The Behavioral Health Needs of Latino Older Adults

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The Behavioral Health Needs of Latino Older
Adults

• Karen Fortuna, MSW Cynthia Zubritsky, PhD
• Center for Mental Health Policy and Services
  Research, University of Pennsylvania
• Lynn Patrone, BS
• The Pennsylvania Behavioral Health and Aging
  Coalition, Behavioral Health Connection
• Pennsylvania Community Providers Association
  Conference, Seven Springs, October
  8, 2009

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Acknowledgements

• This project was funded and supported by the
• Pennsylvania Department of Aging APPRISE Program
• Analyses were provided by The Center for Mental
  Health Policy and Services Research, University
  of Pennsylvania
• (C. Zubritsky, A. Rothbard, K. Fortuna, S.
  Chhatre, N. Sorhagen)
• In partnership with
• Behavioral Health Connection (program of The
  Pennsylvania
• Behavioral Health and Aging Coalition)
• (L. Patrone)
• The Philadelphia Prevention Partnership/Latino
  Golden Age Committee
• (D. Bones-Santiago, F. Feliciano, M. Negron)

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Partnership

• The Pennsylvania Department of Aging, State
  Health Insurance Assistance Program, APPRISE
  developed Behavioral Health Connection.
• The Pennsylvania Department of Aging funded the
  Pennsylvania Behavioral Health Connection to
  assess the mental health needs of Latino older
  adults in Philadelphia.
• The Behavioral Health Connection partnered with
  the Latino Golden Age Committee and Center for
  Mental Health Policy and Services Research,
  University of Pennsylvania.
• Goals of the partnership
• Collaborate to identify the unique behavioral
  health needs of Latino older adults and
• Develop a project that is consumer-centered to
  ensure that the voices of Latino older adults
  were recognized and considered

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Background Demographics

• The Latino older adult population in the United
  States is one of the fastest growing population
  sub-groups of older adults (Global Aging, 2008
  U.S. Census Bureau, 2003 Min, 2005).
• In 2001, 35.3 million individuals identified
  themselves as Latino Americans, and it is
  anticipated that this number will increase to 97
  million by 2050 (U.S. Census).
• As the general Latino population ages, the number
  of Latino older adults in need of mental health
  care will increase, as will the need for
  providers to design culturally competent mental
  health services (U.S. Department of Health and
  Human Services, 2001).

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Background Latino Older Adult Mental Health
Needs

• Latino older adults have high prevalence rates of
  depression compared to non-Latino older adults
  (Brennan et al., 2005 Gonzalez et al., 2001
  Romero et al., 2005).
• Other commonly reported mental health and
  neurological disorders include Post-Traumatic
  Stress Disorder (Ortiz Romero, 2008),
  generalized anxiety disorder (Tolin et al., 2007)
  Alzheimer's disease (Tang et al., 1998), Dementia
  (Haan et al., 2003), and co-occurring mental
  health and physical disorders (Haan et al. Al
  Snih et al., 2006 Brennan et al.).

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Background Latino Older Adults Access to
Treatment

• Latino older adults have poor access to treatment
  services (Marin et al., 2006 Cabassa et al.,
  2006 Vega et al., 1999).
• Numerous studies have shown that Latino older
  adults receive a substandard quality of mental
  health care (Arean Unutzer, 2003 Ell, 2006
  Virnig et al., 2004).
• Substandard level of care may be related to
  services that lack culturally relevant treatment
  for Latinos (Sue, 2003).
• Treatment objectives of existing mental health
  services may not be congruent with the goals of
  minority older adults (Abramson et al., 2002
  Valle et al., 2004).

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Project Goals

• The primary goal of this project was to
  determine the mental health needs of Latino older
  adults in Philadelphia, which includes the
  following goals.
• Goal 1 Effectiveness of existing services
• Goal 2 Quality of care
• Goal 3 Access to care/barriers to treatment
• Goal 4 Service utilization
• Goal 5 Medication adherence

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Data Collection

• A guided self-report survey instrument was
  designed to collect data from Latino older
  adults.
• The Holyoke Interview Guide served as the
  foundation for the survey and was chosen due to
  the high external validity of the instrument
  (Gelman, 2002).
• Modifications were made to the Holyoke Interview
  Guide based on a comprehensive literature review
  of the mental health needs of Latino older
  adults, the clinical expertise of the
  Philadelphia Prevention Partnership/Latino Golden
  Age Committee, and a pilot study.

