Recognizing and Diagnosing Depression in Hispanic/Latinos: Focus on Primary Care

1
Recognizing and Diagnosing Depression in
Hispanic/Latinos Focus on Primary Care

• Javier I. Escobar, M.D.
• Associate Dean for Global Health
• UMDNJ-RWJMS

2

• Disclosure
• National Institute of Mental Health - PI, Mentor,
  consultant, Co-Investigator to grants
• PI for P20-MH074634-01 and 1R13-MH66308-06
• Robert Wood Johnson Foundations Physician
  Scholars Program - National Advisory Committee
• American Psychiatric Associations Task force on
  DSM-V University of New Mexicos NIMH Mentoring
  (MEP) Grant

3
Primary Care, The De Facto Mental Health System

• Most patients with mental health problems go
  first to primary care and present with physical
  symptoms.
• More than one-fourth of all patients presenting
  to primary care have a primary mental disorder,
  most commonly depression and anxiety
• gt75 of people who committed suicide had contact
  with their primary care provider within the year
  before their death 50 of people who committed
  suicide had contact with their primary care
  provider within 1 month of their death

1ÜstünTB, Sartorius N, eds. Mental Illness in
General Health Care An International Study. New
York, NY John Wiley Sons 1995 2Thompson M. J
Ambul Care Manage. 200023(3)1-18 3Mental
Health Culture, Race, and Ethnicity A
Supplement to mental health A Report of the
Surgeon general, US Department of Health and
Human Services, Rockville, MD, 2001.
4
Ethnicity and Medically Unexplained Symptoms in
the United States
Primary Care UC-Irvine Study (2)
Community ECA Study (1)
1-Escobar et al, JNMD, 1989, 177 140-146
2-Escobar et al, Psychosomatic Medicine, 1998.
60 466-472
5
Woody Allens line in Manhattan (1980s)

• I cannot express any anger. That is one of the
  problems I have. I grow a tumor instead.

6
Interpretation of Medically Unexplained Symptoms

• Differs by specialty
• Syndromes made to fit specialty paradigms
  (pathophysiology and nomenclatures)

7
Functional Somatic Syndromes

• Chronic whiplash syndrome
• Chronic Lymes disease
• Silicone breast implant effects
• Candidiasis hypersensitivity
• Food allergy
• Gulf war syndrome
• Mitral valve prolapse
• Hypoglycemia
• Chronic low back pain
• Dizziness
• Interstitial cystitis
• Tinnitus
• Pseudo seizures
• Insomnia
• Systemic Yeast Infection
• Total Allergy Syndrome
• Sick building syndrome

• Irritable bowel syndrome
• Chronic fatigue syndrome
• Multiple chemical sensitivity
• Fibromyalgia
• Nonspecific chest pain
• Premenstrual syndrome
• Non-ulcer dyspepsia
• Repetitive strain injury
• Tension headache
• Temporo mandibular joint disorder
• Atypical facial pain
• Hyperventilation syndrome
• Globus syndrome
• Chronic pelvic pain

Listed hierarchically by number of papers in
which FSS are mentioned Modified from Henningsen
et al, Lancet 2007 369 946-55
8
Somatic Presentations of Common Mental Disorders
in Primary Care

• Presenting with Physical Symptoms
• Universal Language in Medicine
• Usual Presentation for Mental Disorders Worldwide
  
• At the Core of Allopathic Medicine
• --Presenting Symptom
• --Interpretation/Explanation
• --Satisfactory Treatment Outcomes
  

9
Number of Physical Symptoms Highly Correlate With
Mood Disorder
80

• Patients with depression oftenpresent with
  numerous physicalcomplaints
• As the number of physical complaints increase, so
  does the likelihood of a mood disorder1
• 30 of depressed patients experience physical
  symptoms for gt5 years before receiving the proper
  diagnosis 2

60
60
44
40
Patients With Mood Disorders ()
23
20
12
2
0
0-1
2-3
4-5
6-8
?9
Number of Physical Symptoms(N1000)
1Kroenke K, et al. Arch Fam Med.
19943(9)774-779 2Lesse S. Am J Psychother.
198337(4)456-475.
10
STAR-D Study Pain Complaint Scores and Depression
IDS-C30 Item 25 Depressive Symptomatology-Clinicia
n Rating, Range 0-3
Over 40
Hussain MH, Rush AJ, Trivedi MH, et al, Journal
of Psychosomatic Research (2007) 63113-122
11
Depression and Diabetes Often Occur Together in
Hispanics

• Depression Best predictor of hospitalization in
  DM
• Increases risk of CHD
• Reduced compliance with medical regimen
• More failures at weight
• control, exercise programs

