement than the other groups, even after controlling for diagnosis and initial level of functioning.(67) The second is that treatment uptake may differ between groups.(33) In the United Kingdom and the United States, uptake of treatment with antipsychotic medication may be higher in white patients, though the overall influence of ethnicity remains small. (68) The third consideration is that the expectations about the desired endpoint of treatment may not be the same for different groups of people. For example, the expectations of British Asian and white people relating to the process and outcome of a psychological intervention were shown to be different in one study.(69) Outcome may improve if therapists receive information about their clients' cultural background and expectations before treatment. (70> Perhaps the most important consideration is that outcome is a multidimensional concept defying summary statements. For example, clinical outcome in terms of usual symptom severity and risk of self-harm may be better in African-Caribbean patients with psychosis as compared with white people, yet risk of imprisonment and compulsory admission may be greater,(71) as may be the frequency of relapse(72) and the rate of dissatisfaction with services.(73)

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