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Pilot Study

• The survey was piloted at Norris Square Senior
  Center and Residential Facility in Philadelphia
  to measure the validity/ reliability of the
  survey and the accuracy, clarity, and ease of
  understanding.
• Five Latino individuals aged 60 and older
  participated
• A Spanish speaking facilitator translated the
  survey verbally from English to Spanish for
  participants
• A Spanish version of the survey was available
• Each participant received 10 upon the completion
  of the focus group

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Pilot Study

• Focus group participants provided valuable
  suggestions that were incorporated into the final
  version of the survey.
• Modifications to the survey and the
  administration methods were adapted based on the
  pilot project.

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Focus Groups Population Description

• Five focus groups were conducted in Philadelphia
  at Norris Square Senior Center and Residential
  Facility, the Mann Senior Center, Juniata Senior
  Center, and Kensington Pavilion Residential
  Facility.
• Table 1. Focus Group Locations (N121)

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Demographics

• A total of 121 surveys were completed between
  January and February 2009 31 (28) surveys were
  completed by males and 80 (72) surveys by
  females. The average age of the participants was
  72 years-old. The majority of the focus group
  participants identified themselves as Puerto
  Rican (74).
• Table 2. Sociodemographics (N113)

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Lifetime Report of Anxiety/Depression

• Fifty-three percent reported a lifetime clinical
  mental health diagnosis of anxiety or depression
  (N121, N64).
• Table 3. Lifetime Mental Health Diagnosis
  (N121)

1Ataques de nervios is defined as a cultural
syndrome as defined by the DSM-IV as sudden
outbursts of negative emotion such as violence or
yelling because of stress and 2Decaimiento is a
cultural syndrome as defined as feeling down.
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Key Findings

• Goal 1 Treatment Effectiveness
• Of participants who reported a mental illness
• 69 (n44) reported that their mental health
  treatment works
• 44 (n28) reported they do not need help with
  their mental health symptoms.
• 52 (n33) of the participants with a mental
  health condition do not trust their mental health
  provider.

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Key Findings

• Goal 2 Quality of Care
• Fifteen types of services were used by the
  participants, including traditional as well as
  non-traditional services. Overall, the
  participants with a mental health condition
  tended to be satisfied or very satisfied with
  services they have used.
• Satisfaction with Services
• Primary care physicians (84)
• Medication (81)
• Religion/spirituality (76)
• Meditation (75)
• Group therapy (74)
• Self-help groups (72)
• Herbs (71)
• Social work services (68)

Exercise (62) Hospitalization (52) Individual
therapy (50) Art therapy (48) Friend assistance
(47) Family assistance (39) Acupuncture (22)
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Key Findings

• 80 of participants with a mental health
  condition knew where to receive mental health
  treatment.
• The largest perceived barrier to mental health
  services for those with a mental health condition
  was reported as the doctors understanding of the
  consumers culture (82).
• Other frequently reported barriers by persons
  with a mental health condition were no health
  insurance (70) language (67) immigration
  status (19) and stigma (16).

Goal 3 Access to Care/Barriers to Treatment
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Key Findings

• Goal 4 Utilization of Mental Health Services

• 93 of the participants with a mental health
  condition reported they receive mental health
  services from their primary care physician.
• Medication (87), group therapy (76), self-help
  groups (76), and social work services (72) were
  the primary forms of formal mental health support
  used.
• The majority of the participants with a mental
  health condition reported they used alternatives
  to formal mental health services, which included
  meditation (80) spiritual and religious
  supports (80) herbs (74) and exercise (68).
  Fewer participants reported the use of friends
  assistance (51), art therapy (50), and
  acupuncture (27).

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Key Findings

• Goal 5 Medication Adherence
• Of all of the participants (N121) who have
  health insurance (94), 96 take their medication
  regularly.
• Of those individuals with a self reported
  lifetime mental health diagnosis of anxiety or
  depression, 79 reported taking their medications
  as prescribed.
• A barrier to medication adherence was reported as
  the doctors understanding of the Latino culture.

