Using data from a statewide population-based survey, we found significant heterogeneity within the Hispanic population in preferences for the most commonly offered depression treatment options in primary care.18
Spanish-speaking Hispanic respondents were less likely to indicate preferences for options that included antidepressants than English-speaking Hispanic and non-Hispanic white respondents. Additionally, a biomedical explanatory illness representation model of depression was a powerful predictor of preference for treatment options that included antidepressants in all interview language/ethnicity groups (along with age and a history of depression diagnosis), and mediated the effect of interview language on treatment preference among Spanish-speaking Hispanic respondents.
Language preference (Spanish versus English) is a subgroup-defining characteristic commonly used by researchers examining heterogeneity in and clinicians delivering care to the Hispanic population. Similarly, the focus of our study was not to investigate how language itself influences preferences for treatment options that include antidepressants. Rather, language preference may be viewed as a readily assessed marker for more complex, less easily defined and measured social characteristics that predict behavior.26
For example, some have argued that language preference is essentially a marker for access to health care,25
yet others have shown that differences in antidepressant use persist for Spanish-speaking Hispanic persons despite controlling for access.50
More often than as a marker for health care access, preferred language is viewed as a proxy for acculturation that subsumes other equally important Hispanic population characteristics such as race, socioeconomic status, nativity and generation. 14,22-24
To investigate these complex relationships, we examined possible mediators of attitudes toward antidepressant medication preference, adjusting for characteristics other than language/ethnicity associated with treatment preferences (history of depression diagnosis, current depression symptoms, age and gender). While a history of depression diagnosis (possibly due to treatment experience) and older age (possibly due to higher likelihood of depression diagnosis with increasing age) were associated with a preference for antidepressant-containing treatment options for all respondents, only a biomedical explanatory illness representation model of depression was found to mediate the effect of Spanish language interview on the lower preference for pharmacologic treatment options in Spanish-speaking Hispanic respondents. Furthermore, this illness representation model itself was found to be an important predictor of these preferences in all groups when accounting for other factors. Variations in depression illness representations between ethnic groups51
and within the Hispanic population52
have been previously demonstrated. Illness representations have been identified as important predictors of treatment in other medical conditions28,29
and, more specifically, have been postulated as an important mediator of depression treatment in Hispanics.53,54
Our study adds to the limited existing evidence for this connection between illness representation models and depression treatment preference.15,30,55
Antidepressants are the most commonly available depression treatment in primary care,7
in part due to provider attitudes56
and barriers limiting access to counseling services.8
Furthermore, the addition of antidepressants to counseling may be more effective in treating depression than counseling alone in selected patients.17
Therefore, among Spanish-speaking Hispanic patients presented with antidepressant inclusive treatment plans, resistance to such plans created by lower preference for antidepressants may represent one important barrier to initiating or adhering to effective depression care in the primary care setting. Though our findings may apply at the population level, the clinical implications should be assessed cautiously.
Stereotyping Spanish-speaking Hispanic patients as “reluctant” to consider antidepressants without addressing individual depression explanatory models (as our mediation findings highlight) or treatment preferences could worsen disparities in depression care by denying antidepressant treatments to individuals for whom it might be both welcome and effective. Clinicians should avoid making assumptions based on population-level data and consider age, past history of depression treatment, and each individual patient's depression explanatory model (significant predictors in this analysis) along with culturally-based treatment beliefs, as part of developing a therapeutic plan. Similarly, those involved in clinical resource planning should consider these factors along with population characteristics such as ethnicity when allocating treatment resources. Ameliorating antidepressant medication reluctance may be achieved through health education and provider communication interventions implemented in primary care offices.9,10
The role of cross-cultural education for both primary care practitioners57,58
and designers of mental health care delivery systems may be essential to such targeted efforts.
Our study has some limitations. Data were drawn from a cross-sectional survey, so causal pathways cannot be established. Although results were weighted for non-response and telephone availability, the findings may be biased by telephone access, self-selection of call back participation, recall bias, and the low response rate of the BRFSS. Despite being a population-based study, there were also only small numbers of respondents in each of the analytic subgroups of Hispanic respondents, which could have led to false negative results. Furthermore, as discussed, dimensions of cultural identity other than language among Hispanic persons that might influence treatment attitudes, such as length of residence in the U.S., nativity, and race, were either unavailable or measured insufficiently due to small sample size for inclusion in our analyses. These two inter-related limitations to the generalizability of the findings may be especially relevant to our results for depression stigma, which has been shown in previous studies of Hispanic individuals to have a robust association with depression treatment preferences.59,60
Additionally, our attitudinal measures were adaptations of previously developed scales. Finally, given the format of our depression treatment choices, options such as spirituality-based interventions which may be important in some populations61
could not be fully explored.
In conclusion, we found that Spanish-speaking Hispanic respondents participating in the California BRFSS were less likely to endorse treatment with antidepressants than English-speaking Hispanic and non-Hispanic white respondents, and that this difference may be due to differences in underlying depression explanatory illness representation models. Greater understanding of factors leading to barriers to depression treatment in the settings where that treatment most frequently occurs can help direct targeted interventions to overcome these barriers effectively. Such coordinated steps may lead to improving depression outcomes. Therefore, our study suggests that understanding the mechanisms of depression treatment barriers to improve depression care for the Hispanic patients would benefit from further, larger studies in this heterogeneous population.