English-speaking Hispanic participants in a major clinical trial responded
better to antidepressant treatment than did their Spanish-speaking peers, but
language preference is probably a marker for other medical and social factors,
said a report in the November Psychiatric Services.
The study, a secondary analysis of the STAR*D study of depression
treatments, points to the need for culturally informed approaches to
psychiatric diagnosis and care, said Andres Pumariega, M.D., chair of the
Department of Psychiatry at the Reading Hospital and Medical Center in
Reading, Pa., who was not involved in the
"Psychiatrists and primary care physicians need training in a
culturally specific understanding of illness, its cultural expression, and the
signs and symptoms of illness for the population we are serving," said
Pumariega, chair of APA's Committee of Hispanic Psychiatrists.
In the STAR*D study, researchers led by Ira Lesser, M.D., chair of
psychiatry at Harbor-UCLA Medical Center in Los Angeles, sought to find out if
Hispanic patients with major depressive disorder who preferred communicating
in Spanish (n=74) differed in illness severity or response patterns compared
with Hispanic patients who preferred speaking in English (n=121). The
participants all were enrolled in the trial from two Southern California
treatment sites and accounted for 60 percent of the Hispanics in the STAR*D
Research coordinators who were both bilingual and bicultural assessed
participants choosing Spanish, and bilingual and bicultural physicians managed
their treatment with the antidepressant citalopram.
Before adjustment of confounding variables, the Spanish speakers were less
likely to achieve remission and took longer to get there, wrote Lesser and
colleagues. However, adjustment for demographic, clinical, functional, and
severity variables eliminated those differences, indicating that those factors
may be just the ones standing in the way of better outcomes for these
patients, they said.
"[T]he poorer response by Spanish speakers may be related to factors
such as their more disadvantaged socioeconomic status or higher medical
burden, rather than their language preference per se," wrote the
The Spanish speakers tended to be older and less educated than their
counterparts who preferred using English, with lower incomes and a first major
depressive episode occurring later in life.
"These baseline differences are consistent with what we know about
Latinos with mental illness" who prefer to speak Spanish, said
Pumariega. "They have more socioeconomic and medical illness burdens,
but also show more chronicity of mental illness and a longer time to seeking
Part of that disparity may be due not only to socioeconomic issues but to a
preference among Latinos for obtaining mental health care from primary care
providers, who ordinarily know less about mental illnesses than specialists
do, said Pumariega.
"Primary care physicians do not have the same skills as psychiatrists
in diagnosing and treating depression, leading to a less-skilled approach to
management of depression and possibly contributing to some disparities of
outcomes," he said.
Furthermore, a preference for primary care may have deep cultural roots.
Among some Latinos, especially the less educated and the more recent arrivals
in the United States, there is an added burden of stigma in seeking help,
based on experiences in their ancestral countries. To them, seeing a
psychiatrist is just the first step on a slippery slope to
institutionalization, said Pumariega.
Another issue is the variation of subcultures collected under the single
umbrella labeled "Hispanic" or "Latino." "A
Cuban-American psychiatrist may well miss the meaning and context of a
Mexican-American's story," said Pumariega.
Finally, many clinical trials may contain a subtle, invisible barrier
despite all attempts to bridge the gap between researcher and subject, he
"It is assumed that Latinos have a clear conception of what
depression means to the interviewer or psychiatrist," he said. "If
they used culturally specific Spanish-language terms, the responses may have
been different. You have to use terminology they use, not what is used in
"Depression Outcomes of Spanish- and English-Speaking Hispanic
Outpatients in STAR*D" is posted at<http://ps.psychiatryonline.org/cgi/content/full/59/11/1273>.▪