Cultural Competence in Behavioral Health Care

Release Date: November 1, 2012

Expiration Date: November 30, 2014

FACULTY:

Tammie Lee Demler, BS, PharmD, MBA, BCPP
Director of Pharmacy Services
Buffalo Psychiatric Center
Buffalo, New York
Clinical Assistant Professor
Director, Pharmacy Practi/USPExams/Psychiatric
Residency Program
University at Buffalo School of Pharmacy and
Pharmaceutical Sciences

FACULTY DISCLOSURE STATEMENTS:

Dr. Demler has no actual or potential conflicts of interest in relation to this activity.

Postgraduate Healthcare Education, LLC does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced, objective, and scientifically rigorous. Occasionally, authors express opinions that represent their own viewpoint. Conclusions drawn by participants should be derived from objective analysis of scientific data.

ACCREDITATION STATEMENT:

Pharmacy acpe
Postgraduate Healthcare Education, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
UAN: 0430-0000-12-028-H04-P
Credits: 2.0 hours (0.20 ceu)
Type of Activity: Knowledge

FEE INFORMATION:

Payment of $6.50 required for exam to be graded.

TARGET AUDIENCE:

This accredited activity is targeted to pharmacists. Estimated time to complete this activity is 120 minutes.

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DISCLAIMER:

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients’ conditions and possible contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

GOAL:

To educate pharmacists about the requirements in accreditation standards regarding cultural competence in the delivery of pharmaceutical care, the aspects of culture that can affect care, and the trends of changing culture within the U.S.

OBJECTIVES:

After completing this activity, the participant should be able to:

  1. Identify the need for cultural competence in behavioral health and psychiatric pharmacy practice.
  2. Describe trends and shifts of culture within U.S. patient populations.
  3. Describe the cultural factors and health perceptions that can affect care.
  4. Review the benefits of addressing the barriers to health care created by cultural gaps.
  5. Discuss how to develop strategies to achieve cultural competence and meet accreditation requirements.


ABSTRACT: As cultural diversity increases within the United States, those involved in the delivery of behavioral health care must be ready to address the cultural factors and health perceptions that can affect care. Knowing the benefits of addressing potential cultural gaps as true barriers to health care increases the quality of care throughout the continuum. Recent accreditation requirements have formalized the need to document staff competence in the delivery of care to those of different cultures and influences. The need to provide cultural diversity training and orientation to new staff combined with ongoing assessments of current staff results in a positive implication for future safe and effective medication use across the entire patient population.

Every person who requires medical or behavioral health care is unique both in the way clinical symptoms are exhibited and in how that individual's culture impacts his or her health behavior. As patients journey along the continuum of care, it is critical that the health system prepare to identify and address both the clinical aspects of care and the patient's cultural and demographic differences.1

Cultural issues are now recognized to be important elements in the provision of effective health care.2 In addition to serving as the medication experts within teams, pharmacists must learn and understand the cultural factors that affect patients' health care decisions.2 Experts agree that all patients, regardless of race, ethnicity, sex, age, religion, or physical or mental disability, have the right to high-quality health care that reflects knowledge of and sensitivity to the factors of difference. With the majority of the population growth within the U.S. from now to 2050 expected to be within racial and ethnic minority Americans and immigrant groups, our health care system must learn how to address the disparities in health care that arise from factors such as race, ethnicity, and cultural and language barriers.3

Members of racial minority groups, including Latinos and African Americans, are more likely to underutilize mental health services and to delay seeking treatment. This delay often results in individuals who seek services after they have decompensated into an acute stage of illness with a worsened prognosis. Rates of mental illness among people in most ethnic minorities are similar to those of Caucasians; however, members of these minorities are more likely to experience confounding factors such as violence, poverty, and discrimination that may exacerbate the disorder.4

