Denise Velazquez holds back tears as she sits at her dining room table.
“I didn't want anyone to realize what I was going through. I'm known as the one that normally has it together,” said the 41-year-old. “I was in denial about being depressed. I was saying, 'No, I can handle this. I can do this.'”
She would cry at work and eventually had to take some time away from her job as a registered intensive care unit nurse.
Velazquez pauses before recounting the moment she broke down on the floor of her doctor's office. “I couldn't get myself up off of the floor. I had to call a friend to meet me at the [doctor's] office. I didn't want to call my husband or anyone else in my family. I was embarrassed,” said the mother of three.
She was diagnosed with severe depression in 2017.
The National Institute of Mental Health (NIH) defines her diagnosis as “having symptoms of depression that interfere with your ability to work, sleep, study, eat and enjoy life.” Depression must last for at least two weeks before it is categorized as severe.
Her diagnosis came at the same time she was going through marital problems, finishing her master's degree in nursing administration and when she found out her mother was dying of stage four kidney cancer.
“I hated myself because I couldn't get out of the house to go and help my mom,” said the Mexican-American.
Velazquez felt she had failed her family. The non-denominational Christian questioned God about her illness.
“[I kept asking] God, where are you? How is my faith strong? How am I strong? How are you using me through this? My husband is leaving me. My mom is dying. I don't want to finish school. My girls probably see me as a weak woman,”Velazquez said.
She was prescribed medication, but she doesn't remember its name. She refuses to take it. “I never took it. I told myself I [wasn’t] going to put myself on medication. I felt very strong about that. I felt like I was going to get through this with no medication.”
When no one was home, she said she would drag herself on the floor and repeatedly tell herself that she was no good.
"[There were other] days where I would leave the house acting like I was going to work, but I wouldn't go to work. I would stay at a park and sleep for 12 hours until it was time for me to come home. No one knew," she said.
A 2018 report by the California Health Care Foundation found 1 in 6 adults experience mental illness in California. As a Mexican American mother, Velazquez’s overwhelming feeling of having to put her family before her mental health is not uncommon.
Latinas between the ages of 21 to 48-years-old feel overwhelmed and responsible to meet loved one’s needs. This is according to a 2017 UCLA Nursing study published in JMIR Mental Health.
"There's a cultural and social pressure to not share your problems outside of [Latino families]," said UCLA associate professor and co-author of the study, Dr. MarySue Heilemann. "It's better yet to take care of it yourself so that you don't burden the rest of your family because there is such a high focus on the family thriving."
Velazquez dealt with much of her depression alone but credits her church family as her most significant support group.
"I think if we can just take that step of courage and let go of that fear of being judged,” she said. “It'd be good if people spoke out a little bit more."
Velazquez is one of the many Latinos determined to break what UC Davis Professor of Clinical Internal Medicine, Sergio Aguilar-Gaxiola describes as "the culture of silence."
"Latinos experiencing suicidal thoughts or symptoms of depression, prefer to not tell anybody," said Aguilar-Gaxiola. The cultural stigma exists, but Aguilar-Gaxiola said we must be careful to not lump all Latinos into "one monolithic group."
Each sub-group within the Latino identifier is different in many ways, but one constant is the negative response that exists when speaking of mental health in a predominantly Latino/Hispanic household.
In 2015, the Center for Health Policy at the University of Mexico surveyed over 1,000 Hispanics and found that about 300 responded to a question regarding mental health. Seventy-seven said they would not seek help for their emotional or mental health problems. While only 22 said they would look for professional help.
On its website, the National Association of Mental Illness (NAMI) said that many Hispanics fear the label of "loco" or crazy. They would rather struggle alone, instead of putting their pain out for public ridicule and display.
But to Aguilar-Gaxiola the fear of being crazy is not the only factor resulting from the stigma. Lack of connection to one's ancestral roots adds to this mix and can be seen in the silence that exists in past Latino-American generations.
Know Your Culture, Know Yourself?
