This paper traces the causes of higher rates of mental illness in elderly immigrants, the potential treatment approaches that serve to address specific culturally focused triggers and to outline health policy to address this issue.
Supporting the mental health and wellbeing of Anaesthetists. What can the workplace do? Presentation by Hunter Institute of Mental Health Director, Jaelea Skehan.
Supporting the mental health and wellbeing of Anaesthetists. What can the workplace do? Presentation by Hunter Institute of Mental Health Director, Jaelea Skehan.
NBCC, NAADAC, CAADAC, and California Board of Behavioral Sciences approved Mental Health continuing education and addictions counselor training series. Narrated versions and CEUs available at http://www.allceus.com
Overview of international challenges faced by psychiatrists through their practice
Collaborative work of:
1-Dr Yomna Gaber Senior Registrar Psychiatrist
2- Dr Hosam Kasseb Senior Registrar Psychiatrist
3-Dr Wasem Marey Consultant Psychiatrist
Presentation by Hunter Institute of Mental Health Projects Coordinator Ellen Newman for Thrive 2016, weaving wellness and wellbeing conference. This presentation is about mental health literacy and strategies for supporting children’s mental health and wellbeing.
Are you drinking TOO much?
Alcohol is the most commonly used potentially addictive substance in our society. Alcohol is responsible for over half of the $267 million dollars of substance related hospital costs in Canada. Problematic alcohol use significantly impacts individuals, families, and our community, but many struggle to know if they have a problem and where to go for help.
Learn more: http://www.theroyal.ca/mental-health-centre/news-and-events/newsroom/13411/alcohol-how-much-is-too-much/
Presentation by Kathryn Falloon, Dr Serene Teh and Tracy Coward - A positive behavior support approach for mental health consumers. Presented at the Western Australian Mental Health Conference 2019.
View the video here: https://www.youtube.com/watch?v=gCMCNReYnYs
Earn counseling CEUs here: https://www.allceus.com/member/cart/index/product/id/684/c/
Assumption 1: Counselors will not be able to sustain culturally responsive treatment without the organization's commitment to it.
Assumption 2: An understanding of race, ethnicity, and culture (including one's own) is necessary to appreciate the diversity of human dynamics and to treat all clients effectively
Assumption 3: Incorporating cultural competence into treatment improves therapeutic decision-making and offers alternate ways to define and plan a treatment program that is firmly directed toward progress and recovery
Assumption 4: Consideration of culture is important at all levels of operation—individual, programmatic, and organizational
Assumption 5: Culturally congruent interventions cannot be successfully applied when generated outside a community or without community participation.
Assumption 6: Public advocacy of culturally responsive practices can increase trust among the community, agency, and staff.
Presentation by Lucy Jestin and Richelle Seales. Womens Health and Family Services, Be Well program. Presented at the Western Australian Mental Health Conference 2019.
NBCC, NAADAC, CAADAC, and California Board of Behavioral Sciences approved Mental Health continuing education and addictions counselor training series. Narrated versions and CEUs available at http://www.allceus.com
Overview of international challenges faced by psychiatrists through their practice
Collaborative work of:
1-Dr Yomna Gaber Senior Registrar Psychiatrist
2- Dr Hosam Kasseb Senior Registrar Psychiatrist
3-Dr Wasem Marey Consultant Psychiatrist
Presentation by Hunter Institute of Mental Health Projects Coordinator Ellen Newman for Thrive 2016, weaving wellness and wellbeing conference. This presentation is about mental health literacy and strategies for supporting children’s mental health and wellbeing.
Are you drinking TOO much?
Alcohol is the most commonly used potentially addictive substance in our society. Alcohol is responsible for over half of the $267 million dollars of substance related hospital costs in Canada. Problematic alcohol use significantly impacts individuals, families, and our community, but many struggle to know if they have a problem and where to go for help.
Learn more: http://www.theroyal.ca/mental-health-centre/news-and-events/newsroom/13411/alcohol-how-much-is-too-much/
Presentation by Kathryn Falloon, Dr Serene Teh and Tracy Coward - A positive behavior support approach for mental health consumers. Presented at the Western Australian Mental Health Conference 2019.
View the video here: https://www.youtube.com/watch?v=gCMCNReYnYs
Earn counseling CEUs here: https://www.allceus.com/member/cart/index/product/id/684/c/
Assumption 1: Counselors will not be able to sustain culturally responsive treatment without the organization's commitment to it.
Assumption 2: An understanding of race, ethnicity, and culture (including one's own) is necessary to appreciate the diversity of human dynamics and to treat all clients effectively
Assumption 3: Incorporating cultural competence into treatment improves therapeutic decision-making and offers alternate ways to define and plan a treatment program that is firmly directed toward progress and recovery
Assumption 4: Consideration of culture is important at all levels of operation—individual, programmatic, and organizational
Assumption 5: Culturally congruent interventions cannot be successfully applied when generated outside a community or without community participation.
Assumption 6: Public advocacy of culturally responsive practices can increase trust among the community, agency, and staff.
Presentation by Lucy Jestin and Richelle Seales. Womens Health and Family Services, Be Well program. Presented at the Western Australian Mental Health Conference 2019.
ISPCAN Jamaica 2018 (CIHRTeamSV) - Improving Health and Behavioral Outcomes a...Christine Wekerle
Improving Health and Behavioral Outcomes among Sexually Victimized Male Youth: A Qualitative Investigation Among Trauma Treatment Providers
Ashwini Tiwari, Christine Wekerle, Andrea Gonzalez (CIHRTeamSV)
1.1.7 AWHN Conference 6 2010 Federation:
Specialist Mental Health and Women’s HealthWorking In Partnership To Better Address the Intersection(s) of Mental Health and Violence and Abuse. Women’s Health Statewide Zhila Javidi, Centre for Anxiety and Related Disorders
I created this to ultimately present to my Child Life department at the hospital I work at in order to raise awareness of the importance of peer support to the sick and hospitalized adolescent. Perhaps there will be further development of this type of program where I work. Hope you enjoy!
Jeremy Taylor presentation to FT governorsJeremy Taylor
Presentation to Foundation Trust governors in April 2015 explaining National Voices' take on person centred and community focussed care and inviting governors to reflect on their role in making it happen
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
1. Mental Health Policy and Immigrant Elderly:
The South Asian Experience
Nawaz Merchant
Thomas Jefferson University, School of Population
Health
Health Policy
December 11, 2015
2. 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
3. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
4. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
5. Who are South Asian seniors?
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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
6. Who are South Asian seniors?
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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
7. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
8. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
9. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
11. Literature
review
Qual
interviews
Studies that describe
CMDs in SA senior
immigrants
Studies that describe
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
Studies that describe
successful
interventions in
similar populations
Intervention assessment instrument
Analysis of
prevalence
Literature review
#1 #2
11
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
12. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
13. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
14. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
15. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
17. 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%
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
18. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
19. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
20. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
21. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
22. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
23. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
24. The interviews also
revealed a host of
barriers to care!
24
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
25. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
26. Policy to address barriers
26
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
28. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
29. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
30. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
31. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
32. 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
Jefferson University, Health Policy
33. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
34. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
35. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy
36. 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
Nawaz Merchant, MS Thesis, Thomas
Jefferson University, Health Policy