Adherence Barriers to Antidepressants among an Urban Female Latino Population

Introduction

Lack of adherence to antidepressant medication has been well documented as a major difficulty in the successful treatment of Major Depressive Disorder. While this has been a challenge across patient populations, it has been especially pronounced among the U.S. Latino population, which shows a rate of non-adherence almost 40% higher than the rate seen in the U.S. Caucasian population. In some studies, the rate of non-adherence ranges between 31% and 44% among Latinos (Lanouette et al., 2009).

A number of studies have focused on identifying risk factors for the low rates of adherence, but few have gone beyond theoretical barriers to incorporate insights from patients and health care professionals about intervention strategies. The author of this article interviewed patients, care providers, and other health care staff about this topic at a community health center in Seattle, WA in summer 2011 in response to an inquiry made by the center to help increase adherence to antidepressant medication among the clinic’s Latino patients (who are mostly Mexican).

The objectives of this inquiry were to gain insight into the possible causes of decreased adherence to antidepressant medications among the urban Latino population in Seattle, WA, as well as to explore resource and intervention strategies to address those barriers.

Though the patient sample is small, all female, and primarily Mexican, insights and opinions shared in the interviews may be of value to providers in exploring possible themes as they relate to providing health care for individual patients who are Latino.

Methods

The author reviewed relevant articles, focusing on the link between non-adherence to antidepressant medications and the Latino community.  A comprehensive list of risk factors for non-adherence, as well as a list of protective factors for lowering rates of non-adherence were generated (Table 1).

The author, who speaks Spanish fluently, interviewed 12 female Latino patients (the majority were Mexican) who receive primary care at a community health clinic in Seattle, WA; and, a variety of health professionals, including three primary care physicians, one professor of psychiatry, two mental health specialists, two Latino patient advocates, and one medical interpreter.

Literature Review: Risk and Protective Factors

Considerable congruency exists in the literature among factors identified as risks for non-adherence as well as protections against non-adherence, to anti-depressant medications among Latino patient populations. The lists in Table 1 summarize risk and protective factors identified in at least two different studies. Most factors are consistent across a greater number of studies.

The existence of discrepancies in adherence rates among Latinos and non-Latinos and associated risk factors were documented in the literature, but there was little or no mention of intervention strategies considered for overcoming these struggles. In fact, it was noted in one study that “currently, there are no evidence-based interventions specifically to improve psychotropic medication adherence among Latinos.” Preferences towards types of treatment were noted in some cases, documenting that “Latinos were more likely than Euro-Americans to want counseling and less likely to want antidepressants” (Lanouette et al., 2009).

This preference for counseling and therapeutic alliance was expanded upon in a later study conducted by Dr. Alejandro Interian. Interian offers an intervention-centered study on using Motivational Interviewing (MI) to improve antidepressant adherence among Latino patients. The study focused on adapting MI techniques within focus groups, centering on values and treatment goals to allow patients greater ownership in overcoming ambivalence towards medication treatment. Interian’s study provided descriptions of patients’ concerns regarding taking antidepressant medication, as well as considerations for using MI within this patient population particularly (Interian et al., 2010).

Interview Findings: Common Barriers to Antidepressant Adherence 

Among the opinion gathered from providers and patients and in the review of the literature, three dominant themes were found. These themes are crucial to understanding the difficulties patients have with adhering to antidepressant treatment regimens. These dominant themes are:

• Patient’s fear of medication dependence
• Patient’s lack of knowledge about depression as an illness, unfamiliarity with treatment, and stigma
• Patient’s individual and cultural identity

Fear of medication dependence

Contributing Factors:

• Because many patients move frequently / have unstable living situations, it’s considered impractical to refill medications regularly, with increased concern about this for patients who fear addiction or are here illegally.
• Belief that antidepressants may be more addictive than other types of medications, even pain killers.

DISCUSSION: A fear of medication dependence was the most common response given by both medical professionals and patients when asked why Latino patients are reluctant to use antidepressant medication. In part, this fear was related to a general avoidance of medication, as outlined below, but also because of the limitations daily/regular use of medications might have on a person’s mobility of residence. Many of the patients interviewed move fairly frequently, often in search of more affordable housing options or as living situations change and better opportunities become available elsewhere. Access to medication is not guaranteed in the next living situation, so for many patients medications to be taken regularly and refilled continuously can appear unsustainable. For patients who are illegal immigrants, one of biggest barriers is the fear of deportation and that they won’t be able to continue taking medications if deported. Issues around instability and possible legal issues are significant.

