Recognizing and Diagnosing Depression in Hispanic/Latinos: Focus on Primary Care

1. Recognizing and Diagnosing Depression in Hispanic/Latinos: Focus on Primary Care Javier I. Escobar, M.D. Associate Dean for Global Health UMDNJ-RWJMS

2. 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

3. 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.

4. Ethnicity and Medically Unexplained Symptoms in the United States Community: ECA Study (1) Primary Care: UC-Irvine Study (2) 1-Escobar et al, JNMD, 1989, 177: 140-146 2-Escobar et al, Psychosomatic Medicine, 1998. 60: 466-472

5. 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.”

6. Interpretation of Medically Unexplained Symptoms • Differs by specialty • Syndromes made to fit specialty paradigms (pathophysiology and nomenclatures)

7. 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 mentioned Modified from Henningsen et al, Lancet 2007; 369: 946-55

8. 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

9. 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 80 60 60 44 40 Patients With Mood Disorders (%) 23 20 12 2 0 0-1 2-3 4-5 6-8 9 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.

10. STAR-D Study: Pain Complaint Scores and Depression IDS-C30 Item 25 Depressive Symptomatology-Clinician Rating, Range 0-3 Over 40 % Hussain MH, Rush AJ, Trivedi MH, et al, Journal of Psychosomatic Research (2007); 63:113-122

11. Depression 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

12. “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

13. Painful Physical Symptoms in Depressed Latin Americans 989 Patients with MDD Selected in 7 Latin American Countries Lumbar Pain Chest Pain Abdominal Pain Muscle Pain Joint Pain Neck Pain Headache 100% 17.7 22.0 22.4 Reported Pain 32.0 38.5 39.2 80% 51.5 19.0 18.8 18.5 None 60% A Little 20.0 Prevalence (%) Moderate 18.5 21.9 26.2 21.0 22.1 Intense Unbearable 40% 20.5 20.7 17.4 20.0 22.3 20.7 23.3 13.1 20% 17.6 15.7 13.1 11.3 16.2 15.8 13.7 9.7 9.1 6.5 3.7 0% Munoz R, et al, Journal of Affective Disorders, 86: 93-98, 2005

14. 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)

15. Response to Imipramine and Placebo in Depression: Colombian vs. US Patients >50% Reduction in HAM-D Scores Escobar JI, Tuason VB, Psychopharmacology Bulletin, 1980; 16: 49-52

16. Country Origin of Latino Patients in a Primary Care Study of Physical Symptoms, Depression and Anxiety in New Jersey

17. Medically Unexplained Physical Symptoms Augur Psychiatric Disorders In Primary Care 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 = 12 172 Patients with 4-6 MUPS Escobar JI, Gara MA, Diaz-Martinez AM et al (2007), Annals of Family Medicine, 5: 328-335

18. Consumer Satisfaction in aLarge 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

19. Percent With Serious Mental Illness (Dementia, Schizophrenia, MDD, Bipolar) Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003

20. Percent Diagnosed as Schizophrenia or Major Depression TOTAL N=19,219 Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003

21. Feedback on Depression in LatinosFocus 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

22. Risk Factors for Depression in Hispanics • Medical comorbidity (diabetes) • Substance abuse • Longer time in US residence and younger age at immigration • Poverty • Job Loss Moscicki EK, et al. 1989; Kemp BJ, et al. 1987 Vega WA, et al. 1998; U.S. Department of Health and Human Services 2001

23. 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 Lewis-Fernández R 1996

24. 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

25. 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

26. 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.

27. 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

28. 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

29. 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

30. 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.