October 19, 2010 Diversity Rx 2010 National Conference

1. Depression Treatment in Primary Care Settings:An APA-NAMI Collaborative CME Approach to Eliminate Disparities for Racial/Ethnic Communities October 19, 2010 Diversity Rx 2010 National Conference On Quality Health Care for Diverse Populations Baltimore, Maryland Annelle B. Primm, M.D., MPH Director, Minority and National Affairs American Psychiatric Association aprimm@psych.org

3. In Living Color 3 hour CME curriculum, NAMI-APA effort Focuses on treating Depression in Diverse Populations for primary care Taught by teams consisting of a physician, person with history of depression and a family mental health advocate Combines the science and the lived experience of depression among diverse populations PHQ-9 Ethnopsychopharmacology

4. Curriculum Goals • Equip primary care practitioners with the appropriate knowledge and tools to identify and provide treatment of depression in diverse populations • Create awareness of cultural influences and how depression manifests within a cultural context • Model successful communication and partnership between providers and patients of different cultures

5. Course Topics – A Sampling • Recognizing depression in diverse racial and ethnic groups • Overcoming challenges in diagnosis and treatment in these populations • Recognizing cultural influences on mental illness/health • Successful communication

6. Course Topics – A Sampling • Basic Principles of Quality Care • Person-centered care • Culturally competent care • Recovery-oriented care • Treatment and referral • Ethnopsychopharmacology

7. Developers • APA – American Psychiatric Association • NAMI – National Alliance on Mental Illness • Curriculum authors: • Annelle B. Primm, M.D., MPH, APA Office of Minority and National Affairs • Majose Carrasco, MPA, Director, NAMI Multicultural Action Center • Supported by a grant from Praxis Partnership, a consortium of UAB Birmingham, Vanderbilt University, Indicia Medical Education, LLC which received its funds from an unrestricted grant from Wyeth

8. Inspiration and Collaboration • Depression is a prevalent illness found in primary care, costly to treat but even more costly if untreated • Depression is commonly missed or misdiagnosed • Routine screening is recommended as locally accepted best practice in many areas and required by some health care systems and organizations • Disparities in quality depression care exist among patients of diverse populations in whom depression is often undetected or undertreated

9. Unique Characteristics • Innovative presentation format • Presented by a team of 3 trained facilitators (1 physician and 2 consumers/family members • Models effective clinician/patient interaction • Promotion of consumer-centered treatment • President’s New Freedom Commission Report in 2003 recommended that people with mental illness actively participate with health care professionals in designing, developing systems of care in which they are involved.

10. Pilot Phase and Evaluation • Facilitator training • Program piloted in Los Angeles, St. Louis and New Orleans • 45 primary care practitioners participated • Overwhelming positive response to the patient perspective • 86% of participants rated the content of the course as excellent or good • 97% of participants found the curriculum helpful in addressing barriers to and approaches for depression care

11. Evaluation • Statistically significant perceived improvement in 5 out of 7 items from pre to post test • The importance of the role of the clinician’s race, ethnicity and worldview in evaluation and treating patients of different backgrounds • Clinician’s level of confidence in ability to communicate effectively with patients from diverse groups regarding the diagnosis and treatment of depression • Clinician’s confidence in determining when it is appropriate to refer a person with depression to a psychiatrist for treatment

12. Agenda • Part 1: Understanding Depression, Culture and Consumer-Centered Care • Break • Part 2: Recognition and Diagnosis • Break • Part 3: Treatment, Referral and Adherence to Treatment

13. Learning Objectives • Interpret how depression manifests itself in racially and ethnically diverse populations • Identify depression screening, diagnosis and treatment options • Understand how the patient’s and physician’s cultures can affect diagnosis and treatment • Develop strategies for effective physician-patient communication

14. Depression: The Burden of Suffering • Lifetime risk: 13% - 16%. (Hasin et al, 2005; Kessler et al, 2003) • Functional impairment caused by depression is similar to that of many chronic diseases • More than 50% of patients see only primary care providers (Sturm et al, 1996) • Prevalence in primary care: 15-22% overall • major depression 5-9% • dysthymia 2-4% • minor depression 8 -10% (National Library of Medicine, 2005)

15. Depression Under-recognition & Treatment • Only a fraction properly diagnosed and treated • About 50% of depression cases are missed in primary care settings. (Goldman et al,1999) • Diverse populations more frequently undiagnosed and undertreated • African Americans and Latinos/Hispanics are less likely to receive care consistent with practice guidelines (Wang et al 2000)

16. Disparities in Depression Treatment Of people with depression % not accessing any mental health treatment in the past year: • Asians 69% • Latinos 64% • African Americans 59% • Whites 40% Alegria et al , 2008