Ni de aqui´, ni de alla´, Neither from here nor from there. It's a phrase widely used by Hispanics and could also be the reason so many struggles with an identity crisis, said Angelita Rovero-Herrera, a Chicano studies professor at East Los Angeles Community College.
Rovero-Herrera correlates the high percentage of depression found among Latinos and especially young Chicanas with lack of cultural identity.
The Substance Abuse and Mental Health Services Administration reports 1 in 7 Hispanic teenage girls living in the United States will attempt suicide. Culture and family dynamics being two of a variety of factors.
"When we don't teach the next generations what their identity is we fail them," said Rovero-Herrera. "You have a deeper foundation of who you are when you know where you come from."
Mujeres De Maiz (Spanish for Women of the Corn) Co-Founder, Felicia Montes said it’s important to know your indigenous roots to understand your bi-culturalism as a Latino-American in the United States.
"I definitely think that issues of assimilation and acceptance in communities are two opposites. Many times living in that dichotomy is a very hard place to live," said Montes.
Mujeres De Maiz is a grassroots multimedia organization in East Los Angeles. They aim to "empower diverse women and girls through the creation of community spaces by providing holistic wellness."They call this artivism, a blend of art and activism.
"[I wanted] to create a space for women, queer and trans communities, and the indigenous,"said Montes.
The concept of tapping into your cultural roots as a form of healing is not new; it's called la cultura cura, which is Spanish for “culture cures.” It's a principle that stresses the importance of learning indigenous Latin American traditions to understand who you truly are. A concept that's not new, but still not common in bi-cultural communities.
"Nobody teaches them. Nobody knows how to teach identity, "said Rovero-Herrera. "I couldn't capture my own identity until I was an adult. [Chicanas] are acculturated. We are not assimilated," she said.
She describes assimilation as the complete absorption of another culture and having zero connection with your indigenous ancestry. Rovero-Herrera said Chicanos are acculturated because they hold on to their native roots.
Aguilar-Gaxiola describes the two terms as a blend of one another. "[Acculturation] is the process people go through in order to assimilate in a culture other than their own," said Aguilar-Gaxiola.
Traditional gender roles equate with this identity crisis as young Chicanas deal with strong mothers known to put their family's needs above their own.
In 2010, the Mental Health Nursing Journal surveyed low income-second generation Latinas and found that "where emotional problems were concerned, all of [their] focus and efforts were funneled towards solving [their children's] emotional problems rather than [their] own."
For example, revisiting Denise Velazquez's first signs of depression, she said she was unable to confide in her mother, despite their loving relationship.
"When I was getting postpartum [with my daughter]. She was like, you need to stop or I'm going to take her away," said Velazquez.
Based on Rovero-Herrera's upbringing, it is easier to shrug off the topic of mental health and depression than deal with it head-on.
"You can't even talk to your mom about boys, let alone if you're suffering, let alone if you're dealing with any kind of issue mentally. You can't go to your traditional native-born Mexican parent because what they don't know is a blessing," said Rovero-Herrera.
The same was true for Leah Figueroa-Haugen. The 22- year- old remembers her junior year of high school as a time when she wanted to die, and could not turn to her mother to help. "I grew up in a home where you either suck it up and deal with it or if God can't fix it then no one can," said the California native.
She has dealt with symptoms of depression for as long as she can remember. Figueroa-Haugen said her childhood depression later created anxiety.
Rovero-Herrera describes Chicano culture as being chauvinistic where the woman must do everything and still hold themselves together.
"We put in as much or even more work as a man in the household because we are also the mother figure. Most women will probably clean more than most males, and we still work. We still manage and still tend to the things that are needed in the household, said the East Los Angeles Community College professor.
These gender roles are not new. They are embedded in indigenous Mexican culture and date back to the country's pre-Cuauhtemoc period.
"Woman didn't go to school, men did. [Hieroglyphics] show women learning to weave baskets and cooking food. Women were already at that age given certain duties and traditional rules," said Rovero-Herrera.
Velazquez still sticks to gender roles but does not mind them. She grew up in an Americanized household that held on to these traditional roles. "You stand by your husband. You stay with your family. You make it work." she recounts.
