APA Expert Opinion

Andres J. Pumariega, M.D. is the Chair, APA Committee on Hispanic Psychiatrists Chair, Department of Psychiatry, The Reading Hospital and Medical Center
Professor of Psychiatry, Temple University School of Medicine, discusses stigma of mental illness in the Hispanic/Latino Community.

Stigma of mental illness is a fairly common experience amongst Americans of all different racial/ ethnic backgrounds. Is stigma more common amongst Latinos/ Hispanics?
Yes, stigma affects Latinos/ Hispanics as much or perhaps more than other ethnic/ racial groups. It is seen primarily in poor and less educated Latinos, and more frequently in immigrants or older and less acculturated, more traditional Latinos. In younger and more acculturated Latinos, stigma is lessened as there is more familiarity with the concepts of mental illness and emotional disturbances and the use of mental health professionals and services for evaluation and treatment.   

What are the unique cultural beliefs and factors involved in the development of stigma for Latinos/ Hispanics? 
More culturally traditional Latinos often understand mental illness from religious, spiritual, and supernatural perspectives. Such perspectives suggest that mental disturbance results from spiritual crises or conflicts where the individual is at fault of some transgression (or sin) against God, or against family members or loved ones (such as lack of consideration or faithfulness). This may involve having had spells or “the evil eye” (covetous interest by someone) placed on the affected individual, either incidentally (by possession by “evil spirits”) or through having someone consult with a traditional healer to place spells or “hexes” on them. There is much shame in families about having a mentally ill relative, and in some communities it may involve problems for the eligibility for marriage of female relatives for fear of genetic inheritance. Some mental illness (such as depression) can be seen as a sign of personal weakness, particularly in Latino men, with their being the very last to access any mental health services (for example, in one recent study, 54 percent of Latino men with depression did not even acknowledge the illness). 
Some of the stigma faced by Latinos is around the perception of all mental health problems as being serious (“loco” or crazy), and involving long-term confinement in central hospitals with high medication doses and Electro Convulsive Therapy. Some of this comes from the experiences of Latino immigrants in their nations of origin, where the mental health systems can be more akin to those seen in the United States in the 1950’s and 1960’s. There is also double discrimination that Latinos/ Hispanics face if identified with a mental illness or emotional disturbances, already feeling discriminated by being Latino/ Hispanic or being an immigrant. This is especially given the adverse climate created by the recent national debates around immigration.

How does stigma affect help-seeking patterns for mental health needs amongst Latinos/ Hispanics? 
Latinos are loathe to use mental health professionals and formal mental health services as a result of their experiences with stigma. They associate going to a mental health professional, especially to a psychiatrist, as suggestive that they are indeed crazy or too far gone. They prefer to seek services through primary care physicians, traditional healers (curanderos, espiritistas, or santeros), through the local neighborhood wise lady (comadre), or to the priest or minister. Though many of these alternative providers can at times recognize significant mental need and make referrals to mental health professionals, some do not readily identify mental illness or make timely referrals, with the affected individual and family often losing valuable time and experiencing undue suffering. They might also prescribe alternatives (such as benzodiazepines by primary care physicians, or herbal remedies by healers) that at best are not effective, or at worst can mask symptoms or aggravate them. Some Latinos turn to drugs or alcohol in an effort to ameliorate the symptoms of depression or anxiety, then adding another very serious disorder in addition to their primary illness.    

How does stigma contribute to problems in diagnosis and treatment of psychiatric disorders, as well as mental health disparities, amongst Latinos/ Hispanics?
Stigma interferes with timely access to services by people affected by mental illness and emotional disturbances, and this is even more the case with Latinos/ Hispanics. I have witnessed too often many Latino adults and youth come in for evaluation and treatment very late in the course of their illness, almost at death’s door, or at the point they are absolutely unable to function. This includes not seeking services until after severe life-threatening suicide attempts, or after they have suffered psychotic symptoms for months, requiring extremely high doses of medications and many weeks to months to re-compensate. Stigma can also serve to keep Latino patients from being as open about their symptoms and problems as needed to make an accurate diagnosis, with some critical symptoms (such as suicidality) often not revealed due to cultural shame or taboos

Stigma adds to other barriers that Latinos face, such as the lack of insurance coverage, lack of other financial resources to allow for time and transport to access services, lack of interpreter support and bilingual professionals, and lack of culturally competent mental health services that are responsive to the needs of Latinos/ Hispanics. Stigma in the Latino community and individuals, interacting with these other barriers, contributes to increasing mental health disparities we see amongst Latinos, such as rising rates of untreated depression and anxiety disorders, rising suicidality and substance abuse in Latino youth, and rising rates of psychiatric emergency room visits by Latinos.    

How does one best address cultural beliefs associated with stigma in Latino/ Hispanic patients and their families?
Stigma is best addressed by both eliciting and respecting the traditional beliefs that a person might espouse about their mental illness or emotional disturbance, and also working to bridge such beliefs with Western medical understanding. Coming with total opposition to or invalidation of traditional beliefs often causes the individual to reject medical approaches. Some individuals might accept and respond best to the combined use of a traditional healer and a mental health professional, so that spiritual, psychological, and biological needs can all be effectively met. In doing so, it is important that traditional and Western approaches be coordinated so that they do not contradict with each other, both in terms of prescriptions or recommendations made and even in terms of interactions between medication and herbals. Education of family members, especially of family elders (such as grandparents or older aunts/ uncles) can also help greatly to reduce stigma and promote support for treatment adherence. Addressing stigma with family members is critical in improving chances for treatment adherence. Latinos/ Hispanics make their treatment decisions in the context of their families, and family support or disapproval of treatment makes the difference between successful and unsuccessful treatment outcomes.     

What approaches, sources of information and support that Latinos facing mental illness and emotional disturbances (or family members) can use in addressing stigma in family members, friends, or loved ones? 
Latinos/ Hispanics facing mental illness and emotional disturbance have limited resources. This very website (www.healthyminds.org) has excellent educational material translated to Spanish, and some even oriented specifically to Latinos/ Hispanics. The National Alliance for the Mentally Ill (NAMI) has a very active Multicultural Program that provides educational materials and support for accessing and developing support groups for Latino families and consumers.    
Unfortunately, the Latino/ Hispanic media has contributed to the exacerbation of the stigma of mental illness and emotional disturbance. The Latino/ Hispanic media has focused much of their programming on sensational mass entertainment, with programs often portraying stereotyped images of people with mental illness as dysfunctional rather than as full human beings with challenges. Some Spanish language television and radio programs are thankfully beginning to take an educational approach to the subject of mental health and mental illness, with a more progressive and educational approach to addressing the topic in the Latino community.  Such programs are invaluable in addressing perceptions and knowledge amongst Latinos/ Hispanics and facilitating earlier access to services and improved outcomes.     

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