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Cultural Aspects of the Pharmacological Treatment of Depression: Factors Affecting Minority and Youth

(PSYCHIATRIC TIMES) - The cultural and demographic profile of the United States is undergoing a rapid transformation. In many areas of the country, there is no longer an ethnic majority but a multiplicity of racial and cultural groups. These changes can be attributed to 3 principal factors1:

• The aging and lower fertility rates of the European origin population.
• The significant increase of immigration from developing countries, especially from Latin American and Asia.
• The higher fertility rates of the non-European minority groups.

Risk factors for depressive disorders in minority youth
The most recent studies reveal that minority children and adolescents are at a higher risk for depression than white youth. This is particularly true for Hispanic, non-Hispanic black, and American Indian youths.

Suicide rates, which have been traditionally lower among minority youth, are now equal to or surpass those of white youth. Hispanic, non-Hispanic black, and American Indian youth have a higher suicide risk than youth from the mainstream culture.

The stresses of living in poverty are frequently accompanied by variables such as discrimination, gender role pressures, losses related to immigration, and ongoing frustration and deficient support systems, which abound in this population.2,3 Conflict also plays an important role in depression and often evolves into a vicious cycle in which irritability—a common feature of child and adolescent depression—increases interpersonal tensions and may cause parents, teachers, and friends to distance themselves from the depressed person. This, in turn, increases feelings of abandonment and lack of support.1

Evidence for disparities
Minority and immigrant children and adolescents face a number of barriers to effective mental health care. These include population barriers (socioeconomic disparities, stigma, poor health education, and lack of legal immigration status), provider factors (deficits in cross-cultural knowledge and skills and attitudinal sensitivity), and systemic factors (location of services and organizations, and lack of culturally competent services and practitioners).

Minority youth often reside in neighborhoods where services are unavailable, or they lack the public or private insurance necessary to obtain mental health services. Recent studies show that Hispanic families underuse mental health services because of language and cultural barriers,4 non-Hispanic black families underuse health services because of distrust,5 while Asian Americans avoid or delay seeking care because of the stigma that is associated with mental illness.6

Diagnostic challenges
Diagnosing depression in minority and immigrant youths can be challenging to unfamiliar clinicians. There is significant evidence that psychiatric disorders are frequently misdiagnosed among culturally diverse youth. Various studies have found an overdiagnosis of conduct disorder and an underdiagnosis of depressive disorders in minority youths.7-9 Misdiagnosis largely originates from difficulties that clinicians may have in addressing cultural differences, including cognitive biases stemming from stereotyping, lack of systematic assessment, and lack of contextualization of information obtained in diagnostic assessments.10 Most care for depression is provided by primary care physicians who may have relatively little experience with depression in children and adolescents and have added disincentives, such as decreased reimbursement for identifying a mental health versus a somatic health problem.11

Children and adolescents from minority populations may demonstrate different symptoms than white American youths. Somatization and anger, for example, are symptoms more frequently associated with depression in minority youths.12 The degree of emotional reactivity can also vary: Asian Americans who are depressed show heightened reactivity compared with white Americans who show less reactivity when depressed.13 Diagnosis is more challenging with depressed minority children and adolescents because of frequent comorbidities. For example, stresses associated with immigration, acculturation stress, discrimination, and community violence contribute not only to depression but also to anxiety, disruptive behavioral symptoms, substance abuse, and posttraumatic stress disorder (PTSD).14-16

Kleinman17 argues that culture shapes the way individuals not only express but also understand the symptoms of illness. There are significant differences in how the various ethnic groups understand depression, which can influence help-seeking behaviors and invoke spiritual, supernatural, sociological, and interpersonal explanatory models. For example, non-Hispanic blacks often conceptualize depressive symptoms as part of their experience of sociopolitical oppression.18 Stigma also constitutes a major barrier to seeking mental health services in general, and cultural beliefs play a large role in the perpetuation of stigma. Many cultures have major negative associations with any type of mental health assistance, often equating this with serious psychopathology and social undesirability. The fear of double-stigmatization (being culturally different as well as "crazy") presents major barriers to accessing services.19

Kleinman17 developed the exploratory model, which methodically elicits the symptoms that are more salient and worrisome to the patient. This model helps reveal patterns of distress; explores perceived causes and attributions; identifies preferences in help-seeking behavior; helps uncover perceptions of stigma; and ultimately explores the discrepancies that may exist between the patient's understanding of the condition and the clinician's proposed etiology, diagnosis, and treatment plan. This model leads to higher levels of treatment adherence. Values are also intimately associated with levels of acculturation, generational differences, and educational and socioeconomic variables.

Understanding the differences between the values of traditional societies versus modern societies is an important tool that will help improve communication between the clinician and the patient (Table 1).It is also important to remember that a significant portion of immigrants and members of minority populations in the United States are urban or rural poor and that poverty and educational levels are important variables in determining the patient's understanding of illness and help-seeking behaviors.20

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