Depression and Its Treatment: Implications for Minority Populations

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Depression and Its Treatment Implications for
Minority Populations

• Screening
• Assessment
• Diagnosis
• Differential Diagnosis
• Treatment Alternatives

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10 Leading Causes of Disability in the World
(WHO, 1997)

• Unipolar Depression
• Iron-deficiency Anemia
• Falls
• Alcohol Use
• COPD
• Bipolar disorder
• Congenital anomalies
• Osteoarthritis
• Schizophrenia
• Obsessive-compulsive disorder

• 10.7
• 4.7
• 4.6
• 3.3
• 3.1
• 3.0
• 2.9
• 2.8
• 2.6
• 2.2

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CHANGES IN PRIVATE HEALTH CARE EXPENDITURES1988-1
997(HAY GROUP STUDY, 1998)

• Overall health care expenditures decreased by 7
  between 1988-1997
• Mental health care expenditures decreased by 54

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Risk Factors

• Suicide is known as the preventable death because
  most risk factors are modifiable. For example,
  depression can be treated through clinical help.
• Through therapy, even non-modifiable factors,
  such as family history, can reduce the risk of
  suicide.

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Suicide

• Suicide took the lives of 30,622 in 2001.
• Suicide outnumbered homicides 31.
• There were twice as many deaths due to suicide
  than deaths from HIV and AIDS combined.
• There are 4.1 Male deaths for every single female
  death.
• Firearms are the most common method of suicide
  for both men and women.
• Firearms account for 55 of all suicides.

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Suicide

• For every death by suicide, 6 people will survive
  their attempt.
• In the US one person dies every 17.2 minutes by
  committing suicide.
• Based on the over 742,000 suicides from
  1977-2001, it is estimated that the number of
  survivors of suicides is the US is 4.45 million,
  or 1 of every 64 Americans in 2001.

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PORT Process

• Review literature regarding evidence for practice
  (efficacy)
• Analyze data on variations in practice
• Develop outcomes information to examine
  relationship of treatment and patient outcomes
  (effectiveness)
• Develop treatment recommendations based on
  literature and outcome studies
• Disseminate findings to change current practices

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Race Matters-Culture Counts
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Race Matters Culture Counts

• Cultural background plays large role
• Affects how symptoms are reported
• Affects how symptoms are interpreted
• Affects how symptoms are recognized
• Affects how symptoms are treated

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Screening Questions

• You been feeling sad, blue, depressed?
• Have you lost interest in things you used to care
  about?
• When was the last time you enjoyed yourself or
  had some fun?
• Have you been feeling tired or having low energy?

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Sig e-caps

• Sleep
• Interests
• Guilt
• Energy
• Concentration
• Appetite
• Psychomotor Changes
• Sex -- Suicide

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Methods of Diagnosis

• Symptomatic
• Syndromic
• Pathophysiologic
• Etiologic

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Symptoms and Signs of Depression

• Change in mood
• Change in sleep patterns
• Change in appetite
• Change in weight
• Change in activity levels

• Decreased energy
• Decreased motivation
• Decreased interest
• Decreased sex drive
• Decreased concentration and attention

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The Syndrome of Depression

• Not just low mood but a cluster of signs and
  symptoms

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Variables in Diagnosis

• Onset (type and age)
• Signs/Symptoms
• Premorbid Personality
• Family History
• Natural Course
• Response to Treatment
• Laboratory Data

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What Causes Depression?

• Family History Having a family member who has
  depression increases a persons risk
• Neurochemistry - Imbalances of certain brain
  chemicals may lead to depression
• Major Life Changes Positive or negative events
  can trigger depression

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What Causes Depression?

• Major Illnesses Heart attack, stroke, cancer,
  diabetes may trigger depression
• Medications Used alone or in combination can
  cause side effects like depression
• Alcohol and Drugs Can lead to or worsen
  depression
• Depression can occur for no apparent reason

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Environmental Risk Factors

• Events that engender feelings of rejection or
  humiliation
• Job or Financial Loss
• Rage, shame or a desire to get even including
  sexual and physical abuse
• Relational or social loss
• Easy access to lethal means
• Local clusters of suicide that have a contagious
  influence
• Poor parent-child relationships

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Social Risk Factors

• Decreased family stability, divorce, single
  parent households, dual career families with less
  supervision of teen activities.
• Increased access to firearms in the household
• Increased pressure to earn good grades
• Violence modeled on t.v., news, movies ect.

