Humberto Marin, MD

Medically unexplained physical symptoms are more common in women, in persons from lower socioeconomic backgrounds, and in certain ethnic groups, as well as in children and adolescents.

Unexplained physical symptoms tend to have a chronic, protracted course, and the causes are multifactorial.

In treating somatization disorder (SD), psychiatric comorbidities such as significant depression and anxiety symptoms should be specifically addressed.

Because patients with SD may be at higher risk for addiction or dependence, caution is advised for the use of medications with addictive potential, especially opiate analgesics and tranquilizers, such as benzodiazepines.

 somatoform disorder are unexplained physical symptoms or complaints that tend to coexist with other psychiatric syndromes or are linked to psychological issues. These symptoms typically lead to repeated medical or emergency department visits; are associated with serious discomfort, dysfunction, and disability; and lead to significant health expenditures. Despite their frequency and relevance to both primary care and psychiatric practices, the definition, classification, and management of these disorders remain difficult and controversial. Moreover, there are little systematic research data available for these disorders across medical disciplines. Diagnostic changes made on the basis of capricious committee recommendations often become a “moving target,” thus decreasing the ability to compare studies over time.
 


 
 Dramatic and peculiar somatic manifestations that perplex clinicians have been with us since ancient times. A brief review of their historical evolution shows that they metamorphose as medical paradigms change. For example, labels such as hysteria, hypochondria, spleen, English disease, soldier’s heart, neurocirculatory asthenia, neurasthenia, surmenage, humoral disorders, psychosomatic disorders, and many others have been fashionable or relevant during certain periods, but most eventually faded into oblivion or were replaced by more technical terminology. Despite steady efforts to eradicate them, the survival of some of these terms (hysteria, neurasthenia) is probably proof of their validity.

In psychiatry, the term “somatization” has been used for decades to label these somatic presentations. The classical concept of somatization was coined by Wilhelm Stekel,

 a Viennese psychoanalyst who immigrated to America. He described it as a “deep-seated neurosis” or as the “process by which neurotic conflicts appear as a physical disorder.” In North American psychiatry, this concept was expanded by Zbigniew J. Lipowski,

 who described somatization as the “tendency to experience, conceptualize, and/or communicate psychological states or meanings as corporeal sensations, functional changes, or somatic metaphors.”
 
 The psychogenic view generally considered somatic presentations as ancillary manifestations of psychological discomfort. The more direct and pragmatic approach to somatization that would eventually lead to the atheoretical frame of modern nomenclatures began with French psychopathologist Pierre Briquet,

 who, in 1859, brought an observational or experiential perspective to the study of hysteria during the golden age of French psychopathology. His description of a syndrome inclusive of multiple motor and sensorial symptoms (pseudoneurological symptoms) made possible the separation of somatization from conversion.
 
 In the 1950s, a group of investigators at Washington University–Renard Hospital in St Louis resurrected Briquet’s concept of hysteria in several clinical studies. They formulated criteria for the diagnosis of hysteria that required the presence of a specified number of symptoms from a comprehensive list that included physical and psychological manifestations, personality traits, and behavioral expressions, in addition to the neurological symptoms from the traditional French definition.


 
 With a few modifications, these were the criteria for somatization disorder proposed by Feighner and colleagues

 in 1972 in their seminal paper, “Diagnostic Criteria for Use in Psychiatric Research.” After Robert Spitzer and his colleagues

 coined the term “somatoform disorder” (inclusive of the Greek

), it officially entered American and world psychiatric terminology with the publication of the 

 in the 1980s, somatization disorder (SD) became the key somatoform diagnosis. In 

 and its subsequent revisions, SD turned into a simple somatic symptom list that contracted or expanded rather capriciously. Partly because the atheoretical perspective of 

 discarded any presumptions of causality, other manifestations of the syndrome were not included in the criteria.

