Transcript El Camino: Lessons Learned regarding Behavioral Health Needs and Treatment of Latinos GINO AISENBERG, PHD, MSW UW SCHOOL OF SOCIAL WORK MEGAN DWIGHT JOHNSON, MD.

El Camino:
Lessons Learned regarding Behavioral
Health Needs and Treatment of Latinos
GINO AISENBERG, PHD, MSW
UW SCHOOL OF SOCIAL WORK
MEGAN DWIGHT JOHNSON, MD MPH
U C L A D E PA R T M E N T O F P S Y C H I AT R Y
W E S T L O S A N G E L E S VA M E D I C A L C E N T E R
R A N D C O R P O R AT I O N
IDAHO LATINO BEHAVIORAL HEALTH CONFERENCE
NOVEMBER 9, 2011
President’s New Freedom
Commission on Mental Health
often under-
“ U n f o r t u n a t e l y, t h e m e n t a l
health system has not kept
pace with the diverse needs of
racial and ethnic minorities,
serving or inappropriately
s e r v i n g t h e m . S p e c i f i c a l l y, t h e
system has neglected to
incorporate respect or
understanding of the histories,
traditions, beliefs, languages,
and value systems of culturally
diverse groups.” (p. 49)
State of the Field:
Disparities Persist

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
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).
Idaho Partnership for
Hispanic Mental Health
FUNDING: NATIONAL INSTITUTE OF
MENTAL HEALTH NIMH
R21 MH085792-01
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
Financial Barriers and
Discrimination
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

 M a n y r e s p o n d e n t s a l s o i d e n t i f i e d d i s c r i m i n a ti o n
as a barrier for help-seeking among Hispanics
Language Barriers to Care
 Language barriers are a major challenge for
Spanish-speaking Hispanics.
 Too few bilingual and bicultural mental health
p r o f e s s i o n a l s a v a i l a b l e h a m p e r i n g c o m m u n i c ati on
a n d u n d e r s t a n d i ng o f c o n c e r n s a n d c u l t u r a l
d i f f e r e nc e s
 2/3 of respondents did not feel mental health
services were adequate for Hispanics or did not
know if services were available
Impact of Immigration
 With regards to the stressor of documentation or
i m m i g r a t i o n, t h e r e w a s a s t a t i s t i c a l l y s i g n i f i c a nt
d i f f e r e nc e f o r t h o s e w h o h a v e l i v e d i n t h e U S m o r e
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%)
Fear of Deportation
F e a r o f d e p o r t a t i o n i s a s i g n i f i c a nt b a r r i e r - 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
c o m m u n i t i e s , e v e n t h o s e w h o a r e U . S . c i t i z e ns .

 This fear engenders mistrust and has an impact
across generations
Lack of resources
and personnel
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.
Recommendations from
Idaho Study
“The first step would be not to ignore
t h e L a t i n o c o m m u n i t y, b u t r a t h e r p a y
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
p r o b l e m s i n t h e c o m m u n i t y. B e c a u s e i f
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

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
However
 Rejecting 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
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?
1.
• Vickie Ybarra, RN MPH Yakima Valley Farm Workers Clinic
Interventions known
effective in rural Latinos
EXAMPLE:
COLLABORATIVE CARE
FOR DEPRESSION
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 patient
 Patient chooses treatment (medication, counseling)


PCP provides medication, referral
DCM provides on-site brief, evidence based psychotherapy
Problem Solving Therapy,
Cognitive Behavioral Therapy
Behavioral Activation
 DCM provides outreach and tracks symptoms
 PCP uses feedback from DCM to adjust medication based
on treatment guidelines
 DCM 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 states
 1801 older adults randomized to collaborative care
vs. usual primary care
 23% 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
Adapt Evidence Based Practice for
Local Populations
TELEPHONE BASED COGNITIVE
BEHAVIORAL THERAPY FOR
DEPRESSION
FUNDED BY NATIONAL INSTITUTE OF MENTAL
HEALTH R34 MH079191-01A1
Aims of Telephone CBT Pilot Study
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.
1.
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 PCPs
 Registry to track patient progress
 Secure 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 Vista
Major revision of manual to include vignettes reflective of
local rural experiences
Use of trained bilingual, bicultural personnel
First session in person if patient preferred
Enhanced usual care
 Educational
pamphlet
 Referral to PCP
 Medication 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
Female
Male
Latino
Nativity
--US born
--Mexico
--Other
Usual Care
39 (78.0%)
11 (22.0%)
45 (90.0%)
40 (78.4%)
11 (21.6%)
47 (92.2%)
0 (0%)
47 (94.0%)
3 (6.0%)
4 (7.8%)
45 (88.2%)
2 (3.9%)
More Demographics
Intervention
Usual Care
15 (30.0%)
24 (48.0%)
7 (14.0%)
4 (8.0%)
15 (29.4%)
26 (51.0%)
7 (13.7%)
5 (9.8%)
Married
32 (64.0%)
>3 med. prob. 17 (34%)
32 (62.7%)
13 (25%)
Education
<6 yrs,
>6 and <11 yrs
HS graduate
Some college
Work Status and Income
Intervention
Employed
26 (52.0%)
Migrant worker
7 (14.0%)
Seasonal worker
15 (30.0%)
Income
<=$5000
2 (4.2%)
$5001-$15,000
23 (47.9%)
$15,001-$25,000
16 (33.3%)
>=$25,000
7 (14.6%)
Usual Care
24 (47.1%)
3 (5.9%)
17 (33.3%)
6 (11.8%)
13 (25.5%)
15 (29.4%)
10 (19.6%)
SCL-20 Scores over Time
1.4
1.2
1.0
0.8
SCL-20
1.6
1.8
SCL-20
0.0
0.5
1.0
1.5
Wave
2.0
2.5
3.0
PHQ-9 Scores over Time
12
10
8
6
PHQ-9
14
16
PHQ-9
0.0
0.5
1.0
1.5
Wave
2.0
2.5
3.0
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
Month 6 very satisfied with care, N(%)
35 (50.7%) 24 (64%)
12 (33.3%)
7.444
0.015*
0.013*
Baseline SCL
Month 3 SCL
Month 6 SCL
1.8 (0.8)
1.83 (0.12)
1.75 (0.11)
0.24
1.1 (0.8)
1.0 (0.13)
1.21 (0.13)
2.26
0.259
1.0 (1.0)
0.82 (0.9)
1.14 (0.13)
1.85
0.73
Baseline PHQ-9
17.1 (3.5) 17.02 (0.82) 17.34 (0.81)
Month 3 PHQ-9
8.9 (6.4) 8.23 (0.94)
10.08 (0.93)
Month 6 PHQ-9
7.7 (7.4) 5.81 (0.88)
9.54 (0.95)
0.596
chi-square
1.40
0.785
2.09
0.165
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 rapport
 comfort with manual adherence
 comfort with tracking of outcomes
 comfort 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.
Build evidence for
community practices
EXAMPLE:
LOS NIŇOS BIEN EDUCADOS
VICKY YBARRA, RN MPH
MARY O’BRIEN, LCSW
Los Niňos Bien Educados
o Prevention Program, Parenting
o
o
o
o
Education
Target Hispanic, Spanish-speaking,
migrant/seasonal farm worker
families
Culturally-grounded program
Not an evidence based practice (no
randomized trial)
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
Community
Need
Communityengaged
Research
Community
Solution
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 urban
2) Reduce disparities
3) Address structural inequalities in society
Contact Information
Gino Aisenberg
[email protected]
Megan Dw ight -Johnson
[email protected]