Improving Mental Health Service Delivery to Hispanics

Presenters:

Peter J. Guarnaccia, Ph.D. - Rutgers University

Igda Martinez, Psy.D. – Albert Einstein College of Medicine

Henry Acosta, MA, MSW, LSW – National Resource Center for Hispanic Mental Health

National Resource Center for Hispanic Mental Health®Changing Minds, Advancing Knowledge, Transforming Lives™

Training Held on May 5, 2012 on behalf of the agency’s project:

Partners for Culturally Competent Behavioral Health Service Delivery to Hispanics

1

AcknowledgementFunding for Partners for Culturally

Competent Behavioral Health Service Delivery to Hispanics was made possible through a grant from the Bristol-Myers Squibb Foundation.

BMSF had no control over the contents of today’s training or any other program development or intervention activities

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Welcome & Overview

Henry Acosta, MA, MSW, LSWNational Resource Center for

Hispanic Mental Health

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Agenda 10:00 am-10:15 am Welcome, Overview &

Introductions: Henry

10:15 am-10:45 am Assessing Diversity among Latinos: Peter

10:45 am – 11:00am Break

11:00 am-12:30 pm Latino Mental Health: Focus on Depression and Its Treatment: Igda

12:30 pm-1:30 pm Lunch

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Agenda 1:30 pm-2:30 pm DSMIV, Cultural Formulation

and Latinos: Peter 2:30 pm – 2:45 pm Break 2:45 pm-3:30 pm Using Genograms to Elicit

Cultural & Family Issues: Igda 3:30 pm-3:45 pm Social & Cultural Assessment of

Hispanics: Peter 3:45 pm-4:00 pm Evaluation & Wrap-Up

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Assessing Diversity Among Latinos

Peter J. Guarnaccia, Ph.D.Rutgers,

The State University of New Jersey

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Hispanic Identity Question

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Race Question

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¿Hispanic or Latino? One of the most popular debates and one of

the least likely to be solved Hispanic adopted by U.S. Census in 1970◦Seen as an imposed term by U.S. government

◦More identified with Spanish origins

Latino refers to Spanish, Indian & African origins of people from the Americas

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Who are Latinos in New Jersey?

Source : U.S. Census, 200010

National Latino & Asian American Study (NLAAS)

Principal Investigators◦Margarita Alegria, Harvard Medical School◦David Takeuchi, University of Washington

Funding: National Institute of Mental Health, SAMHSA/CMHS and OBSSR

Latino Sample: ◦Nationally representative household sample:

adults 18 and older

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Methods 75.5% response rate Instrument fully translated

and adapted into Spanish Administered by trained

bilingual/bicultural lay interviewers

Analyses performed with sample weights to account for complex sample design

NLAAS Latino Sample (N=2554)

614

495

577

868

Mexican Cuban

Puerto Rican Other

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Demographics - Age

Cubans are significantly older than the other Latino groups

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Demographics - Gender

Mexicans and Cubans include slightly moremales than the other Latino groups

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Demographics - Education

Mexicans have less education thanthe other Latino groups

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Demographics – Income

Mexicans have significantly lower incomesthan the other Latino groups

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Demographics - Citizenship

Puerto Ricans are all citizens. About 60% of the other 3 groups are citizens.

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Migration - Nativity

About 85% of Cuban respondents were born in Cuba. Over half of Puerto Ricans were born on the mainland.

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Migration – Number of Parents Born in the U.S.

More likely that both parents born In US than 1 parent;Cubans least likely to have US born parents

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Migration – Percentage of Life in US

Puerto Ricans have spent more of their life on the U.S. mainland

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Migration – Wanted to Move

Cubans were the only group where a largemajority expressed a desire to move to the US

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Migration – Move Planned

Cubans were more likely to have carefullyplanned their move to the US

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Reasons for Migration% Very Important

Reason for Move

Puerto Rican

Cuban Mexican Other Latinos

p

Employment 66 52 75 65 .001

Join Family 51 53 48 52 .75

Improve Future for Children

78 84 84 79 .05

Political Situation

9 91 17 34 .001

Seek Medical Attention

22 17 8 12 .003

Seek Education 60 56 56 62 .42

Family Problems

10 6 8 5 .03

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Migration – Ease of Visiting Relatives/Friends

For Cubans visiting relatives in their home country was very difficult. For Puerto Ricans it was easy.

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Language of Interview

Cubans were most likely to prefer the interview in Spanish, followedby Mexicans. Puerto Ricans more often preferred English. The bilingualgroup was small and of similar proportions across the groups.

