Depression, Co-morbidities, and Access To Treatment in Hispanic Populations

1
Depression, Co-morbidities, and Access To
Treatment in Hispanic Populations

• Pedro L. Delgado, MD
• Dielmann Distinguished Professor and Chairman,
• Department of Psychiatry,
• Associate Dean for Faculty Development and
  Professionalism
• The University of Texas Health Science Center,
  San Antonio

2
Disclosures

• Advisory Board Wyeth, Eli Lilly, Neuronetics
• Grant Support CNS Response, NIH

3
Treatment of Depression in Hispanics

• Paucity of data from clinical trials
• Results from clinical trials of largely Caucasian
  patients assumed to be applicable to Hispanics
• Depressed Hispanic patients may report increased
  rates of somatization/physical symptoms
• More recent data suggest that compared with
  Caucasians, Hispanics
• Require equal optimal antidepressant doses
• Have similar rates of response to treatment
• Tolerate medicines equally well
• May be more likely to discontinue treatment

U.S. Department of Health and Human Services,
2001 Sanchez-Lacay JA, et al. 2001 Blanco C,
presented 2001 Data on file, Forest Laboratories
4
Distribution of the Hispanic Population
U.S. Census Bureau 2000
5
Summary of Findings Unequal Treatment, a 2001
Report by the Institute of Medicine

• Racial and ethnic disparities in health care
  exist
• Poorer outcomes make change imperative
• These disparities occur in the context of
• Broader historic and contemporary social and
  economic inequality, and
• Evidence of persistent racial and ethnic
  discrimination in many sectors of American life
• Among the contributing sources are health
  systems, health care providers, patients, and
  utilization managers

Smedley BD, et al. 2002
6
Access for Hispanics

• More than 1 in 5 Hispanics live below the poverty
  level
• Insurance status is associated with lower use of
  health care services
• 35 of Hispanics are uninsured
• 63 of these report being employed
• For Hispanics, access to insurance is unevenly
  distributed
• Within families
• By geographic region according to state
• Between Hispanic ethnic subgroups by country of
  origin

Ramirez RR, de la Cruz CG 2003 Kaiser Family
Foundation 2004 Vega WA, Alegria M 2001
7
Hispanic Population Living Below the Poverty
Level vs. US Population
U.S. Department of Health and Human Services
2001 U.S. Census Bureau 2000
8
Uninsured Hispanics by Country of Origin
Kaiser Family Foundation 2004
9
Proportion of Hispanics Lacking Insurance on the
Rise
Ruiz P 1997
10
Depressive Symptomatology in Mexican Americans
Hispanic Health and Nutrition Examination Survey

• High levels of depressive symptoms found in 13.3
  of Mexican Americans
• Higher risk of depression associated with
• Female sex
• Low educational achievement
• US birth
• Anglo-oriented acculturation

Moscicki EK, et al. 1989
11
Norms of Expressing Disorder

• Ethnic minority groups may present symptoms that
  are not part of established nosology
• For example, ataque de nervios is an idiom of
  distress prominent among some ethnic subgroups of
  Hispanics
• Ignoring cultural context can lead to over- and
  under-pathologization of individuals
• Stigma of mental illness, denial of mental health
  problems and values of self-reliance may
  influence Hispanics decisions to seek care

Lewis-Fernandez R 1996 Kleinman A 1988 Karno M,
Jenkins JH 1993 Alegria M, McGuire T
2003 Alarcon RD 1983 Fabrega H Jr. 1990 Ortega
AN, Alegria M 2002 Ortega AN, Alegria M In
press Gonzalez J, et al. unpublished
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CULTURE
Clinician
Patient
Therapeutic Alliance
Expectations (Placebo response)
Adherence
Health belief
Personal Experiences
Lin KM, Smith MW 2000
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Depression Includes Both Emotional and Physical
Symptoms
2.0
Santiago
1.5
Rio de Janeiro
Groningen
1.0
No. of Psychological Symptoms
Paris
Ankara
Manchester
Athens
Seattle
Mainz
Ibadan
Berlin
0.5
Verona
Bangalore
Shanghai
Nagasaki
0.0
1.5
1.0
0.5
0.0
No. of Physical Symptoms
Simon et al. NEJM. 19993411329-35.A
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Major Depression Includes Physical, Emotional and
Cognitive Symptoms
American Psychiatric Association. DSM-IV-TR.
Washington, DC American Psychiatric
Association 2000.
15
Chronic Painful Physical Symptoms Are Common in
People with Depression
43.4
40

35
27.6
30
25
() CPPS
17.1
20
15
10
5
0
Major DepressiveDisorder
General Population
gt1 Depressive Symptoms
18,980 subjects from 5 European countries by
telephone interviews 16.5 at least 1 depressive
symptom 4.0 full diagnosis of major depression
Ohayon Schatzberg Arch Gen Psychiatry.
20036039-47.
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Common Physical Symptoms

