GINO AISENBERG, PHD, MSWUW SCHOOL OF SOCIAL WORK
MEGAN DWIGHT JOHNSON, MD MPHUCLA DEPARTMENT OF PSYCHIATRY
WEST LOS ANGELES VA MEDICAL CENTERRAND CORPORATION
IDAHO LATINO BEHAVIORAL HEALTH CONFERENCENOVEMBER 9, 2011
El Camino: Lessons Learned regarding Behavioral Health Needs and Treatment of Latinos
“Unfortunately, the mental health system has not kept
pace with the diverse needs of racial and ethnic minorities, often under-
serving or inappropriately serving them. Specifically, the system has neglected to incorporate respect or understanding of the histories, traditions, beliefs, languages,
and value systems of culturally diverse groups.” (p. 49)
President’s New FreedomCommission on Mental
Health
Disparities in the availability, access, and provision of quality, culturally and linguistically competent behavioral health care for Latinos remain inadequately addressed (USDHHS, 2010).
Both diagnostic and treatment practices of clinicians may vary according to the ethnic minority status of the client they are seeing-e.g. detection of a mental health disorder varies across races and ethnicities
State of the Field:Disparities PersistDisparities Persist
Mental Health Disparities
Among Latinos with diagnosable mental health condition: Fewer than 1 in 5 contact a general health provider
(<1 in 10 among recent immigrants) Fewer than 1 in 11 contact a mental health specialist
(<1 in 20 among recent immigrants)Even when primary care providers diagnose depression
and recommend treatment: Latinos (OR=0.42) are less likely than whites to report
taking an antidepressant Latinos are less likely than whites to obtain specialty
MH services (OR=0.50) (Miranda & Cooper, 2004) Men, recent immigrants and those with limited
English proficiency are particularly unlikely to receive appropriate care for depression (Young et al., 2001, Vega et al., 1999, Sentell et al., 2007, Brach et al., 2005).
FUNDING: NATIONAL INSTITUTE OF MENTAL HEALTH NIMH
R21 MH085792-01
Idaho Partnership for Hispanic Mental Health
Needs Identified by Community Members
Adults: Depression Anxiety Substance Misuse Trauma/violence
exposure Domestic Violence Immigration related
stress Financial stress Education regarding
mental health issues
Children/Adolescents: Depression Anxiety Substance misuse Trauma/violence
exposure Conduct problems
The most frequently stated barrier were financial barriers such as mental health services being too expensive and families not having enough money to pay for them and lack of health insurance to help with the cost
Many respondents also identified discrimination as a barrier for help-seeking among Hispanics
Financial Barriers and Discrimination
Language barriers are a major challenge for Spanish-speaking Hispanics. Too few bilingual and bicultural mental health professionals available hampering communication and understanding of concerns and cultural differences 2/3 of respondents did not feel mental health services were adequate for Hispanics or did not know if services were available
Language Barriers to Care
With regards to the stressor of documentation or immigration, there was a statistically significant difference for those who have lived in the US more than 13 years compared to those who have lived in US less than 13 yrs (15.1% to 6.2%) Those who were born in US more frequently reported documentation or immigration as a stressor compared to foreign born residents (25.5% to 7.5%)
Impact of Immigration
Fear of deportation is a significant barrier--playing a key role in limiting Hispanics’ abilities to successfully seek out, connect with, or continue with mental health services. This fear--and the realities of knowing people who have been deported--impacts families and communities, even those who are U.S. citizens. This fear engenders mistrust and has an impact across generations
Fear of Deportation
Nearly half of respondents indicated that there was not adequate help in the community to address mental health concerns.
Respondents reported a lack of knowledge about specific places to access help in their communities and about what kind of treatment services for mental health problems was available.
Lack of resources and personnel
“The first step would be not to ignore the Latino community, but rather pay attention to their needs. After all, we do form an integral part of the country of their people. It is of primary concern that they pay attention to the problems in the community. Because if they continue to ignore them, there will never be anything done about it.”