Anderson RJ, Lustman PF, Clouse RE, er al.
Prevalence of depression in adults with diabetes
a systematic review. Diabetes, 2000 49(Suppl 1)
A64. Ciechanowski PS, Katon WJ, Russo JE,
Depression and diabetes impact of depressive
symptoms on adherence, function and costs.
Archives of Internal Medicine 2000 160(21)
3278-85
12
Depression and US Hispanics

• Most Studies include the generic term Hispanic
  or LatinoThey do not Specify
• Geographic Origin Up to 20 Different Countries!
• Racial Admixtures (Amerindian, African,
  Caucasian, Other Various Assortments)
• Immigrant or US-born? Different Outcomes
• Homogeneous Samples are Particularly Critical
  When Studying Biological Aspects of Depressive
  Illness and Depression Treatments

13
Painful Physical Symptoms in Depressed Latin
Americans
989 Patients with MDD Selected in 7 Latin
American Countries
Abdominal Pain
Lumbar Pain
Chest Pain
Muscle Pain
Joint Pain
Neck Pain
Headache
100
17.7
22.0
22.4
32.0
Reported Pain
38.5
39.2
80
51.5
19.0
18.8
18.5
None
60
A Little
20.0
Prevalence ()
Moderate
18.5
21.9
26.2
21.0
22.1
Intense
40
Unbearable
20.5
20.7
17.4
20.0
22.3
20.7
23.3
13.1
20
17.6
15.7
13.1
11.3
16.2
15.8
13.7
9.7
9.1
6.5
3.7
0
Munoz R, et al, Journal of Affective Disorders,
86 93-98, 2005
14
Latin American Patients and Psychopathology

• Somatic presentations are common, according to
  several international studies
• Depression vs. Anguish (angustia). Emphasis
  placed on physical components of depression.
• Stigma of Mental Disorders sign of weakness
  moral infirmity, punishment from heaven
• Machismo, resilience, personal suffering
• Dissociative Syndromes such as el duende, el
  espanto, mal de ojo, ataque de nervios have
  been described in Latin American countries and
  also in Latino-origin patients in the U.S.
  (particularly in those from the Caribbean).
• Magic Realism in Latin American Literature
  (Garcia-Marquez et al)
• Use of Alternative Medicines is frequent
  (Herbals, Native Healers)

15
Response to Imipramine and Placebo in Depression
Colombian vs. US Patients
gt50 Reduction in HAM-D Scores
Escobar JI, Tuason VB, Psychopharmacology
Bulletin, 1980 16 49-52
16
Country Origin of Latino Patients in a Primary
Care Study of Physical Symptoms, Depression and
Anxiety in New Jersey
17
Medically Unexplained Physical Symptoms Augur
Psychiatric Disorders In Primary Care
172 Patients with 4-6 MUPS

• Depression/Anxiety Dx
• N 158 (92)
• Mean Symptom Scores
• HAM-D 18
• HAM-A 21

• No Depression/Anxiety DX
• N 14 (8)
• Mean Symptom Scores
• HAM-D 10
• HAM-A 12

Escobar JI, Gara MA, Diaz-Martinez AM et al
(2007), Annals of Family Medicine, 5 328-335
18
Consumer Satisfaction in a Large Mental Health
System in NJ
(percent rating very good to excellent)
Minsky S, Vega W, Miskimen T, Gara M, Escobar JI,
Arch Gen Psychiatry, 60637-644, 2003
19
Percent With Serious Mental Illness
(Dementia, Schizophrenia, MDD, Bipolar)
Minsky S, Vega W, Miskimen T, Gara M, Escobar JI,
Arch Gen Psychiatry, 60637-644, 2003
20
Percent Diagnosed as Schizophrenia or Major
Depression
TOTAL N19,219
Minsky S, Vega W, Miskimen T, Gara M, Escobar JI,
Arch Gen Psychiatry, 60637-644, 2003
21
Feedback on Depression in Latinos Focus Groups
in the North East

• Based on 4 different projects in New Jersey New
  York
• Diverse groups of Latinos (country of origin,
  time in U.S., age, gender) 94 participants in 12
  different groups
• All groups held in Spanish
• Depression is widely recognized among Latinos as
  a mental health problem Both emotional and
  somatic aspects of depression are recognized
• Belief that depression is a consequence of
  difficult life circumstances, not an illness
  Depression is seen as the result of social
  stressors and losses death of a family member,
  isolation/loneliness, loss of a job and financial
  problems.
• Depression is often connected to diabetes
• Medications are only for people who are severely
  mentally ill
• Tendency to seek out talking cure
  (psychotherapy) first

1-Peter Guarnaccia PhD, Personal Communication
2006
22
Risk Factors for Depression in Hispanics