17. Culture Counts: Influences onMental Illness & Mental Health Communication (verbal and non-verbal) Manifestation of symptoms Family and community support Health-seeking behaviors Support systems and protective factors How people perceive & cope with mental illness How clinicians interact with people with mental illness Stigma and shame associated with mental illness Spirituality (predestination, views of illness, etc) (Surgeon General, 2001)

18. Spirituality and Alternative Sources of Care • Spirituality has an important role in many racial/ethnic communities. • Can promote mental health education and prevention • Key source of support (Surgeon General, 2001) • However, people of color may rely solely on spiritual support in lieu of professional treatment. • Propensity to use alternative care for religious or cultural reasons: 12% of African Americans 27% of Asian Americans 22% of Hispanics 4% of Non-Hispanic Whites (Collins et al, 2002) • Lifetime help-seeking from traditional or spiritual healer for psychiatric disorders in American Indians: • 37% and 20% males (Southwestern and Northern Plain tribes) • 41% and 19% females (Southwestern and Northern Plain tribes) (Beals et al, 2005)

19. Basic Principles of Quality Care Recovery-oriented Culturally Competent Person-centered

20. Recovery-Oriented Care It is important to convey a sense of hope and the fact that depression is treatable. “The American Psychiatric Association endorses and strongly affirms the application of the concept of recovery …. The concept of recovery emphasizes a person’s capacity to have hope and lead a meaningful life, and suggests that treatment can be guided by attention to life goals and ambitions. It focuses on wellness and resilience and encourages patients to participate actively in their care ….” (APA, 2005)

21. Culturally Competent Care • “Cultural competence is a set of values, behaviors, attitudes, and practices within a system that enables people to work effectively across cultures.” (Office of Minority Health) • Cultural competence is the ability to work effectively and sensitively within various cultural contexts.

22. Characteristics ofCulturally Competent Care • Cultural self-awareness (introspection) • Awareness of the cultural context of the other • Understanding the dynamics of the differences • Development of cultural knowledge • Ability to adapt and practice skills to fit the cultural context(s) of others

23. Skills Development: The LEARN Model Listen with empathy and understanding to the person's perception of the situation. Elicit culturally relevant information and Explain your perception of the situation. Acknowledge the similarities and differences between your perceptions and theirs. Recommendoptions/alternatives and Respect the person and her choices. Negotiate agreement. (Berlin & Fowkes, 1983)

24. Person-Centered Care Person-centered care: healthcare partnership among practitioners, patients, and their families to ensure that decisions respond to and respect patients' wants, needs, and preferences and solicit patients' input on the education and support they need to make decisions and participate in their own care. (Adapted from Agency for Healthcare Research and Quality, 2002) Six dimensions of person-centered care: • Respect for patient’s values, preferences, and expressed needs • Coordination and integration of care • Information, communication, and education • Physical comfort • Emotional support • Involvement of family and friends (Gerteis et al, 1993)

25. Physician’s Communication Skills “Focusing attention on patient-centered communication is not merely an ethical imperative in health care; we also believe it will lead to better health outcomes. Communication barriers are especially prevalent among vulnerable minority populations, and efforts to improve patient-centered communication may help alleviate racial and ethnic disparities in health care.” (American Medical Association, 2006) • Data-gathering • Relationship-building • Partnering skills • Patient education and counseling • Facilitation and patient activation • Avoidance of verbal dominance (Adapted from Cooper et al, 2007)

26. Depression in Primary Care:Recognition and Diagnosis • Assessment • Screening—the PHQ-9 • Detection of suicidal ideation • Dual diagnosis

27. Diagnostic Criteria: Major Depressive Disorder At least five of the following symptoms most of the day, nearly every day for at least two weeks: • Depressed mood • Diminished interest or pleasure in most activities • Insomnia or hyper-somnia • Significant weight loss or gain • Feelings of guilt or worthlessness • Fatigue (loss of energy) • Impaired concentration • Psychomotor retardation or agitation • Recurrent thoughts of death or suicide (American Psychiatric Association, 2000)

28. Presenting Depression Complaints Across Cultures (Kales et al, 2005; Tseng and Streltzer, 1997; Mezzich et al, 1996

30. Depression and Suicide • Major depression accounts for about 1/3 of all suicides, and all mood disorders together account for 2/3 of suicides.(SAMHSA, 2007) • The lifetime risk of suicide among people with untreated severe depression is nearly 20%. (Gotlib & Hammen, 2002) • One study reported that “suicide by cop” accounted for 11% of officer-involved shootings.(Hutson, 1998) • Suicide rates are highest among whites and second highest among American Indian and Native Alaskan men. (CDC, 2007) • Among Asian Americans, there is a greater suicide rate among elderly women and those ages 15-24 years. (Surgeon General, 2001) • Caribbean men have particularly high rates of suicide attempts. (Joe et al, 2006)