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General Language Use

There was a trend for Cubans to prefer Spanish and Puerto Ricans English in general use. But there was more expressed bilingualism for this question.

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Language Spoken as Child

Overwhelmingly, everyone spoke Spanish as children.

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English Proficiency- Spoken Language

Puerto Ricans are most English proficient;Cubans are least.

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Spanish Proficiency – Spoken Language

Cubans are most Spanish proficient, with the other groups being similar.

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Ethnic Identity – Identification with Others from Your Group

Everyone identifies closely with theirLatino group.

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Ethnic Identity – How Important to Marry Others from Your Group

Relatively few think it is important to marry within their Latino group.

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Sociocultural Change – Acculturative Distress Scale

Puerto Ricans experienced significantly lower acculturative distress;Mexicans reported the highest levels of acculturative distress.

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Sociocultural Change – Family Cultural Conflict Scale

Puerto Ricans reported significantly higher levels of Family Cultural Conflict than Cubans or Mexicans

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Sociocultural Change – Difference in Social Position

Puerto Ricans and Other Latinos report a significant decline.Cubans on average report a slight increase in social position in the US.

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Concluding Thoughts on Acculturation There are major differences among the 4 groups in

terms of their migration experiences ◦ Puerto Ricans are migrants; the other groups are

immigrants◦ Cubans reported coming overwhelmingly for political

reasons; the reasons for the other groups were more diverse

◦ The reception by U.S. society of the four groups was different depending on how and why they came

◦Acculturation processes begin in people’s home countries given the impact of globalization

The 4 groups are also different in terms of the historical relationships between their home countries and the U.S.

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Concluding Thoughts on Acculturation The majority of Puerto Ricans, Mexicans and

other Latinos (compared to one-third of Cubans) have spent more than 70% of their life on the mainland

This has led to the emergence of new cultural “mosaics” which include the Nuyorican culture of Puerto Ricans in NYC and the Chicano and Hispano cultures of Mexicans in the southwest

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Concluding Thoughts on Acculturation There is considerable diversity among the 4

Latino groups in language preference and use. Language use looks different depending on

the context you ask about◦For example, the distribution of language

use is quite different for language of interview compared to language of thought

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Concluding Thoughts on Acculturation Differences in social capital and in reception by U.S.

society result in significant differences among the groups in social status

Cubans are the only group that report a status increase

Puerto Ricans and Other Latinos report a large status decline, while Mexicans report a small status decline

The reasons for these differences are not currently well understood

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Concluding Thoughts on Acculturation Cubans reflect one end of the continuum where they

strongly maintain Spanish language in all contexts◦By transforming Miami, they were able to succeed without

giving up important aspects of their culture Other Latino groups are more diverse in their cultural

experience, more dispersed geographically, and have more diversity in social capital◦ They have not come to economically and politically

dominate one area leading to very different acculturation experiences

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Cultural Issues in Latinos’ Experience

with Depression

Igda E. Martinez, Psy.D.Albert Einstein

College of Medicine

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Why migration leads to depression

• “Es como perder su techo, perder todo, es como cuando uno ha pasado por un terremoto y perdió todo … es como una acumulación de perdidas”

• It’s like losing the roof over your head, losing everything, it’s as if one had gone through an earthquake and lost everything … it’s an accumulation of losses

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Goals of Research Richer understanding of Latinos’ conceptions

of depression Fuller understandings of Latinos’ attitudes

towards, concerns about, and expectations for treatment

Identify barriers to care from the perspective of community members

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Methods Based on four different projects in New Jersey

and New York to examine:◦diverse Latinos’ conceptions of mental health,

treatment and barriers to care◦elderly Latinos’ understandings of depression and

reactions to standard depression measures◦community concerns about health and mental health

and needed services◦recognition of depression and attitudes towards care

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Methods 94 participants in 12 different focus groups

throughout New Jersey and New York City Diverse group of Latinos in terms of country

of origin, time in U.S., age, gender, education

All of the groups were held in Spanish All groups led by Peter Guarnaccia Majority of the groups facilitated by Igda

Martinez

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What is Mental Health? Social relationships and supports are key to

mental health Mental health was defined as being able to

function in and contribute to society It is being able to live una vida tranquila Being in control of one’s emotions and not

being aggressive Not abusing alcohol or drugs

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Comments about “Mental Health” Para mi una buena vida sería llevar una vida de

tranquilidad, sentirse con un poco de salud, que es lo principal, y ... sentirse para mi bienestar con su familia unida y vivir tranquilo.

