- Email: [email protected]
Cultural Psychiatry Considerations in Older Adults
EDITORIAL
Cultural Psychiatry Considerations in Older Adults Kenneth Sakauye, M.D.
C
ross-cultural psychiatry or transcultural psychiatry is “the comparative study of mental health and mental illness among different societies, nations, and cultures and the interrelationships of mental disorders with cultural environments . . . . In the past decade there has been greatly enhanced interest in the field and rapprochement of psychiatry with cultural anthropology, sociology, and behavioral science generally.”1 Among its many facets, it questions whether psychiatric classifications or disorders are the same across cultures or ethnic groups, cultural factors that pose unique risks or buffers against mental illness, and varied social constructs, values and norms that guide behaviors. For minority populations within other dominant cultural groups, it is often concerned with the impact of trauma, social exclusion, disparities in care and education, and prejudice on development and behavior. Older adults represent a subpopulation where cultural issues seem to be especially important. What has often been surprising for minority populations embedded in different cultures is the resilience they show in having marginally different, instead of higher rates, of major psychiatric diagnoses despite higher rates of exposure to psychosocial pressures known to increase risk for mental illness. It is worth mentioning that consensus documents have been developed to help professionals understand the common issues in dealing with patients from different cultures. For example, professional organizations such as the Amer-
ican Counseling Association,2 the American Psychological Association,3 the National Association of Social Workers,4 and the American Psychiatric Association5–7 have issued guidelines on Cultural Competence. In 2001, the Surgeon General’s Office issued a major report on mental health, race, and ethnicity.8 In 1994, the American Psychiatric Association developed an Outline for Cultural Formulation in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition9 (DSM-IV). The Association of American Medical Colleges now mandates medical schools to provide instruction on culturally competent assessment and treatment; and the Office of Minority Health, under the Substance Abuse and Mental Health Services Administration, developed standards for culturally and linguistically appropriate healthcare.10 This issue of the American Journal of Geriatric Psychiatry brings together six research articles showing some of the diversity in cultural psychiatry. In the first article, Boorsma et al.11 present data on incidence and risk factors of depression in Dutch nursing homes and residential care homes. Like the United States, about 10% of older adults older than 75 live in residential care homes and nursing homes. The InterRAI–Long-Term Care Facility instrument is applied every 3 months. This is an updated version of the Minimum Data Set. Incident depression was defined as the emergence of depression on followup either when there was an absence of a clinical diagnosis of depression or at first observation. The
Received August 9, 2012; revised August 17, 2012; accepted August 21, 2012. From the Department of Psychiatry, University of Tennessee Health Science Center, Memphis, TN. Send correspondence and reprint requests to Kenneth Sakauye, M.D., Department of Psychiatry, 920 Madison Ave, Suite 220, Memphis, TN 38163. e-mail: [email protected] C 2012 American Association for Geriatric Psychiatry DOI: 10.1097/JGP.0b013e3182702c18
Am J Geriatr Psychiatry 20:11, November 2012
911
Copyright © American Association for Geriatric Psychiatry. Unauthorized reproduction of this article is prohibited.