31. Substance Abuse and Depression • Depression and substance abuse commonly co-occur. Almost 1/3 of primary care patients diagnosed with depression reported either hazardous drinking, use of illicit drugs, or misuse of prescription drugs. (Roeloffs et al, 2002) • Untreated depression can increase the risk of substance abuse (self-medication) and vice versa. • There is greater exposure and accessibility to drugs/alcohol in communities of color. • Substance abuse is highest among American Indians and Alaska Natives (21.0%) and lowest among Asians (4.5%). (SAMHSA, 2005)

32. Depression and Co-morbidity • Depression should not be explained away by the existence of other medical conditions. • Medical conditions commonly associated with depression: - Stroke - Dementia - Diabetes - Coronary artery disease - Cancer - Chronic fatigue syndrome - Fibromyalgia - HIV

33. Other Considerations • Major depression versus other mood disorders • Concurrent medications • Other stressors: poverty, loss of employment, traumatic loss, etc

34. Depression in Primary Care: Treatment and Referral

35. Depression Care Process (Adapted from MacArthur Initiative on Depression and Primary Care)

36. Shared Decision Making • Doctor and consumer work together to make health care decisions that are informed by: • The best available evidence about treatment, screening, and illness-management options • Potential benefits and harms, taking into account the consumer’s preferences • Doctor involves consumer in treatment decisions by: • Offering choices • Discussing pros and cons • Asking for preferences and opinions • Negotiating and reaching a mutually agreeable treatment plan

37. Treatment Preferences • If diagnosis is confirmed, educate on the following: • Depression • Treatment options and processes • Peer supports • Recovery • During conversation about treatment options, consider the person’s: • Cultural and social context—e.g., language • Religious and spiritual beliefs • Views of illness • Level of understanding • Family dynamics

38. Factors Determining Pharmacological Response Other factors Culture Ethnicity Environmental factors Genetics Pharmacodynamics Pharmacokinetics Dosage side effects Clinical response (Henderson, 2007)

39. Ethnopsychopharmacology • Ethnic and racial variation in response to psychotropic medication due to specific polymorphic variability which affects drug metabolism • Factors such as age, gender, diet and smoking also play a role in determining differential response

40. Ethnopsychopharmacology • Cytochrome P450 (CYP450) drug-metabolizing enzymes: • >20 human CYP450 enzymes identified1 • Metabolize antidepressants, antipsychotics, and benzodiazepines1,2 • Most relevant to psychiatric treatment include1,2: • CYP2D6 • CYP3A4 • CYP1A2 • CYP2C19 • Smith, MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical Manual of Cultural Psychiatry. Arlington, VA: AP Publishing, Inc.; 2006:207. • Bondy B. Dialogues Clin Neurosci. 2005;7:223.

42. The Ethnopsychopharmacological Approach • Assessment • Cultural formulation for diagnosis • Choice of medication • Use medical history, concurrent medications, diet, food supplements, and herbals combined with knowledge of enzyme activity in certain ethnic groups • Start at lower doses • Monitor patient • Proceed slowly; involve family • If side effects are intolerable, lower dosage or choose drug metabolized through different route • If no response, check adherence, raise dose, and monitor levels; add inhibitors; switch drug (Henderson, 2007)

43. Other Issues in Treatment • Managing side effects • Drug interactions • FDA Advisory Black Box Warning • Maintenance treatment • Psychotherapy and Counseling in Primary Care • Specialist Decision Support and Referral

44. Adherence to Treatment • Homelessness, substance use/abuse, support systems, affordability, cultural norms, and side effects play a role in adherence • Pharmacotherapy discontinuation occurs more frequently among African Americans and Latinos than in other groups (Brown et al, 1999, and Olfson et al, 2006) • Adherence is negatively affected by lack of physician-patient communication and lack of cultural competence in service delivery

45. Peer Supports • Peer support fosters and supports recovery because, among other things, it can help combat the loneliness and the sense of not belonging that people with depression may experience. • NAMI affiliates offer free programs designed to assist individuals and families affected by severe depression and other mental illnesses, including: • Peer-to-Peer • Family-to-Family • NAMI Connection

46. Other organizations that offer peer services for people with depression and other mental illnesses are: • Depression and Bipolar Support Alliance www.dbsalliance.org • Depression is Real Campaign www.depressionisreal.org • Mental Health America www.mentalhealthamerica.net • The MacArthur Initiative of Depression and Primary Care www.depressionprimarycare.org/clinicians/toolkits/ materials/patient_edu/

47. Take Away Messages • Disparities in depression care for communities of color exist. Primary care professionals are in a key position to help eliminate these disparities • Cultural factors are important when diagnosing and treating depression • Person-centered, culturally competent, recovery-oriented services are key ingredients of quality care • PHQ-9 is a quick and easy tool for detecting and monitoring depression. • Good communication and shared decision making are important components of the treatment process