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Public Attitudes and BeliefsNational Mental
Health Association

• 63 of African Americans believed depression is
  a personal weakness
• 31 said depression was a health problem
• 27 would handle it by themselves
• 19 would get help from family, friends
• 1/3 would take medicine if prescribed
• 2/3 believe prayer and faith alone will work

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Etiologies of Depression

• Substance abuse Sedatives, Stimulants
• Medications Antihypertensives
• Occult Malignancies
• Hypothyroidism
• Diabetes
• Cardiovascular Disease
• Idiopathic

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Major Depressive Episode(DSM IV)

• Five or more signs and symptoms
• Every day
• At least two weeks
• A change from previous functioning
• Symptoms include either depressed mood or loss of
  pleasure/interest

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Classic Major Depression

• Decrease in Sleep
• Decrease in Appetite
• Decrease in Weight
• Decrease in Activity levels

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Atypical Depression

• Increase in Sleep
• Increase in Food Intake
• Increase in Weight
• Lethargy
• Agitation
• Earlier age of onset (teens to twenties)
• Alcoholism in male relatives

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Differential Diagnosis

• Dysthymia Chronic low-grade depression
• Bipolar Disorder Highs and lows
• Substance use and abuse
• Adjustment Disorder Stress
• Post Traumatic Stress Disorder
• Seasonal Affective Disorder

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Suicide and Major Depression

• One in seven commit suicide
• Seventy per cent of suicides depressed
• Seventy per cent of suicides saw doctor within
  six weeks of suicide
• Suicide seventh leading cause of death

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Detection of Suicidal Thinking---Ask the
questions

• Have you thought a lot about death?
• Felt like you want to die?
• Felt so low you thought of killing yourself?
• Have you ever tried to kill yourself?
• Do you have a plan? What is it?
• Do you own a gun or knife?

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Risk Factors for Suicide

• Hopelessness
• Medical Illnesses
• Family History of Substance Abuse
• Depression
• Substance Abuse

• Male Gender
• Gun Owner
• Psychotic Symptoms
• Living Alone
• Prior Suicide Attempt

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Treatment

• Suicide intervention or crisis prevention center
• Mental health clinic
• Employee assistance programs
• Primary care physicians
• Clergy
• Psychologists
• A hospital in your community
• Never attempt to help someone on your own unless
  you have been trained to do so

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Pharmacologic Treatment

• Tricyclic antidepressants compounds
• Selective serotonin re-uptake inhibitors
• MAO Inhibitors
• Heterocyclic Agents
• Mixed Serotonin-Norepinephrine Agents

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Non-Compliance Factors

• Duration, complexity, tolerability of regimen
• Lack of trust
• Lack of supportive follow-up
• Perceived mastery over illness
• Doubts about effectiveness

• Doubts about effectiveness
• Lack of social supports
• Poor educational background
• Organicity
• Concomitant substance abuse

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Non-Pharmalogic Treatment

• Patient Education
• Supportive listening
• Self-help reading and activities
• Cognitive therapy
• Behavioral therapy
• Problem-solving therapy
• Interpersonal therapy

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Disparities in Treatment

• African-Americans found to be less likely to
  receive appropriate care for depression
• African-Americans less likely to receive
  antidepressant when diagnosed
• Less likely to receive newer medications, which
  are better tolerated, have fewer side effects
• In older individuals, whites four times more
  likely to use antidepressant than African-American

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Acceptability of TreatmentCooper, et al, Med
Care 2003

• African-Americans, Hispanics less likely to find
  antidepressants acceptable
• African-Americans less likely to find counseling
  acceptable
• Negative beliefs more prevalent among minorities

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Racial Differences in DiagnosisNeighbors and
TrierweilerJ. Health Soc Behav 2003

• Semi-structured diagnostic interview
• Whites more likely to be diagnosed bipolar
• Whites less likely to be diagnosed schizophrenic
• No race differences in major depression
• Historically, African-Americans more often seen
  as schizophrenic rather than depressed

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Diagnosis in Latinos, African Americans,
Euro-AmericansMinsky, VegaArch Gen Psych 2003

• African-Americans dxed schizophrenic
• Latinos dxed major depression
• Latinos self-reported higher levels of psychotic
  symptoms

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Possible Reasons for Disparity

• Self-selection
• Culturally determined expressions of symptoms
• Difficulties with diagnostic instruments and
  application of criteria
• Lack of clinicians cultural competence
• Imprecision in unstructured interviews

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Hidden Cost of Not Treating Depression

• 30,000-35,000 Suicides per year
• Fatal Accidents due to Poor Concentration
• Fatal Illnesses Secondary to Depression
• Patient Morbidity
• Societal Costs family dysfunction, absenteeism,
  decreased productivity, job injuries, poor
  performance in workplace

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Depression A Health Disparity in Minority
Populations

• Ronald O. Forbes, M.D.
• Central State Hospital
• Petersburg, Virginia
• rforbes_at_csh.state.va.us