Eastern vs Western Perspectives on Depression: An Expert Interview With James C.-Y. Chou, MD

March 30, 2005

Editor's Note:
How do specific differences in Eastern and Western cultures lead to different perspectives on depression? And what are the practical clinical ramifications of these differences for the diagnosis and treatment of depression in Asians? On behalf of Medscape, Randall F. White, MD, interviewed James C.-Y. Chou, MD, Associate Professor of Psychiatry, New York University School of Medicine and Staff Psychiatrist, Bellevue Hospital Center, New York, NY.

Medscape: Does the concept of psychological depression have the same validity in Eastern cultures?

James C.-Y. Chou, MD: No, the concept of psychological depression in Eastern cultures is not as well accepted as it is in Western cultures. In fact, the whole idea of illness in Eastern cultures is based on physical illness. In the last 15 or 20 years, there has been an improvement as Asian people are thinking more about psychological illness, but by and large, either you have physical illness or you're not sick. So the idea of psychological illness is not culturally well-accepted. This leads to the frequent presentation of depression as somatic complaints, because it's much easier for patients to have a physical complaint than to have a psychological complaint; if they have a psychological illness, then they are perceived as being a persistently mentally ill patient as you would see in a state hospital. So the 2 things I think about are somatization and stigma.

If you have a mental illness, it's stigmatized, and it means you're seriously ill and you have bad genes, and genetically, your family carries mental illness and no one will want to marry your sister. That's bad for everybody in the family.

Medscape: Can you discuss the Asian concept of neurasthenia, and how a physician would recognize it?

Dr. Chou: Neurasthenia is not a diagnosis that's been accepted in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised (DSM-IV-R), although there are efforts to try to reintroduce it into the next edition. Neurasthenia includes symptoms from mood disorder, generally a chronic, mild depression that would be consistent with dysthymia, and, in addition, a lot of somatic complaints that would be consistent with somatoform disorder in the Western, DSM-IV-R framework. Typically, the somatic complaints include headache, backache, menstrual problems, and general fatigue. It's more common in women, and, in fact, in some epidemiologic studies, it's the most common mental disorder diagnosed in some Asian countries.

Medscape: Is anxiety a significant component of neurasthenia?

Dr. Chou: Yes, it is also a feature, along with chronic depression and somatic complaints. But what the patients don't have is severe depression or psychotic features. And, of course, as a chronic disorder, neurasthenia interacts with the person's personality.

Medscape: What about suicide? Is it viewed differently in Eastern cultures?

Dr. Chou: I think that the Eastern cultures tend to avoid talking or thinking about suicide, and if anyone has had a family member who committed suicide, I think that the most likely thing would be just not to talk about it. Now, there are epidemiologic studies showing that certain groups in Asia are at high risk of suicide; for example, elderly women may have high rates, and Hong Kong has had high suicide rates following economic and political shifts.

I think that suicide is seen as a failure of the whole family system, and the tendency is to ignore it and pretend it never happened. That would be the Chinese denial of the problem.

Medscape: Do we have good data on the suicide rate among Asian immigrants in North America?

Dr. Chou: We have some data. Rural Chinese females residing in China have a 50% higher suicide rate for women aged 20-24 years compared with their counterpart in the United States. Suicide rates in Asians in San Francisco were higher for both males and females than the national average, and also in San Francisco, foreign-born Asians who were over 55 years old had higher rates than the general US population, especially if they were unmarried, unemployed, or retired.[1]

Medscape: Is there anything else clinicians should consider in evaluating this population?

Dr. Chou: When you talk about Chinese patients' views of mental illness, there are basically 7 principal factors that they would think about, even if they are very westernized (and these are pan-Asian concepts). There are organic influences and brain disorders, and there's this notion that excessive sexual activity also leads to organic disorders. Others include supernatural intervention; weak heredity; external stress; metaphysical factors, such as the balance of yin and yang; fatalism, which is just the idea that this is your destiny, there's nothing you can do about it--you're destined to be ill; and character weakness, which is sort of a correlate with neurasthenia.

So some of the questions you want to ask Asian patients are: "Do you feel like you're having some imbalance of yin and yang? Do you feel like your chi, your internal energy, is low?" I've had many patients I can evaluate just by asking a simple question like that -- that's the barometer of their overall feeling of well-being.

Fatalism is a very interesting concept that clinicians don't often ask the patient about: "Do you believe that it's your destiny to have this condition, or do you believe it's your destiny not to have this condition?"

Medscape: Would that correlate with hopelessness?

Dr. Chou: Yes, very much so, but it's a different way of asking it. If you normally ask the patient, "Do you feel hopeless or helpless?" and it's an Asian patient, and they have this concept that it's their destiny and there's nothing they can do to change it, that may lead to hopelessness. Or it may lead to relief -- "I can't be any better and therefore I'm not so upset about it."

Questions that may also be helpful are, "Do you feel that there's some sort of supernatural intervention going on? Are you being cursed, or is this something affecting you supernaturally?"

Medscape: How do you determine whether there's a delusion related to that?