A good life would be living a tranquil life, being in good health, that’s the most important … to feel a sense of well-being about my family’s unity and to live peacefully

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What is Depression?• Depression is widely recognized among Latinos as a

mental health problem• Recognize both emotional and somatic aspects of

depression• Depression is seen as the result of social stressors

and losses: – death of a family member, isolation/loneliness, loss of a

job and financial stresses, events of September 11th

• Depression often connected to diabetes (and other conditions such as high blood pressure)

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Recognition of Depression Cuando una persona está triste, está nostálgica, se pone

a llorar facilmente, está muy cansada y no sabe por que, no tiene ganas de hacer nada. Uno no tiene amigos, no tiene familia, ni nada. Le hace falta más la familia.

When a person is sad, is nostalgic, s/he cries easily, feels very tired and doesn’t know why, s/he has no desire to do anything. One doesn’t have friends, doesn’t have family or anything. When you feel like this, you miss your family even more.

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Recognition of Depression• [Los hombres] se deprimen, ellos buscan el alcohol para

escaparse y no deprimirse. Tienen que hacerse a cargo de la familia acá y tambien mandarle dinero a la familia allá. Conseguir trabajo aquí es difícil.

Men get depressed. They seek out alcohol to escape and not deal with their depression. They are responsible for their family here and also have to send money to their family there, and finding work here is difficult.

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Barriers to Care• Nunca la cojí la consejeria porque yo dije, pero si

ellos me la están ofreciendo y yo fui y yo me presenté. Pero me dijeron, no, el seguro de su esposo no cubre eso. Necesita $250 de down.

I never received the counseling. They were offering me the counseling and I went and presented myself. But then they said, no, your husband’s insurance doesn’t cover this, we need a $250 down payment.

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Barriers to Care• [Nosotros] inmigramos, y nos encontramos con muchas

barreras como el idioma, no tenemos papeles, no tenemos información de muchas cosas, no sabemos cuales son nuestros derechos… la vida aquí es muy difícil. Estamos muy aisladas aquí.

We immigrate here and find ourselves with many barriers: such as language; we don’t have papers; we don’t have information about many things; we don’t know what our rights are … Life here is very difficult. We are very isolated here.

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Attitudes Towards Seeking Help• En la cultura Hispana, piensan que ir a ver a un

psicólogo es cosa de locos. Es la parte de ignorancia, saber entender y saber donde pedir ayuda.

• In the Hispanic culture, we think that going to a psychologist is only for people who are really crazy. It’s due in part to ignorance, not being able to understand depression, and not knowing where to go for help.

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Attitudes Towards Providers Seek help from primary care providers because

are not aware of mental health as a specialty service

Language barriers and cultural issues in understanding American style of mental health treatment

Need to be accessible, to build trust [confianza], and to treat people with respect [respeto]

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Attitudes Towards Treatment Yo he ido a unos cuantos psicoterapias... yo fui a uno que

se sentaba y me decía “habla” y parecía que le estaba hablando a una pared. Pero el de ahora habla, da sus opiniones, se ve que está interesado en conocerme a mi. El trata de obtener mi confianza y así me hace sentir mas cómoda...

I’ve gone to several psychotherapists… I went to one who sat down and said “talk” and it felt like I was talking to a wall. But the one I see now talks, gives his opinions, I can tell that he is interested in getting to know me. He tries to obtain my trust and thus makes me feel more comfortable...

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Attitudes Towards TreatmentBelief that depression is a consequence

of difficult life circumstances, not an illness

Feeling of trying to deal with problems on one’s own [hay que ponerse de su parte]

Medications are only for people who are severely mentally ill

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Attitudes Towards TreatmentTendency to seek out “talking cure”

firstNeed to “unburden oneself”

[desahogarse] Medicine seen as a last resort and a

temporary solution◦Fear of side effects and addictive potential

of psychiatric medications

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Attitudes Towards Medications Fear of addiction is very strong Use models of sleeping pills and coffee to

understand medicines◦Over time people need more and more to have an

effect, and it is difficult to stop When a doctor directly explains the difference

and that the medicine can be stopped, people are much more likely to accept the medicines

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Attitudes Towards Medications Nosotros los Hispanos, nos hemos

acostumbrado en los remedios caseros … la medicina en realidad no es muy receptiva.

We Hispanos have become accustomed to using home remedies … in reality, medications are not very well received by the Hispanic community.

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Improving Care for Depression Therapists need to be sensitive to cultural

expressions of depression (ie, somatization, coraje, and various forms of nervios)

Therapists need to orient Latino patients to the process of mental health treatment

Therapists need to directly explain medications and address concerns about addiction

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Needs for Community InterventionPrograms to help new Latino immigrants

to adjust to life in the U.S. Programs to reduce the stigma of mental

illness and mental health careMore public information in Spanish about

where to get mental health help and how to access care

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Call to Action!“¿Que hace uno cuando hay un

problema? Se preocupa. Pero para resolver hay que quitarle el ‘pre’ y ocuparse”

What do you do when you have a problem? You worry. But to resolve a problem, you have to take off the “pre” and take care of it!

