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
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).
Characteristics of Hispanic Americans3,38
|Age (median, y)||26||35.4|
|Family households (% of total households)||81||68|
|LOEH and English spoken less than very well||40.6%||8.1%|
|25 years and older with high school or higher education||52.4%||80.4%|
|16 years and older in labor force||69.4%||70.7%|
|Living in poverty||22.6%||12.4%|
|LOEH, language other than English at home.|
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.4
Hispanic 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
Prevalence of health risk
factors that may affect the
treatment of mental disorders4
|Factor||Hispanic||Non-Hispanic white||Non-Hispanic black|
|Obesity (> 20 years, age/sex
|Regular leisure-time exercise (> 18 years, sex adjusted)||22.7||33.9||24.1|
|Diabetes prevalence (> 20 years, age adjusted)||11.7||7.9||12.9|
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
1. US Census Bureau. Annual estimates of the population by sex, race and Hispanic or Latino origin for the United States: April 1, 2000 to July 1, 2005. (NC-EST2005-03). Available at: http://www.census.gov/popest/national/asrh/
NC-EST2005-srh.html. Accessed October 31, 2006.
2. US Census Bureau. US interim projections by age, sex, race, and Hispanic origin. Available at: http://www.census.gov/ipc/www/usinterimproj/. Accessed October 31, 2006.
3. Ramirez RR. We the People: Hispanics in the United States. Census 2000 Special Reports. US Census Bureau. Available at: http://www.census.gov/prod/2004pubs/censr-18.pdf. Accessed October 31, 2006.
4. Marin H, Escobar JI, Vega WA. Mental illness in Hispanics: a review of the literature. Focus. 2006;4:23.
5. Brodie M, Steffenson A, Valdex J, et al. 2002 National survey of Latinos: summary of findings. Kaiser Family Foundation; 2002. Available at: http://www.kff.org/ kaiserpolls/20021217a-index.cfm. Accessed October 31, 2006.
6. Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:629-640.
7. US Department of Health and Human Services. 2004 National healthcare disparities report. Available at: http://www.qualitytools.ahrq.gov/disparitiesreport/2004/
download/download_report.aspx. Accessed October 31, 2006.
8. Vega WA, Kolody B, Aguilar-Gaxiola S, Catalano R. Gaps in service utilization by Mexican Americans with mental health problems. Am J Psychiatry. 1999;156:928-934.
9. Lorenzo C, Williams K, Hunt KJ, Haffner SM. Trend in the prevalence of the metabolic syndrome and its impact on cardiovascular disease incidence: the San Antonio Heart Study. Diabetes Care. 2006;29:625-630.
10. Gordon-Larsen P, Harris KM, Ward DS, et al. Acculturation and overweight-related behaviors among Hispanic immigrants to the US: the National Longitudinal Study of Adolescent Health. Soc Sci Med. 2003;57:2023-2034.
11. Lopez SR, Nelson Hipke K, Polo AJ, et al. Ethnicity,
expressed emotion, attributions, and course of schizophrenia: family warmth matters. J Abnorm Psychol. 2004;113:428-439.
12. Weisman A, Rosales G, Kymalainen J, Armesto J. Ethnicity, family cohesion, religiosity and general emotional distress in patients with schizophrenia and their relatives. J Nerv Ment Dis. 2005;193:359-368.
13. Shin HB, Bruno R. Language use and English-speaking ability: 2000. US Census Bureau. Available at: http://www.census.gov/prod/2003pubs/c2kbr-29.pdf. Accessed October 31, 2006.
14. Breslau J, Kendler KS, Su M, et al. Lifetime risk and persistence of psychiatric disorders across ethnic groups in the United States. Psychol Med. 2005;35:317-327.
15. Golding JM, Lipton RI. Depressed mood and major depressive disorder in two ethnic groups. J Psychiatr Res. 1990;24:65-82.
16. Schmaling KB, Hernandez DV. Detection of depression among low-income Mexican Americans in primary care. J Health Care Poor Underserved. 2005;16:780-790.
17. Heneghan AM, Silver EJ, Bauman LJ, Stein RE. Do pediatricians recognize mothers with depressive symptoms? Pediatrics. 2000;106:1367-1373.