The list of somatoform disorders kept expanding with the addition of vague categories, such as “undifferentiated somatoform disorder” or “somatoform disorder NOS [not otherwise specified],” which, unfortunately, are the most common diagnoses within the somatoform genre. These terms failed to transcend specialty boundaries. Perhaps as a corollary of turf issues, general medicine and medical specialties started carving these syndromes with their own tools. The resulting list of “medicalized,” specialty-driven labels that continues to expand includes fibromyalgia, chronic fatigue syndome, multiple chemical sensitivity, and many others (

Irritable bowel syndrome
                         
                         Chronic fatigue syndrome
                         
                         Fibromyalgia
                         
                         Multiple chemical sensitivity
                         
                         Nonspecific chest pain
                         
                         Premenstrual disorder
                         
                         Non-ulcer dyspepsia
                         
                         Repetitive strain injury
                         
                         Tension headache
                         
                         Temporomandibular joint
                         disorder
                         
                         Atypical facial pain
                         
                         Hyperventilation syndrome
                         
                         Globus syndrome
                         
                         Sick building syndrome
                         
                         Chronic pelvic pain
                         
                         Chronic whiplash syndrome
                          

These labels fall under the general category of functional somatic syndromes and seem more acceptable to patients because they may be perceived as less stigmatizing than psychiatric ones. However, using 

 criteria, virtually all these functional syndromes would fall into the somatoform disorders category given their phenomenology, unknown physical causes, absence of reliable markers, and the frequent coexistence of somatic and psychiatric symptoms. 
 
 


 
 Medically unexplained physical symptoms are extremely common in adults. They are more frequently seen in females, in persons from lower socioeconomic backgrounds, and in certain ethnic groups. These symptoms are also fairly common in childhood and adolescence; a recent study showed that 10% of children surveyed had unexplained headaches, 9% had unexplained abdominal pain, and 4% had unexplained pain in the extremities.


 
 The Epidemiological Catchment Area Survey of Mental Disorders in the United States reported that fewer than 0.1% of respondents met strict 

 criteria for SD, and about 5% met criteria for abridged SD, a less restrictive construct of somatization.

 In Germany, about 20% of a community sample met criteria for undifferentiated SD, but very few (about 1%) met criteria for the more specific somatoform disorders.


 
 The prevalence of unexplained physical symptoms is much higher in primary care and medical specialty settings. A World Health Organization (WHO) study at 14 primary care sites in Asia, Europe, and the Americas showed that the rates for abridged SD differed widely across countries. They were lowest in Nigeria (7.6%), Italy (8.9%), and the United States (9.8%) and highest in Germany (25.5%), Brazil (32%), and Chile (36.8%).

In a North American study, patients with SD reported spending an average of 8.8 days sick in bed per month, compared with half a day for those without the disorder. More than 80% of patients with SD stopped working because of “poor health” and their per capita yearly health costs were 9 times higher than average.

 A study of patients with SD who attended a university outpatient service in London showed that 61% were receiving disability benefits, 64% had been treated for spurious physical disorders, 60% had had surgeries with no pathology found, and 16% were using either wheelchairs or crutches without any evidence of organic disorder.

Unexplained physical symptoms tend to have a chronic, protracted course. For example, in the South London Somatization Study, most patients had a chronic unremitting course. About 80% of these persons still qualified for a somatoform diagnosis 4 years later.

 A follow-up in the WHO study showed that, 1 year later, somatization persisted in about half of the patients.


 
 The causes of SD are multifactorial. Although no consistent biological (brain) markers have been documented, genetic factors may play a role. Findings from studies of adopted females with SD suggest excessive alcoholism or violent behavior in the biological fathers.

 More recent studies have shown that there is familial clustering of functional syndromes such as fibromyalgia.

 A large number of studies have shown a frequent association between unexplained physical symptoms and early traumatic experiences; medical illness with long hospitalizations; serious medical illness of a parent; natural disasters; or psychological factors such as sensitization processes, specific cognitive styles, or benefits derived from the sick role (secondary gain).


 
 The most common psychiatric conditions that coexist with unexplained physical symptoms are major depression, anxiety, substance use, personality disorders, and posttraumatic stress disorders.