The surgeon general's 2001 report highlights the disparities in behavioral health services for members of racial and ethnic minority populations based on decreased access to mental health services and reduced quality and quantity of treatments. Minority-based populations are also significantly underrepresented in mental health research. Surgeon General David Satcher, MD, PhD, articulated his findings in a 200-page report that provides a foundation for understanding the relationships among culture, society, mental health, mental illness, and services. The report also provides information about how these issues affect each of the four major racial and ethnic minority groups.5 For example, the report highlights that: 1) individuals who are homeless, incarcerated, in the child welfare system, or are victims of trauma are all at increased risk for mental disorders; 2) as many as 40% of Hispanic Americans report limited English-language proficiency (with few care providers providing Spanish-speaking services, most Hispanic Americans have limited access to ethnically or linguistically similar providers); 3) the suicide rate among certain ethnic groups, namely American Indians and Alaska Natives, is up to 50% higher than the national rate, and the number of individuals with co-occurring mental illness and substance abuse (especially alcohol) is also higher among the youth within these same ethnic groups; and 4) some groups, including Asian Americans/Pacific Islanders, who seek care for a mental illness often present with more severe illnesses. Mental illness is often undiagnosed or misdiagnosed due to the physical nature of the presenting symptoms. Stigma and shame have been identified as critical deterrents to service utilization.

The surgeon general's report proposes courses of action that can improve the quality of mental health care available to racial and ethnic minority populations; these include evaluating and developing systems to promote increased access while reducing barriers to treatment. Culturally competent care and leadership within health care are key principles in addressing these deficits.5

Dr. Satcher said, "The state of our knowledge about health and illness has never been greater. The best way to ensure an end to the disparities we have discovered is for everyone engaged in mental health services to make a steadfast commitment to accomplish the goal. It will take all of us."

Culturally competent environments of care are not facilities where all those involved in the delivery of health care have a fluent understanding of every culture; however, pharmacists can and should play a leading role in developing a culturally "aware" environment by increasing recognition of these differences among health care providers, administrators, and the public. Cultural competence is a set of behaviors and attitudes that allows health care professionals to work effectively with people of different cultures. Cultural competence is not a fixed endpoint and must be continually measured and cultivated in order to achieve the skills needed to work with patients of different cultural backgrounds.5 Promoting a health care environment that embraces diversity requires the facilitation of opportunities for patients and providers to communicate while applying evidence-based guidelines through a multidisciplinary team approach, thus empowering the patient to be more involved in his or her own care. If pharmacists can recognize and understand the disparities that exist, they can develop plans to overcome those that are within their scope to change.6

Measuring professional competency in health care is both a priority and a challenge. Developing and sustaining the ability to perform one's task and be adequately prepared for the job become even more important as health care technology and medication therapy grow increasingly more complex.

In 2010, the Joint Commission released revised standards for patient-centered communication in order to advance effective communication, cultural competence, and patient-and family-centered care. These standards were designed to improve the safety and quality of care for all patients and to ensure that hospitals adopt practices promoting better communication and patient engagement (TABLE 1). The hospital is required to document that staff have been oriented to cultural diversity based on their job duties and responsibilities.1 Many prominent health care organizations are now calling for culturally competent health care and culturally competent professionals.7


tbl1

Trends and Shifts of Culture Within U.S. Patient Populations

Culture includes or influences language, religion, customs, food, codes of manners, behavioral standards, patterns, and beliefs. Culture may also be defined as values and behaviors shared by a group of people such as an ethnic, racial, geographic, religious, gender, class, or age group. Everyone belongs to multiple cultural groups, so that each individual is a blend of many influences.4 Cultural values and beliefs are the foundations of behavior, including that related to health. This integrated pattern of human behavior includes thoughts, communication, beliefs, and customs, and is learned through exposure to the speech, judgments, and actions of others. Ethnicity refers to a shared culture and way of life and is socially distinguished by national origin characteristics. Like ethnicity, race has been described as a sociocultural concept used to distinguish groups of people who share history, geography, and physical characteristics.3

The Joint Commission has defined cultural competence as the ability of health care providers and health care organizations to understand and respond effectively to the cultural and language needs brought by the patient to the health care encounter. Cultural competence requires organizations and their personnel to value diversity, assess themselves, manage the dynamics of difference, acquire and institutionalize cultural knowledge, and adapt to diversity and the cultural aspects of the individuals and communities they serve.1

The U.S. population has been changing significantly and rapidly (TABLE 2). With this increasing diversity, mental health-service providers must be aware of the influence of culture on both the mental illness and the manner in which people seek support and help.4 Census data help us understand some of these trends and shifts; however, these data can be skewed by a group's perception of identity and often overlook the diversity that exists within groups.


tbl2

The term Asian American includes people from a variety of nations, such as Afghanistan, China, India, Syria, and Japan, among others. This group includes families who have immigrated to and lived in the U.S. for generations. African Americans come from 54 countries, speak up to 2,000 different languages, and are composed of 33.9 million people who are related to and share characteristics with the 797 million people living in Africa. Native Americans are people with unmixed ancestry or who have lineage as a fraction of their backgrounds—who may trace roots to any of more than 500 tribes. Native Americans may or may not identify with their tribal ancestry and culture.

