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Depression after traumatic brain injury: A biopsychosocial cultural perspective
Asian Journal of Psychiatry 13 (2015) 56–61
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Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Depression after traumatic brain injury: A biopsychosocial cultural perspective Durga Roy a,*, Geetha Jayaram a, Alex Vassila a, Shari Keach b, Vani Rao a a b
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD USA Johns Hopkins Bayview Medical Center, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 July 2014 Received in revised form 6 October 2014 Accepted 13 October 2014
There are several challenges in diagnosing and treating mental illness amongst South Asians. Often times, formulating a patient’s case presentation cannot adequately be accomplished strictly using a biopsychosocial model. The cultural components play an imperative role in explaining certain psychiatric symptoms and can guide treatment. With the growing population of immigrants coming to the United States, many of which require treatment for mental illness, it is essential that clinicians be cognizant in incorporating cultural perspectives when treating such patients. The authors describe the case of a 24-year old South Asian male who suffered an exacerbation of a depressive syndrome after a traumatic brain injury. Using a biopsychosocial cultural approach, this case highlights how South Asian cultural values can contribute to and incite psychiatric symptoms while simultaneously providing protective drivers for treatment outcomes. ß 2014 Elsevier B.V. All rights reserved.
Keywords: Cultural perspectives Biopsychosocial model Depression Brain injury
1. Introduction Mental illness amongst South Asians in the United States (US) can be challenging to assess and treat due to several factors: the negative social attitudes towards mental illness, somatically focused symptom presentation, lack of empathy and understanding of mental illness among family members or care providers, and avoidance of mental health services by patients and family. Because of the negative stigma that is associated with mental illness, South Asians are less likely to disclose their emotional symptoms and thus have difficulty receiving treatment. Additionally, family members may underestimate the nature and/or severity of illness in their loved ones and discourage psychiatric treatment as a result. Non-South Asian clinicians may find it challenging to distinguish such cultural factors from biopsychosocial factors. In general it is important for clinicians to be aware how culture contributes to mental illness itself. Culture can be defined as attitudes, values and beliefs and behaviors shared by a people but also includes culture related experiences related to being an
* Corresponding author. Tel.: +1 410 550 9616; fax: +1 410 550 8191. E-mail address: [email protected] (D. Roy). http://dx.doi.org/10.1016/j.ajp.2014.10.001 1876-2018/ß 2014 Elsevier B.V. All rights reserved.
ethnic minority (Hwang et al., 2008). As outlined in a paper by Hwang et al. (2008), culture affects the ‘‘prevalence of mental illness, issues with diagnosis and assessment, etiology and course of disease, phenomenology and how distress can be expressed, certain coping styles and help seeking behaviors, as well as issues with treatment interventions’’ (Hwang et al., 2008). South Asian values can be considered allocentric, or grouporiented (Tavkar et al., 2008). Imbibed within this culture are beliefs that sacrifices should be made by individuals for the better good of the family (Tavkar et al., 2008; Segal, 1998). There can be considered a sense of collectivism within the South Asian cultural system in which there is a practice of giving priority to the group as a whole rather than to the individual. Often there are expectations of younger generations to excel in education and develop lucrative careers. If these expectations are not met, a sense of shame upon the family may develop. In a study conducted by Bhattacharya and Schoppelrey (2004), two entities in the Asian culture that steered parental expectations were the responsibility of children in enhancing family pride as well as education which would enable advancement through the social class and the caste systems (Bhattacharya and Schoppelrey, 2004). This may predispose South Asians to certain risk factors in the development of psychopathology. Often younger South Asians,
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particularly students, are placed under immense pressure to excel academically, and often develop mood disorders leading to suicidal thoughts and behaviors. When parental expectations are not met, one feels guilty and ashamed. The individual’s family often compounds the individual’s shame with their own sense of shame and anger. The failure of an individual subsequently represents a failure of the entire family. This can lead to cognitive representations which predispose to depressive symptoms (Wong et al., 2014). Parents may also exert control over their children which impacts the nature of both maternal and paternal bonding. A study conducted by Singh et al. (2012) revealed that Indian college students who experienced affectionless parental control and neglect had higher rates of hopelessness and suicidal ideation (Singh et al., 2012). Asian Indians may often explain psychological distress as a violation of some moral or religious principle or spirit possessions. Physical and mental deficits are thought to be God’s will or past karma. These factors may add to the delay in seeking professional help (Tavkar et al., 2008; Conrad and Pacquiao, 2005). While the above factors may influence the development of certain psychiatric disorders, one could argue that this collectivism and belief in moral and religious principles might also protect the South Asian patient from the sequelae of severe mental illness, namely suicide. All of the above points should be considered when discussing potential precipitants for symptom presentation within South Asians with mental illness. This warrants an accurate and comprehensive approach to psychiatric diagnoses and ultimately treatment. A biopsychosocial perspective may often be inadequate in accounting for all aspects of a patient’s illness. Cultural contributions are essential in comprehensively understanding such patients and can provide for more rigorous treatment approaches. The biopsychosocial model has been described as a scientific model created to include aspects absent in the biomedical model (Engel, 1980). As Engel describes in his paper, the biopsychosocially oriented physician should pay attention to not only biological factors but also psychosocial factors that are both protective and increase the risk for destabilizing a person’s emotional homeostasis (Engel, 1980). Excluding the cultural components from this model however, can leave out vital components of a patient’s psychiatric presentation, particularly when it comes to both diagnosis and treatment. Proponents of the cultural formulation model, as described by Lewis-Fernandez and Diaz (2002) stress the importance of assessing cultural values as they can play a significant role in an individual’s psychiatric symptomatology and can highlight help seeking preferences. These proponents also argue that this can be even more important when physicians and patients are from different cultural backgrounds as an understanding of patients’ cultural values can guide treatment (Lewis-Fernandez and Diaz, 2002; Mezzich et al., 2009). The authors of this article report the case of a young South Asian male living in the US who developed exacerbation of a major depression after a traumatic brain injury. His story illustrates aspects of cultural and social conflicts that need examination in order to comprehensively understand his symptomatology. His presentation reflects on how cultural factors can be both a hindrance in mental health treatment yet simultaneously protective to adverse events that would otherwise arise from severe mental illness. An example of this is suicide. As the numbers of immigrant populations requiring mental health services continue to rise, it is imperative for clinicians to incorporate a cultural mindset when formulating, diagnosing and treating these patients.
