Subjective versus objective: An exploratory analysis of latino primary care patients with self-perceived depression who do not fulfill primary care evaluation of mental disorders patient health questionnaire criteria for depression
Identification and treatment of depression may be difficult for primary care providers when there is a mismatch between the patient's subjective experiences of illness and objective criteria. Cultural differences in presentation of symptoms among Latino immigrants may hinder access to care for treatment of depression. This article seeks to describe the self-perceptions and symptoms of Latino primary care patients who identify themselves as depressed but do not meet screening criteria for depression. A convenience sample of Latino immigrants (N = 177) in Corona, Queens, New York, was obtained from a primary care practice from August 2008 to December 2008. The sample was divided into 3 groups according to whether participants met Patient Health Questionnaire diagnostic criteria for depression and whether or not participants had a self-perceived mental health problem and self-identified their problem as "depression" from a checklist of cultural idioms of distress. Psychosocial, demographic, and treatment variables were compared between the 3 groups. Participants' descriptions of symptoms had a predominantly somatic component. The most common complaints were ánimo bajo (low energy) and decaimiento (weakness). Participants with "subjective" depression had mean scores of somatic symptoms and depression severity that were significantly lower than the participants with "objective" depression and significantly higher than the group with no depression (P < .0001). Latino immigrants who perceive that they need help with depression, but do not meet screening criteria for depression, still have significant distress and impairment. To avoid having these patients "fall through the cracks," it is important to take into account culturally accepted expressions of distress and the meaning of illness for the individual.
Latino Patients With Self-Perceived Depression
Prim Care Companion J Clin Psychiatry 2010;12(5)
Subjective Versus Objective: An Exploratory Analysis of
Latino Primary Care Patients With Self-Perceived Depression
Who Do Not Fulfill Primary Care Evaluation of Mental
Disorders Patient Health Questionnaire Criteria for Depression
Susan Caplan, PhD; Jennifer Alvidrez, PhD; Manuel Paris, PsyD;
Javier I. Escobar, MD; Jane K. Dixon, PhD; Mayur M. Desai, PhD;
Robin Whittemore, PhD; and Lawrence D. Scahill, PhD
Objective: Identification and treatment of
depression may be difficult for primary care
providers when there is a mismatch between the
patient’s subjective experiences of illness and
objective criteria. Cultural differences in presentation
of symptoms among Latino immigrants may
hinder access to care for treatment of depression.
This article seeks to describe the self-perceptions
and symptoms of Latino primary care patients
who identify themselves as depressed but do
not meet screening criteria for depression.
Method: A convenience sample of Latino
immigrants (N = 177) in Corona, Queens, New
York, was obtained from a primary care practice
from August 2008 to December 2008. The sample
was divided into 3 groups according to whether
participants met Patient Health Questionnaire
diagnostic criteria for depression and whether
or not participants had a self-perceived mental
health problem and self-identified their problem as
“depression” from a checklist of cultural idioms of
distress. Psychosocial, demographic, and treatment
variables were compared between the 3 groups.
Results: Participants’ descriptions of symptoms
had a predominantly somatic component. The
most common complaints were ánimo bajo (low
energy) and decaimiento (weakness). Participants
with “subjective” depression had mean scores of
somatic symptoms and depression severity that
were significantly lower than the participants with
“objective” depression and significantly higher
than the group with no depression (P < .0001).
Conclusions: Latino immigrants who perceive
that they need help with depression, but do not meet
screening criteria for depression, still have significant
distress and impairment. To avoid having these
patients “fall through the cracks,” it is important to
take into account culturally accepted expressions of
distress and the meaning of illness for the individual.
Prim Care Companion J Clin Psychiatry 2010;12(5):e1–e12
© Copyright 2010 Physicians Postgraduate Press, Inc.
Submitted: September 30, 2009; accepted December 15, 2009.
Published online: October 21, 2010 (doi:10.4088/PCC.09m00899blu).
Corresponding author: Susan Caplan, PhD, 55 Landing Woods Rd,
Yarmouth, ME 04096 (firstname.lastname@example.org).
Depression is the second most common disorder
encountered in primary care.1 Twelve percent of
primary care patients have major depression, almost
twice the prevalence found in the general population.2
Depression disproportionately affects the most vulnerable
populations,3 including Latino immigrants, the elderly,
and people with chronic illnesses.4–8 Latino immigrants
are less likely to receive treatment for depression than
non-Hispanic whites,4–6,8 and the care that is received
is less likely to conform to treatment guidelines.9,10
Moreover, these groups are most likely to seek care for
mental health problems in the primary care setting.10
There is much debate over the appropriateness of the
current DSM-IV classification of depression, particularly
for those with depressive symptoms who do not meet
criteria for major depressive disorder.11 In primary
care, the prevalence of milder but clinically disabling
conditions, such as dysthymia and minor depression,
is even higher than major depression.12,13 Patients who
do not meet the DSM-IV criteria for major or minor
depressive disorder have been labeled with subthreshold
depression, subclinical depression, or nonspecific
depressive symptoms.14,15 Compared to participants
without depressive symptoms, participants with
subthreshold depression have impaired functional status,
higher rates of service use, increased economic costs
to society, and a greater likelihood of developing major
depression.12,16–18 A recent primary care study showed
promising results for the treatment of minor depression,19
although further research is needed to determine if
treatment is effective for subthreshold depression.12,19,20
It is difficult for the primary care clinician to determine
the treatment implications of self-reports of depressive
symptoms or self-perceived depression in the absence of
a DSM-IV diagnosis, which might be assessed by such
screening instruments as the Primary Care Evaluation of
Mental Disorders Patient Health Questionnaire (PHQ-
9) for depression.21 This is particularly true for patients
whose culture differs from that of the provider.22 An
understanding of the experience and context of depression
among Latino immigrants might be necessary to enhance
Caplan et al
e2 doi:10.4088/PCC.09m00899blu Prim Care Companion J Clin Psychiatry 2010;12(5)
diagnostic accuracy.22 Several studies have supported a
spectrum theory of depressive syndromes with severity
occurring along a continuum.15 Self-reports of depressive
symptoms that do not meet criteria for depression might
represent one end of this spectrum and might serve as a
target for preventive care. This article seeks to explore the
nature of and possible treatment implications for a group
of Latino primary care patients who identify themselves as
depressed but do not meet PHQ-9 criteria for depression.
