The Relationship between Disease Literacy and Stigma in Hispanics with Depression: Results from Structural Equation Modeling

Background and Purpose: Hispanics underutilize mental health services and experience many barriers to mental health treatment including costs of treatment and services, limited English proficiency, low health literacy, and stigma. The current analysis is an examination of depression disease literacy and mental health stigma, and the relationship between these variables, in a baseline sample of Hispanic patients enrolled in DESEO: Depression Screening and Education: Options to Reduce Barriers to Treatment, a study which aims to test a Depression Education Intervention (DEI) to increase disease literacy, and dispel myths about depression and its treatment among Hispanic patients thus reducing stigma and increasing treatment engagement. Researchers hypothesized that depression knowledge at baseline would be significantly related to mental health and antidepressant stigma.

Method: Clinic patients were screened for depression during routine primary care visits. Participants who screened positive for depression were referred to the Depression Educator for enrollment in the study. Participants were 18 years or older, self-identified as Hispanic, met diagnostic criteria for depression, and were not currently receiving treatment for depression. Baseline assessments included demographic information, depression symptoms measured by the Patient Health Questionnaire-9 (PHQ-9), a Depression Knowledge Measure, and two brief depression stigma measures. The stigma measures included Stigma Concerns about Mental Health Care (SCMHC) and Social Distance (SD). Social and personal concerns about psychotropic medication was measured by Latino Scale for Antidepressant Stigma (LSAS). Structural equation modeling (SEM; Mplus 7.4 using WLSMV estimator for categorical data) was used to create an overall stigma of depression treatment with depression knowledge predicting each antidepressant stigma and the stigma over mental health treatment latent variable.

Results: Participants (N=350) were primarily female (93.4%), married (70.6%) and Spanish speaking (95.0%). The average PHQ-9 score was 17.55 (SD=3.89) with 79% (n=277) reporting moderately severe or severe depression. Depression knowledge among the sample was low with an average Depression Knowledge score of 10.76 out of a possible 17 (SD=2.15). Stigma measures scores indicated moderate stigma towards mental health treatment (M=.44, SD=.85, range 0-3) and antidepressants medication (M=6.13, SD=3.45, range 0-14). Social distance desirability from someone with depression was low (M=9.00, SD=3.07). SEM analyses indicated excellent fit of the model to the data (𝜒²=1.627, df=1, p=.202; RMSEA=.043, CFI=.967, WRMR=.348). While depression knowledge predicted overall stigma to mental health treatment (-.472, p=.002), depression knowledge was not predictive of social and personal concerns about antidepressant medication (0.065, p=0.213). Stigma about medications was not significantly correlated with stigma concerning depression treatment (r=.215, p=.120). The model explained 22.3% of the variance in the latent mental health stigma variable.

Conclusion and Implications: Findings from this analysis confirm a significant relationship between depression disease literacy and stigma in a Hispanic primary care population, and suggest the implementation of depression education interventions might increase disease literacy and reduce stigma, leading to an increase in utilization of mental health treatment services. However, given that stigma towards antidepressant medications was not related to disease literacy and overall mental health stigma, more research is needed on the relationship between these variables and its implications for interventions.