Presentation on theme: "Improving Mental Health Service Delivery to Hispanics"— Presentation transcript:
1 Improving Mental Health Service Delivery to Hispanics National Resource Center for Hispanic Mental Health®Changing Minds, Advancing Knowledge, Transforming Lives™Improving Mental Health Service Delivery to HispanicsPresenters:Peter J. Guarnaccia, Ph.D. - Rutgers UniversityIgda Martinez, Psy.D. – Albert Einstein College of MedicineHenry Acosta, MA, MSW, LSW –National Resource Center for Hispanic Mental HealthTraining Held on May 5, 2012 on behalf of the agency’s project:Partners for Culturally CompetentBehavioral Health Service Delivery to Hispanics
2 AcknowledgementFunding for Partners for Culturally Competent Behavioral Health Service Delivery to Hispanics was made possible through a grant from the Bristol-Myers Squibb Foundation.BMSF had no control over the contents of today’s training or any other program development or intervention activities
3 National Resource Center for Hispanic Mental Health Welcome & OverviewHenry Acosta, MA, MSW, LSWNational Resource Center for Hispanic Mental Health
4 Agenda 10:00 am-10:15 am Welcome, Overview & Introductions: Henry 10:15 am-10:45 am Assessing Diversity among Latinos: Peter10:45 am – 11:00am Break11:00 am-12:30 pm Latino Mental Health: Focus on Depression and Its Treatment: Igda12:30 pm-1:30 pm Lunch
5 Agenda 1:30 pm-2:30 pm DSMIV, Cultural Formulation and Latinos: Peter 2:30 pm – 2:45 pm Break2:45 pm-3:30 pm Using Genograms to Elicit Cultural & Family Issues: Igda3:30 pm-3:45 pm Social & Cultural Assessment of Hispanics: Peter3:45 pm-4:00 pm Evaluation & Wrap-Up
6 Assessing Diversity Among Latinos Peter J. Guarnaccia, Ph.D.Rutgers,The State University of New Jersey
9 ¿Hispanic or Latino?One of the most popular debates and one of the least likely to be solvedHispanic adopted by U.S. Census in 1970Seen as an imposed term by U.S. governmentMore identified with Spanish originsLatino refers to Spanish, Indian & African origins of people from the Americas
10 Who are Latinos in New Jersey? 10Source : U.S. Census, 2000
11 National Latino & Asian American Study (NLAAS) Principal InvestigatorsMargarita Alegria, Harvard Medical SchoolDavid Takeuchi, University of WashingtonFunding: National Institute of Mental Health, SAMHSA/CMHS and OBSSRLatino Sample:Nationally representative household sample: adults 18 and older
12 Methods 75.5% response rate Instrument fully translated and adapted into SpanishAdministered by trained bilingual/bicultural lay interviewersAnalyses performed with sample weights to account for complex sample design
13 Demographics - Age Cubans are significantly older than the other Latino groups
14 Demographics - Gender Mexicans and Cubans include slightly more males than the other Latino groups
15 Demographics - Education Mexicans have less education thanthe other Latino groups
16 Demographics – Income Mexicans have significantly lower incomes than the other Latino groups
17 Demographics - Citizenship Puerto Ricans are all citizens. About 60%of the other 3 groups are citizens.
18 Migration - NativityAbout 85% of Cuban respondents were born in Cuba. Over half of Puerto Ricans were born on the mainland.
19 Migration – Number of Parents Born in the U.S. More likely that both parents born In US than 1 parent;Cubans least likely to have US born parents
20 Migration – Percentage of Life in US Puerto Ricans have spent more of theirlife on the U.S. mainland
21 Migration – Wanted to Move Cubans were the only group where a largemajority expressed a desire to move to the US
22 Migration – Move Planned Cubans were more likely to have carefullyplanned their move to the US
23 Reasons for Migration % Very Important Reason for Move Puerto Rican CubanMexicanOther LatinospEmployment66527565.001Join Family515348.75Improve Future for Children788479.05Political Situation9911734Seek Medical Attention22812.003Seek Education605662.42Family Problems1065.03
24 Migration – Ease of Visiting Relatives/Friends For Cubans visiting relatives in their home country wasvery difficult. For Puerto Ricans it was easy.
25 Language of InterviewCubans were most likely to prefer the interview in Spanish, followedby Mexicans. Puerto Ricans more often preferred English. The bilingualgroup was small and of similar proportions across the groups.
26 General Language UseThere was a trend for Cubans to prefer Spanish andPuerto Ricans English in general use. But there wasmore expressed bilingualism for this question.