 Averaging data from several studies, about two-thirds of patients with unexplained symptoms also met criteria for at least one of these psychiatric disorders and a large portion of the remaining one-third, who did not fully meet the criteria, had significant symptoms, mainly depression or anxiety.


 
 Not surprisingly, patients with unexplained physical symptoms are first seen by primary care or nonpsychiatric specialists, who usually make the initial diagnosis. Unfortunately, only about 1 of 4 primary care physicians acknowledge feeling confident about their ability to treat these patients. The percentage of primary care practitioners who report confidence in managing other mental disorders, such as depression or anxiety disorders, is much higher.


 
 Assisting primary care providers through instructional sessions and manuals or simply by using a consultation letter has proved to be useful.

 Referral of these patients to mental health services is generally unsuccessful unless proper bridges between primary and mental health care are built. This requires patient preparation, careful teamwork, and the presence at the primary care site of trained mental health personnel.

Because of the high level of discomfort associated with unexplained symptoms, to be told that “there is no physical problem” is disconcerting to many patients. For the provider, however, finding no physical abnormality generally brings a sense of relief. In building a good therapeutic relationship, it is important for the therapist not to downplay the patient’s discomfort at being told “there is no problem” or “your symptoms are all psychological.” As in any other field of medicine, empathy and acknowledging the patient’s distress are essential ingredients for a sound therapeutic relationship. 

 provides a stepwise list of suggestions for communicating a diagnosis of SD to the patient.
 
 

 
 If properly communicated, the diagnosis of SD may offer relief and encouragement to the patient. For example, in a recent study, patients with unexplained symptoms felt that receiving such a diagnosis after a time of worry and uncertainty was an important factor in successfully managing the disorder.


 
 Regular patient visits should be scheduled (eg, monthly or bimonthly) independent of fluctuations in symptoms. Treatment goals must be concrete, stepwise, and realistic. Do not aim for an all-or-nothing result, but consider a gradual and incremental response. The goal is to progressively decrease emergency visits and calls.
 
 A routine examination is recommended at every visit to reassure the patient and to ensure that there are no physical abnormalities (remember that paranoid people may have real enemies). However, no new tests or consultations should be ordered unless there is a clear indication. Rather than reassuring patients, unwarranted consultations or tests may feed their belief that they have a serious physical illness. 

During the visit, the patient can be allowed to play the “sick role.” Allow him or her to verbalize complaints and concerns without entering into needless arguments on issues related to the reported symptoms. The objective is not to negate the symptoms but to improve functionality and well-being. Briefly discuss current stress factors and other important circumstances, and make sure the patient understands that the unexplained symptoms are elements of a biopsychosocial illness. 

 presents a list of goals to work toward.


 
 Evidence is rapidly growing for the usefulness of modified cognitive-behavioral therapies for somatoform syndromes.

 A comprehensive model successfully applied in several studies included relaxation training, behavioral management, cognitive restructuring, emotion identification, emotion regulation, and interpersonal skills training.

 Other types of psychotherapy have not been tested in well-controlled studies. However, it is our impression that intensive or exploratory therapies that focus on internal conflict and mental change may be counterproductive.
 
 As mentioned, mental disorders such as significant depression and anxiety are common in those with SD and should be specifically addressed. However, there is no clear evidence from randomized clinical trials demonstrating the efficacy of psychotropic drugs for the treatment of unexplained physical symptoms. The benefit observed in some studies has been attributed to the effect of medications on anxiety or depressive symptoms and not to a direct effect on somatic symptoms.
 
 On the basis of our clinical experience, patients with SD accompanied by significant depression and anxiety symptoms can be initially treated with an SSRI or a serotonin norepinephrine reuptake inhibitor. Mirtazapine seems to be a reasonable first option for patients with unexplained symptoms who have significant insomnia or anorexia because of the drug’s positive effects on sleep and appetite. In patients with significant fatigue/sleepiness or poor concentration, or those in whom the avoidance of sexual adverse effects is paramount, bupropion may be a good first-line agent.
 
