Participants perceived depression as a serious debilitating condition. Somatic and anxiety-like symptoms were commonly used to describe depression, and these symptoms were connected to the emotional distress surrounding participants’ suffering. The experience of desesperación, common among many of our participants, illustrated how individuals’ emotional distress caused by the accumulation of social stressors surfaced as physical symptoms (e.g., headaches, chest pain, shortness of breath). Depression was characterized as a condition that blends somatic, anxiety-like, and emotional symptoms that seriously impacts a person’s functioning.
Another important finding regarding participants’ experiences of depression was the use of the cultural idiom of nervios
to describe, categorize, and make senses of depression. Cultural idioms of distress encode local understanding of symptoms and provide individuals meaningful expressions for explaining their illness experiences and suffering (Kleinman, 1988
, a common idiom of distress among Latinos in the U. S. and Latin America, includes an array of symptoms, such as fear, anxiety, irritability, depression, headaches, anger, worries, and loss of control (Guarnaccia, Lewis-Fernandez, & Marano, 2003
). This idiom “refers both to a vulnerability to stressful life experiences and to a syndrome brought on by difficult life circumstances” (e.g., interpersonal problems, strain in social roles, death of loved ones; APA, 2000
, p. 901). Nervios
and not the cultural idiom of susto
was used by participants to describe their illness experiences. Depression was not linked to a specific frightening event or soul loss, key features of susto
(Weller et al., 2002
). Instead, their illness experiences were placed within a larger social context characterized by stressful life circumstances (e.g., poverty, caregiving burden) that impacted their physical and mental health. Nervios
provided our participants what Guarnaccia and colleagues (2003)
have called a “popular nosology”, that is a common language informed by local knowledge and used to express and articulate the intersection they perceived between their illness and social suffering.
The saliency of the social context in participants’ experiences of depression was also apparent in the causes they attributed to this condition. Consistent with other studies (Cabassa et al., 2007
; Pincay & Guarnaccia, 2007
), depression was perceived as a cyclical condition linked to the accumulation of interpersonal turmoil and social stressors. Participants’ explanatory models of the causes of depression were inseparable from the social dimensions (e.g., economic strains, loss of employment, caregiving burdens) that surrounded their illness experiences. Depression was described as a condition caused by outside pressures and stressors that impacted the individual at both an emotional and physical level.
Participants’ discussions about diabetes and depression revealed a reciprocal relationship between these two conditions. For some, diabetes was a major contributing factor of depression either through reductions in functioning or the burden of living and coping with a chronic medical illness. These findings are consistent with those reported in other studies examining mechanisms linking diabetes and depression (e.g., Chapman et al., 2005
). Others reported how diabetes induced an array of symptoms related to depression. Proinflammatory cytokines, common among individuals with diabetes, produce a cluster of symptoms, such as fatigue, anhedonia, and reduced psychomotor activities among others, that overlap with depression and may be a plausible physiological explanation for this perceived relationship (Musselman et al., 2003
). As reported elsewhere (Ciechanowski et al., 2000
; Cherrington et al., 2006
), depression interfered with self-care behaviors and management of diabetes. These findings highlight the different pathways by which diabetes and depression impact one another among low-income Hispanics.
Several intriguing findings emerged regarding participants experiences with depression treatments. Fears about the addictive and harmful properties of antidepressants, worries about taking too many pills, and the stigma attached to taking psychotropic medications were some of the common concerns reported. These findings contribute rich contextual evidence to the existing literature (Cooper, Gonzales, Gallo, Rost, Meredith, Rubenstein, et al., 2003
; Givens et al., 2007
) reporting common apprehensions and misconceptions Hispanics have toward antidepressants. Many of our participants described how these concerns were prevalent in the community and directly impacted initiation and adherence to treatments. However, these misconceptions toward antidepressants were not static. Some participants talked about how the information and encouragement they received from their therapists and/or primary care doctors helped appease their fears and concerns toward antidepressants. Those who took antidepressants reported positive experiences with these medications. These findings suggest that a proactive approach in which clinicians assess and address the concerns and fears Hispanic clients may have toward antidepressant medications can help reduce misconceptions about treatment and improve treatment initiation and adherence.