Opinions on gender roles vary and their direct correlation to mental health is subjective. The idea that knowing more of your cultural history serves as an aid to understanding yourself is a concept that Aguilar-Gaxiola said will aid in lessening the identity crisis.
"The current generation of Latinos are reclaiming their ancestral beliefs and incorporating their cultural identity," said the leading researcher in minority health.
Mexican-American journalist, Maggie Guillen, also believes this is true of her generation.
"We are self-aware. We don't want to be like our parents to some extent where we are not addressing these important issues. We have the power and are slowly changing the way our parents think about our culture," she said.
Rovero-Herrera is not as optimistic about the cultural acceptance of taboo topics, like depression.
"I think it's going to stay the same. I think you're just going to have more people vocal about it who are Chicano. We still have a lot of Mexican natives continue to come and be here in the United States," she said.
If Rovero-Herrera is right, it could be decades before Chicanos, and other Latinos can rid themselves of seeing "ni de aqui, ni de alla" as another way of describing its role in their depression and other mental health issues.
Clinical Lack
An identity crisis and fear of speaking out spreads past the four walls of Latino households. It also affects the number of Latinos attending mental health care on a consistent basis.
A 2017 study from the Los Angeles Department of Mental Health reports that in the 2015-2016 year, out of the 1,027,199 adults who were certified and Medi-Cal eligible, only 20,980 attended five or more special mental health services in Los Angeles County.
Countywide this might be true, but at the Venice Family Clinic demographics look a bit different. The Venice Family Clinic's many locations say that lack of Hispanic attendance is not something they see in their patient demographics. In the last year, Hispanics made up over 50 percent of the clinic's demographics across all of their Westside locations.
NAMI's multicultural fact sheet shows that 5.5 percent of Hispanic males and 9.2 percent of Hispanic females sought out mental health care between the years 2008-2012.
While this is not true for Denise and many of the others who've chosen to speak out, Cypress Community College Professor Dragana Filip said that a lack of consistency or even negative feelings of therapy stem from a much more significant issue.
"They don't seek or find somebody that has the same culture and usually will not seek treatment. It's unfortunate," said the psychiatrist technician instructor and former psychiatric nurse.
The lack of culturally diverse therapists and psychiatrists is a problem noted by 'Between Sessions' Podcast hosts and licensed therapists, Eliza Boquin and Eboni Harris. They say that a client is more likely to "open up knowing they have something in common [with their therapist]."
Filip said the only solution is for more licensed psychiatrists. "There are a lot of therapists and counselors out there, but there's not a lot of psychiatrists. A psychologist cannot write prescriptions. So, that's why a lot of people are not getting the proper treatment because they have to see a psychiatrist," said the instructor.
A lack of these mental health professionals creates another barrier of long wait times for those of Medi-CAL, Affordable Care (ACA), Medicaid and HMO insurance plans.
For those on Medi-Cal and Medicaid, "It usually takes about a month to get seen by the psychiatrist," said Filip. She continues and tell me that others on ACA or HMO are seen in two weeks, but need a referral from their primary doctor.
Even after going to a doctor, the lack of consistency still exists. Boquin said that this due to patients seeking an in and out solution to their illness. "People want a quick fix, and it doesn't happen, so they stop coming," she said.
Velazquez is open to sharing her experience with mental illness but still refuses to take her medication. Something that Darrell Wilkins, a licensed physician's assistant from the Los Angeles Veteran Affairs Hospital said is a case-by-case issue depending on the severity of an individual's need.
"In regards to depression and anxiety, it's not a simple solution. I don't prescribe medication right away. It's tailored to what that individual needs," said Wilkins.
Dr. Roderick Shaner of the Los Angeles County Department for Mental Health said a combination of a well-balanced lifestyle and medication is the most effective.
“It”s not at all unusual, or surprising, that many people hesitate to take medication. The challenge for any good physician is to listen carefully to a patient. They have to understand what their concerns might be to taking the medication, and address those concerns,” said Shaner.
