Psychiatric Times.
No. 14
Issues and Challenges in the Diagnosis and Treatment of Mentally Ill Hispanic Patients
By Humberto Marin, MD |
December 1, 2006
Medication adherence
Some studies show that Hispanic Americans are significantly less adherent than non-Hispanic whites to antipsychotic and antidepressant medication regimens.33,34 However, the perceived difference in medication adherence in Hispanic Americans is likely better
explained by socioeconomic and communication-related factors (ie, being monolingual) than cultural factors. A study looking at records of Hispanic outpatients with schizophrenia in Texas found rates of compliance in line with those of patients of other backgrounds with schizophrenia.35 A study that interviewed community patients in Ohio reported that while the medication adherence for Latino persons with depression was lower than for non-Hispanic whites with depression, the figures were similar for patients with schizophrenia from both groups,36 which may reflect the greater support that patients with schizophrenia receive. A study using an electronic cap to monitor bottle openings in patients with different diagnoses, including schizophrenia, found significantly lower medication adherence in monolingual Hispanic patients than in non-Hispanic whites.37
Regarding psychosocial interventions for mentally ill Hispanic Americans, studies do not suggest an interaction between Hispanic ethnicity and outcome with psychotherapy. However, Hispanic or Spanish-speaking participants seem more likely to improve when they receive supplemental case management, collaborative care, or quality improvement interventions as opposed to treatment as usual.4
Recommendations
Hispanic persons are a heterogeneous group: therefore, clinicians should not let culture-specific information obscure the individual patient. It is important
to get information on origin, generation, number of years in the United States, language, acculturation, personal beliefs, and current socioeconomic characteristics of individual Hispanic
patients.
Linguistic barriers should not be minimized. A professional translator should be used whenever indicated; use of family members or relatives as translators is best avoided, especially because of confidentiality issues and distortion or censorship of information. The list below describes possible responses to linguistic barriers in Hispanic patients. Only the first 2 are considered complete solutions, and the last 3 are emergency or stopgap measures.
- Bilingual/bicultural professional staff.
- Interpreters in situ.
- Language skills training for existing staff.
- Internal language banks.
- Phone-based interpreter services.
- Written translations.
Remember that Hispanic patients are more likely to have their psychiatric problems unrecognized, to present with somatic complaints for mental disorders, or to report psychotic symptoms in the absence of a thought disorder. Be alert to any symptom suggestive of mental disorder, but do not jump to the diagnosis of a psychotic disorder.
If you are in a primary care psychiatry setting, minimize referrals. Hispanic patients are significantly more likely than average to be lost in transit.
Hispanic Americans have less access to health care and once receiving care, they have fewer visits. The time window to treat Hispanic persons is shorter than average. Thus, be careful but not timid when establishing treatment for mentally ill Hispanic persons. Remember that so far, there is no clear evidence that Hispanic patients respond to medication or psychotherapy in different ways from non-Hispanic whites. Also remember that Hispanic persons can benefit more than average from enhanced interventions such as family education, supplemental case management, collaborative care, or quality improvement interventions, as opposed to treatment as usual.
At follow-up visits, ask clearly about negative sides of the therapy, such as lack of response or adverse effects. A Hispanic patient is less likely than average to report information that could look like a negative judgment about the treatment you are providing.
Beware the long-term adverse effects of psychotropic medications, especially on metabolic syndrome. Hispanic Americans have the fastest growing rate of obesity, diabetes, and metabolic syndrome among ethnocultural groups; and Hispanic persons in whom complications develop from psychopharmacologic therapy have a worse chance of receiving treatment for the complications.
Finally, remember that if a good therapeutic alliance is important for any patient, it is critical for Hispanic patients. Without being patronizing, clearly express your interest and sympathy and try to establish an individualized relationship with the Hispanic patient and his or her family.
Dr Marin, born in Colombia, is assistant professor of psychiatry in the division of clinical psychopharmacology, University of Medicine and Dentistry of New Jersey and the Robert Wood Johnson Medical School in Piscataway, NJ, where he is involved in research in cross-cultural psychiatry, general psychopharmacology, and the psychiatric aspects of Parkinson disease. He is also a psychiatrist on the Huntington disease project. He reports that he has taken part in CME activities sponsored by Bristol-Myers Squibb and Otsuka; that he is a consultant for Eli Lilly; and that he has received research support from the National Institute of Neurological Disorders and Stroke and from Pfizer.
Drug Mentioned in This Article
Haloperidol (Haldol)
Evidence-Based References
- Lewis-Fernandez R, Das AK, Alfonso C, et al. Depression in US Hispanics: diagnostic and management considerations in family practice. J Am Board Fam Pract. 2005;
18:282-296.
- Marin H, Escobar JI, Vega WA. Mental illness in Hispanics: a review of the literature. Focus. 2006;4:23-37.
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