Cultural Aspects of
Depression: What Clinicians
Need to Know
Andres J. Pumariega, M.D.
Chair, Department of Psychiatry
The Reading Hospital and Medical Center
Professor of Psychiatry, Temple University
School of Medicine
Clinical Professor, UMDNJ- Camden/ Cooper
Annual Meeting of the National Hispanic Medical Association
Washington, DC, April 18th, 2008.
• No Disclosures
Need and Rationale
• Growing and Diverse Populations of
– Hispanics/ Latinos became the largest ethnic minority
in 2002; fastest growing minority population (40 million)
– Out of 40 million immigrants in the U.S., 16.1 million are
from Latin America
– 800,000 to 1.2 million undocumented immigrants enter
the U.S., most from Mexico and Central America, each
with average of 1-2 US born children
– Majority are Mexican-Americans (30 of 40 million)
– Rest: Puerto Ricans, Central Americans, Dominicans,
Cubans, South Americans
– Populations concentrated in West/ SW, Northeast,
Florida, and large cities
– New Latino Destinations: largest increases in Latinos in
the Southeast: Arkansas, North Carolina, Georgia,
Tennessee (over 100 % growth since 1990 Census)
Need and Rationale
• Diverse cultural and SES backgrounds of
– Hispanics: Spanish-speaking origin (inc. Spain);
Latinos: Latin American origin (inc. Brazil)
– Spanish origins- Before the Pilgrims (1500’s)
– Indian origins (Mexico, Central America, and
Andean spine)
– African origins (Caribbean islands and coast)
– Other origins (Chinese, Italian, Eastern European,
Arab, etc.)
– Most poor and undereducated (Mexican-Americans,
Central Americans, Puerto Ricans, Dominicans).
Cubans and South Americans better off
economically/ educationally.
Culture and Normal
• Latino traditional value orientations:
Present (and past) time orientation
Fatalism, spiritual and supernatural orientation to nature
Hierarchical and collateral relationships
Being orientation to identity (who one is related to, not what
one does)
• Gender and relational roles (centrality of family, traditional
• Latino normative adaptive skills/ strengths
– Cognitive skills
• Practical survival skills, interpersonal skills- personalismo
– Protective adaptive values
• Paciencia, spirituality, forbearance, humor, fatalism,
collectivism, familism, respeto)
– Taboos against risky behaviors
• Substance use and suicide taboos
– Importance of strong ethnic identity
Inherent Supports/
Assets for Latinos
– Extended family
– Padrinos/ madrinas
– Comadres/ compadres
– Churches (RC and increasingly Protestant/
– Community organizations
– Cultural healers (santeros, curanderos)
MH Risk
• Pre-Immigration Stressors
– Poverty and illiteracy
– Pre-existing abuse and neglect for children
– Catastrophic traumas: War, crime, terrorism,
political persecution, famine, disasters.
– Many of these contribute to unrecognized
psychological/ emotional problems.
– Most of these contribute to decision to immigrate.
MH Risk
• Risk Factors in the Immigration Process
– Arduous journeys (long distances, through hostile terrain
or ocean crossings).
– Illegal departures and arrivals
– Victimization during journey (victims to violence or crime,
to natural forces, witness to death and/ or injury, even
detention and incarceration).
– Separation from extended family and even parents and
siblings (at times permanently).
– Parents/ caregivers also dealing with similar stressors, so
are not able to contribute much support/ comfort.
Immigration: MH Risk Factors
• Immediate Post-Immigration Risk Factors
– Fear of discovery and legal risks for illegal
– Prolonged legal processes for legal
– Multiple moves with changes of schools and
neighborhoods, difficulty in establishing
family/ peer supports.
– Economic stresses, both parents working,
lack of supervision and support.
– Linguistic barriers for youth and parents.
– Challenges of learning new processes and
Immigration: MH Risk Factors
• Long Term Risk Factors
– Discrimination (by mainstream population,
by other immigrant youth).
