Less likely to recognize depression Less likely to seek treatment More likely to delay treatment...

Adolescent Hispanics and Depression

Jennie Fernandez BeltzUniversity of North Florida

Hispanics and Mental Health

Less likely to recognize depression Less likely to seek treatment More likely to delay treatment until severe More likely to somatize psych. distress Express it with cultural idioms (ataque de

nervios) Less likely to seek help from MH specialist Greater reliance on primary care doctor or

informal sources (i.e. church, family) Underrepresented in MH programs Greater levels of unmet needs

Perceived Barriers Cultural differences Language issues Poverty status Health insurance status Transportation Lengthy waiting times Stigma attached to services Concerns about deportation Lack of knowledge Acculturation levels Discrimination Low support, lost of family & friends Fear of children being taken away

Adolescents and depression

Hispanic adolescents have higher levels of depression (34%)

Hispanic females greater rate than Hispanic males

Hispanic adolescents are significantly more likely to attempt suicide

Less likely to recognize symptoms Highly underdiagnosed Highly undertreated

Factors to consider Negative views of therapy Counseling preferred over

antidepressants View antidepressants as addictive, and

causing “druggedness” Fatalistic views, belief in external control

may lead to impaired coping

Risk Factors Fewer skills in reading, writing, math, and

science Higher grade retention rates

› mostly in kindergarten and first grade Lower graduation rates from H.S.

› Only over half of Hispanics (53.2%) graduate Lower self-concept Hispanic Females more negative feelings

about their bodies Gender role discrepancy between parents and

children Family dysfunction mediates the effect

Prevention or early detection of depression

Crucial since delayed or non-treatment can lead to school delinquency, school under-achievement, substance abuse, criminal behavior, mental health problems and unemployment

Having depression early in life substantially increases likelihood of episodes later in life

Prevention of suicide attempts and completed suicides

Treatment implications Active treatment preferred over medication Family based treatment

› Family support big mitigating factor› Cultural dissonance with parents› Gender-related family discord

Community based treatment› Attitudes about depression› Targeting and learning about cultural beliefs› More availability of bilingual and/or trusted

clinicians› Engaging the community in research

Treatment implications Interpersonal psychotherapy-Adolescent skills training

(IPT-AST) › addresses interpersonal deficits and conflicts, which

increases risk of depression› Promotes skilled communication and positive relationships,

which protects against the development of depression› This therapy has been shown to be effective with Hispanic

adolescences› Since focus is on relationships this may resonate with

Hispanic value of placing family before individual

Cognitive Behavioral Therapy (CBT)› Most widely used and studied therapy for treatment of

depression in adolescents› Has been shown to be effective with depressed Hispanic

adolescents

Case Study: MariaMaria, a 15-year-old Latina, exhibited MDD that appeared to be precipitated by conflict with her mother. She attended a culturally diverse high school in an urban area and lived with her mother and two siblings in a crowded two bedroom apartment.

Her mother had completed 2 years of high school and was working full-time cleaning offices. Maria was the first in her family to be born in the U.S. She had two older sisters who no longer lived in the home and two younger siblings whom she was regularly required to babysit. Maria had minimal contact with her father who lived in the Dominican Republic.

Maria's mother described Maria as oppositional and disrespectful. According to Maria's mother, upon returning from school each day, Maria would lie on her bed and refuse to do chores. Maria's mother frequently compared Maria to her older siblings, with whom the mother seemed to have had little difficulty. Maria stated that she could not tolerate her mother's level of intrusiveness, frequent criticism, and expectations of her. Maria gave examples of what she thought her mother considered to be her bad behavior: that she wanted to go to parties on the weekend, spend time with friends, had a boyfriend (whom the mother would not allow her to see), and did not spend her time after school and on weekends doing chores at home. Maria complained that her mother thought it was appropriate to visit only family members on the weekends. Clearly, Maria and her mother had different cognitions related to appropriate adolescent behavior, and in the judgment of the therapist, these were influencing Maria's depression.

Case Study: Maria

Consistent with a general CBT approach, the initial treatment focused on helping Maria increase her level of activity. It soon became apparent, however, that Maria had no motivation to "do anything" since, as she reported, there was "nothing" her mother would allow her to do, an illustration of black-and-white thinking. Maria stated that she felt she was not allowed to do anything that her friends at school could do, but instead that she was expected to come home after school and take care of and cook dinner for her younger siblings.

 As these thoughts were discussed, Maria appeared uncomfortable with the therapist. In an effort to allay Maria's discomfort, issues of cultural and ethnic identity were addressed. Maria discussed with the therapist how she felt that she could not "talk bad" about her mother. She discussed how she thought she would be reprimanded if her mother found out that Maria was expressing negative feelings about her family. The therapist helped Maria with this issue and explained to her how it was important for Maria's treatment and recovery that she eventually be able to talk with her mother about what was upsetting her. The therapist helped Maria by role-playing various scenarios that involved requesting permission from her mother to spend time with friends.

 In parent sessions, the therapist discussed with the mother the changes that occur during an adolescent's development and helped her to understand the cultural differences between the mother's culture of origin and the culture of the United States. The therapist discussed how some of Maria and her mother's conflict could be due to acculturation issues related to different expectations for parents and adolescent children.

Case Study: MariaIt was difficult for Maria's mother to accept that Maria was more interested in spending time with her friends than with her family, and she interpreted this as a lack of respect for the family. Sessions with the mother and Maria helped Maria to communicate to her mother the way she thought about spending time with friends. This helped the mother understand that Maria's needs and desires did not reflect a lack of love for the family, thus addressing a key cognition in the conflict between them. The therapist helped the mother to communicate with Maria about her own adolescence in the Dominican Republic and how expectations were different there than in the United States.

 The therapist discussed with Maria and her mother issues related to their levels of acculturation, and discussed Maria's unique status as the first of the family's children to be born and raised in the U.S. Through these discussions of cultural issues, it became apparent that Maria's feelings of being caught between two different cultures were exacerbating her feelings of depression. As a result, her mother was increasingly able to understand how difficult it was for Maria to babysit each afternoon, cook dinner, and do chores on the weekend. Although Maria's mother would not grant Maria the same allowances as her friends, Maria was able to earn some privileges, and Maria and her mother were able to work out strategies that secured Maria more time for herself during the week. Although Maria still had to care for her younger siblings (the mother worked, and the family could not afford day care), they were able to arrange for a neighbor to care for her siblings one day a week. Maria was thus allowed to spend more time with her friends after school and some time on the weekend. This quickly resulted in an overall increase in her level of activity, decrease in feelings of hopelessness, and improvement in depressive symptoms.

Conclusion Significant variability within cultural groups Don’t make assumptions about shared

experiences Be sensitive to cultural differences Most treatment doesn’t address ethnicity

unless clearly part of problem Ask each person about their cultural narrative

and perspective Clarify cultural beliefs and practices Include appropriate family members Alter intervention when needed to fit an ethnic

minority

Sue’s model of multicultural counseling competencies

Awareness about their own personal assumptions

Investigating the worldview of the culturally diverse client

Practice appropriate, culturally sensitive techniques and strategies

Hispanic adolescents in Jacksonville area

Duval county:

Clay county:

St. Johns county:

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