RECOGNITION OF DEPRESSION IN PRIMARY
CARE AND AMONG LATINO PATIENTS
In addition to language barriers and lack of insurance
among Latino patients, a major barrier to the treatment of
depression includes a lack of recognition in the primary
care setting in as many as 30%–50% of patients.23,24 Lack
of recognition may be due, in part, to components of the
primary care infrastructure, such as high productivity
quotas, which preclude in-depth assessment. This
has led the US Preventive Services Task Force25 to
recommend screening for depression in primary care
to improve the accurate identification of depressed
patients. However, the reliability of screening may differ
in certain subpopulations on the basis of culture.
There is much debate as to the extent to which
culture influences the core diagnostic categories and
constellation of symptoms for mental illnesses.26
One element of this debate is whether psychiatric
disorders are universal and biologically based, with
specific cultural variations in expression of symptoms
and manifestation,11 or whether culture is the major
determinant of the development of illness.27
There is less debate about how culture influences the
validity of instruments used to assess illness. Various
health status measures, including self-reported physical
health, the Center for Epidemiologic Studies Depression
scale (CES-D), and the somatic symptoms scale of
the PHQ (PHQ-15), have been susceptible to cultural
bias and lack of conceptual or language equivalence,
which can lead to misclassifications when applying
standard cutoffs.28–32 Moreover, response bias, or
differences in item characteristics by cultural tendencies
to respond in a certain way, can affect validity.33
Cultural Influences on Illness Presentation
Insufficient provider training with regard to the
patient’s cultural differences in presentation may also
create a barrier to recognition of depression.9,34, Among
many cultural groups, including Latino patients,
depression may be primarily experienced in bodily terms
and result in the patient’s perception of a physical problem
for which primary care assistance is sought.35,36 The
patient’s level of health literacy and the degree of stigma
felt about discussing mental health problems may result
in the use of “cultural idioms of distress” or descriptions
of emotional disturbances that differ from Western
biomedical terminology, such as ataques de nervios, susto,
or nervios. Nervios is an idiom of distress referring to an
“alteration” of the nervous system9 and is characterized by
depressive, anxious, somatic, and dissociative symptoms.37
Stress and Self-Perceived Distress
While Latino immigrants have been found to clearly
recognize the phenomenon of depression, it is possible
that it is not always defined as an illness.38 Depression
may be considered to be a predictable response to the
preponderance of stressors Latino immigrants face.38
The strong endorsement of immigration-related or
acculturative stressors such as financial problems, loss
of social networks, and trauma as causes of depression
is discussed in a previous analysis of this data set.39
In sum, for various reasons, including differences
in illness definition and presentation, the stigma of
reporting depression among Latino immigrants, and
cultural factors that may influence responses to screening
instruments, providers may fail to detect depression in
this population. The majority of Latino immigrants with
depression are not receiving treatment4; therefore, it is
important to develop an understanding of people who
self-report that they have a mental health problem. The
aims of this article are to (1) describe the self-perceptions
of a group of Latino primary care patients who identify
themselves as depressed but do not meet PHQ-9 criteria
for depression (subjective depression), (2) describe the
self-reported symptoms and the use of cultural idioms of
distress of the group with subjective depression, and (3)
compare the psychosocial, demographic, and treatment
variables among those with subjective depression, those
who meet PHQ-9 criteria (PHQ-depression), and those
Cl i n i C a l Po i n t s
Among Latino immigrant groups, depression screening questionnaires may not ◆
accurately identify some individuals who have significant distress and impairment.
An informal screening question about self-perceived mental health needs can assist in ◆
identifying individuals who may need treatment for depression.
Primary care providers should elicit the patient’s definition of a mental health problem, ◆
interpretations of the meaning of the problem, and expectations for treatment.
Latino Patients With Self-Perceived Depression
Prim Care Companion J Clin Psychiatry 2010;12(5)
who do not self-report depression and do not have a
PHQ-9 diagnosis of depression (nondepression).
This cross-sectional descriptive survey study took
place at a private family practice site in Corona, Queens,
New York from August 2008 to December 2008.
Corona, Queens, has an urban population of 99,000,
approximately two-thirds of whom are Latino and 62%
are foreign born.40 The ethnic background of Corona
includes residents of Dominican (28%), Mexican (17%),
Ecuadorian (15%), and Colombian (6%) descent.41 One-
quarter of the Hispanic residents in Corona live below
the poverty level. The site was selected because of its
predominantly Latino immigrant patient population
and the particular demographic mix of the population.
The fastest rate of growth in the United States Hispanic
population is among the ethnic groups included in this
study: Dominican, Colombian, and other Central and
South American groups.42 The focus on diverse Latino
groups allowed for an analysis of differences by ethnicity.
The original sample for this study consisted of a
convenience sample of self-identified Latino immigrants
(N = 177) recruited from the waiting room of the
family practice site. There was an equitable selection of
participants since all patients were approached to enter
the study upon registering for their appointments or while
seated in the waiting room. Patients were approached with
a brief introduction about the investigator, the purpose
of the study, and the eligibility criteria and were given a
bilingual flyer providing contact information. Patients
were not approached during the time the investigator
was in a private room conducting interviews. These
patients were informed of the study via bilingual posters
posted in the waiting room and at the registration desk.