Previous studies have documented Hispanics’ preference of psychotherapy over medications, yet little is known about why this preference exists (Cooper et al., 2003
; Dwight-Johnson, Sherbourne, Liao, & Wells, 2000
; Givens et al., 2007
). Our study provides some explanations for this preference. The saliency of social stressors in participants’ explanatory models of depression suggest that psychotherapy is more aligned with their perceived needs and may provide a more tangible treatment to address these social problems than medications. Psychotherapy contrasted with other medical encounters in that participants felt they received much needed information that raised their awareness about depression, reduced stigma, and provided valued interpersonal support and encouragement to remain in treatment. Psychotherapy was also congruent to the cultural value of desahogarse
(Jenkins & Cofresi, 1998
), providing a safe context where participants could unburden their problems and receive advice and support from a trusted individual. Lastly, participants talked about how they valued providers who were warm and respectful, showed genuine sympathy, and listened to them. These characteristics reflect key cultural norms, such as respeto
, and confianza
, that Hispanic cultures value in interpersonal relationships and can inform the tailoring of depression treatments to fit Hispanics’ cultural values and norms (Interian & Díaz-Martínez, 2007
This study has several limitations. Results may not be generalizable to other low-income Hispanics with diabetes and depression in the U. S. since participants were not randomly selected and came from an RCT study based at two large public community-based clinics in Los Angeles, California. As noted earlier, most of our participants were foreign-born Mexican females, thus results may not accurately portray the illness and treatment experiences of Hispanic males, U.S.-born Mexicans and other Hispanic subgroups. Future studies are needed to include more Hispanics males, an under-studied population, and examine variations among different Hispanic groups. In addition, the use of a clinical sample involved in diabetes and depression care may have overestimated knowledge about these conditions and its treatments. It may have also excluded individuals who somatisized their depression since they may have been missed by the depression screener (PHQ-9) used in the parent grant. However, the uniqueness of our sample and the combination of focus group and in-depth interviews enabled us to elicit rich contextual information rarely reported in the literature. The lack of a comparison group prevents us from concluding whether these findings are unique to low-income Hispanics or are generalizable to other ethnocultural groups. Lastly, given the exploratory nature of this study results should be used as hypotheses and tested in larger representative samples.
Implications and Conclusion
This study used an experience-near
approach that produced important insights about the cultural and social dynamics that shaped low-income Hispanics’ illness and treatment experiences with diabetes and depression. Findings revealed that somatic and anxiety-like symptoms, nervios
, and the accumulation of social stressors were central themes in low-income Hispanics’ explanatory models of depression. These findings suggest that clinicians elicitation and attention to individuals’ explanatory models in the assessment and treatment process can help identify key cultural (e.g. idioms of distress) and social (e.g., unemployment, caregiving burdens, poverty) factors that may impact diagnostic accuracy, patient-provider communication, treatment engagement, and quality of care. Moreover, depression treatments that ignore the social dimensions surrounding the experience of depression risk alienating Hispanic patients, resulting in premature termination of services or low adherence to care. The incorporation of case managers into evidence-based depression treatments can help address the social stressors faced by low-income individuals improving access, quality, and outcomes of care (e.g., Miranda, Azocar, Organista, Dwyer, & Areán, 2003
The perceived reciprocal relationships between diabetes and depression observed in this study highlight the multiple pathways by which these two illnesses impact each other. These findings support the integration of diabetes and depression treatments to improve clinical outcomes and quality of life (Katon, Von Korff, Lin, Simon, Ludman, Russo, et al., 2004
). Treatment experience findings emphasize the need to develop community-based psychoeducational approaches in Hispanic communities to dispel misconceptions about antidepressants, reduce stigma, and raise awareness about the benefits of depression treatments. These findings also suggest that structured medication management programs that actively address patients’ concerns and fears about medications, engage patients into treatment, and provide ongoing support and monitoring can reduce treatment drop-out and non-compliance among low-income Hispanics. Lastly, Hispanics’ preferences for psychotherapy seem to be linked to the saliency of social stressors in illness experiences, the cultural value of desahogarse
and the importance of interpersonal aspects of care. Given the high prevalence and detrimental outcomes associated with the co-occurrence of diabetes and depression, more studies are needed to examine how low-income Hispanics and other underserved communities conceptualize and cope with these illnesses in order to develop better patient-centered interventions aimed at reducing the morbidity and mortality associated with these disabling conditions.