Cultural Psychiatry Considerations in Older Adults strength of the study was that data collection is a part of routine care independent of the resident’s cooperation or consent. The incidence and prevalence rates of depression were substantially higher than previously reported in prior studies and were unexpectedly higher in assisted living than in nursing homes. Other risk factors were related to being men, having cancer, and cognitive impairment. Advanced age and hearing impairment appeared protective. The value of extending data sets such as the Minimum Data Set to Assisted Living Facilities seemed clear and could lead to better understanding of potentially manageable risk factors for depression and quality of life in long-term care settings. In the second article, Luck et al.12 report on a longitudinal cohort in the German Study on Aging, Cognition, and Dementia in Primary Care Patients, involving 3,327 general practitioner patients in six study centers. Inclusion criteria were general practitioner patients 75 years and older without dementia in the general practitioner’s view within the prior 12 months. Patients were excluded from the analysis with a likely dementia in the initial visit. The Structured Interview for Diagnosis of Dementia of the Alzheimer type, Multi-infarct Dementia and Dementia of Other Aetiology according to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Text Revision (DSM-III-R), DSM-IV, International Classification of Diseases, Tenth Revision (ICD-10), MiniMental State Examination, instrumental activities of daily living (IADL), and the Geriatric Depression Scale were applied initially and every 1.5 years for 4.5 years. The predictive capability of Mild Cognitive Impairment (MCI) and IADL for incident dementia was calculated. IADL impairment coupled with MCI was predictive of a short time to high predictive power for future dementia. Currently, there is no recommendation by the U.S. Preventive Services Task Force for cognitive screening in older adults because of the low predictive value of screening tests in mild cases. This article provides evidence for the value of adding an IADL measure to a cognitive screening program for use in general practice to improve sensitivity. In the third article, Tappen et al.13 compare two cognitive screening instruments in a multiethnic sample of older adults. Both combine a brief cognitive instrument with a functional assessment questionnaire for IADL problems. The cognitive screening measures were the Mini-Cog, which is
912
arguably less biased by education or language skills, and the Mini-Mental State Examination. The results mirror the Luck study that IADL and a cognitive measure are more sensitive than a cognitive measure alone. In the fourth article, Nilsson et al.14 from Sweden have done an elegant study of how diagnostic criteria will affect the diagnosis of Generalized Anxiety Disorder (GAD) among nondemented older adults by comparing and explaining the main differences between the U.S. and European definitions of anxiety. Although both the DSM-IV and ICD-10 share the core symptoms of worries and anxiety about everyday events and problems, the ICD-10 considers autonomic arousal symptoms mandatory (e.g., tension, feeling dizzy, and somatic symptoms) but the DSM-IV does not (they are only associated features). The differences between the coming ICD-11 and DSM-V will be even greater. The 1-month prevalence of GAD using any of the diagnostic schemas hovered around 4%, with an overlap between the ICD-10 and DSM versions of about 87.5%. However, only the ICD-10 version showed a significant association with morbidity. There was an increased 3year mortality and smoking among the GAD group diagnosed with ICD-10 but not the DSM-IV/V. An additional finding was the strong comorbidity with depression, raising the question of whether GAD in the older adults should be included among the mood disorders. In the fifth article, Gitlin et al.15 examine older African American’s beliefs about depressive symptoms and preferred treatment approaches. It is known that older African Americans with mental health disorders do not receive professional help, but it has not been clear why. The speculative reasons have ranged from misinterpreting depressive symptoms as a medical symptom, beliefs that mental illness is a personal weakness, lack of access to care, to preferences against medications or psychotherapy. This study looked at a Philadelphia senior center membership willing to participate in up to a 2-hour face-to-face interview. Subjects were prescreened when they called by telephone before being asked to participate. The Patient Health Questionnaire (PHQ-9) was used to identify depressed mood. Almost half of the sample thought depression was a normal part of aging. However, when presented with examples, the sample recognized depression and endorsed both medications
Am J Geriatr Psychiatry 20:11, November 2012
Copyright © American Association for Geriatric Psychiatry. Unauthorized reproduction of this article is prohibited.
