Nawaz Merchant Capstone Presentation

Mental Health Policy and Immigrant Elderly:
The South Asian Experience
Nawaz Merchant
Thomas Jefferson University, School of Population
Health
Health Policy
December 11, 2015

Acknowledgements
Capstone Committee
Drew Harris, DPM, MPH
Alison Karasz, PhD
Caroline Golab, PhD
Nancy Chernett, MA, MPH
Subject Matter Experts
South Asian community providers:
1. Sunanda Gaur, MD, MBBS (SATHI, RWJ)
2. Rupa Khetarpal, LCSW (Counselor)
3. Padma Desai, LPS NCC (Counselor)
4. Taruna Tehsildar, MSW (Counselor)
5. Aparna Kalbag, PhD (Counselor)
6. Meena Murthy, MD (Endocrinology, Geriatrics)
7. Meeta Verma, RPN (Nursing home)
South Asian program insight:
1. Aruna Rao, MA (NAMI- NJ)
2. Dinaz Bengali RPN (Director, Indian Program Nursing
Home)
3. Homi Gandhi (VP FEZANA - Interfaith Committee)
4. Govinda Rajan (Agraj Devkendra community group)
Consultation:
• Sunita Mookerjee, MPH (Program Manager, Maternal-
child health programs)
2
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy

Why is this worth doing?
Common mental disorders are widespread….
• By 2030 depression will be the leading cause of disease burden globally
(WHO, 2011)
• Depression affects about 15% (7 million) of the senior population (CDC
Factsheet 2014).
• Only about 10% of seniors with depression receive any help (PsychCentral
website, 2014)
And result in significant social cost
• Depression in the elderly is associated with higher medical costs,
increased risk of suicide, comorbidities and impact on lifespan (Reynolds,
2012).
• Significant impact on families and caregivers
South Asian senior immigrants fall through the gaps in the US healthcare
system.
*Common Mental Disorders include depressive and anxiety disorders, Social Phobias and PTSD 3

Who are South Asian seniors?
3.4 million South Asians* live in the United States (US Census 2010)
• As a ‘model minority’, SA immigrants tend to have higher education and
income levels, a strong work ethic and attitude of self reliance.
Senior South Asians frequently migrate to live with their adult children and
are completely dependent upon them (multi-generational joint families).
• Migrating at a later age is very stressful, seniors have fewer resources to
enable them to adapt.
• Many are widows, or migrate after the loss of their spouse
• Widely dispersed in NY, NJ, CA, GA, TX which compounds their isolation
• Middle class diaspora may not live in close proximity: Seniors are close to
family but far from community/peers
*South Asia includes India, Pakistan, Nepal, Sri-Lanka, Bangladesh, Bhutan and the Maldives 4

South Asian cultural nuances
• Mental health stigma can be a barrier to care
• Stoic endurance and fatalism are common attitudes; distress can escalate
into CMD* with suicidal ideation
• Strong family bonds (socialized to depend on family vs. systems); child is
protective gate-keeper for parents.
• Traditionally male-dominant society; the son (and daughter in law) is
financially responsible for parent’s care (Puri, 2011)
• Seniors may fear the US healthcare system, frequently return to
originating countries for healthcare
• Generally do not advocate for themselves; no culture of political activism
*Common Mental Disorders include depressive and anxiety disorders, Social Phobias and PTSD 5

Lack access to health insurance
– Not covered on adult child’s employer sponsored insurance
– Immigrant sponsorship limits their eligibility for Medicaid
– Continuous stay requirement limits Medicare eligibility ($550/pm)
– Private insurance (exchange coverage >$500/pm) often unaffordable
• Not eligible for subsidies due to sponsors income
– Visitors insurance excludes pre-existing conditions
– Exempt from charity care due to foreign residence or assets
– Results in financial risk to SA families (loans and bankrupt families)
– Impacts mental health of caregivers and families
Frequently cannot drive (women, seniors who never learned, cannot afford a
vehicle/insurance)
– Home-bound seniors are isolated, difficulty accessing needed care
– Vulnerable to Senior Abuse from neglect or expectation of child care
6

South Asian community organizations
South Asians are not one monolithic group
• Multiple sub-groups and sub-cultures (Bengali, Gujarati, South Indian,
Pakistani, Bangladeshi, etc) with different religions (Hinduism, Islam,
Bahai, Sikh, Buddhist, Jain, Zoroastrian etc)
South Asians have organized themselves into groups/community
organizations
• Religious groups (FEZANA, Arsha Bodha, Islamic society of Central
Jersey) are well organized, but small
• Cultural groups (Garba dance performances, festival committees) are
loose affiliations, run by volunteers to host events
• Cause specific groups (Manavi, SAKHI: domestic violence)
• South Asian professional associations include SAMHAJ (within NAMI
NJ Affiliate), SAMHIN, etc.
• SA immigration issues: SAALT South Asian Americans Leading Together
7

