David Krassner, MD

HISTORY: REPEAT OFFENDER

Mr. V, age 68, was incarcerated for 13 years for two separate pedophilia convictions. During that time, he passed numerous rehabilitative courses. With several years left on his sentence, he was paroled on condition that he undergo a bilateral orchiectomy.

Eight months later, Mr. V complained to his primary care physician that he could not have sex with his girlfriend, even after taking 50 mg of sildenafil, which he had obtained from a friend. He requested testosterone injections to allow him to have intercourse. After consulting an endocrinologist, the physician ordered Mr. V to undergo a psychiatric assessment before receiving testosterone. He was referred to our outpatient clinic.

During our evaluation, Mr. V described both pedophilia incidents. In the first, he had fondled a 14-year-old girl who was a friend of his family. He pled guilty to a charge of inappropriate sexual contact with a minor and was sentenced to 3 years in a state prison for sex offenders.

Less than 2 years after he was paroled, Mr. V said, he fondled his 12-year-old granddaughter. He said his daughter “should have known better” than to leave him home alone with the child. Again he was convicted of illegal sexual relations with a minor and sentenced to 10 years at the state hospital for the criminally insane.

As Mr. V describes his past offenses, we begin feeling tremendously uneasy. Although forthcoming, he blandly denies responsibility for either incident. He acknowledges that society views his actions as wrong, but he never indicates that he believes them to be wrong. At times he tries to normalize his behavior, saying “What man would have acted differently?”

Mr. V is polite and appropriate and promises to abide by our recommendation, yet he sees no reason for us to deny his request and no connection between his criminal record and the nature of his crimes or the terms of his parole. His denial and lack of insight are typical of convicted pedophiles (Box 1).

Box 1

The authors’ observations

Anyone evaluating Mr. V would be inclined to treat or dismiss him, or to suppress his or her feelings to avoid prejudice.

Treat or dismiss. As physicians, we are trained to “First, do no harm.” In this case, however, we must consider who could be harmed by treatment or dismissal.

“First, do no harm” is usually taken to mean “no harm to the patient” but could also be interpreted as “no harm to society.” Even if testosterone treatment did not physically harm Mr. V, activating his sex drive could endanger society by spurring him on to molest another child (Box 2). The treatment could also harm Mr. V by making it easier for him to violate parole.

Although failure to treat Mr. V’s sexual dysfunction would likely pose no harm to society, not assessing him might endanger society by clearing the path toward this treatment.

Box 2

When treating patients such as Mr. V, we must not dismiss our feelings—however uncomfortable or unprofessional they might seem—so that we can manage them appropriately. Don’t be ashamed of your feelings—or at least be aware of your shame.

In such cases, these important steps can minimize the risk of compromising treatment or assessment:

• Be aware of your feelings. Reflecting on countertransference after the session, either alone or with other therapists, can help you recognize your feelings.
  
• Seek peer supervision when evaluating a patient such as Mr. V to help identify potential “blind spots.”
  
• Be aware of your limitations. Hubris is among a therapist’s most serious potential pitfalls. We all have strengths and weaknesses and should be mindful of them.
  

The authors’ observations

We took a passive-neutral stance. Sitting with Mr. V without deciding a course of action gave us time to assess our own reactions and limitations and how they might influence our actions.

CONSULTATION: OTHER OPINIONS

The examining psychiatrist (a psychiatric resident) sought advice from an experienced geriatric psychiatrist, a neuropsychologist, and other residents. We discussed our countertransference toward Mr. V and provided mutual supervision. We then acknowledged that none of us had expertise in treating pedophiles and that treating an unfamiliar mental condition would be unethical.

The authors’ observations

In requesting other opinions, we also weighed these important questions:

Is Mr. V violating parole by requesting testosterone injections and taking (unprescribed) sildenafil? We felt we could not rightfully answer this question, since our expertise in the standard of care for patients such as Mr. V was insufficient and any recommendation would be ill-informed.

Sildenafil use is fairly common among convicted sex offenders, as evidenced by the recent controversy over Medicaid providing the drug to this group (see Related resources).

Assuming the testosterone injections promote intercourse, would they increase Mr. V’s arousal? Hall found that offenders who can voluntarily and completely inhibit sexual arousal are less deviant when not attempting to inhibit arousal than are those who cannot completely inhibit arousal.⁸

Hall, however, urges clinicians to consider variables that influence sexual response before determining how arousal affects an offender’s behavior. With no objective measure of sexual arousal, it is unclear whether increasing Mr. V’s testosterone would heighten it—and his potential threat to society.

The Abel Assessment of Sexual Interest was devised to determine sexual pathology, but evidence suggests this test is clinically unreliable.

Would enhancing Mr. V’s arousal increase his risk of recidivism? Although some studies have found that castration decreases a sex offender’s sexual activity, evidence suggests that sexual responsiveness after castration varies considerably. Heim found that:

• 31% of castrates could still have intercourse
  
• rapists are more sexually active than pedophiles after castration
  
• men ages 46 to 59 experience a greater reduction in sexual behavior than do men age 9
  

What standard of care applies to Mr. V? Treating pedophilia is difficult and poorly understood. Psychotherapy is considered an adjunct to medication or surgery. Surgical interventions are akin to punishment, whereas medications—well-studied and often augmented with psychotherapy—are associated with high recidivism rates.^11,14

Surgery. Orchiectomy is by far the most common surgical intervention. Experimental procedures have targeted stereotaxic ablation of specific parts of the brain, usually the hypothalamus or amygdala, but these techniques have not been adequately studied in humans.¹¹ Even so, testosterone therapy can restore sexual function after castration.¹⁰

Medications. Antiandrogens such as medroxy-progesterone acetate (MPA) inhibit intracellular uptake of androgens (such as testosterone) by blocking their binding to the receptor.¹² MPA is most frequently used in the United States.

Long-acting analogs of gonadotropin-releasing hormone (GnRH), such as leuprolide, nafarelin, goserelin, and triptorelin, have shown efficacy in early studies.¹² These agents down-regulate gonadotroph cells, inducing severe but reversible hypogonadism with few other side effects.

Although decreased libido is a common side effect of selective serotonin reuptake inhibitors (SSRIs), use of these agents to reduce sex drive in convicted pedophiles has not been studied. Because onset of decreased libido with SSRI use is unpredictable, we cannot recommend their use to reduce sex drive in convicted offenders.

Psychotherapy. Power¹⁴ nicely outlines the elements of psychotherapy for pedophilia:

• explanation and education
  
• manipulating the environment
  
• suggestion, including hypnosis and persuasion
  
• superficial analysis
  
• deep-transference analysis
  
• sublimation.
  