27 Language Spoken as Child Overwhelmingly, everyone spoke Spanish as children.
28 English Proficiency- Spoken Language Puerto Ricans are most English proficient;Cubans are least.
29 Spanish Proficiency – Spoken Language Cubans are most Spanish proficient,with the other groups being similar.
30 Ethnic Identity – Identification with Others from Your Group Everyone identifies closely with theirLatino group.
31 Ethnic Identity – How Important to Marry Others from Your Group Relatively few think it is important to marrywithin their Latino group.
32 Sociocultural Change – Acculturative Distress Scale Puerto Ricans experienced significantly lower acculturative distress;Mexicans reported the highest levels of acculturative distress.
33 Sociocultural Change – Family Cultural Conflict Scale Puerto Ricans reported significantly higher levels ofFamily Cultural Conflict than Cubans or Mexicans
34 Sociocultural Change – Difference in Social Position Puerto Ricans and Other Latinos report a significant decline.Cubans on average report a slight increase in social position in the US.
35 Concluding Thoughts on Acculturation There are major differences among the 4 groups in terms of their migration experiencesPuerto Ricans are migrants; the other groups are immigrantsCubans reported coming overwhelmingly for political reasons; the reasons for the other groups were more diverseThe reception by U.S. society of the four groups was different depending on how and why they cameAcculturation processes begin in people’s home countries given the impact of globalizationThe 4 groups are also different in terms of the historical relationships between their home countries and the U.S.
36 Concluding Thoughts on Acculturation The majority of Puerto Ricans, Mexicans and other Latinos (compared to one-third of Cubans) have spent more than 70% of their life on the mainlandThis has led to the emergence of new cultural “mosaics” which include the Nuyorican culture of Puerto Ricans in NYC and the Chicano and Hispano cultures of Mexicans in the southwest
37 Concluding Thoughts on Acculturation There is considerable diversity among the 4 Latino groups in language preference and use.Language use looks different depending on the context you ask aboutFor example, the distribution of language use is quite different for language of interview compared to language of thought
38 Concluding Thoughts on Acculturation Differences in social capital and in reception by U.S. society result in significant differences among the groups in social statusCubans are the only group that report a status increasePuerto Ricans and Other Latinos report a large status decline, while Mexicans report a small status declineThe reasons for these differences are not currently well understood
39 Concluding Thoughts on Acculturation Cubans reflect one end of the continuum where they strongly maintain Spanish language in all contextsBy transforming Miami, they were able to succeed without giving up important aspects of their cultureOther Latino groups are more diverse in their cultural experience, more dispersed geographically, and have more diversity in social capitalThey have not come to economically and politically dominate one area leading to very different acculturation experiences
40 Cultural Issues in Latinos’ Experience with Depression Igda E. Martinez, Psy.D.Albert EinsteinCollege of Medicine
41 Why migration leads to depression “Es como perder su techo, perder todo, es como cuando uno ha pasado por un terremoto y perdió todo … es como una acumulación de perdidas”It’s like losing the roof over your head, losing everything, it’s as if one had gone through an earthquake and lost everything … it’s an accumulation of losses
42 Goals of ResearchRicher understanding of Latinos’ conceptions of depressionFuller understandings of Latinos’ attitudes towards, concerns about, and expectations for treatmentIdentify barriers to care from the perspective of community members
43 MethodsBased on four different projects in New Jersey and New York to examine:diverse Latinos’ conceptions of mental health, treatment and barriers to careelderly Latinos’ understandings of depression and reactions to standard depression measurescommunity concerns about health and mental health and needed servicesrecognition of depression and attitudes towards care
44 Methods94 participants in 12 different focus groups throughout New Jersey and New York CityDiverse group of Latinos in terms of country of origin, time in U.S., age, gender, educationAll of the groups were held in SpanishAll groups led by Peter GuarnacciaMajority of the groups facilitated by Igda Martinez
45 What is Mental Health?Social relationships and supports are key to mental healthMental health was defined as being able to function in and contribute to societyIt is being able to live una vida tranquilaBeing in control of one’s emotions and not being aggressiveNot abusing alcohol or drugs
46 Comments about “Mental Health” Para mi una buena vida sería llevar una vida de tranquilidad, sentirse con un poco de salud, que es lo principal, y ... sentirse para mi bienestar con su familia unida y vivir tranquilo.A good life would be living a tranquil life, being in good health, that’s the most important … to feel a sense of well-being about my family’s unity and to live peacefully
47 What is Depression?Depression is widely recognized among Latinos as a mental health problemRecognize both emotional and somatic aspects of depressionDepression is seen as the result of social stressors and losses:death of a family member, isolation/loneliness, loss of a job and financial stresses, events of September 11thDepression often connected to diabetes (and other conditions such as high blood pressure)
48 Recognition of Depression Cuando una persona está triste, está nostálgica, se pone a llorar facilmente, está muy cansada y no sabe por que, no tiene ganas de hacer nada. Uno no tiene amigos, no tiene familia, ni nada. Le hace falta más la familia.When a person is sad, is nostalgic, s/he cries easily, feels very tired and doesn’t know why, s/he has no desire to do anything. One doesn’t have friends, doesn’t have family or anything. When you feel like this, you miss your family even more.