Policy objectives:
Problem Statement
South Asians have high levels of mental distress that are not sufficiently
addressed. Policy makers may not be attentive to this since it is underestimated
in national surveys. While some causes of CMDs are common to other
populations, there are cultural nuances that are unique to SAs.
Culturally appropriate interventions for CMDs in this population have not been
studied. Current healthcare policy has a significant gap in access to care for senior
immigrants, leaving them vulnerable and posing financial risk to caregivers.
This study addresses policy changes needed to close the gaps in access to
mental health care. It examines the impact of culture on the measurement,
causes and acceptability of interventions for Common Mental Disorders among
South Asian senior immigrants.
8

Research questions
• What are the causes (social factors) of CMD in South Asian senior
immigrants?
• What interventions are successful in similar populations? What
intervention is best suited for this population?
• What policy recommendations can address this issue?
9

Methodology
10

Literature
review
Qual
interviews
Studies that describe
CMDs in SA senior
immigrants
CMDs in other
immigrants and seniors
Multi-phase research methods
Causes of
CMDs
Interventions
Match of
interventions
to causes
Policy
implications
interventionscauses
• Cultural nuances
for causes
• Barriers to
accessing care
• Recommend
targeted
intervention
Literature
review
Qual
interviews
successful
interventions in
similar populations
Intervention assessment instrument
Analysis of
prevalence
Literature review
#1 #2
11

Methods: Unit of Analysis
South Asian senior immigrants (orange area of overlap) experience a number of
stressors.
Some stressors are common to other seniors, while others are unique to this group
due to cultural nuances
Distress is defined as sub-threshold levels of CMDs
Seniors
Common
Mental
Disorders
South Asian
Immigrants
12

What data do we have on causes of
CMDs?
Literature review: Data on South Asian senior immigrants
• 8 papers on SA senior immigrants (Asian Indian)
• 4 papers on Senior immigrants (Asian and other immigrants)
• 4 papers on immigrant mental health issues (other than seniors)
Seniors
Common
Mental
Disorders
South Asian
Immigrants
13

What data do we have on
interventions?
Literature review: No studies found that are specifically on interventions in South Asian senior
immigrants
Literature on interventions in similar populations:
• A meta analysis of 15 interventions in Latino, Chinese, Korean, Turkish immigrants
(Antoniades, 2014)
• A meta analysis of 44 interventions in US Seniors (Cuijpers, 2014)
• 14 papers on interventions in seniors (Psychotherapy, Care Co-ordination, activity,
mindfulness, life-story, participatory methods) using home visits, group sessions, one on one
meetings
Seniors
Common
Mental
Disorders
South Asian
Immigrants
14

Methods: Qualitative interviews
Inclusion criteria:
Respondents were South Asian providers with experience treating seniors
with mental health needs and community members with knowledge of
senior-focused programs
• 7 South Asian community providers
• 4 South Asian community members with program insight
11 research interviews conducted on
• Underlying causes of senior distress and CMDs
• Their experience with interventions (successful and less successful)
• Barriers to care and how to address them
• Suggestions for prevention of CMDs
15

Research Results
16

Measurement issues: data may not capture
magnitude of problem
National surveys estimates of
CMDs in South Asian seniors in
may be too low.
• Mental health stigma in
culture which affects
responses to survey questions
• SAs tend to interpret mental
distress as somatic problems
(Chen 2002)
• Terminology of surveys is not
culturally relevant (BRFSS vs
CES-D, GDS)
• National surveys group Asian
sub-groups
0
5
10
15
20
25
30
35
40
45
Asian White Hispanic Black
Prevalence of Depression by Race
CDC (Age 18+) CDC (Age 65+) Diwan (2008) Mui & Kang (2006)
Percent
GDS scaleCES-DBRFSS (2011)
17
4%
11%
40%

Results #1
Causes of CMDs from literature review
stressors assets
Senior Distress
Common Mental Disorders
Migration poses a significant challenge; seniors
tend to have fewer emotional resources to
readjust and cope.
• Emotional stressors (loneliness, isolation)
• Functional stressors (language,
transportation, lacking knowledge of US
systems)
Demographics can disadvantage seniors:
• Risk factors (for depression) include being
female, in poorer health, lower education,
BMI>25
Protective factors are:
• Social support systems
• Positive attitudes about ageing and mental
health
18