Dr. Chou: It depends on the extent of what the person is talking about. The best way to assess whether a culturally based belief is delusional is to ask the family whether they think it's delusional, because if the family says, "Yes, we all believe this," then you know it's a culturally consistent concept. If the family says, "No, this person is nuts," then you know it's psychotic.

It's very important to realize the significance of the family in working with Asian patients. I think the focus of mental health treatment for Asian patients should be family-based. The traditional Asian family has been a very strong unit with multiple generations living under that same roof. The norm over centuries has been that your role in society and your role in the village are determined by who you are in the family, and people do not leave their home town very often.

For some patients, it's a major shock to be here where generally you don't have multiple generations living under the same roof. When kids become old enough to get a job, they're moving out, and often they're becoming Americanized, so you have language problems too. This often leaves the elderly parents abandoned, living in an insulated Asian community.

The particularly vulnerable family members are the elderly; the oldest son, who has a lot of pressure to achieve and carry on the family's good name; and then the youngest daughter, who is often the one that the parents want to keep at home so they can maintain their parenting identity.

Medscape: Let's move on to treatment of depression and neurasthenia. What would the traditional treatment be and how can that be adapted to North American clinical practice?

Dr. Chou: Well, the traditional approach would be to use traditional medicine. An herb might be given, or acupuncture, moxibustion -- burning herbs on or near the body and exposing the body to heat and smoke, massage, or cupping. These probably all help, as does the administration of any treatment to patients with neurasthenia. The Western approach would be to try to use antidepressants for patients like this, and many Asian clinicians do feel that low doses of antidepressants are extremely useful for patients with neurasthenia.

Trying to do psychotherapy with patients is a little bit less well accepted in Asian cultures, and from a cost-effectiveness viewpoint, psychotherapy is of course very expensive and time-consuming. So if you look at the approaches governments might have had to implementing treatment programs, psychotherapy is not high on the list because it's so labor intensive. That's probably a mistake, and the amount of labor needed for psychotherapy may not be any less than that for traditional treatment. Those traditional treatments take a long time too.

Medscape: If a physician in North America is treating an immigrant, what herbal remedies should he or she inquire about and what are the drug interactions of concern?

Dr. Chou: I think that in any Asian patient, especially a recent immigrant, the assumption should be made that they are taking traditional treatments, whether that's herbs or acupuncture -- whatever. Just assume that they're having other treatments, and they may be shy to talk about it. They may not view them as treatments either; they may view them as just sort of homeopathic things that they're doing and that their family has always done. So when I'm seeing an Asian patient in New York's Chinatown, and I'm recommending, for example, a medication -- an antipsychotic, an antidepressant, or anxiolytic -- the question I would ask would be, "What other medications are you taking, including all herbs and Eastern treatments?"

One thing to watch out for is drug interactions. For example, ginseng is a cytochrome P450 inducer, and it may reduce the blood levels of some psychotropic drugs. Other herbs have anticholinergic effects; some are sedating and some are stimulants. Furthermore, we've had situations in New York when the patient was taking an herbal medication that had actually been spiked with Western pharmaceutical agents. For example, the herbal medicine practitioner was giving something for sleep, and in the herb we actually found Valium (diazepam), which of course was helping with sleep. But the herbal practitioner was not regulated and not licensed, so they were just sort of lying to the patient.

I think the most important thing is not to insist that the patient stop the herbs, because a lot of the Asian patients have been using Eastern treatments for generations, and when you try to initiate the Western treatment, they are skeptical about whether the Western treatment is going to work or have a lot of side effects.

I used to tell patients, "Stop the herbs, which are going to have an interaction with the new medication." But patients would often then not take the new medication and stick with the herbs, so my general approach is that whatever they've been doing for many years, assume they're going to continue doing it, and try to fit in the Western treatment on top of the old treatment.

Medscape: How accepted is the use of Western medication among new immigrants?

Dr. Chou: I think it depends on how severely ill the patient is. Our patients in New York are often very accepting of a new medication because they're in a lot of distress. They want some relief and they know that the Western medication provides instant relief. There's a widespread belief that Eastern medicines are mild and have no side effects, and Western medicines are strong but have side effects. By the time they come in for treatment, they're pretty sick and the Eastern medicine may have failed to work, and they're ready to take the stronger medicine.

In fact, I would recommend that if a clinician is seeing an Asian patient for the first visit, the threshold for prescribing medication should be lower. If you see a general patient in a private office, you may not want to give medication on the first visit; you may want to spend more time fully evaluating the patient because you have confidence that the patient will come back for the second visit. With an Asian patient, you may want to give medication on the first visit to give the patient some acute relief, perhaps of insomnia, anxiety, or psychosis, and through that acute relief, encourage them to come for a second visit.

Medscape: Can you discuss the pharmacokinetic considerations in treating Asian patients?

Dr. Chou: There have been some studies showing that Asian patients do have higher blood levels of some drugs, specifically desipramine, alprazolam, risperidone, haloperidol, and clozapine, and the general thinking is that you want to start with lower doses of medication in Asians than you would in a white American population. But it's important to realize that the actual difference in blood level is only about 30%. So the difference that you see between races, if it's only 30%, is actually not that much. If you're adjusting doses of medication properly, the dose range among individuals within the same racial group should vary more than 30%.

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