Self-report of use of traditional Chinese medicine by patients attending a cross-cultural psychiatry outpatient clinic

Background
With the growth in cultural diversity, there has been a corresponding increase in cross-cultural mental health services and community resources. The number of ethnic Chinese clients accessing the services offered by nine Vancouver Coastal community mental health teams has been increasing steadily over the past decade. 

According to the 2001 census, only 50% of Lower Mainland residents speak English as their mother tongue. Immigration trends in this time have also seen a substantial decrease in Chinese immigrants from Hong Kong and Taiwan, and an increase in immigrants from Mainland China. Most recent Chinese immigrants are Mandarin-speaking and are familiar with traditional Chinese medicine (TCM), which encompasses a range of medical practices, including the use of herbal medications developed in China about 3000 years ago.[1] TCM is based on the principle that the human body and its environment are interrelated. Disharmony in the external and internal environment of an individual can cause illness, which TCM can address by bringing the body back into harmony and health.[1] 

Many ethnic patients have strong beliefs in their own traditional healing practices. This influences both their willingness to seek out other methods of treatment and to comply with treatment plans.[2] Chinese patients tend to deal with psychiatric illness initially through family supports and alternative modalities and may only seek help from a family physician once these efforts prove unsuccessful.[3] In addition, Chinese societies tend to place an emphasis on physical symptoms and treatments rather than psychological ones. Metaphors such as “heartache,” conveying sadness, and “fatigue,” conveying despair, are used to express complaints of emotional distress. It is often much more culturally acceptable for Chinese patients to seek help for physical complaints than for psychological ones.[2] Because TCM is not dualistic and does not separate emotional and physical conditions, patients will often present to TCM practitioners with somatic symptoms that are metaphors for an emotional state.

One important principle in TCM is the balance of body “life substances” in an individual. These life substances include:

• Qi, which is considered to be an individual’s “life force energy.”

• Jing, which regulates developmental changes.

• Jin-ye (body fluids), which moisten and nourish the body.

• Xue (blood), which also nourishes the body.

• Shen, which is a manifestation of consciousness.

A deficiency or accumulation of any of these life substances can cause both physical and emotional distress.

An organ-oriented concept of pathology is also found in TCM, which sees the liver representing anger, the heart representing anxiety, and the spleen representing depression. A patient who is overly anxious may be seen to have injured his spleen qi, which in turn has caused an accumulation of body fluids that cloud the shen and result in depression. TCM practitioners are able to “read” these somatic symptoms and identify an underlying psychological problem.

The TCM diagnosis consists of three parts: the interview, the tongue examination, and the pulse examination. The interview involves a thorough symptom inventory. The tongue examination, often considered to be the most important part of the diagnosis, involves looking at the color and texture of the tongue. It is believed that the tongue changes with specific diseases. The TCM practitioner then examines the patient’s pulse because it is believed that the pulse reflects different vital organs and can change according to a patient’s illness. The TCM practitioner will use the information gathered from the interview and the tongue and pulse examinations to arrive at a diagnosis and treatment plan for the patient. The treatment plan usually consists of a combination of herbs.

The use of alternative medicine, particularly TCM, in patients with psychiatric disorders is an area of very limited research, even though a national survey in the US reported that 40.9% of subjects with depression used alternative medicine.[4] 

With the growth of TCM in Canada for patients with physical and psychiatric illnesses, the issue of safety has become especially important. Herbs can contain toxic ingredients. As well, the concentration of active ingredients in herbs can vary as a result of different growing conditions, making overdose a possibility. There is also the potential for interactions with Western psychotropic drugs. With all of these concerns, it is important for physicians to have an understanding of TCM.[5] The object of this preliminary study was to determine the prevalence of TCM use in patients and to examine demographic and clinical factors associated with TCM use.

Methods
Data were collected between December 2005 and February 2006 using a standardized questionnaire (Figure 1) to interview 61 Chinese patients attending the Vancouver General Hospital (VGH) Cross-Cultural Psychiatry Outpatient Clinic. The clinic was set up in 1988 to provide ethnically sensitive mental health services to at least 10 different ethnocultural groups. Eligible participants in the study were ethnic Chinese from three different countries of origin: Taiwan, Mainland China, and Hong Kong.

