Transcript Community Mental Health

William A. Vega, PhD
Provost Professor
Executive Director
Latino Health and Faculty Development Conference
Stanford University, July 22, 2010
Brain Reward Pathways
•The VTA-nucleus
accumbens pathway is
activated by all drugs
of dependence
including alcohol
•This pathway is
important not only in
drug dependence, but
also in essential
physiological
behaviors such as
eating, drinking,
sleeping, and sex
Nucleus
accumbens
Ventral tegmental area
(VTA)
Source: Messing RO. In: Harrison’s Principles of Internal Medicine. 2001:2557-2561.
Systems operating in the etiology of
drug addiction and mental illnesses
DRUGS
social
conduct
neural circuits
protein expression
genome
MENTAL
ILLNESSES
Pathways for interactions among levels:
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Social groups composed of individuals
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Individuals composed of physiological
systems
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Physiological systems composed of cells
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Cells composed of molecules (DNA)
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Only 1 in 10 people who use illicit drugsbecome
dependent on them
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Genetic susceptibility to complex disease usually
results from joint effects of many genes, each
with a small to moderate effect and often with
interaction among themselves (e.g. regions) and
the environment.
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IOM (2006)
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“Schinka et al. have identified a functional
polymorphism within the opioid receptor
gene as a general risk gene for substance
dependence. Substance abuse and
dependence phenotypes that emerge only
after exposure to the environment.”
Licinio, J (2002) Gene-environment interactions
in Molecular Psychiatry.
Molecular Psychiatry 7:123-124
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Tsuang et al. (2001) The Harvard twin study of substance
abuse. Harvard Rev. Psychiatry 9:267-279
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Cooper, R.S. (2003) Gene-environments interactions
and the etiology of common complex disease.
Ann Inter Med 139:437-440
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Lower heart rate variability
Slow recovery from exercise
Elevated cortisol levels related to accelerated
cell aging
Greater risk of metabolic syndrome
Effects on hormonal regulation
(hypothalamic-pituitary-adrena axis)
Increased risk for depression
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Although there are (temporary) exceptions,
such as the immigrant paradox, having better
income and education is protective against
most diseases and mental illnesses in the U.S.
Paradox affects weathering over time and
immigrants have similar disability and chronic
disease levels as U.S. born
Reasons: more persistent life stress, fewer
resources available for avoiding impact of
personal problems and unhealthy behaviors
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SOCIOECONOMIC STATUS
RACE/ETHNICITY
SOCIAL NETWORKS/SOCIAL SUPPORT
PSYCHOSOCIAL WORK ENVIRONMENT
COMMUNITY ENVIRONMENT
IOM (2006)
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Long range impacts of social determinants
and low socioeconomic mobility
Organization of human services to support
optimal human development
Role of research in promoting change
The role of social determinants in changing
public policy
Females: Alcohol Abuse/Dependence Rate
by Parental Risk, Nativity, Time in Country,
Age, and Language Preference
One or more parental risk factors
No parental risk factors
25
20
%
15
10
Females:
5 Alcohol Abuse/Dependence Rate by Parental Risk,
Nativity, Time in Country, Age, and Language Preference
0
Female
immigrant
<13y
(all ages)
Spanish
all the time
Female
immigrant
<13y
(all ages)
Spanish/
English
Female
immigrant
13+y
Age 45-59
Spanish
all the time
Female
immigrant
13+y
Age 45-59
Spanish/
English
Female
immigrant
13+y
Age 18-44
Spanish
all the time
Female
immigrant
13+y
Age 18-44
Spanish/
English
Female
US born
Female
US born
(all ages)
Spanish/
English
(all ages)
English
all or most
Only 3 subgroups show any effect of parental risk factors:
• Female US born English all or most (high acculturation): 20% vs 2% (p < 0.001),
• Female US born Spanish/English (low acculturation): 10% vs 2% (p = 0.04).
• Female immigrant 13+ y Age 18–44 Spanish/English (high acculturation): 9% vs 2%
(suggestive but NS)
Context Dependence: Gene-Environment Interaction Model
Phenotype
GVP
GVA
GVP
GVA
Mexico
USA
Exposure
GVA = Gene Variant Absent
GVP = Gene Variant Present
Adapted from Cooper, R.S. (2003).
Annals of Internal Medicine, 139:437-440
Males: Alcohol Abuse/Dependence Rate
by Parental Risk, Nativity, Time in Country,
Age, and Language Preference
One or more parental risk factors
No parental risk factors
40
30
% 20
10
Males: Alcohol Abuse/Dependence Rate by Parental Risk,
Nativity, Time in Country, Age, and Language Preference
0
Male immigrant Male immigrant Male immigrant Male immigrant Male immigrant Male immigrant
<13y
<13y
13+y
13+y
13+y
13+y
(all ages)
(all ages)
Age 45-59
Age 45-59
Age 18-44
Age 18-44
Spanish
Spanish/
Spanish
Spanish/
Spanish
Spanish/
all the time
English
all the time
English
all the time
English
Male US born
Male US born
(all ages)
Spanish/
English
(all ages)
English
all or most
Only 2 subgroups have a significant effect of parental risk factors:
• Male immigrant <13y Spanish/English (high acculturation): 20% vs 5% (p = 0.01),
• Male US born Spanish/English (low acculturation): 33% vs 9% (p < 0.001).
Age significant for immigrant 13+ y (p = 0.01); NS for US born and immigrant <13y.