Sakauye and active symptom management in the form of behavioral activation (a form of cognitive behavior therapy) and willingness to see a doctor. This differed from expected findings. A large number of people also endorsed faith-based strategies (read the Bible, pray, ask others to pray for them), but not to the exclusion of professional treatment. No one in the sample showed severe depression, and the authors note that there is a difference between beliefs and intentions and behavior that could only be addressed with a clinical sample. The final article by Fuentes16 provides a cogent review of the last 20 years of literature on depression interventions among racial and ethnic minority adults. The author makes a point that evidence-based practices have not been validated for minority populations. In an extensive search of five electronic databases for peer-reviewed articles, only 80 reported depression treatment outcomes for minorities or had sizable minority populations. Of these, only 19 included older adults. An additional four articles were identified outside of electronic data searches. Of these 23 articles, 16 were excluded because they were case studies or did not report outcomes specifically for older minorities. Out of 82,000 initial hits that focused on depression outcomes over the past 20 years, only 7 articles were ultimately used in this review. All included an array of components or treatment approaches (mutisystematic), but collectively involved 882 African American, 673 Latino, and 112 Asian American older adults. It was an interesting observation that most studies did not explicitly mention the cultural adaptations made for diagnosis or procedures, except for language adaptation. The cautious conclusion was a favorable depression treatment effect in all studies. The review concludes with an extensive discussion of the limitations of current research. Similar to the Office of Minority Health recommendations,7 there is a need for instruments that define culturally specific symptom presentation and cultural-bound syndromes and procedures that define how cultural adaptations can be mapped into the dimensions of culturally sensitive treatment.
DISCUSSION It is clear that operationalizing cultural elements is needed for future research in minority populations. One major value of international studies for the United States is that they allow for a control group where the main differences for a given ethnic group living in two countries may be the altered cultural variables. What are cultural variables? The Harvard Encyclopedia of American Ethnic Groups17 defined some of the areas that need to be included in studies of minority groups. Although first published in 1980, it remains relevant. It includes a series of thematic essays that illuminate the key facets of ethnicity, and each group entry has been described that relates ethnicity to education, religion, literature, Americanization, immigration policy and experience, social and dietary patterns that maintain cultural identity, as well as effects of prejudice and discrimination. From an earlier National Institute of Mental Health epidemiologic catchment area study, new immigrants showed the highest rates of mental illness compared with immigrants who had been in the country longer than 20 years. Surprisingly, the long-term immigrants showed even lower rates of psychopathology than American born, although these were mainly European immigrants.18 For minorities in the United States, distance from immigration (generational level), language differences, and degree of assimilation may be markers for when cultural influences would be most profound and who the primary reference group is. One cannot discount traumatic experiences (e.g., hate crimes and prejudice) and lack of opportunities on adult development, self-perception, risk-taking, and initiative. All of these potential risk factors for mental illness in minority populations have not been empirically verified nor easily measured. The studies in this issue present a picture of the evolution of the field. The authors declare no conflicts of interest.
References 1. American Psychiatric Association Council of Minority Health and Health Disparities: Position Statement (draft document), 2012
Am J Geriatr Psychiatry 20:11, November 2012
2. American Counseling Association: Cross-Cultural Competencies and Objectives. 1992. Available at: http://www.counseling.org/
913
Copyright © American Association for Geriatric Psychiatry. Unauthorized reproduction of this article is prohibited.
Cultural Psychiatry Considerations in Older Adults
3.
4.
5.
6.
7.
8.
9.
10.
Resources/Competencies/Cross-Cultural Competencies and Objectives.pdf. Accessed September 10, 2012. American Psychological Association: Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. Am Psychol 2003; 58:377–402 National Association of Social Workers: Standards for Cultural Competence in Social Work Practice. 2001. Available at: http://www.socialworkers.org/practice/standards/ NASWCulturalStandards.pdf. Accessed September 10, 2012. American Psychiatric Association: Practice Guidelines for the Psychiatric Evaluation of Adults. Washington, DC, American Psychiatric Publishing, 1995 American Psychiatric Association and American Association for Geriatric Psychiatry: Curriculum Resource Guide for Cultural Competence: A Joint Project from the APA Council on Aging Committee on Minority Elderly and the American Association for Geriatric Psychiatry. Washington, DC, American Psychiatric Association, 1997 American Psychiatric Association Ethnic Minority Elderly Committee: Ethnic Minority Elderly Curriculum. Washington, DC, American Psychiatric Association Ethnic Minority Elderly Committee, 2006 U.S. Department of Health and Human Services: Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD, DHHS, 2001 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994 U.S. Department of Health and Human Services Office of Minority Health: National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report. Washington, DC,
914
11.
12.
13.
14.
15.