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Latinos and Depression• Immigrant Latinos experience lower rates of

depression than their U.S.-born compatriots and than non-Hispanic Whites– However, Latinos are more likely to endorse depressive

symptoms on item checklists• Latinos are less likely to seek mental health services

when they are depressed compared to Whites (Vega et al, 1998)

• Immigrant Latinos have lower rates of service utilization compared to US born Latinos (Alegria et al, 2004)

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Latinos and Treatment• Minority group members have additional concerns

when entering treatment settings (Atdjian & Vega, 2005 )

• Latinos are more likely than whites to have negative beliefs about antidepressants (Cooper et al, 2003; Miranda & Cooper, 2004)

• Latinos may not initially seek treatment for depression because they see it as a natural reaction to life’s problems, not as an illness – Latinos show a preference for psychotherapy over

medications (Martinez & Guarnaccia, 2007)

– Fear of addiction and stigma attached to taking medications– Cultural value placed on desahogo, or unburdening oneself

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Overall StudyMultiphase study to adapt Motivational

Interviewing (MI) techniques to increase adherence to antidepressants among Latinos◦Phase I: Focus Groups & MI Adaptation◦Phase II: Pilot test of MI Adaptation◦Phase III: Randomized Control Trial

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Purpose of Study• What cultural values influence people’s

decisions to take medications or not?• What do participants know about

antidepressant medications and what fears do they have about this treatment?

• Are participants able to accept the treatment recommendations of their providers? What influences their willingness to accept treatment?

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Familismo (Defined)• Tendency to value family relationships over other

social relationships – Includes concepts such as respeto (respect)to refer the hierarchical

nature of family dynamics (Garcia-Preto, 2005).

• A manifestation of the collectivist nature of Latinos– Benefits, status, and general well-being of the group take precedence

over those of an individual.

• Dynamic concept– Represents family unity, respect and responsibility – Creates both positive and negative pressures– Can lead to covering up severity of depressive symptoms in order to

protect family members66

Family influence (Defined) Instances in which family was mentioned ◦Not necessarily describing the overall value of

familismo.◦Tendency to focus more on instrumental support

Important in the individual’s conceptualization of depression or its treatment◦Directly challenged or influenced client’s

understanding or behavior.

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Research ProcedureMultiphase study◦Results presented are data from Phase I 6 focus groups, 30 participants Completed between April – August 2006 Average group size = 5 participants Audio-taped and transcribed Analyzed using ATLAS.ti

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Sample Characteristics 80% female Age range 27-66◦ Average: 47yrs

Time in U.S. 1-40 yrs◦ Average: 18 yrs

Time w MDD <1-30 yrs◦ Average: 11 yrs

Time on meds <1-24 yrs◦ Average: 9 yrs

50% PR; 23% DR; 17% MX; 10% other

73% completed HS or more 80% read Spanish

Well/fairly well 83% do not speak English 73% speak mostly Spanish

with family 63% speak mostly Spanish

with friends

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Cultural Considerations:Familismo and Family Influence

Familismo◦50 instances were coded◦Brought up by 73% of the participants (n=22)

Family Influence◦84 instances were coded◦Mentioned by 80% of participants (n=24)

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Familismo Expressed• Queremos mucho a los hijos, los papas,

todo, como queremos estar siempre unidos…y todavía se casan y uno quiere los nietos y to’l mundo…que este reunido en la familia, somos la familia muy unidas.

• We care for our children, our parents, everyone, very much; we want to be always united… and even when they get married …one would like one’s grandchildren and everyone … to join together in the family, we are very united families.

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Respeto• Otra cosa que no me gusta de aquí…uno no le puede

decir nada a los hijos…hacen lo que le da la gana…aquí no hay niños y los hijos son los padres, como quien dice. Ellos no obedecen, ni na’. En nuestros países no. Todavía yo vieja obedecía a mi mama y mi papa.

• Another thing that I don’t like about here…one can’t say anything to one’s children…they do whatever they want…here there is no youth and the children are the parents, in a way. They don’t obey or nothin’. In our countries, no. Even in my old age I obeyed my mom and my dad.

