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

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).

TABLE 1
Characteristics of Hispanic Americans3,38
  Characteristic Hispanic   Total population
Age (median, y) 26   35.4
Family households (% of total households) 81   68
Foreign-born 40.2%   11.1%
LOEH 78.6%   17.9%
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%
Health-insured (2003) 67.3%   84.4%
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

TABLE 2
Prevalence of health risk
factors that may affect the
treatment of mental disorders4
           
Within-group percentages
Factor   Hispanic   Non-Hispanic white   Non-Hispanic black  
Obesity (> 20 years, age/sex
adjusted)
       
    Male 27.6 24.3 28.2  
    Female 27.2 21.1 39.3  
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

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