Numerous patients and providers broadened the discussion of instability to include issues of employment status (with seasonal and temporary work commonplace), family situation and legal difficulties. While these may be separate issues, the sense of instability and reality of being prepared to pick up and move on with very little notice all contributed to the notion that use of daily medications would hinder a kind of necessary mobility. The consensus among patients was that it was better to learn to deal with the discomfort of the depression itself and manage the symptoms by more accessible means, even if unpleasant.

For many patients interviewed, the possibility of addiction was the only justification needed to avoid antidepressant medication. While it was difficult for this author to explore this opposition to addiction within the interviews, there appeared to be enough of a negative connotation within the cultural understanding expressed to warrant such a fear of dependence. There was also a generally accepted belief that psychiatric medications, rather than other types of medications or pain killers, were more easily addictive because of their ability to “make you happy.” The prospect of becoming addicted to a medication that acted on and affected your mind was particularly unappealing. Providers should explore patients’ health beliefs. Be aware that in the home country, patients may have heard about someone’s addiction to certain medications, such as Valium. This can significantly influence resistance to antidepressants. 

Lack of knowledge about depression as an illness, unfamiliarity with treatment, and stigma 

Contributing Factors:

• Lack of knowledge that depression is an illness
• Lack of familiarity with Western medicine
• Stigma associated with depression and fear of being labeled “loco” or crazy
• Fear of others discovering that the patient is taking medication for depression and being labeled “crazy”
• Avoidance of medication in general and unfamiliarity with concept of taking medication long-term and consistently for a chronic illness and when symptoms abate
• Fear of or experience with side effects:
  • Reports from family or friends about bad side effects from antidepressants may deter patient from even trying medication for depression.
  • Increased risk of non-adherence if patient does not report to provider that he/she is taking medications sporadically. Unaware, the provider may increase dose resulting in side effects that may perpetuate non-adherence.
• Lack of knowledge about the process of dosing antidepressants to find right level or trying different types of antidepressants to find right one, which may undermine the patient’s confidence/trust in provider. Even when the process of finding the right medication is understood by the patient, some patients find the struggles (stigma and fear of side effects) too daunting to try a course of antidepressants.

DISCUSSION: A significant barrier was patients’ lack of familiarity with Western medicine and with the preferred combination of medication plus therapy that is the standard of care utilized in the treatment of depression. Much of this was rooted in the lack of familiarity with depression as an illness itself. Less than a third of the patients interviewed identified depression as an illness or something affecting your brain, while the majority utilized terms such as “estado de ànimo,” roughly meaning mood, or state of mind. Patients would thoroughly describe periods of being depressed and what it was like, while focusing on the physical manifestations. Health care professionals conveyed that this was most likely rooted in the near absence of depression treatment among basic medical care in Latin America. Providers interviewed who themselves were of Mexican descent reasoned that the absence of depression treatment in Mexican health care was not due to the non-existence of the illness, but to lack of its diagnosis. The little it is recognized, it is in extreme cases most often leading to further psychiatric illnesses, and therefore is correlated with psychosis, polarizing all depressive mental illness as an extreme category of sickness. This is clear in patient accounts, as some respond to diagnoses of depression with clear insistence that “No soy loco.” or “I am not crazy!”

Even when the stigma of the illness itself is overcome, most often by informative conversations and education, a second barrier to treatment becomes evident. That is the stigma related to taking the medications, and the patient’s fear of others knowing about it and assuming that he/she is crazy. The fear is that the greater Latino community and the patient’s own family will not understand and accept the use of medications. This often leads a patient to look for alternative treatment strategies, even when provider recommendations significantly encourage use of anti-depressant medication. In some cases, patients accept prescriptions for medications at the time of their medical visits with a doctor, but do not feel comfortable or intend to fill them. This breakdown in communication may stem from the patient’s sense that the provider did not fully understand the overwhelming reality of the stigma, rather than from a denial on the part of the patient that the medications might help. A number of patients interviewed said they have no aversion to taking medications themselves, just that they did not need them badly enough to endure the struggles associated with taking them (often a combination of expected side effects and stigma).

The very idea of taking medicine continuously, even after symptoms disappear, is foreign to and/or rejected by many Latino patients. One patient advocate suggested providers compare the need to take pills daily to something more culturally-accepted, such as prenatal vitamins, in order to put it in a context that is more easily understood by the patient. Patient advocates also noted differences between what providers and patients may understand is meant by “to take medications regularly.” For example, a patient may be asked if she’s been taking her antidepressant medication regularly.  The patient responds “yes” but later reveals that this, in fact, meant she takes them whenever she feels she needs them. These types of misunderstandings might even be compounded if the doctor, given the patient’s feedback, then tweaks medications which then cause more side effects and perpetuate lower adherence due to treatment discomfort.