 Because patients with SD may be at a heightened risk for addiction or dependence, caution must be exercised when prescribing medications with addictive potential, such as opiate analgesics and tranquilizers such as benzodiazepines. In patients with SD, pain complaints are very common and include headaches, and joint, abdominal, and pelvic pain. NSAIDs should be used whenever possible for pain relief.
 
 


 The anticonvulsant pregabalin and the antidepressant duloxetine have been recently approved for the treatment of fibromyalgia. Pregabalin has analgesic properties, especially for neuropathic pain, and has also shown some antianxiety effects in randomized clinical trials. Duloxetine, a dual action antidepressant, also seems to exert some analgesic properties similar to those reported for other dual action drugs as well as tricyclic antidepressants.
 
 Lufriprostone has been approved for clinical use in irritable bowel symptoms alternating with chronic idiopathic constipation syndromes. This drug appears to exert a laxative action by increasing the secretion of chloride and fluid in the intestinal epithelium.
 
 Fluoxetine, paroxetine, and sertraline have been approved for the treatment of premenstrual dysphoric disorder/premenstrual syndrome, which have a number of somatic manifestations and also include anxiety and depression symptoms. A recent meta-analysis found that all SSRIs seem to be about equally helpful for premenstrual symptoms, their continuous use is better than intermittent use, and their clinical effect on symptoms seems to be relatively small.


 
 As we prepare for the new edition of 

• 	Consider a dimensional approach for unexplained physical symptoms with differences in severity. 
 • 	Avoid further expansion of somatoform categories and the mechanistic count of symptoms and systems. There is a need for evidence-based,inclusive, and simpler definitions.
 • 	Do not devalue the psychological, cultural, and social aspects in patients with somatoform disorders; instead, emphasize their character as complex expressions of distress and sickness.
 • 	Do not subordinate somatic presentations to other mental disorders or to purely mental mechanisms. Acknowledge the unique and independent nature of somatoform disorders.


 Bupropion (Wellbutrin, Zyban)
 Duloxetine (Cymbalta)
 Fluoxetine (Prozac, Sarafem)
 Gabapentin (Neurontin)
 Lubriprostone (Amitiza)
 Mirtazapine (Remeron)
 Paroxetine (Paxil)
 Pregabalin (Lyrica)
 Sertraline (Zoloft)

Lipowski ZJ. Somatization: the concept and its clinical application. 

Purtell JJ, Robins E, Cohen ME. Observations on clinical aspects of hysteria. 

 Perley MJ, Guze SB. Hysteria: the stability and usefulness of clinical criteria. 

Feighner JP, Robins E, Guze SB, et al. Diagnostic criteria for use in psychiatric research. 

Spitzer RL, Endicott J, Robins E. Research diagnostic criteria: rationale and reliability. 

Eminson DM. Medically unexplained symptoms in children and adolescents. 

 Escobar JI, Burnam MA, Karno M, et al. Somatization in the community. 

Grabe HJ, Meyer C, Hapke U, et al. Specific somatoform disorder in the general population. 

Gureje O, Simon GE, Ustun TB, Goldberg DP. Somatization in cross-cultural perspective: a World Health Organization study in primary care. 

Smith GR, Monson RA, Ray DC. Patients with multiple unexplained symptoms: their characteristics, functional health, and health care utilization. 

Articles

he key manifestations of DSM-IV somatoform disorder are unexplained physical symptoms or complaints that tend to coexist with other psychiatric syndromes or are linked to psychological issues. These symptoms typically lead to repeated medical or emergency department visits; are associated with serious discomfort, dysfunction, and disability; and lead to significant health expenditures.

Unexplained Physical Symptoms

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.

 That number is expected to grow to 102.6 million, or 24.4% of the national population, by the year 2050.

 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 (

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.

 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.

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).

 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.

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.

Hispanic Americans show a fast-growing risk for some health issues that can complicate mental disorders or their treatment. These include metabolic syndrome

 or some of its components (obesity, diabetes mellitus, dyslipidemia) and a sedentary lifestyle (

). 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.

