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Self medication with Rx meds - highly common. Cultural shif

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Title: Self medication with Rx meds - highly common. Cultural shif


1
Recognition and Management of Depression and
Co-morbidities in the Hispanic Population
  • Friday, April l8, 1000 a.m. 1200 p.m.
  • National Hispanic Medical Association
  • 12th Annual Conference
  • Washington Hilton
  • Washington, D.C.
  • Supported by educational grants from AstraZeneca
    Pharmaceuticals, Bristol-Myers Squibb Company,
    Eli Lilly and Company, Forest Laboratories, and
    Wyeth Pharmaceuticals

2
Depressed and Hispanic Diagnostic and Treatment
Dilemmas
Julio Licinio, MD Professor and Chairman
Department of Psychiatry Center for
Pharmacogenomics Associate Dean, Project
Development Miller School of Medicine University
of Miami Miami, Florida Licinio_at_miami.edu
3
Disclosures
  • Employee University of Miami
  • Grant/Research Support NIH
  • Consultant Eli Lilly

4
Goals and Objectives
  • We aim to discuss cultural factors impacting on
    the diagnosis and treatment of depression in
    Hispanics.
  • We will show results of recent studies on
    cultural barriers to diagnosis and treatment.
  • We will present emerging genetic data on
    prediction of antidepressant treatment response
    in Mexican Americans.

5
Hispanics
  • Largest minority group in the United States.
  • 1 in 12 Americans are Mexican-American.
  • Buying power of Mexican-Americans the same as
    that of all of Mexico.
  • Limited number of trials and studies on
    Hispanic Health
  • Chronic stress, early loss, deprivation are
    risk factors for depression
  • Common in Hispanic immigrants
  • Are Hispanic immigrants at higher risk for
    mental illness?
  • How do Hispanics deal with mental illness from
    a cultural perspective?
  • How do Hispanics respond to medication?
  • What are the rates of diagnosis, effective
    treatments and adequate follow up in
    Hispanics?

6
The Concept of Hispanic
  • Is it a language issue? What about Portuguese, or
    Mayan, or Aztec?
  • A common heritage? Which heritage?
  • An ethnicity?
  • Races?
  • Anyone could be Hispanic, from a person of pure
    northern European descent, to African, or Asian
    backgrounds.
  • The majority are of Iberic peninsula heritage
    with different admixtures of native American and
    African backgrounds.
  • Iberic peninsula itself is highly heterogeneous
    Melting pot of Celtic, Latin, Basque, Muslim,
    Jewish, Viking, and Germanic backgrounds.
  • Native America is highly heterogeneous,
    multitudes of languages, cultures and backgrounds
    that came in separate waves from Asia and evolved
    differently in different places.
  • Africans taken to America came over hundreds of
    years from myriad locations with vastly different
    cultures and backgrounds.
  • Bottomline The admixtures of highly
    heterogeneous groups can only be highly
    heterogeneous itself - Yet there is something in
    common. What is it?

7
Challenges in Diagnosis andTreatment of
Depression in Hispanics
  • CULTURE
  • STIGMA
  • COMPLIANCE
  • LIMITED DATA

8
Diagnosing Hispanics - Points to Consider
  • Is there a language barrier?
  • Is there a cultural barrier?
  • How are the symptoms of anxiety expressed in this
    culture?Physical?Emotional?
  • How are the symptoms of depression expressed in
    this culture?Physical?Emotional?
  • How are the symptoms of psychosis expressed in
    the culture?Are there culturally-congruent
    non-reality based experiences?How are those
    differentiated from psychiatric symptoms,
    particularly prodomal ones?
  • Do people seek early diagnosis or hide the
    problem?
  • Guilt
  • Shame
  • Do you tell patients their diagnosis?
  • What about their families?Example You (your
    son) has a major depression and is at a high risk
    for killing himself.

