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Psychosomatics 47:408-413, October 2006
doi: 10.1176/appi.psy.47.5.408
© 2006 Academy of Psychosomatic Medicine
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Ethnicity and Use of Alternative Products in Psychiatric Patients

Bernardo Ng, M.D., Alvaro Camacho, M.D., Alan Simmons, Ph.D., and Scott C. Matthews, M.D.

Received March 11, 2005; revised January 10, 2006; accepted January 13, 2006. From the Sun Valley Behavioral Medical Center and the Dept. of Psychiatry, Univ. of California, San Diego. Address correspondence and reprint requests to Dr. Ng, Sun Valley Behavioral Medical Center, 300 S. Imperial Ave., Suite 9, El Centro, CA 92243. e-mail: bng{at}sunvalleyb.com


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The use of herbal and natural products for medical purposes is common in all human civilizations, and use in Western societies has grown considerably in recent years. However, differences in usage patterns between different ethnic groups are yet to be delineated. The current study examined the frequency and type of complementary/alternative medications used by a sample of 453 rural psychiatric outpatients of two different ethnic groups. The products were classified as "natural" (herbal products requiring some preparation before consumption) and "processed" (products in "ready-to-use" form). There were significant ethnic differences in usage patterns of the various preparations: Hispanics, relative to Caucasians, were twice as likely to use natural products, whereas Caucasians were more likely than Hispanics to use processed products. The symptoms addressed were predominantly psychiatric, with natural products, and nonpsychiatric, with processed products. These results may increase awareness among healthcare providers regarding the usage frequency of such complementary/alternative medications products and the different usage patterns across ethnic groups.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Every culture has relied to one degree or another on the purported healing properties found in plants or "herbs."1–3 Americans spent an estimated $5.1 billion on herbal medicine alone in 1997,4 and up to $11 billion/year for chiropractic, naturopathic, and herbal therapies not covered by health plans.5–7 It is estimated that complementary/alternative medications are used by 20% to 30% of the general North American population. According to Astin et al.,5 41% of elderly citizens use some form of complementary/alternative medications, and 80% of them do not report it to their physicians.

The efficacy of herbal products in the treatment of psychiatric conditions has already been studied.8 Just since 1998, there have been 27 double-blind, placebo-controlled studies identified in the literature (Table 1). However, other products that have shown efficacy in non-controlled studies are readily available, including mistletoe, saiboku-to, WeiniCom, shark cartilage, valerian, s-adenosyl-1-methionine (SAM-e), acetyl-L-carnitine, chondroitin sulfate, hawthorn, hyperzine, omega-3 fatty acids, choline, fish extract, melatonin, and chromium picolinate.1,2,9


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TABLE 1. Summary of Placebo-Controlled Studies



The most studied herbal products used for psychotropic effects have been Hypericum perforatum, Ginkgo biloba, and Piper methysticum.10–15 Use of these products is not always benign. Herbal medications contain active ingredients and have their own unique side-effect profiles. For example, Ginkgo biloba has been associated with a case of coma in a dementia patient,16 and Piper methysticum has been associated with hepatitis and liver failure.17,18 Also, herbal medications have been connected with potentially fatal drug–herb interactions. In one case, use of Hypericum perforatum was associated with heart-transplant rejection in a patient taking cyclosporin.

The above studies did not include products most commonly identified in the Hispanic community. Mexican cultural traditions promote using various herbal therapies, including manzanilla (chamomile), savila (aloe vera), ajo (garlic), uña de gato (cat’s claw), and hierba buena (spearmint).4 A study of older Mexican Americans in California, Texas, New Mexico, Colorado, and Arizona showed that 9.8% reported use of herbal products in the previous 2 weeks before being seen by their primary-care physician. Use was particularly common among those with chronic medical conditions, financial difficulties, and high utilizers of healthcare services. The most common products were mint and chamomile.19

In Hispanic patients with advanced cancer (N=58), 27.6% used alternative products, with a high degree of faith in their curative effects, raising the authors’ concern that patients might forgo conventional treatments. A study of Hispanic diabetic patients (N=43) reported no use of herbal therapies, but 84% of such patients knew about them and considered them as secondary to formal treatment.20

In an attempt to better understand the rising number of complementary/alternative medication consumers in Western society, and Hispanic patients’ traditional use of herbs, we studied the frequency and preferences of use of an ethnically diverse population at a rural clinic. This clinic is located in Imperial County, an underserved area in the Southern California desert, situated in the southeast quadrant of the state, which borders Mexico, the state of Arizona, and San Bernardino and San Diego Counties. The California Health Manpower Policy Commission defines a rural Medical Service Study Area as an area with a population density of less than 250 people per square mile and no town within the area with a population over 50,000. Imperial County has a population density of 34.4 people per square mile, and the largest town has 45,000 people. During our study, Imperial County was a designated health-professional underserved area, as it had a population-to-psychiatrist ratio in excess of 20,000:1, and the nearest contiguous area of resources was over 40 minutes away (Report from the Office of Statewide Health Planning and Development, 2002). Like most communities on the U.S. border with Mexico, Imperial County is highly represented by Hispanics, corresponding to 73% of the total population. Slightly over half of the adults older than age 25 are high school graduates, with 30% of the people living below the poverty level and, as a consequence, uninsured. The unemployment rate is 10%, with most job options in the areas of agriculture, retail, and service.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
As part of our routine clinical evaluation, we obtain information on alternative product usage on outpatients coming for treatment to the Sun Valley Behavioral Medical Center. We reviewed the records on visits from February 1st to April 30th, 2002; other than products used and ethnic group; no identifying information was collected for this study.