49 Recognition of Depression [Los hombres] se deprimen, ellos buscan el alcohol para escaparse y no deprimirse. Tienen que hacerse a cargo de la familia acá y tambien mandarle dinero a la familia allá. Conseguir trabajo aquí es difícil.Men get depressed. They seek out alcohol to escape and not deal with their depression. They are responsible for their family here and also have to send money to their family there, and finding work here is difficult.
50 Barriers to CareNunca la cojí la consejeria porque yo dije, pero si ellos me la están ofreciendo y yo fui y yo me presenté. Pero me dijeron, no, el seguro de su esposo no cubre eso. Necesita $250 de down.I never received the counseling. They were offering me the counseling and I went and presented myself. But then they said, no, your husband’s insurance doesn’t cover this, we need a $250 down payment.
51 Barriers to Care[Nosotros] inmigramos, y nos encontramos con muchas barreras como el idioma, no tenemos papeles, no tenemos información de muchas cosas, no sabemos cuales son nuestros derechos… la vida aquí es muy difícil. Estamos muy aisladas aquí.We immigrate here and find ourselves with many barriers: such as language; we don’t have papers; we don’t have information about many things; we don’t know what our rights are … Life here is very difficult. We are very isolated here.
52 Attitudes Towards Seeking Help En la cultura Hispana, piensan que ir a ver a un psicólogo es cosa de locos. Es la parte de ignorancia, saber entender y saber donde pedir ayuda.In the Hispanic culture, we think that going to a psychologist is only for people who are really crazy. It’s due in part to ignorance, not being able to understand depression, and not knowing where to go for help.
53 Attitudes Towards Providers Seek help from primary care providers because are not aware of mental health as a specialty serviceLanguage barriers and cultural issues in understanding American style of mental health treatmentNeed to be accessible, to build trust [confianza], and to treat people with respect [respeto]
54 Attitudes Towards Treatment Yo he ido a unos cuantos psicoterapias... yo fui a uno que se sentaba y me decía “habla” y parecía que le estaba hablando a una pared. Pero el de ahora habla, da sus opiniones, se ve que está interesado en conocerme a mi. El trata de obtener mi confianza y así me hace sentir mas cómoda...I’ve gone to several psychotherapists… I went to one who sat down and said “talk” and it felt like I was talking to a wall. But the one I see now talks, gives his opinions, I can tell that he is interested in getting to know me. He tries to obtain my trust and thus makes me feel more comfortable...
55 Attitudes Towards Treatment Belief that depression is a consequence of difficult life circumstances, not an illnessFeeling of trying to deal with problems on one’s own [hay que ponerse de su parte]Medications are only for people who are severely mentally ill
56 Attitudes Towards Treatment Tendency to seek out “talking cure” firstNeed to “unburden oneself” [desahogarse]Medicine seen as a last resort and a temporary solutionFear of side effects and addictive potential of psychiatric medications
57 Attitudes Towards Medications Fear of addiction is very strongUse models of sleeping pills and coffee to understand medicinesOver time people need more and more to have an effect, and it is difficult to stopWhen a doctor directly explains the difference and that the medicine can be stopped, people are much more likely to accept the medicines
58 Attitudes Towards Medications Nosotros los Hispanos, nos hemos acostumbrado en los remedios caseros … la medicina en realidad no es muy receptiva.We Hispanos have become accustomed to using home remedies … in reality, medications are not very well received by the Hispanic community.
59 Improving Care for Depression Therapists need to be sensitive to cultural expressions of depression (ie, somatization, coraje, and various forms of nervios)Therapists need to orient Latino patients to the process of mental health treatmentTherapists need to directly explain medications and address concerns about addiction
60 Needs for Community Intervention Programs to help new Latino immigrants to adjust to life in the U.S.Programs to reduce the stigma of mental illness and mental health careMore public information in Spanish about where to get mental health help and how to access care
61 Call to Action!“¿Que hace uno cuando hay un problema? Se preocupa. Pero para resolver hay que quitarle el ‘pre’ y ocuparse”What do you do when you have a problem? You worry. But to resolve a problem, you have to take off the “pre” and take care of it!
