Cultural Aspects of Depression: What Clinicians Need to Know

1. Cultural Aspects of Depression: What Clinicians Need to Know Andres J. Pumariega, M.D. Chair, Department of Psychiatry The Reading Hospital and Medical Center Professor of Psychiatry, Temple University School of Medicine Clinical Professor, UMDNJ- Camden/ Cooper Annual Meeting of the National Hispanic Medical Association Washington, DC, April 18th, 2008.

2. Disclosures • No Disclosures

3. Need and Rationale • Growing and Diverse Populations of Hispanics/Latinos • Hispanics/ Latinos became the largest ethnic minority in 2002; fastest growing minority population (40 million) • Out of 40 million immigrants in the U.S., 16.1 million are from Latin America • 800,000 to 1.2 million undocumented immigrants enter the U.S., most from Mexico and Central America, each with average of 1-2 US born children • Majority are Mexican-Americans (30 of 40 million) • Rest: Puerto Ricans, Central Americans, Dominicans, Cubans, South Americans • Populations concentrated in West/ SW, Northeast, Florida, and large cities • New Latino Destinations: largest increases in Latinos in the Southeast: Arkansas, North Carolina, Georgia, Tennessee (over 100 % growth since 1990 Census)

4. Need and Rationale • Diverse cultural and SES backgrounds of Hispanics • Hispanics: Spanish-speaking origin (inc. Spain); Latinos: Latin American origin (inc. Brazil) • Spanish origins- Before the Pilgrims (1500’s) • Indian origins (Mexico, Central America, and Andean spine) • African origins (Caribbean islands and coast) • Other origins (Chinese, Italian, Eastern European, Arab, etc.) • Most poor and undereducated (Mexican-Americans, Central Americans, Puerto Ricans, Dominicans). Cubans and South Americans better off economically/ educationally.

5. Culture and Normal Adaptation • Latino traditional value orientations: • Present (and past) time orientation • Fatalism, spiritual and supernatural orientation to nature • Hierarchical and collateral relationships • Being orientation to identity (who one is related to, not what one does) • Gender and relational roles (centrality of family, traditional roles) • Latino normative adaptive skills/ strengths • Cognitive skills • Practical survival skills, interpersonal skills- personalismo • Protective adaptive values • Paciencia, spirituality, forbearance, humor, fatalism, collectivism, familism, respeto) • Taboos against risky behaviors • Substance use and suicide taboos • Importance of strong ethnic identity

6. Inherent Supports/ Assets for Latinos • Extended family • Padrinos/ madrinas • Comadres/ compadres • Churches (RC and increasingly Protestant/ Pentecostal) • Community organizations • Cultural healers (santeros, curanderos)

7. Immigration: MH Risk Factors • Pre-Immigration Stressors • Poverty and illiteracy • Pre-existing abuse and neglect for children • Catastrophic traumas: War, crime, terrorism, political persecution, famine, disasters. • Many of these contribute to unrecognized psychological/ emotional problems. • Most of these contribute to decision to immigrate.

8. Immigration: MH Risk Factors • Risk Factors in the Immigration Process • Arduous journeys (long distances, through hostile terrain or ocean crossings). • Illegal departures and arrivals • Victimization during journey (victims to violence or crime, to natural forces, witness to death and/ or injury, even detention and incarceration). • Separation from extended family and even parents and siblings (at times permanently). • Parents/ caregivers also dealing with similar stressors, so are not able to contribute much support/ comfort.

9. Immigration: MH Risk Factors • Immediate Post-Immigration Risk Factors • Fear of discovery and legal risks for illegal immigrants. • Prolonged legal processes for legal immigrants • Multiple moves with changes of schools and neighborhoods, difficulty in establishing family/ peer supports. • Economic stresses, both parents working, lack of supervision and support. • Linguistic barriers for youth and parents. • Challengesof learning new processes and customs.