• Sentencing laws are often unclear or do not take into account scientific research on pedophilia. For example, psychological testing often is not ordered before a treatment is mandated, even though knowing the patient’s psychological profile and the nature of his predilections are crucial to treatment and prognosis.¹²
  
• Many laws do not suggest an instrument of implementation. For example, most laws that mandate a patient evaluation do not specify whether a licensed psychiatrist, psychologist, or other clinician should evaluate the patient.
  
• Many laws directed against pedophilia are punitive in nature. Mandated treatment—or the informed consent that precedes it—is often inadequate,¹⁰ and physicians can be held liable in either case. However, we could not determine the liability that could result from enhancing a convicted pedophile’s libido.
  

REFERRAL: TREATMENT ADVICE

We referred Mr. V back to his primary care physician and advised the doctor to:

• discuss the testosterone treatment request with physicians who treated Mr. V at the state prison
  
• call our hospital’s attorney to investigate the legal implications of treating Mr. V.
  

Related resources

• Sex offenders get Medicaid-paid Viagra. Associated Press May 22, 2005. http://msnbc.msn.com/id/7946129/.
  
• Conte JR, Wolf S, Smith T. What sexual offenders tell us about prevention strategies. Child Abuse Negl 1989;13:293-301.
  
• U.S. Department of Justice, Bureau of Justice Statistics. Statistics on sex offenders and victims. www.ojp.usdoj.gov/bjs/abstract/saycrle.htm.
  

• Goserelin • Zoladex
  
• Leuprolide • Eligard, others
  
• Medroxyprogesterone acetate • Depo-Provera, others
  
• Nafarelin • Synarel
  
• Sildenafil • Viagra
  
• Triptorelin • Trelstar Depot
  

The authors thank Cynthia Meyer, chief librarian, VA Hospital, Fresno, CA, for her help with researching this article.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

HISTORY: REPEAT OFFENDER

Mr. V, age 68, was incarcerated for 13 years for two separate pedophilia convictions. During that time, he passed numerous rehabilitative courses. With several years left on his sentence, he was paroled on condition that he undergo a bilateral orchiectomy.

Eight months later, Mr. V complained to his primary care physician that he could not have sex with his girlfriend, even after taking 50 mg of sildenafil, which he had obtained from a friend. He requested testosterone injections to allow him to have intercourse. After consulting an endocrinologist, the physician ordered Mr. V to undergo a psychiatric assessment before receiving testosterone. He was referred to our outpatient clinic.

During our evaluation, Mr. V described both pedophilia incidents. In the first, he had fondled a 14-year-old girl who was a friend of his family. He pled guilty to a charge of inappropriate sexual contact with a minor and was sentenced to 3 years in a state prison for sex offenders.

Less than 2 years after he was paroled, Mr. V said, he fondled his 12-year-old granddaughter. He said his daughter “should have known better” than to leave him home alone with the child. Again he was convicted of illegal sexual relations with a minor and sentenced to 10 years at the state hospital for the criminally insane.

As Mr. V describes his past offenses, we begin feeling tremendously uneasy. Although forthcoming, he blandly denies responsibility for either incident. He acknowledges that society views his actions as wrong, but he never indicates that he believes them to be wrong. At times he tries to normalize his behavior, saying “What man would have acted differently?”

Mr. V is polite and appropriate and promises to abide by our recommendation, yet he sees no reason for us to deny his request and no connection between his criminal record and the nature of his crimes or the terms of his parole. His denial and lack of insight are typical of convicted pedophiles (Box 1).

Box 1

The authors’ observations

Anyone evaluating Mr. V would be inclined to treat or dismiss him, or to suppress his or her feelings to avoid prejudice.

Treat or dismiss. As physicians, we are trained to “First, do no harm.” In this case, however, we must consider who could be harmed by treatment or dismissal.

“First, do no harm” is usually taken to mean “no harm to the patient” but could also be interpreted as “no harm to society.” Even if testosterone treatment did not physically harm Mr. V, activating his sex drive could endanger society by spurring him on to molest another child (Box 2). The treatment could also harm Mr. V by making it easier for him to violate parole.

Although failure to treat Mr. V’s sexual dysfunction would likely pose no harm to society, not assessing him might endanger society by clearing the path toward this treatment.

Box 2

When treating patients such as Mr. V, we must not dismiss our feelings—however uncomfortable or unprofessional they might seem—so that we can manage them appropriately. Don’t be ashamed of your feelings—or at least be aware of your shame.

In such cases, these important steps can minimize the risk of compromising treatment or assessment:

• Be aware of your feelings. Reflecting on countertransference after the session, either alone or with other therapists, can help you recognize your feelings.
  
• Seek peer supervision when evaluating a patient such as Mr. V to help identify potential “blind spots.”
  
• Be aware of your limitations. Hubris is among a therapist’s most serious potential pitfalls. We all have strengths and weaknesses and should be mindful of them.
  

The authors’ observations

We took a passive-neutral stance. Sitting with Mr. V without deciding a course of action gave us time to assess our own reactions and limitations and how they might influence our actions.

CONSULTATION: OTHER OPINIONS

The examining psychiatrist (a psychiatric resident) sought advice from an experienced geriatric psychiatrist, a neuropsychologist, and other residents. We discussed our countertransference toward Mr. V and provided mutual supervision. We then acknowledged that none of us had expertise in treating pedophiles and that treating an unfamiliar mental condition would be unethical.

The authors’ observations

In requesting other opinions, we also weighed these important questions:

Is Mr. V violating parole by requesting testosterone injections and taking (unprescribed) sildenafil? We felt we could not rightfully answer this question, since our expertise in the standard of care for patients such as Mr. V was insufficient and any recommendation would be ill-informed.

Sildenafil use is fairly common among convicted sex offenders, as evidenced by the recent controversy over Medicaid providing the drug to this group (see Related resources).

Assuming the testosterone injections promote intercourse, would they increase Mr. V’s arousal? Hall found that offenders who can voluntarily and completely inhibit sexual arousal are less deviant when not attempting to inhibit arousal than are those who cannot completely inhibit arousal.⁸

Hall, however, urges clinicians to consider variables that influence sexual response before determining how arousal affects an offender’s behavior. With no objective measure of sexual arousal, it is unclear whether increasing Mr. V’s testosterone would heighten it—and his potential threat to society.

The Abel Assessment of Sexual Interest was devised to determine sexual pathology, but evidence suggests this test is clinically unreliable.

