Transcript Document

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
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Disclosures
• Advisory Board: Wyeth, Eli Lilly,
Neuronetics
• Grant Support: CNS Response, NIH
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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
moreand
likely
discontinue
treatment
U.S.–Department
of Health
Humanto
Services,
2001
Sanchez-Lacay JA, et al. 2001
Blanco C, presented 2001
Data on file, Forest Laboratories
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Distribution of the
Hispanic Population
Spaniard
0%
All Other
Hispanic
17%
South
American
Central
4%
American
5% Dominican
2%
Cuban
4%
U.S. Census Bureau 2000
Mexican
58%
Puerto
Rican
10%
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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
Smedley
BD, et al. 2002
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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
Ramirez RR, de la Cruz CG 2003
Kaiser Family Foundation 2004
Vega WA, Alegria M 2001
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Hispanic Population Living
Below the Poverty Level vs.
US Population
40%
Total US Population
Cubans
Puerto Ricans
31%
30%
27%
Mexicans
20%
12%
14%
10%
0%
% Below the Poverty Line
U.S. Department of Health and Human Services 2001
U.S. Census Bureau 2000
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Uninsured Hispanics by
Country of Origin
50
45
40
35
30
25
20
15
10
5
0
Mexican
Kaiser Family Foundation 2004
Puerto Rican
Cuban
Centeral
American
South
American
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Proportion of Hispanics Lacking
Insurance on the Rise
Private Health Insurance
Medicaid or Medicare
Uninsured
60%
50%
40%
30%
20%
10%
0%
1977
Ruiz P 1997
1987
1997
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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
Moscicki EK, et al. 1989
– Anglo-oriented acculturation
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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 underpathologization 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
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CULTURE
Therapeutic
Alliance
Clinician
Patient
Adherence
Health
belief
Lin KM, Smith MW 2000
Expectations
(Placebo response)
Personal
Experiences
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Depression Includes Both
Emotional and Physical Symptoms
2.0
No. of Psychological
Symptoms
Santiago
1.5
Rio de Janeiro
Groningen
Paris
Ankara
Manchester
Seattle Athens
Mainz
Ibadan
Berlin
Verona
Bangalore
Shanghai
Nagasaki
1.0
0.5
0.0
0.0
0.5
1.0
1.5
No. of Physical Symptoms
Simon et al. NEJM. 1999;341:1329-35.A
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Major Depression Includes
Physical, Emotional and
Cognitive Symptoms
Physical
Emotional
Cognitive
Weight change
Depressed mood
Impaired
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
14.
40
35
Chronic Painful Physical
Symptoms
Are Common in People with
43.4%
Depression
*
27.6%
(%) CPPS
30
25
20
17.1%
15
10
5
0
General
Population
>1 Depressive
Symptoms
Major Depressive
Disorder
18,980 subjects from 5 European countries by telephone interviews
16.5% at least 1 depressive symptom; 4.0% full diagnosis of major depression
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Ohayon & Schatzberg Arch Gen Psychiatry. 2003;60:39-47.
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.
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Somatic Symptoms and Psychiatric
Disorders
0 Symptoms
3-5 Symptoms
6+ Symptoms
90
80
70
60
50
40
30
20
10
0
Any Disorder
Kroenke K, et al. 1994
Mood
Anxiety
Phases of Treatment
Remission
No Depression
Full Recovery
Relapse
Recurrence
Severity
Relapse
Symptoms
Response
Syndrome
Acute
Continuation Maintenance
Treatment Phases
Time
Adapted from: Kupfer, et al. J Clin Psychiatry. 1991;52:28-34.
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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
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Depression: Response vs.
Remission
HAM-D17
Scores
15
7
Depression
Response: 50% reduction in baseline
HAM-D score or HAM-D  15
Remission: HAM-D Score  7
“Virtually Complete Symptom
Resolution”
HAM-D17 Scores (total possible score = 56)
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Percentage With Pain Relief
on Taking Treatment
Antidepressants are Generally
Helpful in Reducing Chronic Pain
100
75
50
25
Diabetic neuropathy
Postherpetic neuralgia
0
0
25
50
75
Percentage With Pain Relief on Taking Placebo
100
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
unlabeled or investigational uses
McQuay et al BMJ. 1997;314:763-4.
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Treatment of Neuropathic Pain
Conditions with Antidepressants
Number Needed to Treat
TCA (mainly amitriptyline)
2–3
SNRI (mainly venlafaxine)
4–5
SSRI (fluoxetine, citalopram)
NRI (reboxetine)
NaSSA (mirtazapine)
7 or more
insufficient
reliable data
unlabeled or investigational uses
Sindrup SH, et al. Basic Clin Pharmacol Toxicol. 2005;96:399-409.
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Efficacy for the Treatment of MDD:
Venlafaxine vs SSRI vs Placebo
Remission rate (%)
50
Venlafaxine
¶║
SSRI
40
*
Placebo
30
*
§
‡
‡
20
*
†
*
10
0
†
†
1
2
3
4
6
8
Week of treatment
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.
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Duloxetine Versus Placebo in MDD
With Painful Physical Symptoms
• 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
Least Squares Mean Change
Duloxetine 80 mg/day
Duloxetine 60 mg/day
Duloxetine 40 mg/day
Study 1
2
Duloxetine 20 mg/day
Study 2
Placebo
Study 3
0
-2
-4
-6
b
b
-8
a
a
-10
a
b
c
b
a
-12
0 1 2 3 4 5 6 7 8 9
0 1 2 3 4 5 6 7 8 9
0 1 2 3 4 5 6 7 8 9
Treatment (Weeks)
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.
a Significant
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Goldstein DJ, et al. Psychosomatics. 2004;45:17-28.
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
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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
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depression with physical symptoms