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.

 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.


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.

 A significant number of Hispanic Americans report difficulty in communicating with physicians and other health care providers.

 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 (

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.


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.


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.

 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.

 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.

 This underrecognition also includes the young, since several studies have suggested lower recognition and treatment of attention-deficit/hyperactivity disorder in Hispanic children.

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.

 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.

 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.

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.

 A study in Rhode Island found that Hispanic patients with major depression were more likely to report psychotic symptoms.

 Finally, a Boston study found that 46% of outpatient Caribbean Latinos had reported hallucinations, yet a thought disorder was diagnosed in only 9%.

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.

 In a California study, depressed Latino women (and African American women) scored significantly higher than non-Hispanic whites on somatization.

 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.

Medication responseSo 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.

 Comparative studies have also been negative for the genotypes of CYP3A4, methylenetetrahydrofolate reductase, aldehyde-dehydrogenases ADH2 and ALDH2, or CYP4502E1 and CYP3A.

 A study of the metabolism of 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.

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.


Some studies show that Hispanic Americans are significantly less adherent than non-Hispanic whites to antipsychotic and antidepressant medication regimens.

 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.

 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,

 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.

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.


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.

	Language skills training for existing staff.

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.

 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

 US Census Bureau. US interim projections by age, sex, race, and Hispanic origin. Available at: 

http://www.census.gov/ipc/www/usinterimproj/

 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

 Marin H, Escobar JI, Vega WA. Mental illness in Hispanics: a review of the literature. Focus. 2006;4:23.	


 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

 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.


 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

 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.


 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.


 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.


 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.


 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.


 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

 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.	


 Golding JM, Lipton RI. Depressed mood and major depressive disorder in two ethnic groups. J Psychiatr Res. 1990;24:65-82.


 Schmaling KB, Hernandez DV. Detection of depression among low-income Mexican Americans in primary care. J Health Care Poor Underserved. 2005;16:780-790.


 Heneghan AM, Silver EJ, Bauman LJ, Stein RE. Do pediatricians recognize mothers with depressive symptoms? Pediatrics. 2000;106:1367-1373.


 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.


 Mukherjee S, Shukla S, Woodle J, et al. Misdiagnosis of schizophrenia in bipolar patients: a multiethnic comparison. Am J Psychiatry. 1983;140:1571-1574.	


 Chen YR, Swann AC, Burt DB. Stability of diagnosis in schizophrenia. Am J Psychiatry. 1996;153:682-686.	


 Kales HC, Blow FC, Bingham CR, et al. Race and inpatient psychiatric diagnoses among elderly veterans. Psychiatr Serv. 2000;51:795-800.


 Olfson M, Lewis-Fernandez R, Weissman MM, et al. Psychotic symptoms in an urban general medicine practice. Am J Psychiatry. 2002;159:1412-1419.


 Posternak MA, Zimmerman M. Elevated rates of psychosis among treatment-seeking Hispanic patients with major depression. J Nerv Ment Dis. 2005;193:66-69.	


 Geltman D, Chang G. Hallucinations in Latino psychiatric outpatients: a preliminary investigation. Gen Hosp Psychiatry. 2004;26:153-157.


 DuAlba L, Scott RL. Somatization and malingering for workers’ compensation applicants: a cross-cultural MMPI study. J Clin Psychol. 1993;49:913-917.


 Myers HF, Lesser I, Rodriguez N, et al. Ethnic differences in clinical presentation of depression in adult women. Cultur Divers Ethnic Minor Psychol. 2002;8:138-156.


 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.


 Lam YWF, Casto DT, Dunn JF. Drug metabolizing capacity in Mexican Americans. Clin Pharmacol Ther. 1991;49:159.


 Mendoza R, Wan YJ, Poland RE, et al. CYP2D6 polymorphism in a Mexican American population. Clin Pharmacol Ther. 2001;70:552-560.


 Casner PR. The effect of CYP2D6 polymorphisms on dextromethorphan metabolism in Mexican Americans. 
J Clin Pharmacol. 2005;45:1230-1235.


