Issues and Challenges in the Diagnosis and Treatment of Mentally Ill Hispanic Patients

In July 2005, the Hispanic American population was estimated to be 42.7 million, 14.4% of the population and the largest minority in the United States.¹ That number is expected to grow to 102.6 million, or 24.4% of the national population, by the year 2050.² Despite these impressive numbers and the accepted validity of Hispanic as a distinct demographic and cultural category, we have only fragmentary evidence and scarce guidelines regarding the treatment of mentally ill Hispanic Americans. This article provides a brief review of the topics with the most clinical relevance to diagnosis and treatment of mental disorders in Hispanic Americans.

Some highlights regarding Hispanic Americans
Compared with the national average, Hispanic Americans are younger, poorer, less educated, and more likely to lack health insurance. However, their participation in the labor force is very close to average (Table 1).

Hispanic Americans cannot be seen as a monolithic group regarding health-especially mental health. Despite the common cultural identification, Hispanic Americans are heterogeneous in aspects that could influence the incidence, presentation, course, and treatment of mental illness, such as birthplace/acculturation, genetics/race, health care access/use, and language.

Ethnically, Hispanic persons include groups that are predominantly mestizo, Native American, black, white, or an admixture of all possible combinations. Although we have no comparative studies among subgroups, the ethnic/racial variety implies pharmacokinetic and pharmacodynamic differences for psychotropic medications.

The 2000 census shows that 2 of 5 Hispanic Americans (40.2%) are foreign-born.³ This is an important consideration because recent studies have consistently shown lower rates of diagnosable mental disorders among first-generation (immigrant) than among United States-born Hispanic persons. However, studies with some highly vulnerable Hispanic populations, such as the elderly, the young, or women living in poverty, have shown the opposite trend toward higher psychopathology levels in immigrants. It is likely that increased acculturative and socioeconomic stress changes the direction of the effect for these populations.⁴Hispanic Americans are more likely to be uninsured-and even when insured, they have less access to medical care than do other Americans. In 2002, 35% of Hispanic Americans reported being uninsured (vs 14% of non-Hispanic whites and 21% of African Americans).⁵ The recent National Comorbidity Replication Survey showed that the 12-month odds ratio (OR) for Hispanic persons receiving treatment for mental disorders was 0.6 (95% confidence interval, 0.5 to 0.8; P = .05) compared with non-Hispanic whites.^6,7

Hispanic persons are significantly more likely to receive attention for mental disorders in primary care settings than in specialized settings. Mexican Americans with mental disorders showed a 12-month utilization rate of 18.4% for a general care provider and 8.8% for a mental health specialist.⁸

Hispanic Americans show a fast-growing risk for some health issues that can complicate mental disorders or their treatment. These include metabolic syndrome⁹ or some of its components (obesity, diabetes mellitus, dyslipidemia) and a sedentary lifestyle (Table 2). As does the risk for mental illness, the incidence of these health risk factors seems to increase with level of acculturation and length of stay.¹⁰

Cohesive families may influence mental illness and its treatment in a more positive way for Hispanic Americans than for other groups, such as non-Hispanic white Americans. A study in patients with schizophrenia and their families found that "family warmth" seemed to work as a protective factor for Mexican Americans but as a risk factor for non-Hispanic Americans.¹¹ Another study found that Mexican American patients with schizophrenia and their relatives reported lower rates of expressed emotion than comparable non-Hispanic white patients. High expressed emotion predicted relapse for the whites but not for the Mexican Americans.¹²

Language barriers
Hispanic persons are very likely to experience linguistic barriers in health and mental health care. About half of adult Hispanic Americans report low English proficiency. According to the 2000 US census, approximately 80% of Hispanic Americans aged 5 years and older speak Spanish at home, and half of those consider their proficiency in English unsatisfactory.¹³ A significant number of Hispanic Americans report difficulty in communicating with physicians and other health care providers.⁵ This is worrisome because poor English fluency in itself is a risk factor for decreased health care and mental health care use among Hispanic Americans (Table 3).

