Mental Health Disparities Among Hispanic Populations in the US
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Mental Health Disparities Among Hispanic Populations in the US
- 1. Yelena Bugbee Westberg, Shalimar Bulaclac, Julie Radford Submitted to Dr. Robertson California State University, Fullerton 508: Vulnerable Populations September 27, 2010
Editor's Notes
- 1. What is it? a. Mental illnesses are medical conditions that affect thinking, feeling, speaking and ability to function on a daily basis. b. The term refers to a broad range of mental health conditions including schizophrenia, anxiety disorders, major depression, obsessive compulsive disorder, eating disorders, borderline personality disorder, addictive disorder, post-traumatic stress disorder, and bipolar disorder.
- 2. Who has it? a. 1 in 17 Americans live with a serious mental illness (National Alliance on Mental Illness (NAMI), 2010). b. Mental illness affects the very young, the very old, the rich and poor, and across all religious and ethnic lines. c. NAMI (2010) states “mental illness is not a result of personal weakness, lack of character, or poor upbringing” and usually strike during adolescence.
- Monetary a. In the United States (US), the annual indirect cost from loss of productivity from mental illness is estimated to be $63 to $79 billion dollars (NAMI, 2010). b. Non-treatment for these diseases cost the US more than $100 billion each year (NAMI, 2010). Personal and quality of life a. If left untreated, mental illness can lead to substance abuse, suicide, preventable disability, unemployment, and homelessness. b. In addition, it has been shown to lead to decreased quality of life, functioning, and shorter life span (WHO, 2001).
- Depression 1. While all mental disorders create vulnerability, the most prevalent, and easily treatable of all mental illness is depression. 2. Depression through history a. Hippocrates (330-399 AD) used the term “melancholia” in his works to describe early classification of mental illness disorders. b. Even Job and King David are noted in the Bible as having melancholy. c. The term depression comes from Latin and means to “press down” (Aguilar-Gaxiola, 2008) and over hundreds of years has become the all encompassing definition now known today. 3. Current thought a. “I continue to be amazed about a mental health condition that is common, pervasive, costly, debilitating, painful, stigmatizing, and puzzling, but at the same time highly treatable and challenging to us all regardless of where we live, and whether we are clients, family members, friends, providers, researchers, policy makers or administrators” (Agular-Gaxiola, 2008).
- Prevalence of depression in the US a. Depression affects a large majority of the population and is a major health concern. b. In a 10 year study, depression was found to have increased from 3.3% to 7.1% in the general population (Compton, Consway, Stinson, & Grant, 2006). c. More alarming are reports that children are also showing signs and symptoms of the disorder. Recent studies have also linked maternal depression to increasing the risk for major childhood depression (Weissman, et al, 2005). d. Depression numbers continue to rise and by 2020 it is predicted to be the second most prevalent disease after cardiovascular illness (Murray & Lopez, 1996; Vega, 2010).
- Depression as a problem a. Studies have shown that people with depression have fewer days of employment with the same employer, lower academic success and income, and poor working status (Coryell, Endicott, & Keller, 1990). b. Only 20-25% of clinically depressed people seek help for depression with a majority of the diagnosis occurring in the primary care provider’s office (Aguilar-Gaciola, 2008).
- D. Health disparities and depression 1. Major report a. In 2001, the Surgeon General reported that major health disparities existed between various races in the US (USDHHS, 2001). b. This report specifically named Latino immigrants, African American’s and Native Americans as being underserved in healthcare. 2. Other reports a. Other studies have also shown that Latino immigrants are more likely to suffer from mental illness, especially depression and anxiety, and even with health insurance, less likely to get help for it when compared to whites (Bayard-Burfield, 2001; Ritsner, 2001; Wittig, 2008). b. Depression has historically been reported to be highest among white males. However, Golding, and Burnam (1990), Plant and Sachs-Ericsson (2004), and Roberts (1980) report that Latinos have a higher episode of stress and depression as compared to non-Latino Whites and African Americans. 3. Presentation Focus a. Newly immigrated Latinos and their families will be focused on in this presentation as a representative of the immigrant experience of depression.
