1. A Mental Health Screening Intervention in a Rural Honduran Medical Clinic Heena Panchal, MD, PGY 4 Family Medicine and Psychiatry Co-authors: Mike Huijon, MD, Mark Meyer, MD Affiliation: University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic, McKeesport Family Medicine, St. Margaret Family Medicine, Shadyside Family Medicine

2. 2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Heena Panchal, MD, Mike Huijon, MD and Mark Meyer, MD have indicated they have no relevant financial relationships to disclose.

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5. Background Clinic is located in San Jose del Negrito It serves approximately 12 surrounding communities It provides general medical care of adults, children, elderly, as well as gynecological and obstetric care. A locally trained Honduran physician, Dr. Tania Castillo, runs the clinic with her nurse Veronica Guevara-Munoz year round. The clinic sees approximately 40-50 patients daily. 5

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7. Background The organization partnered with the community and provides not only medical care, but clean water. Nutrition supplement developed for the children has decreased malnutrition within the community, and has involved >900 local children. Care of patients is based on training of the individual MD and most Honduran physicians have little opportunity for mental health care education given dearth of services. Individual screening of patients as part of our routine medical evaluation shows large number of patients with depressive and anxiety symptoms. Determining the prevalence of depressive and anxiety symptoms will help us see if increased mental health services would benefit the community. 7

8. Introduction  The World Health Organization (WHO) has identified psychiatric illness as a leading cause of years lived with disability worldwide.  Nevertheless, little is known about the prevalence of depression and anxiety in many locales, owing to an underrepresentation of mental health services.  Within the rural community in Honduras in which we work in San Jose del Negrito, there is a need for increased mental health services and competency in areas which can be adequately managed by the primary care physician or ambassadors of mental health. 8

9. Introduction Previous work has shown that screening tools used in developed countries such as the Spanish-language translation of the PHQ-9 and GAD-7 are valid means of eliciting depressive symptoms in primary care settings. We set out to screen a local Honduran population in the rural community of San Jose del Negrito for major depressive disorder (MDD) and generalized anxiety disorder (GAD). 9

10. Introduction The screening was an initial mental health community needs assessment for a quality-improvement intervention in a community-oriented primary care setting. The information obtained from the screening will help determine future educational needs of the local health providers in the community It will help inform the development of a sustainable mental health education training curriculum for local providers. 10

11. Objectives 1.Conduct a community mental health needs assessment 2.Learn about existing mental health resources in the area. 3.Learn about the prevalence of depression and anxiety in a rural Honduran population and differences based on surrounding communities, age, and gender. 4.Educate the clinic staff on screening for depression and anxiety using the validated Spanish PHQ-9 and GAD 7. 5.Use data in future to develop an educational curriculum in mental health care for the Honduran healthcare providers in order to make mental health care sustainable in the clinic. 11

12. Methods As part of our intervention, treatment providers gave adult patients older than age 17, who presented to a private clinic in rural Honduras for their routine medical care a two-question screen for MDD and GAD over a period of 10 days. Screening was done in a private room separate from the clinic and information in the medical records were kept confidential, and secured. 12

13. Methods Positive responses led to a full screening with a validated Spanish-language PHQ-9 and GAD-7 followed by a brief psychiatric interview and evaluation to ascertain the nature of that individuals’ stressors. Referral to existing treatment resources was then offered where appropriate. 13

14. Demographics A majority of the patients were from San Jose del Negrito, where the clinic was located and also from the surrounding communities (figure 1). A total of 163 patients were screened of which 124 were female and 40 were male. 14

15. A substantial number of patients screened positive on PHQ-2 and GAD-2. Of these patients, 21.5% expressed suicidal ideation. 15 ScreenPHQ-2GAD-2Suicidal ideation Positive97 (59.5%)48 (29.4%)35 (21.5%) Negative66 (40.4%)116 (71.2%)128 (78.5%) Results

16. 16 PHQ-9 ScorePatientsFemaleMaleAnxiety disorder 0-484 (51.5 %)58 (46.8 %)26 (65 %)4 (8.3 %) 5-930 (18.4 %)25 (20.2 %)5 (12.5 %)8 (18.7 %) 10-1424 (14.7 %)17 (13.7 %)7 (17.5 %)13 (27.1 %) 15-1912 (7.4 %)10 (8.1 %)2 (5 %)10 (20.8 %) 20-2713 (8.0%)13 (10.5 %)0 (0 %)13 (27.1 %) total1631244048 Results