Results #1
Causes of CMDs from interviews
South Asian senior immigrants (SASI) feel isolated
– Culture clash with adult children (“cultural contradictions”)
– SASIs do not live independently, lack mobility, since they don’t drive
– Lack knowledge of the US insurance and healthcare systems
Childcare role can be positive (“joint families”)
– Elder abuse occurs if consent is taken for granted
Cultural attitudes
– Stigma for mental illness (“pagal”=madness; mental illness is seen as a
sign of ‘faulty genes’ that impair child’s marriageability )
– Ageism
– Fatalism (framed as philosophy of karma)
– Treat emotional issues as somatic problems (insomnia, back pain etc)
19

Results #2
Literature review of interventions
Interventions used various formats (home visits, group sessions, one on one
meetings)
• Meta analysis of 15 interventions in Latino, Chinese, Korean, Turkish
immigrants (Antoniades, 2014)
– Psychotherapy is more effective in immigrants than Depression Care Management /care
co-ordination
– Many studies cited high attrition rates
– (Culturally adapted) Cognitive Behavior Therapy, Behavior Activation was more effective
– Problem Solving Therapy effective with and without cultural adaptation
• Meta analysis of 44 interventions for CMDs in US Seniors (Cuijpers, 2014)
– CBT and PST are effective treatments for senior depression (Overall effect size g=0.64)
• 14 papers on interventions for CMDs in seniors (US and abroad)
– Psychotherapy with and without medication
– Care Co-ordination and Depression Care Management
– Mindfulness, life-story review
20

Results #2
Interview results from interventions
Cultural adaptation is essential
– Examples: CBT can re-traumatize patients due to cultural norms of loyalty to
family
– A modified form of DBT successfully used to address fatalism (by using
validation and impetus for change)
– Home visits must include the caregiver/adult child
– Help seniors to increase social support
Addressing stigma is critical
– Change language from ‘mental health’ (=“pagal”). Instead use
“tension” “emotional wellbeing” which are more acceptable
Gaps
– Lack of insurance coverage
– Lack of culturally appropriate care and facilities
– Reaching the home bound senior
21

Holistic interventions are more likely to be
successful
emotional
stressors
• SASI: isolation,
loneliness,
fatalism
functional
stressors
• SASI: mobility,
language,
knowledge of US
systems
social support
• SASI: need
stronger
networks,
relationship with
adult children
Attitudes
• SASI: Stigma for
mental illness,
ageism
Individual
Psychotherapy
Group
therapy/activity
DCM with Home
Visit
Ecosystem Focused
Therapy
22
Treatment models

Policy recommendation
Programs are more likely to be effective when treatment models are holistic,
culturally attuned and use local community resources
Example: Ecosystem focused therapy
• Uses Problem Solving Therapy
• Includes home visits under PCP/specialist advisement
• Uses available local community resources
EFT process
• Increases adaptation and mastery: Imparts skills maximizing his/her
remaining functions,
• Personalized for the senior’s capabilities: modifies the patient’s physical
environment,
• Includes caregiver: engages family members in helping the patient bring
to bear his/her skills
23

The interviews also
revealed a host of
barriers to care!
24

Improved outcome
Conceptual framework for pathways to
care
Tell someone
(family, PCP..)
Healthcare insurance
Seek treatment
Find appropriate
provider
Maintain treatment
Mental Health stigma and fear
Lack of health insurance
Knowledge gap
Fear of HC system and costs
Lack culturally competent care
Home-bound
Worsened health, premature
ageing, early demise, suicide
25

Policy to address barriers
26

Healthcare Stakeholders
Consumers,
community
organizations
Local, County,
State policy
makers
ProvidersEmployers
Insurers
27

Improved outcome
Policy to overcoming barriers to care
Tell
someone
(family,
PCP)
Healthcare
coverage
Seek
treatment
Find
appropriate
provider
Maintain
treatment
Mental Health stigma and fear
Lack of health insurance
Knowledge gap
Fear of HC system and costs
Lack culturally competent care
Home-bound
Worsened health,
premature ageing, early
demise, suicide
Increase acceptance, change attitudes
Medicare policy, availability and awareness of
affordable insurance products
Disseminate resources
Cultural competence training, culturally
adapted screeners, affordable facilities
Reimburse home health visits/ telehealth;
transport services
Maintain health and wellness in senior years
28

1. Mental Health stigma and fear
Address stigma through acceptance, change attitudes
• Changing language to consumers from “mental health” to “emotional
wellness”
• Encourage SA public discussion – share experiences
• Media campaigns, leverage cultural events
• Fund mental health training for religious and secular leaders
• Fund advocacy programs (ex. NAMI NJ, SATHI-RWJ)
Reduce isolation by building senior support systems
• Leverage existing services such as SAPNA-NYC ‘tiffin project’ that send
heart healthy meals to seniors
• Form senior activity committees
• Engage volunteers to visit seniors
CommunityOrganizationsEmployers
29
PolicyMakers

