HISPANICS: Mental & Emotional Disorders Eneida G ómez, MD Child, Adolescent & Adult Psychiatrist This is part 7 of an 8 part series of seminars on Hispanic Health Issues brought to you by the University of North Florida’s Dept. of Public Health, College of Health, a grant from AETNA, and the cooperation of Duval County Health Department. For more information or register for the seminars, please call 620-1289.

Objectives Background/statistics Mental disorders and Hispanics “Nerves” versus diagnosable disorders The future: research

Background/statistics

Mental disorders and Hispanics

“Nerves” versus diagnosable disorders

The future: research

BACKGROUND AND STATISTICS

Background Statistics: Geographic Distribution Adapted from Reference # 1

Background Statistics: Family Structure Familism is as much a reflection of social process as of culture practice Are more likely to live in family households than alone Family households that include children 63% Hispanics 47% White 56% Black Living alone 14% Hispanics 30% both Black and White Reference # 1

Familism is as much a reflection of social process as of culture practice

Are more likely to live in family households than alone

Family households that include children

63% Hispanics

47% White

56% Black

Living alone

14% Hispanics

30% both Black and White

Background Statistics: Education But for the foreign-born it is lower that the US-born Hispanic despite same or higher motivation to complete their education There is further variability in the three main Hispanics subgroups regarding H.S vs. College respectively: 70 vs. 25%% of Cuban-Am. 64 vs.11% Puerto Ricans 50 vs. 7% Mexican-Am. Reference # 1 25% 11% Graduated College 83% 56% Graduated H.S. More formal Ed. Less formal Ed. Overall ( > 25 y/o) National Average Latino

But for the foreign-born it is lower that the US-born Hispanic despite same

or higher motivation to complete their education

There is further variability in the three main Hispanics subgroups regarding

H.S vs. College respectively:

70 vs. 25%% of Cuban-Am.

64 vs.11% Puerto Ricans

50 vs. 7% Mexican-Am.

Background Statistics: Income Cuban-Americans are more affluent (first two migration groups were skilled and affluent) Median Income/family and % below poverty level respectively Cubans : $39,530 14% Puerto Ricans : $28,953 31% Mexicans : 27,883 27% Reference # 1

Cuban-Americans are more affluent (first two migration groups were skilled and affluent)

Median Income/family and % below poverty level respectively

Cubans : $39,530 14%

Puerto Ricans : $28,953 31%

Mexicans : 27,883 27%

Cultural Bias for DSM-IV Diagnosis The Diagnostic and Statistical Manual (DSM-IV) is a set of diagnostic standards regarding diagnosis of mental disorders. The DSM-IV does not take into account Stress without a formal disorder (especially immigrants Little flexibility to take into account culturally patterned forms of distress and disorder Reference # 1

The Diagnostic and Statistical Manual (DSM-IV) is a set of diagnostic standards regarding diagnosis of mental disorders.

The DSM-IV does not take into account

Stress without a formal disorder (especially immigrants

Little flexibility to take into account culturally patterned forms of distress and disorder

Background Mental Disorders: Adults Figure 6-2 compares data for the lifetime prevalence of CIDI disorders among immigrant and U.S. born Mexican Americans in Fresno, California versus the general population rates from the National Comorbidity Survey. Adapted from Reference # 1

Background Mental Disorders: Adults Mexican and Puerto Rican born and Latinos living in their countries of origin have less rates of mental disorders than those that migrate to the US (due to close knit families) Acculturation has been implicated but not research studies to back-up this. Rates of suicide: Hispanics have 6% vs. 13% Whites Reference # 1, 2, 9

Mexican and Puerto Rican born and Latinos living in their countries of origin have less rates of mental disorders than those that migrate to the US (due to close knit families)

Acculturation has been implicated but not research studies to back-up this.

