El Camino : Lessons Learned regarding Behavioral Health Needs and Treatment of Latinos

1. 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 UCLA Department of Psychiatry West Los Angeles VA Medical Center RAND Corporation Idaho Latino Behavioral Health Conference November 9, 2011

2. President’s New FreedomCommission on Mental Health “Unfortunately, the mental health system has not kept pace with the diverse needs of racial and ethnic minorities, often under- serving or inappropriately serving them. Specifically, the system has neglected to incorporate respect or understanding of the histories, traditions, beliefs, languages, and value systems of culturally diverse groups.” (p. 49)

3. 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

4. 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).

5. Idaho Partnership for Hispanic Mental Health Funding: National Institute of mental health NIMH R21 MH085792-01

6. 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

7. 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 Many respondents also identified discrimination as a barrier for help-seeking among Hispanics

8. Language Barriers to Care Language barriers are a major challenge for Spanish-speaking Hispanics. Too few bilingual and bicultural mental health professionals available hampering communication and understanding of concerns and cultural differences 2/3 of respondents did not feel mental health services were adequate for Hispanics or did not know if services were available

9. Impact of Immigration With regards to the stressor of documentation or immigration, there was a statistically significant difference for those who have lived in the US more 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%)

10. Fear of Deportation Fear of deportation is a significant barrier--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 communities, even those who are U.S. citizens. This fear engenders mistrust and has an impact across generations

11. 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.

12. Recommendations from Idaho Study “The first step would be not to ignore the Latino community, but rather pay 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 problems in the community. Because if they continue to ignore them, there will never be anything done about it.”

13. 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

14. Evidence-Based Responses to Community Needs

15. 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.

16. Rational Approach to Evidence Based Practice within Rural Latino Communities • Is there an evidence-based intervention known effective in rural and Latino populations? • Are there evidence-based interventions that could be adapted for rural and Latino populations? • Can an evidence base be developed for a community based practice? • Vickie Ybarra, RN MPH Yakima Valley Farm Workers Clinic

17. Interventions known effective in rural Latinos Example: Collaborative Care for Depression

18. 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

19. 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

20. 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.

21. 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.

22. Collaborative Care Improves Quality of Care IIAnti-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.

23. 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.

24. Collaborative Care Implementation Help • http://impact-uw.org/ • Involves organizational resources and re-design

25. Adapt Evidence Based Practice for Local Populations Telephone based Cognitive behavioral Therapy for depression Funded by National Institute of mental health R34 MH079191-01A1

26. Aims of Telephone CBT Pilot Study • Examine the effectiveness of an adapted telephone based cognitive behavioral therapy intervention among rural Latino primary care patients. • Describe intervention implementation. • Identify the need for further manual adaptation.

27. 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

28. 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

29. 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

30. Enhanced usual care • Educational pamphlet • Referral to PCP • Medication management if provided by PCP

31. 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

32. 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

33. Demographics InterventionUsual Care Female 39 (78.0%) 40 (78.4%) Male 11 (22.0%) 11 (21.6%) Latino 45 (90.0%) 47 (92.2%) Nativity --US born 0 (0%) 4 (7.8%) --Mexico 47 (94.0%) 45 (88.2%) --Other 3 (6.0%) 2 (3.9%)

34. More Demographics InterventionUsual Care Education <6 yrs, 15 (30.0%) 15 (29.4%) >6 and <11 yrs 24 (48.0%) 26 (51.0%) HS graduate 7 (14.0%) 7 (13.7%) Some college 4 (8.0%) 5 (9.8%) Married 32 (64.0%) 32 (62.7%) >3 med. prob. 17 (34%) 13 (25%)

35. Work Status and Income InterventionUsual Care Employed 26 (52.0%) 24 (47.1%) Migrant worker 7 (14.0%) 3 (5.9%) Seasonal worker 15 (30.0%) 17 (33.3%) Income <=$5000 2 (4.2%) 6 (11.8%) $5001-$15,000 23 (47.9%) 13 (25.5%) $15,001-$25,000 16 (33.3%) 15 (29.4%) >=$25,000 7 (14.6%) 10 (19.6%)

36. SCL-20 Scores over Time

37. PHQ-9 Scores over Time

38. OVERALL INTERVENTION UC CHI SQ p 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 0.015* Month 6 very satisfied with care, N(%) 35 (50.7%) 24 (64%) 12 (33.3%) 7.444 0.013*

39. OVERALL mean(SD) INTERVENTION UC T p Baseline SCL 1.8 (0.8) 1.83 (0.12) 1.75 (0.11) 0.24 0.596 Month 3 SCL 1.1 (0.8) 1.0 (0.13) 1.21 (0.13) 2.26 0.259 Month 6 SCL 1.0 (1.0) 0.82 (0.9) 1.14 (0.13) 1.85 0.73 chi-square Baseline PHQ-9 17.1 (3.5) 17.02 (0.82) 17.34 (0.81) 1.40 0.785 Month 3 PHQ-9 8.9 (6.4) 8.23 (0.94) 10.08 (0.93) 2.09 0.165 Month 6 PHQ-9 7.7 (7.4) 5.81 (0.88) 9.54 (0.95) 2.67 0.003*

40. 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

41. 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

42. 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

43. 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

44. 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.

45. Build evidence for community practices Example: Los niŇos bien educados Vicky Ybarra, RN MPH Mary O’brien, lcsw

46. Los Niňos Bien Educados • Prevention Program, Parenting 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

47. 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.

48. FUTURE DIRECTIONS

49. 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

50. Contact Information Gino Aisenberg ginoa@u.washington.edu Megan Dwight-Johnson meganj@rand.org