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2. Case presentation 2.1. Chief complaint Mr. P is a 24-year old Indian male with history of severe traumatic brain injury who was presented to the Johns Hopkins Neuropsychiatry clinic for evaluation and management of mood, cognitive and behavioral symptoms. 2.2. Present illness Mr. P was reportedly doing well until he sustained a severe traumatic brain injury (TBI) in 2008. A few months after the injury he developed a myriad of depressive symptoms including persistent low mood, anhedonia, decreased self-attitude, feelings of frustration, hopelessness and passively suicidal thoughts. He also reported cognitive symptoms including difficulty learning new information, processing information, distraction and an inability to stay on task. Prior to the TBI, he had one episode of depression during his second year of college and was treated with fluoxetine 20 mg with good response. After the TBI, his episodes of depression were reportedly longer and more intense, lasting several weeks in comparison to his first episode. He was frustrated with his living situation and lack of independence. He repeatedly spoke about the ‘‘high expectations and demands from Indian parents,’’ including his parent’s refusal to let him live independently in the college dormitory in order to integrate with Western college peers. His parents encouraged him to associate with predominantly Indian peers and maintain a similar network even outside school. As a result, he reported strong feelings of inadequacy and failure for not accomplishing as much as his Indian peer counterparts. Months prior to coming to the Johns Hopkins Neuropsychiatry clinic he had sought psychiatric treatment elsewhere. The dose of fluoxetine was increased from 20 mg to 30 mg and then to 40 mg with minimal improvement in his depressive symptoms. This previous psychiatrist had also started him on methylphenidate 5 mg and donepezil 10 mg, which had led to some improvement in his attention and short-term memory. At the time of initial evaluation, he denied any current or history of manic or psychotic symptoms. 2.3. Family, personal and social history At the time of initial evaluation, his father was 54 years old and had diabetes. His mother was 49 years old and had Rheumatoid Arthritis. His 20-year old sister was in good health. Both parents were born in India and raised in the Hindu religion. His father is trained as an ear, nose and throat (ENT) surgeon in India. Since coming to the US he had changed his career. He was at first involved in a business with a friend in North Carolina but later gave it up, moved to Baltimore and joined the Physician’s Assistant program. He was still training at the time Mr. P first came to the Johns Hopkins Neuropsychiatry clinic. Mr. P’s father reportedly gave up a lucrative ENT practice in India and moved to the US to provide better academic opportunities for his children. As per Mr. P’s report, his father was the head of the family and made all family decisions. There was no known neuropsychiatric history in any of Mr. P’s close or extended family members, except for a stroke in a paternal uncle. Mr. P had no history of current use of alcohol, tobacco or illicit drug use, and no significant legal history. Mr. P was born and raised in India. He came to the US 11 years ago. He was in the 10th grade when he and his family arrived from India to North Carolina. He completed his high school and then
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went on to enroll as a Biology major in North Carolina State University in 2006. Though he preferred to live in a dormitory, he was not allowed to do so secondary to financial reasons and parents’ concerns about losing traditional values. He was a sophomore in college in a 4-year program when he was involved in a car accident (see details in past medical history) After the accident and rehabilitation, secondary to his physical and cognitive deficits, he quit the 4-year program and joined a local community college to pursue an Associate of Arts (AA) degree. He was in his first year of the program at the time of his initial visit to the Johns Hopkins Neuropsychiatry clinic. Since his injury, his parents encouraged him to continue to remain at home and minimally socialize with non-Indian peers, as per Mr. P his parents were concerned that socializing outside his community would result in reckless behaviors. There was also a sense of shame and embarrassment that the accident impeded Mr. P from his academic trajectory and this resulted in frequent comparison’s to his counterparts.
hopelessness, poor self-attitude, variable sleep pattern, lack of appetite and suicidal thoughts. At the urging and request of his parents, he had received outpatient psychiatric treatment for major depression at that time (2008) by an outpatient psychiatrist. He was treated with fluoxetine 20 mg daily with good response and improvement in his depressive symptoms. For cognitive symptoms he was started on donepezil and methylphenidate. He presented to the Johns Hopkins neuropsychiatry clinic in 2011 after his family moved to Baltimore, with a relapse of depressive symptoms. 2.7. Mental status exam at the time of the initial evaluation
His medical history is significant only for a motor vehicle accident (MVA), which occurred in the fall of 2008, in North Carolina. He was the belted driver of a car that lost control in the rain, crossed midline, spun and struck an oncoming pickup truck. He sustained a severe traumatic brain injury (TBI) with approximately 30 days of coma and 3 weeks of intubation. Brain scans were significant for diffuse axonal injury, multiple contusions; right frontal subarachnoid hemorrhage and subdural hematoma, both of which did not require neurosurgical intervention. Other injuries included cervical soft tissue injuries, C1–C2 ligament tear and occipital condyle fracture which required surgery 10 days after trauma. He also sustained splenic laceration and fracture of left scapula; neither required surgery. He also developed laryngeal stenosis and required a total of seven laryngeal surgeries in 2009. He was treated in a North Carolina hospital in an inpatient facility for 75 days and later in an outpatient rehabilitation for several months, until the middle of 2009.
Mr. P was an young Indian male who appeared stated age. He had good hygiene, grooming and was appropriately dressed. He was obese and had a tracheal scar. He was cooperative and pleasant during the evaluation while maintaining good eye contact. There were no psychomotor abnormalities. His speech was dysarthric and sometimes difficult to understand, however there was no formal thought disorder. He described his mood as ‘‘depressed; frustrated’’. His affect was restricted and appropriate for mood. His self-attitude and vital sense were decreased. He felt ‘‘hopeless’’ about his future. He endorsed passive death wishes but denied active suicidal, homicidal or violent thoughts. No delusions, hallucinations or other abnormal experiences were elicited. He denied obsessions, compulsions or phobias. He displayed fair judgment but poor insight. He was not interested in continuing psychiatric treatment and attributed his sadness to lack of independence and having to live with his parents. Physical exam: Pertinent findings in his physical examination included: left hemiparesis, mild deviation to right on tongue protrusion, deep tendon reflexes 2 + right upper and lower extremity and 1 + left upper and lower extremity Plantar responses were: Right flexor; left equivocal, Gait was normal; but unable to tandem. Modified Mini mental State (3 MS) exam: 86/100-3 immediate recall; -3 delayed recall; -4 orientation; -1 pentagon, -2 naming; -1 3-stage command
2.5. Medications at the time of initial evaluation
2.8. Diagnostic findings
2.4. Past medical history
Fluoxetine 40 mg daily. Donepezil 10 mg daily. Methylphenidate 5 mg daily. 2.6. Past psychiatric history Mr. P had no history of inpatient psychiatric hospitalizations or suicide attempts. He first developed depressive symptoms in the fall of 2006. This was when he first enrolled in college in North Carolina. He reported that he had a strong desire to live in the dormitories with his college peers rather than live at home with his parents. After his parents’ strong objection to this, Mr. P began feeling depressed and demoralized that he could not participate in on campus housing, leaving him isolated from his peers with whom he desired socialization. He was obligated to stay home, as this was demanded by his parents who were also his financial support. He developed depressed mood, poor sleep and feelings of amotivation. He continued to maintain excellent grades, and at that time did not experience any suicidal ideation or behaviors. He did not seek psychiatric treatment at that time as he felt that this was merely a reaction to his parents’ demands and did not feel he needed any psychiatric intervention. After his TBI in 2008, he developed a severe depression associated with several weeks of persistent sadness, anhedonia, feelings of
Soon after the initial evaluation, the treatment team performed comprehensive blood work including complete blood count, comprehensive metabolic panel, thyroid function tests, 25 hydroxy Vitamin-D level and lipid panel. He was referred to his primary care doctor for management of low Vitamin D and elevated triglycerides. His liver enzymes (AST and ALT) were initially high but returned to normal on follow-up. He was advised to follow up with his primary medical doctor regarding persistently elevated blood pressure readings. Computerized tomography (CT) of the head soon after trauma revealed right frontal subarachnoid hemorrhage and subdural hematoma adjacent to the right tentorium. Magnetic resonance imaging (MRI) of brain revealed extensive shear-type injury involving the body and splenium of the corpus callosum, the right frontal lobe, parietal and temporal lobes and, left frontal lobe. Very mild shear injuries were also noted in the left basal ganglia and right thalamus and hemorrhagic contusions involving the right temporal lobe and right superior frontal gyrus. Cervical spine (C-spine) MRI revealed right occipital condyle fracture and injury to interspinous ligament between C1 and C2. Neuropsychological testing conducted 8 months after the injury revealed severe memory problems, both verbal and visual with predominantly retrieval problems, decreased visual attention and poor performance on tests of mental efficiency.