10. Immigration: MH Risk Factors • Long Term Risk Factors • Discrimination (by mainstream population, by other immigrant youth). • Margination (socially, economically) • Poverty and economic pressures • Relative to American standards • Heightened by exposure to American materialistic culture by media) • Exposure to Violence • Community violence (crime, gangs) • Domestic violence

11. Acculturation and Mental Health • Acculturation stress in youth and younger adults • Pressure to acculturate to avoid margination (social, economic) • Focus on material achievement and disruption of family relations (spouses, children) • Loss of natural protective beliefs and values (e.g. lower suicidality taboo) • Loss of extended family support (isolation, social networks) • Changing gender roles and marital conflict: Domestic violence • Impact of discrimination and margination • Generational change in expression of psychopathology(e.g. eating disorders) • Acculturation stress associated with higher levels of depression in Latino adolescents (Hovey and King, 1996; Romero et al, 2007)

12. Acculturation and Mental Health • Acculturation stress in older adults • Latino elders had 44% higher risk for depression and more significant clinical symptoms (44% versus 22%) vs. whites (Brennan et al, 2005) Loss of status of elders within family • Risk factors: • Lack of contact with younger family members (due to work and school) • Lack of knowledge of culture and language barriers leads to isolation if not connected to “ethnic enclave” • Isolation of Latino elders in the home associated with increased anxiety and depression. • Added risk of benzodiazepine (older Latinas) and alcohol abuse (older Latinos) in context of depression and isolation

13. Cultural Factors in the Mental Health of Latinos • Conceptualization of physical or mental illness • Relating to traditional cultural beliefs/values, as well as SES background • Attribution/ understanding • Spiritual, supernatural, interpersonal/ emotional • Threshold of distress • Mainland Latinos; long-suffering; Caribbean Latinos- low threshold

14. Cultural Factors in the Mental Health of Latinos • Conceptualization of physical/mental illness • Differential symptoms for emotional distress (somatization, agitation, dissociation, etc.) • Help-seeking expectations/behaviors (present oriented, problem-focused) • Use of cultural healers (curanderos, santeros, herbal remedies) • Stigma and beliefs around serious mental illness • Primary care management more acceptable

15. Twelve-Month Rates of Utilization of Health Care Services by Mexican Americans with Mental and Substance Use Disorders Vega WA, et al. Gaps in service utilization by Mexican Americans with mental health problems. Am J Psychiatry 1999;156:928-34.

16. Cultural Factors in the Mental Health of Latinos • Conceptualization of mental illness • Culture-bound syndromes • Susto: • Variant of depression/ anxiety (fright/ traumatic experience followed by chronic depression • Explanatory model: Loss of the soul after traumatic experience • Healing approach: Reunite soul and body • Ataque de Nervios: • Constellation of depression, anxiety, somatic, and dissociative symptoms; seen most in Caribbean Latinos; can present in fits/ attacks • Empache • GI distress with “heaviness” of stomach • Can be caused by emotional upset (“disgusto”)

17. Depression in Latinos • Prevalence rates in adults • Overall rates of adult depression equivalent for Latinos, (ECA, Robins & Regier, 1991); NCS, Kessler, et al, 1994), though with a non-significant increased risk (NCS-R, Kessler et al, 2003). • US born Latinos significant higher risk than counterparts in nations of origin, except for Puerto Ricans (high rates in both island and NYC groups). Overall higher prevalence in Puerto Ricans than Cubans than Mexican-Americans. • Symptomatic expression • Somatization (should differentiate from alexithymia) • Fatigue (“sofocado/a”) • “Nervios” • Anger/ irritability (youth); also “colera” or “bilis” in adults

18. Depression in Latino Youth • Roberts and colleagues (1992, 1995, 1997): Higher risk for depression and suicidality in Mexican-Am youth compared to other groups. • Mikolajczyk et al (2007, Calif Health Survey): Latino youth have twice as higher rates of depressive symptoms than whites, low acculturation associated with higher depression. • Roberts (1992): Association between somatic symptoms and mood symptoms in Latino youth. • Swanson et al. (1992): Youth on both sides of the border have equally high levels of depressive symptoms using the CES-D (about 40%), but 3-4 times suicidal ideation in Mexican-American youth; high correlation between depression and SA. • Pumariega et al. (1999): Cultural factors (family cohesion, media exposure, non-supervised time with friends, no religious ties) associatedwith higher SI but not actual history of attempts. • Higher depression and suicidality in Latino runaway substance abusers (Slesnick, et al., 2002). • CDC Youth Risk Behavior Survey (2005): Latinos have highest rates of sadness/ hopelessness, suicidal ideation, suicidal plans, suicide attempts, and serious suicidal attempts vs. Caucasians and African-Americans.