– Margination (socially, economically)
– Poverty and economic pressures
• Relative to American standards
• Heightened by exposure to American
materialistic culture by media)
– Exposure to Violence
• Community violence (crime, gangs)
• Domestic violence
Acculturation and Mental Health
• Acculturation stress in youth and younger adults
– Pressure to acculturate to avoid margination (social,
– Focus on material achievement and disruption of family
relations (spouses, children)
– Loss of natural protective beliefs and values (e.g. lower
suicidality taboo)
– Loss of extended family support (isolation, social networks)
– Changing gender roles and marital conflict: Domestic violence
– Impact of discrimination and margination
– Generational change in expression of psychopathology (e.g.
eating disorders)
– Acculturation stress associated with higher levels of
depression in Latino adolescents (Hovey and King, 1996;
Romero et al, 2007)
Acculturation and Mental Health
• Acculturation stress in older adults
– Latino elders had 44% higher risk for depression
and more significant clinical symptoms (44%
versus 22%) vs. whites (Brennan et al, 2005) Loss
of status of elders within family
– Risk factors:
• Lack of contact with younger family members (due to
work and school)
• Lack of knowledge of culture and language barriers
leads to isolation if not connected to “ethnic enclave”
• Isolation of Latino elders in the home associated with
increased anxiety and depression.
• Added risk of benzodiazepine (older Latinas) and alcohol
abuse (older Latinos) in context of depression and
Cultural Factors in the
Mental Health of Latinos
• Conceptualization of physical or mental
– Relating to traditional cultural beliefs/values,
as well as SES background
– Attribution/ understanding
• Spiritual, supernatural, interpersonal/ emotional
– Threshold of distress
• Mainland Latinos; long-suffering; Caribbean
Latinos- low threshold
Cultural Factors in the
Mental Health of Latinos
• Conceptualization of physical/mental
– Differential symptoms for emotional distress
(somatization, agitation, dissociation, etc.)
– Help-seeking expectations/behaviors (present
oriented, problem-focused)
– Use of cultural healers (curanderos, santeros,
herbal remedies)
– Stigma and beliefs around serious mental
– Primary care management more acceptable 14
Twelve-Month Rates of Utilization of
Health Care Services by Mexican
Americans with Mental and Substance
Use Disorders
Mood Disorder
Anxiety Disorder
Substance Use Disorder
Mental Health
General Medical
Informal Care
Vega WA, et al. Gaps in service utilization by Mexican Americans with mental health problems. Am J
Psychiatry 1999;156:928-34.
Cultural Factors in the
Mental Health of Latinos
• Conceptualization of mental illness
– Culture-bound syndromes
• Susto:
– Variant of depression/ anxiety (fright/ traumatic experience
followed by chronic depression
– Explanatory model: Loss of the soul after traumatic experience
– Healing approach: Reunite soul and body
• Ataque de Nervios:
– Constellation of depression, anxiety, somatic, and dissociative
symptoms; seen most in Caribbean Latinos; can present in
fits/ attacks
• Empache
– GI distress with “heaviness” of stomach
– Can be caused by emotional upset (“disgusto”)
Depression in Latinos
• Prevalence rates in adults
– Overall rates of adult depression equivalent for Latinos,
(ECA, Robins & Regier, 1991); NCS, Kessler, et al, 1994),
though with a non-significant increased risk (NCS-R,
Kessler et al, 2003).
– US born Latinos significant higher risk than counterparts in
nations of origin, except for Puerto Ricans (high rates in
both island and NYC groups). Overall higher prevalence in
Puerto Ricans than Cubans than Mexican-Americans.
• Symptomatic expression
Somatization (should differentiate from alexithymia)
Fatigue (“sofocado/a”)
Anger/ irritability (youth); also “colera” or “bilis” in adults
Depression in Latino Youth
– Roberts and colleagues (1992, 1995, 1997): Higher risk for depression and
suicidality in Mexican-Am youth compared to other groups.
– Mikolajczyk et al (2007, Calif Health Survey): Latino youth have twice as
higher rates of depressive symptoms than whites, low acculturation
associated with higher depression.
– Roberts (1992): Association between somatic symptoms and mood
symptoms in Latino youth.