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Caretaking/Functioning• A mi lo que me motivo fue mi familia, porque mi familia

ahorita no esta conmigo pero ya va a venir mi hija y mi esposa. Entonces yo, yo, mi problema fue que yo no quería hablar con nadie y yo no le tenia confianza a nadie y fue lo que me motivo a tomarla, el querer estar bien para cuando viniera mi hija y mi familia.

• What motivated me was my family, because my family right now is not with me but soon my daughter and my wife will come. So then I, I, my problem was that I did not want to talk with anyone and I did not trust anyone, and what motivated me to take [the antidepressants], was wanting to be well for when my wife and my family came.

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Caretaking/Functioning• …el ver que eran ellos los que ya me lo estaban

bañando o dando de comer porque yo pasaba llorando, tirada en la cama, eso fue lo que me hizo a mi…claro, que era yo la que tenía que hacerme responsable de mi hijo y dejar que mis otros dos hijos tengan su niñez.

• …to see that it was they who were already bathing him and feeding him because I spent my time crying, lying in bed, that was what made me… Of course, it was I who needed to make myself responsible for my son and let my two other children have their childhood.

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Protecting Family from Personal Problems

• Yo no comparto con mi familia mis problemas porque no quiero molestarlos …cuando ellos me preguntan que como estoy yo les digo que bien o que a veces me siento triste para no preocuparlos y ya todo lo que siento lo cuento a la doctora

• I do not share my problems with my family because I do not want to bother them… when they ask me how I am doing I tell them that I am fine or that sometimes I feel sad so that I do not worry them and then everything that I feel I tell the doctor.

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Protecting Family from Personal Problems• … es preferible uno hablar esas cosas con un particular que

con la misma familia. Con mis hijos yo no hablo nada de lo que siento...pero fíjate, yo a veces me siento que seria bueno uno poder hablar con los hijos o con la familia y compartir el dolor que uno siente, pero al fin y al cabo lo que salen son problemas, mas problemas.

• … it is preferable for one to speak about those things with someone in particular than with your own family. With my children I do not say anything about what I feel...but you know I sometimes feel it would be good to be able to speak with one's kids or with the family and share the pain that one feels, but in the end what you get are problems, more problems.

76

Family Influence Treatment Supportive family influence ◦60% of participants mentioned (n=18) ◦Help access care◦Providing support and reminders to take medications◦Help to obtain medications

Treatment Discouraging family influence◦30% of participants mentioned (n=9)◦Expressed disagreement with the concept of

depression as an illness or the need for medications as treatment.

77

Treatment Supportive Family Influence • Ella sale a, trata de buscar el dinero para comprar la

pastilla. Si ve que me falta, me la busca. Cuando la dejo en la farmacia, ella va y me la recoge. Si por caso, no tengo tiempo, ella trata de ser pendiente. Me dice, ‘¿Tienes las pastillas contigo?’

• She goes out to, she tries to find the money to buy the pill. If she sees that I am short, she looks for it. When I leave it at the pharmacy, she will go and pick it up for me. If for any reason I don’t have time, she always tries to pay attention, she says to me, ‘Do you have the pills with you?’

78

Treatment Supportive Family Influence• Y mi hermana fue la que me llevo y yo estaba como muy,

pa’donde quiera que ella me tiraba yo me iba… Ella era la que me decía a mi, “Gloria, te tienes que tomar este medicamento.” Y yo decía, “¿Pa’ que es eso?” Entonces dice, “Para curarte, para que estés bien como antes.”

• And my sister was the one who took me and I was very, where ever she took me I would go…She was the one who would say to me, “Gloria, you have to take this medication.” I would say, “What’s that for?”and then she’d say, “To cure you, so you can be well, like before.”

79

Treatment Discouraging Family Influence• …mis padres me enseñaron …que podíamos bregar

con los problemas sin necesidad de medicamentos. Y a la vez que uno empezó con medicación …yo me sentí como si hubiera sido como de otro planeta vamos a decir. Era algo que estaba fuera de mis manos.

• …my parents taught me that …we could deal with problems without medication. And the minute that I started with the medication …I felt as if I was from another planet, let’s say. It was something that was out of my hands.

80

Treatment Discouraging Family Influence• A veces mi mama me dice, “Yo tantos problemas que he

tenido y nunca he tenido que ir a un psiquiatra. ¿En que fallaste tú? ¿Qué tu hiciste?” Y yo bueno, “Cada cual es un mundo diferente,” le dije yo. “A lo mejor tú pudiste con tus problemas pero yo con los míos no.”

• Sometimes my mom says to me, “Me with all the problems that I’ve had and I’ve never had to go to a psychiatrist. What did you fail in? What did you do?”And I well, “Everyone is different,” I tell her, “Maybe you could deal with your problems but I can’t with mine.’”