Would enhancing Mr. V’s arousal increase his risk of recidivism? Although some studies have found that castration decreases a sex offender’s sexual activity, evidence suggests that sexual responsiveness after castration varies considerably. Heim found that:

• 31% of castrates could still have intercourse
  
• rapists are more sexually active than pedophiles after castration
  
• men ages 46 to 59 experience a greater reduction in sexual behavior than do men age 9
  

What standard of care applies to Mr. V? Treating pedophilia is difficult and poorly understood. Psychotherapy is considered an adjunct to medication or surgery. Surgical interventions are akin to punishment, whereas medications—well-studied and often augmented with psychotherapy—are associated with high recidivism rates.^11,14

Surgery. Orchiectomy is by far the most common surgical intervention. Experimental procedures have targeted stereotaxic ablation of specific parts of the brain, usually the hypothalamus or amygdala, but these techniques have not been adequately studied in humans.¹¹ Even so, testosterone therapy can restore sexual function after castration.¹⁰

Medications. Antiandrogens such as medroxy-progesterone acetate (MPA) inhibit intracellular uptake of androgens (such as testosterone) by blocking their binding to the receptor.¹² MPA is most frequently used in the United States.

Long-acting analogs of gonadotropin-releasing hormone (GnRH), such as leuprolide, nafarelin, goserelin, and triptorelin, have shown efficacy in early studies.¹² These agents down-regulate gonadotroph cells, inducing severe but reversible hypogonadism with few other side effects.

Although decreased libido is a common side effect of selective serotonin reuptake inhibitors (SSRIs), use of these agents to reduce sex drive in convicted pedophiles has not been studied. Because onset of decreased libido with SSRI use is unpredictable, we cannot recommend their use to reduce sex drive in convicted offenders.

Psychotherapy. Power¹⁴ nicely outlines the elements of psychotherapy for pedophilia:

• explanation and education
  
• manipulating the environment
  
• suggestion, including hypnosis and persuasion
  
• superficial analysis
  
• deep-transference analysis
  
• sublimation.
  

• Sentencing laws are often unclear or do not take into account scientific research on pedophilia. For example, psychological testing often is not ordered before a treatment is mandated, even though knowing the patient’s psychological profile and the nature of his predilections are crucial to treatment and prognosis.¹²
  
• Many laws do not suggest an instrument of implementation. For example, most laws that mandate a patient evaluation do not specify whether a licensed psychiatrist, psychologist, or other clinician should evaluate the patient.
  
• Many laws directed against pedophilia are punitive in nature. Mandated treatment—or the informed consent that precedes it—is often inadequate,¹⁰ and physicians can be held liable in either case. However, we could not determine the liability that could result from enhancing a convicted pedophile’s libido.
  

REFERRAL: TREATMENT ADVICE

We referred Mr. V back to his primary care physician and advised the doctor to:

• discuss the testosterone treatment request with physicians who treated Mr. V at the state prison
  
• call our hospital’s attorney to investigate the legal implications of treating Mr. V.
  

Related resources

• Sex offenders get Medicaid-paid Viagra. Associated Press May 22, 2005. http://msnbc.msn.com/id/7946129/.
  
• Conte JR, Wolf S, Smith T. What sexual offenders tell us about prevention strategies. Child Abuse Negl 1989;13:293-301.
  
• U.S. Department of Justice, Bureau of Justice Statistics. Statistics on sex offenders and victims. www.ojp.usdoj.gov/bjs/abstract/saycrle.htm.
  

• Goserelin • Zoladex
  
• Leuprolide • Eligard, others
  
• Medroxyprogesterone acetate • Depo-Provera, others
  
• Nafarelin • Synarel
  
• Sildenafil • Viagra
  
• Triptorelin • Trelstar Depot
  

The authors thank Cynthia Meyer, chief librarian, VA Hospital, Fresno, CA, for her help with researching this article.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

HISTORY: REPEAT OFFENDER

Mr. V, age 68, was incarcerated for 13 years for two separate pedophilia convictions. During that time, he passed numerous rehabilitative courses. With several years left on his sentence, he was paroled on condition that he undergo a bilateral orchiectomy.

Eight months later, Mr. V complained to his primary care physician that he could not have sex with his girlfriend, even after taking 50 mg of sildenafil, which he had obtained from a friend. He requested testosterone injections to allow him to have intercourse. After consulting an endocrinologist, the physician ordered Mr. V to undergo a psychiatric assessment before receiving testosterone. He was referred to our outpatient clinic.

During our evaluation, Mr. V described both pedophilia incidents. In the first, he had fondled a 14-year-old girl who was a friend of his family. He pled guilty to a charge of inappropriate sexual contact with a minor and was sentenced to 3 years in a state prison for sex offenders.

Less than 2 years after he was paroled, Mr. V said, he fondled his 12-year-old granddaughter. He said his daughter “should have known better” than to leave him home alone with the child. Again he was convicted of illegal sexual relations with a minor and sentenced to 10 years at the state hospital for the criminally insane.

As Mr. V describes his past offenses, we begin feeling tremendously uneasy. Although forthcoming, he blandly denies responsibility for either incident. He acknowledges that society views his actions as wrong, but he never indicates that he believes them to be wrong. At times he tries to normalize his behavior, saying “What man would have acted differently?”

Mr. V is polite and appropriate and promises to abide by our recommendation, yet he sees no reason for us to deny his request and no connection between his criminal record and the nature of his crimes or the terms of his parole. His denial and lack of insight are typical of convicted pedophiles (Box 1).

Box 1

The authors’ observations

Anyone evaluating Mr. V would be inclined to treat or dismiss him, or to suppress his or her feelings to avoid prejudice.

Treat or dismiss. As physicians, we are trained to “First, do no harm.” In this case, however, we must consider who could be harmed by treatment or dismissal.

“First, do no harm” is usually taken to mean “no harm to the patient” but could also be interpreted as “no harm to society.” Even if testosterone treatment did not physically harm Mr. V, activating his sex drive could endanger society by spurring him on to molest another child (Box 2). The treatment could also harm Mr. V by making it easier for him to violate parole.

Although failure to treat Mr. V’s sexual dysfunction would likely pose no harm to society, not assessing him might endanger society by clearing the path toward this treatment.

Box 2

When treating patients such as Mr. V, we must not dismiss our feelings—however uncomfortable or unprofessional they might seem—so that we can manage them appropriately. Don’t be ashamed of your feelings—or at least be aware of your shame.

In such cases, these important steps can minimize the risk of compromising treatment or assessment:

• Be aware of your feelings. Reflecting on countertransference after the session, either alone or with other therapists, can help you recognize your feelings.
  
