Mental Health in Latinos Along the US-Mexico Border

1
Mental Health in Latinos Along the US-Mexico
Border

• Francisco Moreno, MD
• Professor of Psychiatry
• Deputy Dean for Diversity and Inclusion
• University of Arizona College of Medicine

2
Overview

• Demographics of Border States
• Challenges for Mental Health Care Along the
  Border
• Approaches to Minimize Mental Health Care
  Disparities
• Primary Care Services and Integrated Care approach

3
Profile of Latinos in the US
4
Census 2010 and 2000 Percent Hispanic Along
Border States
5
Latinos in the US Census

• 52 million Latinos (16.7 of US population)
• 76 speak other than English at home
• 35 state they are not fluent in English
• 62 have a HS diploma vs. 91 of NHW
• 13 have a BA or higher vs. 31 of NHW
• 24.8 live in poverty vs. 10.6 of NHW
• 30.7 are uninsured vs. 11.7 of NHW

6
Social Determinants of Mental Health
Social Issue Level of Evidence
Low SES Very convincing
Low education Very convincing
Unemployment or underemployment Very convincing
Food insecurity and early deficiency Strong
Gender inequity Strong
Low income Strong
7
Social Determinants

• Mental health prevention and intervention efforts
  concentrate overwhelmingly on affecting
  individual, family and/or community change
• Broader social, political and economic conditions
  determine the determinants.

8
Heterogeneity of Hispanic Americans

• Birthplace
• Acculturation
• Language
• Literacy
• Genetics
• Race
• Education
• SES
• Urbanicity, region, etc.

Pew Research Center
9
Risk Factors for Mental Illness

• Medical conditions Diabetes, obesity, pain
• Domestic violence, Machismo effects on gender
  equity, parenting, help seeking
• Certain family dynamics
• Acculturation
• Early life trauma
• Financial challenges
• Racism
• Physical environment

10
Migration Related Stress

• Failure to succeed in the country of origin
• Immigration Experience
• Adaptation Process
• Limited Resources
• Restricted Mobility
• Marginalization and isolation
• Blame/stigmatization and guilt/shame
• Vulnerability/exploitability
• Fear and fear-based behaviors
• Family stress Role and tradition changes

11
Fronterizo Related Stress

• Contrasting cultures separated by language,
  religion, race, philosophy, history
• Separation from the heartland areas
• Physical isolation
• Frontier conditions
• Transnational frictions
• Ethnic rivalries

(Riding 1984 Martinez 1994)
12
IMMIGRANT SOCIAL ADAPTATION AND VULNERABILITY TO
MH PROBLEMS
Family Stress Loss of traditional family
customs Family Acculturation stress Family
role changes
Context of Exit Developmental Stage Family
circumstances prior to migration
Acculturation Stress Adolescent acculturation
stress Parental acculturation stress
Immigration Experience Circumstances of exit
Circumstances of entrance
VULNERABILITY TO MH PROB.
Acculturation Process Family Acculturation
Adolescent acculturation
Segmented Assimilation Assimilation into local
environment
13
Serious Psychological Distress18 y/o or older
(2009-2010)
Hispanic Mexican American NHW Mexican/NHW Ratio Hispanic/NHW Ratio
3.6 2.8 3.1 0.9 1.2
NHW Non-Hispanic Whites
14
Latino nativity differences

• Higher rates of mental illness among the native
  born and long-term U.S. residents
• Replicated in Mexican immigrants and Puerto Rico
  Islanders. Also replicated in US-Mexico Border
  for Depression, Anxiety, Sub. Abuse
• Exceptions include Central American immigrants
  often exposed to trauma and Cuban Americans in
  Florida