81

SummaryFamilies are important◦Familismo served in some cases as a

motivating factor to seek treatment, and in some cases as a trigger for depression.◦A new issue arose within the value of

familismo: the idea of protecting the family from self◦Families influenced the ways FG participants

understood their symptoms and viewed their treatment.

82

What did we learn?What cultural values influence

people’s decisions to take medications or not?◦Familismo ◦Religion◦Poner de su parte (Do one’s part)◦Trabajar/luchar/aprovechar

(Work/Struggle/Take Advantage)83

Clinical Implications• Clinicians need to be culturally sensitive

– It is not always wise to include or exclude family members in treatment

– Should listen to the patient’s own experience of family relationships and decide together

– If family is included, focus should be on psychoeducation

• Patients should be encouraged to take an active role in treatment planning– Patients should be empowered to negotiate with

clinician and decide their family’s role in their own treatment.

84

DSMIV, Cultural Formulation and Latinos

Peter J. Guarnaccia, Ph.D.Rutgers,

The State University of New Jersey

85

Guidelines: Complementary Cultural Formulation

Cultural Identity of the ClientCultural Explanations of the Client’s IllnessCultural Factors Related to the Psycho-Social

Environment and Levels of FunctioningCultural Elements of the Relationship between

the Provider and ClientOverall Cultural Formulation

Outline for Cultural Formulation, DSM-IV86

Guidelines: Complementary Cultural Formulation

Cultural Explanations of the Client’s Illness◦Predominant illness idioms◦Relation of client's signs and symptoms to

cultural norms◦Local illness categories◦Perceived causes used to explain illness◦Current preferences and past experiences of

help seeking ‑

87

Ataque de Nervios An idiom of distress particularly prominent among

Latinos from the Caribbean, but recognized among many Hispanic groups

Commonly reported symptoms include: screaming

uncontrollably, attacks of crying, trembling, heat in the chest rising into the head, and becoming verbally or physically aggressive

Dissociative experiences, seizure like or fainting ‑episodes and suicidal gestures are prominent in some ataques but absent from others

Glossary of Culture-Bound Syndromes, DSM-IV

88

Ataque de Nervios A general feature of an ataque de nervios is a sense

of being out of control

Ataques de nervios frequently occur as a direct result of a stressful event relating to the family, such as news of a death of a close kin or a separation/ divorce from a spouse

After the ataque de nervios, people often experience amnesia of what occurred. However, they otherwise rapidly return to their usual level of functioning.

89

Ataque de Nervios While descriptions of ataques de nervios most closely

fit with panic episodes, factors that distinguish them from panic include:◦ association of most ataques with a precipitating event ◦ frequent absence of the hallmark symptom of acute fear or

apprehension

Ataques de nervios span the range from:◦ normal expressions of distress not associated with psychiatric

disorder ◦ to expressions of distress associated with anxiety, depression,

dissociation, or somatoform disorders

90

No Ataque Ataques de nervios Odds Ratio

Depression (5%) 19 (2%) 29 (20%) 9.84

Dysthymia (12%) 67 (9%) 40 (28%) 3.63

Generalized Anxiety (18%) 108 (14%) 55 (38%) 3.73

Panic Disorder (2%) 3 (0.4%) 13 (9%) 25.08

PTSD (6%) 29 (4%) 25 (17%) 5.30

Any Affective 49 (6%) 43 (30%) 6.18

Any Anxiety 109 (14%) 58 (40%) 4.02

Any DIS Diagnosis 214 (28%) 91 (63%) 4.35

N= 912 N=767 (84%) N=145 (16%)

Relationship between Ataque de Nervios & Psychiatric Diagnosis

Guarnaccia, et al., 1993, JNMD 91

Phenomenological comparison of ataques and panic disorder

Ataques distinct from PD

Provoked

Crescendo > 10

minutes

Followed by relief

Common to Ataques and PD

Recurrence

Symptoms during

episode

Fear during episode

Sequelae

92

Association between Ataques de Nervios and Psychiatric Disorder in Puerto Rican Children

Community Sample (n = 1891)

Diagnoses Absence of AdN (n=1723)

Presence of AdN (n=168) 2

Any Depression 33 (2.3) 16 (15.2) 8.11**

Any Anxiety 87 (5.4) 38 (22.1) 17.88***

Any Disruptive 171 (9.7) 39 (24.8) 12.09***

Any Diagnosis 243 (14.0) 62 (40.9) 24.43***

Any Impairment 196 (10.5) 55 (39.6) 19.20***

Guarnaccia, et al., 2005, JAACAP 93

Association between Ataques de Nervios and Psychiatric Disorder in Puerto Rican Children