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3. Discussion In summary, Mr. P is an young adult Indian male who had sustained a severe traumatic brain injury secondary to an MVA. He had suffered from major depression prior to the TBI and had responded well to fluoxetine. After the TBI, the episodes of major depression were becoming more frequent, severe and were minimally responsive to pharmacological treatment. At the time of presentation to the Johns Hopkins Neuropsychiatry Clinic, he was severely depressed. In addition, he had cognitive deficits in the domains of memory and executive functioning. His psychosocial stressors included frequent arguments with his parents, difficulty balancing Indian and American cultural values, and a strong desire to be independent despite not having adequate resources. We formulated a multipronged approach to the management of Mr. P’s major depression using a biopsychosocial cultural perspective as his mood disorder was complicated by several factors: severe TBI, cognitive deficits, adolescent behavior and cultural issues. We will discuss his symptoms as they fit with each of the domains and describe our treatment recommendations. 3.1. Biological component Though he had no known genetic loading for any neuropsychiatric symptomatology, a severe TBI resulting in neuroanatomic and neurobiological changes may explain the sequelae of mood symptoms consistent with major depression. Damage to the circuitry involving regions of the prefrontal cortex, amygdala, hippocampus, basal ganglia and thalamus have been associated with mood disorders in patients with traumatic brain injury (Jorge and Starkstein, 2005). Based on literature review (Fann et al., 2009; Neurobehavioral Guidelines Working Group et al., 2006) and the authors’ clinical experience in the use of serotonergic agents for the treatment of major depression associated with TBI, initially the dose of fluoxetine was increased from 40 to 60 mg. As there was no significant improvement in his depressive symptoms, he was weaned off the fluoxetine and started on venlafaxine, a serotonin– norepinephrine reuptake inhibitor. He received close monitoring and the dose was gradually increased to 150 mg over the course of 8 months with good improvement in depressive symptoms. Methylphenidate and donepezil were continued. A trial off these medications were done at different times but were restarted as he reported to worsening of his attention and memory problems. 3.2. Psychosocial component When attempting to understand factors other than disease states that may exacerbate psychiatric symptoms after a TBI, personality traits should be considered. These traits can significantly impact the way in which a person perceives and experiences his/her symptoms. The study of personality relates to examinations of traits an individual possesses, and the function and adjustment of traits one relates to his or her environment. The excess or lack of any given trait does not inherently mean that the patient has a disorder. Instead, it gives information as to how one adjusts and responds to one’s environment (Treisman and Angelino, 2004). In Mr. P’s case, his innate personality traits are complicated by the brain injury that can cause changes ranging from mild exaggeration of the person’s pre-injury personality to striking changes from pre-morbid status. Per his parents, even prior to the brain injury, Mr. P was ‘‘somewhat of a rebel’’, and Mr. P described himself as someone who ‘‘lived in the moment’’, and this was the rationale behind why his parents wanted to limit his interactions with peers who might
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trigger impulsive and rash behaviors. Since the TBI he had been reported to be demanding and to resistant to rules. Additionally since the TBI, he was more impulsive with poor frustration tolerance leading to periods of anger, agitation and explosive verbal outbursts triggered by trivial events and/or during his interactions with his parents. All these traits are consistent with a Cluster B personality disorder, which can negatively impact interpersonal relationships. One of the most significant factors that may explain much of Mr. P’s symptom presentation is the trauma from the MVA, which has left him severely impaired physically, emotionally and cognitively. Psychosocial consequences of the injury included stepping down from a 4-year college program to a 2-year program, losing old friends and making new ones, compounding the pre-existing high parental expectations to succeed. This led to Mr. P feeling exceedingly helpless. He fell into patterns of self-deprecation as he often compared his subjective lack of accomplishments to peers his age. Despite encouragement from his psychiatric treatment team who called attention to his excellent adaptation to the new college, and the educational accomplishment of graduating with an Associate’s degree in light of the severe injury he suffered, Mr. P persistently pointed out that this was ‘‘not good enough’’ and compared himself to both Indian and non-Indian peers of his age who had advanced professional degrees. This sense of shame did drive Mr. P to persevere through his community college course and ultimately apply for a job which occurred a few years after extensive physical and cognitive rehabilitation. He continued to ruminate, however in treatment on his sub-par grades and felt inferior to others. He also expressed frustration and feeling stressed about living in a supervised setting at home despite his desire to obtain his independence which had cultural drivers as discussed below. Self-deprecatory feelings and negative behaviors were addressed in regular psychotherapy sessions. In addition to TBI education and support, treatment focused on helping Mr. P identify his negative perceptions. Examples included: all or nothing thinking (‘‘I am a total failure in life because I am not getting good grades like my Indian friends’’); tendency to mind-read and jump to conclusions (‘‘my parents are not happy with me and think that I will never be successful) and over-generalizing events (‘‘I am not living in the dormitory now which means I will never be independent in my life’’). Therapy also included self-monitoring behavioral methods such as ‘stop-think-act’, cognitive reframing and developing strategies to channel his negative emotions to healthy behaviors–exercising and developing a hobby. Mr. P gradually made significant improvement. He is now close to graduating from his 2-year program and earning an AA degree. He plans to work after graduation. His conflicts with his parents are less severe and frequent. He has been regularly attending a youth program at his local temple, although he was reluctant to do so at first. He is more comfortable in the program now and has made a few good friends. 3.3. Cultural component An important factor that needs to be weighed into the formulation is Mr. P’s cultural background and its role in contributing to his stress. It starts with the fact that his father, an ENT surgeon in India migrated to the United States for better opportunities that could potentially be provided for his children. In doing this, there was a sense of ‘‘an investment’’ he was making in his children which came inherently with an expectation for them to succeed in the US, a common theme in South Asian families. While the family underwent a state of acculturation, Mr. P likely found himself in a conflict about identity, being raised as part of an Indian diaspora. His parents strongly encouraged Mr. P to affiliate
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only with Indian peers, maintain all practices of Indian customs and preserve his Indian identity. In addition there was a strong push from his family to abide by strict religious values and associate with peers from the Hindu temple, despite his desire to want to live in a dormitory and integrate with non-Indian peers. He experienced an internal struggle with a choice of cultural values against a desire to acculturate as a mainstream American. In addition, there were cultural, professional and social expectations placed on him by his parents such that he was consistently under scrutiny for all of his actions. Specifically, there was a coercion to study continuously so as to focus on his education and career, and to abide by his parent’s rules. This ‘‘helicopter parenting’’ strategy may have further pushed Mr. P to strive for his own independence, leading him to make his own decisions about his social life and the values that he believed in. The parents perceived their actions as economical, emphasizing education, cultural values and identity. From Mr. P’s perspective, this was an exertion of total control by his parents and absence of independence which, as described above may predispose patients of Indian origin to depressive symptoms. A review of literature reveals that it typically takes three generations for immigrants to fully assimilate