• Seek peer supervision when evaluating a patient such as Mr. V to help identify potential “blind spots.”
  
• Be aware of your limitations. Hubris is among a therapist’s most serious potential pitfalls. We all have strengths and weaknesses and should be mindful of them.
  

The authors’ observations

We took a passive-neutral stance. Sitting with Mr. V without deciding a course of action gave us time to assess our own reactions and limitations and how they might influence our actions.

CONSULTATION: OTHER OPINIONS

The examining psychiatrist (a psychiatric resident) sought advice from an experienced geriatric psychiatrist, a neuropsychologist, and other residents. We discussed our countertransference toward Mr. V and provided mutual supervision. We then acknowledged that none of us had expertise in treating pedophiles and that treating an unfamiliar mental condition would be unethical.

The authors’ observations

In requesting other opinions, we also weighed these important questions:

Is Mr. V violating parole by requesting testosterone injections and taking (unprescribed) sildenafil? We felt we could not rightfully answer this question, since our expertise in the standard of care for patients such as Mr. V was insufficient and any recommendation would be ill-informed.

Sildenafil use is fairly common among convicted sex offenders, as evidenced by the recent controversy over Medicaid providing the drug to this group (see Related resources).

Assuming the testosterone injections promote intercourse, would they increase Mr. V’s arousal? Hall found that offenders who can voluntarily and completely inhibit sexual arousal are less deviant when not attempting to inhibit arousal than are those who cannot completely inhibit arousal.⁸

Hall, however, urges clinicians to consider variables that influence sexual response before determining how arousal affects an offender’s behavior. With no objective measure of sexual arousal, it is unclear whether increasing Mr. V’s testosterone would heighten it—and his potential threat to society.

The Abel Assessment of Sexual Interest was devised to determine sexual pathology, but evidence suggests this test is clinically unreliable.

Would enhancing Mr. V’s arousal increase his risk of recidivism? Although some studies have found that castration decreases a sex offender’s sexual activity, evidence suggests that sexual responsiveness after castration varies considerably. Heim found that:

• 31% of castrates could still have intercourse
  
• rapists are more sexually active than pedophiles after castration
  
• men ages 46 to 59 experience a greater reduction in sexual behavior than do men age 9
  

What standard of care applies to Mr. V? Treating pedophilia is difficult and poorly understood. Psychotherapy is considered an adjunct to medication or surgery. Surgical interventions are akin to punishment, whereas medications—well-studied and often augmented with psychotherapy—are associated with high recidivism rates.^11,14

Surgery. Orchiectomy is by far the most common surgical intervention. Experimental procedures have targeted stereotaxic ablation of specific parts of the brain, usually the hypothalamus or amygdala, but these techniques have not been adequately studied in humans.¹¹ Even so, testosterone therapy can restore sexual function after castration.¹⁰

Medications. Antiandrogens such as medroxy-progesterone acetate (MPA) inhibit intracellular uptake of androgens (such as testosterone) by blocking their binding to the receptor.¹² MPA is most frequently used in the United States.

Long-acting analogs of gonadotropin-releasing hormone (GnRH), such as leuprolide, nafarelin, goserelin, and triptorelin, have shown efficacy in early studies.¹² These agents down-regulate gonadotroph cells, inducing severe but reversible hypogonadism with few other side effects.

Although decreased libido is a common side effect of selective serotonin reuptake inhibitors (SSRIs), use of these agents to reduce sex drive in convicted pedophiles has not been studied. Because onset of decreased libido with SSRI use is unpredictable, we cannot recommend their use to reduce sex drive in convicted offenders.

Psychotherapy. Power¹⁴ nicely outlines the elements of psychotherapy for pedophilia:

• explanation and education
  
• manipulating the environment
  
• suggestion, including hypnosis and persuasion
  
• superficial analysis
  
• deep-transference analysis
  
• sublimation.
  

• Sentencing laws are often unclear or do not take into account scientific research on pedophilia. For example, psychological testing often is not ordered before a treatment is mandated, even though knowing the patient’s psychological profile and the nature of his predilections are crucial to treatment and prognosis.¹²
  
• Many laws do not suggest an instrument of implementation. For example, most laws that mandate a patient evaluation do not specify whether a licensed psychiatrist, psychologist, or other clinician should evaluate the patient.
  
• Many laws directed against pedophilia are punitive in nature. Mandated treatment—or the informed consent that precedes it—is often inadequate,¹⁰ and physicians can be held liable in either case. However, we could not determine the liability that could result from enhancing a convicted pedophile’s libido.
  

REFERRAL: TREATMENT ADVICE

We referred Mr. V back to his primary care physician and advised the doctor to:

• discuss the testosterone treatment request with physicians who treated Mr. V at the state prison
  
• call our hospital’s attorney to investigate the legal implications of treating Mr. V.
  

Related resources

• Sex offenders get Medicaid-paid Viagra. Associated Press May 22, 2005. http://msnbc.msn.com/id/7946129/.
  
• Conte JR, Wolf S, Smith T. What sexual offenders tell us about prevention strategies. Child Abuse Negl 1989;13:293-301.
  
• U.S. Department of Justice, Bureau of Justice Statistics. Statistics on sex offenders and victims. www.ojp.usdoj.gov/bjs/abstract/saycrle.htm.
  

• Goserelin • Zoladex
  
• Leuprolide • Eligard, others
  
• Medroxyprogesterone acetate • Depo-Provera, others
  
• Nafarelin • Synarel
  
• Sildenafil • Viagra
  
• Triptorelin • Trelstar Depot
  

The authors thank Cynthia Meyer, chief librarian, VA Hospital, Fresno, CA, for her help with researching this article.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

History: Noncompliance and ‘resignation’

Mr. V, 43, has a history of diabetes. He was admitted to the hospital with altered mental status as manifested by confusion, fluctuating sensorium, and disorientation. His altered mental status was most likely caused by septicemia secondary to osteomyelitis from a right plantar foot ulcer that had become necrotic, tracking through the foot bones into the tibia and fibula.

An emergent amputation was performed of the right tibia and fibula approximately 15 cm distal to the patella, with intent to close the wound within 24 to 48 hours; Mr. V also was started on IV antibiotics. The patient, however, refused the closure procedure, stating that he had not been properly informed before the amputation and would not consent to another procedure until he could speak with his elder brothers.

The surgical team noted that Mr. V had signed the consent form before the amputation. The surgeons also feared that not closing the wound promptly could lead to reinfection, further limb loss, or even death.