Moreover, once Hispanic patients access the services, poor English proficiency is a risk factor for lower quality of care, delayed services, poorer follow-up, longer hospital stay, higher resource utilization, lower psychotropic medication adherence, and patient dissatisfaction with provider and treatment.⁴

Chronicity of illness
Even if Hispanic Americans do have a lower risk of mental disorders, they appear to have more persistent disorders. This seems logical, taking into account their social disadvantages and reduced access to, use of, and quality of mental health care.^14,15

Different patterns of diagnosis
Hispanic Americans seem to be at higher risk for underdiagnosis of mental health problems in different care settings-especially in primary care. In a recent study, primary care providers noted depression in 21% of Mexican Americans with depressive disorders according to a systematic evaluation.¹⁶ In a pediatric clinic, only 24% of Hispanic mothers were correctly identified as depressed, compared with 31% of black mothers and 38% of mothers of other races.¹⁷ A study in elderly Medicare recipients found that Hispanic/other patients had an OR of 0.72 for diagnosed depression, compared with non-Hispanic whites.¹⁸ This underrecognition also includes the young, since several studies have suggested lower recognition and treatment of attention-deficit/hyperactivity disorder in Hispanic children.⁴

Hispanic Americans seem more likely to receive a diagnosis of psychotic disorder and less likely to receive one of mood disorder than do non-Hispanic whites. In the 1980s, a review of the records of 76 patients with bipolar disorder showed that Hispanic (Puerto Rican) and black patients were more likely than whites to have a misdiagnosis of schizophrenia, particularly if they were young and experienced auditory hallucinations.¹⁹ A study in Texas that followed 936 inpatients with at least 4 hospitalizations found that of the Hispanic patients in whom schizophrenia was initially diagnosed, the diagnosis was subsequently changed in 44%, a rate double that of non-Hispanic whites and African Americans.²⁰ A study of an inpatient national sample of elderly veterans found that African Americans and Hispanic Americans were more likely than non-Hispanic whites to have a diagnosis of a psychotic disorder.²¹

A high incidence of psychotic symptoms without formal psychosis but associated with depression has been reported in Hispanic Americans. At a general medicine practice in New York, psychotic symptoms were found to be more common in Hispanic patients who were depressed than in non-Hispanic black or white patients who were depressed.²² A study in Rhode Island found that Hispanic patients with major depression were more likely to report psychotic symptoms.²³ Finally, a Boston study found that 46% of outpatient Caribbean Latinos had reported hallucinations, yet a thought disorder was diagnosed in only 9%.²⁴

A tendency for Hispanic persons to somatize distress has been repeatedly reported in Latin America, although the methodology of the studies has been criticized. An American study, using a personality inventory in claims for workers compensation, found that Hispanic persons were more likely to somatize than non-Hispanic whites.²⁵ In a California study, depressed Latino women (and African American women) scored significantly higher than non-Hispanic whites on somatization.²⁶ A recent study on anxiety and fear found that parents of Mexican children in Mexico and Hispanic American children in the United States reported more worry and physiologic symptoms for their children than did non-Hispanic white parents.²⁷

Medication responseSo far, the scarce information available does not show significant differences in the metabolism and pharmacokinetics of psychotropic medications in Hispanic Americans. Regarding cytochrome CYP2D6, perhaps the most important enzyme in psychopharmacology, 3 studies involving Mexican Americans found a low percentage of slow metabolizers (4.5%, 3.2%, and 6%, respectively), a frequency similar to that among non-Hispanic whites.^28-30 Comparative studies have also been negative for the genotypes of CYP3A4, methylenetetrahydrofolate reductase, aldehyde-dehydrogenases ADH2 and ALDH2, or CYP4502E1 and CYP3A.⁴ A study of the metabolism of haloperidol in 250 patients with schizophrenia from 4 ethnic groups (non-Hispanic black, non-Hispanic white, Mexican in the United States, and Chinese in Taiwan) found a statistically significant difference between the Chinese and the other 3 groups but not among the non-Chinese groups.³¹

We have scarce information on the response of Hispanic persons to psychotropic medications. Large studies sponsored by pharmaceutical companies include too few minority subjects. As for large government-sponsored studies, the recruitment rates of Hispanic persons for the CATIE (schizophrenia), STEP-D (depression), and the STEP-BD (bipolar disorder) were 12%, 9%, and 4%, respectively-all lower than the percentage of Hispanic persons in the overall population. Open-label studies in a small number of subjects showed some differences for Hispanic persons in dose and placebo response in schizophrenia and depression. However, larger ones, usually retrospective analyses of databases at pharmaceutical companies, have not confirmed this.^4,32