2. Affordable Health Insurance
Health Exchange coverage presently offers catastrophic coverage at high
premiums ($500+/pm with $6,500 deductible)
Exchange plan changes
• Cover all mental health services at low copay (without deductibles)
• Reimburse home visits (for screening and treatment)
• Share savings from ‘staying healthy’ (Reimburse part of premium for
each year that the senior is not hospitalized)
Medicare/Medicaid changes
• Allow Medicare ‘buy in’ without continuous stay requirement
• Shared savings for seniors with healthy outcomes
Self-insurance option
• Mobilize support and create workable plan (SAALT)
• Negotiate with health systems in states with larger SA population
Insurers
Community
Organizations
PolicyMakers
30

3. Fear of HC system and costs
ACOs Population Health efforts
• Create depression care programs that use social workers* who speak
the patient’s language
• Integrate mental health providers into PCP “medical homes”
• Promote community senior support groups through wellness grants
Disseminate resources
• Communicate insurance benefits, distribute community resource lists
• Share resource guides (ex. Senior Blue Book, SA provider directory)
*Example:
• Annual cost of Univ. of Washington IMPACT (DCM) model for seniors was
$750 per participant, $250 per SW; Participants twice as likely to have
50% reduction in depressive symptoms (8 session trial)
• Total healthcare cost reduction was $3,300 per patient (CDC, Benson
2010)
Community
OrganizationsProviders
31
PolicyMakers

4. Culturally competent care*
• States with high immigrant populations should require MDs to have
cultural competence training (State licensure)
• Mandate use of culturally adapted screening instruments to identify
immigrant mental health needs (ex: NJ postnatal screening)
• Add quality measures to Medicare/ Commercial patient-centric and
value based programs, and quality reporting
– Provider certification in cultural competency (add to PQRS)
– PCP training in mental health (Hospital-Compare, Physician-Compare)
– ACOs should be required to deliver mental health services (ex: MSPP)
• Provide courses in SA cultural competency
• SA Provider Assoc. can build culturally adapted screening instruments
• Affordable/relevant adult daycare facilities (with SA food, music,
activities, providers)
PolicyMakersCommunity
Organizations
32*policy serves multiple immigrant groupsNawaz Merchant, MS Thesis, Thomas

5. Home-bound seniors
Leverage the power of local/county government
• Convene groups
• Fund grants and preventative programs
Reimbursement
• Reimburse home visits for mental health needs
• Telehealth visits*
Address functional limitations
• Promote transport services (SA UBER taxi service?)
• Share information on free local and county transportation
*Examples: Telehealth visit cost ~$49/session (American Well Services)
Capture-Proof tablet technology pilot for chronic pain patients; kit cost
$130/patient (MedStar Health System)
InsurersCommunityOrganizations
33
PolicyMakers

Suggested policy initiative for home-
bound seniors
Organize program on the lines of the Tiffin Program by SAPNA NY (low income
SA women cook heart-healthy, meals delivered to seniors)
• Objective: To build strong support networks among and for seniors to
prevent depression
• Who: Local health systems, local government, SA community groups
• Fund: Secure government/foundation funding for preventative program
• Execute: Create a senior-activity committee to encourage volunteerism (example
Agraj Devkendra)
– Engage home bound seniors, arrange group activities, visits to senior center,
farmers markets, parks and gyms
– SA volunteers are paired with home bound seniors through common interests
• Measure: Survey short term difference in pre-post symptoms; long term
health outcomes (vs. wait list or did not participate)
34

Conclusion
As immigrant communities mature, they tend to organize and
become more successful in meeting the needs of their members
Community empowerment
• The SA community needs to become better advocates for
themselves
• Invest in advocacy training to gain an appreciation of what
government can do for them
• Leverage political power through organizing and lobbying
government entities
35

Study Limitations and Next Steps
Limitations
– Few studies listed the costs of their interventions
– Interventions explored were representative of the types of
interventions available, not comprehensive
– Interviews conducted were focused on SA experience in NJ, and may
not be generalizable to other areas
Suggested future studies
– Epidemiological studies of the SASI population and CMD in language
which accurately assesses prevalence
– Suicide ideation, completions of suicides among SAs
– Cost of disease progression, comorbidities and medical cost from CMD
– Cost effectiveness of tele mental health
– Adult daycare facilities and reduction in regulation to safely decrease
costs
36

Thank You!
37

Nawaz Merchant Capstone Presentation

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