- Latino/ Hispanic A. Demographics 1. “Latino”: A Catch All Name a. The name Latino or Hispanic accounts for over 20 different countries of origin. b. The Spanish language is the only uniting thread between all Latinos. c. All 20 countries have individual cultures, beliefs, politics, histories, and customs (Aguilar-Gaxiola & Gullotta, 2008). d. Major countries include: Mexico (64%), Puerto Rican (9%), Cuban (3.4%), Dominicans (2.8%), with Central and South American’s comprising 5.5-7.6% of the US Latino population (Aguilar-Gaxiola & Gullotta, 2008).
- 2. Why they come to the US a. Inequalities and poverty in their homeland compel many Latinos to immigrate to other countries. b. Many immigrate to US due to its close proximity, better education and economic conditions (Aguilar-Gaxiola, 2008)
- 3. Growth in the US a. Latinos are the largest growing population in the US and make up 14.8% of the total population (US Census Bureau, 2006). b. Estimated that by 2050 the Latino population will be 24.4% (102.6 million) of the US population. (US Census Bureau, 2004).
- A. Prevalence 1. estimated at 28% to 44%, with second biggest prevalence of depression for race in U.S. (Saiz-Santiago 2003).
- B. Risk factors 1. chronic health conditions- DM, heart disease, substance abuse 2. low economic status/ financial hardship/ poverty/ manual labor 3. immigration issues / legal problems- personal stories of children being taken and parents deported. Fear of deportation leads to poor housing and bad work conditions. 4. lack of insurance 5. acculturization- difficulties with (Shattell, 2009) 6. discrimination “based on assumed immigration status” (Shattell, 2009) Can create PTSD and anger. a. story about highly educated psychologists who accidently took off parts of fingers with a lawnmower. X-ray tech said “you’ll have to change your line of work, no more cutting grass, get a safer job. Perhaps you can make hamburgers or tortillas at mcdonalds” i. discrimination leads to anger which can lead to depression 7. limited number of bilingual speaking health providers (shattell, 2009)
- Cultural barriers to mental healthcare treatment from the emic view- Many of these ideas flow together. 1. Stigma surrounding mental illness- blocks acceptance of treatment a. Somatization- Physical symptoms that mask anxiety and depression among certain ethnic groups, especially latinos. Manifest as chest pain, palpitations, gas, and GI disturbances (Alegria, 2007b). Clinicians may treat cultural symptoms without a focus on depression. b. Afraid of “labels” associated with mental health dx and medication (vega, 2010) 2. familismo - Family and close friends. The most important concept of Latino culture. Big family dinners are often held on a weekly basis with traditional food being served. Family may hold a strong influence over how individuals use services and get treatment for mental health issues (Anez, et al., 2005). a. Family can also be a protective factor that deflects depression in an individual. ii. Many reports state that Latinas preferred to discuss depressive episodes with other female relatives over a healthcare professional and stranger. 3. machismo vs marianismo – gender roles a. men are providers and protectors. i. Men may have a harder time even presenting to the doctors office as it is seen as a sign of weakness (Vega, 2010). ii. Recent studies show that many men do not recognize the signs and symptoms of depression but think it is a serious issue. iii. Men may try to mask their depression with alcohol abuse. b. women are spiritual, subservient, raise children, support husbands and are to be “the spiritual heart of the family” (Dreby, 2006) i. Mother Mary ii. When a woman becomes pregnant she becomes “elevated” in status among the family members 4. simpatica -avoiding interpersonal conflict (Gloria & Peregoy, 1996) a. Latinos will be agreeable with healthcare professional’s POC in person and noncompliant with mediations or prescribed regimens later 5. respeto - hierarchy of respect for elders and those in authority (Anez, 2005) a. Latinos may also show simpatico to healthcare professionals and not question their prescribed regimen while in the office, but to have simpatica wait to follow non-compliance until later. b. Personal story of pt. who was obviously in pain from abdominal surgery but when questioned if she wanted medication for it smiled and said “whatever you think is best. You are the professional.” 6. verguenza - shame. a. Especially when seeking out care for mental health issues for self and family (Gloria & Peregoy, 1996). More prevalent in men due to machismo thought but also seen in women. 7. fatalismo – external locus of control. a. Can create a problem with resolving mental illness especially if patients believe in depression being a “punishment from God” for their bad deeds. b. May try to resolve depression by traditional medicine of Curanderismo or Santaria priest. i. Curanderismo- Mainly practiced by Mexicans. Belief that illness is caused by natural, supernatural or external forces ii. Santeria-combined elements of magic and Catholic beliefs. Mainly practiced by Cubans. Beliefs and practices differ according to priest and followers needs. 8. Personalismo -refers to idea that business is conducted after participants get to know each other on a personal level (Anez, 2005) a. Latinos will often not discuss personal issues that may bring them shame or verguenza until the healthcare provider has taken the time to socialize and get to know them 9. Religiositiy a. May be used as a protective barrier to depression but can also hinder service utilization due to fatalismo perspective