The questionnaire used for the face-to-face interviews asked about patient demographics, patient experience with TCM, and patient attitudes toward psychiatry and psychotropic medications.

The patients interviewed (Table 1) ranged in age from 17 to 71 years, with a mean age of 43.5. There was equal representation from the three major countries of origin, with the mean number of years spent in Canada being 13.2. 

Results
Patients were found to use TCM both prior to and while seeking treatment at the VGH Cross-Cultural Psychiatry Outpatient Clinic (Table 2). Twelve patients (20%) reported having used TCM prior to seeking psychiatric treatment. There was no significant difference in terms of the three different country of origin groups. Among the 12 patients who had used TCM, 10 did not know the name of the herbal medication they had taken and many of the patients reported taking TCM products for somatic symptoms (such as insomnia or pain) and not specifically for emotional symptoms. Five patients (8%) reported using TCM concurrently while seeking psychiatric treatment. Most of the patients who had used TCM products prior to seeing a psychiatrist discontinued their use of such products when advised to do so by a psychiatrist. 

Patients had a number of expectations regarding the types of treatments they might receive at the clinic (Figure 2). Thirty-six percent of patients expected medications only, 17% expected psychotherapy only, 26% expected medications and psychotherapy, and 21% said that they did not know what to expect. The majority of patients (80%) had positive responses regarding psychotropic medications, with many of them saying that they had found the medications to be helpful. Patient concerns about psychotropic medications were focused on side effects, particularly weight gain and drowsiness. Forty-one patients (67%) felt that psychotherapy was helpful. Fifty-one patients (85%) had support from their family members or partner regarding treatment at the clinic. Patients whose family members or partner did not know they were seeking psychiatric treatment said it was because of privacy and confidentiality.

One of the questions in the survey asked patients to describe their understanding of their emotional difficulties and it was interesting to see the variety of responses. Many patients attributed their emotional difficulties to somatic problems, such as pain or insomnia, while others attributed their emotional difficulties to their anxious personality or to stress from school, work, or family. One patient described his emotional difficulties as being due to a “chemical imbalance in the brain.”

Conclusions
This preliminary descriptive study looked at the use of TCM by ethnic Chinese patients as well as the general attitudes of these patients toward psychiatry and psychotropic medications. Limitations in this study include the small sample size and the possibility of a sample bias, as our subjects were selected from patients who were in psychiatric treatment.

We found that 20% of patients reported using TCM prior to seeking psychiatric treatment. A study of four family practices in metropolitan Vancouver found that a similar percentage of Chinese patients (28%) used traditional Chinese medicine. Several other studies found, as we did, that Chinese patients with emotional difficulties tend to present to the caregiver with physical symptoms (somatization), and many Chinese patients turn to traditional Chinese medicine, with its emphasis on physical symptoms and treatments. 

The majority of Chinese patients at the VGH Cross-Cultural Outpatient Psychiatry Clinic were taking TCM for physical complaints, such as low energy or pain. Patients who were using TCM concurrently while seeking psychiatric treatment were generally taking it for colds and other health conditions. 

Most patients interviewed (85%) had support from their families. This was higher than expected, given that Chinese societies tend to associate stigma and shame with psychiatric illness, and families often work hard to conceal the illness in order to “save face.”[1] 

The attitude toward psychiatry and psychotropic medications in our patient population was generally very positive. The majority of patients felt that both psychotropic medications and psychotherapy were helpful and their major concerns involved the side effects of medications.

Despite our patients’ positive attitude toward psychiatry, use of TCM for psychiatric illnesses is increasing. This makes the safety of TCM an important issue. There is currently no formal regulatory process for TCM products and no postmarketing surveillance. In addition, there is variability in ingredients and the potential for interactions with Western psychotropic medications. Larger-scale qualitative studies involving other Canadian centres are required to obtain a better understanding of TCM use in psychiatry.

Competing interests
None declared.

Figure 1. Standardized questionnaire for investigating use of traditional Chinese medicine (TCM) by patients at the VGH Cross-Cultural Psychiatry Outpatient Clinic.

Table 1. Characteristics of 61 patients at VGH Cross-Cultural Outpatient Psychiatry Clinic.

Table 2. Patients admitting to traditional Chinese medicine (TCM) use prior to and while seeking treatment at the clinic.