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

Mental Health Along the Mental Health Along the BorderBorder

Francisco Moreno, MDFrancisco Moreno, MD

Professor of PsychiatryProfessor of Psychiatry

University of ArizonaUniversity of Arizona

OverviewOverview

Demographics of Border StatesDemographics of Border States Challenges for Mental Health Care Challenges for Mental Health Care

Along the Border Along the Border Approaches to Minimize Mental Approaches to Minimize Mental

Health Care DisparitiesHealth Care Disparities

Census 2000:Census 2000: Percent Hispanic Percent Hispanic Along Border StatesAlong Border States

25.3

32.0

32.4

42.1

Percent of total population

New MexicoCaliforniaTexasArizona

Heterogeneity of Hispanic Heterogeneity of Hispanic AmericansAmericans

BirthplaceBirthplace AcculturationAcculturation LanguageLanguage LiteracyLiteracy GeneticsGenetics RaceRace EducationEducation SESSES Additional shared factors: urbanicity, Additional shared factors: urbanicity,

region, etc.region, etc.

Mexican Born Population in the Mexican Born Population in the USUS

32% of those who are Foreign Born32% of those who are Foreign Born 10.2 % of the Population in Mexico10.2 % of the Population in Mexico

Hispanic Americans Hispanic Americans DemographicsDemographics

Characteristic Characteristic Hispanic Gen Population Hispanic Gen PopulationMedian age (years) Median age (years) 26.0 26.0 35.435.4Foreign born (%) Foreign born (%) 40.2 40.2 11.111.1Foreign language spoken at home (%) Foreign language spoken at home (%) 78.6 78.6 17.917.9English spoken less than “very well” (%)English spoken less than “very well” (%) 40.6 40.6 8.18.1Age ≥25 years with ≥high school education (%) 52.4 Age ≥25 years with ≥high school education (%) 52.4 80.480.4Age 16 years and older in labor force (%)Age 16 years and older in labor force (%) 69.4 69.4 70.770.7Median household income in 2003 (US$) Median household income in 2003 (US$) 32,997 32,997 43,31843,318Living in poverty (%) Living in poverty (%) 22.6 22.6 12.412.4Health insurance in 2003 (%) Health insurance in 2003 (%) 67.3 67.3 84.484.4

Ramirez 2004Ramirez 2004

DeNavas-Walt et al. DeNavas-Walt et al. 20042004

Highest Degree Earned by Highest Degree Earned by People 20 and Older by Race & People 20 and Older by Race &

Ethnicity, 2008Ethnicity, 2008

Richard Fry, Senior Research Associate Pew Hispanic Center

Hispanic Immigrants and Hispanic Immigrants and EducationEducation

Richard Fry, Senior Research Associate Pew Hispanic Center

Risk Factors for Mental Risk Factors for Mental IllnessIllness

Medical conditions: Diabetes, obesity, Medical conditions: Diabetes, obesity, etcetc

Domestic violence, “Machismo” effectsDomestic violence, “Machismo” effects Beneficial and otherwise effects of Beneficial and otherwise effects of

family involvement and demandsfamily involvement and demands AcculturationAcculturation Early life traumaEarly life trauma Financial challengesFinancial challenges RacismRacism

Migration Related StressMigration Related Stress Failure to succeed in the country of originFailure to succeed in the country of origin Immigration ExperienceImmigration Experience Adaptation Process:Adaptation Process:

Limited ResourcesLimited Resources Restricted MobilityRestricted Mobility Marginalization and isolationMarginalization and isolation Blame/stigmatization and guilt/shameBlame/stigmatization and guilt/shame Vulnerability/exploitabilityVulnerability/exploitability Fear and fear-based behaviorsFear and fear-based behaviors Family stress: Role and tradition Family stress: Role and tradition

changeschanges

Border Area Latino:Border Area Latino:Access to Mental HealthcareAccess to Mental Healthcare

Increased number of uninsured and Increased number of uninsured and underinsuredunderinsured

Geographic accessibility concernsGeographic accessibility concerns Specialty services limitationsSpecialty services limitations Linguistic and cultural incongruenceLinguistic and cultural incongruence Sick time benefitsSick time benefits Schedule flexibilitySchedule flexibility Immigration issuesImmigration issues Even in government programs (Medicare, VA)Even in government programs (Medicare, VA)

Depression Screening in Depression Screening in Immigrant Latinas in L.A.Immigrant Latinas in L.A.

02468

101214161820

Imigrant Latina Women withDepression

No Children

Living With Children

Living WithoutChildren

Miranda et al., 2005

N= 5122

Language BarriersLanguage Barriers

Price and Cuellar in 1981 compared separately Price and Cuellar in 1981 compared separately recorded Spanish- and English-language recorded Spanish- and English-language interviews. They found that subjects expressed interviews. They found that subjects expressed more symptoms during the Spanish interviewmore symptoms during the Spanish interview

In a similar study (Malgady and Costantino In a similar study (Malgady and Costantino 1998) reported that symptom severity among 1998) reported that symptom severity among Hispanic patients with schizophrenia and Hispanic patients with schizophrenia and depression was rated highest in bilingual depression was rated highest in bilingual interviews, followed by those in Spanish, and interviews, followed by those in Spanish, and lowest in those in Englishlowest in those in English

Family Domain

SocioculturalDomain

PersonalDomain

AccessDomain

Provider Domain

Beliefs andAttitudes

Impairment, History ofTx and Dx, Self Rated Mental Health Status,Self-defined Problem,

Insurance andTreatment Exper.