9
Treating Hispanics - Points to Consider
  • Do patients express psychological symptoms
    somatically?
  • Does the patient accept the diagnosis and the
    need for treatment?
  • Will the patient accept the type of treatment?
  • Can they afford the treatment?
  • Do they understand they need to take medication
    way after they feel better?
  • Do they understand they will deteriorate if they
    stop taking meds on their own?
  • Do you trust what the patient tells you?
  • Does the patient trust what you tell him/her?
  • Will the patient accept a drug with a potential
    deleterious effect regarding sexual function?
  • Will the patient tell you about sexual side
    effects?
  • Will men tell you what can be culturally
    perceived as weakness - womens stuff
    Sadness Crying spells
  • Inadequacy
  • Guilt
  • Decreased libido
  • Suicidality

10
Trauma, Domestic and Sexual Violence Documented
Risk Factors for Depression
  • Is it disclosed?
  • What about non-traditional women abusing men?
  • Will intervention worsen what can be a very
    precarious and hard immigrant life?
  • When do you try to help?
  • When do you involve the legal system?
  • When and why do you keep the legal system aside?
  • Are there children in the picture?
  • What do you when you know it is happening but
    they will all deny it?
  • Is it appropriate to call Child Protective
    Services on a hunch?
  • If you dismantle a family structure, albeit
    problematic, what do you offer to replace it?

11
The Stigma of Antidepressant Treatment in
Hispanics
  • Data generated from six focus groups of Latino
    outpatients receiving antidepressants (N30).
  • Perceptions of stigma - related to both the
    diagnosis of depression and use of antidepressant
    medication.
  • Antidepressant use - seen as implying more severe
    illness, weakness or failure to cope with
    problems, and being under the effects of a drug.
  • Reports of stigma - related to social
    consequences.
  • Stigma - prominent concern among Latinos
    receiving antidepressants
  • Stigma often affected adherence.
  • Culture - important role in the communication of
    stigma and its associated complications.
  • Interian A, Martinez IE, Guarnaccia PJ, Vega WA,
    Escobar JI. Psychiatr Serv. 2007581591-4.
  • A qualitative analysis of the perception of
    stigma among Latinos receiving antidepressants.

12
Stigma for Seeking Mental Health Treatment in
Latinas
  • Study examined the extent to which stigma-related
    concerns about mental health care account for the
    underuse of mental health services among
    low-income immigrant and U.S.-born black and
    Latina women.
  • Participants 15,383 low-income women screened
    for depression in county entitlement services
    asked about barriers to care, stigma-related
    concerns, and whether they wanted or were getting
    mental health care.
  • Compared with U.S.-born white women, immigrant
    African women (OR.18, plt.001), immigrant
    Caribbean women, U.S.-born black women, and
    U.S.-born Latinas were less likely to want
    treatment.
  • Conversely, compared with U.S.-born white women,
    immigrant Latinas were more likely to want
    treatment.
  • Stigma related to antidepressant treatment -
    greater in US-born than immigrant Latinas.
  • Nadeem E, Lange JM, Edge D, Fongwa M, Belin T,
    Miranda J. Psychiatr Serv. 2007581547-1554.
  • Does stigma keep poor young immigrant and
    U.S.-born Black and Latina women from seeking
    mental health care?

13
Diagnostic and Treatment Rates for Depression in
Hispanics
  • Data from the National Ambulatory Medical Care
    Survey for the time-frames 1992-1997, and
    2003-2004 Partitioned into four, 2-year time
    intervals for trend analysis among patients aged
    20-79 years.
  • From 1992-1993 to 2003-2004, annualized rate of
    visits documenting diagnosis of depression
    increased from 10.9 to 15.4 per 100 US population
    for whites, from 4.2 to 7.6 for blacks, and from
    4.8 to 7.0 for Hispanics.
  • A concomitant diagnosis of depression and
    antidepressant use increased from 6.5 to 11.4 per
    100 for whites, from 2.6 to 5.2 for blacks, and
    from 3.0 to 5.6 for Hispanics.
  • By 2003-2004, diagnostic and treatment rates were
    comparable among blacks and Hispanic, but were
    less than half the observed rates for whites.
  • Sclar DA, Robison LM, Skaer TL. Int Clin
    Psychopharmacol. 2008 Mar23(2)106-109.
  • Ethnicity/race and the diagnosis of depression
    and use of antidepressants by adults in the
    United States.