Eligible participants endorsed that they were Latino,
aged 18 years or over, patients at the practice, and
born either outside of the United States or in Puerto
Rico. The study received institutional review board
approval from Yale University School of Nursing, New
Haven, Connecticut. Informed consent documents
contained information on the specific purposes of the
study, potential risks and benefits, and permission
to divulge to the primary care practitioner results
of psychiatric screening and/or any other medical
conditions requiring immediate attention. Informed
consent and interviews were conducted in Spanish or
English, according to language preference, in a private
room to ensure confidentiality. Seven participants
(4%) in the sample chose to be interviewed in
English. All questionnaires and informed consent
documents were read aloud to participants.
All measures used in this study had preexisting
validated Spanish translations and utilized the back
translation method.42 Two independent native Spanish
speakers translated instructions and consent forms. The
investigator pretested and/or reviewed the measures for
comprehension and usage among monolingual Spanish
speakers from Mexico, Guatemala and Puerto Rico,
the Dominican Republic, Ecuador, and Colombia.
The dependent variable, depression status, was
assessed by the PHQ, a screening instrument developed
for use in primary care settings that screens for anxiety
disorders, alcohol abuse, and depression.43 The depression
module (PHQ-9),21 is a 9-item scale that assesses all
DSM-IV depression symptoms during the last 2 weeks.
Severity of complaints ranges on a 4-point scale from “not
at all” (0) to “nearly every day” (3). Presence or absence
of depression is determined by a diagnostic algorithm
that must include either depressed mood or anhedonia
for at least “more than half the days” and at least 2 other
symptoms for at least “more than half the days.” By
convention, presence of 5 additional symptoms is defined
as “major depression,” whereas 2 to 4 additional symptoms
are defined as “other depression.”22 Depression severity
was calculated as a continuous variable by scoring the
response categories from 0 to 3 for scores ranging from
0–27. Scores of 5, 10, 15, and 20 are the recommended
cutoff points for mild, moderate, moderately severe,
and severe depression, respectively.22 In a sample of
primary care patients, there was a sensitivity of 88% and
a specificity of 88% for major depression at a score ≥ 10
based on a structured clinical interview.22 Although
many studies use a score ≥ 10 (moderate or more severe
depression), we used the less conservative score of ≥ 5
(at least mild depression), because one of the purposes
of this study was to determine who was being “missed”
by the screening.44 Internal consistency and test-retest
reliability was excellent at 0.89 for the English version.21
The Spanish version of the PHQ has been validated
in 974 Hispanic primary care and obstetrics/gynecology
patients of whom 74% were monolingual Spanish
speaking (n = 717).22 Compared with the United States
primary care sample, 3 studies in Spanish-speaking
countries showed similar sensitivity ranging from
77%–87% and specificity ranging from 88%–100%.45–47
List of illness labels. Participants who said “yes”
to a past-month mental health problem or who
endorsed fair or poor self-perceived mental health
were asked to identify the nature of the problem
from a list of illness labels that included symptoms
and experiences such as loneliness, family problems,
and problems with drugs or alcohol. This list
Caplan et al
e4 doi:10.4088/PCC.09m00899blu Prim Care Companion J Clin Psychiatry 2010;12(5)
was previously used in a study of depression self-
recognition48 and was adapted from Yokopenic et al.49
This list was expanded by incorporating the cultural
idioms of distress suggested in the DSM-IV11 such as
nervios (nerves), ataques de nervios (attacks of nerves),
agitación (agitation), and decaimiento (weakness).
During the pilot study, a few items were dropped
from the interview if the majority of participants had
not heard of the expressions. Subsequently, if these
items had not been endorsed by any of the first set of
participants, they were dropped from the interview,
ie, pasmo (fright, soul loss). Additionally, coraje (rage,
anger) was added to the list as a cultural idiom of
distress, because it was volunteered by a majority of
the participants during the initial interviews. Similarly,
agitamiento (agitation, nervousness) was changed to
agitación based on participants’ word recognition.
Experience of symptoms. Participants who said
“yes” to having experienced a past-month mental
health problem or who endorsed fair or poor
self-perceived mental health were asked about
their experience of symptoms by the open-ended
question, What do you feel like when you have?”
Independent variables. Independent variables
included the demographic variables listed in Table 1.
Demographic variables included age, gender, income
level, educational level, employment status, ethnicity,
and the acculturation variables of language usage and
number of years in the country. Psychosocial variables
listed included perceived stigma and acculturative
stress. The clinical/treatment variables included the
variables somatic symptoms, severity of depression,
functional status, previous history of treatment, and
previous history of help seeking for mental health
problems by the participant or his/her family or friends.
Spanish- or English-language usage. Language usage
was assessed by the following question scored from 1 to
5 with higher scores reflecting greater English-language
usage, “Do you speak Spanish only, mostly Spanish
(some English), Spanish and English about the same,
mostly English (some Spanish), or English only?”
Perceived stigma. Perceived stigma contained 3
items reflecting the belief that the participant would
be stigmatized by employers, friends, or family
if he/she sought treatment for depression. These
questions were used in a large-scale Internet study on
depression50; however, minimal psychometric data are
available for these questions. In the current sample,
Cronbach α = 0.71, mean = 8.5, SD = 3.8, with a range
of 3–15 (higher scores indicating greater stigma).
Acculturative stress was measured by the abbreviated
version of the Hispanic Stress Inventory for Immigrants,51
a shorter version of the Hispanic Stress Inventory-
Immigrant version.52 The abbreviated version is a 17-item
questionnaire designed to assess stressors specific to
the Latino immigrant experience, such as immigration,
discrimination, family, and cultural issues. In a study of
143 Latino immigrants in the St. Louis, Missouri, area,
internal consistencies were 0.86 and 0.87 for the 2 factors
of the scale, intrafamilial stress and extrafamilial stress.51
Somatic symptoms. The somatic symptoms scale of
the PHQ43 contains 15 items about physical complaints
that have been shown to be the most common somatic
symptoms, including, for example, stomach pain, back
pain, headaches, chest pain, and shortness of breath. The
items are rated from 0, 1, and 2 corresponding to “not at
all,” “bothered a little,” and “bothered a lot.” Cronbach
α for both Hispanics and non-Hispanics was 0.79.30
Functional status. Functional status was assessed
by the single question on the PHQ, “How difficult have
these problems made it for you to do you work, take care
of things at home, or get along with other people?” It is
scored on a 4-point scale ranging from “not at all difficult”
to “extremely difficult.” This question was associated with
functional impairment on the mental health subscale
of the 20-item Medical Outcomes Study Short-Form
General Health Survey scales with a correlation of 0.53.43
A subsample was selected for purposes of this analysis.
