Latino Patient with Depression Presenting to Primary Care

1. Latino Patient with Depression Presenting to Primary Care Provided by: Javier I Escobar, MD Presenters: Theresa Miskimen, MD Esperanza Diaz, MD Presentation at the opening of the Clínica Latina RWJMS/UBHC July 19, 2006

2. Patient ID • Hispanic female widow aged 56 years. She is the mother of 4 children aged 20 to 35 years and is a recent immigrant. She lives with her married daughter and speaks only Spanish. Her daughter is her interpreter. • Chief Complaint at first primary care clinic visit: • severe weakness • back pain • joint pain

3. Other somatic complaints identified on examination: • abdominal pain/flatulence • headaches • palpitations • dizziness

4. Medical and Family History • Medical History: mild hypertension. She was prescribed a low-dose diuretic that she had not taken for several months • Family History: diabetes mellitus and hypertension (brother and sister) • 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.

5. Treatment Course • The Primary Care Physician (PCP) saw pt with daughter serving as interpreter. PCP prescribed a low-dose ACE-inhibitor; two month follow up • Follow up visit: daughter indicated mother’s pain had continued, 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 via her daughter

6. Crisis: few days later, the PCP received an urgent call from family indicating that the patient was in crisis. She was 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

7. Crisis Assessment and Recommendations • Screening tool: PRIME-MD depression/anxiety • Treatment recommendation: benzodiazepine for sleep and psychiatric referral • The family disagreed with the recommendation (“The symptoms are not in her head!”) • Second opinion: also suspected depression • Psychiatric referral failed because the bilingual psychiatrist in practice nearby did not accept Medicaid patients

8. Course • Symptoms continued to escalate with subsequent second crisis/brought to the emergency department of a university hospital • Following physical clearance, a psychiatry resident diagnosed major depressive disorder (MDD) and started the patient on an antidepressant after explaining the diagnosis and reasons for the prescription to the family • Follow up: primary care clinic • The patient hesitantly started taking the medication, but soon discontinued her treatment because it made her feel nauseous

9. Case assignment: Spanish-speaking APN • Treatment recommendations: trial another antidepressant, brief weekly visits, brief physicals • Other interventions: supportive therapy to talk about stressors; psychoeducation “depression can hurt” • Family intervention: family sessions/encouraged family to endorse the treatment • Update: condition improved and after 6 to 8 weeks, her symptoms were largely resolved • She is now examined biannually for continuation treatment

10. Factors • System Level Barrier: • Language • Community Centered Barrier: • Stigma • Provider Barrier: • Medicaid • Access to Care: • primary care clinic