Brought to you by the Depression Is Real Coalition, The Down & Up Show is dedicated to the reality of depression. Each week our hosts will talk with some of the world's top experts on depression, as well as people who have been impacted by this illness. The reality of depression is that it is a debilitating and potentially deadly medical condition that affects more than 15 million Americans every year. The other reality of depression is that there is hope.

Down & Up Show #22: Depression in the Latino Community

RAHN BAILEY INTRO:
Welcome to the down and up show on depressionisreal.org. I'm Dr. Rahn Kennedy Bailey (ph.), your host today. Very happy that we'll be speaking with Dr. Andre Pumeraga (ph.) today about clinical depression. Dr. Pumeraga is Chair of the Department of Psychiatry at the Reading Hospital and Medical Center in Reading, Pennsylvania and Professor of Psychiatry at Temple University School of Medicine in Philadelphia.

He's devoted his entire academic career to child and adolescent psychiatry in the areas of child systems, children systems care and cultural diversity. Currently Dr. Pumeraga serves as Chair of the American Psychiatric Association's Committee of Hispanic Psychiatrists.

Dr. Pumeraga today will discuss with us the impact of clinical depression in the Latino American community. Thank you so much for being with us today, Andre. How you doing Andy?

ANDRES PUMARIEGA ANSWER:
I'm fine thank you. Thank you Rahn.

RAHN BAILEY QUESTION:
So why don't we just begin by asking you how does the rate of clinical depression in Latinos compare with the rates in Caucasians and African-Americans?

ANDRES PUMARIEGA ANSWER:
You know some of the earlier studies looking at depression in Latinos reported lower rates of depression. But the more recent studies are reporting equal and in some cases higher rates of depression. There's a Latino sub-populations for example amongst Puerto Ricans, amongst Cubans where you actually see higher rates of depression than you do in the general population or in Caucasians, African-Americans.

The other group where we're seeing higher rates of depression within Latinos are within the young, in Latino youth, and there there's a consistent literature that points to higher rates of depression than either Caucasians or African-Americans. So it's really raises concern as to whether this is a illness that perhaps Latinos face some high risk factors for and/or are not receiving sufficient treatment for.

RAHN BAILEY QUESTION:
Well, doesn't that show that the rate of depression in Latinos may be even higher than in Caucasians and African-Americans? Is that consistent–although we break it down based on gender. Was up all Latino women versus all Latino men were likely to higher rates of depression or do you haveÑdo you notice differences when you break it down based on gender?

ANDRES PUMARIEGA ANSWER:
When you break it down based on gender uh definitely Latino women have higher rates than Latino men although probably the rates on Latino men are maybe under recognized or under reported. Possibly even some of the earlier studies had some confounds in terms of not recognizing some alternative symptoms of depression like for example Latinos tend to semanticize [sic] a great deal when they experience depression, focus on aches and pains and gastrointestinal abnormalities and headaches.

So that could certainly lead to under reporting. But women I think are particularly a vulnerable group.

RAHN BAILEY QUESTION:
I also wonderÑI'd love to hear your thoughts on what role does stigma play in this overall concern?

ANDRES PUMARIEGA ANSWER:
Well, I think in some ways it's both gender and culture interacting. You haveÑwith Latino women there'sÑthere's some similar issues thatÑthat are faced, asked with women in other ethnic and racial and cultural groups in terms of pressures around their role function. Some of the conflict between the more traditional roles that have been proposed in terms of family and child rearing versus career roles and greaterÑbroader opportunities.

Latinas I think face some of those conflicts even more starkly in part because of the speed with which they face those difficulties. They overnight upon immigrating and acculturating go from very traditional role expectations as mothers, as wives, as daughters to then a much greater degree of freedom and much greaterÑmany more options both socially and also economically.

Sometimes better options that are faced by immigrant Latino men. So that raises stress levels in the family in such a significant extent that it can even lead to violence such as domestic violence. But even when it doesn't lead to domestic violence it creates a certain level of stress that then will interact with any vulnerability to depression.

Stigma is also a significant problem in terms of seeking treatment for Latinos in general. But for Latino women the whole issue of acknowledging that somehow they're facing this level of distress in their relationships, seeing depression as somewhat of a weakness, sometimes even having difficulty sharing personal information and personal emotions with people outside the family.

That in itself is a significant taboo in Latino cultures. So I think that sometimes prevents people from being able to be more open. Then also the whole idea of seeking psychiatric treatment. For many Latinos that's really perceived as someone whose essentially lost their mind, who is psychotic and about to go into a long term psychiatric hospital.

The concept of community-based psychiatry and out-patient services is something that's not very well known in countries of origin. So it's a concept that has not really been promulgated in Latino community.