The subsample (n = 161) consisted of 3 groups: PHQ-
depression, subjective depression, and nondepression.
PHQ-depression (n = 47) included participants
who met PHQ-9 diagnostic criteria for depression
(major or other) or were currently being treated
for depression and therefore would not be
considered “missed” or “nonrecognized.”
Subjective depression (n = 21) included participants
who were not in current treatment for depression,
did not meet PHQ-9 diagnostic criteria for
depression, and endorsed either a “yes” response to
(1) or a “fair” or “poor” rating to (2) as follows:
(1) In the past month, have you ever had
personal, emotional, behavioral, mental, or
alcohol or drug problems severe enough
that you felt you needed help?48
(2) Self-rated mental health: how would
you rate your overall mental health—
excellent, good, fair, or poor?53
Subjective depression was additionally defined by
either the identification of depression from the list of
illness labels or a response, indicating predominantly
depressive symptoms, such as tristeza (sadness) or
depresión (depression) to the open-ended question,
“How do you feel when you have the above-mentioned
problem?” The 16 participants who had a self-perceived
mental health problem but did not endorse an illness
label of depression or symptoms of depression (eg, stated
Latino Patients With Self-Perceived Depression
Prim Care Companion J Clin Psychiatry 2010;12(5)
that their mental health problem was “memory loss, drug
abuse, or alcoholism”) were not considered in the analysis.
Nondepression (n = 93) included participants who
did not meet PHQ criteria for anxiety, depression, or
alcohol abuse; were not in current treatment for any
psychological disorders; and endorsed a “no” response to
(a) above and a “good” or “excellent” rating to (b) above.
Analyses were conducted in SAS version 9.1 (SAS
Institute Inc, Cary, North Carolina). We used univariate
analyses, eg, frequencies, means, and distributions to
describe the demographic, psychosocial, and clinical/
treatment characteristics of the sample, as well as to
characterize the frequencies of endorsement for specific
illness labels and responses to the open-ended questions.
We examined differences between the mean
scores on the continuous variables using analysis of
variance and Duncan’s test for pairwise comparisons.
The .05 significance level was applied.
We examined the differences in distributions of
psychosocial, demographic, and clinical/treatment
categorical variables first between the group with
subjective depression and the group with PHQ-
depression and second between the group with subjective
depression and the nondepression group using the
χ2 test or Fisher exact test depending on cell size.
Demographic and clinical characteristics of the sample
are presented in Table 1. The largest ethnic group in
this sample was of Dominican origin, followed by those
of Ecuadorian and Colombian origin. The majority
of the sample (71%) had an income of under $20,000
annually, with 36% earning less than $10,000 a year. The
majority (approximately 85%) of the practice’s patient
population was enrolled in Medicaid health maintenance
organizations. The remainder of the population
received Medicare or private health insurance or, in a
few cases, were self-paying (Enrique Malamud, MD,
personal communication, July 7, 2008). About half of
the sample was employed either part-time or full-time,
and approximately 30% of the sample was unemployed.
The majority was monolingual Spanish speaking or
spoke very little English (85%). Of the population, 29%
had depression by PHQ-9 criteria, including those
with scores ≥ 5, indicating at least mild depression.
Compared with Ecuadorian, Colombian, and other
Central and South American patients, participants
from the Dominican Republic were more likely to be
monolingual Spanish speaking and to have a lower income
and less than an eighth grade education. Dominican
participants were more than twice as likely to be out of the
work force as the other ethnic groups (26% vs 12%). The
refusal rate for participation varied from approximately
75% initially to about 10% by the end of the study.
Subjective Descriptions of Illness
Descriptions of illness included those items endorsed
on the list of illness labels and the responses to the
open-ended question on symptoms. Among the group
with subjective depression, illness labels were relatively
similar in order of frequency as those endorsed by the
PHQ-depression group; however, the PHQ-depression
group had a higher percentage of endorsements for
most items (Table 2). Among those with subjective
depression, the most highly endorsed symptoms and
idioms of distress were sentir el animo bajo (low energy),
n = 21 (100%); decaimiento (weakness), n = 18 (86%);
depression, n = 17 (81%); loneliness, n = 16 (76%); and
anxiety and financial problems, each n = 15 (71%).
Verbal responses to the question, “How do you feel
when you have (any of the above problems)?” were
transcribed and are listed by thematic content in Table
Table 1. Characteristics of 161 Latino Patients From a Primary
18–49 79 (49)
Female 119 (74)
< $10,000 58 (36)
$10,000–$19,999 57 (35)
≥ $20,000 34 (21)
Refused or don’t know 12 (7)
≤ 8th grade 39 (24)
Some high school 51 (32)
General equivalency diploma or high school 32 (20)
Some college or technical school 21 (13)
College graduate or graduate school 18 (11)
Dominican 84 (52)
Ecuadorian 27 (17)
Colombian 20 (12)
Other Central/South American 30 (19)
Full-time 55 (34)
Part-time 28 (17)
Out of work force (retired, student, disability) 29 (18)
Unemployed 49 (30)
Age at migration, mean (SD), y 29.0 (12.1)
Years in country
0–5 17 (11)
6–10 10 (6)
11–15 24 (15)
16–20 26 (16)
> 20 83 (52)
Spanish only 49 (30)
Mostly Spanish (some English) 89 (55)
Spanish and English about the same—mostly English 23 (14)
Presence of depression 47 (29)
aData are presented as n (%) unless otherwise specified.
