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1 Depression, Co-morbidities, and Access To Treatment in Hispanic Populations Pedro L. Delgado, MD Dielmann Distinguished Professor and Chairman, Department.

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Presentation on theme: "1 Depression, Co-morbidities, and Access To Treatment in Hispanic Populations Pedro L. Delgado, MD Dielmann Distinguished Professor and Chairman, Department."— Presentation transcript:

1 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 2 Disclosures Advisory Board: Wyeth, Eli Lilly, Neuronetics Grant Support: CNS Response, NIH

3 3 U.S. Department of Health and Human Services, 2001 Sanchez-Lacay JA, et al. 2001 Blanco C, presented 2001 Data on file, Forest Laboratories 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

4 4 U.S. Census Bureau 2000 Distribution of the Hispanic Population

5 5 Smedley BD, et al. 2002 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

6 6 Ramirez RR, de la Cruz CG 2003 Kaiser Family Foundation 2004 Vega WA, Alegria M 2001 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

7 7 U.S. Department of Health and Human Services 2001 U.S. Census Bureau 2000 Hispanic Population Living Below the Poverty Level vs. US Population

8 8 Kaiser Family Foundation 2004 Uninsured Hispanics by Country of Origin

9 9 Ruiz P 1997 Proportion of Hispanics Lacking Insurance on the Rise

10 10 Moscicki EK, et al. 1989 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

11 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

12 12 Expectations (Placebo response) ClinicianPatient Adherence CULTURE Therapeutic Alliance Health belief Personal Experiences Lin KM, Smith MW 2000

13 13 Depression Includes Both Emotional and Physical Symptoms Simon et al. NEJM. 1999;341:1329-35.A No. of Psychological Symptoms 0.0 0.5 1.0 1.5 2.0 1.51.00.5 0.0 Groningen Paris Ankara Athens Mainz Manchester Rio de Janeiro Santiago Berlin Bangalore Nagasaki Shanghai Seattle Ibadan Verona No. of Physical Symptoms

14 14 Major Depression Includes Physical, Emotional and Cognitive Symptoms PhysicalEmotionalCognitive Weight changeDepressed moodImpaired concentration Fatigue, loss of energy Guilt/worthlessnes s Suicidal ideation Insomnia/hyperso mnia Diminished pleasure/interest Psychomotor retardation or agitation Pain/Somatic complaints Anxiety American Psychiatric Association. DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

15 15 Chronic Painful Physical Symptoms Are Common in People with Depression Ohayon & Schatzberg Arch Gen Psychiatry. 2003;60:39-47. * 0 5 10 15 20 25 30 35 40 >1 Depressive Symptoms Major Depressive Disorder (%) CPPS 43.4% 17.1% General Population 27.6% 18,980 subjects from 5 European countries by telephone interviews 16.5% at least 1 depressive symptom; 4.0% full diagnosis of major depression

16 16 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. 2002;33:849-57.

17 Somatic Symptoms and Psychiatric Disorders Kroenke K, et al. 1994

18 18 Phases of Treatment Adapted from: Kupfer, et al. J Clin Psychiatry. 1991;52:28-34. MaintenanceContinuationAcute Full Recovery Severity Time Response Relapse Recurrence Treatment Phases Symptoms Remission Syndrome Relapse Progression to disorder No Depression

19 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 20 Depression: Response vs. Remission HAM-D 17 Scores 15 7 Response: 50% reduction in baseline HAM-D score or HAM-D  15 Remission: HAM-D Score  7 “Virtually Complete Symptom Resolution” Depression HAM-D 17 Scores (total possible score = 56)

21 21 Antidepressants are Generally Helpful in Reducing Chronic Pain McQuay et al BMJ. 1997;314:763-4. 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 Percentage With Pain Relief on Taking Treatment Percentage With Pain Relief on Taking Placebo 50 25 75 100 0 0 25 5075 100 Diabetic neuropathy Postherpetic neuralgia unlabeled or investigational uses

22 22 Treatment of Neuropathic Pain Conditions with Antidepressants Number Needed to Treat TCA (mainly amitriptyline)2–3 SNRI (mainly venlafaxine)4–5 SSRI (fluoxetine, citalopram) 7 or more NRI (reboxetine)insufficient NaSSA (mirtazapine) reliable data Sindrup SH, et al. Basic Clin Pharmacol Toxicol. 2005;96:399-409. unlabeled or investigational uses

23 23 Efficacy for the Treatment of MDD: Venlafaxine vs SSRI vs Placebo 123468 0 50 40 30 20 10 Week of treatment Remission rate (%) Venlafaxine SSRI Placebo * * † ‡ ‡ ¶ ║¶ ║ § 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 placebo; § P<.001 SSRI vs placebo; ¶ P<.001 venlafaxine vs SSRI; ║ P<.001 venlafaxine vs placebo. HAM-D=Hamilton Depression Rating Scale; MDD=major depressive disorder. Thase ME et al. Br J Psychiatry. 2001;178:234-241.

24 24 Duloxetine 80 mg/day Duloxetine 60 mg/day Duloxetine 40 mg/day Duloxetine 20 mg/day Placebo Duloxetine Versus Placebo in MDD With Painful Physical Symptoms Goldstein DJ, et al. Psychosomatics. 2004;45:17-28. -12 -10 -8 -6 -4 -2 0 2 0123456789 b b b b c a aa a 01234567890123456789 Treatment (Weeks) Least Squares Mean Change 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. Study 1Study 2 Study 3 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

25 25 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

26 26 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


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