62 Latinos and Depression Immigrant Latinos experience lower rates of depression than their U.S.-born compatriots and than non-Hispanic WhitesHowever, Latinos are more likely to endorse depressive symptoms on item checklistsLatinos are less likely to seek mental health services when they are depressed compared to Whites (Vega et al, 1998)Immigrant Latinos have lower rates of service utilization compared to US born Latinos (Alegria et al, 2004)In addition, Latinos have very low rates of use of mental health servicesLatinos have lower rates of treatment adherenceDisparities in mental health treatment continue to existLatinos in general have lower rates of depression compared to Whites. Puerto Ricans tend to have higher lifetime prevalence compared to Mexicans, Cubans, and other Latinos.
63 Latinos and TreatmentMinority group members have additional concerns when entering treatment settings (Atdjian & Vega, 2005 )Latinos are more likely than whites to have negative beliefs about antidepressants (Cooper et al, 2003; Miranda & Cooper, 2004)Latinos may not initially seek treatment for depression because they see it as a natural reaction to life’s problems, not as an illnessLatinos show a preference for psychotherapy over medications (Martinez & Guarnaccia, 2007)Fear of addiction and stigma attached to taking medicationsCultural value placed on desahogo, or unburdening oneselfThis research shows that when accessing services, minority group members need to determine whether or not they will feel comfortable in the treatment setting and with their individual provider. For example, they need to verify if their narratives, value systems, coping strategies, and experiences with discrimination will be understood in a flexible manner by their psychiatrist.Latinos were more likely than whites to have negative beliefs about antidepressants, for example believing that they are addictive and disagreeing that they are effective.Martínez and Guarnaccia (2007) completed a series of focus groups with Latinos. All were community samples recruited through a range of community mental health and social service agencies as well as community resources such as churches and day care centers. Overall there were 94 participants in 12 different groups throughout New Jersey and New York City.
64 Overall StudyMultiphase study to adapt Motivational Interviewing (MI) techniques to increase adherence to antidepressants among LatinosPhase I: Focus Groups & MI AdaptationPhase II: Pilot test of MI AdaptationPhase III: Randomized Control Trial
65 Purpose of StudyWhat cultural values influence people’s decisions to take medications or not?What do participants know about antidepressant medications and what fears do they have about this treatment?Are participants able to accept the treatment recommendations of their providers? What influences their willingness to accept treatment?Based on the literature, I expected values such as respeto (respect) to influence their adherence with antidepressant medications. I expected family to be involved in patient’s treatment. Today, I will specifically focus on the cultural value of familismo and the related topic of family influence.
66 Familismo (Defined)Tendency to value family relationships over other social relationshipsIncludes concepts such as respeto (respect)to refer the hierarchical nature of family dynamics (Garcia-Preto, 2005).A manifestation of the collectivist nature of LatinosBenefits, status, and general well-being of the group take precedence over those of an individual.Dynamic conceptRepresents family unity, respect and responsibilityCreates both positive and negative pressuresCan lead to covering up severity of depressive symptoms in order to protect family membersThe term familism was created about 60 yrs ago “normative commitment of individuals to their family and family relationships”On several studies, Latinos have come out higher on various indices of family comitment,indicating its importance and relevance for Latino health research. Family relationships for Latinos tend to include members outside of the nuclear family, and individuals are generally raised to be dependent on the family (vs Anglos, where individuals are raised to be independent of their family). Researchers have identified two domains of familism that are important to understand: attitudinal and behavioral (Villarreal, Blozis & Widaman, 2005).Other studies have tried to break down attitudinal familism, and found to be made up of 4 constructs: familial support, familial interconnectedness, familial honor, and subjugation of self for family. (Lugo Steidel & Contreras, 2003). It is this last construct that most interests me. They defined it as the belief that a person must yield and be submissive to the family.Items: Person should always support family members in need, even if big sacrifice.Person should often do activities w family members.Person should be expected to always defend family honor no matter what.Person should respect older siblings regardless of different pov.Person should be a good person for sake of family.Children should obey w/o questioning even if they think parents are wrong.I argue that familism is a dynamic concept, that is more complex than just valuing the family unit. For people with mental illnesses such as depression, the value of familism can in fact become somewhat of a burden and create negative pressures. This can lead to patients covering up their symptoms or their illness severity in order to protect the family, to not burden them.
67 Family influence (Defined) Instances in which family was mentionedNot necessarily describing the overall value of familismo.Tendency to focus more on instrumental supportImportant in the individual’s conceptualization of depression or its treatmentDirectly challenged or influenced client’s understanding or behavior.