14
Diagnostic and Treatment Rates for Depression in
Hispanics
  • Systematic review the literature to determine
    whether racial disparities exist in the diagnosis
    and treatment of depression in the United States.
  • PubMed search of population-based studies
    examining the diagnosis and/or treatment of
    depression or data from prospective studies
    stratifying the rates of diagnosis and/or
    treatment of depression by race/ethnicity and
    ethnic comparisons between Caucasians, African
    Americans and/or Hispanics.
  • Initial searches identified 2,396 articles.
  • 14 articles eligible for inclusion.
  • Four included data on the diagnosis of depression
    in different ethnic groups
  • Results were not consistent.
  • Twelve included data on treatment variability in
    the treatment of depression.
  • Overall lower rates of treatment for African
    Americans and Hispanics than for Caucasians.
  • More research is needed focusing on ethnic
    variation in the diagnosis of depression.
  • Simpson SM, Krishnan LL, Kunik ME, Ruiz P.
    Psychiatr Q. 2007783-14.
  • Racial disparities in diagnosis and treatment
    of depression a literature review.

15
Hispanic and Suicide
  • Data are from the National Violent Death
    Reporting System (NVDRS), a state-based data
    integration system
  • For 2004 data from 13 US states.
  • NVDRS integrates medical examiner, toxicology,
    death certificate, and law enforcement data.
  • Comorbid substance abuse and mental health
    problems were more likely among non-Hispanic
    whites and non-Hispanic blacks, while Hispanics
    were more likely to have a substance abuse
    problem without comorbid mental health problems.
  • Hispanics were less likely to have been diagnosed
    with a mental illness or to have received
    treatment, although family reports of depression
    were comparable to non-Hispanic whites and other
    racial/ethnic groups.
  • Karch DL, Barker L, Strine TW. Inj Prev. 2006
    Dec12 Suppl 2ii22-ii27.
  • Race/ethnicity, substance abuse, and mental
    illness among suicide victims in 13 US states
    2004 data from the National Violent Death
    Reporting System.

16
Hispanic Perception of Antidepressant Treatment
Modalities
  • Depressed Hispanic patients' perceptions of
    primary care treatments and the specific benefits
    associated with them.
  • Semi-structured interviews with 121 depressed
    Hispanic patients .
  • More than half of patients viewed physician
    consultation and medication as helpful.
  • Almost all patients considered psychotherapy to
    be helpful.
  • Supportive talk - the most commonly mentioned
    specific benefit of physician consultation.
  • The most common benefit of medication
    anxiolytic, sedative effect.
  • Energizing effects less common.
  • Most common benefits associated with
    psychotherapy support, advice, and catharsis.
  • Patients currently taking medication for
    depression had a more favorable view of
    pharmacological treatment.
  • Differences by language of interview were noted.
  • English speakers - twice as likely as Spanish
    speakers to believe that medication would have
    tonic effects, making them more active,
    energetic, or able to concentrate (21 vs 10).
  • Karasz A, Watkins L. Ann Fam Med. 20064527-33.
  • Conceptual models of treatment in depressed
    Hispanic patients.

17
STARD Outcomes for Hispanics
  • Sequenced Treatment Alternatives to Relieve
    Depression (STARD) compared rates of remission
    and response for blacks (n 495), whites (n
    1853), and Hispanics (n 327) with non-psychotic
    major depressive disorder treated with
    citalopram.
  • Outpatients treated in 23 psychiatric and 18
    primary care centers.
  • Participants received flexible doses of
    citalopram for up to 14 weeks, with dosage
    adjustments based on clinical assessments.
  • Goal remission.
  • Significant differences among groups on many
    baseline demographic, sociocultural, and clinical
    variables.
  • Blacks and Hispanics - more socially
    disadvantaged and more co-morbidity than whites.
  • Before adjusting for differences, blacks had
    lower remission rates than whites, with Hispanics
    intermediate between the 2.
  • After adjustments, remission rates for groups
    were not significantly different on the 17-item
    HRSD, but lower for blacks compared with whites
    with the 16-item QIDS-SR.
  • Lesser IM, Castro DB, Gaynes BN, et al. Med Care.
    2007451043-51.
  • Ethnicity/race and outcome in the treatment
    of depression results from STARD.

