Medical Therapy for Major Depressive Disorder in Latinos
Alan Podawiltz, DO, MS, FAPA
Texas College of Osteopathic Medicine, and the Department of Psychiatry and Behavioral Health, University of North Texas Health Science Center, Fort Worth
Larry Culpepper, MD, MPH
Department of Family Medicine, Boston University School of Medicine, Boston, Massachusetts
Hispanic or Latino refers to a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. In this activity, the terms Hispanic and Latino are used interchangeably.
Currently, no separate recommendations for the treatment of MDD in Latino veterans or their families exist. Current guidelines1,2 recommend beginning treatment with antidepressant monotherapy for patients with acute MDD and asking patients from different ethnic groups about their treatment preferences. However, Hispanic patients may be less likely to accept antidepressant medication than other ethnicities3,4 and may believe such medication is addictive.4 They are also more likely to accept counseling, believe prayer can help heal depression, and prefer health care professionals of the same ethnicity.3,4
In general, Latinos worry about “strong” medicines4 and may notice side effects and drug latency more readily than patients of other ethnicities.5,6 One study4 found that Latinos had more side effects with tricyclic antidepressants than did other ethnicities. This reaction, however, may be due to the somatic nature of depression in this population.5
Other considerations when choosing an antidepressant or other drug therapy for MDD in Latinos include drug-drug interactions and the use of any medications obtained in other countries or from ethnic healers.
Choosing Antidepressants for Latinos
Little research exists on the most appropriate antidepressants for Latino veterans, but as personalized medicine moves from the research setting to the physician’s office, this may change.4,6 Among the few studies to evaluate antidepressants in Hispanics with depression is an open-label study7 of paroxetine and fluoxetine in Hispanic and non-Hispanic women, which found similar rates of response. However, a pooled analysis8 of 14,875 adults with depression or anxiety who participated in 104 double-blind, placebo-controlled paroxetine clinical trials found that Hispanics with depression had a slightly lower response rate and the lowest rate of “full response” than other ethno-racial groups (AV 1). Hispanics also exhibited a higher placebo response rate, which could account for some of the difference in response rates. Other studies found no response difference in Hispanics to nefazodone9 or duloxetine10 compared with other populations.
Lindeman et al11 noted that Hispanics tended to have lower levels of folate, vitamin B12, and vitamin C, which can have a negative impact on cognitive function. Cognitive function, in turn, has been shown to have an impact on drug response when treating depression.12 However, note that depression is the most common neuropsychiatric manifestation of folate deficiency and may mimic impaired cognitive function.13
Adherence to treatment for depression is an issue regardless of ethnicity, but some evidence has found that nonadherence rates may be higher in Hispanic populations. Patients face financial and transportation issues, often have multiple jobs, and may have culturally based concerns regarding the stigma of treatment and adverse effects from the medication.4 The concept of familismo may lead some Hispanic patients, particularly women, to put the needs of their family before their own need to use financial resources on medication. Poor patient/physician communication may also contribute to nonadherence.4,14
Recommendations for Medical Treatment for MDD in Hispanics
Established guidelines for the treatment of MDD should be followed when treating Hispanic veterans. Evidence-based guidelines from TMAP1 call for antidepressant medication to be used as a first-line treatment, with the choice of medication based on patient and clinician preference, potential side effects, and cost. An adequate trial of an antidepressant should generally last 8 to 12 weeks. In the absence of side effects or tolerability issues, the dosage of medication should be increased every 2 to 3 weeks until remission occurs, the maximum dosage of the medication is reached, or treatment-emergent side effects limit dosage titration.