RAHN BAILEY QUESTION:
Let me ask about this NIMH work on the website that discusses that 54% of Latin American men or Latino men have one episode of depression in their lifetime. Nobody recognizes it as being a mental health problem. Why do you think that is and what kinds of activities are currently in place or is APA involved in it for example to try to bridge this gap?

ANDRES PUMARIEGA ANSWER:
Well actuallyÉ.

RAHN BAILEY QUESTION:
Ésee these issues as being of a psychiatric origin?

ANDRES PUMARIEGA ANSWER:
Uh huh. Well, with Latino men then you have other barriers that are gender specific and culturally specific. Again with the whole issue of the image of males as being strong, as being resilient, in some ways in the patriarchal system having to be role models, that is something that prevents many Latino men from even acknowledging that they have anything going on psychiatrically or emotionally.

RAHN BAILEY QUESTION:
Is there any difference between whether the person is a U.S. immigrant or U.S.Ñexcuse me, immigrants versus U.S. born in the rates of depression (unint.)?

ANDRES PUMARIEGA ANSWER:
You definitely see higher rates inÑin either immigrants who've been here a while or the second generation. In some ways immediate immigrants still retain certain protective cultural beliefs I guess you could say–some of the strong religious beliefs, some of the taboos against thinking about suicide, of being very open to family and community support and being able to readily access that family and community support.

The longer they're in the United States orÑthe longer thatÑor in the next generation some of those community support ties or loosened and some of those taboos are loosened.

RAHN BAILEY QUESTION:
Oh absolutely. We spoke loosely of taboos. I wonder about any particular barriers to treatment for Latinos different than others?

ANDRES PUMARIEGA ANSWER:
Well, barriers for treatment are many. To start with besides stigma the other biggy is insurance and access to insurance coverage. Latinos comprise theÑthey have the highest percent of uninsured of any racial ethnic group in the United States.

This has to do in part with lack of documentation, also in part with the kinds of jobs that Latinos takes which often are jobs that do not come with health benefits. Also obviouslyÉ.

RAHN BAILEY QUESTION:
Much (unint.) access to Spanish-speaking providers.

ANDRES PUMARIEGA ANSWER:
Exactly. That's another major barrier, and the other inherent barrier even if we're talking about Spanish-speaking providers it's the idea of even going to a mental health provider. Latinos feel far more comfortable going to general practitioners and sometimes even to cultural healers.

In fact some of theÑthere's a recent data from theÑfrom the Cambridge Health Collaborative Allegay Unconino (ph.) looked at it and they looked at where Latinos were accessing their depression care and itÑmental health professionals were like almost last on the list. They almost went to neighbors before they went to a professional health provider.

ANDRES PUMARIEGA ANSWER:
WellÉ

RAHN BAILEY QUESTION:
Éis that any different?

ANDRES PUMARIEGA ANSWER:
The rate of suicide amongst older Latinos is somewhat lower. But we're seeing a major increase in the young. In fact per the latest Youth Risk Behavior Survey as conducted in 2005, published in 2006 by the Centers for Disease Control, Latino youth are at the head of the class in terms of percent to report sadness to hopelessness, who report having thought about suicide, who report having attempted suicideÑpanned it, attempted it and having attempted suicide with seriousÑattempted suicide with serious medical complications that required treatment.

I don't know if we have data on completion.

RAHN BAILEY QUESTION:
É.we are (unint.) cultural competence that may address some of these. Any pointers that you might want to give me let along your audience because I am down here in Houston with increasingly a growing Hispanic and Spanish-speaking patient population. I want to make sure that I'm not missing the ball on some particular factors that would be useful and adequate let alone optimallyÑdiagnosing and treating depression in this unique patient population.

ANDRES PUMARIEGA ANSWER:
Well, I think there are a number of culturally-specific approaches that are very important. One is obviously as we mentioned earlier having a location, an ambience, bilingual/bicultural staff if possible. If necessary interpreters but if possible professionals who can actually deliver the services.

Or a system delivering the services including even case managers. The other piece that's very important is engaging the family. Families are strong decision makers for Latinos, and they will often turn to family members for sanction or permission to pursue evaluation and treatment.

Treatment also needs to be presented in a practical and very problem-oriented fashion rather than seen in a very long term perspective.

RAHN BAILEY QUESTION:
What are your thoughts on things that we can do in psychiatry or as professional clinicians in psychology, psychiatry, social work and mental health in general to kind of break down some of these barriers and encourage a more open path with the patients to come to us whether we are of their same background or not and to be able to enhance the line of communication?

ANDRES PUMARIEGA ANSWER:
Well I think working with for example Latino community organizations and that includes lay organizations, that includes Latino predominated churches which by the way these days are not predominantly Catholic. They are predominantly Pentecostal.

