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

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 response So 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(Drug information on 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