Azúcar y nervios: Explanatory models and treatment experiences of Hispanics with diabetes and depression

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Abstract

This study examined the explanatory models of depression, perceived relationships between diabetes and depression, and depression treatment experiences of low-income, Spanish-speaking, Hispanics with diabetes and depression. A purposive sample (n = 19) was selected from participants enrolled in a randomized controlled trial conducted in Los Angeles, California (United States) testing the effectiveness of a health services quality improvement intervention. Four focus groups followed by 10 in-depth semi-structured qualitative interviews were conducted. Data were analyzed using the methodology of coding, consensus, co-occurrence, and comparison, an analytical strategy rooted in grounded theory. Depression was perceived as a serious condition linked to the accumulation of social stressors. Somatic and anxiety-like symptoms and the cultural idiom of nervios were central themes in low-income Hispanics' explanatory models of depression. The perceived reciprocal relationships between diabetes and depression highlighted the multiple pathways by which these two illnesses impact each other and support the integration of diabetes and depression treatments. Concerns about depression treatments included fears about the addictive and harmful properties of antidepressants, worries about taking too many pills, and the stigma attached to taking psychotropic medications. This study provides important insights about the cultural and social dynamics that shape low-income Hispanics' illness and treatment experiences and support the use of patient-centered approaches to reduce the morbidity and mortality associated with diabetes and depression.

Introduction

The co-occurrence of diabetes and depression disproportionately affects low-income Hispanics served in primary care. Diabetes is the fifth leading cause of death among Hispanics and is twice as prevalent in this population as in non-Hispanic Whites (Center for Disease Control and Prevention, 2004). It is estimated that depression affects 10–30% of individuals with diabetes and is associated with adverse diabetes outcomes leading to reduced functioning and quality of life (Ciechanowski et al., 2000, Musselman et al., 2003). The comorbidity of diabetes and depression is estimated to be around 25% in the elderly Mexican American population (Black, Ray, & Markides, 1999) and as high as 33% in Hispanic primary care samples (Gross et al., 2005). Hispanics are also at higher risk than non-Hispanic Whites of developing diabetes-related complications, such as heart disease, blindness, kidney disease, and of receiving lower quality of care for their diabetes and depression (Institute of Medicine, 2003, Lanting et al., 2005). Compared to non-Hispanic Whites, Hispanics are less likely to receive guideline congruent depression care even after controlling for clinical and economic factors (United States Department of Health and Human Services [USDHHS], 2001), more likely to be served by physicians who fail to detect a mental health problem when one exists (Borowsky et al., 2000) and at higher risk to discontinue antidepressant use during the first 30 days of treatment (Olfson, Marcus, Tedeschi, & Wan, 2006). As a result of these disparities in health and mental health care, Hispanics with diabetes and depression experience a disproportionate burden of disability associated with these conditions (Lanting et al., 2005, United States Department of Health and Human Services, 2001).

Despite the high prevalence and disparities associated with diabetes and depression in the Hispanic community, little is known about the illness experiences of low-income Hispanics with these conditions. An experience-near (López & Guarnaccia, 2000) approach that relies on qualitative methods to examine the social and cultural context surrounding illness experiences from the individual's point of view can help address this lacuna in knowledge and elucidate how Hispanics make sense and attach meaning to these complex symptoms, experience treatments, and cope with these chronic illnesses. This study used a combination of focus group and in-depth qualitative interviews among Hispanics with diabetes and depression to examine explanatory models of depression, perceived relationships between diabetes and depression, and experiences with depression treatments.

Previous studies consistently find that Hispanics tend to perceive depression as a mental health problem caused by social stressors rather than biological or genetic factors (e.g., Cabassa et al., 2007, Givens et al., 2007, Heilemann et al., 2004). Pincay and Guarnaccia (2007) reported that among different Hispanic groups (e.g., Puerto Ricans, Dominicans, Mexicans, Cubans), depression was equated to social isolation and the consequence of multiple stressors and losses, such as death of a loved one, loss of employment, financial crises, traumatic experiences, and physical illnesses. Similarly, Cabassa et al. (2007) and Heilemann et al. (2004) found that low-income Hispanics, mostly of Mexican origin, attributed depression to interpersonal problems (e.g., divorce, domestic violence), lack of social support, and other external stressors. These conceptualizations of depression differ markedly from contemporary biopsychiatric models of depression and highlight how social and cultural dimensions of illness are essential in shaping Hispanics' explanatory models of depression. The explanatory models individuals hold about depression and its treatments influence their help-seeking behaviors (Kleinman, 1988) and, along with structural and economic barriers, may help explain some of the disparities that Hispanics face in the entry, retention, and treatment of depression (Lewis-Fernandez, Das, Alfonso, Weissman, & Olfson, 2005).