– Swanson et al. (1992): Youth on both sides of the border have equally
high levels of depressive symptoms using the CES-D (about 40%), but 3-4
times suicidal ideation in Mexican-American youth; high correlation
between depression and SA.
– Pumariega et al. (1999): Cultural factors (family cohesion, media
exposure, non-supervised time with friends, no religious ties) associated
with higher SI but not actual history of attempts.
– Higher depression and suicidality in Latino runaway substance abusers
(Slesnick, et al., 2002).
– CDC Youth Risk Behavior Survey (2005): Latinos have highest rates of
sadness/ hopelessness, suicidal ideation, suicidal plans, suicide
attempts, and serious suicidal attempts vs. Caucasians and AfricanAmericans.
Maternal Depression and
• Higher overall prevalence, ranging from
23 to 50 % depending on the study
(Chaudron et al, 2005; Ortega, 2006)
• Howell et al. (2005):
– Prevalence of 47% among Latina mothers
– Odds ratios at approximately 2 to 1 with whites
– Higher odds even controlling for other demographic factors,
history of depression, skills in managing infant, social
support, and daily function.
• Factors that contribute to increased risk
in minority mothers: Poverty, family
Maternal Depression and
• Added adverse impact of maternal depression on Latino
– Adverse effect on reading scores and language scores (Onunaku,
– Adverse effect on infant behavioral regulation and child behavioral
problems (Onunaku, 2005; Barrueco, Lopez, and Miles, 2004; Patcher
et al, 2006)
– Effect of maternal depression in Latinas indirectly mediated through
parenting practices (Patcher, Auinger, Palmer, & Weltzman, 2006)
– May possibly explain the Latino Paradox (lower infant mortality and
higher birth weight in Latino infants but delays in language
– Young children from low-income and minority households are at overall
increased risk for mental health and developmental problems; so 20
maternal depression may contribute to child MH disparities
Depression- Latino Adult
• Diagnostic Disparities
– Misdiagnosis of underlying medical conditions due to
somatization possible
– Debate of whether less depression or underdiagnosed
• Treatment Access Disparities
– Largely related to stigma, health literacy, lack of trust in
treatments, clinician bias, and lack of insurance (Lewis
Fernandez et al, 2003; Interian et al, 2007).
– Latinos have highest rates of treatment non-adherence for
depression (Skaer et al, 2000, Sanchez-Lacay et al, 2001).
– PCP’s recommend depression treatments to Latinos equally, but
Latinos less likely to take antidepressant medications and to
obtain specialty MH services (Miranda & Cooper, 2004)
– Latinos are half as likely to receive guideline level depression
care, controlling for age, SES, co-morbid medical illnesses and
anxiety (Lagomasino et al, 2005)
Depression- Latino Youth
• Diagnostic disparities
• Latino youth significantly less likely than whites to be
diagnosed with depression (Richardson et al, 2003; national
Medicaid database)
• Treatment Access Disparities
– Service access:
• Latino youth use significantly fewer MH services than other
ethnic/ racial groups (Pumariega, et al, 1999; Juszczak,
Melinkovich, Kaplan, 2003; Yeh, et al. 2003; Richardson et al,
– Pharmacological treatment:
• Martin et al. (2003); Snowden, Cuellar, & Libby (2003); Leslie et
al. (2003); Richardson et al, 2003: Lower rates of prescribing
psychotropics overall for Latino youth versus Caucasians
Evidence-Based in Treatment of
Depression for Latino Adults
• Pharmacotherapy
– Equal response to SSRI’s (Siery et al, 1999), nefazodone (SanchezLacay et al, 2001), and duloxetine (Plewes et al, 2004)
– Latinos have higher placebo response (Wagner, et al, 1998, Escobar &
Tuason, 1980)
• Psychotherapy
– CBT enhanced with case management improves adherence and
outcomes with Latinos (Miranda, et al, 2003)
• Primary care treatment of depression
– Equal outcomes vs. whites but lower employment (Miranda, et al, 2004)
– QI interventions (CBT, nurse education and follow-up, translation and
cultural training for MD’s) improved outcomes for minorities (including
Latinos) equal to whites (Miranda, et al, 2003).