A lack of understanding of the process of dosing antidepressants and determining the right medication for an individual was identified as a struggle for patients.  There is an expectation among patients that physicians should know answers and what medications to prescribe. Experience of adverse side effects, or medications that in fact worsened symptoms, led patients to reject medication as a treatment strategy altogether rather than to consider that a different medication or tweaking of dosage might be necessary. In some cases, stories from family members or neighbors about bad side effects were enough to deter many from even trying medication for depression as a treatment option. There is lack of awareness of the variety of antidepressants, and that effective regimens are determined on an individual basis possibly requiring multiple doctor visits and tweaking regimens to find what works best for a particular patient. Even when the full process of treatment and medication monitoring was explained and understood by the patient, it was often greeted by feelings of overwhelming complication, and a preference to avoid using medication despite recognition of long-term advantages.

Patient’s individual and cultural identity

Contributing Factors:

• Desire for autonomy in dealing with struggles and not wanting to rely on external support.
• Preference among Mexican patients for natural remedies and help from “curandero” or folk healer because they are part of cultural identity and practice.

DISCUSSION: The value of individual identity and autonomy in dealing with one’s own life struggles was a theme that appeared repeatedly in a number of interviews with Latino patients and providers. For some patients, this was tied to their Catholic faith as a calling to carry one’s own cross, meaning to bear the challenges each individual is presented in life, with dignity and self-responsibility. There was a sense expressed by patients of not wanting to be reliant on external support to deal with life’s surprises or to metaphorically hang your sheets out to dry in front of the entire community. For many patients, family members’ opinions about depression and mental illness play a role in dealing with treatment. If family members in home countries hold certain beliefs about depression, it is difficult for patients to escape those notions and be open to more American explanations of mental illness and the effectiveness of medications in treatment. Even further, for Mexican patients coming from more rural backgrounds, where the “curandero” or folk healer has been the primary support person for the family regarding physical ailments, natural remedies are highly preferred to any sort of Westernized medical strategies.

A Mexican American reviewer of this article stated that in her experience curanderos are usually consulted about somatic complaints versus behavioral health issues. In her experience, for behavioral health, people from Mexico will consult with a “brujo” or “bruja” (witch) who acts as a faith healer.

Understanding these facets of cultural norms as influencing a patient’s struggles with adherence proved important for primary care providers in their work of finding the treatment option with which patients would be comfortable and adhere. While improving adherence itself is an important goal, providers reportedly also gained from recognizing certain cultural realities that may not be changeable. There was recognition of the need to adjust approaches early on to find a treatment strategy that would be more embraced by the patient, or to improve a therapeutic alliance that would increase openness to medication recommendations.

The provider should ask if the patient uses natural healers. If the patient does, tell the patient it would be good to include the healer in the care team so that each provider is respectful of each others’ approach.

Intervention Strategies

In the analysis of patient feedback and with the insight of medical professionals in the field, some important themes regarding intervention strategies surfaced.

1. Relationship Focus: Build rapport, define roles of care team

A predominant theme articulated by both patients and providers who were interviewed was the importance of relationship to elicit patient involvement and follow-up care. The majority of female patients working with combinations of social workers, doctors, and other therapists expressed preferences for their interactions with the social workers. The number one reason for this was a sense of “confianza” – trust. Once a rapport was built up and a relationship established, patients were more forthcoming about their struggles with depression and with the recommended treatment.  If they were not comfortable with the person with whom they were speaking, patients were very hesitant to speak about an already stigmatized issue such as depression.

Patient advocates explained the centrality of building relationships within Latino culture, and that patients are much more likely to follow recommended treatments when they believe they have a personal relationship with the provider.  While time to build those relationships is not always available with primary care providers in many community health centers, having a case manager or social worker directly managing care for patients proved very valuable and a significant protective factor for adherence, especially among female patients.