Information regarding use of natural or alternative products in the last 30 days was collected. Once identified, the agents were classified in one of the following groups: 1) natural products: an actual herb (i.e., roots, leaves, flowers) that required preparation (i.e., cooking or boiling) before consumption; 2) processed products: derivatives of natural products available in the form of a pill or capsule, ready to be ingested; 3) nutritional supplements: vitamins, multi-vitamins, and minerals. Each group was analyzed separately, using a chi-square test, as some charts listed products of more than one group. The reason for using the product was tallied verbatim from the patient’s report.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Information was obtained from 453 charts, of which 234 patients (52%) were Caucasian and 219 (48%) Hispanic. A total of 180 (40%) used some form of complementary product, including 105 (45%) of the Caucasian and 75 (34%) of the Hispanic subsamples.

In the Caucasian subsample, 33 used a combination of products from two or more of the groups. Of those who reported using products from only one group, 5 subjects reported using natural products; 13, processed products; and 54, nutritional products. In the Hispanic subsample, 7 reported using products from two or more groups; of those using products from only one group, 19 reported using natural products; 14, processed products; and 35, nutritional products. The ethnic distribution is presented in Table 2, illustrating the significant differences according to type of product; note that the sum of subjects from each ethnic subsample is in excess of the above description because some subjects are repeated in two or more of the groups.


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TABLE 2. Supplement Use by Ethnic Group



The reasons given for using each product were extremely varied. The five most common reasons given in each group are presented in Table 3.


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TABLE 3. Purpose for Use by Type of Product



The five most-cited products in each group are listed in Table 4. Others, less commonly mentioned, but not less interesting, were pepper nut, star anise (Illicium verum), alfalfa (Medicago sativa), cilantro (Coriandro sativum), sopamelo, orange skin, gordolobo (Gnaphalium attenuatum), eucalyptus globulus, and cinnamon (Melia azedarach) in the natural products group; kava, black cohosh, flaxseed oil, in the processed products group; and Metabolife®, zinc, and antioxidants in the nutritional products group.


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TABLE 4. Individuals Reporting Use of Most Common Products




  DISCUSSION

 
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 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
Forty percent of the sample reported use of an alternative product, aside from their prescribed medication, which decreased to 20% when eliminating those taking nutritional products exclusively.

Although it may be argued that because of the remarkable progress in biomedicine, globalization, and information dissemination; health beliefs and practices should become increasingly homogenous across cultural and ethnic groups. However, indigenous medical concepts and practices remain vibrant and influential in non-Western societies worldwide and in ethnic minority communities in the United States, as suggested by Ni et al.8 and supported by our findings. Furthermore, figures emerging from the 2000 population census show a rise in the proportion of Hispanic and, to a lesser degree, Asian citizens, promising a profound impact on the cultural, social, economic, and political fabric of the United States and its healthcare system.21

There were significant ethnic differences in the type of product used, supporting the idea that traditions remain influential in rural Hispanic people. The reasons for taking any of the products varied considerably; listing the top five reasons (Table 3), there were three listed under "natural products," and only one (a psychiatric symptom) for the "processed products" group.

The top two natural products (manzanilla and siete azahares) are reported to have psychotropic effects.19 Although manzanilla (chamomile) is available in the U.S. market, "siete azahares" is not. One of the authors (BN) visited Mexico to acquire a sample of this product, which is sold over the counter. It is a combination of seven ingredients. The first one consists of four different flowers, or "azahares," and the rest are different leaves and other flowers. We were able to find purported medicinal effects of some of its ingredients, and it appears that this product is believed to have antidepressant and anxiolytic effects.14 Given Hispanics’ preference for natural products, it is inevitable to think about the relationship between herbal-products consumption and medication compliance.7 Our clinical impression was that rural Hispanic patients choose to use these products, hoping to prevent the need for psychotropic medication, or, if they are already taking medication, to prevent side effects or development of dependence.

On the other hand, side effects from herbs and natural products seem to be largely minimized in reports by consumers. In a survey of 100 prospective customers of a health-food store, it was found that 19% were experiencing potential side effects but did not attribute them to such products.22

In summary, our finding that 21% of patients were using alternative products (natural or processed) is consistent with other reports. The variation in the type of products seemed to be associated with patients’ ethnicity. It appears that whereas rural Hispanic patients keep their traditions regarding use of natural products in the form of teas and other herbs, rural Caucasian patients prefer alternative products available in ready-to-use preparations.

Physicians must be aware of the frequency and ethnic variations in the use of these products. The types of agents used and reasons for their use differed significantly between rural Hispanic and rural Caucasian patients.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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Related Collections
* Cross-Cultural Psychiatry
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