The hospital’s psychiatric consultation service was asked to determine the patient’s mental capacity. It should be noted that Mr. V emigrated to the United States from a Laotian refugee camp 12 years prior to admission. He speaks only Hmong, the language of the Hmong people indigenous to Southeast Asia.

Mr. V was diagnosed 12 years ago with insulin-dependent diabetes mellitus and has been hospitalized numerous times for foot ulcers. His chart indicates that he has repeatedly disregarded doctors’ orders and has not performed proper foot hygiene.

Previous physicians and caregivers, however, were even more frustrated with the apparent attitude of resignation with which Mr. V has approached his diabetes. He seems to believe that his medical condition is causing his problems and that he cannot prevent diabetic sequelae. He has no history of mental disorders and to our knowledge had never received a psychiatric evaluation.

Why has Mr. V. not complied with diabetes treatment? Is he unable to understand the gravity of his condition?

Dr. Krassner’s observations

Noncompliance is a recurring theme in the treatment of Hmong patients,^1-4 as is clinician frustration with their lack of compliance.^5,6 This suggests that cultural differences that could have contributed to Mr. V’s noncompliance need to be examined before determining his mental state.

Approaching a culturally sensitive case with an open mind and a respectful attitude will increase the chances of a positive outcome and provide a valuable learning experience for the clinician. You might proceed as follows:

Question your assumptions. Some clinicians assume that psychiatry applies universally to any patient, regardless of cultural background. However, the categories psychiatry imposes on illnesses may not adequately describe an illness as a patient of a different culture experiences it.^7-9

Find an interpreter—one who speaks the language and has a “lexicon for emotional experience” similar to the patient’s.¹⁰ In this case, we wanted an interpreter who not only spoke Hmong, but who understood the complexities of the animistic Hmong spirituality and could reconcile it with our empirically derived Western belief system.

Depending on a family member to translate can be problematic if that person cannot accurately explain the patient’s disorder, the need for treatment, or the implications of noncompliance. We found the ideal interpreter: a Hmong registered nurse. If you cannot find an interpreter of the same ethnicity as the patient, at least find one who speaks the same language.

Beware of misinterpretation. A patient from another culture who understands some English may not assign the same meaning to words or phrases that we do. For example, when a Hmong says yes, he or she means, “I am listening, and I respect what you’re saying.” In this way, “yes” can be mistaken for consent; noncompliance by Hmong patients can often be traced to this misinterpretation.¹¹

Define “capacity” and its implications. Capacity is always assessed in the context of the question, “capacity to do what?” The context must be explicitly identified, because life decisions require varying levels of capacity. For example, elderly patients with dementia often lack capacity to manage their finances, but have capacity to resolve end-of-life issues (e.g., hospice placement, do-not-resuscitate requests).

For Mr. V, the question was whether he had capacity to refuse the second surgery. To have capacity to consent to or refuse a procedure, a patient must understand the procedure, its risks and benefits, and the risks and benefits of refusing the procedure. The patient also must not be vulnerable to coercion (e.g., by a family member).

Clearly, Mr. V understood the procedure based on his notions of health, illness, life, death, family, social structure, and other concepts.^6,12,13 One might question whether a patient such as Mr. V is ever fully informed before giving consent. Even though he had signed a consent form for the amputation, the signature in his eyes did not qualify as consent. Further, having read through our hospital’s consent form, I defy anyone to translate its legal subtleties into Hmong.

Perhaps even more important, the Hmong adhere to a strict social hierarchy: males are held in higher esteem than females, the elderly higher than the young.^6,11,14 Therefore, Mr. V’s desire to ask his brothers for advice before consenting to surgery makes sense within his cultural norms and was not a stalling tactic as the surgeons believed.

Try to understand the patient’s concept of illness. We found Mr. V to have capacity within the confines of his medical understanding. He knew the operation was major surgery, and he wanted to consult with his elder brothers—all eight of them (most of whom live in Minneapolis)—prior to consenting. Conversely, the surgeons could think only within the confines of their cultural and clinical understanding. They wanted to perform the procedure expediently to avoid additional diabetic sequelae.

We discussed these concerns with the patient and surgeons and struck a compromise: the surgeons agreed to defer surgery for 10 days, as long as Mr. V indemnified them against complications secondary to the delay. After that, the surgery would be performed regardless of whether Mr. V had consulted his brothers. Mr. V also agreed to continue IV antibiotic therapy. This compliance is not paradoxical: the Hmong often accept antibiotics because of their relatively rapid efficacy.⁶

For clinicians wishing to understand the Hmong and their view of illness, Anne Fadiman’s The Spirit Catches You and You Fall Down is an excellent resource.⁶ Kleinman’s seminal work on treating patients from other cultures also emphasizes the importance of eliciting the patient’s understanding in order to diagnose and negotiate treatment.¹⁵ Several good textbooks address transcultural patient care; curiously, most are nursing rather than physician texts (see “Related resources,”).

Treatment: Recovery’s rocky road

Closure was delayed for 8 days, during which no complications arose. Mr. V tolerated the antibiotics well. He contracted a low-grade fever at times, but septicemia did not re-emerge.

We continued to follow the patient, who on several occasions became delirious. He was neither violent nor agitated, so he was not treated with neuroleptics, which can cause delirium in Hmong patients.^3,4

The patient contacted his brothers and consented to closure surgery, after which he recuperated well for 3 days. On day four, however, he developed respiratory failure. He was resuscitated, intubated, and transferred to the intensive care unit. He was extubated and returned to the floor 24 hours later, at which time he appeared despondent. He exhibited depressed mood, blunted affect, anorexia, anhedonia, and minimal interaction with family or physicians.

Could a different approach to treatment have produced a more favorable response? Also, would you address Mr. V’s depression and, if so, how?

Dr. Krassner’s observations

One might argue that being culturally sensitive and exposing Mr. V to the risks of infection and respiratory distress was a poor medical judgment. This argument takes into account only the biological aspect of Mr. V’s illness, however. Viewed from a biopsychosocial perspective, Mr. V’s course, even with its vicissitudes, was not a “failure” in any sense. He consented to the procedure on his own terms. We identified roadblocks to treatment and unearthed cultural resources (in our case, the patient’s brothers) that could enhance or even replace traditional psychiatric treatments.