19. Maternal Depression and Latinas • Higher overall prevalence, ranging from 23 to 50 % depending on the study (Chaudron et al, 2005; Ortega, 2006) • Howell et al. (2005): • Prevalence of 47% among Latina mothers • Odds ratios at approximately 2 to 1 with whites • Higher odds even controlling for other demographic factors, history of depression, skills in managing infant, social support, and daily function. • Factors that contribute to increased risk in minority mothers: Poverty, family conflict, domestic violence, acculturation/ margination stresses.

20. Maternal Depression and Latinas • Added adverse impact of maternal depression on Latino children • Adverse effect on reading scores and language scores (Onunaku, 2005) • Adverse effect on infant behavioral regulation and child behavioral problems (Onunaku, 2005; Barrueco, Lopez, and Miles, 2004; Patcher et al, 2006) • Effect of maternal depression in Latinas indirectly mediated through parenting practices (Patcher, Auinger, Palmer, & Weltzman, 2006) • May possibly explain the Latino Paradox (lower infant mortality and higher birth weight in Latino infants but delays in language development) • Young children from low-income and minority households are at overall increased risk for mental health and developmental problems; so maternal depression may contribute to child MH disparities

21. Depression- Latino Adult Disparities • Diagnostic Disparities • Misdiagnosis of underlying medical conditions due to somatization possible • Debate of whether less depression or underdiagnosed • Treatment Access Disparities • Largely related to stigma, health literacy, lack of trust in treatments, clinician bias, and lack of insurance (Lewis Fernandez et al, 2003; Interian et al, 2007). • Latinos have highest rates of treatment non-adherence for depression (Skaer et al, 2000, Sanchez-Lacay et al, 2001). • PCP’s recommend depression treatments to Latinos equally, but Latinos less likely to take antidepressant medications and to obtain specialty MH services (Miranda & Cooper, 2004) • Latinos are half as likely to receive guideline level depression care, controlling for age, SES, co-morbid medical illnesses and anxiety (Lagomasino et al, 2005)

22. Depression- Latino Youth Disparities • Diagnostic disparities • Latino youth significantly less likely than whites to be diagnosed with depression (Richardson et al, 2003; national Medicaid database) • Treatment Access Disparities • Service access: • Latino youth use significantly fewer MH services than other ethnic/ racial groups (Pumariega, et al, 1999; Juszczak, Melinkovich, Kaplan, 2003; Yeh, et al. 2003; Richardson et al, 2003). • Pharmacological treatment: • Martin et al. (2003); Snowden, Cuellar, & Libby (2003); Leslie et al. (2003); Richardson et al, 2003: Lower rates of prescribing psychotropics overall for Latino youth versus Caucasians

23. Evidence-Based in Treatment of Depression for Latino Adults • Pharmacotherapy • Equal response to SSRI’s (Siery et al, 1999), nefazodone (Sanchez-Lacay et al, 2001), and duloxetine (Plewes et al, 2004) • Latinos have higher placebo response (Wagner, et al, 1998, Escobar & Tuason, 1980) • Psychotherapy • CBT enhanced with case management improves adherence and outcomes with Latinos (Miranda, et al, 2003) • Primary care treatment of depression • Equal outcomes vs. whites but lower employment (Miranda, et al, 2004) • QI interventions (CBT, nurse education and follow-up, translation and cultural training for MD’s) improved outcomes for minorities (including Latinos) equal to whites (Miranda, et al, 2003).