The STAR*D study15 found that 40.3% of patients who attained remission with antidepressant treatment did so after the initial 8 weeks of treatment. Therefore, a patient who is improving but not yet in remission at 8 weeks should be continued on treatment. Sustained response (4 weeks) enables the patient to enter the continuation phase of treatment. Inadequate or no response requires medication switching, augmentation, or greater titration than sustained response.1,2 Patients who remit with pharmacotherapy during acute-phase treatment should continue their medication for at least 6 to 9 months after symptoms remit at the same dosage responsible for the therapeutic response.2
Approximately 50% of patients with MDD will experience a recurrence of depression after an initial episode without long-term treatment, with the risk of recurrence increasing with each subsequent episode of depression.1 By the third episode of depression, approximately 90% of patients will experience recurrence without maintenance antidepressant treatment.1
Based on the evidence showing a high risk of recurrence in patients with a history of MDD, the TMAP panel1 recommends that all patients who experience ≥ 3 major depressive episodes should be maintained on antidepressant medication for a course of preventive therapy. Maintenance medication should be prescribed at the same dose that produced symptom remission.1 The duration of maintenance phase treatment varies between 1 year and lifetime, depending on risk factors for recurrence and patient preference.1
Although no separate guidelines exist for the medical treatment of MDD in Hispanic veterans or their families, cultural considerations, including the patient’s perception of medication, must be considered. Evidence-based guidelines for the diagnosis and treatment of depression are generally applicable to a Hispanic population (AV 2). Thus, treatment should employ a stepped approach beginning with antidepressant monotherapy. An adequate trial generally lasts 8 to 12 weeks, although nonresponsive patients may be switched at 4 weeks. Close monitoring is critical until patients reach a sustained response and move into the continuation stage, at which point they may be monitored every 3 months.
MDD = major depressive disorder
STAR*D = Sequenced Treatment Alternatives to Relieve Depression
TMAP = Texas Medication Algorithm Project
duloxetine (Cymbalta), fluoxetine (Prozac and others), paroxetine (Paxil and others)
- Crismon ML, Trivedi MH, Pigott TA, et al. The Texas Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Major Depressive Disorder. J Clin Psychiatry. 1999;60(3):142–156.
- Kaiser Permanente Care Management Institute. Depression Clinical Practice Guidelines. http://www.guideline.gov/summary/pdf.aspx?doc_id=9632&nbr=5152&ss=68x1=999stat=1&string. Accessed June 24, 2009.
- Cooper LA, Gonzales JJ, Gallo JJ, et al. The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients. Med Care. 2003;41(4):479–489.
- Lewis-Fernández R, Das AK, Alfonso C, et al. Depression in US Hispanics: diagnostic and management considerations in family practice. J Am Board Fam Pract. 2005;18(4):282–296.
- Lin KM. Biological differences in depression and anxiety across races and ethnic groups. J Clin Psychiatry. 2001;62(suppl 13):13–19; discussion 20–21.
- Marin H, Escobar JI. Special issues in the psychopharmacological management of Hispanic Americans. Psychopharmacol Bull. 2001;35(4):197–212.
- Alonso M, Val E, Rapaport MH. An open-label study of SSRI treatment in depressed Hispanic and non-Hispanic women. J Clin Psychiatry. 1997;58(1):31.
- Roy-Byrne PP, Perera P, Pitts CD, et al. Paroxetine response and tolerability among ethnic minority patients with mood or anxiety disorders: a pooled analysis. J Clin Psychiatry. 2005;66(10):1228–1233.
- Sánchez-Lacay JA, Lewis-Fernández R, Goetz D, et al. Open trial of nefazodone among Hispanics with major depression: efficacy, tolerability, and adherence issues. Depress Anxiety. 2001;13(3):118–124.
- Lewis-Fernández R, Blanco C, Mallinckrodt CH, et al. Duloxetine in the treatment of major depressive disorder: comparisons of safety and efficacy in US Hispanic and majority Caucasian patients. J Clin Psychiatry. 2006;67(9):1379–1390.
- Lindeman RD, Romero LJ, Koehler KM, et al. Serum vitamin B12, C and folate concentrations in the New Mexico elder health survey: correlations with cognitive and affective functions. J Am Coll Nutr. 2000;19(1):68–76.
- Gorlyn M, Keilp JG, Grunebaum MF, et al. Neuropsychological characteristics as predictors of SSRI treatment response in depressed subjects. J Neural Transm. 2008;115(8):1213–1219.
- Alpert JE, Fava M. Nutrition and depression: the role of folate. Nutr Rev. 1997;55(5):145–149.
- Sleath BL, Williams JW Jr. Hispanic ethnicity, language, and depression: physician-patient communication and patient use of alternative treatments. Int J Psychiatry Med. 2004;34(3):235–246.
- Trivedi MH, Rush AJ, Wisniewski SR, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry. 2006;163(1):28–40.