to the lifestyle of the dominant culture. This interval is about the amount of time it takes to accept Western medical care more readily than traditional care. In general, the younger people are when they migrate, the more readily they adapt to living in a country in the West (Kramer et al., 2002). Mr. P and his family are still in the transition period and struggling between balancing an acceptance of Western cultural norms and maintaining their Indian identity. In many South Asian families there exists a hierarchical system. Most often it is a paternalistic model in which the father makes all the decisions and mother and siblings are expected to follow. The head of the family demands respect and his authority is often unquestioned. Maintaining harmony is also an important value; therefore, there is a strong emphasis on avoiding conflict or direct confrontation. It is often considered disrespectful when children, question parents and do not follow household rules. A similar model exists in Mr. P’s family. Mr. P was battling to understand and accept this model and his family struggled to understand his need for independence. In addition to regular sessions with the patient, the treatment team also met with his parents. The treatment team was multiracial: the two physicians (VR and DR) were South Asians and the therapist (SK) was a non-South Asian American. The treatment team worked in unison, discussed the pros and cons of each of the issues raised by the patient and family from both the Eastern and Western perspectives and provided a neutral humanistic approach to treatment, with an emphasis on minimizing his disability, maximizing his productivity and improving his overall satisfaction with life. His culture might have also played a role in his and his family’s perception of recovery and how the adjustments to his new life were experienced differently. While studies have looked at the impact of culture on TBI recovery (Arango-Lasprilla et al., 2007; Gary et al., 2009), the sample populations studied were African American and Latino, no studies have looked at Indian culture and its impact on recovery. Mr. P’s parents attended sessions regularly. Both the patient and family were very comfortable with pharmacological management but had some initial resistance to psychotherapy. However, with time, and as sessions continued, they became more comfortable about discussing Eastern versus Western family values. They also became more accepting of the need and importance of respecting and reconciling cultural differences. The team’s strength as a multidisciplinary/bicultural group helped in better understanding the patient’s and the parents issues
and in keeping the management strategies balanced, neutral, and geared towards the individual. What is most striking is how the cultural values in Mr. P’s presentation directly impacted the outcomes of his symptomatology and treatment. On one hand, due to the stigma of mental illness and reluctance to accept depression as a true entity, Mr. P and his family were initially reluctant to engage in psychotherapy that was a critical component of the treatment. On the other hand, it is evident that these same cultural values clearly affected Mr. P’s depressive syndrome in a protective way, which might be attributed to the collectivist thinking as described above. Specifically, Mr. P had chronic passive suicidal thoughts, yet consistently had strong cultural beliefs that suicide would dishonor and bring shame to his family. Suicide is not actively discouraged in Hinduism. Souls are considered to be given life by God and exist even after death, and reincarnation occurs as a result of cycling from lower through higher forms of life. Rooted within reincarnation is karma, which is the bond across time concerned with morality and cause and effect. Completing suicide to escape suffering is generally not condoned within the Hindu faith, though some holy men have condoned it based on interpretive religious beliefs (Richards and Bergin, 2000; Leong et al., 2007). This concept may be a protective entity which might discourage Indian patients from suicidal thoughts and behaviors. During therapy, when questioned about his suicidal thoughts, he responded that suicide would go against the cultural expectations; suicide reflected weakness and not strength, and that harming himself would in turn result in negative consequences in the next life (the concept of karma). These factors positively influenced Mr. P’s self-directed outcomes amidst a severe depression.
4. Summary Mr. P has several components in his history which may contribute to and explain his depressive symptomatology. He has known biological factors from a brain injury that may explain much of his depressive syndrome, cluster B personality traits that became more prominent after injury and were challenging to the family and treatment team and finally, a very strong South Asian cultural background that played an important role in the maintenance of his depressive symptoms but also protected him from self-harm. The goal in describing this case is not to make any firm rules regarding the evaluation and treatment of South Asians with mental illness, but rather to stress the importance of having a cross-cultural mindset as this can have an enormous impact in formulation and management. Acknowledgment This literature review was supported in part by grant from the Department of Defense W81XWH-13-1-0469.
References Hwang, W.C., Myers, H.F., Abe-Kim, J., Ting, J.Y., 2008. A conceptual paradigm for understanding culture’s impact on mental health: the cultural influences on mental health (CIMH) model. Clin. Psychol. Rev. 28 (2 (Feb)), 211–227. Tavkar, P., Iyer, S.N., Hansen, D.J., 2008. Barriers to mental health services for Asian Indians in America. In: Poster presented at the 42nd Annual Convention of the Association for Behavioral and Cognitive Therapies, Orlando, FL. Segal, U.A., 1998. The Asian Indian-American family. In: Mindel, C.H., Habenstein, R.W., Wright, Jr., R. (Eds.), Ethnic Families in America: Patterns and Variation. 4th ed. Prentice-Hall, Upper Saddle River, NJ.
D. Roy et al. / Asian Journal of Psychiatry 13 (2015) 56–61 Bhattacharya, G., Schoppelrey, S.L., 2004. Preimmigration beliefs of life success, postimmigration experiences, and acculturative stress: South Asian immigrants in the United States. J. Immigr. Health 6 (2 (Apr)), 83–92. Wong, Y.J., Kim, B.S., Nguyen, C.P., Cheng, J.K., Saw, A., 2014. The interpersonal shame inventory for Asian Americans: scale development and psychometric properties. J. Couns. Psychol. 61 (1 (Jan)), 119–132. Singh, S., Manjula, M., Philip, M., 2012. Suicidal risk and childhood adversity: a study of Indian college students. Asian J. Psychiatr. 5 (2(Jun)), 154–159. Conrad, M.M., Pacquiao, D.F., 2005. Manifestation, attribution, and coping with depression among Asian Indians from the perspectives of health care practitioners. J. Transcult. Nurs. 16, 32–40. Engel, G.L., 1980. The clinical application of the biopsychosocial model. Am. J. Psychiatry 137 (5 (May)), 535–544. Lewis-Fernandez, R., Diaz, N., 2002. The cultural formulation: a method for assessing cultural factors affecting the clinical encounter. Psychiatr. Q. 73 (4 (Winter)), 271–295. Mezzich, J.E., Caracci, G., Fabrega Jr., H., Kirmayer, L.J., 2009. Cultural formulation guidelines. Transcult. Psychiatry 46 (3 (Sep)), 383–405. Jorge, R.E., Starkstein, S.E., 2005. Pathophysiologic aspects of major depression following traumatic brain injury. J. Head Trauma Rehabil. 20 (6 (Nov–Dec)), 475–487.
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Fann, J.R., Hart, T., Schomer, K.G., 2009. Treatment for depression after traumatic brain injury: a systematic review. J. Neurotrauma 26 (12 (Dec)), 2383–2402. Neurobehavioral Guidelines Working Group, Warden, D.L., Gordon, B., McAllister, T.W., Silver, J.M., Barth, J.T., et al., 2006. Guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury. J. Neurotrauma 23 (10 (Oct)), 1468–1501. Treisman, G.J., Angelino, A.F., 2004. The Psychiatry of AIDS. Johns Hopkins University Press, Baltimore, pp. 80–85. Kramer, E.J., Kwong, K., Lee, E., Chung, H., 2002. Cultural factors influencing the mental health of Asian Americans. West J. Med. 176 (4 (Sep)), 227–231. Arango-Lasprilla, J.C., Rosenthal, M., Deluca, J., Komaroff, E., Sherer, M., Cifu, D., et al., 2007. Traumatic brain injury and functional outcomes: does minority status matter? Brain Inj. 21 (7 (Jun)), 701–708. Gary, K.W., Arango-Lasprilla, J.C., Stevens, L.F., 2009. Do racial/ethnic differences exist in post-injury outcomes after TBI? A comprehensive review of the literature. Brain Inj. 23 (10 (Sep)), 775–789. Richards, P.S., Bergin, A.E., 2000. Handbook of Psychotherapy and Religious Diversity. American Psychological Association, Washington, DC. Leong, F.T., Leach, M.M., Yeh, C., Chou, E., 2007. Suicide among Asian Americans: what do we know? What do we need to know?. Death Stud. 31 (5 (May–Jun)), 417–434.