People identified as Hispanic can have Mexican, Puerto Rican, Cuban, Salvadoran, or Dominican backgrounds. Others within the Hispanic group have Central America, South America, or other Latino origins.4

Cultural Factors and Health Perceptions

How can specific aspects of diversity impact medication therapy? Every patient has a belief about illness, treatment, and expected recovery. This belief regarding the underlying cause and resolution may have a spiritual basis. Therefore, pharmacists need to have the skills that allow them to develop a treatment plan that respects the patient's spiritual health beliefs. Religion impacts many areas related to medication management (FIGURE 1 and TABLE 3). These are the primary issues:


fig1

Gender-Specific Care and Modesty: Provision of care, regardless of type, may require that the health care providers be of a specific gender. Use care in some cultures not to initiate physical contact unless the patient grants permission first. This often applies to both men and women.

Fasting: Additional consideration must be given to prescribing medications that must be taken with food during periods of religious fasts.

Dietary Restrictions: Dietary restrictions may create a barrier to successful medication therapy since some components of medication must be avoided, unless allowed when medically necessary or under lifesaving conditions (TABLE 3).


tbl3

Patients should be questioned about any diet restrictions they may have because of religious or traditional practices, such as alcohol consumption (TABLE 4). Pharmacists must determine what the patient normally eats before giving dietary advice.13 Vegetarians do not eat meat; vegans do not consume anything from an animal, including eggs and dairy. Gelatin used in medication capsules can be made from the tendons of animals and thus may not be accepted by many who have dietary restrictions, so alternatives may need to be considered.


tbl4

Racial, Ethnic, and Cultural Factors

Individuals who are of a racial and ethnic minority can often be at risk of inappropriate or inadequate medication therapy.4 Research has demonstrated the vast difference in both the quality and quantity of health care received by minority populations versus the majority population. Though many factors can contribute to this disparity, the lack of insurance and income are among those suggested as the most influential. Preventive care provided by primary care physicians is often lacking in minority groups such as African Americans and Hispanic Americans, who are more likely to rely on hospitals and clinics for their main source of care as compared to white Americans (16%, 13%, and 8%, respectively). Members of these minority groups are also less likely to rate the care they do receive as good in part due to communication deficits.14 Research has suggested that patients who experience racial or ethnic discrimination are more likely to have mental health disorders. Cultural groups differ in both their interest in seeking care and acceptance of therapeutic recommendations. Reports of treatment rejections and refusals as high as 6% have been documented in African Americans.15

As pharmacists become more culturally competent and learn about the culture of their patients, they must use care not to stereotype patients. Stereotyping involves defining all the members of a group with the same terms and is often viewed as an endpoint without variance. Instead, it is more appropriate to gather information from our interactions and research and use this to generalize in order to create a starting point from which we can begin to interact with patients of a particular culture. Generalizations help us understand and anticipate patient behavior.15 Here are some suggested generalizations about health behavior and beliefs of just a few of the more common cultures in the U.S.16

General Health Behavior and Beliefs

Hispanic and Latino Patients: Men tend to seek care only when they are unable to perform their necessary work. If they can continue to work with discomfort, they will often do so for the sake of their family. Women tend to be the members that seek care for the family and often sacrifice their own health to accomplish this goal. Family is often engaged in decision making for significant health care matters. For Hispanics who seek complementary and alternative medicine (CAM), providers should consider that holistic healers may be included in self-care and not disclosed for fear of negative responses by traditional Western physicians.

African American Patients: Patients within this group are reported not to seek preventive services due to the belief that life is of the present rather than the future. Obesity is common and accepted as a cultural norm for many. Individuals may also exhibit a great degree of mistrust for the health system for a variety of reasons, including centuries of mistreatment and abuse. Folk medicine alternatives may be used to treat certain illnesses, so practitioners should be aware of this possibility.