U.S.1
Mexico2
Immigrants U.S. born
Alcohol abuse
0.4
1.0
8.7
Alcohol
dependence
0.5
1.7
11.0
Drug abuse
0.0
0.6
5.2
Drug dependence
0.1
0.3
3.2
Nicotine
dependence
0.9
1.5
9.8
1
NESARC.
2
from M. Medina-Mora et al., in press.
U.S.1
Mexico2
Immigrants U.S. born
Alcohol abuse
4.9
15.4
25.2
Alcohol
dependence
8.8
9.6
19.4
Drug abuse
2.3
1.8
12.0
Drug dependence
0.7
0.5
4.5
Nicotine
dependence
2.2
5.1
10.2
1
NESARC.
2
from M. Medina-Mora et al., in press.
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Any alcohol abuse/dependence with or
without drug dependence, and a co-occurring
non-addictive DSM-IV disorder
Total for immigrant women 0.68%,
men 5.25%
Total for U.S. born women 7.33%,
men 16.22%
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Drugs: Costa Rica 15, Mex. 10, U.S. 29
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Alcohol: Costa Rica 20, Mex. 19, U.S. 34
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Any Sub A/D: Costa Rica 25,Mex. 23,
U.S. 45
Crabbe, JC (2002) Genetic contributions to addiction.
Annu Rev Psychol 53:435-62
“The First Law of Improvement”
from Donald Berwick
Every system is perfectly designed to achieve
exactly the results it gets.
“In other words it sure didn’t get this way by accident”
Bill Vega
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Access to care in a cost-control environment
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Reconfiguring a fragmented health care system
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Poor coordination of payers to providers for safety net populations
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Low visibility and high stigma of mental health providers and treatments
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Low availability of linguistically competent staff or translators
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Low availability of co-ethnic specialists
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Most mental health problems presented in primary care where behavioral
health specialists are not available and providers are not disposed to offer
treatment
 Current levels of practicing mental health professionals: 29 Hispanics per 100,000 vs.
173 European Americans per 100,000
The Chain of Effect
in Improving Cultural Competence
regulations
Standards of care,
enforcement accountability
Research
knowledge
Model testing and development, efficacy and effectiveness trials, scaling up
Organizational
Context
processes of
care
Policy development and
implementation
Macro-system
Clinical Skills
Design Concepts for practice standards, clinical
culture, upskilling staff and continuous quality
improvement
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THE REGULATORY COMMUNITY IMPOSING STANDARDS AND
ACCOUNTABILITY FOR SYSTEMS OF CARE (INCLUDING FEDS,
LICENSURE AND ACCREDITING BODIES)
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THE RESEARCH COMMUNITY PROVIDING THEORY, IMPLEMENTATION
MODELS, AND EVIDENCE OF EFFECTIVENESS
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THE INDIVIDUAL AS THE NEXUS OF CULTURALLY COMPETENT
(INDIVIDUALIZED) CARE MODELS
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THE HEALTH CARE ORGANIZATION AS THE WEBWORK CONTROLLING
ACCESS, PROCESSES OF CARE AND PRACTICE INNOVATIONS, AND
OUTREARCH TO PATIENTS AND COMMUNITY
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Clarifying national aims for improvement
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Changing the care, itself
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Changing the organizations that deliver
care
Changing the environment that affects
organizational and professional behavior
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Spanish-speaking Latinos less likely to have
physician visits, flu shots, or mammograms than
English speaking Latinos or non-Latino whites.
(Fiscella)
Children whose parents speak Spanish less likely
to have usual source of care than English
speaking Latinos or non-Latino whites. (Weinick)
Spanish speakers who could not communicate
with their physicians less likely to be discharged
from the ER with a follow-up appointment.
(Sarver)
Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the
insured. Med Care 2002;40:52-9.
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Spanish speakers less likely to be discharged from the
ER with an understanding of their medications, special
instructions, and plans for follow-up care (Crane)
Spanish-speaking Latinos more likely to report
problems with communication than English-speaking
Latinos (Commonwealth Fund 2002 Health Care
Quality Survey)
Spanish speakers who needed but didn't receive an
interpreter were at much higher risk for not
understanding discharge medications. (Andrulis in
toolkit/Appendix A)
Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J
Emerg Med 1997;15:1-7.
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Speaking a primary language other than
English was an independent predictor of
patient-reported drug complications.
(Ghandi)
Spanish speaking patients less likely to
receive standard of care (prompt surgery)
in cholecystitis. (Diehl)
Ghandi TK, Burstin HR, Cook EF, et al. Drug complications in outpatients. JGIM 2000;15:149-154.
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Patients whose primary language was not
English significantly less likely to want to
return to same ER for future care
(Carrasquillo)
Patients who needed but didn't receive an
interpreter in the ER were less satisfied
with the care they received, as well as less
satisfied with their physician. (Baker)
Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency
department. JGIM 1999; 14: 82-87.
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Pediatric patients with a language barrier had
higher charges ($38) and longer stays (20 min)
than those without language barriers. (Hampers
1999)
Pediatric patients who needed, but didn't receive,
a professional interpreter had higher test costs
and were the most likely to be admitted to the
hospital (compared to patients who could speak
directly with their doctors, and patients who had
a trained interpreter). (Hampers 2002)
Hampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE. Language barriers and resources utilization in a pediatric emergency
department. Peds 1999; 103(6): 1253-1256.
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Repeated studies have shown that African Americans
tend to receive significantly higher doses of
antipsychotics than Caucasians
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On the other hand, Hispanics and Asians seem likely to
receive lower antipsychotic doses than Caucasians
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African and Hispanic Americans are more likely to receive
depot antipsychotics than Caucasians
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African and Hispanic Americans seem more likely to
receive typical antipsychotics than Caucasians