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Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Depression after traumatic brain injury: A biopsychosocial cultural perspective Durga Roy a,*, Geetha Jayaram a, Alex Vassila a, Shari Keach b, Vani Rao a a b
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD USA Johns Hopkins Bayview Medical Center, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 July 2014 Received in revised form 6 October 2014 Accepted 13 October 2014
There are several challenges in diagnosing and treating mental illness amongst South Asians. Often times, formulating a patient’s case presentation cannot adequately be accomplished strictly using a biopsychosocial model. The cultural components play an imperative role in explaining certain psychiatric symptoms and can guide treatment. With the growing population of immigrants coming to the United States, many of which require treatment for mental illness, it is essential that clinicians be cognizant in incorporating cultural perspectives when treating such patients. The authors describe the case of a 24-year old South Asian male who suffered an exacerbation of a depressive syndrome after a traumatic brain injury. Using a biopsychosocial cultural approach, this case highlights how South Asian cultural values can contribute to and incite psychiatric symptoms while simultaneously providing protective drivers for treatment outcomes. ß 2014 Elsevier B.V. All rights reserved.
Keywords: Cultural perspectives Biopsychosocial model Depression Brain injury
1. Introduction Mental illness amongst South Asians in the United States (US) can be challenging to assess and treat due to several factors: the negative social attitudes towards mental illness, somatically focused symptom presentation, lack of empathy and understanding of mental illness among family members or care providers, and avoidance of mental health services by patients and family. Because of the negative stigma that is associated with mental illness, South Asians are less likely to disclose their emotional symptoms and thus have difficulty receiving treatment. Additionally, family members may underestimate the nature and/or severity of illness in their loved ones and discourage psychiatric treatment as a result. Non-South Asian clinicians may find it challenging to distinguish such cultural factors from biopsychosocial factors. In general it is important for clinicians to be aware how culture contributes to mental illness itself. Culture can be defined as attitudes, values and beliefs and behaviors shared by a people but also includes culture related experiences related to being an
* Corresponding author. Tel.: +1 410 550 9616; fax: +1 410 550 8191. E-mail address: [email protected] (D. Roy). http://dx.doi.org/10.1016/j.ajp.2014.10.001 1876-2018/ß 2014 Elsevier B.V. All rights reserved.
ethnic minority (Hwang et al., 2008). As outlined in a paper by Hwang et al. (2008), culture affects the ‘‘prevalence of mental illness, issues with diagnosis and assessment, etiology and course of disease, phenomenology and how distress can be expressed, certain coping styles and help seeking behaviors, as well as issues with treatment interventions’’ (Hwang et al., 2008). South Asian values can be considered allocentric, or grouporiented (Tavkar et al., 2008). Imbibed within this culture are beliefs that sacrifices should be made by individuals for the better good of the family (Tavkar et al., 2008; Segal, 1998). There can be considered a sense of collectivism within the South Asian cultural system in which there is a practice of giving priority to the group as a whole rather than to the individual. Often there are expectations of younger generations to excel in education and develop lucrative careers. If these expectations are not met, a sense of shame upon the family may develop. In a study conducted by Bhattacharya and Schoppelrey (2004), two entities in the Asian culture that steered parental expectations were the responsibility of children in enhancing family pride as well as education which would enable advancement through the social class and the caste systems (Bhattacharya and Schoppelrey, 2004). This may predispose South Asians to certain risk factors in the development of psychopathology. Often younger South Asians,
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particularly students, are placed under immense pressure to excel academically, and often develop mood disorders leading to suicidal thoughts and behaviors. When parental expectations are not met, one feels guilty and ashamed. The individual’s family often compounds the individual’s shame with their own sense of shame and anger. The failure of an individual subsequently represents a failure of the entire family. This can lead to cognitive representations which predispose to depressive symptoms (Wong et al., 2014). Parents may also exert control over their children which impacts the nature of both maternal and paternal bonding. A study conducted by Singh et al. (2012) revealed that Indian college students who experienced affectionless parental control and neglect had higher rates of hopelessness and suicidal ideation (Singh et al., 2012). Asian Indians may often explain psychological distress as a violation of some moral or religious principle or spirit possessions. Physical and mental deficits are thought to be God’s will or past karma. These factors may add to the delay in seeking professional help (Tavkar et al., 2008; Conrad and Pacquiao, 2005). While the above factors may influence the development of certain psychiatric disorders, one could argue that this collectivism and belief in moral and religious principles might also protect the South Asian patient from the sequelae of severe mental illness, namely suicide. All of the above points should be considered when discussing potential precipitants for symptom presentation within South Asians with mental illness. This warrants an accurate and comprehensive approach to psychiatric diagnoses and ultimately treatment. A biopsychosocial perspective may often be inadequate in accounting for all aspects of a patient’s illness. Cultural contributions are essential in comprehensively understanding such patients and can provide for more rigorous treatment approaches. The biopsychosocial model has been described as a scientific model created to include aspects absent in the biomedical model (Engel, 1980). As Engel describes in his paper, the biopsychosocially oriented physician should pay attention to not only biological factors but also psychosocial factors that are both protective and increase the risk for destabilizing a person’s emotional homeostasis (Engel, 1980). Excluding the cultural components from this model however, can leave out vital components of a patient’s psychiatric presentation, particularly when it comes to both diagnosis and treatment. Proponents of the cultural formulation model, as described by Lewis-Fernandez and Diaz (2002) stress the importance of assessing cultural values as they can play a significant role in an individual’s psychiatric symptomatology and can highlight help seeking preferences. These proponents also argue that this can be even more important when physicians and patients are from different cultural backgrounds as an understanding of patients’ cultural values can guide treatment (Lewis-Fernandez and Diaz, 2002; Mezzich et al., 2009). The authors of this article report the case of a young South Asian male living in the US who developed exacerbation of a major depression after a traumatic brain injury. His story illustrates aspects of cultural and social conflicts that need examination in order to comprehensively understand his symptomatology. His presentation reflects on how cultural factors can be both a hindrance in mental health treatment yet simultaneously protective to adverse events that would otherwise arise from severe mental illness. An example of this is suicide. As the numbers of immigrant populations requiring mental health services continue to rise, it is imperative for clinicians to incorporate a cultural mindset when formulating, diagnosing and treating these patients.
