Prescribing antidepressants to Latino patients with Dr. Roberto Lewis-Fernández

Roberto Lewis-Fernández, MD, returns to the MDedge Psychcast, this time to discuss ways to approach pharmacotherapy for Latino patients with depression. Previously, on episode 36 of the Psychcast, Dr. Lewis-Fernández discussed the role of cultural assessments in providing person-centered mental health care.

Dr. Lewis-Fernández, professor of clinical psychiatry at Columbia University and director of the New York state Center of Excellence for Cultural Competence and the Hispanic Treatment Program at the New York Psychiatric Institute, spoke with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, at the 2019 fall meeting of the Group for the Advancement of Psychiatry, or GAP.

And later, in the "Dr. RK" segment, Renee Kohanski, MD, asks whether some euphemisms that are becoming more common in society keep us from finding real solutions to problems.

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How Latino patients typically think of illness and medications

• Commonly, patients of Latino descent seek mental health treatment after trying other interventions, such as talking with family, clergy, and primary care clinicians. Latino patients, similar to other patient populations, sometimes present with ambivalence about medications and concerns that the medications might be "fairly strong" or addictive. The need to take medications is seen as an admission of sorts that the presenting problem of depression or anxiety is serious.
• Specifically, Latino patients are concerned about medications and risk of physical and psychological addiction and being reliant on a crutch. For example, a Latino patient might worry that by taking an antidepressant medication, they will lose their innate ability to improve on their own. This belief plays out when Latino patients stop medication prematurely, just as it begins to be effective, in order to "poner de mi parte," which translates to "do my share." The Latino culture puts weight on self-reliance.
• Latino patients often look for flexibility in medications and express concern about their effect on the body. For example, some patients might want to take medication only on days in which they feel sick. Others might ask for days off from the medication to ensure that the body does not weaken from being dependent on medications.
• Natural remedies often are favored by Latino patients. In some Latino communities, there might be natural pharmacies and "botanicas," which provide herbal and vitamin remedies. Natural medicines are viewed as "gentle" and more in line with what the body needs.
• Psychotherapy for the treatment of mild depression often is favored by patients who want to use therapy before medications. Latino patients usually prefer more "advice"-driven psychotherapy that focuses on problem solving.

Possible structural barriers to treating Latino patients

• Common structural barriers to accessing care include limited time to make appointments because of work and family obligations as well as a fragmented health care system with ever changing clinicians.
• Stigma and concerns about "harm to the body" can prove to be barriers.

How clinicians might work with Latino patients

• Be open to being flexible to patients' requests, such as the desire to perhaps skip a day each week or even stop medications. Exerting clinical authority based on biological understanding of the medication and diagnosis can backfire and can result in patients stopping the medication altogether.
• Understand different conceptions in the Latino community about how and when emotions should be expressed. The "ataque de nervios" ("attack of nerves") presented in the DSM-5 as a culture-bound syndrome is indicative of the Latino attitude that emotions are meant to be expressed but also controlled. So "un ataque de nervios" represents a situation that is so overwhelming that emotions take over, such as an attack and cannot be controlled.
• Know that warmth is more important than expertise in the eyes of some Latino patients.

References

Vargas SM et al. Toward a cultural adaptation of pharmacotherapy: Latino views of depression and antidepressant therapy. Transcult Psychiatry. 2015 Apr;52(2):244-73.

Lewis-Fernández R et al. Impact of motivational pharmacotherapy on treatment retention among depressed Latinos. Psychiatry. 2013 Fall; 76(3):210-2.

Moitra E et al. Examination of ataque de nervios and ataque de nervios like events in a diverse sample of adults with anxiety disorders. Depress Anxiety. 2018 Dec;35(12):1190-7.

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