American Indian and Alaska Native Patients: Patients within these groups have a common belief that harmony with nature and traditional healing ceremonies are designed to reestablish balance. It is common for American Indians to use traditional therapies with the Western medications they receive. Some American Indians believe that illness is a punishment and is associated with evil spirits. If the tribal medicine healer cannot heal the disease, he or she will refer the patient for Western medicinal interventions. It is recommended that Western medical health care practitioners blend traditional cultural health and values with Western medical strategies.

Complementary and Alternative Medicine

Nearly 40% of adults in the U.S. use CAM. The National Institutes of Health has defined CAM as a group of diverse medical and health care practices and products not presently considered to be part of conventional medicine. The range of such interventions can include biologically based therapies such as herbs, food, vitamins, and dietary supplements as well as mind-body interventions such as meditation, energy therapy, and manipulative body-based methods like massage. The increased use of CAM may be based on cultural influences that attract patients to therapies that are more compatible and consistent with their spiritual beliefs and view of the world. American society includes many first-generation immigrants and multicultural families who have regularly used CAM for generations.17 While CAM is used among individuals from all backgrounds, it is used more by ethnic groups of Native Americans and less among Black/African Americans and Hispanic Americans (FIGURE 2).


fig2

Increased contact with other cultures that traditionally have used CAM has also made it a more popular alternative. Pharmacists can serve a critical role in the management of this cultural therapy choice since many patients fear disapproval by their physician and withhold such information. However, they often will tell the pharmacist they are using CAM in addition to their prescribed therapy. If pharmacists inquire in a nonjudgmental fashion and ask specifically about the use of these agents, patients may be more likely to reveal their actual CAM use. Nearly 60% of Hispanic women surveyed indicate that their physician never asked about CAM use. Physicians self-report that they lack the necessary resources and training to respond to patient requests for information about CAM. Due to the lack of evidence-based information regarding the efficacy and safety of CAM therapies, most health care facilities nationwide require a physician's order for a patient's home supply of dietary supplements.17

The American Society of Health-System Pharmacists has stated that the widespread and indiscriminate use of dietary supplements presents substantial risks to public health, and that pharmacists have both an opportunity and a responsibility to reduce risks to patients who use them. For this reason, pharmacists should become competent in the following elements of safe use of CAM from the Professional Standards for Pharmacists3,18: typical uses of common supplements; research and scientific literature regarding the efficacy and safety of agents used; proven and potential interactions with conventional medications (both prescription and OTC); methods to therapeutically monitor the effects of common supplements, including symptoms of potential adverse events and toxicities; and the safety of supplements before and after surgery as well as the proven and potential impact of certain disease states on the pharmacokinetics of the supplements.

Race and Ethnicity

As we continue to learn more about the role of genetics in drug metabolism, it has become increasingly clear that patient response and drug efficacy can vary in different patient populations. One factor in the wide interpersonal variation of drug metabolism is the DNA polymorphism seen in the genes that encode the cytochrome P-450 enzymes (CYP450) responsible for hepatic metabolism. While there are greater than 50 CYP450 enzymes known, roughly half of these are susceptible to polymorphism and include some of those well known to have significant contribution to drug metabolism. CYP450 2A6, 2C9, 2C19, 2D6, and others are responsible for roughly 40% of the CYP-dependent drug metabolism.19 While genetic testing is not yet a mainstream intervention used to predict efficacy, when there is either an exaggerated or suboptimal response to therapy that is given at an adequate dose for an adequate duration, pharmacists can consider the possibility of altered metabolism of certain drugs due to changes in drug clearance seen in certain ethnic groups (FIGURE 3).


fig3

One of the more significant enzymes involved in the metabolism of many psychotropic drugs is the CYP2D6 enzyme. Many antipsychotic medications are metabolized by CYP2D6, though the degree to which they are affected varies by each drug. Fluoxetine and paroxetine are antidepressants well known to be metabolized through this specific enzymatic pathway.20 Ethnic differences exist in terms of CYP2D6 activity, with the result that some groups are able to rapidly metabolize psychotropic drugs (ultrarapid metabolizers). Such individuals will need a higher dose compared to "poor metabolizers," who are more sensitive to these medications. For example, Saudi Arabian and Ethiopian populations are able to metabolize drugs much more rapidly than Northern European patient populations.19 The frequency of the poor metabolizer phenotype varies significantly across different populations, and within ethnic populations the differences can be even greater.