Rates of suicide: Hispanics have 6% vs. 13% Whites

Background Mental Disorders: Children and Youth Studies use behavioral lists and not diagnostic instruments Hispanic youth in Middle School reported more anxiety than Whites Hispanic youth reported more delinquency type problems than White in southwestern states In Florida Hispanics youth reported similar rates of delinquency to any other group Youth of Mexican origin reported higher rates of depression – 12% vs. 6% White in Houston Youth at the US-Mexican border reported higher rates of depression (48% vs. 39%) , drug use and suicide Nationally: 10% attempted suicide vs. 23% considered it Reference # 1, 12, 13

Studies use behavioral lists and not diagnostic instruments

Hispanic youth in Middle School reported more anxiety than Whites

Hispanic youth reported more delinquency type problems than White in southwestern states

In Florida Hispanics youth reported similar rates of delinquency to any other group

Youth of Mexican origin reported higher rates of depression – 12% vs. 6% White in Houston

Youth at the US-Mexican border reported higher rates of depression (48% vs. 39%) , drug use and suicide

Nationally: 10% attempted suicide vs. 23% considered it

Background Mental Disorders: Elderly 26% had major depression or dysphoria It was highly related to their physical health Relationship between low blood pressure and higher levels of depression Studies suggest higher risks of Alzheimer’s for Hispanic-AM and than White-Am Reference # 1

26% had major depression or dysphoria

It was highly related to their physical health

Relationship between low blood pressure and higher levels of depression

Studies suggest higher risks of Alzheimer’s for Hispanic-AM and than White-Am

Barriers to Care Providers Managed Care, Medicare/Medicaid Consumers unapreciative of treatment Healthcare providers unaware of treatments (PMD unaware of CMH) Language Lack of understanding consumers fear of ψ med Hisp. are 3x more likely to be labeled schizophrenia than are W. Hispanic Consumer Income, higher uninsured rates Stigma Language Fatalism among foreign-born (can’t control their destiny) Majority are CYP2D6 extensive metabolizers (usually requiring higher doses of medications like whites) Reference # 2, 15, 16, 17, 20

Providers

Managed Care, Medicare/Medicaid

Consumers unapreciative of treatment

Healthcare providers unaware of treatments (PMD unaware of CMH)

Language

Lack of understanding consumers fear of ψ med

Hisp. are 3x more likely to be labeled schizophrenia than are W.

Hispanic Consumer

Income, higher uninsured rates

Stigma

Language

Fatalism among foreign-born (can’t control their destiny)

Majority are CYP2D6 extensive metabolizers (usually requiring higher doses of medications like whites)

High Need Hispanic Populations Incarcerated 9% Hispanics vs. 3% Whites Vietnam War Veterans Higher risk for post-war related trauma than black or whites (post traumatic stress disorder) Refugees 33 to 60% Central America refugees experience post traumatic stress disorder Drugs and Alcohol use similar to other groups While Hispanic men have relatively higher rates, women have unusually lower rates Reference # 2

Incarcerated

9% Hispanics vs. 3% Whites

Vietnam War Veterans

Higher risk for post-war related trauma than black or whites (post traumatic stress disorder)

Refugees

33 to 60% Central America refugees experience post traumatic stress disorder

Drugs and Alcohol use

similar to other groups

While Hispanic men have relatively higher rates, women have unusually lower rates

Availability of Mental Health Services In 1990 about 40% Hispanics did not speak English It is estimated that there are 29 Hispanic mental health professionals for every 100,000 Hispanics Compared to 173 White providers for every 100,000 persons Reference # 2, 4, 11

In 1990 about 40% Hispanics did not speak English

It is estimated that there are 29 Hispanic mental health professionals for every 100,000 Hispanics

Compared to 173 White providers for every 100,000 persons

Access of Mental Health Services 37% Hispanics are uninsured vs. 16% for all Americans Employer coverage Hispanics 43% Whites 73% Medicaid and other public coverage reaches 18% Hispanics Reference # 2, 11