• Medical comorbidity (diabetes)
• Substance abuse
• Longer time in US residence and younger
• age at immigration
• Poverty
• Job Loss

Moscicki EK, et al. 1989 Kemp BJ, et al.
1987 Vega WA, et al. 1998 U.S. Department of
Health and Human Services 2001
23
Guidelines for Cultural Formulation of
Psychiatric Diagnosis

• Clinical history
• Cultural identity
• Cultural explanation of the illness
• Cultural factors related to psychosocial
  environment and levels of functioning
• Cultural elements of the clinician-patient
  relationship
• Overall cultural assessment

Lewis-Fernández R 1996
24
Acceptability of Treatment for Depression in
Primary Care

• Telephone Survey including 829 primary care
  patients (659 non-Hispanic Whites, 97 African
  Americans and 73 Hispanic).
• Patients met criteria for major depressive
  disorder within the last year
• African Americans and Hispanic were significantly
  less likely to find medications acceptable than
  Whites.
• Hispanics were significantly more likely to find
  counseling acceptable than other groups

Cooper L, Gonzales J, Gallo J, et al, Medical
Care, 2003 41 479-489
25
Hispanic/Latinos With Depression in Primary Care
Clinical Vignette

• Mrs. Gonzalez is a Hispanic (Mexico-born) female
  aged 56 years, a widow and a recent immigrant.
  She lives with her married daughter and speaks
  only Spanish. Her daughter is her interpreter
• At her first primary care clinic visit, Mrs.
  Gonzalez complained of severe weakness, back
  pain, and joint pain, all of which she had been
  experiencing for several months. Other somatic
  complaints included abdominal pain, flatulence,
  headaches, palpitations, and dizziness

26
Clinical Vignette (Continued)

• Mrs. Gonzalezs medical history included a
  previous diagnosis of mild hypertension. She was
  prescribed a low-dose diuretic that she had not
  taken for several months
• Her family history included diabetes mellitus and
  hypertension (brother and sister)
• A physical examination showed nothing abnormal,
  except for slight obesity and mild hypertension
  (145/90 mm Hg). Laboratory assessments, including
  EKG, CBC, LFTs, and thyroid panel, were normal

EKGelectrocardiogram CBCcomplete blood count
LFTsliver function tests.
27
Clinical Vignette (Continued)

• The PCP prescribed a low-dose ACE-inhibitor and
  asked the patient to return in 2 months. At the
  next visit, the daughter indicated her mothers
  pain had continued and was unresponsive to
  acetaminophen. In addition, she noted that her
  mother slept poorly and did not want to leave the
  house because of her physical problems. The PCP
  reassured the patient with interpretation from
  the daughter
• A few days later, the PCP received an urgent call
  from Mrs. Gonzalezs family indicating she was in
  crisis, agitated, not sleeping, sobbing, eating
  little, and complaining of multiple pains. The
  doctor suspected a psychiatric problem and asked
  the nurse at the clinic to assess the patient in
  an emergency visit

28
Clinical Vignette (Continued)

• The patient was assessed by the clinics nurse
  with the PRIME-MD that elicited significant
  depression and anxiety symptoms. The physician
  prescribed a benzodiazepine for sleep and
  referred the patient to a mental health clinic
  nearby. The family, however, disagreed with the
  recommendation (The symptoms are not in her
  head!) and took the patient to another PCP.
  Although the new physician also suspected
  depression, his psychiatric referral failed
  because the bilingual psychiatrist in practice
  nearby did not accept Medicaid or Medicare
  patients

29
Clinical Vignette (Continued)

• Mrs. Gonzalezs symptoms escalated until she was
  brought to the emergency department of a
  university hospital. Following physical
  clearance, a psychiatry resident elicited
  depressive symptoms, diagnosed MDD and started
  the patient on an antidepressant after explaining
  the diagnosis and reasons for the prescription to
  the family. She was then referred to a
  university-affiliated primary care clinic for
  follow up. The patient hesitantly started taking
  the medication and soon discontinued her
  treatment because it made her feel nauseous

30
Clinical Vignette (Continued)

• When Mrs. Gonzalez visited the clinic for her
  first follow-up appointment, her case was
  assigned to a Spanish-speaking nurse
  practitioner. The nurse practitioner convinced
  the patient to try another antidepressant and
  encouraged the family to endorse the treatment.
  The nurse practitioner scheduled brief weekly
  visits, performed brief physicals, reassured the
  patient, allowed her to talk about stressors, and
  avoided telling her things such as your symptoms
  are psychological or symptoms are in your
  head. Gradually, Mrs. Gonzalezs condition
  improved. After 6 to 8 weeks, her symptoms were
  largely resolved, and she is seen every 2 months
  or so.