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2. Case presentation 2.1. Chief complaint Mr. P is a 24-year old Indian male with history of severe traumatic brain injury who was presented to the Johns Hopkins Neuropsychiatry clinic for evaluation and management of mood, cognitive and behavioral symptoms. 2.2. Present illness Mr. P was reportedly doing well until he sustained a severe traumatic brain injury (TBI) in 2008. A few months after the injury he developed a myriad of depressive symptoms including persistent low mood, anhedonia, decreased self-attitude, feelings of frustration, hopelessness and passively suicidal thoughts. He also reported cognitive symptoms including difficulty learning new information, processing information, distraction and an inability to stay on task. Prior to the TBI, he had one episode of depression during his second year of college and was treated with fluoxetine 20 mg with good response. After the TBI, his episodes of depression were reportedly longer and more intense, lasting several weeks in comparison to his first episode. He was frustrated with his living situation and lack of independence. He repeatedly spoke about the ‘‘high expectations and demands from Indian parents,’’ including his parent’s refusal to let him live independently in the college dormitory in order to integrate with Western college peers. His parents encouraged him to associate with predominantly Indian peers and maintain a similar network even outside school. As a result, he reported strong feelings of inadequacy and failure for not accomplishing as much as his Indian peer counterparts. Months prior to coming to the Johns Hopkins Neuropsychiatry clinic he had sought psychiatric treatment elsewhere. The dose of fluoxetine was increased from 20 mg to 30 mg and then to 40 mg with minimal improvement in his depressive symptoms. This previous psychiatrist had also started him on methylphenidate 5 mg and donepezil 10 mg, which had led to some improvement in his attention and short-term memory. At the time of initial evaluation, he denied any current or history of manic or psychotic symptoms. 2.3. Family, personal and social history At the time of initial evaluation, his father was 54 years old and had diabetes. His mother was 49 years old and had Rheumatoid Arthritis. His 20-year old sister was in good health. Both parents were born in India and raised in the Hindu religion. His father is trained as an ear, nose and throat (ENT) surgeon in India. Since coming to the US he had changed his career. He was at first involved in a business with a friend in North Carolina but later gave it up, moved to Baltimore and joined the Physician’s Assistant program. He was still training at the time Mr. P first came to the Johns Hopkins Neuropsychiatry clinic. Mr. P’s father reportedly gave up a lucrative ENT practice in India and moved to the US to provide better academic opportunities for his children. As per Mr. P’s report, his father was the head of the family and made all family decisions. There was no known neuropsychiatric history in any of Mr. P’s close or extended family members, except for a stroke in a paternal uncle. Mr. P had no history of current use of alcohol, tobacco or illicit drug use, and no significant legal history. Mr. P was born and raised in India. He came to the US 11 years ago. He was in the 10th grade when he and his family arrived from India to North Carolina. He completed his high school and then
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went on to enroll as a Biology major in North Carolina State University in 2006. Though he preferred to live in a dormitory, he was not allowed to do so secondary to financial reasons and parents’ concerns about losing traditional values. He was a sophomore in college in a 4-year program when he was involved in a car accident (see details in past medical history) After the accident and rehabilitation, secondary to his physical and cognitive deficits, he quit the 4-year program and joined a local community college to pursue an Associate of Arts (AA) degree. He was in his first year of the program at the time of his initial visit to the Johns Hopkins Neuropsychiatry clinic. Since his injury, his parents encouraged him to continue to remain at home and minimally socialize with non-Indian peers, as per Mr. P his parents were concerned that socializing outside his community would result in reckless behaviors. There was also a sense of shame and embarrassment that the accident impeded Mr. P from his academic trajectory and this resulted in frequent comparison’s to his counterparts.
hopelessness, poor self-attitude, variable sleep pattern, lack of appetite and suicidal thoughts. At the urging and request of his parents, he had received outpatient psychiatric treatment for major depression at that time (2008) by an outpatient psychiatrist. He was treated with fluoxetine 20 mg daily with good response and improvement in his depressive symptoms. For cognitive symptoms he was started on donepezil and methylphenidate. He presented to the Johns Hopkins neuropsychiatry clinic in 2011 after his family moved to Baltimore, with a relapse of depressive symptoms. 2.7. Mental status exam at the time of the initial evaluation
His medical history is significant only for a motor vehicle accident (MVA), which occurred in the fall of 2008, in North Carolina. He was the belted driver of a car that lost control in the rain, crossed midline, spun and struck an oncoming pickup truck. He sustained a severe traumatic brain injury (TBI) with approximately 30 days of coma and 3 weeks of intubation. Brain scans were significant for diffuse axonal injury, multiple contusions; right frontal subarachnoid hemorrhage and subdural hematoma, both of which did not require neurosurgical intervention. Other injuries included cervical soft tissue injuries, C1–C2 ligament tear and occipital condyle fracture which required surgery 10 days after trauma. He also sustained splenic laceration and fracture of left scapula; neither required surgery. He also developed laryngeal stenosis and required a total of seven laryngeal surgeries in 2009. He was treated in a North Carolina hospital in an inpatient facility for 75 days and later in an outpatient rehabilitation for several months, until the middle of 2009.
Mr. P was an young Indian male who appeared stated age. He had good hygiene, grooming and was appropriately dressed. He was obese and had a tracheal scar. He was cooperative and pleasant during the evaluation while maintaining good eye contact. There were no psychomotor abnormalities. His speech was dysarthric and sometimes difficult to understand, however there was no formal thought disorder. He described his mood as ‘‘depressed; frustrated’’. His affect was restricted and appropriate for mood. His self-attitude and vital sense were decreased. He felt ‘‘hopeless’’ about his future. He endorsed passive death wishes but denied active suicidal, homicidal or violent thoughts. No delusions, hallucinations or other abnormal experiences were elicited. He denied obsessions, compulsions or phobias. He displayed fair judgment but poor insight. He was not interested in continuing psychiatric treatment and attributed his sadness to lack of independence and having to live with his parents. Physical exam: Pertinent findings in his physical examination included: left hemiparesis, mild deviation to right on tongue protrusion, deep tendon reflexes 2 + right upper and lower extremity and 1 + left upper and lower extremity Plantar responses were: Right flexor; left equivocal, Gait was normal; but unable to tandem. Modified Mini mental State (3 MS) exam: 86/100-3 immediate recall; -3 delayed recall; -4 orientation; -1 pentagon, -2 naming; -1 3-stage command
2.5. Medications at the time of initial evaluation
2.8. Diagnostic findings
2.4. Past medical history
Fluoxetine 40 mg daily. Donepezil 10 mg daily. Methylphenidate 5 mg daily. 2.6. Past psychiatric history Mr. P had no history of inpatient psychiatric hospitalizations or suicide attempts. He first developed depressive symptoms in the fall of 2006. This was when he first enrolled in college in North Carolina. He reported that he had a strong desire to live in the dormitories with his college peers rather than live at home with his parents. After his parents’ strong objection to this, Mr. P began feeling depressed and demoralized that he could not participate in on campus housing, leaving him isolated from his peers with whom he desired socialization. He was obligated to stay home, as this was demanded by his parents who were also his financial support. He developed depressed mood, poor sleep and feelings of amotivation. He continued to maintain excellent grades, and at that time did not experience any suicidal ideation or behaviors. He did not seek psychiatric treatment at that time as he felt that this was merely a reaction to his parents’ demands and did not feel he needed any psychiatric intervention. After his TBI in 2008, he developed a severe depression associated with several weeks of persistent sadness, anhedonia, feelings of
Soon after the initial evaluation, the treatment team performed comprehensive blood work including complete blood count, comprehensive metabolic panel, thyroid function tests, 25 hydroxy Vitamin-D level and lipid panel. He was referred to his primary care doctor for management of low Vitamin D and elevated triglycerides. His liver enzymes (AST and ALT) were initially high but returned to normal on follow-up. He was advised to follow up with his primary medical doctor regarding persistently elevated blood pressure readings. Computerized tomography (CT) of the head soon after trauma revealed right frontal subarachnoid hemorrhage and subdural hematoma adjacent to the right tentorium. Magnetic resonance imaging (MRI) of brain revealed extensive shear-type injury involving the body and splenium of the corpus callosum, the right frontal lobe, parietal and temporal lobes and, left frontal lobe. Very mild shear injuries were also noted in the left basal ganglia and right thalamus and hemorrhagic contusions involving the right temporal lobe and right superior frontal gyrus. Cervical spine (C-spine) MRI revealed right occipital condyle fracture and injury to interspinous ligament between C1 and C2. Neuropsychological testing conducted 8 months after the injury revealed severe memory problems, both verbal and visual with predominantly retrieval problems, decreased visual attention and poor performance on tests of mental efficiency.