Recommendations from Idaho Study
Provide access to linguistically and culturally appropriate mental health and health services for Hispanics Address fears and stigma associated with mental health and accessing mental health services experienced by Hispanics at multiple levels (e.g. providers, community) Provide basic and pertinent information about availability of services--some individuals simply don’t know what services are available to them and where to go Engage in outreach to rapidly growing immigrant Hispanic community
Recommendations from Idaho Study
Evidence-Based Responses to Community
Needs
Evidence Based Practices in Communities of Color
Existing evidence based practices (EBPs) may not be relevant to communities of color because most studies do not include: Researchers from communities of color Study participants from communities of color Study sites within communities of color Outcome measures relevant to communities of color and
their ways of knowing what works
HoweverRejecting the use of EBPs in communities of color
can deprive them of access to funding and needed treatment and potentially perpetuate disparities in care.
Rational Approach to Evidence Based Practice within Rural Latino Communities
1. Is there an evidence-based intervention known effective in rural and Latino populations?
2. Are there evidence-based interventions that could be adapted for rural and Latino populations?
3. Can an evidence base be developed for a community based practice?
• Vickie Ybarra, RN MPH Yakima Valley Farm Workers Clinic
EXAMPLE: COLLABORATIVE CARE
FOR DEPRESSION
Interventions known effective in rural Latinos
Collaborative Care for Depression
Team: • Patient• Depression Care Manager (DCM)• Primary care provider (PCP)• Consulting psychiatrist
• Key elements to improve Chronic Illness Care:• Self-management support• Reorganize care to provide active outreach• Decision support
• Use of evidence based treatments • Access to consultation
• Use of technology to track patients
Collaborative Care for Depression Process
DCM educates and activates patientPatient chooses treatment (medication, counseling)
PCP provides medication, referral DCM provides on-site brief, evidence based
psychotherapyProblem Solving Therapy, Cognitive Behavioral TherapyBehavioral Activation
DCM provides outreach and tracks symptomsPCP uses feedback from DCM to adjust medication
based on treatment guidelinesDCM supervised by consulting psychiatrist
Provides feedback to PCP Consultation available if patient not improving
IMPACT Study
Randomized trial of Collaborative Care for depression in older adults
7 primary care sites in 5 states1801 older adults randomized to
collaborative care vs. usual primary care23% ethnic minority (8% Latino)
Improving Depression Care for Older, Minority Patients in Primary Care.Arean, Patricia; Ayalon, Liat; Hunkeler, Enid; Lin, Elizabeth; MD, MPH; Tang, Lingqi; Harpole, Linda; Hendrie, Hugh; Williams, John; Jr MD, MHSc; Unutzer, Jurgen; MD, MPH, Medical Care. 43(4):381-390, April 2005.
Collaborative Care Improves Quality of Care Use of Counseling
Improving Depression Care for Older, Minority Patients in Primary Care.Arean, Patricia; Ayalon, Liat; Hunkeler, Enid; Lin, Elizabeth; MD, MPH; Tang, Lingqi; Harpole, Linda; Hendrie, Hugh; Williams, John; Jr MD, MHSc; Unutzer, Jurgen; MD, MPH, Medical Care. 43(4):381-390, April 2005.
Collaborative Care Improves Quality of Care II
Anti-depressant Use
Improving Depression Care for Older, Minority Patients in Primary Care.Arean, Patricia; Ayalon, Liat; Hunkeler, Enid; Lin, Elizabeth; MD, MPH; Tang, Lingqi; Harpole, Linda; Hendrie, Hugh; Williams, John; Jr MD, MHSc; Unutzer, Jurgen; MD, MPH, Medical Care. 43(4):381-390, April 2005.
Collaborative Care Improves Mean SCL-20 Depression Outcomes
Improving Depression Care for Older, Minority Patients in Primary Care.Arean, Patricia; Ayalon, Liat; Hunkeler, Enid; Lin, Elizabeth; MD, MPH; Tang, Lingqi; Harpole, Linda; Hendrie, Hugh; Williams, John; Jr MD, MHSc; Unutzer, Jurgen; MD, MPH, Medical Care. 43(4):381-390, April 2005.