One needs to make outreaches that essentially will bringÑfacilitate the discussion about mental health being about treatment in a comfortable fashion within the Latino community. Also working with primary care physicians and primary care clinics and having models of outreach that facilitate access for Latino communities.

There's even a model that's been used for example in border communities for many decades of outreach for health prevention, Compro ModotosÑhealth promoters. Essentially you recruit the wise ladies in the neighborhood to be community health workers and you train them with information so they can disseminate that information and then facilitate access.

I think those are all very important. Reaching out through Latino media, and I think that's starting to happen through some of our advocacy organizations and also in beginning to develop more ethnically specific support structures and organizations and support groups.

Some communities for example in our own community here in Burke's (ph.) County NAMI (ph.) is looking at specific support groups for Latino family members and for Latino consumers.

RAHN BAILEY QUESTION:
I'm also interested in this overall issue/concern of advice to Latino individuals themselves and how they might be able to break through some of these barriers because we all can certainly see how often individuals, Latino or Spanish-speaking, they may be limited in their approach and they only cal other persons or seek care for persons who are Latino, who are Spanish-speaking although somebody else may not be but may actually have access to an interpreter.

Probably to figure out ways to expand options and increase avenues to get people to care early on is gonna be a lot better at primary prevention and preventing these problems from actually becoming more substantial and more heavily weighted before they actually finally get in to see someone. We all know at those point there's less likely what we're gonna do is gonna work, or not gonna work all the way to the point of remission.

ANDRES PUMARIEGA ANSWER:
Exactly. There really needs to be a many doors and portals and with many helpers to facilitate outreach to particularly the Latino community but I think to many diverse communities in the sense the not one size fits all and that you reallyÑagain, the concept of timely mental health services is something that needs to be presented and then people need to feel the facilitation and comfort in accessing it.

RAHN BAILEY QUESTION:
Before I go to closing thoughts I kind of want to ask you just any comments about medical co-morbidity.

ANDRES PUMARIEGA ANSWER:
Exactly. For Latinos I think in terms of medical co-morbidities and in particular diabetes is a major problem in the Latino community and some studies are starting to show high rates of co-morbidity for depression and diabetes in the Latino community. Heart disease as well is another one that's fairly prevalent, and we need to be on the lookout for depression in Latinos who suffer from heart disease.

That's also especially true of the Latino elders who obviously suffer from a lot of the medical co-morbidities. Although the Latino population is relatively young that's got to be a growing cohort, and all the literature shows that they have actually again an increasing rate of depression as they some ways they deal with not only their medical co-morbidities but also relative isolation inÑfrom their culture of origin and in the mainstream culture.

RAHN BAILEY QUESTION:
Absolutely. Hey, I really enjoyed. I think very good points all the way around. I hope the audience as well as myself have really learned some strategies that we can consider and use to really try to address this growing problem, and that's really the need for more and more persons in our community, in our society who are Latino to be able to obtain and receive high quality of available and accessible mental health careÑpreventatively and when they're in the throws of more substantial depression.

ANDRES PUMARIEGA ANSWER:
Uh huh.

RAHN BAILEY QUESTION:
Any other closing comments or closing thoughts that you'd like to address, Andres. I have worked with you over the years and I'm very aware of the high quality work you do through APA.

ANDRES PUMARIEGA ANSWER:
Well, thank you.

RAHN BAILEY QUESTION:
Any closing thoughts, sir?

ANDRES PUMARIEGA ANSWER:
Uh, I'mÑalso want to say that APA has in their Healthy Minds Campaign has taken very seriously the charge to provide community outreach and community education and also through the office of minority national Affairs, Dr. Anell Prim (ph.) has done an incredible job of reaching out to various minority in diverse communities including the Latino community and also are the website on healthminds.org that has actually not only we're gonna have a larger number of expert opinion pieces about different perspectives about Latino mental health including stigma, access issues, suicide, etc., but also we have downloadable brochures in Spanish that were reviewed by The Committee on Hispanic Psychiatrists and in some instances translated and designed by the Community of Hispanic Psychiatrists.

So you have some good work by Hispanic psychiatrists who hopefully reach out to the broader Latino community.

RAHN BAILEY QUESTION:
Absolutely. (Unint.) outstanding. All good points, all relevant points and all points I think that the audienceÑmyself and the audience have certainly appreciated and benefited from. So thank you so much Dr. Pumeraga.

But from Depression Is Real Coalition I'm Dr. Ron Kennedy Bailey. Thank you so much for joining us and please join us next time for another episode of the Down or Up Show on depressionisreal.org. Thank you Andre.

ANDRES PUMARIEGA ANSWER:
Oh, thank you. Thank you very much Rahn.

RAHN BAILEY CLOSE:
You take care. Bye.

(END OF TAPE)