A review of the way that psychiatric medications may effect people depending on their ethnic backgrounds.
Q&A on Ethnic Psychopharmacology
Prepared by Center for Public Representation
Q. When asked by clients of color about their legal rights regarding psychiatric medication, are there any special issues or concerns of which I should make them aware?
A. Yes. There is a growing body of research that suggests that people respond differentlyto psychotropic medication based on their ethnic background. This area of study is called EthnicPsychopharmacology. African Americans, Asians, Hispanics, and Caucasians have differentresponses to the same dosages of commonly prescribed psychotropic medication. Furthermore,recent immigrants from Asia, Africa, and from Latin American countries have different responsesto such than do persons of the same racial background who have lived in this country for manyyears (Mendoza et al 1991, Mendoza and Smith 2000). Researchers have found that bothbiological and environmental differences among ethnicities play major roles in an individual'sresponse to psychotropic medications. Despite the amount of research, its clear conclusions, andits important implications, many clinicians, advocates and clients remain uninformed.
(See footnote 1)
P&Aadvocates should be prepared to alert their minority clients to these issues and to advocate for theplanning, design, and implementation of culturally responsive and ethnic specific treatmentmodalities in every element of the service system.
Research dating back as far as the 1920s documents findings of differences in responses to medications based on ethnicity. The initial research was done with cocaine, ephedrine, atropineand scopolamine (Hu et al 1991). Since then, a large body of biological data has supported theearly findings. Although the bulk of this research has traced differences in the effects ofmedications between and among African American, Asians, and Caucasians, research regardingother ethnic groups, primarily Native Americans and Hispanics, is growing (Mendoza et al 1991).
Multiple studies have concluded that African Americans are more likely than other ethnicgroups to be misdiagnosed and over medicated (Lawson 2000, Adebimpe, Caminah-Bacote 2002,Baker et al 1999, Lin et al 1995). Because African Americans are repeatedly misdiagnosed withschizophrenia, depressive disorders are often not diagnosed (Lawson 2000). Consequently,African Americans receive more antipsychotic medication, are more likely than Caucasians todevelop tardive dyskinesia, and may have an increased likelihood of incidents of neuroleptictoxicity (Lawson 2000). Likewise, African Americans have more side effects than Caucasianswith treated with the standard dosage of lithium (Caminah-Bacote 2002, Lin, Poland 1996,Lawson 2000). However, research has not yet conclusively established the advisability of usinglower doses of psychotropics across the board with African American clients.
As used in the relevant research, the term “Hispanic” refers to Mexicans, CentralAmericans, Cubans, Puerto Ricans, South Americans, and individuals of Spanish descent living inthe United States. While some research has found similarities in responses to psychiatric treatmentfor Hispanics as a whole, there are also differences within the subgroups. Hispanics tend torespond better to lower doses of Risperidone, for example, and they have a higher rate of adverseside effects (Lawson 2000).
(See footnote 2)
Doctors in Latin America typically prescribe lower doses of psychiatric medications than their counterparts in the United States. Interestingly, the rate ofimprovement is faster in Latin American countries (Campinah-Bacote 2002, Adams 1984,Mendoza 1991). For example, in Argentina and Chile, patients are typically treated withClozapine at 300 mg/day which is less than the amount typically used in the United States tosuccessfully treat Caucasians (Mendoza and Smith 2000).
The term “Asian” refers to Chinese, Filipino, Indian, Korean, Vietnamese, Japanese and
other groups of people from the continent of Asia. Many of the ethnic psychopharmacologystudies have concluded that Asian patients require lower doses of antipsychotic medications thanCaucasian patients (Campinah-Bacote 2002, Lin et al 1999, Lin et al 1995 Pi 2000). Research inthis area has had an impact on recommended dosage levels for Asians. Researchers havesuggested that dosage level start at half of the standard dosage for all psychiatric medication(Campinah-Bacote 2002, Lin et al 1999, Lin et al 1995, Pi 2000). There is also some data tosuggest that Asians may be at an increased risk of developing acute dystonic reactions fromantipsychotics ( Pi 2000).
