HISPANICS: Mental & Emotional Disorders

Eneida Gómez, MDChild, Adolescent & Adult Psychiatrist

This is part 7 of an 8 part series of seminars on Hispanic Health Issues brought to you by the University of North Florida’s Dept. of Public Health, College of Health, a grant from AETNA, and the cooperation of

Duval County Health Department. For more information or register for the seminars, please call 620-1289.

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Objectives

• Background/statistics

• Mental disorders and Hispanics

• “Nerves” versus diagnosable disorders

• The future: research

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BACKGROUND

AND

STATISTICS

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Background Statistics: Geographic Distribution

Adapted from Reference # 1

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Background Statistics: Family Structure

• Familism is as much a reflection of social process as of culture practice

• Are more likely to live in family households than alone

• Family households that include children– 63% Hispanics– 47% White– 56% Black

• Living alone– 14% Hispanics– 30% both Black and White

Reference # 1

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Background Statistics: EducationLatino National Average

Overall (> 25 y/o) Less formal Ed. More formal Ed.

Graduated H.S. 56% 83%

Graduated College 11% 25%

•But for the foreign-born it is lower that the US-born Hispanic despite same or higher motivation to complete their education•There is further variability in the three main Hispanics subgroups regarding H.S vs. College respectively:

•70 vs. 25%% of Cuban-Am. •64 vs.11% Puerto Ricans•50 vs. 7% Mexican-Am.Reference # 1

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Background Statistics: Income

• Cuban-Americans are more affluent (first two migration groups were skilled and affluent)

• Median Income/family and % below poverty level respectively– Cubans : $39,530 14%– Puerto Ricans : $28,953 31%– Mexicans : 27,883 27%

Reference # 1

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Cultural Bias for DSM-IV Diagnosis

• The Diagnostic and Statistical Manual (DSM-IV) is a set of diagnostic standards regarding diagnosis of mental disorders.

• The DSM-IV does not take into account – Stress without a formal disorder (especially

immigrants – Little flexibility to take into account culturally

patterned forms of distress and disorder

Reference # 1

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Background Mental Disorders: Adults

Figure 6-2 compares data for the lifetime prevalence of CIDI disorders among immigrant and U.S. born Mexican Americans in Fresno, California versus the general population rates from the National Comorbidity Survey.

Adapted from Reference # 1

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Background Mental Disorders: Adults

• Mexican and Puerto Rican born and Latinos living in their countries of origin have less rates of mental disorders than those that migrate to the US (due to close knit families)

• Acculturation has been implicated but not research studies to back-up this.

• Rates of suicide: Hispanics have 6% vs. 13% Whites

Reference # 1, 2, 9

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Background Mental Disorders:Children and Youth

• Studies use behavioral lists and not diagnostic instruments• Hispanic youth in Middle School reported more anxiety than

Whites• Hispanic youth reported more delinquency type problems

than White in southwestern states• In Florida Hispanics youth reported similar rates of

delinquency to any other group• Youth of Mexican origin reported higher rates of depression

– 12% vs. 6% White in Houston• Youth at the US-Mexican border reported higher rates of

depression (48% vs. 39%) , drug use and suicide• Nationally: 10% attempted suicide vs. 23% considered it

Reference # 1, 12, 13

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Background Mental Disorders: Elderly

• 26% had major depression or dysphoria– It was highly related to their physical health– Relationship between low blood pressure and

higher levels of depression– Studies suggest higher risks of Alzheimer’s for

Hispanic-AM and than White-Am

Reference # 1

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Barriers to CareProviders

• Managed Care, Medicare/Medicaid

• Consumers unapreciative of treatment

• Healthcare providers unaware of treatments (PMD unaware of CMH)

• Language• Lack of understanding

consumers fear of ψ med• Hisp. are 3x more likely to

be labeled schizophrenia than are W.

Hispanic Consumer• Income, higher uninsured

rates• Stigma• Language• Fatalism among foreign-

born (can’t control their destiny)

• Majority are CYP2D6 extensive metabolizers (usually requiring higher doses of medications like whites)

Reference # 2, 15, 16, 17, 20

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High Need Hispanic Populations

• Incarcerated– 9% Hispanics vs. 3% Whites

• Vietnam War Veterans– Higher risk for post-war related trauma than black or

whites (post traumatic stress disorder)

• Refugees– 33 to 60% Central America refugees experience post

traumatic stress disorder• Drugs and Alcohol use

– similar to other groups– While Hispanic men have relatively higher rates,

women have unusually lower rates

Reference # 2

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Availability of Mental Health Services

• In 1990 about 40% Hispanics did not speak English

• It is estimated that there are 29 Hispanic mental health professionals for every 100,000 Hispanics – Compared to 173 White providers for every

100,000 persons

Reference # 2, 4, 11

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Access of Mental Health Services

• 37% Hispanics are uninsured vs. 16% for all Americans

• Employer coverage– Hispanics 43%– Whites 73%

• Medicaid and other public coverage reaches 18% Hispanics

Reference # 2, 11

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Use of Mental Health Services

• Hispanic-Am. with a mental disorder– 1 in 11 contact mental health specialists– 1 in 5 contact general health care providers

• Hispanic immigrants with mental disorders– < 1 in 20 contact mental health specialists– < 1 in 10 use general health care providers

• Regarding the consultation with Curanderos– One study found < 4% Mexican-Am consulted One– While other studies range from 7 – 44%– The use of remedies is more common and are to

complement mainstream care

Reference # 2, 10

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Appropriateness and Outcome of Mental Health Services

• There are few studies in Hispanics in this area• Persons with schizophrenia are more likely to suffer

significant exacerbations in highly structured families (familism) than in the less structured case management

