Ethnic and cultural perspectives in psychopharmacology

Culture and ethnicity represent indispensable dimensions in patient care. Reflecting their cultural and personal backgrounds, patients’ concepts on the cause and course of illnesses and treatment expectations often diverge substantially from their physicians deeply immersed in biomedical traditions directing their attention, assessment, and treatment goals. Such discrepancies, pervasive in most clinical encounters, further aggravated where patients and physicians come from distinct cultural systems, contribute to clinically significant nonadherence and placebo response. Efforts in exploring and bridging such gaps are crucial in enhancing therapeutic alliance, treatment engagement, optimization of placebo response, and thus better outcome. At the same time, cross-ethnic variations in pharmacological responses, caused by both genetic and epigenetic factors, are also ubiquitous and clinically significant. Genes controlling both pharmacokinetics and pharmacodynamics are highly polymorphic, whose patterns vary across ethnicity. Superimposed on such genetic variations, exposure to various xenobiotics including herbs, as well as psychosocial stresses, also affect drug responses through pharmacokinetic and pharmacodynamic mechanisms. The rapidly developing fields of pharmacogenetics and pharmacogenomics hold promise for clinicians to take both genetic and epigenetic factors into consideration at the same time, in order to predict the dosing, side-effect profiles, and efficacy of psychiatric medications. Ethnicity is an important dimension in the construction of such pharmacogenomic panels and in interpreting testing results. Finally, while striving to be cognizant of the importance of culture and ethnicity in clinical care, clinicians should also be mindful of the fact that cross-ethnic variations are embedded in interindividual variations and guard against the pitfalls of stereotyping.