Information about MHProblem IdentificationStigmaSupport for treatment

SES, Nativity.Age,Ethnicity, Accul.

Referral sourceStaff CourtesyTransportationWork ObligationsEligibility for Services

Appropriateness of careTimely Appointments

PREDISPOSING NEED ENABLING OUTCOMES

OPERATIONALIZATION OF A SOCIOBEHAVIORAL MODEL OF HELP SEEKING

PersistenceSatisfaction

TreatmentEffectiveness

NOTE: MODEL FOR GENERATING TESTS OF HYPOTHESES AND MULTIVARIATE MODELS

Cultural Explanations of the Cultural Explanations of the IllnessIllness

• Idioms of distress and Idioms of distress and local illness categorieslocal illness categories

• Meaning of the illness in Meaning of the illness in relation to cultural norms & relation to cultural norms & severity of symptoms based severity of symptoms based on perceptionon perception

• Help-seeking and care Help-seeking and care experiences with experiences with professional or traditional professional or traditional sources. Effects in planssources. Effects in plans

Some Elements of Cultural Some Elements of Cultural CongruenceCongruence

Language of interview, communication Language of interview, communication adequacyadequacy

Nature of work-up and interpretation of Nature of work-up and interpretation of symptomssymptoms

Role assigned to precipitants/stressors and Role assigned to precipitants/stressors and their interaction with individual/social their interaction with individual/social vulnerabilitiesvulnerabilities

Treatments offered and outcomes expectedTreatments offered and outcomes expected Attitudes towards inclusion of family, social Attitudes towards inclusion of family, social

networks, including spiritual communitiesnetworks, including spiritual communities Addressing stigmaAddressing stigma Healthcare accessHealthcare access

Cultural Elements of the Cultural Elements of the Clinician-Patient RelationshipClinician-Patient Relationship

•Differences in culture, social status or role Differences in culture, social status or role between the clinician and patientbetween the clinician and patient

•Communicating with a professional in a Communicating with a professional in a field unknown to the patient in his/her own field unknown to the patient in his/her own culture.culture.

•Communicating with a figure of the Communicating with a figure of the establishment or authority information that establishment or authority information that may be damaging to an immigration claim, may be damaging to an immigration claim, insurance, probation, etc.insurance, probation, etc.

•Negotiating levels of intimacy and rapport Negotiating levels of intimacy and rapport with members of a different race, religion or with members of a different race, religion or profession.profession.

Treatment ReadinessTreatment Readiness

Concept of illness, cause, and Concept of illness, cause, and treatmenttreatment

Physical access, cost, and flexibilityPhysical access, cost, and flexibility Psychoeducation, stigma abatementPsychoeducation, stigma abatement Relating as allies, compassionate Relating as allies, compassionate

collaborators, without judgment collaborators, without judgment Language and cultural understandingLanguage and cultural understanding Incorporation of client valuesIncorporation of client values

Arizona Border Mental Arizona Border Mental HealthHealth

Example of Academic and Example of Academic and Community CollaborationsCommunity Collaborations

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

College of MedicineCollege of Medicine

Mission: To continually Mission: To continually improve health care for improve health care for all Arizonans through all Arizonans through education, research and education, research and clinical care.clinical care.

Services: Among its 20 Services: Among its 20 departments and 8 departments and 8 interdisciplinary centers interdisciplinary centers includes the includes the Arizona Hispanic Center Arizona Hispanic Center of Excellence; Arizona of Excellence; Arizona Telemedicine ProgramTelemedicine Program

The University of ArizonaHealth Sciences Center

FOUNDED 1962FOUNDED 1962Mission of caring for the Mission of caring for the

uninsured and underserved for uninsured and underserved for 48 years in Tucson and 48 years in Tucson and

Southern ArizonaSouthern Arizona

Purpose and RationalePurpose and Rationale Our Our broad long-term objectivebroad long-term objective is to improve the is to improve the

quality of care to underserved Hispanics affected quality of care to underserved Hispanics affected with depressive disorders using health with depressive disorders using health information technology.information technology.

This technology can be used to provide This technology can be used to provide appropriate patient centered care, with culturally appropriate patient centered care, with culturally and linguistically congruent providers.and linguistically congruent providers.

Results from this study may help inform the Results from this study may help inform the manner in which quality and specialized manner in which quality and specialized psychiatric care can be delivered using real time psychiatric care can be delivered using real time video communication through the internet video communication through the internet (webcam), a medium that is now readily and (webcam), a medium that is now readily and economically available.economically available.