 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.


 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.


 Opolka JL, Rascati KL, Brown CM, Gibson PJ. Role of ethnicity in predicting antipsychotic medication adherence. Ann Pharmacother. 2003;37:625-630.


 Sleath B, Rubin RH, Huston SA. Hispanic ethnicity, physician-patient communication, and antidepressant adherence. Compr Psychiatry. 2003;44:198-204.


 Hosch HM, Barrientos GA, Fierro C, et al. Predicting adherence to medications by Hispanics with schizophrenia. Hisp J Behav Sci. 1995;17:320-333.


 Jenkins JH. Subjective experience of persistent schizophrenia and depression among US Latinos and Euro-Americans. Br J Psychiatry. 1997;171:20-25.


 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.


 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

 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.

Despite 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.

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

Hispanics have become the largest minority group in the United States. Compared to non-Hispanic whites, Hispanics are younger and less educated, with the concomitant problems of unemployment, poverty, lack of insurance and poor health care. In addition to the socioeconomic barriers other minorities face, a significant percentage of Hispanics speak poor or no English. In spite of the weight of Hispanics in the national population and the progress in a half-century of clinical psychopharmacology, we have no truly reliable data about treating mentally ill Hispanic-Americans with psychotropic medications.

For this brief review, I have taken a pragmatic approach, collecting information from heterogeneous sources, with very different degrees of reliability. The goal is not to give an erudite revision but to build a general picture that allows us to draw some conclusions regarding the pharmacotherapy of Hispanic-Americans suffering from depression and schizophrenia. I have focused on these disorders because we have some, albeit poor, information regarding the use of antidepressants and antipsychotics in Hispanics. However, for medication groups as important as mood stabilizers or anxiolytics, we have practically no information at all. 

. According to the U.S. Census 2000, Hispanics number 35.3 million or 12.5% of the U.S. population (Guzm'n, 2001). Their ranks grew 60% between 1990 and 2000, and three out of five Hispanics are foreign-born (Brodie et al., 2002). Hispanics are younger than the average American; 35.7% are less than 18 years old (versus 23.5% for non-Hispanic whites) (Therrien and Ramirez, 2001). They tend to concentrate in the central cities of metropolitan areas (46.4% versus 21.2% for non-Hispanic whites), live in larger households (30.6% in households of five or more people versus 11.8% for non-Hispanic whites), be less educated (57% are high school graduates versus 88.4% for non-Hispanic whites) and earn less money (in 1999, 23.3% of Hispanics and 49.3% of non-Hispanic whites earned $35,000 or more, and only 9.6% of Hispanics made $50,000 or more versus 27.4% of non-Hispanic whites) (Therrien and Ramirez, 2001).

 Only 28% of foreign-born Hispanics are English-dominant or bilingual versus 96% of U.S.-born Latinos. Forty-two percent of foreign-born and 8% of native-born Latinos report difficulty communicating with doctors or health care providers because of language barriers (Brodie et al., 2002).

. Mexicans are, by far, the largest Hispanic subgroup (60%) in the United States, with the other major subgroups (Puerto Ricans, Central Americans, South Americans and Cubans) in single digits (Guzm'n, 2001). This heterogeneity is a matter of contention, and some researchers prefer to identify their subjects according to specific subgroup. Although the issue is unsettled, I favor considering Hispanics as a single group for pharmacological purposes, because (among other reasons): a) the main Hispanic subgroups seem to share genes from the same ethnic pools, albeit in different proportions; and b) in spite of regional differences, Hispanics seem to be acceptably homogeneous, sharing habits, identities and attitudes. This last point is important, as the response to medications is determined not only by biological but also environmental and social factors (e.g., diet, toxin exposure and expectations).

. At least one--fatalism--needs to be mentioned. Among Hispanics, the differences in fatalism seem to be generational more than geographic. While over half of foreign-born Latinos believe they do not control their destiny, only one-quarter of U.S.-born Latinos feel this way (Brodie et al., 2002).