In the end, Filip and Boquin agree that more needs to be done. "It's a family issue. The whole family needs to go and seek out a mental health professional," said Boquin.
"We need more providers, more resources, more outreach," said Filip.
Therapists like, Boquin and Harris say they are doing their part through their podcast and website, Melanin and Mental Health. Their podcast discusses issues like, "Why Aren't Black and Brown Families Going to the Therapist?" Their website is home to a national database of Black and Latino/Hispanic therapists who have been screened by both Harris and Boquin.
Websites like this and a new generation of mental health artists could be the beginning of breaking down the culture of silence, with the use of art to speak out.
The Art of Speaking Out
Growing up in what she describes as a Cuban-Jewish household, 27-year-old Anna Salinas never had a difficult time speaking with her immediate family about her mental health issues, which are shared by many in her family.
"Mental illness was always a topic of discussion in my family," she said. "I didn't accept that I had depression or that it was depression because I was looking at my [other family members] as this extreme."
"I thought [depression] was this huge scary thing that involved being institutionalized," she said.
In an attempt to cope with depression, Salinas turned to doodling, took a photo of her first comic and posted it on Instagram for the world to see.
Salinas began an Instagram page under the username BadComixByAnna, after her third round of depression.
The aspiring actress was diagnosed with depression in college and channels her mental illness to make art through films, improv comedy and comic books.
"Through the vehicle of a joke and an [online] comic it let people know that I wasn't okay but that, that was okay," said Salinas.
The comic features a "plumpy person." She's topless in her underwear, with a block of cheese in one hand and a bottle of wine in the other.
"She's me," Salinas said.
Her Instagram page, which is followed by over 30,000 people, is a way for her to track how she felt."Looking back I can say,“Oh, I know it was really bad at that part. [That one] didn't have a punch line," Salinas said.
BadComix has been a part of Anna's life for quite some time, but it was not until recently that the page began to gain traction on social media.
“I had a lot of people reach out and say, “I feel the same thing,” she said.
In Dr. Heilemann's 2017 study it was determined that "culturally tailored multimedia content holds great promise for encouraging Latina woman to seek help for, and address the symptoms of, anxiety and depression."
The study required a group of Latinas to individually watch online content and blogs from a fictional character named Catalina. The fictional blogger would tell her followers about her symptoms of depression through online reflection.
"If people can relate to the media and the characters, they engage, and they react to those characters," said Heilemann.
Salinas' artwork caters to those of all ethnicities, gender and other social constructs. Her idea is that the more we talk about mental health, the better, whether it be through conversation, social media, entertainment or word of mouth.
Her artwork started out as a way of coping and has become a place for others to share their own stories with the artist. For Vero Higareda, speaking out was always the intention.
The 23-year-old is the co-founder of Spark! An organization that makes personalized bracelets and encourages their customers to spark conversations about mental health.
"They each carry a different meaning, and they come with a little guide to help people to spark conversations about mental health," Higareda said.
Higareda started the organization in 2013. She's originally from Reynosa, Mexico and remembers how hard it was to put a label on her obsessive-compulsive disorder (OCD).
"I attempted suicide because of my struggle with OCD. It got to the point where I felt like I could, and a lot of things were going on in my life, and I didn't know how to ask for help," she said.
She said her hometown was not a place where she could openly talk about her mental health. She was 15 years old when she finally put a name to her mental illness.
"The city I was from was very Catholic and very conservative, and we don't talk about those things. My mom and I, we started buying books and looking at Google to see what it was. We found out the symptoms that I had were manifestations of OCD," said Higareda.
Today, she wants to change this. Her organization holds open-mic events for others to share their stories. According to the co-founder, these open-mic nights have a positive effect on other's lives.
"When someone shares their story, other people are encouraged to share theirs as well and the stigma kind of breaks through that," said Higareda.
Denise Velazquez shares the same sentiment with Higareda and Salinas.
"If I stay quiet, how am I going to help anybody else? So that's why I am speaking out," said Velazquez.
She's speaking out, and so are other Latinos. They're using their voices to change mental health stigma by sharing their own stories with their communities and the rest of the world.