16.
17.
18.
DHHS, 2001. Available at: http://minorityhealth.hhs.gov/assets/ pdf/checked/finalreport.pdf. Accessed September 10, 2012. Boorsma M, Joling K, Dussel M, et al: The incidence of depression and its risk factors in Dutch nursing homes and residential care homes. Am J Geriatr Psychiatry 2012; 20:932–942 Luck T, Luppa M, Wiese B, et al: Prediction of incident dementia: impact of impairment in instrumental activities of daily living and mild cognitive impairment – results from the German study on ageing, cognition, and dementia in primary care patients. Am J Geriatr Psychiatry 2012; 20:943–954 Tappen RM, Rosselli M, Engstrom G: Use of the MC-FAQ and MMSE-FAQ in cognitive screening of older African Americans, Hispanic Americans and European Americans. Am J Geriatr Psychiatry 2012; 20:955–962 Nilsson J, Osling S, Waern M, et al: The 1-month prevalence of generalized anxiety disorder according to DSM-IV, DSM-V, and ICD-10 among nondemented 75-year olds in Gothenburg, Sweden. Am J Geriatr Psychiatry 2012; 20:963–972 Gitlin LN, Chernett NL, Dennis MP, et al: Identification of and beliefs about depressive symptoms and preferred treatment approaches among community-living older African Americans. Am J Geriatr Psychiatry 2012; 20:973–985 Fuentes D, Aranda M: Depression interventions among racial and ethnic minority older adults: a systematic review across 20 years. Am J Geriatr Psychiatry 2012; 20:915–931 Thernstrom S, Orlov A, Handlin Oeds. Harvard Encyclopedia of American Ethnic Groups. Cambridge, MA, Belnap Press of Harvard University, 1980 Srole L, Langner TS, Michael ST: The Midtown Manhattan Study: Mental Health in the Metropolis. New York, New York University Press, 1978
Am J Geriatr Psychiatry 20:11, November 2012
Copyright © American Association for Geriatric Psychiatry. Unauthorized reproduction of this article is prohibited.
Cultural Psychiatry Considerations in Older Adults Kenneth Sakauye, M.D.
C
ross-cultural psychiatry or transcultural psychiatry is “the comparative study of mental health and mental illness among different societies, nations, and cultures and the interrelationships of mental disorders with cultural environments . . . . In the past decade there has been greatly enhanced interest in the field and rapprochement of psychiatry with cultural anthropology, sociology, and behavioral science generally.”1 Among its many facets, it questions whether psychiatric classifications or disorders are the same across cultures or ethnic groups, cultural factors that pose unique risks or buffers against mental illness, and varied social constructs, values and norms that guide behaviors. For minority populations within other dominant cultural groups, it is often concerned with the impact of trauma, social exclusion, disparities in care and education, and prejudice on development and behavior. Older adults represent a subpopulation where cultural issues seem to be especially important. What has often been surprising for minority populations embedded in different cultures is the resilience they show in having marginally different, instead of higher rates, of major psychiatric diagnoses despite higher rates of exposure to psychosocial pressures known to increase risk for mental illness. It is worth mentioning that consensus documents have been developed to help professionals understand the common issues in dealing with patients from different cultures. For example, professional organizations such as the Amer-
ican Counseling Association,2 the American Psychological Association,3 the National Association of Social Workers,4 and the American Psychiatric Association5–7 have issued guidelines on Cultural Competence. In 2001, the Surgeon General’s Office issued a major report on mental health, race, and ethnicity.8 In 1994, the American Psychiatric Association developed an Outline for Cultural Formulation in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition9 (DSM-IV). The Association of American Medical Colleges now mandates medical schools to provide instruction on culturally competent assessment and treatment; and the Office of Minority Health, under the Substance Abuse and Mental Health Services Administration, developed standards for culturally and linguistically appropriate healthcare.10 This issue of the American Journal of Geriatric Psychiatry brings together six research articles showing some of the diversity in cultural psychiatry. In the first article, Boorsma et al.11 present data on incidence and risk factors of depression in Dutch nursing homes and residential care homes. Like the United States, about 10% of older adults older than 75 live in residential care homes and nursing homes. The InterRAI–Long-Term Care Facility instrument is applied every 3 months. This is an updated version of the Minimum Data Set. Incident depression was defined as the emergence of depression on followup either when there was an absence of a clinical diagnosis of depression or at first observation. The
Received August 9, 2012; revised August 17, 2012; accepted August 21, 2012. From the Department of Psychiatry, University of Tennessee Health Science Center, Memphis, TN. Send correspondence and reprint requests to Kenneth Sakauye, M.D., Department of Psychiatry, 920 Madison Ave, Suite 220, Memphis, TN 38163. e-mail: [email protected] C 2012 American Association for Geriatric Psychiatry DOI: 10.1097/JGP.0b013e3182702c18
Am J Geriatr Psychiatry 20:11, November 2012
911
Copyright © American Association for Geriatric Psychiatry. Unauthorized reproduction of this article is prohibited.