37% Hispanics are uninsured vs. 16% for all Americans

Employer coverage

Hispanics 43%

Whites 73%

Medicaid and other public coverage reaches 18% Hispanics

Use of Mental Health Services Hispanic-Am. with a mental disorder 1 in 11 contact mental health specialists 1 in 5 contact general health care providers Hispanic immigrants with mental disorders < 1 in 20 contact mental health specialists < 1 in 10 use general health care providers Regarding the consultation with Curanderos One study found < 4% Mexican-Am consulted One While other studies range from 7 – 44% The use of remedies is more common and are to complement mainstream care Reference # 2, 10

Hispanic-Am. with a mental disorder

1 in 11 contact mental health specialists

1 in 5 contact general health care providers

Hispanic immigrants with mental disorders

< 1 in 20 contact mental health specialists

< 1 in 10 use general health care providers

Regarding the consultation with Curanderos

One study found < 4% Mexican-Am consulted One

While other studies range from 7 – 44%

The use of remedies is more common and are to complement mainstream care

Appropriateness and Outcome of Mental Health Services There are few studies in Hispanics in this area Persons with schizophrenia are more likely to suffer significant exacerbations in highly structured families (familism) than in the less structured case management Bilingual patients are evaluated differently when interviewed in English as opposed to Spanish Hispanic bipolar patients are more likely to diagnosed as suffering with schizophrenia than Whites 24% Hispanics vs. 34% White-Am with depression and anxiety received appropriate care Hispanic who visited a general medical doctor are less likely as whites to receive a diagnosis of depression Reference # 3, 10

There are few studies in Hispanics in this area

Persons with schizophrenia are more likely to suffer significant exacerbations in highly structured families (familism) than in the less structured case management

Bilingual patients are evaluated differently when interviewed in English as opposed to Spanish

Hispanic bipolar patients are more likely to diagnosed as suffering with schizophrenia than Whites

24% Hispanics vs. 34% White-Am with depression and anxiety received appropriate care

Hispanic who visited a general medical doctor are less likely as whites to receive a diagnosis of depression

Lifetime risk and persistence of psychiatric disorders Hispanics had a lower lifetime risk of substance use disorders as compared to Whites Hispanics with mood and anxiety disorders were more likely to be persistently ill as compared to Blacks In general members of disadvantaged ethnic group in the US do not have an increase risk for psychiatric disorders, but they do have more persistent disorders Reference # 6, 9

Hispanics had a lower lifetime risk of substance use disorders as compared to Whites

Hispanics with mood and anxiety disorders were more likely to be persistently ill as compared to Blacks

In general members of disadvantaged ethnic group in the US do not have an increase risk for psychiatric disorders, but they do have more persistent disorders

Depression in Hispanics How do Hispanics experience depression Lower suicide rates 6%H, 13%W However, youth have higher suicide ideation and attempts Culture-bound syndromes may be diagnosed as a disorder: susto, ataque de nervios Cuban-Am had the lowest one-year prevalence 2.8, while mainland Puerto Ricans had 6.9 (controversial: some studies show higher prevalence in Cubans than Puerto Ricans) Reference # 4, 7, 10, 19

How do Hispanics experience depression

Lower suicide rates 6%H, 13%W

However, youth have higher suicide ideation and attempts

Culture-bound syndromes may be diagnosed as a disorder: susto, ataque de nervios

Cuban-Am had the lowest one-year prevalence 2.8, while mainland Puerto Ricans had 6.9 (controversial: some studies show higher prevalence in Cubans than Puerto Ricans)

ADHD in Hispanics Hispanics are more likely to be labeled with ADHD by teacher (when child has learning difficulties) Hispanics strongly disagree that ADHD primarily affects Anglo or White children Hispanics responded not having enough info. on ADHD and not knowing where to go for help Language barriers prevent obtaining proper Dx and care. 52% H compared to 62% W children needing medication received it. AA were lowest at 49% Reference # 13, 14

Hispanics are more likely to be labeled with ADHD by teacher (when child has learning difficulties)

Hispanics strongly disagree that ADHD primarily affects Anglo or White children

Hispanics responded not having enough info. on ADHD and not knowing where to go for help

Language barriers prevent obtaining proper Dx and care.

