By Fátima Reynolds, M.P.H.

Dr. Junji Takeshita is a Clinical Professor of Psychiatry at the John A. Burns School of Medicine, University of Hawaii. He is the Director of Medical Education and Patient Care Services for Consultation/Liaison Psychiatry. Dr. Takeshita graduated from Temple University School of Medicine, completed his residency in psychiatry at Yale and is board certified in General and Geriatric Psychiatry. He is the President of the American Association for Emergency Psychiatry. He is a member of the Asian-American Caucus of the American Psychiatric Association and has presented nationally regarding cultural issues in psychiatry.

I became interested in the medical aspects of psychiatry through a consultation/liaison (CL) elective as a medical student. Both CL and geriatrics deal with a medically ill population, and I got grandfathered in without needing to do a fellowship. It was serendipity. During the first several years as an attending, I had the opportunity to start a geriatric psychiatry fellowship along with Dr. Iqbal Ahmed. Later, I ran the psychiatric emergency room and became involved with the American Association for Emergency Psychiatry where I am the current president.

I think being Asian-American and growing up on the East Coast in an area with little diversity has resulted in greater awareness of race, culture and ethnicity affecting the presentation of mental illness. I joined the APA’s Asian American Caucus, which has been a wonderful experience. It is a group of people interested in cultural issues, with many that have similar experiences to mine in terms of witnessing a demographic shift towards diversity.

APA members and psychiatrists in general are much more aware and attuned to these cultural and diversity issues already. The hard part is to treat the patient as an individual and not stereotype. I think it is important to acknowledge personal limitations about culture, remain humble, curious and ask for help. In some instances, cultural assumptions may be quite wrong and attribute pathological symptoms to culture rather than psychiatric illness. During my residency, I treated a Haitian woman who hallucinated and had delusions about voodoo which were due to schizophrenia rather than what other clinicians thought was rooted in her cultural background.

Awareness of cultural issues and implementation of evidence-based medicine are complementary and just a part of good patient care. A competent practitioner knows that culture is one of many variables that affect the presentation of illness. Our medical school and residency focused on culture, with an emphasis on Asian Pacific Islanders. Our department was involved in a book entitled People and Cultures of Hawaii which looked at the various groups in Hawaii. I was a co-author on the chapter involving Japanese in Hawaii. Currently our department faculty and staff are going to Maui to assist in mental health care. Local knowledge of cultural and generational issues has been helpful in working with disaster agencies.

The patients are older and have medical issues, so you must be aware of comorbidities. It happens that patients receive inappropriate medications that cause psychiatric problems. There is an overlap of the medical presentations of disorders like delirium, dementia, and depression in older populations. Treatment can be based on what information you receive from the patient, which could lead to incorrect treatment plans. Culture and diversity issues factor in as English proficiency may be limited. This could lead to inaccurate medical histories. We often ask families for medical histories, as they can provide a rich background of information, in the presence of a language or cognitive barrier.

The biggest challenge in geriatric psychiatry, however, has been recruitment. As an example, although we have had a fellowship program for over twenty-five years, since 2015 we have not had a trainee. We are not alone with this problem and nationally, many positions in geriatric psychiatry remain unfilled. The opportunity is that the population of elderly has increased significantly while the number of psychiatrists with added qualifications in geriatric psychiatry has decreased. While there is significant demand for geriatric mental health care, Medicare limits reimbursement. Graduates of psychiatry programs are facing high medical student debt – choosing a geriatric psychiatry fellowship over working as a general psychiatrist may be a difficult option.

Telemedicine is here to stay, and many studies have shown comparable care with all populations including the elderly.   Families are often needed to assist although many elderly people are quite facile with technology.  I provided telemedicine during the COVID pandemic for nursing homes. Despite the data, some administrators remain skeptical and believe that traditional face-to-face care is the only way to see patients. 

Family meetings are crucial to bridge the gap of expectations particularly in terms of caregiving for dementia.  Historically, the elderly did not have a long ageing period and had large extended families living nearby to assist with care. This is no longer the case with families now scattered across the country.   

The ethnic elderly have had varied life experiences and can provide a personal view of major world events such as WWII.  I have had patients who experienced near death wartime experiences and others from Micronesia who spoke fluent Japanese due to the Japanese occupation of their home country. 

I hope that there will be more of you in the future since there are so few geriatric psychiatrists, let alone individuals with interest and expertise in cultural issues. The need is tremendous, we can’t fill programs locally or nationally, a lot of it has to do with finances and stigma. It goes back to finance, if you are a lower income individual, who is an ethnic minority, you will have even larger loans, and will be less likely to spend an additional year in specialized training. I wrote a paper exploring the reasons trainees pursued geriatric specialties and found that family, culture and the values of the training program played a role. (A Survey of Geriatric Psychiatry Fellows and Program Directors: Specialty Choice, Program Choice, and Program Quality - PubMed, nih.gov).

The CDC released a report this year on emergency department visits related to mental health disorders, finding that mental health related emergency department visits comprised 12.3% of all ED visits. It also found that Black adults had the highest rates of mental health–related emergency department (ED) visits and the longest wait times and were less likely to be admitted or transferred to another hospital than Hispanic or White adults. Can you please share your thoughts on this, and its implications for psychiatry? 

Cultural and racial inequities in the emergency setting unfortunately have not changed.  I suspect much of the problem lies with implicit bias.   It is important for practitioners to be aware of their own bias and to take the implicit bias test.   The psychiatric emergency setting is particularly prone to implicit bias given the fast pace and need to make quick decisions.  It is also difficult to determine how much of the problem is influenced by other psychosocial issues such as homelessness, poverty and social support. 

The emergency room is a unique setting in medicine with involvement of law enforcement in bringing in patients.  There has been considerable data showing African Americans receiving more first-generation antipsychotics, less clozapine, and less electroconvulsive treatment.  African Americans are more likely to be brought in by law enforcement. Dementia is underdiagnosed among African Americans in contrast to schizophrenia which is over diagnosed. It remains unclear how much of these differences reflect racism and bias, differences in help seeking behavior versus other factors such as poverty and generational trauma.  But unfortunately, there has been little change in racial disparities through the past several decades. 

There is a major trend in emergency psychiatry: the living room model. Historically patients received care in standard-looking emergency rooms. These rooms were not very friendly, with the living room model, the setting is more humane. There are chairs and seats much like a living room. Patients receive care and medications, and those that are intoxicated, and psychotic can be discharged quickly using this model. The architecture really comes to bear on the quality of emergency psychiatric care.

I am most proud of the fact that I have been involved in medical student and resident training, we are the only resident program here in Hawaii and I have been involved in training the majority of psychiatrists in the state.