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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?
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.
Demographics. 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).
Language. 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).
Subgroups and heterogeneity. 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).
Cultural traits. 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).
Health care. 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).
Psychiatric symptoms. 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 cytochrome system. 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.
Pharmacokinetics. 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).
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 (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.
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 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.
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