52% H compared to 62% W children needing medication received it. AA were lowest at 49%

Adapted from reference # 17

Common misconceptions In some communities eye contact is a sign of disrespect. Spanish speaking doctors re-assessed psychotic behaviors: ½ were found to suffer from depression. If it sounds unusual then it is psychosis Persons perceive bipolar illness differently depending their ethnicity: Hispanics, AA and European Am perceive their illness equally Reference # 16, 17, 19, 20

In some communities eye contact is a sign of disrespect. Spanish speaking doctors re-assessed psychotic behaviors: ½ were found to suffer from depression.

If it sounds unusual then it is psychosis

Persons perceive bipolar illness differently depending their ethnicity: Hispanics, AA and European Am perceive their illness equally

Culture Bound Syndromes Ataque de nervios : uncontrollable shouting, crying, trembling, verbal/physical aggression as a result of a stressful event related the family Bilis and colera (muina) : strongly experienced anger or rage Locura : chronic psyhosis Mal de ojo : infant/young children are especially at risk for it. Fitful sleep, crying w/o apparent cause, diarrhea, vomiting & fever Nervios : general state of vulnerability to stressful life experiences and to a syndrome brought on by difficult life circumstances Susto : (fright or soul loss) also known as espanto, pasmo, tripa ida, perdida del alma, or chibih. It is an illness attributed to afrightening event that causes the soul to leave the body and results in unhappiness and sickness. Reference # 16, 17, 19, 20

Ataque de nervios : uncontrollable shouting, crying, trembling, verbal/physical aggression as a result of a stressful event related the family

Bilis and colera (muina) : strongly experienced anger or rage

Locura : chronic psyhosis

Mal de ojo : infant/young children are especially at risk for it. Fitful sleep, crying w/o apparent cause, diarrhea, vomiting & fever

Nervios : general state of vulnerability to stressful life experiences and to a syndrome brought on by difficult life circumstances

Susto : (fright or soul loss) also known as espanto, pasmo, tripa ida, perdida del alma, or chibih. It is an illness attributed to afrightening event that causes the soul to leave the body and results in unhappiness and sickness.

References Mental Health: Culture, Race, and Ethnicity, A Supplement to Mental Health: A Report of the Surgeon General (2001) CDC en Espa ñol; www.cdc.gov/spanish/mental.htm CDC Office of Minority Help www.Healthyplace.com ; How Do Hispanics Experience Depression Levin, Aaron; Does Resilience Protect Minorities From Mental Illness?; Psychiatric News, May 29, 2005;Volume 40 number 10, P. 48; Am. Psych. Assoc.

Mental Health: Culture, Race, and Ethnicity, A Supplement to Mental Health: A Report of the Surgeon General (2001)

CDC en Espa ñol; www.cdc.gov/spanish/mental.htm

CDC Office of Minority Help

www.Healthyplace.com ; How Do Hispanics Experience Depression

Levin, Aaron; Does Resilience Protect Minorities From Mental Illness?; Psychiatric News, May 29, 2005;Volume 40 number 10, P. 48; Am. Psych. Assoc.

6. Breslau, Joshua, et al; Lifetime risk and persistence of psychiatric disorders across ethnic groups in the United States; Psychological Medicine (2005) 35 : 3 :317-327; Cambridge University Press. 7. Archart-Treichel, Joan; Ethnic Variations in Depression, Suicide Rates Puzzle Researches; Psychiatric News; Oct. 5, 2001, P. 25; Volume 36 Number 10; Am Psych Assoc. Grant, Bridget F.; Immigration and Lifetime Prevalence of DSM-IV Psychiatric Disorders Among Mexican Americans and Non-Hispanic Whites in the United States; Archives of Gen. Psych. Vol. 61 No 12, Dec 2004 Levin, Aaron; Why Are Mental Illness Rates Lower in Some Immigrants?; Psychiatric News Jan 21, 2005 Volume 40 Number 2, P. 16; Am Psych Assoc.