Medication adherence
Some studies show that Hispanic Americans are significantly less adherent than non-Hispanic whites to antipsychotic and antidepressant medication regimens.^33,34 However, the perceived difference in medication adherence in Hispanic Americans is likely better explained by socioeconomic and communication-related factors (ie, being monolingual) than cultural factors. A study looking at records of Hispanic outpatients with schizophrenia in Texas found rates of compliance in line with those of patients of other backgrounds with schizophrenia.³⁵ A study that interviewed community patients in Ohio reported that while the medication adherence for Latino persons with depression was lower than for non-Hispanic whites with depression, the figures were similar for patients with schizophrenia from both groups,³⁶ which may reflect the greater support that patients with schizophrenia receive. A study using an electronic cap to monitor bottle openings in patients with different diagnoses, including schizophrenia, found significantly lower medication adherence in monolingual Hispanic patients than in non-Hispanic whites.³⁷Regarding psychosocial interventions for mentally ill Hispanic Americans, studies do not suggest an interaction between Hispanic ethnicity and outcome with psychotherapy. However, Hispanic or Spanish-speaking participants seem more likely to improve when they receive supplemental case management, collaborative care, or quality improvement interventions as opposed to treatment as usual.⁴

Recommendations
Hispanic persons are a heterogeneous group: therefore, clinicians should not let culture-specific information obscure the individual patient. It is important to get information on origin, generation, number of years in the United States, language, acculturation, personal beliefs, and current socioeconomic characteristics of individual Hispanic patients.

Linguistic barriers should not be minimized. A professional translator should be used whenever indicated; use of family members or relatives as translators is best avoided, especially because of confidentiality issues and distortion or censorship of information. The list below describes possible responses to linguistic barriers in Hispanic patients. Only the first 2 are considered complete solutions, and the last 3 are emergency or stopgap measures.

• Bilingual/bicultural professional staff.
• Interpreters in situ.
• Language skills training for existing staff.
• Internal language banks.
• Phone-based interpreter services.
• Written translations.

Remember that Hispanic patients are more likely to have their psychiatric problems unrecognized, to present with somatic complaints for mental disorders, or to report psychotic symptoms in the absence of a thought disorder. Be alert to any symptom suggestive of mental disorder, but do not jump to the diagnosis of a psychotic disorder.

If you are in a primary care psychiatry setting, minimize referrals. Hispanic patients are significantly more likely than average to be lost in transit.

Hispanic Americans have less access to health care and once receiving care, they have fewer visits. The time window to treat Hispanic persons is shorter than average. Thus, be careful but not timid when establishing treatment for mentally ill Hispanic persons. Remember that so far, there is no clear evidence that Hispanic patients respond to medication or psychotherapy in different ways from non-Hispanic whites. Also remember that Hispanic persons can benefit more than average from enhanced interventions such as family education, supplemental case management, collaborative care, or quality improvement interventions, as opposed to treatment as usual.

At follow-up visits, ask clearly about negative sides of the therapy, such as lack of response or adverse effects. A Hispanic patient is less likely than average to report information that could look like a negative judgment about the treatment you are providing.

Beware the long-term adverse effects of psychotropic medications, especially on metabolic syndrome. Hispanic Americans have the fastest growing rate of obesity, diabetes, and metabolic syndrome among ethnocultural groups; and Hispanic persons in whom complications develop from psychopharmacologic therapy have a worse chance of receiving treatment for the complications.

Finally, remember that if a good therapeutic alliance is important for any patient, it is critical for Hispanic patients. Without being patronizing, clearly express your interest and sympathy and try to establish an individualized relationship with the Hispanic patient and his or her family.

Dr Marin, born in Colombia, is assistant professor of psychiatry in the division of clinical psychopharmacology, University of Medicine and Dentistry of New Jersey and the Robert Wood Johnson Medical School in Piscataway, NJ, where he is involved in research in cross-cultural psychiatry, general psychopharmacology, and the psychiatric aspects of Parkinson disease. He is also a psychiatrist on the Huntington disease project. He reports that he has taken part in CME activities sponsored by Bristol-Myers Squibb and Otsuka; that he is a consultant for Eli Lilly; and that he has received research support from the National Institute of Neurological Disorders and Stroke and from Pfizer.

References:

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