Dec 11, 2019
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
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
- 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
- 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
- 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
- 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
- Stigma and concerns about “harm to the body” can prove to be
How clinicians might work with Latino
- 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
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
- Know that warmth is more important than expertise in the eyes
of some Latino patients.
Vargas SM et al. Toward a cultural adaptation of
pharmacotherapy: Latino views of depression and antidepressant
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
Anxiety. 2018 Dec;35(12):1190-7.
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