Clinical Sample (n = 757)

Diagnoses Absence of AdN (n=563)

Presence of AdN (n=194) 2

Any Depression 39 (7.0) 57 (30.2) 45.66***

Any Anxiety 83 (14.6) 72 (37.7) 35.53***

Any Disruptive 190 (33.4) 98 (50.7) 18.50***

Any Diagnosis 251 (44.7) 125 (65.4) 27.75***

Any Impairment 245 (44.1) 118 (62.4) 21.55***

Guarnaccia, et al., 2005, JAACAP 94

Relationship of Ataques de Nervios to Mental Health (NLAAS)

5558

31

20

62 62

36

2316 16

8 10

010203040506070

Any depression disorder

Any anxiety disorder Suicidal Symptoms Psychotic Symtpms

Self-Label Syndrome Total Sample

*** ***

***

***

Guarnaccia, et al., 200895

Issues in Differential Diagnosis

Social and psychiatric vulnerabilityRelation to panic disorderRelation to depression and suicidal

ideation & attemptsRelation to dissociationRelation to trauma

96

Susto Folk illness prevalent among Latinos in the U.S. and

among people in Mexico, Central America and South America

Susto results from a frightening event causing the soul to leave the body and resulting in unhappiness and sickness

Symptoms may appear anywhere from days to years after the fright is experienced and may result in death.

Glossary of Culture-Bound Syndromes, DSM-IV97

Susto The core symptoms include: lack of appetite or

appetite gain; sleeping too much or too little; troubled sleep or dreams; feeling sad; lack of motivation to do anything or go anywhere; feelings of low self worth or dirtiness

Diagnosis of susto is often confirmed by family, friends and especially by a traditional healer, who will help the sufferer to identify the source of the fright

Sufferers of susto also experience significant strains in key social roles.

98

Susto Treatment for susto often occurs simultaneously

from biomedical providers and traditional healers◦A ritual healing is performed to call the soul back to the

body and to "cleanse" the person to restore bodily and spiritual balance

An interpersonal susto characterized by feelings of loss, abandonment and not being loved by family with accompanying symptoms of sadness, poor self image, and suicidal ideation seems to be closely related to major depression

99

Susto across Latino groups Mexican Americans in Texas, Mexicans in

Guadalajara & mestizos in Guatemala all recognize susto as an illness◦ Puerto Ricans do not

Fright, but not necessarily soul loss, a key symptom Core symptoms: agitation, crying, nervousness,

trembling, fear of unfamiliar places, sleep disturbances

Serious illness that could cause diabetes and lead to death

Weller, et al., 2002, CMP 100

Relationship of susto to psychiatric disorders

Women with susto (cibih in Zapotec) more likely to meet CES-D criteria for depression than those without (72% vs. 24%; N=40)

Types of susto◦ Interpersonal Depression

Feelings of loss, abandonment by family, sadness, poor self image, suicidal ideation

◦ Traumatic event PTSD◦ Somatic symptoms Somatoform

Health care from several practitioners

Taub, 1992 101

Susto in an urban clinic in Mexico 69% reported susto and 65% nervios (N=400) Higher depression scores (Zung scale) for both susto

and nervios sufferers◦ Susto: 42 points vs. 38 (p<.04)◦ Nervios: 44 points vs. 34 (p<.001)

Those with susto and nervios higher depression scores

Those with nervios more likely to be diagnosed as depressed compared to those with susto

Weller, et al., 2005102

Issues in Differential DiagnosisVulnerability to distress

Relation to fright, anxiety and traumaRelation to depressionRelation to somatization

Link to diabetesGreater risk of mortality

103

Source: Communicating Effectively Through an Interpreter. Cross-Cultural

Health Care Program, Seattle, WA, 1998.©

Video Excerpt and Discussion on the use of Interpreters in

Mental Health Setting

104

Toward DSM-V Incorporate a mixed anxiety-depression

diagnosis◦ Included in ICD-10◦ Fits with a number of cultural syndromes◦ Common presentation in primary care

Refine and expand Outline for Cultural Formulation

Update Glossary of Culture-Bound Syndromes◦Link syndromes to specific disorder chapters

105

Relationship among Anxiety, Depression and Cultural Syndromes

Anxiety Depression

Dissociation

CulturalSyndrome

Somatization

106

Clinical Examples of the Cultural Formulation

107

Rural migrant from Puerto Rico13 years in U.S.Circular migrantPredominantly Spanish-speakingPoor English fluencyLived in Puerto Rican neighborhoodLimited contact with broader society