To treat Mr. V’s depression, we first assessed the symptoms. We then tried to understand how he experienced his illness within the context of his culture.⁸ Mr. V’s symptoms certainly implied depression, but in many Asian cultures, patients with depression often present with somatic complaints.¹

Also, how were we to know that these symptoms were not due to what Asian cultures refer to as loss of vital energy—or qi—because his sadness and frustration compressed on his heart?¹ In order to treat Mr. V’s depression, we must instead call it qi. Only then can we diagnose and treat the patient in a way that makes sense to him or her.¹⁵

Even arriving at a differential diagnosis is complicated. For example, if Mr. V were Chinese, we would have to include (in addition to our own narrowly defined depression and dysthymia): mên, depressed or troubled; fan-tsao, anxious or troubled; kan-huo, angry; and hsin-ching pu-hao, generalized, nonspecific emotional upset or bad spirits.¹⁵

Further treatment: From grave to grateful

Mr. V was started on sertraline, 50 mg/d, for symptoms of depression. He tolerated the agent well (no GI upset or other side effects). After only 1 week, he had a brighter affect and was more conversant. He expressed thanks for all we had done for him.

The remainder of his recovery was incident-free, and he was discharged 6 days later on sertraline, with psychiatric follow-up arranged with the county mental health services’ Southeast Asian Team.

Related resources

• Giger JN, Davidhizar RE. Transcultural nursing: assessment & intervention (3rd ed). St. Louis: Mosby, 1999.
• Leininger M, McFarland M. Transcultural nursing: concepts, theories, research & practice (2nd ed). New York: McGraw-Hill, 1995.
• Spector RE. Cultural diversity in health & illness (5th ed). Upper Saddle River, NJ: Prentice Hall Health, 2000.

Author affiliations

David Krassner, MD, third-year resident in psychiatry, department of psychiatry, University of California at San Francisco-Fresno Residency Training Program, Fresno, CA.

Drug brand names

• Sertraline • Zoloft

History: Noncompliance and ‘resignation’

Mr. V, 43, has a history of diabetes. He was admitted to the hospital with altered mental status as manifested by confusion, fluctuating sensorium, and disorientation. His altered mental status was most likely caused by septicemia secondary to osteomyelitis from a right plantar foot ulcer that had become necrotic, tracking through the foot bones into the tibia and fibula.

An emergent amputation was performed of the right tibia and fibula approximately 15 cm distal to the patella, with intent to close the wound within 24 to 48 hours; Mr. V also was started on IV antibiotics. The patient, however, refused the closure procedure, stating that he had not been properly informed before the amputation and would not consent to another procedure until he could speak with his elder brothers.

The surgical team noted that Mr. V had signed the consent form before the amputation. The surgeons also feared that not closing the wound promptly could lead to reinfection, further limb loss, or even death.

The hospital’s psychiatric consultation service was asked to determine the patient’s mental capacity. It should be noted that Mr. V emigrated to the United States from a Laotian refugee camp 12 years prior to admission. He speaks only Hmong, the language of the Hmong people indigenous to Southeast Asia.

Mr. V was diagnosed 12 years ago with insulin-dependent diabetes mellitus and has been hospitalized numerous times for foot ulcers. His chart indicates that he has repeatedly disregarded doctors’ orders and has not performed proper foot hygiene.

Previous physicians and caregivers, however, were even more frustrated with the apparent attitude of resignation with which Mr. V has approached his diabetes. He seems to believe that his medical condition is causing his problems and that he cannot prevent diabetic sequelae. He has no history of mental disorders and to our knowledge had never received a psychiatric evaluation.

Why has Mr. V. not complied with diabetes treatment? Is he unable to understand the gravity of his condition?

Dr. Krassner’s observations

Noncompliance is a recurring theme in the treatment of Hmong patients,^1-4 as is clinician frustration with their lack of compliance.^5,6 This suggests that cultural differences that could have contributed to Mr. V’s noncompliance need to be examined before determining his mental state.

Approaching a culturally sensitive case with an open mind and a respectful attitude will increase the chances of a positive outcome and provide a valuable learning experience for the clinician. You might proceed as follows:

Question your assumptions. Some clinicians assume that psychiatry applies universally to any patient, regardless of cultural background. However, the categories psychiatry imposes on illnesses may not adequately describe an illness as a patient of a different culture experiences it.^7-9

Find an interpreter—one who speaks the language and has a “lexicon for emotional experience” similar to the patient’s.¹⁰ In this case, we wanted an interpreter who not only spoke Hmong, but who understood the complexities of the animistic Hmong spirituality and could reconcile it with our empirically derived Western belief system.

Depending on a family member to translate can be problematic if that person cannot accurately explain the patient’s disorder, the need for treatment, or the implications of noncompliance. We found the ideal interpreter: a Hmong registered nurse. If you cannot find an interpreter of the same ethnicity as the patient, at least find one who speaks the same language.

Beware of misinterpretation. A patient from another culture who understands some English may not assign the same meaning to words or phrases that we do. For example, when a Hmong says yes, he or she means, “I am listening, and I respect what you’re saying.” In this way, “yes” can be mistaken for consent; noncompliance by Hmong patients can often be traced to this misinterpretation.¹¹

Define “capacity” and its implications. Capacity is always assessed in the context of the question, “capacity to do what?” The context must be explicitly identified, because life decisions require varying levels of capacity. For example, elderly patients with dementia often lack capacity to manage their finances, but have capacity to resolve end-of-life issues (e.g., hospice placement, do-not-resuscitate requests).

For Mr. V, the question was whether he had capacity to refuse the second surgery. To have capacity to consent to or refuse a procedure, a patient must understand the procedure, its risks and benefits, and the risks and benefits of refusing the procedure. The patient also must not be vulnerable to coercion (e.g., by a family member).

Clearly, Mr. V understood the procedure based on his notions of health, illness, life, death, family, social structure, and other concepts.^6,12,13 One might question whether a patient such as Mr. V is ever fully informed before giving consent. Even though he had signed a consent form for the amputation, the signature in his eyes did not qualify as consent. Further, having read through our hospital’s consent form, I defy anyone to translate its legal subtleties into Hmong.

Perhaps even more important, the Hmong adhere to a strict social hierarchy: males are held in higher esteem than females, the elderly higher than the young.^6,11,14 Therefore, Mr. V’s desire to ask his brothers for advice before consenting to surgery makes sense within his cultural norms and was not a stalling tactic as the surgeons believed.

Try to understand the patient’s concept of illness. We found Mr. V to have capacity within the confines of his medical understanding. He knew the operation was major surgery, and he wanted to consult with his elder brothers—all eight of them (most of whom live in Minneapolis)—prior to consenting. Conversely, the surgeons could think only within the confines of their cultural and clinical understanding. They wanted to perform the procedure expediently to avoid additional diabetic sequelae.