Collaborative Care Implementation Help
http://impact-uw.org/Involves organizational resources and re-
design
TELEPHONE BASED COGNITIVE BEHAVIORAL THERAPY FOR
DEPRESSION
FUNDED BY NATIONAL INSTITUTE OF MENTAL HEALTH R34 MH079191-01A1
Adapt Evidence Based Practice for Local Populations
Aims of Telephone CBT Pilot Study
1. Examine the effectiveness of an adapted telephone based cognitive behavioral therapy intervention among rural Latino primary care patients.
2. Describe intervention implementation.3. Identify the need for further manual adaptation.
Study site
Yakima Valley Farm Workers’ Clinic (YVFWC), Walla Walla Family Medical Center site Private, not for profit Serves low-income predominantly Latino patients,
including patients from Oregon Wide range of integrated primary care services No on-site psychotherapeutic intervention available No licensed, bilingual practitioner available in region
to provide psychotherapy
Intervention
Structured 8-session CBT Provided by trained MSWs In Spanish or English Optional initial in person session
Weekly telephone group supervision Feedback to PCPsRegistry to track patient progressSecure digital recordings of sessions for
supervision
Case management Assistance with making appt with primary care physician
for medication if desired Active follow-up and intervention with community resources Provided by trained BSW level person
Socio-cultural Adaptation
Original manual developed by Gregory Simon and Evette Ludman (Group Health Research Institute)
Translation of manual into Spanish—Nueva VistaMajor revision of manual to include vignettes
reflective of local rural experiencesUse of trained bilingual, bicultural personnelFirst session in person if patient preferred
Enhanced usual care
Educational pamphletReferral to PCPMedication management if provided
by PCP
Outcomes
Blinded telephone assessments at 6 weeks, 3 months, 6 months post screening› Hopkins Symptom Checklist (SCL-20) depression
scale› Patient Health Questionnaire (PHQ-9)› Patient rated improvement› Patient rated satisfaction
Qualitative exit interviews at 6 months
Recruitment Flow Chart
Total N=869 agree to screener
14% (N=119) met inclusion criteria
85% (N=101) enroll and complete baseline assessments
Randomization
N= 50 Intervention N= 51 Usual Care
Demographics
Intervention Usual CareFemale 39 (78.0%) 40 (78.4%)Male 11 (22.0%) 11 (21.6%)Latino 45 (90.0%) 47 (92.2%)Nativity
--US born 0 (0%) 4 (7.8%)--Mexico 47 (94.0%) 45 (88.2%)--Other 3 (6.0%) 2 (3.9%)
More Demographics
Intervention Usual CareEducation <6 yrs, 15 (30.0%) 15 (29.4%)>6 and <11 yrs 24 (48.0%) 26
(51.0%)HS graduate 7 (14.0%) 7
(13.7%)Some college 4 (8.0%) 5 (9.8%)
Married 32 (64.0%) 32 (62.7%)>3 med. prob. 17 (34%) 13 (25%)
Work Status and Income
Intervention Usual CareEmployed 26 (52.0%) 24 (47.1%)Migrant worker 7 (14.0%) 3 (5.9%)Seasonal worker 15 (30.0%) 17 (33.3%)Income<=$5000 2 (4.2%) 6 (11.8%)$5001-$15,000 23 (47.9%) 13 (25.5%)$15,001-$25,000 16 (33.3%) 15 (29.4%)>=$25,000 7 (14.6%) 10 (19.6%)
SCL-20 Scores over Time
0.0 0.5 1.0 1.5 2.0 2.5 3.0
0.8
1.0
1.2
1.4
1.6
1.8
SCL-20
Wave
SC
L-2
0
PHQ-9 Scores over Time
0.0 0.5 1.0 1.5 2.0 2.5 3.0
68
10
12
14
16
PHQ-9
Wave
PH
Q-9
Month 3 SCL reduction >50%, N(%)30 (42.3%) 19 (54.3%) 11 (30.6%) 4.096 0.043*
Month 6 SCL reduction >50%, N(%)42 (57.5%) 26 (66.7%) 16 (47.1%) 2.858 0.091
Month 3 PHQ-9 reduction >50%, N(%)37 (55.2%) 19 (59.4%) 18 (51.4%) 0.427 0.514
Month 6 PHQ-9 reduction >50%, N(%)42 (63.6%) 27 (77.1%) 15 (48.4%) 5.874 0.015*
Month 6 very satisfied with care, N(%)35 (50.7%) 24 (64%) 12 (33.3%) 7.444 0.013*