68 Research Procedure Multiphase study Results presented are data from Phase I6 focus groups, 30 participantsCompleted between April – August 2006Average group size = 5 participantsAudio-taped and transcribedAnalyzed using ATLAS.ti
69 Sample Characteristics 80% femaleAge range 27-66Average: 47yrsTime in U.S yrsAverage: 18 yrsTime w MDD <1-30 yrsAverage: 11 yrsTime on meds <1-24 yrsAverage: 9 yrs50% PR; 23% DR; 17% MX; 10% other73% completed HS or more80% read Spanish Well/fairly well83% do not speak English73% speak mostly Spanish with family63% speak mostly Spanish with friendsThe inclusion criteria for participation in this study were that participants needed to be self-identified Latinos between the ages of 18 and 65, carry a primary DSM-IV diagnosis of major depressive disorder, and be currently taking antidepressant medications.
70 Cultural Considerations: Familismo and Family Influence 50 instances were codedBrought up by 73% of the participants (n=22)Family Influence84 instances were codedMentioned by 80% of participants (n=24)
71 Familismo ExpressedQueremos mucho a los hijos, los papas, todo, como queremos estar siempre unidos…y todavía se casan y uno quiere los nietos y to’l mundo…que este reunido en la familia, somos la familia muy unidas.We care for our children, our parents, everyone, very much; we want to be always united… and even when they get married …one would like one’s grandchildren and everyone … to join together in the family, we are very united families.
72 RespetoOtra cosa que no me gusta de aquí…uno no le puede decir nada a los hijos…hacen lo que le da la gana…aquí no hay niños y los hijos son los padres, como quien dice. Ellos no obedecen, ni na’. En nuestros países no. Todavía yo vieja obedecía a mi mama y mi papa.Another thing that I don’t like about here…one can’t say anything to one’s children…they do whatever they want…here there is no youth and the children are the parents, in a way. They don’t obey or nothin’. In our countries, no. Even in my old age I obeyed my mom and my dad.
73 Caretaking/Functioning A mi lo que me motivo fue mi familia, porque mi familia ahorita no esta conmigo pero ya va a venir mi hija y mi esposa. Entonces yo, yo, mi problema fue que yo no quería hablar con nadie y yo no le tenia confianza a nadie y fue lo que me motivo a tomarla, el querer estar bien para cuando viniera mi hija y mi familia.What motivated me was my family, because my family right now is not with me but soon my daughter and my wife will come. So then I, I, my problem was that I did not want to talk with anyone and I did not trust anyone, and what motivated me to take [the antidepressants], was wanting to be well for when my wife and my family came.
74 Caretaking/Functioning …el ver que eran ellos los que ya me lo estaban bañando o dando de comer porque yo pasaba llorando, tirada en la cama, eso fue lo que me hizo a mi…claro, que era yo la que tenía que hacerme responsable de mi hijo y dejar que mis otros dos hijos tengan su niñez.…to see that it was they who were already bathing him and feeding him because I spent my time crying, lying in bed, that was what made me… Of course, it was I who needed to make myself responsible for my son and let my two other children have their childhood.
75 Protecting Family from Personal Problems Yo no comparto con mi familia mis problemas porque no quiero molestarlos …cuando ellos me preguntan que como estoy yo les digo que bien o que a veces me siento triste para no preocuparlos y ya todo lo que siento lo cuento a la doctoraI do not share my problems with my family because I do not want to bother them… when they ask me how I am doing I tell them that I am fine or that sometimes I feel sad so that I do not worry them and then everything that I feel I tell the doctor.a Mexican male in his mid 20s, went on to say that not only is it better to hold back experiences and the negative emotions associated with depression, but that it is best to withhold that information for the good of the family.
76 Protecting Family from Personal Problems … es preferible uno hablar esas cosas con un particular que con la misma familia. Con mis hijos yo no hablo nada de lo que siento...pero fíjate, yo a veces me siento que seria bueno uno poder hablar con los hijos o con la familia y compartir el dolor que uno siente, pero al fin y al cabo lo que salen son problemas, mas problemas.… it is preferable for one to speak about those things with someone in particular than with your own family. With my children I do not say anything about what I feel...but you know I sometimes feel it would be good to be able to speak with one's kids or with the family and share the pain that one feels, but in the end what you get are problems, more problems.
77 Family Influence Treatment Supportive family influence 60% of participants mentioned (n=18)Help access careProviding support and reminders to take medicationsHelp to obtain medicationsTreatment Discouraging family influence30% of participants mentioned (n=9)Expressed disagreement with the concept of depression as an illness or the need for medications as treatment.This was how we originally defined family influence when we were coding the transcripts. However, one question that I pose to you today, is whether you find that this definition significantly differs from what I just defined to you as familismo. Keep this question in mind as I present to you what I see as instances of positive and negative family influences, which DIFFER from familismo as a value. Then I will present to you several quotes that were originally coded as family influence (Not familismo), but which I am unclear if the distinction is clear.
