1 / 33

Mental Health Along the Border

Mental Health Along the Border. Francisco Moreno, MD Professor of Psychiatry University of Arizona. Overview. Demographics of Border States Challenges for Mental Health Care Along the Border Approaches to Minimize Mental Health Care Disparities.

janus
Download Presentation

Mental Health Along the Border

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Mental Health Along the Border Francisco Moreno, MD Professor of Psychiatry University of Arizona

  2. Overview • Demographics of Border States • Challenges for Mental Health Care Along the Border • Approaches to Minimize Mental Health Care Disparities

  3. Census 2000:Percent Hispanic Along Border States

  4. Heterogeneity of Hispanic Americans • Birthplace • Acculturation • Language • Literacy • Genetics • Race • Education • SES • Additional shared factors: urbanicity, region, etc.

  5. Mexican Born Population in the US • 32% of those who are Foreign Born • 10.2 % of the Population in Mexico

  6. Hispanic Americans Demographics Characteristic Hispanic Gen Population Median age (years) 26.0 35.4 Foreign born (%) 40.2 11.1 Foreign language spoken at home (%) 78.6 17.9 English spoken less than “very well” (%) 40.6 8.1 Age ≥25 years with ≥high school education (%) 52.4 80.4 Age 16 years and older in labor force (%) 69.4 70.7 Median household income in 2003 (US$) 32,997 43,318 Living in poverty (%) 22.6 12.4 Health insurance in 2003 (%) 67.3 84.4 Ramirez 2004 DeNavas-Walt et al. 2004

  7. Highest Degree Earned by People 20 and Older by Race & Ethnicity, 2008 Richard Fry, Senior Research Associate Pew Hispanic Center

  8. Hispanic Immigrants and Education Richard Fry, Senior Research Associate Pew Hispanic Center

  9. Risk Factors for Mental Illness • Medical conditions: Diabetes, obesity, etc • Domestic violence, “Machismo” effects • Beneficial and otherwise effects of family involvement and demands • Acculturation • Early life trauma • Financial challenges • Racism

  10. Migration Related Stress • Failure to succeed in the country of origin • Immigration Experience • Adaptation Process: • Limited Resources • Restricted Mobility • Marginalization and isolation • Blame/stigmatization and guilt/shame • Vulnerability/exploitability • Fear and fear-based behaviors • Family stress: Role and tradition changes

  11. Border Area Latino:Access to Mental Healthcare • Increased number of uninsured and underinsured • Geographic accessibility concerns • Specialty services limitations • Linguistic and cultural incongruence • Sick time benefits • Schedule flexibility • Immigration issues • Even in government programs (Medicare, VA)

  12. Depression Screening in Immigrant Latinas in L.A. N= 5122 Miranda et al., 2005

  13. Language Barriers • Price and Cuellar in 1981 compared separately recorded Spanish- and English-language interviews. They found that subjects expressed more symptoms during the Spanish interview • In a similar study (Malgady and Costantino 1998) reported that symptom severity among Hispanic patients with schizophrenia and depression was rated highest in bilingual interviews, followed by those in Spanish, and lowest in those in English

  14. OPERATIONALIZATION OF A SOCIOBEHAVIORAL MODEL OF HELP SEEKING PREDISPOSING NEED ENABLING OUTCOMES Beliefs and Attitudes Personal Domain SES, Nativity.Age, Ethnicity, Accul. Persistence Satisfaction Sociocultural Domain Information about MH Problem Identification Stigma Support for treatment Family Domain Impairment, History of Tx and Dx, Self Rated Mental Health Status, Self-defined Problem, Insurance and Treatment Exper. Referral source Staff Courtesy Transportation Work Obligations Eligibility for Services Treatment Effectiveness Access Domain Appropriateness of care Timely Appointments Provider Domain NOTE: MODEL FOR GENERATING TESTS OF HYPOTHESES AND MULTIVARIATE MODELS

  15. Cultural Explanations of the Illness • Idioms of distress and local illness categories • Meaning of the illness in relation to cultural norms & severity of symptoms based on perception • Help-seeking and care experiences with professional or traditional sources. Effects in plans