Baseline SCL1.8 (0.8) 1.83 (0.12) 1.75 (0.11) 0.24
0.596 Month 3 SCL
1.1 (0.8) 1.0 (0.13) 1.21 (0.13) 2.26 0.259
Month 6 SCL1.0 (1.0) 0.82 (0.9) 1.14 (0.13) 1.85
0.73chi-square
Baseline PHQ-917.1 (3.5) 17.02 (0.82) 17.34 (0.81) 1.40
0.785Month 3 PHQ-9
8.9 (6.4) 8.23 (0.94) 10.08 (0.93) 2.09 0.165
Month 6 PHQ-9 7.7 (7.4) 5.81 (0.88) 9.54 (0.95) 2.67
0.003*
Qualitative Exit Interviews
More guidance about involving family members to support behavioral activation
More specific role of therapist in facilitating medication for those with more severe depression
Lessons learned: Implementation
Important therapist qualities:Interpersonal warmth important to establish
trust and rapportcomfort with manual adherencecomfort with tracking of outcomescomfort and proficiency with basic computer
technology
Lessons learned: Implementation
Importance of sustained communication with PCPs
Case Management valued by patients, PCPs, and study team
Pts experience multiple stressors—patience and extensive outreach and follow-up is crucial
Be responsive to gender matching concerns or issues
Address patient concerns about confidentiality in small rural communities
Lessons learned: Training
Role playing each session by phone in pairs:--increased familiarity with material--encouraged mutual support
Address cultural factors and not presume cultural competency even if Latino
Behavioral change interventions are needed to diminish racial/ethnic health disparities
Need for training in: Basics of depression and its treatment Clinical assessment Use of tracking sheet and digital recorders
Conclusions
Telephone CBT appears effective in reducing depressive symptoms among rural low income Latino primary care patients.
Telephone delivery was acceptable to patients and feasible in rural primary care—strong rapport and trust established.
Low income Latinos in rural areas have many competing priorities. Extensive outreach is essential and more practical with telephone interventions that is responsive to their context.
EXAMPLE: LOS NIŇOS BIEN EDUCADOS
VICKY YBARRA, RN MPHMARY O’BRIEN, LCSW
Build evidence for community practices
Los Niňos Bien Educados
o Prevention Program, Parenting Education
o Target Hispanic, Spanish-speaking, migrant/seasonal farm worker families
o Culturally-grounded program o Not an evidence based
practice (no randomized trial)o Conducted at YVFWC for over
15 years
Creating Local Evidence
Understand (or establish) the theory of change for services offered
Work with program developer to identify core program components in order to monitor fidelity
Create a database to analyze outcomes Over 2 years, 75% of migrant parents attended >8 of 12
sessions 65% of children of parents attending the program showed
measurable behavioral improvement A majority of parents reported positive outcomes in:
improved family communication, elimination of punitive discipline techniques, improved access to support services, and increased satisfaction with their child's behavior.
FUTURE DIRECTIONS
• Build on strengths, including meaningful partnerships with providers & community leaders & community-universities, and develop relationships• Seek funding (e.g. funding to partner with Idaho, CA & WA in telephone depression care)• Strategically plan to develop workforce• Acknowledge and address stigma • Engage cultural context in trustworthy & respectful ways• Develop local strategies to address access issues
Goals: 1) Provide quality and sustainable mental health care for Hispanics, rural and urban2) Reduce disparities3) Address structural inequalities in society
Future Directions