We discussed these concerns with the patient and surgeons and struck a compromise: the surgeons agreed to defer surgery for 10 days, as long as Mr. V indemnified them against complications secondary to the delay. After that, the surgery would be performed regardless of whether Mr. V had consulted his brothers. Mr. V also agreed to continue IV antibiotic therapy. This compliance is not paradoxical: the Hmong often accept antibiotics because of their relatively rapid efficacy.⁶

For clinicians wishing to understand the Hmong and their view of illness, Anne Fadiman’s The Spirit Catches You and You Fall Down is an excellent resource.⁶ Kleinman’s seminal work on treating patients from other cultures also emphasizes the importance of eliciting the patient’s understanding in order to diagnose and negotiate treatment.¹⁵ Several good textbooks address transcultural patient care; curiously, most are nursing rather than physician texts (see “Related resources,”).

Treatment: Recovery’s rocky road

Closure was delayed for 8 days, during which no complications arose. Mr. V tolerated the antibiotics well. He contracted a low-grade fever at times, but septicemia did not re-emerge.

We continued to follow the patient, who on several occasions became delirious. He was neither violent nor agitated, so he was not treated with neuroleptics, which can cause delirium in Hmong patients.^3,4

The patient contacted his brothers and consented to closure surgery, after which he recuperated well for 3 days. On day four, however, he developed respiratory failure. He was resuscitated, intubated, and transferred to the intensive care unit. He was extubated and returned to the floor 24 hours later, at which time he appeared despondent. He exhibited depressed mood, blunted affect, anorexia, anhedonia, and minimal interaction with family or physicians.

Could a different approach to treatment have produced a more favorable response? Also, would you address Mr. V’s depression and, if so, how?

Dr. Krassner’s observations

One might argue that being culturally sensitive and exposing Mr. V to the risks of infection and respiratory distress was a poor medical judgment. This argument takes into account only the biological aspect of Mr. V’s illness, however. Viewed from a biopsychosocial perspective, Mr. V’s course, even with its vicissitudes, was not a “failure” in any sense. He consented to the procedure on his own terms. We identified roadblocks to treatment and unearthed cultural resources (in our case, the patient’s brothers) that could enhance or even replace traditional psychiatric treatments.

To treat Mr. V’s depression, we first assessed the symptoms. We then tried to understand how he experienced his illness within the context of his culture.⁸ Mr. V’s symptoms certainly implied depression, but in many Asian cultures, patients with depression often present with somatic complaints.¹

Also, how were we to know that these symptoms were not due to what Asian cultures refer to as loss of vital energy—or qi—because his sadness and frustration compressed on his heart?¹ In order to treat Mr. V’s depression, we must instead call it qi. Only then can we diagnose and treat the patient in a way that makes sense to him or her.¹⁵

Even arriving at a differential diagnosis is complicated. For example, if Mr. V were Chinese, we would have to include (in addition to our own narrowly defined depression and dysthymia): mên, depressed or troubled; fan-tsao, anxious or troubled; kan-huo, angry; and hsin-ching pu-hao, generalized, nonspecific emotional upset or bad spirits.¹⁵

Further treatment: From grave to grateful

Mr. V was started on sertraline, 50 mg/d, for symptoms of depression. He tolerated the agent well (no GI upset or other side effects). After only 1 week, he had a brighter affect and was more conversant. He expressed thanks for all we had done for him.

The remainder of his recovery was incident-free, and he was discharged 6 days later on sertraline, with psychiatric follow-up arranged with the county mental health services’ Southeast Asian Team.

Related resources

• Giger JN, Davidhizar RE. Transcultural nursing: assessment & intervention (3rd ed). St. Louis: Mosby, 1999.
• Leininger M, McFarland M. Transcultural nursing: concepts, theories, research & practice (2nd ed). New York: McGraw-Hill, 1995.
• Spector RE. Cultural diversity in health & illness (5th ed). Upper Saddle River, NJ: Prentice Hall Health, 2000.

Author affiliations

David Krassner, MD, third-year resident in psychiatry, department of psychiatry, University of California at San Francisco-Fresno Residency Training Program, Fresno, CA.

Drug brand names

• Sertraline • Zoloft

History: Noncompliance and ‘resignation’

Mr. V, 43, has a history of diabetes. He was admitted to the hospital with altered mental status as manifested by confusion, fluctuating sensorium, and disorientation. His altered mental status was most likely caused by septicemia secondary to osteomyelitis from a right plantar foot ulcer that had become necrotic, tracking through the foot bones into the tibia and fibula.

An emergent amputation was performed of the right tibia and fibula approximately 15 cm distal to the patella, with intent to close the wound within 24 to 48 hours; Mr. V also was started on IV antibiotics. The patient, however, refused the closure procedure, stating that he had not been properly informed before the amputation and would not consent to another procedure until he could speak with his elder brothers.

The surgical team noted that Mr. V had signed the consent form before the amputation. The surgeons also feared that not closing the wound promptly could lead to reinfection, further limb loss, or even death.

The hospital’s psychiatric consultation service was asked to determine the patient’s mental capacity. It should be noted that Mr. V emigrated to the United States from a Laotian refugee camp 12 years prior to admission. He speaks only Hmong, the language of the Hmong people indigenous to Southeast Asia.

Mr. V was diagnosed 12 years ago with insulin-dependent diabetes mellitus and has been hospitalized numerous times for foot ulcers. His chart indicates that he has repeatedly disregarded doctors’ orders and has not performed proper foot hygiene.

Previous physicians and caregivers, however, were even more frustrated with the apparent attitude of resignation with which Mr. V has approached his diabetes. He seems to believe that his medical condition is causing his problems and that he cannot prevent diabetic sequelae. He has no history of mental disorders and to our knowledge had never received a psychiatric evaluation.

Why has Mr. V. not complied with diabetes treatment? Is he unable to understand the gravity of his condition?

Dr. Krassner’s observations

Noncompliance is a recurring theme in the treatment of Hmong patients,^1-4 as is clinician frustration with their lack of compliance.^5,6 This suggests that cultural differences that could have contributed to Mr. V’s noncompliance need to be examined before determining his mental state.

Approaching a culturally sensitive case with an open mind and a respectful attitude will increase the chances of a positive outcome and provide a valuable learning experience for the clinician. You might proceed as follows:

Question your assumptions. Some clinicians assume that psychiatry applies universally to any patient, regardless of cultural background. However, the categories psychiatry imposes on illnesses may not adequately describe an illness as a patient of a different culture experiences it.^7-9

Find an interpreter—one who speaks the language and has a “lexicon for emotional experience” similar to the patient’s.¹⁰ In this case, we wanted an interpreter who not only spoke Hmong, but who understood the complexities of the animistic Hmong spirituality and could reconcile it with our empirically derived Western belief system.

