Depression in a Latino Man in New York

Luis meets criteria for major depressive disorder with anxious distress of mild to moderate severity. His personal and family history may be sources of temperamental and genetic vulnerability without reaching personality disorder levels. Environmental risk factors include adverse early experiences (his father’s heavy drinking, the abrupt decision to emigrate).

The case includes several clinical features frequently seen in depressed Latino patients. Somatization (or somatoform manifestations, grouped under somatic symptom disorder in DSM-5), is a complex phenomenon sometimes reported as the presenting complaint (1, 2). In Luis’s case, headaches and chest pain were the main manifestations. Somatization may play a minimizing, defensive role against eventual negative reactions to threatening symptoms.

Stigma about mental illness and psychiatric diagnoses in general is a powerful sociocultural feature among Latinos, particularly those of low socioeconomic status (3). Patients experience it as guilt and shame, leading to social isolation, self-criticism, and low self-esteem. Acquaintances, coworkers, peers, and relatives may express overt condemnation, demeaning names, coldness, or cruel and intense bullying (4). The effect of stigma was intensified in Luis’s case by a hostile acculturation process and a fragile, vulnerable temperament. Notably, Luis was bullied by other Latinos, perhaps driven by actual or perceived differences between first- and second-generation immigrants and fueled by the bullies’ own self-hatred (5, 6). Acculturation syndrome (now called acculturation difficulty, included among “other conditions that may be a focus of clinical attention”) entails anxiety and reiterated self-commiseration as prominent clinical manifestations (7). In Luis’s case, it was complicated by the ambiguous meaning of his father’s message to “date a gringa” and Luis’s implicit criticism of U.S. social formalities (i.e., nonacceptance of demonstrations of affection among males).

The role and impact of traditional healers in Latino populations are well known (8). To their position of authority in highly hierarchical social groups, they add an aura of wisdom and charisma with associated “special powers” (communication with deities, use of strange languages, exotic rituals, and so on), which is enhanced by the religious fervor of people like Luis’s mother. Coexistence of traditional beliefs and adherence to mainstream religions such as Catholicism is the rule. The patient frequently found himself conflicted by his mother’s gospel-inspired convictions and his own rational analyses.

Patient-identified explanatory models or “causal attributions” represent a critical component of the cultural assessment of any case (9); they uncover cultural beliefs, full of symbolic meanings, transmitted through generations, with highly persuasive impact. In Latino and Latin American culture, these are rich and complex: clinicians would do well to inquire about them systematically and consider them in open discussions with the patient (10). Luis’s clinicians showed little understanding and did not attempt to “harmonize” the patient’s thoughts with scientifically valid views about the symptoms and their psychotherapeutic management. In some cases, these explanatory models are “idioms of distress,” that is, “ways of talking about suffering” among individuals of a cultural group, such as “nervios” (mental distress) among Latinos (11). They convey a wide range of discomfort, and discussing them may have an alleviating effect, a therapeutic objective in itself.

Finally, the biological aspects of diagnosis may have ethnic roots, as does the prediction of response to medications, as documented by pharmacogenomic profiles. Among Latinos, the predominant presence of a slow-metabolizer CYP-450 genotype (12) may explain Luis’s early side effects and his better response to a reduced dosage of the tricyclic antidepressant.

The Cultural Formulation Interview in DSM-5 systematizes cultural information relevant to diagnosis, treatment, prognosis, and prevention (13). It may be particularly useful when the patient’s and clinician’s ethnic and cultural backgrounds differ or when there is uncertainty about the meaning of culturally distinctive manifestations such as pain, symptom reporting, family atmosphere, religious factors, and so on. It is designed to define problems in cultural terms, explore self-coping and help-seeking patterns, and ultimately “enhance the cultural validity of diagnostic assessment, facilitate treatment planning, and promote the individual’s engagement and satisfaction” (DSM-5, p. 751). In Luis’s case, its use might have assisted the psychiatrist in obtaining a better understanding of the family and social environment (including notions of friendship, gender relationships, language, differences between first- and second-generation immigrants, and so on), making distinctions in the depression-anxiety equation, and rationally weighing the patient’s explanatory models and the healer’s interventions. There is little doubt that another powerful cultural feature, personal identity (14), was retrieved in the process of the group meetings and that its reaffirmation may have had a markedly positive impact on Luis’s improvement.