- B. Other barriers to mental healthcare treatment from the etic view 1. Many Latinos live in poverty a. Inability to access information easily from internet due to lack of computer and internet use b. inability to afford health insurance i. even those with insurance are still less likely than Caucasians to use mental health programs 2. Shortage of mental health programs a. Problems with finding on line assistance b. Decreased funding for programs 3. Language barrier and unknown healthcare infrastructure (Alegria et al, 2007a) a. 45% of Hispanic Americans have poor English utilization (kochlar, 2005) b. medical terminology barrier c. translator issues- colloquialism (slang) variations among Spanish translators unknown and may speak “disrespectfully” to patient losing their trust (Aguilar-Gaxiola, 2008) 4. Belief in alternative health systems: Curanderos / folk healers, Santaria 5. Inability to pay for medication and noncompliance with taking them (vega, 2010)
- Hello, I’m Shalimar and I’ll be presenting on the interventions for Latinos with depression. We start with those catered towards Latino adults with depression.
- A systematic review of depression treatments in primary care for Latino adults A systematic review of depression treatments in primary care for Latino adults by Cabassa & Hansen (2007) concluded that depression treatment programmes for Latinos delivered in primary care using a collaborative care model, were more effective than usual care, and that collected evidence-based treatments in primary care were effective and cost-effective for reducing mental health care disparities among Latinos. Under this collaborative care model, the guideline-based care is comprised of: Short-term psychological interventions (i.e. Individual or group cognitive-behavioural therapy or problem-solving therapy) Standard pharmacological protocols and/or Education or monitoring within a quality improvement case management or collaborative-care framework
- Racial Disparities in Diagnosis and Treatment of Depression (Simpson, Krishnan, Kunik , & Ruiz, 2007) Suggested solutions to improve treatment rates among Hispanics are: to improve existing programs by having more culturally and linguistically appropriate educational materials. to make mental health-care treatment more accessible to underserved communities. Since, treatment preferences (e.g., counseling versus medications) are observed to vary across ethnic/racial groups, then treatment programs should have multiple intervention choices The use of informal support systems by ethnicity may also help to determine the means that a minority may seek and acquire psychological interventions.
- We continue with complementary and alternative medicine use in depressed, underserved Hispanic patients Due to lack or limited access to care, the underserved Hispanic patients diagnosed with depression or subsyndromal depression have been found to extensively use complementary and alternative medicine for symptoms of depression, as a substitute to conventional care. Therefore, it is imperative to understand the different types and the ways that the underserved Hispanic communities use CAM, because this knowledge can be useful in designing interventions to improve care for depression in this population (Bazargan, et al., 2008).
- Mental Health Care Preferences Among Low-income and Minority Women (Nadeem, Lange, & Miranda, 2008). It is also important to know the mental health care preferences of low-income and immigrant women, which can be a significant barrier to accessing care by low-income populations. Low-income Hispanic women preferred active mental health treatment, particularly individual counseling, followed by group counseling, as compared to medication treatment. This may be due to some concerns of ethnic women about the consequences associated with medication use to help with emotional problems. Group therapy can provide a social support network, and be effective in treating depression and other psychiatric disorders, and it may reflect the interest among immigrant Latinas for mutually supportive relationships with those coping with similar problems. However, concerns about stigmatization among close-knit communities, particularly among recent immigrant groups, could prevent these women from participating in group therapy. They would rather disclose their information to someone outside of their community (i.e. through individual therapy). If these concerns arise, then explore the issues with the patient, further explain confidentiality procedures, and educate them about how group therapy may be useful. While at the same time, being sensitive to their concerns, and ensuring that confidentiality is followed through. Additionally, a majority of these low-income minority women indicated that faith was a way their problems could be helped, followed by support from friends and family. This suggests that partnering with faith-based organizations and incorporating faith and spirituality into existing mental health treatments, may bring effective mental health treatment to low-income minority women. We can also promote community education about depression and its care to help these women obtain the support from family and friends, which may then influence their help-seeking behaviors.
