Transcript Recognizing and Diagnosing Depression in Hispanic/Latinos

Recognizing and Diagnosing Depression in
Hispanic/Latinos: Focus on Primary Care
Javier I. Escobar, M.D.
Associate Dean for Global Health
UMDNJ-RWJMS
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 Foundation’s Physician Scholars Program -
National Advisory Committee
 American Psychiatric Association’s Task force on DSM-V; University of
New Mexico’s NIMH Mentoring (MEP) Grant
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
 >75% 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. 2000;23(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.
Ethnicity and Medically Unexplained
Symptoms in the United States
Community: ECA Study
25%
(1)
Primary Care: UC-Irvine Study
30%
Central
Americans
White Mexicans African American Puertoricans
25%
20%
Mexicans
Non-Latinos
MexicanAmericans
20%
15%
15%
10%
10%
5%
5%
0%
0%
4-6 Symptoms
1-Escobar et al, JNMD, 1989, 177: 140-146
(2)
13 or more
Symptoms
2-Escobar et al, Psychosomatic Medicine, 1998. 60: 466-472
“I cannot express any anger. That is
one of the problems I have. I grow a
tumor instead.”
Woody Allen’s line in “Manhattan” (1980’s)
Interpretation of Medically Unexplained
Symptoms


Differs by specialty
Syndromes made to fit specialty paradigms
(pathophysiology and nomenclatures)
Functional Somatic Syndromes*
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
Chronic whiplash syndrome
Chronic Lyme’s 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
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
Number of Physical Symptoms Highly
Correlate With Mood Disorder
Patients With
Mood Disorders (%)
80
60
60

Patients with depression often
present with numerous physical
complaints

As the number of physical
complaints increase, so
does the likelihood of a
mood disorder1

30% of depressed patients
experience physical symptoms
for >5 years before receiving
the proper diagnosis 2
44
40
23
20
0
12
2
0-1
2-3
4-5
6-8
Number of Physical Symptoms
(N=1000)
1Kroenke
9
K, et al. Arch Fam Med. 1994;3(9):774-779; 2Lesse S. Am J Psychother. 1983;37(4):456-475.
STAR-D Study: Pain Complaint Scores and
Depression
IDS-C30 Item 25 Depressive Symptomatology-Clinician Rating,
Range 0-3
50%
40%
36%
30% 23%
25%
20%
16%
Over 40 %
10%
0%
No Pain
Mild pain
Pain Most of
Pain Causes
Complaints
the
Time
Hussain MH, Rush AJ, Trivedi
MH, et al, Journal of Psychosomatic Research
(2007);
63:113-122Functional
Impairment
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
“Depression” and US Hispanics
Most Studies include the generic term “Hispanic” or
“Latino”—They 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
Painful Physical Symptoms in
Depressed Latin Americans
989 Patients with MDD Selected in 7 Latin American Countries
Muscle Pain Abdominal Lumbar Chest
Pain
Pain
Pain
100%
17.7
Prevalence (%)
19.0
38.5
Neck Pain
22.0
39.2
51.5
18.8
18.5
60%
40%
21.9
20.5
23.3
20%
13.7
11.3
3.7
22.1
21.0
15.7
16.2
6.5
22.3
20.7
13.1
Munoz R, et al, Journal of Affective Disorders, 86: 93-98, 2005
18.5
17.4
17.6
9.7
None
Moderate
Intense
Unbearable
20.7
20.0
13.1
Reported
Pain
A Little
20.0
26.2
0%
Joint
Pain
22.4
32.0
80%
Headache
9.1
15.8
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)
Response to Imipramine and Placebo in Depression:
Colombian vs. US Patients
Imipramine
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Placebo
>50% Reduction in HAM-D Scores
Colombia
Escobar JI, Tuason VB, Psychopharmacology Bulletin, 1980; 16: 49-52
United States
Country Origin of Latino Patients in a Primary Care Study of
Physical Symptoms, Depression and Anxiety in New Jersey
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
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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
Consumer Satisfaction in a Large Mental Health System in NJ
(percent rating very good to excellent)
Latinos
Blacks
Whites
64%
62%
60%
58%
56%
54%
52%
Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003
Percent With Serious Mental Illness
MDD, Bipolar)
Latinos
Blacks
50
45
40
35
30
25
20
15
10
5
0
Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003
(Dementia, Schizophrenia,
Whites
Percent Diagnosed as Schizophrenia or Major
Depression
TOTAL N=19,219
Latinos (N=1531)
Blacks (N= 6,475)
Whites (N=10,339
30
25
20
15
10
5
0
Schizophrenia
Major
Depression
Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003
Feedback on Depression in Latinos
Focus Groups in the North East
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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
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
Guidelines for Cultural Formulation of Psychiatric
Diagnosis

Clinical history

Cultural “identity”
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Cultural explanation of the illness
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Cultural factors related to psychosocial environment and levels
of functioning
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Cultural elements of the clinician-patient relationship
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Overall cultural assessment
Lewis-Fernández R 1996
Acceptability of Treatment for Depression
in Primary Care

Telephone Survey including 829 primary care patients (659 nonHispanic 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
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
Clinical Vignette (Continued)

Mrs. Gonzalez’s 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
EKG=electrocardiogram; CBC=complete blood count; LFTs=liver function tests.
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
mother’s 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.
Gonzalez’s 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
Clinical Vignette (Continued)

The patient was assessed by the clinic’s 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
Clinical Vignette (Continued)

Mrs. Gonzalez’s 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
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. Gonzalez’s condition improved. After 6 to 8 weeks,
her symptoms were largely resolved, and she is seen every 2
months or so.