Caplan et al
e6 doi:10.4088/PCC.09m00899blu Prim Care Companion J Clin Psychiatry 2010;12(5)
3. Reponses were noted in the language of preference.
Of the 21 people with subjective depression, 2 were
bilingual and 2 preferred English as the language of
interview. Responses for most people clearly indicated
distress and were consistent with DSM-IV criteria for
depression. Themes were overlapping and focused
predominantly on the symptoms of crying, depression
and sadness, anxiety, nervousness, and tension and the
experiences of loneliness, personal losses, and trauma.
Comparison of Variables by Depression Status
As shown in Table 4, participants with subjective
depression had mean scores of somatic symptoms
and depression severity that were significantly
lower than those of participants with PHQ-
depression and significantly higher than those of
the nondepression group. The nondepression and
subjective depression groups did not differ from each
other in terms of perceived stigma and acculturative
stress, but both were significantly lower on these
2 variables than those with PHQ-depression.
Bivariate comparisons between the subjective
depression and PHQ-depression groups indicated
that only the clinical/treatment characteristics were
significantly different (Table 5). Compared to the PHQ-
depression group, the subjective depression group was
less likely to have had chronic illnesses. There were no
differences between the groups in terms of demographic
factors such as gender, employment status, age, or the
acculturation factor of language usage. The subjective
depression group compared to the nondepression group
was significantly more likely to have had previous
treatment for a mental health problem, to have impaired
functional status, and to have “fair” or “poor” self-rated
physical health. Although not statistically significant,
there was a trend for the subjective depression group
to have been residing in the United States for a shorter
period of time and to have had a greater likelihood of
having family members or friends who had received
mental health treatment than the PHQ-depression group.
The goal of this study was to explore the meaning
of Latino patients’ self-perceptions of depression and
the clinical implications of these perceptions. The
findings of significant impairment of functional status
and worse self-perceived physical health among those
with subjective depression compared to those who
do not have self-perceived mental health problems
are similar to the findings of studies of subthreshold
depression in primary care.16,18 Participants with
subjective depression had mean scores between those
with PHQ-depression and the nondepression group in
terms of somatic symptoms and depression severity, thus
supporting the spectrum hypothesis of depression.12
In general, when probed with an open-ended
question, subjective descriptions of symptoms very
closely matched the DSM-IV criteria for depression.11
Nevertheless, participants’ illness labels had a
predominantly somatic component, similar to the
findings of other researchers.22,54–56 The most common
symptoms of depression were ánimo bajo (low energy)
and decaimiento (weakness). In a community survey of
166 Puerto Rican residents of Worcester, Massachusetts,
the most commonly endorsed symptoms of mental health
problems were decaimiento (56.2%), nervios (50.6%),
and agitamiento (40.7%), supporting the commonality of
these idioms of distress and symptoms to describe mental
health problems.57 Anxiety, tension, and nerves were
reported by the majority of participants and indicated
the prevalence and overlap of these symptoms with
symptoms of depression, similar to the descriptions of
depression among elderly Puerto Rican and Dominican
subjects58 and among Puerto Rican women.22
To our knowledge, this is the first study to examine
the construct of subjective depression among Latino
patients in primary care. A few prior studies have
examined the related construct of self-recognition
of depression, defined as participants who believe
that they are depressed and meet the criteria for
depression. These studies also indicated that the most
salient factors related to self-recognition were clinical
factors including severity of illness, suicidality, history
Table 2. Endorsement of Illness Labels Among Patients in the
Subjective Depression (n = 21) and PHQ-Depression (n = 31)
Sentir el ánimo bajo (low energy) 21 (100) 30 (97)
Decaimiento (weakness) 18 (86) 30 (97)
Depression 17 (81) 31 (100)
Soledad (loneliness) 16 (76) 27 (87)
Ansiedad (anxiety) 15 (71) 30 (97)
Financial problems 15 (71) 25 (81)
Nervios (nerves) 14 (67) 27 (87)
Tension 14 (67) 28 (90)
Family problems 12 (57) 22 (71)
Agitación (agitation) 11 (52) 22 (71)
Coraje (rages) 11 (52) 24 (77)
Susto (fright) 8 (38) 23 (74)
Espanto (sudden fear) 4 (19) 16 (52)
Other 3 (14) 4 (13)
Pánico (panic) 3 (14) 14 (45)
Ataques de nervios (nervous attacks) 2 (10) 7 (23)
Perdida del alma (soul loss) 2 (10) 9 (29)
Tripa ida (insides disappearing) 1 (5) 9 (29)
Problems with alcohol 1 (5) 0 (0)
Problems with drugs 0 (0) 0 (0)
aSpanish language was used for cultural idioms of distress in both
English and Spanish versions of the interview.
bOf the 47 participants in the PHQ-depression group, only 31 endorsed
having a mental health problem.
Abbreviation: PHQ = Patient Health Questionnaire.
Latino Patients With Self-Perceived Depression
Prim Care Companion J Clin Psychiatry 2010;12(5)
of self or family/friend mental health treatment,
and poor self-perceived mental health.48,50,53,59
Nevertheless, the absence of significant findings
in terms of demographic factors such as gender or
level of acculturation is not entirely consistent with
previous research. Gender has been shown to influence
self-recognition of emotional problems. Although
Puerto Rican men have been shown to have less self-
recognition of emotional problems than women53 and
Latino men are less likely to seek help for depression,
anxiety, and substance abuse than Latina women,6,10
results of this study showed no gender differences in
subjective depression. Perhaps the study provided an
informal or less intrusive means of help seeking or
discussion of depression than the more traditional
and potentially stigmatizing route of discussing
mental health problems with one’s provider. However,
a careful examination of help-seeking behavior
by gender is beyond the scope of this article.