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3. Discussion In summary, Mr. P is an young adult Indian male who had sustained a severe traumatic brain injury secondary to an MVA. He had suffered from major depression prior to the TBI and had responded well to fluoxetine. After the TBI, the episodes of major depression were becoming more frequent, severe and were minimally responsive to pharmacological treatment. At the time of presentation to the Johns Hopkins Neuropsychiatry Clinic, he was severely depressed. In addition, he had cognitive deficits in the domains of memory and executive functioning. His psychosocial stressors included frequent arguments with his parents, difficulty balancing Indian and American cultural values, and a strong desire to be independent despite not having adequate resources. We formulated a multipronged approach to the management of Mr. P’s major depression using a biopsychosocial cultural perspective as his mood disorder was complicated by several factors: severe TBI, cognitive deficits, adolescent behavior and cultural issues. We will discuss his symptoms as they fit with each of the domains and describe our treatment recommendations. 3.1. Biological component Though he had no known genetic loading for any neuropsychiatric symptomatology, a severe TBI resulting in neuroanatomic and neurobiological changes may explain the sequelae of mood symptoms consistent with major depression. Damage to the circuitry involving regions of the prefrontal cortex, amygdala, hippocampus, basal ganglia and thalamus have been associated with mood disorders in patients with traumatic brain injury (Jorge and Starkstein, 2005). Based on literature review (Fann et al., 2009; Neurobehavioral Guidelines Working Group et al., 2006) and the authors’ clinical experience in the use of serotonergic agents for the treatment of major depression associated with TBI, initially the dose of fluoxetine was increased from 40 to 60 mg. As there was no significant improvement in his depressive symptoms, he was weaned off the fluoxetine and started on venlafaxine, a serotonin– norepinephrine reuptake inhibitor. He received close monitoring and the dose was gradually increased to 150 mg over the course of 8 months with good improvement in depressive symptoms. Methylphenidate and donepezil were continued. A trial off these medications were done at different times but were restarted as he reported to worsening of his attention and memory problems. 3.2. Psychosocial component When attempting to understand factors other than disease states that may exacerbate psychiatric symptoms after a TBI, personality traits should be considered. These traits can significantly impact the way in which a person perceives and experiences his/her symptoms. The study of personality relates to examinations of traits an individual possesses, and the function and adjustment of traits one relates to his or her environment. The excess or lack of any given trait does not inherently mean that the patient has a disorder. Instead, it gives information as to how one adjusts and responds to one’s environment (Treisman and Angelino, 2004). In Mr. P’s case, his innate personality traits are complicated by the brain injury that can cause changes ranging from mild exaggeration of the person’s pre-injury personality to striking changes from pre-morbid status. Per his parents, even prior to the brain injury, Mr. P was ‘‘somewhat of a rebel’’, and Mr. P described himself as someone who ‘‘lived in the moment’’, and this was the rationale behind why his parents wanted to limit his interactions with peers who might
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trigger impulsive and rash behaviors. Since the TBI he had been reported to be demanding and to resistant to rules. Additionally since the TBI, he was more impulsive with poor frustration tolerance leading to periods of anger, agitation and explosive verbal outbursts triggered by trivial events and/or during his interactions with his parents. All these traits are consistent with a Cluster B personality disorder, which can negatively impact interpersonal relationships. One of the most significant factors that may explain much of Mr. P’s symptom presentation is the trauma from the MVA, which has left him severely impaired physically, emotionally and cognitively. Psychosocial consequences of the injury included stepping down from a 4-year college program to a 2-year program, losing old friends and making new ones, compounding the pre-existing high parental expectations to succeed. This led to Mr. P feeling exceedingly helpless. He fell into patterns of self-deprecation as he often compared his subjective lack of accomplishments to peers his age. Despite encouragement from his psychiatric treatment team who called attention to his excellent adaptation to the new college, and the educational accomplishment of graduating with an Associate’s degree in light of the severe injury he suffered, Mr. P persistently pointed out that this was ‘‘not good enough’’ and compared himself to both Indian and non-Indian peers of his age who had advanced professional degrees. This sense of shame did drive Mr. P to persevere through his community college course and ultimately apply for a job which occurred a few years after extensive physical and cognitive rehabilitation. He continued to ruminate, however in treatment on his sub-par grades and felt inferior to others. He also expressed frustration and feeling stressed about living in a supervised setting at home despite his desire to obtain his independence which had cultural drivers as discussed below. Self-deprecatory feelings and negative behaviors were addressed in regular psychotherapy sessions. In addition to TBI education and support, treatment focused on helping Mr. P identify his negative perceptions. Examples included: all or nothing thinking (‘‘I am a total failure in life because I am not getting good grades like my Indian friends’’); tendency to mind-read and jump to conclusions (‘‘my parents are not happy with me and think that I will never be successful) and over-generalizing events (‘‘I am not living in the dormitory now which means I will never be independent in my life’’). Therapy also included self-monitoring behavioral methods such as ‘stop-think-act’, cognitive reframing and developing strategies to channel his negative emotions to healthy behaviors–exercising and developing a hobby. Mr. P gradually made significant improvement. He is now close to graduating from his 2-year program and earning an AA degree. He plans to work after graduation. His conflicts with his parents are less severe and frequent. He has been regularly attending a youth program at his local temple, although he was reluctant to do so at first. He is more comfortable in the program now and has made a few good friends. 3.3. Cultural component An important factor that needs to be weighed into the formulation is Mr. P’s cultural background and its role in contributing to his stress. It starts with the fact that his father, an ENT surgeon in India migrated to the United States for better opportunities that could potentially be provided for his children. In doing this, there was a sense of ‘‘an investment’’ he was making in his children which came inherently with an expectation for them to succeed in the US, a common theme in South Asian families. While the family underwent a state of acculturation, Mr. P likely found himself in a conflict about identity, being raised as part of an Indian diaspora. His parents strongly encouraged Mr. P to affiliate
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only with Indian peers, maintain all practices of Indian customs and preserve his Indian identity. In addition there was a strong push from his family to abide by strict religious values and associate with peers from the Hindu temple, despite his desire to want to live in a dormitory and integrate with non-Indian peers. He experienced an internal struggle with a choice of cultural values against a desire to acculturate as a mainstream American. In addition, there were cultural, professional and social expectations placed on him by his parents such that he was consistently under scrutiny for all of his actions. Specifically, there was a coercion to study continuously so as to focus on his education and career, and to abide by his parent’s rules. This ‘‘helicopter parenting’’ strategy may have further pushed Mr. P to strive for his own independence, leading him to make his own decisions about his social life and the values that he believed in. The parents perceived their actions as economical, emphasizing education, cultural values and identity. From Mr. P’s perspective, this was an exertion of total control by his parents and absence of independence which, as described above may predispose patients of Indian origin to depressive symptoms. A review of literature reveals that it typically takes three generations for immigrants to fully assimilate