Cultural Psychiatry Considerations in Older Adults strength of the study was that data collection is a part of routine care independent of the resident’s cooperation or consent. The incidence and prevalence rates of depression were substantially higher than previously reported in prior studies and were unexpectedly higher in assisted living than in nursing homes. Other risk factors were related to being men, having cancer, and cognitive impairment. Advanced age and hearing impairment appeared protective. The value of extending data sets such as the Minimum Data Set to Assisted Living Facilities seemed clear and could lead to better understanding of potentially manageable risk factors for depression and quality of life in long-term care settings. In the second article, Luck et al.12 report on a longitudinal cohort in the German Study on Aging, Cognition, and Dementia in Primary Care Patients, involving 3,327 general practitioner patients in six study centers. Inclusion criteria were general practitioner patients 75 years and older without dementia in the general practitioner’s view within the prior 12 months. Patients were excluded from the analysis with a likely dementia in the initial visit. The Structured Interview for Diagnosis of Dementia of the Alzheimer type, Multi-infarct Dementia and Dementia of Other Aetiology according to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Text Revision (DSM-III-R), DSM-IV, International Classification of Diseases, Tenth Revision (ICD-10), MiniMental State Examination, instrumental activities of daily living (IADL), and the Geriatric Depression Scale were applied initially and every 1.5 years for 4.5 years. The predictive capability of Mild Cognitive Impairment (MCI) and IADL for incident dementia was calculated. IADL impairment coupled with MCI was predictive of a short time to high predictive power for future dementia. Currently, there is no recommendation by the U.S. Preventive Services Task Force for cognitive screening in older adults because of the low predictive value of screening tests in mild cases. This article provides evidence for the value of adding an IADL measure to a cognitive screening program for use in general practice to improve sensitivity. In the third article, Tappen et al.13 compare two cognitive screening instruments in a multiethnic sample of older adults. Both combine a brief cognitive instrument with a functional assessment questionnaire for IADL problems. The cognitive screening measures were the Mini-Cog, which is
912
arguably less biased by education or language skills, and the Mini-Mental State Examination. The results mirror the Luck study that IADL and a cognitive measure are more sensitive than a cognitive measure alone. In the fourth article, Nilsson et al.14 from Sweden have done an elegant study of how diagnostic criteria will affect the diagnosis of Generalized Anxiety Disorder (GAD) among nondemented older adults by comparing and explaining the main differences between the U.S. and European definitions of anxiety. Although both the DSM-IV and ICD-10 share the core symptoms of worries and anxiety about everyday events and problems, the ICD-10 considers autonomic arousal symptoms mandatory (e.g., tension, feeling dizzy, and somatic symptoms) but the DSM-IV does not (they are only associated features). The differences between the coming ICD-11 and DSM-V will be even greater. The 1-month prevalence of GAD using any of the diagnostic schemas hovered around 4%, with an overlap between the ICD-10 and DSM versions of about 87.5%. However, only the ICD-10 version showed a significant association with morbidity. There was an increased 3year mortality and smoking among the GAD group diagnosed with ICD-10 but not the DSM-IV/V. An additional finding was the strong comorbidity with depression, raising the question of whether GAD in the older adults should be included among the mood disorders. In the fifth article, Gitlin et al.15 examine older African American’s beliefs about depressive symptoms and preferred treatment approaches. It is known that older African Americans with mental health disorders do not receive professional help, but it has not been clear why. The speculative reasons have ranged from misinterpreting depressive symptoms as a medical symptom, beliefs that mental illness is a personal weakness, lack of access to care, to preferences against medications or psychotherapy. This study looked at a Philadelphia senior center membership willing to participate in up to a 2-hour face-to-face interview. Subjects were prescreened when they called by telephone before being asked to participate. The Patient Health Questionnaire (PHQ-9) was used to identify depressed mood. Almost half of the sample thought depression was a normal part of aging. However, when presented with examples, the sample recognized depression and endorsed both medications
Am J Geriatr Psychiatry 20:11, November 2012
Copyright © American Association for Geriatric Psychiatry. Unauthorized reproduction of this article is prohibited.