6. Breslau, Joshua, et al; Lifetime risk and persistence of psychiatric disorders across ethnic groups in the United States; Psychological Medicine (2005) 35 : 3 :317-327; Cambridge University Press.

7. Archart-Treichel, Joan; Ethnic Variations in Depression, Suicide Rates Puzzle Researches; Psychiatric News; Oct. 5, 2001, P. 25; Volume 36 Number 10; Am Psych Assoc.

Grant, Bridget F.; Immigration and Lifetime Prevalence of DSM-IV Psychiatric Disorders Among Mexican Americans and Non-Hispanic Whites in the United States; Archives of Gen. Psych. Vol. 61 No 12, Dec 2004

Levin, Aaron; Why Are Mental Illness Rates Lower in Some Immigrants?; Psychiatric News Jan 21, 2005 Volume 40 Number 2, P. 16; Am Psych Assoc.

10. CRHRE’s Weekkly Mental Health Bulletin: Mental Illness and Minorities; http://www.health.uwyo.edu/MH_Bulletins/(28)Minorities.htm Lopez, Steven R., Special Programs and Initiatives: National Congress of Hispanic Mental Health—The Mental Health Needs of Hispanics in the US, March 20-21, 2000 Mental Health Problems among minorities; http://healthyplace.com/Communities/Anxiety/minorities.asp New Nationwide Survey Examines Ethnic Attitudes and Experiences with ADHD; http://www.mental-health-matters.com Bodiford, Kimberly J; The Presence of Health Disparities among Children with ADHD; http://forum.psu.edu/equity/stropapers/2004/BodifordKimberly.pdf

10. CRHRE’s Weekkly Mental Health Bulletin: Mental Illness and Minorities; http://www.health.uwyo.edu/MH_Bulletins/(28)Minorities.htm

Lopez, Steven R., Special Programs and Initiatives: National Congress of Hispanic Mental Health—The Mental Health Needs of Hispanics in the US, March 20-21, 2000

Mental Health Problems among minorities; http://healthyplace.com/Communities/Anxiety/minorities.asp

New Nationwide Survey Examines Ethnic Attitudes and Experiences with ADHD; http://www.mental-health-matters.com

Bodiford, Kimberly J; The Presence of Health Disparities among Children with ADHD; http://forum.psu.edu/equity/stropapers/2004/BodifordKimberly.pdf

15. Marin, Humberto; Hispanics and Psychiatric Medications: An Overview; Psychiatric Times, October 2003, Vol. XX, Issue 10 16. Acosta, Henry’ Model Mental Health Program for Hispanics; 2003, NJ, MH Institute, Inc. 17. Vedantam, Shankar; Racial Disparities Found in Pinpointing Mental Illness; Washingtom Post, Tuesday, June28, 2005, Page A01 Pollack, Linda et al; Patients’ Perception of Their Bipolar illness in a Public Hospital Setting; Psychiatric Quarterly, Vol. 72, Num. 2 Saddock BJ, et al; Synopsis of Psychiatry 9 th Ed. 2003, Chapter 14, Pages 530-531. Mezzich JE, et al; Cultural Psychiatry: International Perspectives; The Psych Clinics of North Am, Sep 2001

15. Marin, Humberto; Hispanics and Psychiatric Medications: An Overview; Psychiatric Times, October 2003, Vol. XX, Issue 10

16. Acosta, Henry’ Model Mental Health Program for Hispanics; 2003, NJ, MH Institute, Inc.

17. Vedantam, Shankar; Racial Disparities Found in Pinpointing Mental Illness; Washingtom Post, Tuesday, June28, 2005, Page A01

Pollack, Linda et al; Patients’ Perception of Their Bipolar illness in a Public Hospital Setting; Psychiatric Quarterly, Vol. 72, Num. 2

Saddock BJ, et al; Synopsis of Psychiatry 9 th Ed. 2003, Chapter 14, Pages 530-531.

Mezzich JE, et al; Cultural Psychiatry: International Perspectives; The Psych Clinics of North Am, Sep 2001