SubjectsSubjects

N= 150 Self identified as Hispanics, age N= 150 Self identified as Hispanics, age ≥ 18 ≥ 18 y/oy/o

MINI based DSM-IV diagnosis of Major MINI based DSM-IV diagnosis of Major Depressive Disorder (MDD)Depressive Disorder (MDD)

Excluded: bipolar disorder, schizophrenia, Excluded: bipolar disorder, schizophrenia, dementia, active substance dependence; dementia, active substance dependence; requiring inpatient or residential treatment; requiring inpatient or residential treatment; serious medical illness; lacking capacity to serious medical illness; lacking capacity to consent; pregnant or lactating women; and consent; pregnant or lactating women; and people with safety concerns (DTS, DTO). people with safety concerns (DTS, DTO).

Webcam InterventionWebcam Intervention Patients receive services on site at SEHC and Patients receive services on site at SEHC and

will be oriented and ushered by study will be oriented and ushered by study personnel.personnel.

Psychiatric visits include a 45-60 minute full Psychiatric visits include a 45-60 minute full psychiatric interview, informed consent and psychiatric interview, informed consent and treatment planning procedures treatment planning procedures (American Psychiatric (American Psychiatric

Association Treatment Guidelines)Association Treatment Guidelines). In addition to . In addition to pharmacotherapy, other aspects of care may pharmacotherapy, other aspects of care may include psychoeducation, and brief eclectic include psychoeducation, and brief eclectic interventions as appropriate.interventions as appropriate.

Follow up visits will take place monthly for 20-Follow up visits will take place monthly for 20-30 minutes, for rapport maintenance, progress 30 minutes, for rapport maintenance, progress and safety monitor, treatment adjustment if and safety monitor, treatment adjustment if needed.needed.

After hour coverage will be provided through After hour coverage will be provided through the Psychiatry Research Clinician on call at UMCthe Psychiatry Research Clinician on call at UMC

Treatment as UsualTreatment as Usual Depression treatment will be obtained Depression treatment will be obtained

from the patient’s PCP as it is normally from the patient’s PCP as it is normally done at SEHC.done at SEHC.

TAU often includes antidepressants, in TAU often includes antidepressants, in adherence to AHCPR treatment adherence to AHCPR treatment guidelines.guidelines.

Patients who require additional mental Patients who require additional mental health care are referred to behavioral health care are referred to behavioral health services or community mental health services or community mental health agencies. health agencies. (patients with specific psychosocial (patients with specific psychosocial issues, safety concerns, evident need for couples or family therapy)issues, safety concerns, evident need for couples or family therapy)

Crisis services related to depression are Crisis services related to depression are provided through standard clinic provided through standard clinic protocols.protocols.

Data Collection Tools Data Collection Tools ScheduleSchedule

MiMinn

RaterRater BasBase-e-

lineline

Mo Mo 11

Mo Mo 22

Mo Mo 33

Mo Mo 4 4

Mo Mo 55

Mo Mo 66

PHQ-9PHQ-9 22 SelfSelf XX XX XX

MINIMINI 3030 ClinClin XX

Q-LES-QQ-LES-Q 55 SelfSelf XX XX XX

SF-8SF-8 55 SelfSelf XX XX XX

MADRSMADRS 1515 ClinClin XX XX XX

VSQ-9VSQ-9 22 SelfSelf XX XX XX XX XX XX XX

WAI-S-WAI-S-C+TC+T

55 Self/Self/ClinClin

XX XX XX

ARSMA-IIARSMA-II 1010 SelfSelf XX XX XX

Baseline/ Baseline/ Other InfoOther Info

55 SelfSelf XX XX XX

CompliancCompliance ratinge rating

11 Self Self /Clin/Clin

XX XX XX XX XX XX

Depression Outcome Depression Outcome MADRSMADRS

Time Effect: p<.01 Treatment Interaction: p <.05 Time Effect: p<.01 Treatment Interaction: p <.05

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

Quality of Life OutcomeQuality of Life OutcomeTime Effect: p<.01 Treatment Interaction: p <.05Time Effect: p<.01 Treatment Interaction: p <.05

Disability OutcomeDisability OutcomeTime Effect: p<.01 Treatment Interaction: p <.05Time Effect: p<.01 Treatment Interaction: p <.05

Patient Doctor RelationshipPatient Doctor RelationshipTime Effect: p<.01 Treatment Interaction: p <.05Time Effect: p<.01 Treatment Interaction: p <.05

SummarySummary

US-Mexico Border Mental Health is US-Mexico Border Mental Health is associated with unique stressors related to associated with unique stressors related to immigration, acculturation, and common immigration, acculturation, and common socioeconomic issuessocioeconomic issues

Providing screening and treatment Providing screening and treatment requires cultural, linguistic, and literacy requires cultural, linguistic, and literacy sensitivitysensitivity

Specialized care is sparse yet effective Specialized care is sparse yet effective when accessed and properly delivered.when accessed and properly delivered.