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

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) 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 DistressPercent of Poverty NHW= Non-Hispanic Whites

16. Percentage feeling depressive symptoms all the time 2010 NHW= Non-Hispanic Whites

17. Percentage feeling anxious symptoms most the time 2010 NHW= Non-Hispanic Whites

18. Death Rates for Suicide by Sex and Ethnicity (by 100,000) NHW= Non-Hispanic Whites

19. Suicidal Attempts in HS Students NHW= Non-Hispanic Whites

20. Percentage receiving counseling / medication in 2008 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? • <1/11 Latinos seek Mental Health Tx • <1/5 Latinos seek general medical care • <1/20 immigrants seek Mental Health Tx • <1/10 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. (Malgadyand Costantino1998) • 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 Beliefs and Attitudes Personal Domain 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 Appropriateness of care Timely Appointments Provider Domain 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) • Improve the health of the population • Enhance the patient experience of care (including quality, access, and reliability) • Reduce, or at least control, the per capita cost of care.

29. Border Area Latino:Access 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/executive.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 • Respect all cultures • Understand your own cultural identity • Find out each patient’s cultural identification • See patients in a culturally comfortable environment • Conduct culturally sensitive evaluations • Elicit patient (family) expectations, preferences, and prior attempts to get help. • Adapt treatment techniques to cultural values of the patient • Determine your cultural effectiveness • Understand broader societal influences on cultural groups. • 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 patient’s 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

49. Depression Outcome MADRS Time Effect: p<.01 Treatment Interaction: p <.05

50. MADRS: Categorical Outcome