Other issues to consider when treating patients with mental illness who are of diverse populations include not only a potentially different response to therapy, but also a difference in the cost to treat patients with polymorphisms. Studies have demonstrated costs that reach thousands of dollars more to treat patients with these genetic variables.20 Patients with different genetic backgrounds may have unique treatment profiles. One such example is the condition of benign ethnic neutropenia, which results in a low baseline leukocyte and neutrophil count. Approximately 25% to 50% of persons of African descent and some ethnic groups in the Middle East have benign ethnic neutropenia. A normal white blood count (WBC) for an African American male greater than 18 years of age can range between 3.1 and 9.9 (×103/µL) with an absolute neutrophil count (ANC) between 1.3 and 6.6. Caucasian and Mexican American males show a WBC range between 4.1 and 11.4 with an ANC between 2.1 and 8.0. Though these levels are different, African Americans do not have an increased risk of infection. It is important to recognize the existence of this condition for patients who are on antipsychot-ics and other classes of psychiatric medications that contribute to potential blood dyscrasias. This common form of neutro-penia can result in both the underutilization and unnecessary avoidance of psychiatric medications that may be prescribed safely with appropriate monitoring.21 Given these ethnic differences, evidence-based guidelines may differ based on race and other related factors.

Not all cultural differences may be considered as equally benign. During the domestic development of the atypical antipsychotic Clozaril (clozapine), a disproportionate number of the U.S. cases of agranulocytosis occurred in patients of Jewish background compared to the overall proportion of patients exposed to this drug. There have been no additional monitoring requirements suggested by the FDA based on cultural/ethnic differences in the U.S. for this antipsychotic agent; however, the importance of baseline bloodwork and strict adherence to the monitoring schedules that currently exist is underscored.22,23

Communication Skills

The number of people in the U.S. aged 5 years and older who speak a language other than English at home has more than doubled in the last 3 decades and has increased at a rate four times greater than the population growth of the US. The U.S. Census Bureau report that analyzed data from the 2007 American Community Survey and over a time period from 1980 to 2007 reflected that the percentage of speakers of non-English languages grew by 140% while the overall national population only grew by 34%. Spanish speakers had the largest numeric increase nationwide, with 23.4 million more Spanish speakers in 2007 than in 1980, a 211% increase, whereas the Vietnamese-speaking population accounted for the largest percentage of increase at 511% (1.0 million speakers) over the same time frame.24

Limited English Proficiency Regulations Upcoming

Limited English proficient (LEP) individuals are those who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English. These individuals may be entitled to language assistance with respect to a particular type of service, benefit, or encounter. Federal laws already exist that prohibit discrimination based on national origin, and many individual federal programs, states, and localities also have provisions requiring language services for LEP individuals. Gov. Andrew Cuomo of New York signed New York State Education law "Interpretation and Translation Requirements for Prescription Drugs and Standardized Medication Labeling."25 According to Christopher Jadoch, BS Pharmacy, JD (assistant professor for pharmacy law at D'Youville College, School of Pharmacy, Buffalo, New York), this is a patient-safety initiative. "By removing language as a barrier between individuals with limited English proficiency and pharmacists as front-line health care providers, communication will be improved resulting in the safer delivery of health care," said Dr. Jadoch. New York State is not the front-runner in addressing the language disparity, as this communication barrier has been addressed in various ways in other states, namely Cali-fornia, North Carolina, and Texas. According to Dr. Jadoch, the LEP concept for New York State is also not entirely novel, as it has been required for several pharmacy chains by New York City law.

Conclusion

As pharmacists explore expanding roles as culturally competent medication experts within health systems that are ever increasing in demographic diversity, we must remember that the delivery of safe and effective care is the priority for all of our patients. Ethnic and cultural differences must be acknowledged in order for us to apply unbiased communication skills and the necessary empathy to improve health care for patients who have different physical, spiritual, and language needs.