- Mental health service needs of a Latino population: a community-based participatory research project. (Shattell, Hamilton, Starr, Jenkins, & Hinderliter, 2008) A community-based participatory research (CBPR) approach can be used to identify and create ways to address factors affecting mental health services access and use at individual, organizational, and community levels. This approach can promote awareness and advocacy initiatives, instigate organizational change, and potentially impact local, state, and federal mental health policies. In a study using this approach to address mental health service needs of a Latino population, there have been several influential factors identified that have contributed to the mental health care disparity in Latinos, but are an important part of their culture. Thus, health care providers need to learn to work with these factors, in order to promote participation from the Latino population. The first issue identified, is that many Latinos expressed symptoms of mental illness or distress somatically. Somatization of the illness mean differently for individuals—such as a means of expressing disease, psychopathology, internal conflict, and/or social discontent. Having a better understanding of the meaning of somatization for Latinos, can lead to more accurate diagnoses and appropriate treatments. The second issue is that of trust. Latinos are often suspicious of the provider and reluctant to disclose complaints or problems. Therefore, trust and rapport can only be really established in a therapeutic client-practitioner relationship, when there is a mutual understanding and incorporation of specific cultural constructs (i.e. familismo and personalismo). The third issue is the language barrier as a factor in the use of mental health services by Latinos. Since there are limited number of practitioners who share the same culture and speak the same language, interpreters are the closest substitute. However, conversations with clients are complicated as many practitioners direct their attention on the interpreter during the conversation, and so the client begins to place more trust on the interpreter rather than the provider. This is just an example of how interpreters and/or culturally appropriate health education materials can be improperly used. Hence, t he adoption of the National Standards for Culturally and Linguistically Appropriate Services for Health Care was created in an effort to increase access, satisfaction, and maintenance of needed care. It serves as mandates for organizations in providing culturally and linguistically appropriate interpreters and educational materials. Additionally, the CBPR approach also addresses the lack of adequate income and health insurance as major barriers to Latinos accessing mental health care. To address these financial barriers to care, governmental policies, such as Medicaid, need to be expanded. Moreover, programs that offer sliding-scale fee schedules for mental health services, also need to be financially supported.
- Adolescent onset depression is also important to address, as there is an increased likelihood of recurrence and chronicity in adulthood if depression is left undiagnosed and untreated (Cook, Peterson, & Sheldon, 2009)
- We start with assessment strategies to properly diagnose depression in adolescents. Adolescent depression: an update and guide to clinical decision making (Cook, Peterson, & Sheldon, 2009) Careful assessment and differential diagnosis of depression in adolescents is essential. Key symptoms of depression include: sad or irritable mood anhedonia or the inability to experience pleasure and have fun For children in school, signs of depression might include: deteriorating academic performance weight or appetite loss or gain social withdrawal changes in sleep patterns increased defiance (related to irritability), and discontinuation of activities that were once preferred Any of these signs of increasing negative moods should trigger further assessment for: Alteration in thinking to more negative thoughts about themselves, the world, and the future…and Suicidal ideation and screening for safety While most signs and symptoms of depression in youth are similar to those seen in adults, it is important to know that there are some differences attributed to their developmental level. For instance, children are more likely than adults to exhibit irritability and display more indirect manifestations of disturbed mood through their behavior, such as having temper outbursts or social withdrawal Moreover, they are less likely than adults to openly complain about feeling depressed Accurate screening methodology can be facilitated by using depressive symptom checklists (i.e. the Child Depression Inventory Scale) or parent self reports. Schools may be a good place to conduct depression screening in children and adolescents (Cuijpers, van Straten, Smits, Smit, 2006) During screening and interview sessions with children and adolescents, open-ended or indirect questions is recommended because they do not always readily report symptoms of psychiatric disorders Additionally, i nformation from parents, and/or caregivers, and teachers are often essential to confirm the screening data derived from children.
