6. Does the family have a supportive community? What are their beliefs about mental illness? Whom do they trust in their community? A religious leader? A local doctor? Who treats the women in the community?
7. If there is time, other issues can be explored. For example, what were the circumstances of their immigration? What has the transition from Bangladesh to life in the United States been like for the family?
8. Who will care for her at home? Who will ensure she takes her medications? Who will take her to follow-up visits?
There are many unknowns in this case that require further exploration. Time taken to arrange for a medically qualified interpreter and an extended family meeting will help the physician and psychiatric team understand the current situation and set up an appropriate plan of care.
Cultural perspective
The case material raises many questions. In the first place, there is no need to assume that the husband was behaving in a “culturally sanctioned and consistent way.” In a large population like that of Bangladeshi Muslims, significant heterogeneity exists, and there are more ways than one to respond. Although access to care is increasing for some population segments, Bangladesh still has limited mental health services and resources.
Dr. Anne E. Becker
What were the reasons for the patient to be admitted to a psychiatric unit? How many days after the delivery? Were there any hostile actions or reactions to the baby? What is the patient’s pregnancy history? What meaning was ascribed to the symptoms and behavior that the patient manifested prior to hospitalization? Was this the first episode of psychiatric illness for the patient? Has she shown any dangerous behaviors before?
The reason why the husband is taking the wife home against medical advice is unclear. What reason did the husband give for this decision? Could stigma toward mental illness or hospitalization play a role? Was an interpreter used to help understand his reasoning? Was the husband dissatisfied about something? This is important, because it is likely that the husband brought the wife for hospitalization in the first place. Were the inpatient physician and nurses male or female, and could gender-related issues have been a barrier to accepting care? Might there have been a Muslim chaplain in the hospital or in the community or someone else who could have served as a cultural broker earlier in the hospitalization to have prevented this impasse?
Dr. Robert C. Like
The Cultural Formulation Interview (CFI) in the DSM-5 and the CFI-Informant Version for family members provide a framework to explore these questions and the questions recommended in the Family Perspective throughout the course of treatment.
Additional relevant questions include the following: What are cultural norms for their expectations for support of a new mother during the postpartum period? What are the norms for who, besides the mother, provides infant care? Are normative postpartum practices possible, or have they been disrupted in the hospital setting and/or in their home? If the mother and baby are both on the unit, is the request motivated by a desire to bring the baby home? If the baby is not on the unit, is this driving the family’s concern?
How isolated will the woman feel when she is home with the baby and her husband is out working as a taxi driver? Are there community-based organizations that the clinicians could collaborate with to provide resources and support for this woman (for example, women’s groups, immigrant groups, religious groups)? This would require learning more about what appeals to her, which groups she might identify with, and what is available in her neighborhood/community that aligns with what appeals to her.
It also would be important to determine if the patient was having any side effects from her psychotropic medications. Many South Asians have a low tolerance for side effects. Did the patient or family have any religious or cultural concerns about how the medications were manufactured or their composition (for example, worries about alcohol content)? Could any of these factors be related to the patient’s possible “cheeking” of her medications?
Dr. Annelle Primm
The major ethical/legal question to address is the patient’s attitude toward and relationship with the baby, and whether she was and is currently a danger to herself or others. Was the baby with the patient in the hospital? Did she feed the baby? What were the signs of psychosis that the patient exhibited, and what were the bases of her diagnosis? Was there an opportunity to discuss these issues with the husband? If so, what was his response?