Risk factors for disease, like obesity and diabetes mellitus, are gaining importance among Hispanics. For example, from 1991 to 1998, Hispanics suffered the largest increase in obesity among ethnic groups, from 11.6% to 20.8% (versus 12.0% to 17.9% for the population as a whole) (Mokdad et al., 1999). In addition, the prevalence of diabetes mellitus in Hispanics rose from 5.6% in 1990 to 7.7% in 1998 (versus 4.9% to 6.5% for the population as a whole) (Mokdad et al., 2000).Use of Psychotropic Medications
Antidepressants. Most of the comparative clinical trials with Hispanics have been performed for antidepressants. Because of design shortcomings and sample size, their significance is limited, but several studies point toward a better response, higher attrition and higher side-effect reporting in Hispanics given antidepressants. A higher placebo response in Hispanics is also mentioned (Marin, 2003; Marin and Escobar, 2001).
Antipsychotics. The same considerations made for antidepressants apply to trials with antipsychotics. Several studies with typical antipsychotics point toward lower dosages in Hispanics as compared to whites (Marin, 2003). At least two found that Hispanics and African-Americans were more likely than whites to receive depot antipsychotics. In general, no differences have been found regarding the incidence of acute extrapyramidal side effects or tardive dyskinesia.
Several studies have been published comparing the doses of atypical antipsychotics in Hispanics versus other groups, but they are too small to allow any conclusion. Hispanics seem to be more likely than whites to receive typical, rather than atypical, antipsychotics (Marin, 2003). This is not surprising, considering the lower socioeconomic status and lack of health insurance among Hispanics.
Compliance. As I mentioned for antidepressant treatment, Hispanics seem to have inferior compliance and completion rate for antipsychotic treatment. For example, Hispanics are less likely to meet the criterion of two adequate antipsychotic trials when considered for treatment with clozapine(Drug information on clozapine) (Clozaril).
Compliance/adherence is a complex issue influenced by factors related to the patient, the provider and the environment (Dassori et al., 1995). In Hispanics, probable factors contributing to poor compliance include low socioeconomic status, lack of family financial support and inferior communication with mental health care providers.Some Recommendations
Communication. If communication is difficult, ask for a translator without delay. Experience shows that non-Spanish-speaking practitioners who insist on using their Spanish skills have adverse results. Also, improvised translators may do a poor job, censoring the information in both directions. Make sure the patient understands the information and has no more questions. Also, make sure to ask all the same questions you ask non-Hispanic patients.
Try medications. Without forfeiting other treatments, consider medications. Hispanics have higher expectations for medication and may respond more positively. However, start low, as they are probably more likely to notice adverse effects. It is also important to emphasize adequate dosing, as Hispanics worry about strong medications and may be more likely to tamper with the dosage. Hispanics are also more likely to see the long latency of antidepressants or antipsychotics and the need for long-term medication in a negative fashion.
Ask about self-medication and folk remedies. Both are common practices in Latin America, where prescription-only medications can easily be bought without a prescription, and people tend to get their herbal medicine from informal providers, like friends or the curandero.
Be aware of different patterns of alcohol(Drug information on alcohol) use. The rate of alcohol disorders in Hispanics is not higher than in whites, but the pattern of use seems to be different: Hispanics are likely to drink larger amounts at once. If alcohol abuse is a possibility, explore it in a very precise way, as Hispanic parameters regarding alcohol consumption may differ from general standards in the United States.
Keep risk factors and general health in mind. Hispanics have less access to health care and relatively higher risk factors such as obesity and diabetes mellitus. Consider the metabolic side effects of psychotropics, especially antipsychotics and mood stabilizers. Address diet and lifestyle issues.
Discuss compliance. If results are unsatisfactory, consider the issue of noncompliance, and keep in mind that noncompliance may result from multiple causes. Remember that the Hispanic patient may have difficulty getting medications and may have hidden that fact from you. Ask about side effects, including sexual side effects. Ask about concerns regarding the dose. Be nonjudgmental and rely more on help, interest and trust than on authority in efforts to improve compliance.