Sakauye and active symptom management in the form of behavioral activation (a form of cognitive behavior therapy) and willingness to see a doctor. This differed from expected findings. A large number of people also endorsed faith-based strategies (read the Bible, pray, ask others to pray for them), but not to the exclusion of professional treatment. No one in the sample showed severe depression, and the authors note that there is a difference between beliefs and intentions and behavior that could only be addressed with a clinical sample. The final article by Fuentes16 provides a cogent review of the last 20 years of literature on depression interventions among racial and ethnic minority adults. The author makes a point that evidence-based practices have not been validated for minority populations. In an extensive search of five electronic databases for peer-reviewed articles, only 80 reported depression treatment outcomes for minorities or had sizable minority populations. Of these, only 19 included older adults. An additional four articles were identified outside of electronic data searches. Of these 23 articles, 16 were excluded because they were case studies or did not report outcomes specifically for older minorities. Out of 82,000 initial hits that focused on depression outcomes over the past 20 years, only 7 articles were ultimately used in this review. All included an array of components or treatment approaches (mutisystematic), but collectively involved 882 African American, 673 Latino, and 112 Asian American older adults. It was an interesting observation that most studies did not explicitly mention the cultural adaptations made for diagnosis or procedures, except for language adaptation. The cautious conclusion was a favorable depression treatment effect in all studies. The review concludes with an extensive discussion of the limitations of current research. Similar to the Office of Minority Health recommendations,7 there is a need for instruments that define culturally specific symptom presentation and cultural-bound syndromes and procedures that define how cultural adaptations can be mapped into the dimensions of culturally sensitive treatment.
DISCUSSION It is clear that operationalizing cultural elements is needed for future research in minority populations. One major value of international studies for the United States is that they allow for a control group where the main differences for a given ethnic group living in two countries may be the altered cultural variables. What are cultural variables? The Harvard Encyclopedia of American Ethnic Groups17 defined some of the areas that need to be included in studies of minority groups. Although first published in 1980, it remains relevant. It includes a series of thematic essays that illuminate the key facets of ethnicity, and each group entry has been described that relates ethnicity to education, religion, literature, Americanization, immigration policy and experience, social and dietary patterns that maintain cultural identity, as well as effects of prejudice and discrimination. From an earlier National Institute of Mental Health epidemiologic catchment area study, new immigrants showed the highest rates of mental illness compared with immigrants who had been in the country longer than 20 years. Surprisingly, the long-term immigrants showed even lower rates of psychopathology than American born, although these were mainly European immigrants.18 For minorities in the United States, distance from immigration (generational level), language differences, and degree of assimilation may be markers for when cultural influences would be most profound and who the primary reference group is. One cannot discount traumatic experiences (e.g., hate crimes and prejudice) and lack of opportunities on adult development, self-perception, risk-taking, and initiative. All of these potential risk factors for mental illness in minority populations have not been empirically verified nor easily measured. The studies in this issue present a picture of the evolution of the field. The authors declare no conflicts of interest.