There are yet very few conclusions about the long term effects of medication based onethnicity. For example, the relationship is between ethnicity and neuroleptic malignant syndromeis unknown (Pi 2000). As noted earlier, African Americans have a higher rate of tardivedyskinesia (Lawson 2000). Although the reasons are unknown, it may be due to a biologicalfactor or because higher numbers of African Americans are given antipsychotic medications.
Overall, this research provides significant information that P&A clients need to knowwhen making decisions about psychiatric medication. In most circumstances, individuals have aright to determine the nature and extent of their medical care. The legal doctrine of informed consent requires doctors to explain the treatment options to their patients and to obtain consentprior to administering treatment. The doctrine is usually described as having three parts: (1) the doctor's duty to disclose in a reasonable manner all significant medical information that thephysician possesses or reasonably should possess that is material to an intelligent decision by thepatient (information): (2) the ability of the individual to understand the information provided(competence or capacity); and, (3) that the consent is given free of coercion (voluntariness).
(See footnote 3)
Using this standard, an argument can be made that a reasonable person would consider, ofrexample, knowledge of an increased risk of adverse side effects significant in making his or herdecision to consent to treatment. Therefore, it can be argued that the doctor has a duty to discloseinformation about the potential differing impact of psychiatric medications to a person of color.
As advocates, is it also important for us to let our clients know about the existence of thisinformation and to urge them to discuss it with their doctors. The Center for PublicRepresentation has developed a training module which it has presented, often with the assistanceof a clinician, to professional, family and client groups. P&A staff may contact Regina Hill inCPR's Newton, Massachusetts office for more information (617-965-0776).
A bibliography of articles on Ethnic Psychopharmacology follows a chart listing importantresearch findings by ethnic background.
Research Findings Chart
(Numbers are references to the articles listed below the chart)
A higher rate of misdiagnosisand over-medication (2,3,6,7,16,18,38)
Better results have been foundwith lower doses of clozaril (7,18,33)
Tend to respond better tolower doses of Risperidone (1, 7, 28)
Have more side effects withthe standard doses of lithium (2,3,7,8,16,18,31,39)
For many Taiwanese the
therapeutic level of lithium islower than the standard range (7,33,39,38)
In Latin America, lower dosesof medications are often used,than in the United States andthe rate of improvement isfaster (1,7,28)
Higher risks of side effectsfrom TricyclicAntidepressants such as Elaviland Vivactil (3,7)
It is best to start at half of thestandard dosage of allpsychiatric medication (5,7,18,19,20,21,33)
Tricyclic antidepressant sideeffects like dry mouth,impaired vision, and weightgain, are seen at half the dosesgiven to European Americans (1,7,28)
Tend to have a better andmore rapid response withtricyclic antidepressants whengiven the proper dosage. (2,3,16)
Tend to use alternativetreatment methods, such asherbal remedies, which mayeffect responses topsychotropic medication (19,23,33)
Are more likely to benonresponders to Fluoxetine(Prozac) (2,3,)
Tend to metabolize TricyclicAntidepressants more slowlythan Caucasians (18,19,33)
Tend to have significantlyfaster responses than otherracial groups from benzodiazepines such asAtivan and Halcion (2,3,18)
Higher rate of tardivedyskinesia (16,34,45)
More likely to receive depotmedication (16)
Zyprexa typically works betteras an anti-psychotic (3,10,12,26)
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Footnote: 1 For example, there is evidence that metabolic absorption rates and side effects vary inethnic minorities. This could contribute to “treatment resistance” by some individuals, raising thechance for forced treatment.
Footnote: 2 This study was of patients from Puerto Rico and the Dominican Republic.Footnote: 3 Informed consent laws vary from state to state and most jurisdictions have exceptions forpeople with mental disabilities in certain circumstances. A full description of the law of informedconsent and the right to refuse treatment is beyond the scope of this Q&A. However, pertinentmaterials are available on the NAPAS web site. For a very recent discussion about therequirement for informed consent in the context of experimental medical therapies see Heinrich vSweet, ___F.3d ___ 2002 WL 1941483 (1st Cir 2002). A helpful discussion of informed consent,again in the medical context, can be found at Harnish v Children's Hospital Medical Center, 439N.E.2d 240 (Mass. Sup. Jud. Ct. 1982)