Evidence-Base in the Treatment
of Depression for Latino Youth
• TADS Study
• With 26% minority participants, race/ ethnicity not significant factor predicting
outcome (Curry, 2006)
• IPT and CBT for depression
• Rosello and Bernal, UPR, 1999: Efficacy of interpersonal psychotherapy and
CBT for depression in Puerto Rican youth
• Cardemil et al (2007): Effectiveness of school-based CBT
• Cognitive Behavioral Intervention for Traumatic Stress
• School-based intervention for traumatic stress in children and youth; evaluated
in LASD (Kataoka, Stein, et al., 2003)
• Evidence-based for Latinos, African-Americans, and Caucasians
• Suicide intervention
• Telenovelas as ER intervention with suicidal Latinas in Los Angeles (Rotheram
Borus, et al, 2004)
Culturally Competent
Treatment of Latinos:
Critical Elements: Important
• Cultural Competence Model (Cross, Bazron,
Dennis, & Isaacs, 1989)
– For the individual: The state of being capable
of functioning effectively in the context of
cultural differences.
– For the organization: A set of congruent
practice skills, attitudes, policies, and
structures, which come together in a system,
agency, or among professionals; and enable
them to work effectively in the context of
cultural difference.
Culturally Competent Treatment
of Latinos: Critical Elements: Important
• Practitioner CC
• Awareness/ acceptance
of difference
• Awareness of own
cultural values
• Understanding
dynamics of difference
• Development of cultural
• Ability to adapt practice
to cultural context of
• Organizational CC
• Valuing diversity
• Cultural selfassessment
• Managing for the
dynamics of difference
• Institutionalization of
cultural knowledge
• Adaptation to diversity
(policies, values,
structure, and services)
Culturally Competent Treatment
of Latinos: Critical Elements
• Access: Location within Latino
communities, public transport, hours around
work schedules.
• Engagement: Youth and family, bicultural
approach, address stigma.
• Assessment: Cultural context of symptoms/
problems, symptomatic expression, context
of level of adaptation, cultural strengths.
• Family Involvement: Critical; family therapy
focus on generational conflicts, mobilizing 27
DSM IV Cultural Formulation
• Systematic approach to assessment of cultural
– Cultural identity (reference group, language, developmental
factors, involvement with culture of origin and host culture)
– Cultural explanation of illness (idioms of distress, meaning and
severity, causes and explanatory models, help-seeking
– Cultural perspective on psychosocial environment and functioning
(social stressors, social supports, level of function and disability)
– Cultural element of physician-patient relationship (characteristics
of physician, organizational/ structural factors)
– Overall cultural assessment (contribution of culture to diagnosis
and treatment)
Culturally Competent Treatment
of Latinos: Critical Elements
• Psychotherapy: Practical problemsolving; address immigration traumas,
acculturation conflicts (internal or
generational), use of culturally specific
modalities or themes.
• Pharmacotherapy: Demistify, educate,
address metabolic issues, culturally
appropriate consent, empowerment.
• Contextual/ systemic: Utilize family/
community supports (churches,
Culturally Competent Treatment
of Latinos: Critical Elements
• Linguistic Support
– Critical importance of language
Establishment of alliance/ relationship/ adherence
Establishment of urgency
Accurate communication of symptoms
Accurate communication of treatment
• Patient education about illness and treatment
• Failure leads to errors, misalliance, bad outcomes
– Critical elements in interpretation
Knowledge of language
Knowledge of culture (idioms, non-verbals, etc.)
Knowledge of content matter
Objectivity (problem with relatives)
NEVER use children/ youth (roles, boundaries)
Recognition and Management of
Depression and Co-morbidities in
the Hispanic Population
Friday, April l8, 10:00 a.m. – 12:00 p.m.
National Hispanic Medical Association
12th Annual Conference
Washington Hilton
Washington, D.C.
Supported by educational grants from AstraZeneca Pharmaceuticals, Bristol-Myers Squibb
Company, Eli Lilly and Company, Forest Laboratories, and Wyeth Pharmaceuticals