78 Treatment Supportive Family Influence Ella sale a, trata de buscar el dinero para comprar la pastilla. Si ve que me falta, me la busca. Cuando la dejo en la farmacia, ella va y me la recoge. Si por caso, no tengo tiempo, ella trata de ser pendiente. Me dice, ‘¿Tienes las pastillas contigo?’She goes out to, she tries to find the money to buy the pill. If she sees that I am short, she looks for it. When I leave it at the pharmacy, she will go and pick it up for me. If for any reason I don’t have time, she always tries to pay attention, she says to me, ‘Do you have the pills with you?’
79 Treatment Supportive Family Influence Y mi hermana fue la que me llevo y yo estaba como muy, pa’donde quiera que ella me tiraba yo me iba… Ella era la que me decía a mi, “Gloria, te tienes que tomar este medicamento.” Y yo decía, “¿Pa’ que es eso?” Entonces dice, “Para curarte, para que estés bien como antes.”And my sister was the one who took me and I was very, where ever she took me I would go…She was the one who would say to me, “Gloria, you have to take this medication.” I would say, “What’s that for?”and then she’d say, “To cure you, so you can be well, like before.”
80 Treatment Discouraging Family Influence …mis padres me enseñaron …que podíamos bregar con los problemas sin necesidad de medicamentos. Y a la vez que uno empezó con medicación …yo me sentí como si hubiera sido como de otro planeta vamos a decir. Era algo que estaba fuera de mis manos.…my parents taught me that …we could deal with problems without medication. And the minute that I started with the medication …I felt as if I was from another planet, let’s say. It was something that was out of my hands.
81 Treatment Discouraging Family Influence A veces mi mama me dice, “Yo tantos problemas que he tenido y nunca he tenido que ir a un psiquiatra. ¿En que fallaste tú? ¿Qué tu hiciste?” Y yo bueno, “Cada cual es un mundo diferente,” le dije yo. “A lo mejor tú pudiste con tus problemas pero yo con los míos no.”Sometimes my mom says to me, “Me with all the problems that I’ve had and I’ve never had to go to a psychiatrist. What did you fail in? What did you do?”And I well, “Everyone is different,” I tell her, “Maybe you could deal with your problems but I can’t with mine.’”
82 Summary Families are important Familismo served in some cases as a motivating factor to seek treatment, and in some cases as a trigger for depression.A new issue arose within the value of familismo: the idea of protecting the family from selfFamilies influenced the ways FG participants understood their symptoms and viewed their treatment.Familismo was not specifically asked about in our focus group protocol.Participants mentioned on their own the various ways in which families were involved in their lives, with specific reference to their experience of depression
83 What did we learn?What cultural values influence people’s decisions to take medications or not?FamilismoReligionPoner de su parte (Do one’s part)Trabajar/luchar/aprovechar (Work/Struggle/Take Advantage)
84 Clinical Implications Clinicians need to be culturally sensitiveIt is not always wise to include or exclude family members in treatmentShould listen to the patient’s own experience of family relationships and decide togetherIf family is included, focus should be on psychoeducationPatients should be encouraged to take an active role in treatment planningPatients should be empowered to negotiate with clinician and decide their family’s role in their own treatment.
85 DSMIV, Cultural Formulation and Latinos Peter J. Guarnaccia, Ph.D.Rutgers,The State University of New Jersey
86 Guidelines: Complementary Cultural Formulation Cultural Identity of the ClientCultural Explanations of the Client’s IllnessCultural Factors Related to the Psycho-Social Environment and Levels of FunctioningCultural Elements of the Relationship between the Provider and ClientOverall Cultural FormulationOutline for Cultural Formulation, DSM-IV
87 Guidelines: Complementary Cultural Formulation Cultural Explanations of the Client’s IllnessPredominant illness idiomsRelation of client's signs and symptoms to cultural normsLocal illness categoriesPerceived causes used to explain illnessCurrent preferences and past experiences of help‑seeking
88 Ataque de NerviosAn idiom of distress particularly prominent among Latinos from the Caribbean, but recognized among many Hispanic groupsCommonly reported symptoms include: screaming uncontrollably, attacks of crying, trembling, heat in the chest rising into the head, and becoming verbally or physically aggressiveDissociative experiences, seizure‑like or fainting episodes and suicidal gestures are prominent in some ataques but absent from othersGlossary of Culture-Bound Syndromes, DSM-IV
89 Ataque de NerviosA general feature of an ataque de nervios is a sense of being out of controlAtaques de nervios frequently occur as a direct result of a stressful event relating to the family, such as news of a death of a close kin or a separation/ divorce from a spouseAfter the ataque de nervios, people often experience amnesia of what occurred. However, they otherwise rapidly return to their usual level of functioning.