24. Evidence-Base in the Treatment of Depression for Latino Youth • TADS Study • With 26% minority participants, race/ ethnicity not significant factor predicting outcome (Curry, 2006) • IPT and CBT for depression • Rosello and Bernal, UPR, 1999: Efficacy of interpersonal psychotherapy and CBT for depression in Puerto Rican youth • Cardemil et al (2007): Effectiveness of school-based CBT • Cognitive Behavioral Intervention for Traumatic Stress (CBIT) • School-based intervention for traumatic stress in children and youth; evaluated in LASD (Kataoka, Stein, et al., 2003) • Evidence-based for Latinos, African-Americans, and Caucasians • Suicide intervention • Telenovelas as ER intervention with suicidal Latinas in Los Angeles (Rotheram Borus, et al, 2004)

25. Culturally Competent Treatment of Latinos:Critical Elements: Important Principles • Cultural Competence Model (Cross, Bazron, Dennis, & Isaacs, 1989) • For the individual: The state of being capable of functioning effectively in the context of cultural differences. • For the organization: A set of congruent practice skills, attitudes, policies, and structures, which come together in a system, agency, or among professionals; and enable them to work effectively in the context of cultural difference.

26. Practitioner CC Awareness/ acceptance of difference Awareness of own cultural values Understanding dynamics of difference Development of cultural knowledge Ability to adapt practice to cultural context of patient Organizational CC Valuing diversity Cultural self-assessment Managing for the dynamics of difference Institutionalization of cultural knowledge Adaptation to diversity (policies, values, structure, and services) Culturally Competent Treatment of Latinos: Critical Elements: Important Principles

27. Culturally Competent Treatment of Latinos: Critical Elements • Access: Location within Latino communities, public transport, hours around work schedules. • Engagement:Youth and family, bicultural approach, address stigma. • Assessment: Cultural context of symptoms/ problems, symptomatic expression, context of level of adaptation, cultural strengths. • Family Involvement: Critical; family therapy focus on generational conflicts, mobilizing family support, respect for family structure, gender roles, confidentiality issues.

28. DSM IV Cultural Formulation • Systematic approach to assessment of cultural factors • Cultural identity (reference group, language, developmental factors, involvement with culture of origin and host culture) • Cultural explanation of illness (idioms of distress, meaning and severity, causes and explanatory models, help-seeking experiences) • Cultural perspective on psychosocial environment and functioning (social stressors, social supports, level of function and disability) • Cultural element of physician-patient relationship (characteristics of physician, organizational/ structural factors) • Overall cultural assessment (contribution of culture to diagnosis and treatment)

29. Culturally Competent Treatment of Latinos: Critical Elements • Psychotherapy: Practical problem-solving; address immigration traumas, acculturation conflicts (internal or generational), use of culturally specific modalities or themes. • Pharmacotherapy: Demistify, educate, address metabolic issues, culturally appropriate consent, empowerment. • Contextual/ systemic: Utilize family/ community supports (churches, community groups, support groups); community-based, ethnically specific programs if available; improve health literacy (materials from APA, NAMI, NMHA, etc.).

30. Culturally Competent Treatment of Latinos: Critical Elements • Linguistic Support • Critical importance of language • Establishment of alliance/ relationship/ adherence • Establishment of urgency • Accurate communication of symptoms • Accurate communication of treatment recommendations • Patient education about illness and treatment • Failure leads to errors, misalliance, bad outcomes • Critical elements in interpretation • Knowledge of language • Knowledge of culture (idioms, non-verbals, etc.) • Knowledge of content matter • Objectivity (problem with relatives) • NEVER use children/ youth (roles, boundaries)

31. Recognition and Management of Depression and Co-morbidities in the Hispanic Population Friday, April l8, 10:00 a.m. – 12:00 p.m. National Hispanic Medical Association 12th Annual Conference Washington Hilton Washington, D.C. Supported by educational grants from AstraZeneca Pharmaceuticals, Bristol-Myers Squibb Company, Eli Lilly and Company, Forest Laboratories, and Wyeth Pharmaceuticals