18
Antidepressant Discontinuation in Latinos
  • Despite growth in number of antidepressant
    medications, many patients discontinue medication
  • Reasons such as nonresponse, side effects,
    stigma, and miscommunication.
  • Some analysts have suggested that Latinos may
    have higher antidepressant discontinuation rates
    than other US residents.
  • This paper examines Latino antidepressant
    discontinuation, using data from a national
    probability survey of Latinos in the USA.
  • In this sample, 8 of Latinos had taken an
    antidepressant in the preceding 12 months.
  • Among those users, 33.3 had discontinued taking
    antidepressants at the time of interview, and
    half had done so without prior input from their
    physician.
  • Even controlling for clinical and other
    variables, patients who reported good or
    excellent English proficiency were less likely to
    stop at all.
  • Patients were also less likely to stop if they
    were older, married, had public or private
    insurance, or had made eight or more visits to a
    nonmedical therapist.
  • Hodgkin D, Volpe-Vartanian J, Alegría M. J Behav
    Health Serv Res. 200734329-42.
  • Discontinuation of antidepressant medication
    among Latinos in the USA.

19
Cuban-Americans - UM Focus Group
  • Cuban is primary identification - even for US
    born.
  • Different immigrant group.
  • Limited to no identification with newly arrived.
  • Common cultural values Family - honor - word
  • View of medical research guinea pig -
    suspicion.
  • Older individual complete mistrust / suspicion
    of medical establishment.
  • Take meds as they think right.
  • Share meds among friends/family.
  • Self medication with Rx meds - highly common.
  • Cultural shift - YUCAs - much more accepting of
    American medicine and medical establishment.
  • Mistrust of drug companies whose mission is
    selling drugs. Therefore, addressing symptoms,
    not searching for cures.
  • Hope cure - Fear unexpected side effects
    Celebrex.

20
Pharmacogenomics of Antidepressant Treatment in
Mexican Americans
The complexity of this field is best approached
by rigorous explorations of known candidate
systems in conjunction with the use of genomic
tools to discover new targets for antidepressants
and to predict clinical outcomes. M-L Wong J
Licinio Nature Reviews Neuroscience
20012343-351.
  • Phenotype antidepressant response
  • Genotype
  • Candidates Systems
  • Specific Candidates
  • Bioinformatics approach to SNP identification
    along pathways
  • Searching for New Targets
  • Expression data
  • Genome-wide scan
  • Clinical Translation
  • Ethical Implications

21
Pharmacogenomics of AntidepressantTreatment in
Mexican Americans Study
Features of the study Creation of a
phenotype-genotype with DNA samples from
500-600 patients. Correctly assigned phenotype
(both for disease and course of drug response).
Treatment with two widely used drugs
fluoxetine, the most widely SSRI and desipramine,
a TCA (both off patent). (1 week single-blind
placebo lead in, 8 weeks of double-blind drug)
Prospective, standardized, weekly treatment
responses (continuum rather than categorical), by
the same team of research clinicians.
Genotyping - performed collaboratively with
Sanger Institute, Cambridge, UK.
22
Suicide Antidepressant Use
Sharma A, et al. Suicidality scores during
double-blind fluoxetine and desipramine treatment
in Mexican-Americans. J Clin Psychopharmacology
20072799-101
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24
Thestress neuroendocrineneuroimmune axis
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  • A 32 effect of the GCG haplotype of
    antidepressant response

27
Conclusions
  • Depression is an important health problem in
    Hispanics (as much as in the overall population).
  • Hispanics are the largest minority group in the
    US.
  • Cultural factors impact on the treatment of
    depression in Hispanics.
  • Rates of dx and tx are lower in Hispanics than in
    whites (lt50).
  • STARD - After adjustments, remission rates for
    groups were not significantly different on the
    17-item HRSD.
  • English speakers more likely to see benefits of
    pharmacological antidepressant treatment.
  • Genetic factors also underlie the predisposition
    to depression and antidepressant treatment
    response in Mexican-Americans.
  • Findings from Mexican-Americans replicated in
    others (Chinese, African-Americans) from
    replication to scientific discovery.

28
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