90 Ataque de NerviosWhile descriptions of ataques de nervios most closely fit with panic episodes, factors that distinguish them from panic include:association of most ataques with a precipitating eventfrequent absence of the hallmark symptom of acute fear or apprehensionAtaques de nervios span the range from:normal expressions of distress not associated with psychiatric disorderto expressions of distress associated with anxiety, depression, dissociation, or somatoform disorders
91 Relationship between Ataque de Nervios & Psychiatric Diagnosis Guarnaccia, et al., 1993, JNMD
92 Phenomenological comparison of ataques and panic disorder Ataques distinct from PDCommon to Ataques and PDProvokedCrescendo > 10 minutesFollowed by reliefRecurrenceSymptoms during episodeFear during episodeSequelae
93 Association between Ataques de Nervios and Psychiatric Disorder in Puerto Rican Children Community Sample (n = 1891)DiagnosesAbsence of AdN (n=1723)Presence of AdN (n=168)2Any Depression33 (2.3)16 (15.2)8.11**Any Anxiety87 (5.4)38 (22.1)17.88***Any Disruptive171 (9.7)39 (24.8)12.09***Any Diagnosis243 (14.0)62 (40.9)24.43***Any Impairment196 (10.5)55 (39.6)19.20***Guarnaccia, et al., 2005, JAACAP
94 Association between Ataques de Nervios and Psychiatric Disorder in Puerto Rican Children Clinical Sample (n = 757)DiagnosesAbsence of AdN (n=563)Presence of AdN (n=194)2Any Depression39 (7.0)57 (30.2)45.66***Any Anxiety83 (14.6)72 (37.7)35.53***Any Disruptive190 (33.4)98 (50.7)18.50***Any Diagnosis251 (44.7)125 (65.4)27.75***Any Impairment245 (44.1)118 (62.4)21.55***Guarnaccia, et al., 2005, JAACAP
95 Relationship of Ataques de Nervios to Mental Health (NLAAS) ************Guarnaccia, et al., 2008
96 Issues in Differential Diagnosis Social and psychiatric vulnerabilityRelation to panic disorderRelation to depression and suicidal ideation & attemptsRelation to dissociationRelation to trauma
97 SustoFolk illness prevalent among Latinos in the U.S. and among people in Mexico, Central America and South AmericaSusto results from a frightening event causing the soul to leave the body and resulting in unhappiness and sicknessSymptoms may appear anywhere from days to years after the fright is experienced and may result in death.Glossary of Culture-Bound Syndromes, DSM-IV
98 SustoThe core symptoms include: lack of appetite or appetite gain; sleeping too much or too little; troubled sleep or dreams; feeling sad; lack of motivation to do anything or go anywhere; feelings of low self worth or dirtinessDiagnosis of susto is often confirmed by family, friends and especially by a traditional healer, who will help the sufferer to identify the source of the frightSufferers of susto also experience significant strains in key social roles.
99 SustoTreatment for susto often occurs simultaneously from biomedical providers and traditional healersA ritual healing is performed to call the soul back to the body and to "cleanse" the person to restore bodily and spiritual balanceAn interpersonal susto characterized by feelings of loss, abandonment and not being loved by family with accompanying symptoms of sadness, poor self image, and suicidal ideation seems to be closely related to major depression
100 Susto across Latino groups Mexican Americans in Texas, Mexicans in Guadalajara & mestizos in Guatemala all recognize susto as an illnessPuerto Ricans do notFright, but not necessarily soul loss, a key symptomCore symptoms: agitation, crying, nervousness, trembling, fear of unfamiliar places, sleep disturbancesSerious illness that could cause diabetes and lead to deathWeller, et al., 2002, CMP
101 Relationship of susto to psychiatric disorders Women with susto (cibih in Zapotec) more likely to meet CES-D criteria for depression than those without (72% vs. 24%; N=40)Types of sustoInterpersonal DepressionFeelings of loss, abandonment by family, sadness, poor self image, suicidal ideationTraumatic event PTSDSomatic symptoms SomatoformHealth care from several practitionersTaub, 1992
102 Susto in an urban clinic in Mexico 69% reported susto and 65% nervios (N=400)Higher depression scores (Zung scale) for both susto and nervios sufferersSusto: 42 points vs. 38 (p<.04)Nervios: 44 points vs. 34 (p<.001)Those with susto and nervios higher depression scoresThose with nervios more likely to be diagnosed as depressed compared to those with sustoWeller, et al., 2005
103 Issues in Differential Diagnosis Vulnerability to distressRelation to fright, anxiety and traumaRelation to depressionRelation to somatizationLink to diabetesGreater risk of mortality
105 Toward DSM-V Incorporate a mixed anxiety-depression diagnosis Included in ICD-10Fits with a number of cultural syndromesCommon presentation in primary careRefine and expand Outline for Cultural FormulationUpdate Glossary of Culture-Bound SyndromesLink syndromes to specific disorder chapters
106 Relationship among Anxiety, Depression and Cultural Syndromes DissociationAnxietyDepressionCulturalSyndromeSomatization
108 Cultural Identity Rural migrant from Puerto Rico 13 years in U.S. Circular migrantPredominantly Spanish-speakingPoor English fluencyLived in Puerto Rican neighborhoodLimited contact with broader society