. Hispanics are more likely to be uninsured and have less access to medical care. In 2002, 35% of Hispanics reported being uninsured (versus 14% of whites and 21% of African-Americans) (Brodie et al., 2002). Even when they are insured, Hispanics receive less medical services. For example, Hispanic Medicare beneficiaries have an odds ratio of 0.36 of receiving a hip replacement, as compared to non-Hispanic Medicare beneficiaries (Escalante et al., 2002). As this procedure is fully covered by Medicare, the finding suggests that underutilization of health services by Hispanics cannot be attributed to lack of health insurance alone. 

Regarding mental health, Hispanics have both fewer visits and less chance of their mental problems being detected. For example, Latinos with fair and poor English proficiency reported approximately 22% fewer physician visits than non-Latinos, after adjusting for other determinants (Derose and Baker, 2000). In a review of 19,309 patients and 349 internists and family physicians, Hispanics and African-Americans were found to be at higher risk for non-detection of their mental health problems (Borowsky et al., 2000).

. The expression and reporting of psychiatric symptoms is partially determined by culture. I will not debate here the controversial issue of misdiagnosis in Hispanics. However, Hispanics with bipolar disorder are more likely to be labeled with schizophrenia, and Hispanics with depression (and probably anxiety) tend to somatize distress, reporting an excess of somatic and hypochondriacal features (Escobar, 1987; Mukherjee et al., 1983).

. The only available data on Hispanics correspond to cytochrome P450 (CYP) 2D6 activity in Mexican-Americans, and show no significant differences with white Americans or African-Americans. Although their genotype for ADH2 and ALDH2 does not seem to be significantly different from whites, Mexican-Americans have shown a higher frequency for the mutant CYP 2E1, a cytochrome whose importance increases with alcohol consumption (Konishi et al., 2003). This could play a role in the growing rate of alcoholic liver disease in Mexican-Americans.

. Very few pharmacokinetic studies with psychotropics have been performed in Hispanics. No differences were found in the pharmacokinetics of nortriptyline (Aventyl, Pamelor) between Hispanic and non-Hispanic subjects (Gaviria et al., 1986). The same is true for the biotransformation of haloperidol (Haldol): the curves of Hispanics, whites and African-Americans were close and differed from the Chinese (Jann et al., 1992).

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). 

. 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).

. 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.

. 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 (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.

. 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.

. 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 

Be aware of different patterns of 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. 

. 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.

Borowsky SJ, Rubenstein LV, Meredith LS et al. (2000), Who is at risk of nondetection of mental health problems in primary care? J Gen Intern Med 15(6):381-388.
 

Brodie M, Steffenson A, Valdez J et al. (2002), 2002 National Survey of Latinos. Pew Hispanic Center/Kaiser Family Foundation. Menlo Park, Calif./Washington, D.C.
 

Dassori AM, Miller AL, Saldana D (1995), Schizophrenia among Hispanics: epidemiology, phenomenology, course, and outcome. Schizophr Bull 21(2):303-312.
 

Derose KP, Baker DW (2000), Limited English proficiency and Latinos' use of physician services. Med Care Res Rev 57(1):76-91.
 

Escalante A, Barrett J, del Rincon I et al. (2002), Disparity in total hip replacement affecting Hispanic Medicare beneficiaries. Med Care 40(6):451-450 [see comment].
 

Escobar JI (1987), Cross-cultural aspects of the somatization trait. Hosp Community Psychiatry 38(2):174-180.
 

Gaviria M, Gil AA, Javaid JI (1986), Nortriptyline kinetics in Hispanic and Anglo subjects. J Clin Psychopharmacol 6(4):227-231.
 

Guzm'n B (2001), The Hispanic Population: Census 2000 Brief. C2KBR/01-3. Washington, D.C.: U.S. Census Bureau.
 

Hispanics are now officially the largest minority in the United States. They are also highly prone to psychiatric disorders. What are the unique challenges of treating this ethnic population?

Humberto Marin, MD

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