A salient limitation of the existing literature is that few studies have examined Hispanics' explanatory models of depression in the context of other comorbid conditions, such as diabetes. In one of the few studies exploring how Hispanic adults with type 2 diabetes viewed depression, Cherrington, Ayala, Sleath, and Corbie-Smith (2006) reported that depression and diabetes were closely linked to the illness experiences of these individuals. For some, the diagnosis of diabetes evoked strong emotional reactions leading to anger and hopelessness, while difficulties in diabetes management led to anxiety and depression. The reciprocal link between diabetes and depression was also associated with the presence of social stressors and the availability or lack of family support. Previous studies among Latinos with diabetes have described a connection between strong emotions and diabetes through the folk illness of susto (e.g., Poss & Jezewski, 2002). This culturally bound syndrome, translated literally as fright or soul loss, is mostly seen in some U.S. Latino groups and individuals from Mexico, Central and South America (American Psychiatric Association [APA], 2000). Susto is commonly attributed to a frightening event that causes the soul to leave the body resulting in bodily changes, somatic symptoms, vulnerability to physical and mental illnesses, and in extreme cases death (American Psychiatric Association, 2000, Poss and Jezewski, 2002, Weller et al., 2002). Susto may be one of the culturally mediated processes by which Hispanics link depression to diabetes. Among individuals with diabetes, depression has also been linked to diabetic-related complications, unemployment, functional impairment associated with diabetes and difficulties in adapting to the lifestyle changes imposed by diabetes (Chapman, Perry, & Strine, 2005).

The co-occurrence of depression and diabetes is not only common but can influence symptom appraisal, explanatory models, help-seeking, self-care behaviors, and treatment adherence. In order to understand how Hispanics manage diabetes and depression and develop better services, it is important to examine how these individuals make sense and cope with these two conditions in their everyday lives. In an effort to examine how these conditions are integrated into individuals' explanatory models, we elicited Hispanics' perceptions of how their diabetes and depression are related to each other and how one illness may impact the other.

In the present report, we used a combination of focus groups and in-depth semi-structured qualitative interviews to study the illness and treatment experiences of low-income Hispanic with diabetes and depression. An analytical approach rooted in grounded theory was used to examine explanatory models of depression, perceived relations between diabetes and depression, and depression treatment experiences.

Section snippets

Methods

Participants were selected from a randomized controlled trial (RCT), the Multi-faceted Depression and Diabetes Program for Hispanics (MDDP, PI: KE) designed to test the effectiveness of a health services quality improvement intervention on improvements in depressive symptoms, patient adherence to diabetes self-care regimens, glycemic control, functional status, and quality of life among low-income Hispanic adults with diabetes. Patients were recruited from two large public urban community-based

Participants

Nineteen individuals participated in the current study. Participants averaged age was 55 years (range 44–63 years, SD = 5.6). Sixteen were female and three were male. Only one participant had completed 12 years of education, seven had some high school, and 11 had less than 7 years of education. All participants were foreign-born; 18 were of Mexican origin and 1 was Peruvian. On average, participants had lived in the United States for 25 years (range 2–49 years, SD = 10.8). Twelve were married, two

Discussion

Participants perceived depression as a serious debilitating condition. Somatic and anxiety-like symptoms were commonly used to describe depression, and these symptoms were connected to the emotional distress surrounding participants' suffering. The experience of desesperación, common among many of our participants, illustrated how individuals' emotional distress caused by the accumulation of social stressors surfaced as physical symptoms (e.g., headaches, chest pain, shortness of breath).

Acknowledgment

We extend our gratitude to the individuals who participated in this study. We wish to thank Judith Pleitez, Erica Lizano, and Yvonnee Paredes-Alexander for their help in the recruitment and interviewing of participants, and review of transcripts.

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    This research was supported in part by the National Institute of Mental Health (NIMH) grant 5R01MH068468 to K. Ell and an NIMH supplement award to this same grant to L.J. Cabassa.

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