109 Cultural Explanations of Illness Nervios and Ataque de NerviosFits of anxiety and rage, followed by impulsive suicidalityDistressing, but culturally specific, dissociative symptoms (hearing voices, seeing shadows)Children saw as difficult, overwhelmingNerves altered by unresolved family conflictsFirst saw internist, then accepted family therapy and medical supervision of Latino psychiatrist
110 Psychosocial Environment Key stressor – estrangement from childrenFirst husband abusive, second murderedDaughter had drug problems and lost her childrenPrecarious social supports
111 Relationship between Provider and Client Treatment prior to Latino clinic hindered by lack of cultural assessment of symptomsLatino clinic provided more intensive assessmentFocus on character pathology
112 Overall Cultural Assessment Corrected psychotic label resulting from dissociative symptoms and stopped antipsychotic medicationsFocused on resolving family conflicts with children through family therapyDiagnosis refocused on Borderline Personality DisorderRecurrent dysphoria, but did not meet criteria for Dysthymia
113 Using Genograms to Elicit Cultural and Family Issues Igda E. Martinez, Psy.D.Albert Einstein College of Medicine
114 Areas of AssessmentSociocultural, sociopolitical, & socioeconomic factorsFinancesCultural HeritageBelief systems, religion, spiritual beliefsLanguage skills and acculturation of family membersConnections to communityMigration history
115 Socio-cultural, -political, -economic Are there sociocultural factors (ethnicity, race, social class, legal status, employment potential, education level) that are impacting family’s current functioning?Any past suffering/conflicts with family members due to past political history?Where does family fit in the community?
116 FinancesPressures from family – jealousy, resentment, pressure to help other family membersShame or conflict due to loss of statusUpper class in country of originLower class in USStruggling to meet ongoing needs
117 Cultural Heritage Culture/ethnic background of family members Experiences with racismHow are they received in their local communities?Are belief systems accepted/encouraged?
118 Belief Systems, Religion, Spiritual Beliefs What primary beliefs organize the family?What is the history of the family’s beliefs, what have been the changes, if any?Reactions to changes in the family?Differences within the community?
119 Language Skills and Acculturation What languages are spoken in home?Among adults? Children?Power imbalances?How much of heritage is retained?How are those decisions made?
120 Connections to Community How do family members maintain friendships?How accessible are social support networks?Friends, family, school, religious organizations, physicians, social service agencies, therapy, etcAny moves from ethnic enclaves to other communities?Stress of change, how adapted, who helped?
121 Migration HistoryWhy did family migrate? What were they looking for? What did they leave behind?Premigration history: political/economic situation in country of originMigration history: trauma?Postmigration history and culture shock: arrival to US. Language, immigration, poverty? Shock of cultural values? Supportive/antagonistic community?Migration and life cycle: age of family members when migrated, age of those left behind, change in family dynamics (children ->adult status due to language), reunifications?
122 Social & Cultural Assessment of Latinos Peter J. Guarnaccia, Ph.D.Rutgers,The State University of New Jersey
123 LANGUAGE CAPABILITIES & PREFERENCES What language(s) do you currently speak with family, friends, co-workers, store clerks?English skills: Speaking___ Understanding_____ Reading_____ Writing_______Spanish skills: Speaking_____Understanding_____ Reading_______ Writing________Answer Key: 1 = fluent; 2 = very good; 3 = good; 4 = poor; 5 = no ability
124 SOCIAL CONNECTIONS: FAMILY/SOCIAL SUPPORT Were you born in the United States? oYes o No If not, where?How long have you lived in the United States?Where does most of your core (immediate) family live?How often are you in contact with your family (in person, by phone, by letter, by )?Who do you turn to for advice about where to go for healthcare or other services?
125 HEALTHCARE UTILIZATION What do you call your current health problem?Have you suffered from your current health problem before? If so, what did you do about it?When you were sick in your home country, what did you do?When you have been sick in the United States, where have you gone for treatment?
126 RELIGIOUS BELIEFS AND PRACTICES What religion are you? Do you consider yourself a religious person?Have you or your family consulted a religious leader or healer about your health problems?Does your religion have any beliefs that might affect your treatment (like not using certain medicines; accepting transfusions)?
127 The State University of New Jersey Evaluation & Wrap-UpPeter J. Guarnaccia, Ph.D.Rutgers,The State University of New Jersey
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