Increasing level of acculturation, whether measured
by greater proficiency in the English language or specific
acculturation scales, is believed to influence perceptions
about depression. Knowledge of the English language
results in greater exposure to media, pharmaceutical
Table 3. Description of Symptoms by Study Participants
Crying Me dan ganas de llorar, trato de solucionar los Nervios. I feel like crying, I try to settle the nerves.
Me ponía a llorar, soy muy sentimental, tengo problemas con mi esposo, con mis hijos y trato de arreglar la situación pero
no me escuchan. Un sentimiento de soledad. I started crying, I am very emotional, I have problems with my husband,
with my children, and I try to straighten out the situation, but they don’t listen to me. I have a feeling of loneliness.
Tenía un hermano que sufrió de depresión y se mató. A veces lloro, una cosita pasajera a veces, se me olvidan muchas
cosas, me pongo nerviosa y hago las cosas desesperada, como fregada, quizás. I had a brother that suffered from
depression and he killed himself. At times I cry over a temporary passing thing. At times, I forget a lot of things, I
become nervous, and I do desperate things, like I’m messed up, maybe.
Depression, sadness, emptiness Pensamientos sobre cosas del pasado, mucha tristeza, deprimida. Thoughts from the past, a lot of sadness, depressed.
Siento tristeza en mi alma, si alguien me dice que tengo una depresión…me siento muy sola, no deseo comer, no soy la
misma, traté de explicárselo al doctor, pero falto el tiempo. I feel like I have sadness in my soul, when someone tells
me that I have a depression. I feel so alone. I don’t want to eat, I am not the same. I tried to explain it to the doctor,
but I didn’t have enough time.
I don’t want to be alive, emptiness, purposelessness.a
Depresiva, me veo sola, me voy a la calle, como en la calle encuentro una amiga, trato de distraerme. Depressive, I see
myself as alone, I go outside, because on the street I might find a friend and I try to distract myself.
Triste, mal, sin deseo de nada, una tristeza profunda. Sadness, bad, like this, without desire for anything, a deep
Siento un poquito de depresión porque estoy con esta incapacidad, de eso la viene la depression. I feel a little depressed
because of this disability; this is what causes my depression.
Worry, tension, anxiety, stress Me da insomnio, me preocupo mucho por mis hijos. I have insomnia. I worry a lot about my children.
Stressed and tired, from work, being a father.b
Preocupado, porque mi novia está embarazada. Worried, because my girlfriend is pregnant. She doesn’t want to live
with me. Normally, I’m okay.c
Un poquito de ansiedad, me siento muy triste. I feel a little anxious, I feel very sad.
Tengo miedo de que voy a morir, podría tener una enfermedad grave. I’m afraid that I’m going to die, that I could have a
Nightmares, hearing voices Porque estoy sin trabajo, soy y no estoy, me dan muchas pesadillas, oigo voces, no quiero salir, paso los días sola, pienso
muchas cosas malas. Because I am without work, I am here, but I don’t exist, I have a lot of nightmares, I hear voices,
I don’t want to go out, I spend the days alone, I think a lot of bad things.
Weakness Decaído, sin ánimo, triste. Weak, without energy, sad.
Loneliness Vivo solo, me siento triste, cuando llamo al Perú y hablo con mis primos, se portan mal y tengo que regañarlos. I live
alone, I feel sad, when I call Peru and speak with my cousins, they are behaving badly and I have to chastise them.
Me siento sola, con ganas de llorar, quisiera tener alguien con quien poder desahogarme, pero no lo tengo. I feel alone, I
feel like crying, I would have liked to have someone with whom I could unburden myself, but I don’t have anyone.
Personal losses, trauma En el sueño me pongo como tensa, no puedo dormir. Me siento sola porque he perdido mucho … muchos golpes en mi
familia, he perdido mis hermanos. When I’m sleeping, I feel like tense, I can’t sleep. I feel alone because I have lost a
lot…many blows to the family, I have lost my brothers.
Un poco deprimida, perdí un hijo hace trece años, tengo ganas de llorar, me siento de mal humor, me voy a la iglesia, a
veces no quiero hablar con nadie. A little depressed, I lost a son 13 years ago, I feel like crying, I feel like I’m in a bad
mood, I go to the church, at times I don’t want to talk to anyone.
Nunca se borran de la mente estos recuerdos, no tenia ayuda de nadie, uno se siente traumatizado, por eso me vine a este
país. These memories can never be erased from my mind, I didn’t have help from anyone, one feels traumatized,
because of this, I came to this country.
aParticipant interviewed in English.
bParticipant interviewed in English.
cParticipant interviewed in English and Spanish.
Caplan et al
e8 doi:10.4088/PCC.09m00899blu Prim Care Companion J Clin Psychiatry 2010;12(5)
Table 4. Analysis of Continuous Variables by Depression Statusa,b
Variable PHQ-Depression (n = 47 [29%]) Subjective Depression (n = 21 [13%]) Nondepression (n = 93 [58%]) P Value
Perceived stigma 10.1 (3.9) A 8.4 (4.0) B 8.0 (3.3) B .0046
Severity of depression 14.4 (6.1) A 5.9 (3.7) B 1.8 (2.1) C < .0001
Somatic symptoms 13.0 (6.0) A 8.0 (5.1) B 4.6 (3.5) C < .0001
Acculturative stress 29.4 (16.1) A 16.9 (14.9) B 12.9 (13.1) B < .0001
aData are presented as mean (SD).
bVariables with the same letter (A, B, or C) are not significantly different.
Abbreviation: PHQ = Patient Health Questionnaire.