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Barriers to Medication Adherence
Table 4. Barriers to Medication Adherence (N91)
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Findings

• Alternative Therapies
• 45 of all respondents and 52 of respondents
  with a mental health condition take between 1 and
  5 natural remedies per day.
• The majority of all participants reported using
  meditation (80), spiritual or religious supports
  (80), herbs (74), and exercise (68) services.
• Less than half of the respondents (40) believe
  that alternative medicine helps with their mental
  health symptoms.

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Findings

• Mental Health Risk Factors
• The greatest risk factors for a mental health
  condition were 1) poor physical health (34) 2)
  money problems (34) 3) family member with a
  mental illness (28) and 4) death of a friend or
  family member (23).
• Individuals with financial problems had higher
  rates of depression (74), panic attacks (42),
  and ataques de nervios (52,) than individuals
  without financial difficulties.
• Poor physical health was related to depression
  (85), exhaustion (75), panic attacks (50), and
  ataques de nervios (52).

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What Providers Can Do Preferred Services

• This study found that many Latino older adults
  make use of informal support services as a
  substitute for formal mental health services.
  Development of nontraditional mental health
  services such as spiritual supports, social
  support services, and peer services may increase
  Latino Older Adults use of services

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What Providers Can Do Transportation

• Transportation services were cited (59) as a
  barrier to accessing mental health services.
• Undocumented Latino older adults do not qualify
  for Medicaid.
• Few pharmacies exist in walking distance from
  provider sites.
• There is limited or no public transportation near
  provider sites.
• Transportation in the form of shared rides,
  on-site services, transportation vouchers, or
  other methods should be developed.

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What Providers Can Do Culture-bound Syndromes

• Individuals from the Latino community have their
  own cultural understanding of mental illnesses or
  culture-based syndromes.
• Mental health providers and primary care
  physicians who provide services to this
  population need to develop an expertise of these
  culture-based syndromes including, but not
  limited to, Ataque de Nervios and Decaimiento.

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What Administrators Can Do Language Preference

• Language was a frequently reported barrier to
  access, engagement, and adherence to mental
  health services.
• Administrators could address this issue by 1)
  asking consumers if they prefer to talk with
  someone in Spanish or English 2) ensuring that
  there are culturally and linguistically competent
  providers available and/or 3) providing Spanish
  education or translation services for existing
  practitioners.
• Administrators and providers may also consider
  education for family members in understanding
  mental illness.

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What Administrators Can Do Risk Factors

• The findings show that clinical staff need to
  better understand stressors related to the
  relationship between acculturation and the
  increased risk of a mental illness.
• Staff training and education, with input from
  Latino older adults should be required for all
  persons working with this population.

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What Administrators Can Do Cultural Competency

• Service delivery systems, both primary care and
  mental health systems, need to review and address
  the cultural competence of providers. Mental
  health providers and administrators should
  prioritize comprehensive cultural training for
  line staff.
• Cultural competency training should include
  information on the identification of
  culture-based syndromes, the effects of family
  disapproval of mental illness, and attitudinal
  barriers including stigma and machismo.

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Action Items Access/Increasing Services

• Replicate existing services currently serving
  Latino older adults
• Expand existing programs to increase access and
  utilization
• Develop specialty services to be offered on-site
  in currently used settings
• Example COHMAR
• Identify home bound Latino seniors and determine
  their need for mobile or telephonic services
• Address language barriers

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Action Items Training Dissemination

• Develop and provide specialty training to new
  mental health and aging professionals
• Train current professionals and providers and
  provide continuing education
• Develop a training curriculum for caregivers and
  families to enhance their understanding of mental
  illness and reduce stigma
• Identify mechanisms to disseminate effective
  treatment interventions
• Develop a resource guide

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Action Items Community Partnerships

• Develop new community partnerships, i.e. with
  local churches, to expand services
• Partnerships could include the following.
• Prevention/ education
• Screening/assessments
• Individual counseling/group therapy

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Action Items Certified Peer Specialists

• Certified Peer Specialists (CPS) could be trained
  to work with Latino older adults.
• Incorporate Certified Peer Specialists service
  into existing programs would result in
• Cost effective services
• Reduction of negative perceptions of older adults
  toward mental health professionals and
• Reduce transportation barriers.

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