• Fatigue
• Leaden feelings in arms or legs
• Insomnia
• Hypersomnia
• Decreased appetite
• Weight loss
• Increased appetite
• Weight gain

• Reduced libido
• Erectile dysfunction
• Delayed orgasm
• Headaches
• Muscle tension
• Gastrointestinal upset
• Heart palpitations
• Burning or tingling sensations

Cassano P, Fava M. J Psychosom Res.
200233849-57.
17
Somatic Symptoms and Psychiatric Disorders
Kroenke K, et al. 1994
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Phases of Treatment
Adapted from Kupfer, et al. J Clin Psychiatry.
19915228-34.
19
Candidates for Maintenance Treatment

• Three episodes, or
• Two episodes and a risk factor
• Family history of bipolar disorder or recurrent
  major depression
• Psychotic or severe prior episodes
• Closely spaced episodes
• Incomplete interepisode recovery
• Patient preference

20
Depression Response vs. Remission
HAM-D17 Scores
Depression
15
Response 50 reduction in baseline HAM-D score
or HAM-D ? 15 Remission HAM-D Score ?
7 Virtually Complete Symptom Resolution
7
HAM-D17 Scores (total possible score 56)
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Antidepressants are Generally Helpful in Reducing
Chronic Pain
100
75
Percentage With Pain Relief on Taking Treatment
50
25
Diabetic neuropathy Postherpetic neuralgia
0
100
0
25
50
75
Percentage With Pain Relief on Taking Placebo
Meta-analysis L'Abbe plot for trials of
antidepressants in diabetic neuropathy and
postherpetic neuralgia, showing percentage of
patients achieving at least 50 pain relief when
taking antidepressants versus placebo
McQuay et al BMJ. 1997314763-4.
unlabeled or investigational uses
22
Treatment of Neuropathic Pain Conditions with
Antidepressants
Number Needed to Treat TCA (mainly
amitriptyline) 23 SNRI (mainly
venlafaxine) 45 SSRI (fluoxetine, citalopram)
7 or more NRI (reboxetine) insufficient NaSSA
(mirtazapine) reliable data
unlabeled or investigational uses
Sindrup SH, et al. Basic Clin Pharmacol Toxicol.
200596399-409.
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Efficacy for the Treatment of MDD Venlafaxine vs
SSRI vs Placebo
50


40

30


Remission rate ()

20


10
0
1
2
3
4
6
8
Week of treatment
Remission rates (score 7 on 17-item HAM-D) for
pooled studies.P.05 venlafaxine vs SSRI
P.05 venlafaxine vs placebo P.05 SSRI vs
placeboPlt.001 SSRI vs placebo Plt.001
venlafaxine vs SSRI Plt.001 venlafaxine vs
placebo.HAM-DHamilton Depression Rating Scale
MDDmajor depressive disorder. Thase ME et al.
Br J Psychiatry. 2001178234-241.
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Duloxetine Versus Placebo in MDD With Painful
Physical Symptoms

• Change from baseline in overall pain severity
  scores of patients with major depressive disorder
  in three studies evaluating the effects of
  duloxetine on painful physical symptoms

Duloxetine 80 mg/day Duloxetine 60 mg/day
Duloxetine 40 mg/day Duloxetine 20 mg/day
Placebo
Study 1
Study 2
Study 3
2
0
-2
-4
Least Squares Mean Change
-6
b
b
a
-8
c
b
a
a
-10
b
a
-12
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Treatment (Weeks)
a Significant difference, compared with placebo,
P 0.05. b Significant difference, compared with
placebo, P 0.001. c Significant difference,
compared with placebo, P 0.01.
Goldstein DJ, et al. Psychosomatics.
20044517-28.
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Summary

• Hispanics face similar depression risks as
  Caucasians
• Although presentation may vary
• Gender and socioeconomic status contribute more
  to risk than ethnicity
• Culture, sociodemographic factors impact patient
  interaction with, adherence to treatment programs
• Few trials have identified Hispanics as a
  distinct treatment population
• CBT focus on environmental factors is valuable
• Response to antidepressants is comparable
• More research is needed
• Much still to be known

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Conclusion

• Despite improved recognition in treatment
  advances, depression remains a significant health
  care burden
• Goal of treating depression should be complete
  symptom resolution
• Antidepressants that effect both 5-HT and NE may
  have advantages over more selective
  antidepressants
• Goal to achieve remission
• Unmet need exists for patients with depression
  with physical symptoms
• Serotonin and norepinephrine are shared
  biochemical mediators in modulating depression,
  including physical symptoms of depression