  16. Some Elements of Cultural Congruence • Language of interview, communication adequacy • Nature of work-up and interpretation of symptoms • Role assigned to precipitants/stressors and their interaction with individual/social vulnerabilities • Treatments offered and outcomes expected • Attitudes towards inclusion of family, social networks, including spiritual communities • Addressing stigma • Healthcare access

  17. Cultural Elements of the Clinician-Patient Relationship • Differences in culture, social status or role between the clinician and patient • Communicating with a professional in a field unknown to the patient in his/her own culture. • Communicating with a figure of the establishment or authority information that may be damaging to an immigration claim, insurance, probation, etc. • Negotiating levels of intimacy and rapport with members of a different race, religion or profession.

  18. Treatment Readiness • Concept of illness, cause, and treatment • Physical access, cost, and flexibility • Psychoeducation, stigma abatement • Relating as allies, compassionate collaborators, without judgment • Language and cultural understanding • Incorporation of client values

  19. Arizona Border Mental Health

  20. Example of Academic and Community Collaborations • A study proposing to compare the acceptability and effectiveness of depression treatment for Hispanic patients provided by a psychiatrist through internet videoconferencing (webcam) with treatment as usual with the primary care provider (TAU).

  21. College of Medicine • Mission: To continually improve health care for all Arizonans through education, research and clinical care. • Services: Among its 20 departments and 8 interdisciplinary centers includes the Arizona Hispanic Center of Excellence; Arizona Telemedicine Program The University of Arizona Health Sciences Center

  22. FOUNDED 1962Mission of caring for the uninsured and underserved for 48 years in Tucson and Southern Arizona

  23. Purpose and Rationale • Our broad long-term objective is to improve the quality of care to underserved Hispanics affected with depressive disorders using health information technology. • This technology can be used to provide appropriate patient centered care, with culturally and linguistically congruent providers. • Results from this study may help inform the manner in which quality and specialized psychiatric care can be delivered using real time video communication through the internet (webcam), a medium that is now readily and economically available.

  24. Subjects • N= 150 Self identified as Hispanics, age ≥ 18 y/o • MINI based DSM-IV diagnosis of Major Depressive Disorder (MDD) • Excluded: bipolar disorder, schizophrenia, dementia, active substance dependence; requiring inpatient or residential treatment; serious medical illness; lacking capacity to consent; pregnant or lactating women; and people with safety concerns (DTS, DTO).

  25. Webcam Intervention • Patients receive services on site at SEHC and will be oriented and ushered by study personnel. • Psychiatric visits include a 45-60 minute full psychiatric interview, informed consent and treatment planning procedures (American Psychiatric Association Treatment Guidelines). In addition to pharmacotherapy, other aspects of care may include psychoeducation, and brief eclectic interventions as appropriate. • Follow up visits will take place monthly for 20-30 minutes, for rapport maintenance, progress and safety monitor, treatment adjustment if needed. • After hour coverage will be provided through the Psychiatry Research Clinician on call at UMC

  26. Treatment as Usual • Depression treatment will be obtained from the patient’s PCP as it is normally done at SEHC. • TAU often includes antidepressants, in adherence to AHCPR treatment guidelines. • Patients who require additional mental health care are referred to behavioral health services or community mental health agencies. (patients with specific psychosocial issues, safety concerns, evident need for couples or family therapy) • Crisis services related to depression are provided through standard clinic protocols.

  27. Data Collection Tools Schedule

  28. Depression Outcome MADRS Time Effect: p<.01 Treatment Interaction: p <.05

  29. Depression Outcome PHQ-9 Time Effect: p<.01 Treatment Interaction: p <.05

  30. Quality of Life Outcome Time Effect: p<.01 Treatment Interaction: p <.05

  31. Disability Outcome Time Effect: p<.01 Treatment Interaction: p <.05

  32. Patient Doctor Relationship Time Effect: p<.01 Treatment Interaction: p <.05

  33. Summary • US-Mexico Border Mental Health is associated with unique stressors related to immigration, acculturation, and common socioeconomic issues • Providing screening and treatment requires cultural, linguistic, and literacy sensitivity • Specialized care is sparse yet effective when accessed and properly delivered.

More Related