The Mount Sinai journal of medicine, New York
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Certain individuals have a metabolic deficiency in the metabolism of debrisoquin, sparteine, dextromethorphan, and more than 80 other clinically important drugs. Examples of such drugs include tricyclic antidepressants, neuroleptics, selective serotonin reuptake inhibitors, beta-adrenoceptor blockers, and antiarrhythmics. ⋯ CYP2D6 deficiency has important therapeutic consequences, such as increased side effects when medications that are substrates of this enzyme are prescribed for such individuals. To optimize drug therapy, physicians should therefore determine the metabolic capacity of their patients.
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Ethnic differences in pharmacological response have been recognized for a long time. New research methodologies in the field of pharmacogenetics have begun to provide us with important insights concerning the biological mechanisms that underlie this differential response. The emerging data have highlighted the central role of genetic factors in the metabolism, and perhaps plasma protein binding, of many of the psychotropic agents used today. ⋯ However, it is clear that as for psychiatry in general, the role of the environment in these genetic factors must be understood when considering psychopharmacological response in particular. The utility and possible application of these research methodologies in the clinical setting is still undetermined; these data must be pursued. The information concerning the relative efficiency of the drug-metabolizing enzymes which is made available through genotyping and phenotyping methodologies could be used by clinicians who provide psychopharmacotherapeutic services to patients from diverse ethnic backgrounds.
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Modern psychopharmacology provides us with several effective antidepressants. We are increasingly recognizing the importance of interindividual differences in plasma concentration with these drugs. ⋯ The importance of studies in this area has been underscored by anecdotal reports as well as cross-cultural surveys of prescribing patterns which indicate that antidepressant dosage requirements may differ among racial groups. This review will focus on the relatively young field of cross-cultural psychopharmacology and the efforts being made to determine the importance of society, culture, environment, genetics, and biophysiology in the prescribing and metabolism of and response to antidepressant drugs.
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Recent research and clinical experience has shown that African Americans may be at greater risk for inappropriate treatment. Such experiences can interact negatively with an existing distrust of the mental health system. Providers may show different prescribing patterns with racial and ethnic minorities: they may overuse antipsychotics, dispense higher dosages, and more commonly give involuntary treatment, which results in more side effects and a poorer outcome. ⋯ Newer pharmacological agents may be potentially more helpful for minorities because they are better tolerated, have better side effect profiles, and demonstrate better efficacy. However, African Americans have limited access to these agents. Education of providers and patients, policy changes in the public sector, wider implementation of research policies concerning inclusion of minorities, and different marketing strategies by pharmaceutical concerns are probably necessary to maximize pharmacotherapy of minorities.
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This study is the second in a series examining the prescribing of antipsychotic medication to patients with schizophrenia in cross-cultural clinical programs. A computer search identified all patients with the diagnosis of "schizophrenia" treated during a 1-year period in an inpatient Hispanic and Asian psychiatric unit(s); second computer search identified a matched (admission date) sample of Anglo patients from the general inpatient psychiatry services. The medication variables included type of neuroleptic drug used, the maximum dose, the stabilized dose (i.e., neuroleptic dose at discharged and the dose associated with first report of extrapyramidal symptoms. ⋯ The analysis with maximum dose revealed a significant main effect for both actual (p < 0.05) and standardized CPZ (p < 0.05). Similar results were also found for stabilized dose with both actual (p < 0.05) and standardized CPZ (p < 0.05). Examination of the direction of mean differences for both medication dosing variables using both CPZ comparisons revealed that the patients in general sample received significantly larger doses of antipsychotic medication than either Asian or Hispanic patients.