18. Crystal S, Sambamoorthi U, Walkup JT, Akincigil A.
Diagnosis and treatment of depression in the elderly medicare population: predictors, disparities, and trends. J Am Geriatr Soc. 2003;51:1718-1728.
19. Mukherjee S, Shukla S, Woodle J, et al. Misdiagnosis of schizophrenia in bipolar patients: a multiethnic comparison. Am J Psychiatry. 1983;140:1571-1574.
20. Chen YR, Swann AC, Burt DB. Stability of diagnosis in schizophrenia. Am J Psychiatry. 1996;153:682-686.
21. Kales HC, Blow FC, Bingham CR, et al. Race and inpatient psychiatric diagnoses among elderly veterans. Psychiatr Serv. 2000;51:795-800.
22. Olfson M, Lewis-Fernandez R, Weissman MM, et al. Psychotic symptoms in an urban general medicine practice. Am J Psychiatry. 2002;159:1412-1419.
23. Posternak MA, Zimmerman M. Elevated rates of psychosis among treatment-seeking Hispanic patients with major depression. J Nerv Ment Dis. 2005;193:66-69.
24. Geltman D, Chang G. Hallucinations in Latino psychiatric outpatients: a preliminary investigation. Gen Hosp Psychiatry. 2004;26:153-157.
25. DuAlba L, Scott RL. Somatization and malingering for workers’ compensation applicants: a cross-cultural MMPI study. J Clin Psychol. 1993;49:913-917.
26. Myers HF, Lesser I, Rodriguez N, et al. Ethnic differences in clinical presentation of depression in adult women. Cultur Divers Ethnic Minor Psychol. 2002;8:
27. Varela RE, Vernberg EM, Sanchez-Sosa JJ, et al. Anxiety reporting and culturally associated interpretation biases and cognitive schemas: a comparison of Mexican, Mexican American, and European American families.
J Clin Child Adolesc Psychol. 2004;33:237-247.
28. Lam YWF, Casto DT, Dunn JF. Drug metabolizing capacity in Mexican Americans. Clin Pharmacol Ther. 1991;49:159.
29. Mendoza R, Wan YJ, Poland RE, et al. CYP2D6 polymorphism in a Mexican American population. Clin Pharmacol Ther. 2001;70:552-560.
30. Casner PR. The effect of CYP2D6 polymorphisms on dextromethorphan metabolism in Mexican Americans.
J Clin Pharmacol. 2005;45:1230-1235.
31. Lam YW, Jann MW, Chang WH, et al. Intra- and interethnic variability in reduced haloperidol to haloperidol ratios. J Clin Pharmacol. 1995;35:128-136.
32. Lewis-Fernandez R, Blanco C, Mallinckrodt CH, et al. Duloxetine in the treatment of major depressive disorder: comparisons of safety and efficacy in US Hispanic and majority Caucasian patients. J Clin Psychiatry. 2006;67: 1379-1390.
33. Opolka JL, Rascati KL, Brown CM, Gibson PJ. Role of ethnicity in predicting antipsychotic medication adherence. Ann Pharmacother. 2003;37:625-630.
34. Sleath B, Rubin RH, Huston SA. Hispanic ethnicity, physician-patient communication, and antidepressant adherence. Compr Psychiatry. 2003;44:198-204.
35. Hosch HM, Barrientos GA, Fierro C, et al. Predicting adherence to medications by Hispanics with schizophrenia. Hisp J Behav Sci. 1995;17:320-333.
36. Jenkins JH. Subjective experience of persistent schizophrenia and depression among US Latinos and
Euro-Americans. Br J Psychiatry. 1997;171:20-25.
37. Diaz E, Neuse E, Woods S, Rosenheck R. Ethno cultural determinants of medication adherence. Poster presented at: Annual Meeting of the American Psychiatric Association; May 17-22, 2003; San Francisco.
38. DeNavas-Walt C, Proctor BD, Mills RJ. Income, poverty, and health insurance coverage in the United States: 2003. US Census Bureau. Available at: http://www.census.gov/prod/2004pubs/p60-226.pdf. Accessed October 31, 2006.
39. Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the insured: findings from a national sample. Med Care. 2002;40:52-59.