recognizing and diagnosing depression in hispanic/latinos: focus on primary care javier i. escobar,...
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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.
Non-Latinos
Mexicans Mexican-Americans
Central Americans
0%
5%
10%
15%
20%
25%
30%
0%
5%
10%
15%
20%
25%
4-6 Symptoms 13 or moreSymptoms
White Mexicans African American Puertoricans
1-Escobar et al, JNMD, 1989, 177: 140-146
Primary Care: UC-Irvine Primary Care: UC-Irvine Study Study (2)(2)
Community: ECA Study Community: ECA Study (1)(1)
Ethnicity and Medically UnexplainedSymptoms in the United States
2-Escobar et al, Psychosomatic Medicine, 1998. 60: 466-472
Woody Allen’s line in “Manhattan” (1980’s)
“I cannot express any anger. That is one of the problems I have. I grow a tumor instead.”
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
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
*Listed hierarchically by number of papers in which FSS are mentionedModified from Henningsen et al, Lancet 2007; 369: 946-55
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 depression oftenpresent with numerous physicalcomplaints
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
60
44
23
12
20
20
40
60
80
0-1 2-3 4-5 6-8 9
Pati
en
ts W
ith
Mood
Dis
ord
ers
(%
)
Number of Physical Symptoms(N=1000)
1Kroenke 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
Hussain MH, Rush AJ, Trivedi MH, et al, Journal of Psychosomatic Research (2007); 63:113-122
IDS-C30 Item 25 Depressive Symptomatology-Clinician Rating,Range 0-3
23%
36%
25%
16%
0%
10%
20%
30%
40%
50%
No Pain
Complaints
Mild pain Pain Most of
the Time
Pain Causes
Functional
Impairment
Over 40 %
Depression and Diabetes Often Occur Together in HispanicsDepression 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
13.7
3.79.7 6.5
16.29.1
15.8
23.3
11.3
17.6
13.1
20.7
15.7
22.3
26.2
13.1
20.7
20.0
22.1
17.4
21.0
19.0
20.5
20.0
21.9
18.5
18.5
18.8
17.7
51.5
32.038.5
22.4
39.2
22.0
0%
20%
40%
60%
80%
100%
Muscle Pain Abdominal Pain
Lumbar Pain
Chest Pain Headache
Joint Pain
Neck Pain
Pre
vale
nce (
%)
None
A Little
Moderate
Intense
Unbearable
Munoz R, et al, Journal of Affective Disorders, 86: 93-98, 2005
989 Patients with MDD Selected in 7 Latin American 989 Patients with MDD Selected in 7 Latin American CountriesCountries
Reported Pain
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
0%10%20%30%40%50%60%70%80%90%
100%
Colombia United States
Imipramine Placebo
>50% Reduction in HAM-D Scores
Escobar JI, Tuason VB, Psychopharmacology Bulletin, 1980; 16: 49-52
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Country Origin of Latino Patients in a Primary Care Study of Physical Symptoms, Depression and Anxiety in New Jersey
Medically Unexplained Physical Symptoms Medically Unexplained Physical Symptoms Augur Psychiatric Disorders In Primary Augur Psychiatric Disorders In Primary CareCare
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
172 Patients with 4-6 MUPS
Consumer Satisfaction in a Large Mental Health System in NJ (percent rating very good to excellent)
Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003
52%
54%
56%
58%
60%
62%
64%
Latinos Blacks Whites
Percent With Serious Mental Illness (Dementia, Schizophrenia, MDD, Bipolar)
0
5
10
15
20
25
30
35
40
45
50
Latinos Blacks Whites
Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003
Percent Diagnosed as Schizophrenia or Major Depression
0
5
10
15
20
25
30
Schizophrenia MajorDepression
Latinos (N=1531) Blacks (N= 6,475) Whites (N=10,339
Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003
TOTAL N=19,219
Feedback on Depression in Latinos Focus Groups in the North East
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
Moscicki EK, et al. 1989; Kemp BJ, et al. 1987
Vega WA, et al. 1998; U.S. Department of Health and Human Services 2001
Risk Factors for Depression in Hispanics
Medical comorbidity (diabetes) Substance abuse Longer time in US residence and younger
age at immigration Poverty Job Loss
Lewis-Fernández R 1996
Guidelines for Cultural Formulation of Psychiatric Diagnosis
Clinical history
Cultural “identity”
Cultural explanation of the illness
Cultural factors related to psychosocial environment and levels of functioning
Cultural elements of the clinician-patient relationship
Overall cultural assessment
Acceptability of Treatment for Depression in Primary Care
Telephone Survey including 829 primary care patients (659 non-Hispanic 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.