Table 5. Analysis of Categorical Variables by Depression Status
(n = 47 [29%])
(n = 21 [13%])
(n = 93 [58%]) P Value P Value
0 1 2 1 vs 0a1 vs 2b
Age, n (%), y .557 (NS) .879 (NS)
18–49 21 (45) 11 (52) 47 (51)
≥ 50 26 (55) 10 (48) 46 (49)
Gender, n (%) .773 (NS) .880 (NS)
Male 12 (24) 5 (24) 25 (27)
Female 35 (76) 16 (76) 68 (73)
Work status, n (%) .770 (NS) .341 (NS)
Full-time or part-time 18 (38) 10 (48) 55 (59)
Out of work force, retired, student, disability 13 (28 ) 5 (24) 11 (12)
Unemployed 16 (34) 6 (29) 27 (29)
Income level, n (%) .222 (NS) .980 (NS)
< $10,000 22 (48) 6 (33) 30 (35)
$10,000–$19,999 19 (41) 7 (39) 31 (36)
≥ $20,000 5 (11) 4 (28) 25 (28)
Education level, n (%) .184 (NS) .153 (NS)
≤ 8th grade 15 (32) 6 (29) 18 (19)
Some high school 15 (32) 3 (14) 33 (35)
High school graduate/graduate school 17 (36) 12 (57) 42 (45)
Ethnicity, n (%) .531 (NS) .711 (NS)
Dominican 23 (49) 12 (57) 49 (53)
Other Central/South America 24 (51) 9 (43) 44 (47)
Years in country, n (%)c.083 (NS) .303 (NS)
> 20 28 (61) 8 (38) 47 (50)
0–20 18 (39) 13 (62) 46 (49)
Language, n (%)
Spanish only 18 (38) 5 (24) 26 (28) .234 (NS) .924 (NS)
Mostly Spanish (some English) 26 (55) 12 (57) 51 (55)
Spanish and English the same—mostly English 3 (6) 4 (19) 16 (17)
Function, n (%) .109 (NS) < .0001
Somewhat to extremely difficult 32 (68) 10 (48) 5 (5)
Not at all difficult 15 (32) 11 (52) 88 (95)
History of family/friend mental health treatment, n (%)
Yes 13 (28) 10 (48) 32 (34) .108 (NS) NS (.257)
No 34 (72) 11 (52) 61 (66)
Self-rated physical, n (%)
Good/excellent 12 (26) 4 (19) 63 (68) .759 (NS) < .0001
Fair/poor 35 (74) 17 (81) 30 (32)
Chronic illness, n (%)
Yes 36 (77) 10 (48) 47 (51) .0183 .809 (NS)
No 11 (23) 11 (52) 46 (49)
Previous treatment for depression, anxiety, or substance abuse, n (%)
Yes 22 (47) 8 (38) 11 (12) .504 (NS) .0035
No 25 (53) 13 (62) 82 (88)
aSubjective depression vs PHQ-depression.
bSubjective depression vs nondepression.
cOne participant was unable to recall number of years in the country.
Abbreviations: NS = not significant, PHQ = Patient Health Questionnaire.
Latino Patients With Self-Perceived Depression
Prim Care Companion J Clin Psychiatry 2010;12(5)
advertising, and public health campaigns designed
to educate the public about mental health and has
brought about increases in mental health service
usage.3,60 However, acculturation does not occur in a
linear fashion, and contextual factors, such as living
in a predominantly monolingual Spanish-speaking
ethnic enclave, may have a culturally protective
effect and can influence the process of acculturation,
particularly for immigrants who have entered the
country as adults.61 Further research could more closely
examine the relationship between problem recognition
and help-seeking behavior as well as the effects of
acculturation, gender, ethnicity, and other demographic
factors on recognition of mental health problems.
There are a number of possible explanations for
the lack of congruence between DSM-IV criteria and
subjective depression. First, due to predominantly
somatic presentations, participants may not have met
PHQ criteria for depression. Among Latino subjects,
somatic symptoms, tension, and anxiety may be
endorsed more frequently than “depressed mood”
compared to non-Hispanic whites, as suggested in the
literature27 and evidenced by people’s reluctance to
endorse sadness and depression more than just “some
of the time.” The hesitance to report severity of illness
in terms of “number of days” experiencing depressive
mood symptoms may be characterized as a response
set bias, possibly due to strong social mores prohibiting
reporting of negative mood states22 and the economic
imperatives of not being able to lose work due to illness.4
Second, it is also possible that since the group with
subjective depression experienced less perceived stigma
about depression than those with PHQ-depression,
they may have been more willing to label themselves
as depressed at a lower level of depression severity
and thus may be a group amenable to preventive
interventions. Third, the 38% of the subgroup with
subjective depression who had been treated in the past
may not have achieved full remission and were reflecting
residual symptoms, a recurrent episode of depression, or
dysthymia. Finally, due in part to the response set biases
mentioned previously, we may not have enough evidence
of validity of the PHQ-9 among the following groups
of latinos: male and middle-aged and elderly adults.
The PHQ-9 has been validated in 3,000 primary
care patients, of whom 4% were Hispanic, and 3,000
obstetrics-gynecology patients, of whom 39% were
Hispanic.21 In these studies, the samples of Hispanic
subjects were overwhelmingly female (97.8%) and
young (mean age of 29 years). Criterion validity
by means of an independent standard such as the
Structured Clinical Interview for DSM-IV62 was not
performed for monolingual Spanish speakers.
Clinical and Public Health Implications
Depression screening and assessment. These
findings suggest that people endorsing some
symptoms of depression on the PHQ-9, but not
enough to trigger a diagnosis, should be evaluated
clinically for other factors that may affect decisions
about management and treatment. As suggested
by Spitzer et al,43 potential questions to enhance
accuracy of diagnosis include the following:
Have current symptoms been triggered by •
psychosocial stressor(s)? If, so how?
To what extent are the patient’s symptoms •
impairing his or her usual work and activities?
Is there a history of similar episodes, •
and were they treated?
Is there a family history of similar conditions?•
Are there other comorbid psychological problems •
(eg, anxiety, panic attacks, or substance abuse)?