While providing a context where relationships can be nurtured, accurate explanation about the roles of various providers was important in helping patients continue their involvement in the treatment plan. Patients and providers alike articulated a lack of familiarity among less acculturated patients with the various players in a Western medical setting. Patients did not always know the different responsibilities and roles of the doctor, nurse, medical assistant, social worker, psychiatrist, and counselor. In one example, a doctor asked a female Latino patient if she would like to meet with the social worker, and the patient said no. The interpreter later asked why not, and the patient said she didn’t even know what a social worker does. When the role was explained and it was made clear to the patient what types of services social workers offered, the patient was eager for the meeting. This type of barrier was very common, where a lack of familiarity and understanding of the available services and the various types of care directly interfered with efforts to increase treatment adherence and success.  Patients and patient advocates alike suggested that brief explanations of the roles of the medical professionals with whom they would interact allowed them to better understand the medical system and to whom they could go for help with different struggles.

2. Behavior therapy

As suggested in the literature review and confirmed by individual interviews, the preference of female Latino patients for counseling instead of medication was significant. There appeared to be a desire among these patients for advice and behavior-focused therapy within the counseling model.  Patients articulated that counseling and conversations with social workers were most helpful when they included specific action steps or behavior recommendations.

Patients often implemented breathing strategies, recommendations for exercise or getting out of the house, and even participated in support groups or group activities at the clinic, when these activities were presented as viable strategies to improve depression. Often, the support group experience led patients to further discoveries of helpful personal steps to improve their condition, beyond the group session itself. Similar to motivational interviewing techniques that successfully empower patients to consider what changes and actions could be effective for them, offering patients some concrete ideas that have worked for others was a way to begin that process as well.  It was found in both the literature and interviews that individual community health centers had their own strategies that were practiced and emphasized. The overarching approach that was successful with patients involved a post-listening response that included behavioral action steps.

In the interviews, the few negative accounts of a counseling intervention were all related to patients’ feelings that the sessions were not doing anything. They felt the therapist would just sit there and listen and not offer any advice, and the continual reliving and recounting of the depression only seemed to have them dwell on it longer. Many patients stopped attending sessions such as these, believing they were not in fact getting anything out of the experiences.  One patient advocate used the predominance of the Catholic faith among Latinos to put this into context. She explained how the tradition of confession with the penance given by the priest is a form of action taken to overcome the negative feelings of guilt. Similarly, she noted, patients look to physicians and other medical professionals for solutions and concrete actions that can be taken to overcome the negative feelings of depression.

3. Culturally informed providers

The interviews highlighted the importance of patients having providers with cross-cultural awareness who were knowledgeable about the cultural stigmas present around depression and its treatment with medication.  

Recommendations for Providers

• Patients do not always know the different responsibilities and roles of the doctor, nurse, medical assistant, social worker, psychiatrist, and counselor.  Provide brief explanations of the roles of various members of the patient’s care team.
• The PCP should introduce the social worker or therapist in person if at all possible. Connections to other members of the health care team that are made before the patient leaves the clinic appointment with his/her PCP prove much more likely to continue compared to ones that begin on the phone or in a scheduled initial meeting without prior contact. This emphasizes the relationship basis of care that is most successful in leading to treatment adherence, as explained above. Within these relationships, the recognition of the weight that mental illness carries for the patient is conveyed, and the difficulty of the situation is acknowledged in an empathetic, compassionate way. If possible, have a case manager or social worker directly manage the care for patients. This will help build relationships and trust and result in patients following the recommended treatment.
• PCP’s should explain what depression is.
• Social workers or mental health professionals should follow up by ensuring that the patient understands what depression is.
• Explore patients’ health beliefs. Be aware that in the home country, patients may have heard about someone’s addiction to certain medications, such as Valium. This can significantly influence resistance to antidepressants.
• For patients who are illegal immigrants, one of biggest barriers is the fear of deportation and concern that they won’t be able to continue taking medications if deported. Issues around instability and possible legal issues are significant.
• The provider should ask if the patient uses natural healers. If the patient does, tell the patient it would be good to include the healer in the care team so that each provider is respectful of each others’ approach.
• Clarify how and when to take medicines. Establish common understanding of what it means to be taking medicine regularly. Address treatment options with an understanding that medications are often avoided more adamantly within this population, and therefore introduce medication use in a sensitive way as a part of a larger treatment plan. According to interviews, taking this approach is most well-received by patients.
• Explain that effective medication regimens are determined on an individual basis, possibly requiring multiple doctor visits and that adjusting dosage or trying other medications may be necessary to find what works best for a particular patient. Encourage patient to not be discouraged.
• Explain to patients that the treatment most successful is the combination of both counseling and antidepressant medication. This allows patients to consider what is most successful for others in their own decision-making process. When patients feel comfortable beginning the medications in the first place, fewer struggles are noted later on and the positive effects and usefulness of the medications overshadow initial concerns or hesitance.

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