Cultural Identity

108

Nervios and Ataque de Nervios Fits of anxiety and rage, followed by impulsive

suicidality Distressing, but culturally specific, dissociative

symptoms (hearing voices, seeing shadows) Children saw as difficult, overwhelming Nerves altered by unresolved family conflicts First saw internist, then accepted family

therapy and medical supervision of Latino psychiatrist

Cultural Explanations of Illness

109

Key stressor – estrangement from children

First husband abusive, second murdered

Daughter had drug problems and lost her children

Precarious social supports

Psychosocial Environment

110

Treatment prior to Latino clinic hindered by lack of cultural assessment of symptoms

Latino clinic provided more intensive assessment

Focus on character pathology

Relationship between Provider and Client

111

Corrected psychotic label resulting from dissociative symptoms and stopped antipsychotic medications

Focused on resolving family conflicts with children through family therapy

Diagnosis refocused on Borderline Personality Disorder

Recurrent dysphoria, but did not meet criteria for Dysthymia

Overall Cultural Assessment

112

Using Genograms to Elicit Cultural and Family Issues

Igda E. Martinez, Psy.D.Albert Einstein College of Medicine

113

Areas of Assessment• Sociocultural, sociopolitical, & socioeconomic factors• Finances• Cultural Heritage• Belief systems, religion, spiritual beliefs• Language skills and acculturation of family members• Connections to community• Migration history

114

Socio-cultural, -political, -economicAre there sociocultural factors (ethnicity,

race, social class, legal status, employment potential, education level) that are impacting family’s current functioning?

Any past suffering/conflicts with family members due to past political history?

Where does family fit in the community?

115

FinancesPressures from family – jealousy,

resentment, pressure to help other family members

Shame or conflict due to loss of status ◦Upper class in country of origin◦Lower class in US

Struggling to meet ongoing needs

116

Cultural HeritageCulture/ethnic background of family

members◦Experiences with racism

How are they received in their local communities?

Are belief systems accepted/encouraged?

117

Belief Systems, Religion, Spiritual Beliefs

What primary beliefs organize the family?

What is the history of the family’s beliefs, what have been the changes, if any?◦Reactions to changes in the family?◦Differences within the community?

118

Language Skills and Acculturation

What languages are spoken in home? ◦Among adults? Children?

Power imbalances?How much of heritage is retained?◦How are those decisions made?

119

Connections to Community How do family members maintain friendships? How accessible are social support networks?◦Friends, family, school, religious organizations,

physicians, social service agencies, therapy, etc Any moves from ethnic enclaves to other

communities?◦Stress of change, how adapted, who helped?

120

Migration History• Why did family migrate? What were they looking for?

What did they leave behind?– Premigration history: political/economic situation in

country of origin– Migration history: trauma?– Postmigration history and culture shock: arrival to US.

Language, immigration, poverty? Shock of cultural values? Supportive/antagonistic community?

– Migration and life cycle: age of family members when migrated, age of those left behind, change in family dynamics (children ->adult status due to language), reunifications?

121

Social & Cultural Assessment of Latinos

Peter J. Guarnaccia, Ph.D.Rutgers,

The State University of New Jersey

122

1. What language(s) do you currently speak with family, friends, co-workers, store clerks?

2. English skills: Speaking___ Understanding_____ Reading_____ Writing_______

3. Spanish skills: Speaking_____Understanding_____ Reading_______ Writing________

Answer Key: 1 = fluent; 2 = very good; 3 = good; 4 = poor; 5 = no ability

LANGUAGE CAPABILITIES & PREFERENCES

123

1. Were you born in the United States? oYes o No If not, where?

2. How long have you lived in the United States?3. Where does most of your core (immediate) family

live? 4. How often are you in contact with your family (in

person, by phone, by letter, by e-mail)? 5. Who do you turn to for advice about where to go

for healthcare or other services?

SOCIAL CONNECTIONS: FAMILY/SOCIAL SUPPORT

124

1. What do you call your current health problem?

2. Have you suffered from your current health problem before? If so, what did you do about it?

3. When you were sick in your home country, what did you do?

4. When you have been sick in the United States, where have you gone for treatment?

HEALTHCARE UTILIZATION

125

1. What religion are you? Do you consider yourself a religious person?

2. Have you or your family consulted a religious leader or healer about your health problems?

3. Does your religion have any beliefs that might affect your treatment (like not using certain medicines; accepting transfusions)?

RELIGIOUS BELIEFS AND PRACTICES

126

Evaluation & Wrap-Up

Peter J. Guarnaccia, Ph.D.Rutgers,

The State University of New Jersey

127