REFERENCES

  1. The Joint Commission. (2010). Advancing effective communication, cultural competence, and patient- and family-centered care: a roadmap for hospitals. www.jointcommission.org/assets/1/6/ARoadmapfor Hospitalsfinalversion727.pdf. Accessed July 20, 2012.
  2. Zweber A. Cultural competence in pharmacy practice. Am J Pharm Educ. 2002; 66(2):172-176.
  3. American Society of Health-System Pharmacists. Best Practices for Hospital and Health System Pharmacy. Bethesda, MD: ASHP; 2010.
  4. Community integration tools. In: The Temple University Collaborative on Community Inclusion of Individuals with Psychiatric Disabilities. http://tucollaborative.org/pdfs/Toolkits_ Monographs_Guidebooks/community_ inclusion/Cultural_Competence_in_MH.pdf Accessed July 23, 2012.
  5. Thompson D. Culture counts in mental health services and research finds new surgeon general report. U.S. Department of Health and Human Services. August 26, 2001. www.surgeongeneral.gov/news/2001/08/cre.html. Accessed July 23, 2012.
  6. Rudd KM, Stack NM. Cultural competency for new practitioners. Am J Health Syst Pharm. 2006;63(15):912-913.
  7. Sue S, Zane N, Nagayama G, et al. The case of cultural competency in psychotherapeutic interventions. Annu Rev Psychol. 2009;60:525-548.
  8. Joint Commission standards and comprehensive accreditation manual for hospitals (CAMH). (2012). The Joint Commission. www.jointcommission.org/standards_information/ standards.aspx. Accessed June 20, 2012.
  9. United States Census 2010. http://2010.census. gov/2010census/data/. Accessed July 30, 2012.
  10. Pew Research Center. Church statistics and religious affiliations. U.S. Religious Landscape Study. In: The Pew Forum on Religion & Public Life. http://religions.pewforum.org/affiliations. Accessed July 23, 2012.
  11. South Devon Healthcare. Religious, spiritual, pastoral & cultural care: a guide for staff in providing good religious, spiritual, pastoral & cultural care. South Devon Healthcare NHS Foundation Trust. www.sdhct.nhs.uk/pdf_docs/culture-andreligionhandbook.pdf. Accessed July 23, 2012.
  12. National Library of Medicine, National Institutes of Health. http://dailymed.nlm.nih.gov. Accessed October 1, 2012.
  13. Galanti GA. Caring for Patients from Different Cultures. 4th ed. Philadelphia, PA: University of Pennsylvania Press; 2008.
  14. Blendon RJ, Buhr T, Cassidy EF, et al. Disparities in physician care; experiences and perceptions of a multi-ethnic America. Health Aff (Millwood). 2008;27(2):507-517.
  15. Smedley BD. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care [e-book version]. 2004. www.iom.edu/Reports/2002/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care.aspx. Accessed October 25, 2012.
  16. Hiker H. Cultural competency for pharmacy. November 9, 2009. Walgreens. https://webapp.walgreens.com/cePhar-macy/viewpdf?fileName=culturalcompetence.pdf. Accessed July 23, 2012.
  17. Ventola CL. Current issues regarding complementary and alternative medicine (CAM) in the United States, part I: the widespread use of CAM and the need for better-informed health care professionals to provide patient counseling. PT. 2010;35(8):461-468.
  18. Cohen KR, Cerone P, Ruggiero R. Complementary/ alternative medicine use: responsibilities and implications for pharmacy services. PT. 2002;27(9):440-446.
  19. Bernard S, Neville K, Nguyen A, Flockhart D. Interethnic differences in genetic polymorphisms of CYP2D6 in the U.S. population: clinical implications. Oncologist. 2006;11(2):126-135.
  20. Lin KM. Biological differences in depression and anxiety across races and ethnic groups. J Clin Psychiatry. 2001;62(suppl 13):13-19.
  21. Lim EM, et al. Race-specific WBC and neutrophil count reference intervals. Int J Lab Hematol. 2010;32(6 part 2):590-597.
  22. Clozaril [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2011.
  23. Haddy TB, Rana SR, Castro O. Benign ethnic neutrope-nia: what is a normal absolute neutrophil count? J Lab Clin Med. 1999;133(1):15-22.
  24. Shin HB, Kominski RB. April 2010. US Census language use in the United States: 2007. April 2010. www.census.gov/ prod/2010pubs/acs-12.pdf. Accessed July 23, 2012.
  25. Interpretation and Translation Requirements for Prescription Drugs and Standardized Medication Labeling. New York State Education Law, Article 137, §6829. http://public.leginfo.state.ny.us/LAWSSEAF.cgi?QUERYTYP E=LAWS+&QUERYDATA=$$EDN6829$$@TXEDN0682 9+&LIST=LAW+&BROWSER=EXPLORER+&TOKEN=1 9225924+&TARGET=VIEW. Accessed July 30, 2012.

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