National Council of La Raza Institute for
Hispanic Health 2005
15
Serious Psychological Distress Percent of Poverty
Hispanic NHW Hispanic/NHW Ratio
Below 100 6.4 10.1 0.6
100 - 200 4.1 5.5 0.7
200 - 400 2.6 3.2 0.8
NHW Non-Hispanic Whites
16
Percentage feeling depressive symptoms all the
time 2010
Hispanic NHW Hispanic/NHW Ratio
Sadness 4.6 2.8 1.6
Hopelessness 3.3 2.0 1.7
Worthlessness 2.3 1.7 1.6
Everything is an effort 6.5 5.6 1.2
NHW Non-Hispanic Whites
17
Percentage feeling anxious symptoms most the time
2010
Hispanic NHW Hispanic/NHW Ratio
Nervousness all or most the time 5.4 4.9 1.1
Restlessness all or most the time 5.6 6.4 0.9
NHW Non-Hispanic Whites
18
Death Rates for Suicide by Sex and Ethnicity (by
100,000)
Hispanic NHW Hispanic/NHW Ratio
Male 9.8 23.2 0.4
Female 2.0 6.0 0.3
Total 5.9 14.3 0.4
NHW Non-Hispanic Whites
19
Suicidal Attempts in HS Students
Hispanic NHW Hispanic/NHW Ratio
Male 6.9 4.6 1.5
Female 13.5 7.9 1.7
Total 10.2 6.2 1.6
NHW Non-Hispanic Whites
20
Percentage receiving counseling / medication in
2008
Hispanic NHW Hispanic/NHW Ratio
Male 5.2 / 4.0 10.8 /9.1 0.5 / 0.4
Female 8.4 / 6.5 20.8 / 18.3 0.4 / 0.4
Total 6.8 / 5.2 16.0 / 13.9 0.4 / 0.4
NHW Non-Hispanic Whites
21
Some Common Issues in Latino Mental Health

• Latino children with developmental and mental
  disorders remain largely undiagnosed
• Latino children are treated more frequently than
  other groups but adults are not (US-SG 01)
• Latinos are identified as a high risk group for
  depression, anxiety, and substance abuse
  (National Alliance for Hispanic Health 2001)
• Ineffective coping and increased stress may lead
  to higher suicidal ideation and behavior

22
Latinos Health Seeking

• What do I have? Why do I have it? What is going
  to help? Who do I go to?
• lt1/11 Latinos seek Mental Health Tx
• lt1/5 Latinos seek general medical care
• lt1/20 immigrants seek Mental Health Tx
• lt1/10 immigrants seek general medical Tx

23
Reasons provided by patients for not seeking help

• Lack of knowledge of where to seek care
• Lack of proximity to treatment centers
• Transportation problems
• Lack of Spanish speaking providers who are
  culturally and linguistically trained
• La ropa sucia se lava en casa

(Aguilar-Gaxiola et al, 2002)
24
Latino Mental Health Care

• Twice as likely to seek health care in PCP
  clinics, faith based organizations
• PCPs prescribe 67 of psychotropics and 80 of
  antidepressants (Chapa, 2004)
• We have 20 Latino Mental Health Professionals per
  100,000 Latinos in the US

Mexican American Prevalence and Services Survey
(MAPSS)
25
Language Barriers

• Patients report more symptoms during Spanish
  interviews (Price and Cuellar 1981)
• Clinicians detect higher symptom severity in
  Hispanic patients with schizophrenia and
  depression during bilingual interviews followed
  by Spanish, and lowest in English. (Malgady and
  Costantino 1998)
• Nearly half Spanish speaking Latinos report
  trouble communicating with their physicians and
  understanding information about medication and
  written instructions (The Commonwealth Fund 2003)

26
OPERATIONALIZATION OF A SOCIOBEHAVIORAL MODEL OF
HELP SEEKING
PREDISPOSING NEED ENABLING OUTCOMES
Personal Domain
Beliefs and Attitudes
SES, Nativity.Age, Ethnicity, Accul.
Persistence Satisfaction
Sociocultural Domain
Information about MH Problem Identification Stigma
Support for treatment
Family Domain
Impairment, History of Tx and Dx, Self Rated
Mental Health Status, Self-defined Problem,
Insurance and Treatment Exper.
Referral source Staff Courtesy Transportation Work
Obligations Eligibility for Services
Treatment Effectiveness
Access Domain
Provider Domain
Appropriateness of care Timely Appointments
NOTE MODEL FOR GENERATING TESTS OF HYPOTHESES
AND MULTIVARIATE MODELS
27
Mental Illness In the context of Culture

• Expression Consistent with self, family,
  society.
• Assessment Related to perceived experience and
  assigned rationale.
• Treatment Congruent to notion of illness and its
  cause.