- Following assessments, are prevention and early intervention strategies Optimal prevention strategies include: for managing depression in adolescents (Cook, Peterson, & Sheldon, 2009) Cognitive restructuring Problem solving Stress management Accessing social support But the most successful strategy identified is by targeting at-risk cohorts and utilizing expert clinicians to deliver the treatments. Selecting a well-known risk factor (i.e. parental depression and/or subsyndromal depression), and attempting to enhance protective factors, is a viable prevention strategy against adolescent depression.
- Next we move on to treatment/therapy strategies The latest evidence-based treatments for children and adolescents with depression include: Cognitive-behavioral therapy….which has been a very effective treatment in reducing symptoms of depression within 3 months and maintenance up to 2 years post-treatment. (Hamrin V; Pachler MC, 2005) Another form of treatment is interpersonal psychotherapy…which has been shown to help improve adolescent introspection, problem-solving, and fosters their communication skills (Hamrin V; Pachler MC, 2005) The third form of treatment is psychopharmacological….which is shown to be moderately effective in treating depression in children and adolescents. However, close monitoring is required for this type of treatment to evaluate for adverse events, including suicidal behavior and agitation. (Hamrin V; Pachler MC, 2005) The last is psychodynamic therapy and family therapy (Carr, 2008) next slide
- Beardslee Preventive Intervention Program for Depression for use with predominantly low income, Latino families (D'Angelo, et al., 2009). We move on to interventions for Latino families Adaptations were made to the Beardslee Preventive Intervention Program for Depression for use with predominantly low income, Latino families, which included: Offering the program in either English or Spanish, depending on the preference of the family Expanding the intervention to include the contextual experience of Latino families in the US, with special attention to cultural metaphors, and Used a strength-based, family-centered approach Several implications were made from this study Importance of the Family Meeting The families in this project found the family meeting to be the most important aspect of the intervention. For many families, this was the first time they were having a family conversation about difficult issues. Recognition of Potential Difficulties in the Family Conversation 2. The program facilitated conversation between parents and children of multigenerational Latino families. The preventionists served as cultural interpreters to help families to recognize and resolve intergenerational conflicts, by highlighting cultural strengths and in exploring solutions to these problems. Understanding Depression and Resilience 3. In keeping with the focus on ‘‘family and children’’ in Latino cultures, it was also important to note the impact of family separation and the loss of support networks due to immigration… and how this form of familial and cultural separation has impacted parental depression
- Speaking of community interventions, it is important for providers to know about the services offered within the community to be able to appropriately refer patients to these centers and avail of the services offered there. Thus, we surveyed Orange County for Mental Health agencies that are great resources for referrals for treating depression and other mental health disorders: First is the Depression and Bipolar Support Alliance (DBSA) of Orange County Which is a referral and education center for patients and their families affected by mood disorders (more specifically, depression and bipolar disorder). They offer support groups, educational meetings, a newsletter, a lending library, and referrals to hospitalization/medical treatment, emergency housing, therapy, counseling, employment opportunities, and to other mental health organizations. 2. Second is the Mental Health Association of Orange County They offer a range of services, to individuals with developmental disabilities and their families, including rehabilitative services to mentally ill homeless individuals 3. NAMI (the National Alliance for the Mentally Ill) They offer support groups and other education to families or individuals living with a mental disorder. You may visit the websites provided for more information regarding these particular agencies
- In conclusion: Understanding community attitudes about mental health care and their preference towards the different sources of care can aid in better structuring mental health care services to cater to particular underserved communities. Since there are multifactorial causes for racial health disparities, improvement efforts need to be multisystematic. That is, there needs to be improvements in interventions at all levels of health care policy to effect change. Improvements in the access to health care services and the treatment of depression in vulnerable populations, like the Latino population, will not only result in improvements in their quality of life, but also prevent the economic repercussions of depression “sick” days and disability that may prove detrimental to the lives of underserved individuals. In combination, these efforts will begin to close the health disparity gap between Latinos and their Caucasian counterpart (Simpson, Krishnan, Kunik , & Ruiz, 2007).