17. Screening with PHQ-9 and GAD-7 showed a prevalence of 48.5% MDD and 29.4% GAD. Females had a higher prevalence of severe depressive symptoms compared to males 17

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19. Discussion Main stressors that patients reported with depressive and anxiety symptoms:  Being sole provider for family, especially if female  Chronic medical illness (HTN, Diabetes, asthma, autoimmune, pain)  Disability  Loss of family member or relative  Poverty  Limited access to healthcare services and basic needs such as clean water and limited transportation 19

20. Discussion Patients who screened positive for suicidal ideation were given counseling, educated on removing pesticides and guns from their home. They were also referred to the clinic physician and nurse for future follow up and prescribed medication if they were interested in treatment. Medications were prescribed after explanation of side effects, benefits and alternatives were given. 20

21. Discussion The Honduran physician and staff were subsequently presented data on patients screened in clinic. They expressed interest and were trained on administering the PHQ-9 and GAD-7 in clinic for their patients. 21

22. Conclusion The prevalence of MDD and GAD in a primary care setting in rural Honduras appears nearly twice as high compared to primary care populations in the United States. In a cohort of 2,421 adult patients who presented in 10 primary care health centers in the U.S, 23.8% of minorities (non-Caucasian) had depression and 16.6% had anxiety symptoms, compared to 48.5% and 29.4% respectively in our rural Honduran adult population. 22

23. Conclusion There is a dearth of local mental health services in Honduras and the data shows a high prevalence of depressive and anxiety disorders. Currently providers have little to no training in managing depressive and anxiety disorders. The consequences of this are fairly severe—high prevalence of untreated depression and anxiety and also suicidal ideation. 23

24. Conclusion The rates of completed suicide are unknown, and there appears to be stigma regarding mental illness and discussion of this within the community. The attitudes surrounding discussion of mental illness within the community will need to be further ascertained. There is also a link between untreated depression and anxiety with worsening to chronic disease outcomes. Therefore, further capacity building and training of local primary care providers to treat mental health is necessary to improve mental health outcomes. 24

25. Future Directions Data will be used to inform the local health committee and local Honduran physician who runs the clinic about the need for increased mental health services and access. Assess the attitudes and cultural perceptions surrounding mental health within the community Use a system identified by WHO to be effective in increasing mental health resources within the community. This includes an approach with combines education of primary care provider in mental health and mental health ambassadors. Assess effectiveness of our intervention. 25

26. References 26 Report on mental health systems in Honduras. WHO Department of Mental Health and Substance Abuse. 2008 Wulsin, L., Somoza, E., Jeffery, H., The feasibility of using the Spanish PHQ-9 to screen for depression in primary care in Honduras. Prim Care Companion J Clin Psychiatry. 2002 Oct;4(5):191-195. Becker, A., Kleinman, A. Mental Health and the Global Agenda. N Engl J Med 2013; 369: 66-73. Garcia-Campayo, J. et al. The Assessment of Generalized Anxiety Disorder: Psychometric Validation of the Spanish Version of the Self-Administered GAD-2 Scale in Daily Medical Practice. Health and Quality of Life Outcomes. 2012. 10:114. Janosky, J., South-Paul, J., Lin, C. Pain and Depression in a Cohort of Underserved Community-Dwelling Primary Care Patients. J Am Board Fam Med. 2012 May-June. 25(3): 300-307.

27. References 27 Tol, Wietse A, et al. Mental Health and Psychosocial Support in Humanitarian Settings: linking Practice and Research. The Lancet. Oct 2011. 378 (9802):1581-1591 Eaton, Julian et al. Scale up of Services for Mental Health in Low-income and Middle- income Countries. The Lancet. Oct 2011. 378 (9802): 1592-1603 Kakuma, Ritsuko et al. Resources for Mental Health Care: Current Situation and Strategies for Action. The Lancet. Oct 2011. 378 (9802): 1654-1663

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