28
Institute for Healthcare Improvement (Triple Aim)

1. Improve the health of the population
2. Enhance the patient experience of care (including
   quality, access, and reliability)
3. Reduce, or at least control, the per capita cost
   of care.

29
Border Area LatinoAccess to Mental Healthcare

• Increased number of uninsured and underinsured
• Geographic accessibility concerns
• Specialty services limitations
• Linguistic and cultural incongruence
• Decrease utilization of government programs
  (Medicare, VA)
• Sick time benefits
• Schedule flexibility
• Immigration issues

30
A method for improving cultural congruence The
Cultural Formulation

• Systematic assessment of cultural factors
  impacting Dx and Tx (1994)
• Cultural identity
• Cultural explanations of illness
• Cultural factors related to psycho-social
  environment and function
• Physician patient relationship
• Overall Cultural Assessment

31
CLAS standards

• The collective set of Culturally and
  Linguistically Appropriate Services (CLAS
  Mandates US-DHHS-OMH 2001) intended to guide,
  inform, and facilitate required and recommended
  practices related to culturally and
  linguistically appropriate health services.
• http//minorityhealth.hhs.gov/assets/pdf/checked/e
  xecutive.pdf

32
D Cultural Elements of the Clinician-Patient
Relationship

• Differences in culture, social status or role
  between the clinician and patient
• Communicating with a professional in a field
  unknown to the patient in his/her own culture.
• Communicating with a figure of the establishment
  or authority information that may be damaging to
  an immigration claim, insurance, probation, etc.
• Negotiating levels of intimacy and rapport with
  members of a different race, religion or
  profession.

33
Some Elements of Cultural Congruence

• Language of interview, communication adequacy
• Nature of work-up and interpretation of symptoms
• Role assigned to precipitants/stressors and their
  interaction with individual/social
  vulnerabilities
• Treatments offered and outcomes expected
• Attitudes towards inclusion of family, social
  networks, including spiritual communities
• Addressing stigma
• Healthcare access

34
Cultural Sensitivity Ten Commandments

1. Respect all cultures
2. Understand your own cultural identity
3. Find out each patients cultural identification
4. See patients in a culturally comfortable
   environment
5. Conduct culturally sensitive evaluations
6. Elicit patient (family) expectations,
   preferences, and prior attempts to get help.
7. Adapt treatment techniques to cultural values of
   the patient
8. Determine your cultural effectiveness
9. Understand broader societal influences on
   cultural groups.
10. Advocate for institutional policies and practices
    of cultural competence.

35
Dealing with Stress (Really?)
36
Adapted Interventions Balance

• Go to bed earlier, enjoy your partner and rest
• Avoid drinking excessively, or using drugs
• Enjoy family and friends
• Walk/run in a safe and pleasant environment
• Go to church, read that helpful book
• Worry about what you need to, only
• Celebrate your strengths/gifts, share them
• Take parenting classes, join marital groups

37
Screening and Treatment

• Early detection, meet them where they are
• Any clinic registration, PCP, OBGYN, Peds,
  Geriatrics, Cancer Clinics, Pain Clinics, Rehab
• PHQ-9 (2)
• GAD-7
• TMAP algorithm
• Realistic referral options

38
Integrated Mental Health Care

• Integrating mental health services into primary
  care services and integrating primary care
  services into mental health and substance abuse
  care settings to improve quality of care.

39
Example of Academic and Community Collaborations

• A study proposing to compare the acceptability
  and effectiveness of depression treatment for
  Hispanic patients provided by a psychiatrist
  through internet videoconferencing (webcam) with
  treatment as usual with the primary care provider
  (TAU).