How severe is the depression?•
To help in identifying those patients with symptoms
of depression who do not meet PHQ-9 criteria, an
informal screening question about self-perceived mental
health needs (such as that used in this study) might
be advisable. More frequent screening may be most
productive in patients with a history of depression,
chronic illness, unexplained somatic symptoms,
comorbid psychological conditions (eg, panic disorder
or generalized anxiety), substance abuse, chronic
pain, high levels of stress, and recent losses.25
Communication strategies and patient education.
To provide culturally appropriate services, the primary
care provider should be aware of and discuss the patient’s
belief systems, illness interpretations, and expectations
of treatment. The framework for conversation can utilize
the ESFT model,63 which would include the patient’s
Explanatory model of illness, Social and financial
barriers to illness treatment, Fears and concerns about
treatment, and Therapeutic contracting and playback.
For the patient who acknowledges having a mental
health problem, the provider should elicit the patient’s
definition of the problem and reflect the patient’s
illness label, rather than impose a diagnostic category
of depression. Somatic symptoms should be explored
to ascertain the patient’s understanding of these
symptoms. These physical symptoms can be validated and
presented as a manifestation of the presenting problem
or current stressors by using open-ended questions.27
Psychoeducation should address beliefs contributing to
stigma and mental health literacy. If the patient is willing,
family members may be included in treatment planning.27
Caplan et al
e10 doi:10.4088/PCC.09m00899blu Prim Care Companion J Clin Psychiatry 2010;12(5)
The sample consisted of an immigrant primary care
population from different Latin American countries,
which limits the possibility of generalizing to all Latino
primary care populations in the United States. The
small sample size of the subjective depression group
may have limited the power of this study to detect
significant differences between groups. The homogeneity
of the group in terms of an overwhelming preference
for Spanish as the language of interview precluded an
exploration of the role that language might play in the
reporting of symptoms. The study is further limited
by a convenience sampling strategy and a variable
refusal rate. Similar to the findings of other researchers
working with Latino immigrant populations,64,65
participants were initially wary of the investigator
and, per staff report, believed that the investigator was
from the Immigration and Naturalization Service. To
counter this initial mistrust, the investigator employed
a culturally syntonic methodology similar to the plática
methodology,65 which relied upon staff members familiar
to potential participants to vouch for the trustworthiness
of the researcher. By the end of the recruitment period,
when the investigator was well known to the potential
participants, some of whom had already participated in
the study, the refusal rate was minimal. Due to Health
Insurance Portability and Accountability Act regulations
and the need to protect patient privacy, only minimal
eligibility data were obtained from potential participants
in the waiting room, and no other personal identifying
information was obtained from nonparticipants
that could subsequently be used to compare
participants with those who refused to participate.
The finding of 47 participants with a PHQ-9 score
indicative of depression or current treatment for
depression does not represent prevalence of depression in
the clinic, because patients were not randomly sampled.
Some patients may have self-selected into the study in
order to be screened or to obtain help for depression or,
alternatively, may have elected not to participate to avoid
detection of depression. Nevertheless, 29% (26% of the
full sample of 177) is within the range of results of other
primary care studies of Latino immigrants and low-
income primary care patients.57,66,67 Although, the PHQ-9
is based on DSM-IV criteria and shows high agreement
with clinical diagnosis as evidenced by an overall accuracy
rate of 88%, the absence of a clinical interview to verify
the PHQ-9 results obtained here may mean that some
participants may have been misclassified as “depressed” or
“not depressed.” Moreover, the PHQ-9 cannot distinguish
depression from dysthymia. It also does not screen for
substance abuse, and, therefore, this potential diagnosis
could not be carefully examined. Since this is a primary
care population, it would be assumed that there is some
overlap of somatic and psychiatric comorbidities, so one
cannot definitely discern if impairment is due to chronic
illness or symptoms of depression. Finally, the cross-
sectional design of this analysis precludes identification
of the causal directions of the variables under study.
Our research supports the idea that Latino immigrants
who perceive that they need help with depression
but do not meet screening criteria for depression still
have significant distress and impairment. For some
patients, subjective depression or self-perceived mental
health may be as reliable an indicator of depression
status as the currently used screening instruments. To
avoid having these patients “fall through the cracks,”
it is important to take into account culturally accepted
expressions of distress, the meaning of illness for the
individual, and the effect of the illness on lifestyle,
behaviors, functioning, and social activities. Given the
above limitations, this study contributes to the literature
by quantitatively and qualitatively exploring Latino
immigrants’ self-descriptions of emotional distress.
Author affiliations: College of Nursing and Health Professions,
University of Southern Maine, Portland (Dr Caplan); Department
of Psychiatry, University of California, San Francisco (Dr Alvidrez);
Department of Psychiatry (Dr Paris), Department of Nursing (Drs
Dixon and Whittemore), Division of Chronic Disease Epidemiology
(Dr Desai), and Department of Nursing & Child Psychiatry (Dr Scahill),
Yale University, New Haven, Connecticut; and Department of Psychiatry,
University of Medicine and Dentistry of New Jersey, Robert Wood
Johnson Medical School, Piscataway (Dr Escobar).
Potential conflicts of interest: None reported.
Funding/support: This research was partially supported by a grant from
Sigma Theta Tau International Honor Society of Nursing, Indianapolis,
Acknowledgments: Special thanks to Joshua Farkovits; Tatiana
Castrillon; Monica Diaz; Enrique Malamud, MD; Marta Miguez; Jasmine
Ramos; Romana Suero, MA; and Johanna Tudino, all of Privileged
Care Medical Center, Elmhurst, New York, and Gabriela Rosas-Garcia,
MD, from the Department of Medicine, Infectious Diseases Fellowship
Program, State University of New York Downstate Medical Center,
Brooklyn. The acknowledged individuals report no conflicts of interest
relevant to the subject of this article.
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