Transcript Integrating Community Health Workers in a Faith Based

Mental Health Along the Border
Francisco Moreno, MD
Professor of Psychiatry
University of Arizona
Overview
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Demographics of Border States
Challenges for Mental Health Care Along
the Border
Approaches to Minimize Mental Health
Care Disparities
Census 2000: Percent Hispanic Along
Border States
42.1
32.4
32.0
25.3
Percent of total population
New Mexico
California
Texas
Arizona
Heterogeneity of Hispanic Americans
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Birthplace
Acculturation
Language
Literacy
Genetics
Race
Education
SES
Additional shared factors: urbanicity,
region, etc.
Mexican Born Population in the US
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32% of those who are Foreign Born
10.2 % of the Population in Mexico
Hispanic Americans Demographics
Characteristic
Hispanic Gen Population
Median age (years)
26.0
Foreign born (%)
40.2
Foreign language spoken at home (%)
78.6
English spoken less than “very well” (%)
40.6
Age ≥25 years with ≥high school education (%) 52.4
Age 16 years and older in labor force (%)
69.4
Median household income in 2003 (US$)
32,997
Living in poverty (%)
22.6
Health insurance in 2003 (%)
67.3
35.4
11.1
17.9
8.1
80.4
70.7
43,318
12.4
84.4
Ramirez 2004
DeNavas-Walt et al. 2004
Highest Degree Earned by People 20
and Older by Race & Ethnicity, 2008
Richard Fry, Senior Research Associate Pew Hispanic Center
Hispanic Immigrants and Education
Richard Fry, Senior Research Associate Pew Hispanic Center
Risk Factors for Mental Illness
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Medical conditions: Diabetes, obesity, etc
Domestic violence, “Machismo” effects
Beneficial and otherwise effects of family
involvement and demands
Acculturation
Early life trauma
Financial challenges
Racism
Migration Related Stress
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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
Border Area Latino:
Access to Mental Healthcare
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Increased number of uninsured and underinsured
Geographic accessibility concerns
Specialty services limitations
Linguistic and cultural incongruence
Sick time benefits
Schedule flexibility
Immigration issues
Even in government programs (Medicare, VA)
Depression Screening in Immigrant
Latinas in L.A.
20
18
16
14
12
10
8
6
4
2
0
N= 5122
No Children
Living With Children
Living Without
Children
Imigrant Latina Women with
Depression
Miranda et al., 2005
Language Barriers
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Price and Cuellar in 1981 compared separately
recorded Spanish- and English-language
interviews. They found that subjects expressed
more symptoms during the Spanish interview
In a similar study (Malgady and Costantino 1998)
reported that symptom severity among Hispanic
patients with schizophrenia and depression was
rated highest in bilingual interviews, followed by
those in Spanish, and lowest in those in English
OPERATIONALIZATION OF A SOCIOBEHAVIORAL MODEL OF HELP SEEKING
PREDISPOSING
Beliefs and
Attitudes
SES, Nativity.Age,
Ethnicity, Accul.
Information about MH
Problem Identification
Stigma
Support for treatment
Referral source
Staff Courtesy
Transportation
Work Obligations
Eligibility for Services
Appropriateness of care
Timely Appointments
NEED
ENABLING
OUTCOMES
Personal
Domain
Persistence
Satisfaction
Sociocultural
Domain
Family
Domain
Impairment, History of
Tx and Dx, Self Rated
Mental Health Status,
Self-defined Problem,
Insurance and
Treatment Exper.
Access
Domain
Provider
Domain
NOTE: MODEL FOR GENERATING TESTS OF HYPOTHESES AND MULTIVARIATE MODELS
Treatment
Effectiveness
Cultural Explanations of the Illness
• Idioms of distress and local
illness categories
• Meaning of the illness in
relation to cultural norms &
severity of symptoms based on
perception
• Help-seeking and care
experiences with professional or
traditional sources. Effects in
plans
Some Elements of Cultural
Congruence
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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
Cultural Elements of the ClinicianPatient 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.
Treatment Readiness
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Concept of illness, cause, and treatment
Physical access, cost, and flexibility
Psychoeducation, stigma abatement
Relating as allies, compassionate
collaborators, without judgment
Language and cultural understanding
Incorporation of client values
Arizona Border Mental Health
Example of Academic and
Community Collaborations
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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).
College of Medicine
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The University of Arizona
Health Sciences Center
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
FOUNDED 1962
Mission of caring for the uninsured
and underserved for 48 years in
Tucson and Southern Arizona
Purpose and Rationale
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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.
Subjects
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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).
Webcam Intervention
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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
Treatment as Usual
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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)
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Crisis services related to depression are
provided through standard clinic protocols.
Data Collection Tools Schedule
Min Rater
Base
-line
PHQ-9
2
Self
X
MINI
30
Clin
X
Q-LES-Q
5
Self
SF-8
5
MADRS
Mo
1
Mo
2
Mo 3
Mo 4
Mo 5
Mo 6
X
X
X
X
X
Self
X
X
X
15
Clin
X
X
X
VSQ-9
2
Self
X
WAI-S-C+T
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
X
X
X
X
X
X
Depression Outcome MADRS
Time Effect: p<.01
Treatment Interaction: p <.05
Depression Outcome PHQ-9
Time Effect: p<.01
Treatment Interaction: p <.05
Quality of Life Outcome
Time Effect: p<.01
Treatment Interaction: p <.05
Disability Outcome
Time Effect: p<.01
Treatment Interaction: p <.05
Patient Doctor Relationship
Time Effect: p<.01
Treatment Interaction: p <.05
Summary
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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
Specialized care is sparse yet effective when
accessed and properly delivered.