to the lifestyle of the dominant culture. This interval is about the amount of time it takes to accept Western medical care more readily than traditional care. In general, the younger people are when they migrate, the more readily they adapt to living in a country in the West (Kramer et al., 2002). Mr. P and his family are still in the transition period and struggling between balancing an acceptance of Western cultural norms and maintaining their Indian identity. In many South Asian families there exists a hierarchical system. Most often it is a paternalistic model in which the father makes all the decisions and mother and siblings are expected to follow. The head of the family demands respect and his authority is often unquestioned. Maintaining harmony is also an important value; therefore, there is a strong emphasis on avoiding conflict or direct confrontation. It is often considered disrespectful when children, question parents and do not follow household rules. A similar model exists in Mr. P’s family. Mr. P was battling to understand and accept this model and his family struggled to understand his need for independence. In addition to regular sessions with the patient, the treatment team also met with his parents. The treatment team was multiracial: the two physicians (VR and DR) were South Asians and the therapist (SK) was a non-South Asian American. The treatment team worked in unison, discussed the pros and cons of each of the issues raised by the patient and family from both the Eastern and Western perspectives and provided a neutral humanistic approach to treatment, with an emphasis on minimizing his disability, maximizing his productivity and improving his overall satisfaction with life. His culture might have also played a role in his and his family’s perception of recovery and how the adjustments to his new life were experienced differently. While studies have looked at the impact of culture on TBI recovery (Arango-Lasprilla et al., 2007; Gary et al., 2009), the sample populations studied were African American and Latino, no studies have looked at Indian culture and its impact on recovery. Mr. P’s parents attended sessions regularly. Both the patient and family were very comfortable with pharmacological management but had some initial resistance to psychotherapy. However, with time, and as sessions continued, they became more comfortable about discussing Eastern versus Western family values. They also became more accepting of the need and importance of respecting and reconciling cultural differences. The team’s strength as a multidisciplinary/bicultural group helped in better understanding the patient’s and the parents issues
and in keeping the management strategies balanced, neutral, and geared towards the individual. What is most striking is how the cultural values in Mr. P’s presentation directly impacted the outcomes of his symptomatology and treatment. On one hand, due to the stigma of mental illness and reluctance to accept depression as a true entity, Mr. P and his family were initially reluctant to engage in psychotherapy that was a critical component of the treatment. On the other hand, it is evident that these same cultural values clearly affected Mr. P’s depressive syndrome in a protective way, which might be attributed to the collectivist thinking as described above. Specifically, Mr. P had chronic passive suicidal thoughts, yet consistently had strong cultural beliefs that suicide would dishonor and bring shame to his family. Suicide is not actively discouraged in Hinduism. Souls are considered to be given life by God and exist even after death, and reincarnation occurs as a result of cycling from lower through higher forms of life. Rooted within reincarnation is karma, which is the bond across time concerned with morality and cause and effect. Completing suicide to escape suffering is generally not condoned within the Hindu faith, though some holy men have condoned it based on interpretive religious beliefs (Richards and Bergin, 2000; Leong et al., 2007). This concept may be a protective entity which might discourage Indian patients from suicidal thoughts and behaviors. During therapy, when questioned about his suicidal thoughts, he responded that suicide would go against the cultural expectations; suicide reflected weakness and not strength, and that harming himself would in turn result in negative consequences in the next life (the concept of karma). These factors positively influenced Mr. P’s self-directed outcomes amidst a severe depression.
4. Summary Mr. P has several components in his history which may contribute to and explain his depressive symptomatology. He has known biological factors from a brain injury that may explain much of his depressive syndrome, cluster B personality traits that became more prominent after injury and were challenging to the family and treatment team and finally, a very strong South Asian cultural background that played an important role in the maintenance of his depressive symptoms but also protected him from self-harm. The goal in describing this case is not to make any firm rules regarding the evaluation and treatment of South Asians with mental illness, but rather to stress the importance of having a cross-cultural mindset as this can have an enormous impact in formulation and management. Acknowledgment This literature review was supported in part by grant from the Department of Defense W81XWH-13-1-0469.
References Hwang, W.C., Myers, H.F., Abe-Kim, J., Ting, J.Y., 2008. A conceptual paradigm for understanding culture’s impact on mental health: the cultural influences on mental health (CIMH) model. Clin. Psychol. Rev. 28 (2 (Feb)), 211–227. Tavkar, P., Iyer, S.N., Hansen, D.J., 2008. Barriers to mental health services for Asian Indians in America. In: Poster presented at the 42nd Annual Convention of the Association for Behavioral and Cognitive Therapies, Orlando, FL. Segal, U.A., 1998. The Asian Indian-American family. In: Mindel, C.H., Habenstein, R.W., Wright, Jr., R. (Eds.), Ethnic Families in America: Patterns and Variation. 4th ed. Prentice-Hall, Upper Saddle River, NJ.
D. Roy et al. / Asian Journal of Psychiatry 13 (2015) 56–61 Bhattacharya, G., Schoppelrey, S.L., 2004. Preimmigration beliefs of life success, postimmigration experiences, and acculturative stress: South Asian immigrants in the United States. J. Immigr. Health 6 (2 (Apr)), 83–92. Wong, Y.J., Kim, B.S., Nguyen, C.P., Cheng, J.K., Saw, A., 2014. The interpersonal shame inventory for Asian Americans: scale development and psychometric properties. J. Couns. Psychol. 61 (1 (Jan)), 119–132. Singh, S., Manjula, M., Philip, M., 2012. Suicidal risk and childhood adversity: a study of Indian college students. Asian J. Psychiatr. 5 (2(Jun)), 154–159. Conrad, M.M., Pacquiao, D.F., 2005. Manifestation, attribution, and coping with depression among Asian Indians from the perspectives of health care practitioners. J. Transcult. Nurs. 16, 32–40. Engel, G.L., 1980. The clinical application of the biopsychosocial model. Am. J. Psychiatry 137 (5 (May)), 535–544. Lewis-Fernandez, R., Diaz, N., 2002. The cultural formulation: a method for assessing cultural factors affecting the clinical encounter. Psychiatr. Q. 73 (4 (Winter)), 271–295. Mezzich, J.E., Caracci, G., Fabrega Jr., H., Kirmayer, L.J., 2009. Cultural formulation guidelines. Transcult. Psychiatry 46 (3 (Sep)), 383–405. Jorge, R.E., Starkstein, S.E., 2005. Pathophysiologic aspects of major depression following traumatic brain injury. J. Head Trauma Rehabil. 20 (6 (Nov–Dec)), 475–487.
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Fann, J.R., Hart, T., Schomer, K.G., 2009. Treatment for depression after traumatic brain injury: a systematic review. J. Neurotrauma 26 (12 (Dec)), 2383–2402. Neurobehavioral Guidelines Working Group, Warden, D.L., Gordon, B., McAllister, T.W., Silver, J.M., Barth, J.T., et al., 2006. Guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury. J. Neurotrauma 23 (10 (Oct)), 1468–1501. Treisman, G.J., Angelino, A.F., 2004. The Psychiatry of AIDS. Johns Hopkins University Press, Baltimore, pp. 80–85. Kramer, E.J., Kwong, K., Lee, E., Chung, H., 2002. Cultural factors influencing the mental health of Asian Americans. West J. Med. 176 (4 (Sep)), 227–231. Arango-Lasprilla, J.C., Rosenthal, M., Deluca, J., Komaroff, E., Sherer, M., Cifu, D., et al., 2007. Traumatic brain injury and functional outcomes: does minority status matter? Brain Inj. 21 (7 (Jun)), 701–708. Gary, K.W., Arango-Lasprilla, J.C., Stevens, L.F., 2009. Do racial/ethnic differences exist in post-injury outcomes after TBI? A comprehensive review of the literature. Brain Inj. 23 (10 (Sep)), 775–789. Richards, P.S., Bergin, A.E., 2000. Handbook of Psychotherapy and Religious Diversity. American Psychological Association, Washington, DC. Leong, F.T., Leach, M.M., Yeh, C., Chou, E., 2007. Suicide among Asian Americans: what do we know? What do we need to know?. Death Stud. 31 (5 (May–Jun)), 417–434.