40
College of Medicine

• Mission To continually improve health care for
  all Arizonans through education, research and
  clinical care.
• Services Among its 20 departments and 8
  interdisciplinary centers
  includes
  the Arizona Hispanic Center of Excellence
  Arizona Telemedicine Program

The University of Arizona Health Sciences Center
41
FOUNDED 1962Mission of caring for the uninsured
and underserved for 48 years in Tucson and
Southern Arizona
42
Purpose and Rationale

• Our broad long-term objective is to improve the
  quality of care to underserved Hispanics affected
  with depressive disorders using health
  information technology.
• This technology can be used to provide
  appropriate patient centered care, with
  culturally and linguistically congruent
  providers.
• Results from this study may help inform the
  manner in which quality and specialized
  psychiatric care can be delivered using real time
  video communication through the internet
  (webcam), a medium that is now readily and
  economically available.

43
Subjects

• N 150 Self identified as Hispanics, age 18 y/o
• MINI based DSM-IV diagnosis of Major Depressive
  Disorder (MDD)
• Excluded bipolar disorder, schizophrenia,
  dementia, active substance dependence requiring
  inpatient or residential treatment serious
  medical illness lacking capacity to consent
  pregnant or lactating women and people with
  safety concerns (DTS, DTO).

44
Webcam Intervention
45
Webcam Intervention

• Patients receive services on site at SEHC and
  will be oriented and ushered by study personnel.
• Psychiatric visits include a 45-60 minute full
  psychiatric interview, informed consent and
  treatment planning procedures (American
  Psychiatric Association Treatment Guidelines). In
  addition to pharmacotherapy, other aspects of
  care may include psychoeducation, and brief
  eclectic interventions as appropriate.
• Follow up visits will take place monthly for
  20-30 minutes, for rapport maintenance, progress
  and safety monitor, treatment adjustment if
  needed.
• After hour coverage will be provided through the
  Psychiatry Research Clinician on call at UMC

46
Treatment as Usual by PCP
47
Treatment as Usual

• Depression treatment will be obtained from the
  patients PCP as it is normally done at SEHC.
• TAU often includes antidepressants, in adherence
  to AHCPR treatment guidelines.
• Patients who require additional mental health
  care are referred to behavioral health services
  or community mental health agencies. (patients
  with specific psychosocial issues, safety
  concerns, evident need for couples or family
  therapy)
• Crisis services related to depression are
  provided through standard clinic protocols.

48
Data Collection Tools Schedule
Min Rater Base-line Mo 1 Mo 2 Mo 3 Mo 4 Mo 5 Mo 6
PHQ-9 2 Self X X X
MINI 30 Clin X
Q-LES-Q 5 Self X X X
SF-8 5 Self X X X
MADRS 15 Clin X X X
VSQ-9 2 Self X X X X X X X
WAI-S-CT 5 Self/Clin X X X
ARSMA-II 10 Self X X X
Baseline/ Other Info 5 Self X X X
Compliance rating 1 Self /Clin X X X X X X
49
Depression Outcome MADRS

• Time Effect plt.01 Treatment Interaction p
  lt.05

50
MADRS Categorical Outcome
51
Depression Outcome PHQ-9
Time Effect plt.01 Treatment Interaction p
lt.05
52
Quality of Life Outcome
Time Effect plt.01 Treatment Interaction p
lt.05
53
Disability Outcome
Time Effect plt.01 Treatment Interaction p
lt.05
54
Patient Doctor Relationship(Patient Ratings)
Time Effect plt.01 Treatment Interaction p
lt.05
55
Overall Visit Satisfaction
Time Effect plt.01 Treatment Interaction p
gt.1
56
Summary

• US-Mexico Border Mental Health is associated with
  unique stressors related to immigration,
  acculturation, and common socioeconomic issues
• Providing screening and treatment requires
  cultural, linguistic, and literacy sensitivity
• PCPs (non-psychiatrists) are an important source
  of adequate mental health care
• Specialized care is sparse yet effective when
  accessed and properly delivered.

57
Acknowledgements