Family Members of Hispanic Military Veterans: The Risk of Major Depressive Disorder
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.
Families of Veterans
Hispanics make up 11.2% of US enlisted personnel and 4.9% of US military officers.1 However, these numbers are expected to rise in the near future, as the Department of Defense increasingly targets Hispanics in its recruiting efforts, and over the next 15 years, when Hispanic youth are expected to comprise the largest pool of potential recruits.2 Latino military families are also becoming more common because the US offers citizenship for military service.3
In addition, about 25% of Hispanics in the military are assigned to front-line or hazardous duty occupations.2 A soldier's family is already under unique stressors when the soldier is deployed, the result of extended separations, increased workloads, shifting demands, and unstable deployment schedules. These stressors significantly increase the risk of MDD in family members.4
Children are particularly vulnerable to the stress from deployment (AV 1). They tend to exhibit symptoms of depression, such as increased irritability and impulsiveness, poor academic performance, and negative behavioral adjustment, before, during, and after a family member's deployment. The stressors related to deployment may overwhelm adolescents, with some becoming socially isolated.4,5 This isolation may be particularly prevalent in Latinos, who are often reluctant to discuss depression,6–8 and may be dangerous in Hispanic female adolescents, who are more likely to attempt suicide than their peers.9 Thus, clinicians need to understand the unique issues related to depression in the family members of Hispanic veterans.
Depression in Hispanics
The risk of major depression appears to be greater for US-born Hispanics than for immigrants, possibly related to a lack of social and family support in this population. However, no significant difference exists between the rate of MDD in Hispanic individuals and non-Hispanic individuals.10 The lifetime prevalence of depression in Hispanics in the United States is 13.5%, compared with 17.9% for non-Hispanic whites and 10.8% in non-Hispanic blacks.11
Differences between Hispanics and other ethnicities include the findings that Hispanics tend to report more depressive symptoms12 and are twice as likely to seek care for depression from primary care physicians than mental health professionals.13,14 Overall, Hispanics are less likely than any other ethnicity to receive an appropriate diagnosis of depression14 and, when diagnosed, just 24% receive appropriate treatment (AV 2).7
Hispanic patients often describe depression not with the typical terms such as sad, tired, or depressed but with the terms for Hispanic folk illnesses that have strong correlations with depression: nervios and susto.15 Susto, or fright, is typically triggered by a frightening experience, such as seeing someone killed, being in an accident, or receiving a sudden shock. Symptoms include crying, trouble sleeping, shaking/trembling, sadness, irritability, and hopelessness. Nervios is similar but can be used to explain an illness or a symptom of an illness and includes a variety of somatic symptoms, such as headache, chest and abdominal pain, changes in blood pressure, and feelings of desperation.
Weller et al15 interviewed native Mexicans and found susto to be significantly associated with stress and depressive symptoms (P < .05). However, nervios was more strongly associated with depression (P < .0001).15
Barriers to Effective Treatment
The stigma of mental illness remains very strong in Hispanic communities. Other barriers to diagnosing depression in the Hispanic community include financial, language, and health literacy challenges, as well as a strong disconnect between the medical world and the cultural world of Hispanics, in which mental health illnesses are more likely to be viewed in terms of the religious, spiritual, and supernatural.16
Hispanic cultures also value personalismo, or self-sufficiency, making them far less likely to seek help for medical or psychological problems, and familismo, or family centeredness, in which they feel they should keep problems within the family.17–19 This concept may also delay recognition, particularly in women, who may prioritize the needs of their family before seeking care for their own symptoms.
The number of Hispanics serving in the US military is expected to grow substantially. Frequent deployments and combat assignments put significant stress on military families, increasing the risk of major depression. The family members of Hispanic military personnel may manifest depression differently than other ethnicities. Hispanic patients are also less likely to seek help, more likely to seek care from primary care physicians, and less likely to be appropriately diagnosed and treated for depression. Thus, clinicians should be aware of the risk and presentation of MDD in family members of US military veterans.
MDD = major depressive disorder
- Segal MW, Segal DR. Latinos claim larger share of US military personnel. Population Reference Bureau. www.prb.org/Articles/2007/HispanicsUSMilitary.aspx. Published October 2007. Accessed July 1, 2009.
- Pernick, D. Recruiting Latinos in the military. http://lideres.nclr.org/content/article/detail/1561. Published September 12, 2005. Accessed July 1, 2009.
- US Citizenship and Immigration Services. Naturalization through military service. www.uscis.gov/files/pressrelease/milnatz_280108.pdf. Updated January 28, 2008. Accessed July 1, 2009.
- Johnson SJ, Sherman MD, Hoffman JS, et al, for the American Psychological Association Presidential Task Force on Military Deployment Services for Youth, Families and Service Members. The Psychological needs of US military service members and their families: a preliminary report. http://www.apa.org/releases/MilitaryDeploymentTaskForceReport.pdf. Published February 2007. Accessed July 1, 2009.
- Huebner AJ, Mancini JA. Adjustments among adolescents in military families when a parent is deployed: final report to the Military Family Research Institute and Department of Defense Quality of Life Office. www.cfs.purdue.edu/mfri/pages/research/Adjustments_in_adolescents.pdf. Published June 30, 2005. Accessed July 1, 2009.
- Interian A, Martinez IE, Guarnaccia PJ, et al. A qualitative analysis of the perception of stigma among Latinos receiving antidepressants. Psychiatr Serv. 2007;58(12):1591–1594.
- Young AS, Klap R, Sherbourne CD, et al. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry. 2001;58(1):55–61.
- Hirschfeld RM, Keller MB, Panico S, et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277(4):333–340.
- Centers for Disease Control and Prevention. Suicide: facts at a glance. www.cdc.gov/ncipc/dvp/suicide/SuicideDataSheet.pdf. Published Summer 2007. Accessed July 1, 2009.
- Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289(23):3095–3105.
- Breslau J, Aguilar-Gaxiola S, Kendler KS, et al. Specifying race-ethnic differences in risk for psychiatric disorder in a USA national sample. Psychol Med. 2006;36(1):57–68.
- Menselson T, Rehkopf DH, Kubzansky LD. Depression among Latinos in the United States: a meta-analytic review. J Consult Clin Psychol. 2008;76(3):355–366.
- McGuire TG, Ayanian JZ, Ford DE, et al. Testing for statistical discrimination by race/ethnicity in panel data for depression treatment in primary care. Health Serv Res. 2008;43(2):531–551.
- US Department of Health and Human Services. Mental Health: Culture, Race, and Ethnicity: a Supplement to Mental Health: a Report of the Surgeon General, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Rockville, MD: US Department of Health and Human Services; 2001. http://www.surgeongeneral.gov/library/mentalhealth/cre/sma-01-3613.pdf. Accessed July 1, 2009
- Weller SC, Baer RD, Garcia de Alba Garcia J, et al. Susto and nervios: expressions for stress and depression. Cult Med Psychiatry. 2008;32(3):406–420.
- Lewis-FernÃ¡ndez 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.
- 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.
- Culpepper L, Currier MB, Diaz M. The Cuban American with depression in primary care. Prim Care Companion J Clin Psychiatry. 2004;6(5):213–216.
- Marin H, Escobar JI. Special issues in the psychopharmacological management of Hispanic Americans. Psychopharmacol Bull. 2001;35(4):197–212.