Depending on a family member to translate can be problematic if that person cannot accurately explain the patient’s disorder, the need for treatment, or the implications of noncompliance. We found the ideal interpreter: a Hmong registered nurse. If you cannot find an interpreter of the same ethnicity as the patient, at least find one who speaks the same language.

Beware of misinterpretation. A patient from another culture who understands some English may not assign the same meaning to words or phrases that we do. For example, when a Hmong says yes, he or she means, “I am listening, and I respect what you’re saying.” In this way, “yes” can be mistaken for consent; noncompliance by Hmong patients can often be traced to this misinterpretation.¹¹

Define “capacity” and its implications. Capacity is always assessed in the context of the question, “capacity to do what?” The context must be explicitly identified, because life decisions require varying levels of capacity. For example, elderly patients with dementia often lack capacity to manage their finances, but have capacity to resolve end-of-life issues (e.g., hospice placement, do-not-resuscitate requests).

For Mr. V, the question was whether he had capacity to refuse the second surgery. To have capacity to consent to or refuse a procedure, a patient must understand the procedure, its risks and benefits, and the risks and benefits of refusing the procedure. The patient also must not be vulnerable to coercion (e.g., by a family member).

Clearly, Mr. V understood the procedure based on his notions of health, illness, life, death, family, social structure, and other concepts.^6,12,13 One might question whether a patient such as Mr. V is ever fully informed before giving consent. Even though he had signed a consent form for the amputation, the signature in his eyes did not qualify as consent. Further, having read through our hospital’s consent form, I defy anyone to translate its legal subtleties into Hmong.

Perhaps even more important, the Hmong adhere to a strict social hierarchy: males are held in higher esteem than females, the elderly higher than the young.^6,11,14 Therefore, Mr. V’s desire to ask his brothers for advice before consenting to surgery makes sense within his cultural norms and was not a stalling tactic as the surgeons believed.

Try to understand the patient’s concept of illness. We found Mr. V to have capacity within the confines of his medical understanding. He knew the operation was major surgery, and he wanted to consult with his elder brothers—all eight of them (most of whom live in Minneapolis)—prior to consenting. Conversely, the surgeons could think only within the confines of their cultural and clinical understanding. They wanted to perform the procedure expediently to avoid additional diabetic sequelae.

We discussed these concerns with the patient and surgeons and struck a compromise: the surgeons agreed to defer surgery for 10 days, as long as Mr. V indemnified them against complications secondary to the delay. After that, the surgery would be performed regardless of whether Mr. V had consulted his brothers. Mr. V also agreed to continue IV antibiotic therapy. This compliance is not paradoxical: the Hmong often accept antibiotics because of their relatively rapid efficacy.⁶

For clinicians wishing to understand the Hmong and their view of illness, Anne Fadiman’s The Spirit Catches You and You Fall Down is an excellent resource.⁶ Kleinman’s seminal work on treating patients from other cultures also emphasizes the importance of eliciting the patient’s understanding in order to diagnose and negotiate treatment.¹⁵ Several good textbooks address transcultural patient care; curiously, most are nursing rather than physician texts (see “Related resources,”).

Treatment: Recovery’s rocky road

Closure was delayed for 8 days, during which no complications arose. Mr. V tolerated the antibiotics well. He contracted a low-grade fever at times, but septicemia did not re-emerge.

We continued to follow the patient, who on several occasions became delirious. He was neither violent nor agitated, so he was not treated with neuroleptics, which can cause delirium in Hmong patients.^3,4

The patient contacted his brothers and consented to closure surgery, after which he recuperated well for 3 days. On day four, however, he developed respiratory failure. He was resuscitated, intubated, and transferred to the intensive care unit. He was extubated and returned to the floor 24 hours later, at which time he appeared despondent. He exhibited depressed mood, blunted affect, anorexia, anhedonia, and minimal interaction with family or physicians.

Could a different approach to treatment have produced a more favorable response? Also, would you address Mr. V’s depression and, if so, how?

Dr. Krassner’s observations

One might argue that being culturally sensitive and exposing Mr. V to the risks of infection and respiratory distress was a poor medical judgment. This argument takes into account only the biological aspect of Mr. V’s illness, however. Viewed from a biopsychosocial perspective, Mr. V’s course, even with its vicissitudes, was not a “failure” in any sense. He consented to the procedure on his own terms. We identified roadblocks to treatment and unearthed cultural resources (in our case, the patient’s brothers) that could enhance or even replace traditional psychiatric treatments.

To treat Mr. V’s depression, we first assessed the symptoms. We then tried to understand how he experienced his illness within the context of his culture.⁸ Mr. V’s symptoms certainly implied depression, but in many Asian cultures, patients with depression often present with somatic complaints.¹

Also, how were we to know that these symptoms were not due to what Asian cultures refer to as loss of vital energy—or qi—because his sadness and frustration compressed on his heart?¹ In order to treat Mr. V’s depression, we must instead call it qi. Only then can we diagnose and treat the patient in a way that makes sense to him or her.¹⁵

Even arriving at a differential diagnosis is complicated. For example, if Mr. V were Chinese, we would have to include (in addition to our own narrowly defined depression and dysthymia): mên, depressed or troubled; fan-tsao, anxious or troubled; kan-huo, angry; and hsin-ching pu-hao, generalized, nonspecific emotional upset or bad spirits.¹⁵

Further treatment: From grave to grateful

Mr. V was started on sertraline, 50 mg/d, for symptoms of depression. He tolerated the agent well (no GI upset or other side effects). After only 1 week, he had a brighter affect and was more conversant. He expressed thanks for all we had done for him.

The remainder of his recovery was incident-free, and he was discharged 6 days later on sertraline, with psychiatric follow-up arranged with the county mental health services’ Southeast Asian Team.

Related resources

• Giger JN, Davidhizar RE. Transcultural nursing: assessment & intervention (3rd ed). St. Louis: Mosby, 1999.
• Leininger M, McFarland M. Transcultural nursing: concepts, theories, research & practice (2nd ed). New York: McGraw-Hill, 1995.
• Spector RE. Cultural diversity in health & illness (5th ed). Upper Saddle River, NJ: Prentice Hall Health, 2000.

Author affiliations

David Krassner, MD, third-year resident in psychiatry, department of psychiatry, University of California at San Francisco-Fresno Residency Training Program, Fresno, CA.

Drug brand names

• Sertraline • Zoloft