References 1. American Psychiatric Association Council of Minority Health and Health Disparities: Position Statement (draft document), 2012
Am J Geriatr Psychiatry 20:11, November 2012
2. American Counseling Association: Cross-Cultural Competencies and Objectives. 1992. Available at: http://www.counseling.org/
913
Copyright © American Association for Geriatric Psychiatry. Unauthorized reproduction of this article is prohibited.
Cultural Psychiatry Considerations in Older Adults
3.
4.
5.
6.
7.
8.
9.
10.
Resources/Competencies/Cross-Cultural Competencies and Objectives.pdf. Accessed September 10, 2012. American Psychological Association: Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. Am Psychol 2003; 58:377–402 National Association of Social Workers: Standards for Cultural Competence in Social Work Practice. 2001. Available at: http://www.socialworkers.org/practice/standards/ NASWCulturalStandards.pdf. Accessed September 10, 2012. American Psychiatric Association: Practice Guidelines for the Psychiatric Evaluation of Adults. Washington, DC, American Psychiatric Publishing, 1995 American Psychiatric Association and American Association for Geriatric Psychiatry: Curriculum Resource Guide for Cultural Competence: A Joint Project from the APA Council on Aging Committee on Minority Elderly and the American Association for Geriatric Psychiatry. Washington, DC, American Psychiatric Association, 1997 American Psychiatric Association Ethnic Minority Elderly Committee: Ethnic Minority Elderly Curriculum. Washington, DC, American Psychiatric Association Ethnic Minority Elderly Committee, 2006 U.S. Department of Health and Human Services: Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD, DHHS, 2001 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994 U.S. Department of Health and Human Services Office of Minority Health: National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report. Washington, DC,
914
11.
12.
13.
14.
15.
16.
17.
18.
DHHS, 2001. Available at: http://minorityhealth.hhs.gov/assets/ pdf/checked/finalreport.pdf. Accessed September 10, 2012. Boorsma M, Joling K, Dussel M, et al: The incidence of depression and its risk factors in Dutch nursing homes and residential care homes. Am J Geriatr Psychiatry 2012; 20:932–942 Luck T, Luppa M, Wiese B, et al: Prediction of incident dementia: impact of impairment in instrumental activities of daily living and mild cognitive impairment – results from the German study on ageing, cognition, and dementia in primary care patients. Am J Geriatr Psychiatry 2012; 20:943–954 Tappen RM, Rosselli M, Engstrom G: Use of the MC-FAQ and MMSE-FAQ in cognitive screening of older African Americans, Hispanic Americans and European Americans. Am J Geriatr Psychiatry 2012; 20:955–962 Nilsson J, Osling S, Waern M, et al: The 1-month prevalence of generalized anxiety disorder according to DSM-IV, DSM-V, and ICD-10 among nondemented 75-year olds in Gothenburg, Sweden. Am J Geriatr Psychiatry 2012; 20:963–972 Gitlin LN, Chernett NL, Dennis MP, et al: Identification of and beliefs about depressive symptoms and preferred treatment approaches among community-living older African Americans. Am J Geriatr Psychiatry 2012; 20:973–985 Fuentes D, Aranda M: Depression interventions among racial and ethnic minority older adults: a systematic review across 20 years. Am J Geriatr Psychiatry 2012; 20:915–931 Thernstrom S, Orlov A, Handlin Oeds. Harvard Encyclopedia of American Ethnic Groups. Cambridge, MA, Belnap Press of Harvard University, 1980 Srole L, Langner TS, Michael ST: The Midtown Manhattan Study: Mental Health in the Metropolis. New York, New York University Press, 1978
Am J Geriatr Psychiatry 20:11, November 2012
Copyright © American Association for Geriatric Psychiatry. Unauthorized reproduction of this article is prohibited.