• Bilingual patients are evaluated differently when interviewed in English as opposed to Spanish

• Hispanic bipolar patients are more likely to diagnosed as suffering with schizophrenia than Whites

• 24% Hispanics vs. 34% White-Am with depression and anxiety received appropriate care

• Hispanic who visited a general medical doctor are less likely as whites to receive a diagnosis of depression

Reference # 3, 10

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Lifetime risk and persistence of psychiatric disorders

• Hispanics had a lower lifetime risk of substance use disorders as compared to Whites

• Hispanics with mood and anxiety disorders were more likely to be persistently ill as compared to Blacks

• In general members of disadvantaged ethnic group in the US do not have an increase risk for psychiatric disorders, but they do have more persistent disorders

Reference # 6, 9

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Depression in Hispanics

Reference # 4, 7, 10, 19

•How do Hispanics experience depression–Lower suicide rates 6%H, 13%W–However, youth have higher suicide ideation and attempts–Culture-bound syndromes may be diagnosed as a disorder: susto, ataque de nervios–Cuban-Am had the lowest one-year prevalence 2.8, while mainland Puerto Ricans had 6.9 (controversial: some studies show higher prevalence in Cubans than Puerto Ricans)

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ADHD in Hispanics

Reference # 13, 14

•Hispanics are more likely to be labeled with ADHD by teacher (when child has learning difficulties)•Hispanics strongly disagree that ADHD primarily affects Anglo or White children•Hispanics responded not having enough info. on ADHD and not knowing where to go for help•Language barriers prevent obtaining proper Dx and care.•52% H compared to 62% W children needing medication received it. AA were lowest at 49%

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Adapted from reference # 17

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Common misconceptions

• In some communities eye contact is a sign of disrespect. Spanish speaking doctors re-assessed psychotic behaviors: ½ were found to suffer

from depression.

• If it sounds unusual then it is psychosis• Persons perceive bipolar illness differently

depending their ethnicity: Hispanics, AA and European Am perceive their illness equally

Reference # 16, 17, 19, 20

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Culture Bound Syndromes• Ataque de nervios:

uncontrollable shouting, crying, trembling, verbal/physical aggression as a result of a stressful event related the family

• Bilis and colera (muina): strongly experienced anger or rage

• Locura: chronic psyhosis• Mal de ojo: infant/young

children are especially at risk for it. Fitful sleep, crying w/o apparent cause, diarrhea, vomiting & fever

• Nervios: general state of vulnerability to stressful life experiences and to a syndrome brought on by difficult life circumstances

• Susto: (fright or soul loss) also known as espanto, pasmo, tripa ida, perdida del alma, or chibih. It is an illness attributed to afrightening event that causes the soul to leave the body and results in unhappiness and sickness.

Reference # 16, 17, 19, 20

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References

1. Mental Health: Culture, Race, and Ethnicity, A Supplement to Mental Health: A Report of the Surgeon General (2001)

2. CDC en Español; www.cdc.gov/spanish/mental.htm 3. CDC Office of Minority Help4. www.Healthyplace.com; How Do Hispanics Experience

Depression5. Levin, Aaron; Does Resilience Protect Minorities From

Mental Illness?; Psychiatric News, May 29, 2005;Volume 40 number 10, P. 48; Am. Psych. Assoc.

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6. Breslau, Joshua, et al; Lifetime risk and persistence of psychiatric disorders across ethnic groups in the United States; Psychological Medicine (2005) 35:3:317-327; Cambridge University Press.

7. Archart-Treichel, Joan; Ethnic Variations in Depression, Suicide Rates Puzzle Researches; Psychiatric News; Oct. 5, 2001, P. 25; Volume 36 Number 10; Am Psych Assoc.

8. Grant, Bridget F.; Immigration and Lifetime Prevalence of DSM-IV Psychiatric Disorders Among Mexican Americans and Non-Hispanic Whites in the United States; Archives of Gen. Psych. Vol. 61 No 12, Dec 2004

9. Levin, Aaron; Why Are Mental Illness Rates Lower in Some Immigrants?; Psychiatric News Jan 21, 2005 Volume 40 Number 2, P. 16; Am Psych Assoc.

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10. CRHRE’s Weekkly Mental Health Bulletin: Mental Illness and Minorities; http://www.health.uwyo.edu/MH_Bulletins/(28)Minorities.htm

11. Lopez, Steven R., Special Programs and Initiatives: National Congress of Hispanic Mental Health—The Mental Health Needs of Hispanics in the US, March 20-21, 2000

12. Mental Health Problems among minorities; http://healthyplace.com/Communities/Anxiety/minorities.asp

13. New Nationwide Survey Examines Ethnic Attitudes and Experiences with ADHD; http://www.mental-health-matters.com

14. Bodiford, Kimberly J; The Presence of Health Disparities among Children with ADHD; http://forum.psu.edu/equity/stropapers/2004/BodifordKimberly.pdf

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15. Marin, Humberto; Hispanics and Psychiatric Medications: An Overview; Psychiatric Times, October 2003, Vol. XX, Issue 10

16. Acosta, Henry’ Model Mental Health Program for Hispanics; 2003, NJ, MH Institute, Inc.

17. Vedantam, Shankar; Racial Disparities Found in Pinpointing Mental Illness; Washingtom Post, Tuesday, June28, 2005, Page A01

18. Pollack, Linda et al; Patients’ Perception of Their Bipolar illness in a Public Hospital Setting; Psychiatric Quarterly, Vol. 72, Num. 2

19. Saddock BJ, et al; Synopsis of Psychiatry 9th Ed. 2003, Chapter 14, Pages 530-531.

20. Mezzich JE, et al; Cultural Psychiatry: International Perspectives; The Psych Clinics of North Am, Sep 2001