Community Mental Health

1. Community Mental Health William A. Vega, PhD Provost Professor Executive Director Latino Health and Faculty Development Conference Stanford University, July 22, 2010

5. Brain Reward Pathways Nucleus accumbens Ventral tegmental area (VTA) • The VTA-nucleus accumbens pathway is activated by all drugs of dependence including alcohol • This pathway is important not only in drug dependence, but also in essential physiological behaviors such as eating, drinking, sleeping, and sex Source: Messing RO. In: Harrison’s Principles of Internal Medicine. 2001:2557-2561.

7. Links between major levels of organization in living systems Pathways for interactions among levels: • Social groups composed of individuals • Individuals composed of physiological systems • Physiological systems composed of cells • Cells composed of molecules (DNA)

8. Genetic polymorphisms • Only 1 in 10 people who use illicit drugsbecome dependent on them • Genetic susceptibility to complex disease usually results from joint effects of many genes, each with a small to moderate effect and often with interaction among themselves (e.g. regions) and the environment. • IOM (2006)

9. Genetic etiology confers a general vulnerability • “Schinka et al. have identified a functional polymorphism within the opioid receptor gene as a general risk gene for substance dependence. Substance abuse and dependence phenotypes that emerge only after exposure to the environment.” Licinio, J (2002) Gene-environment interactions in Molecular Psychiatry. Molecular Psychiatry 7:123-124

10. “22% of the variance in marijuana abuse is influenced by genes that also influence abuse of other drugs, 11% is due to genetic factors specific to marijuana, 17% is due to family environmental factors that also influence other drugs, and 12% is due to family environment specific to marijuana, and so on…” • Tsuang et al. (2001) The Harvard twin study of substance abuse. Harvard Rev. Psychiatry 9:267-279

11. “ The question is whether different genotypes have a different relationship to the phenotype in different environments.” • Cooper, R.S. (2003) Gene-environments interactions and the etiology of common complex disease. Ann Inter Med 139:437-440

13. Biological Effects of Cumulative Adversity • Lower heart rate variability • Slow recovery from exercise • Elevated cortisol levels related to accelerated cell aging • Greater risk of metabolic syndrome • Effects on hormonal regulation (hypothalamic-pituitary-adrena axis) • Increased risk for depression

14. Long term effects of low income • Although there are (temporary) exceptions, such as the immigrant paradox, having better income and education is protective against most diseases and mental illnesses in the U.S. • Paradox affects weathering over time and immigrants have similar disability and chronic disease levels as U.S. born • Reasons: more persistent life stress, fewer resources available for avoiding impact of personal problems and unhealthy behaviors

15. Social determinants for G X E research • SOCIOECONOMIC STATUS • RACE/ETHNICITY • SOCIAL NETWORKS/SOCIAL SUPPORT • PSYCHOSOCIAL WORK ENVIRONMENT • COMMUNITY ENVIRONMENT • IOM (2006)

16. Implications for research and social policy • Long range impacts of social determinants and low socioeconomic mobility • Organization of human services to support optimal human development • Role of research in promoting change • The role of social determinants in changing public policy

18. Context Dependence: Gene-Environment Interaction Model GVP Phenotype GVP GVA GVA Mexico USA Exposure GVA = Gene Variant Absent GVP = Gene Variant Present Adapted from Cooper, R.S. (2003). Annals of Internal Medicine, 139:437-440

19. Females: Alcohol Abuse/Dependence Rate by Parental Risk, Nativity, Time in Country, Age, and Language Preference • Only 3 subgroups show any effect of parental risk factors: • Female US born English all or most (high acculturation): 20% vs 2% (p < 0.001), • Female US born Spanish/English (low acculturation): 10% vs 2% (p = 0.04). • Female immigrant 13+ y Age 18–44 Spanish/English (high acculturation): 9% vs 2% (suggestive but NS)

20. Context Dependence: Gene-Environment Interaction Model GVP Phenotype GVA GVP GVA Mexico USA Exposure GVA = Gene Variant Absent GVP = Gene Variant Present Adapted from Cooper, R.S. (2003). Annals of Internal Medicine, 139:437-440

21. Males: Alcohol Abuse/Dependence Rate by Parental Risk, Nativity, Time in Country, Age, and Language Preference • Only 2 subgroups have a significant effect of parental risk factors: • Male immigrant <13y Spanish/English (high acculturation): 20% vs 5% (p = 0.01), • Male US born Spanish/English (low acculturation): 33% vs 9% (p < 0.001). • Age significant for immigrant 13+ y (p = 0.01); NS for US born and immigrant <13y.

23. Lifetime DSM-IV Rates (%) of Substance Disordersin Mexican Women and Mexican-origin Women in U.S. 1 NESARC. 2 from M. Medina-Mora et al., in press.

24. Lifetime DSM-IV Rates (%) of Substance Disordersin Mexican Men and Mexican-origin Men in U.S. 1 NESARC. 2 from M. Medina-Mora et al., in press.

25. NLAAS Lifetime dual diagnoses rates for U.S. national sample of Latinos • Any alcohol abuse/dependence with or without drug dependence, and a co-occurring non-addictive DSM-IV disorder • Total for immigrant women 0.68%,men 5.25% • Total for U.S. born women 7.33%, men 16.22%

26. Rates of lifetime A/D in Latino schizophrenia twin study • Drugs: Costa Rica 15, Mex. 10, U.S. 29 • Alcohol: Costa Rica 20, Mex. 19, U.S. 34 • Any Sub A/D: Costa Rica 25,Mex. 23, U.S. 45

27. Understanding the complexity of genetic interactions is crucial because the relevant clinical traits are extensively comorbid, e.g., alcoholism, drug dependence, impulsivity, ADHD, depression, etc. Crabbe, JC (2002) Genetic contributions to addiction. Annu Rev Psychol 53:435-62

28. HEALTH CARE AND ITS DISCONTENTS Every system is perfectly designed to achieve exactly the results it gets. “In other words it sure didn’t get this way by accident” Bill Vega “The First Law of Improvement” from Donald Berwick

32. Challenges Ahead • Access to care in a cost-control environment • Reconfiguring a fragmented health care system • Poor coordination of payers to providers for safety net populations • Low visibility and high stigma of mental health providers and treatments • Low availability of linguistically competent staff or translators • Low availability of co-ethnic specialists • Most mental health problems presented in primary care where behavioral health specialists are not available and providers are not disposed to offer treatment • Current levels of practicing mental health professionals: 29 Hispanics per 100,000 vs. 173 European Americans per 100,000

33. The Chain of Effectin Improving Cultural Competence Standards of care, enforcement accountability Macro-system regulations Model testing and develop- ment, efficacy and effective- ness trials, scaling up Research knowledge Organizational Context processes of care Policy development and implementation Design Concepts for practice standards, clinical culture, upskilling staff and continuous quality improvement Clinical Skills

34. Levels of Activity • THE REGULATORY COMMUNITY IMPOSING STANDARDS AND ACCOUNTABILITY FOR SYSTEMS OF CARE (INCLUDING FEDS, LICENSURE AND ACCREDITING BODIES) • THE RESEARCH COMMUNITY PROVIDING THEORY, IMPLEMENTATION MODELS, AND EVIDENCE OF EFFECTIVENESS • THE INDIVIDUAL AS THE NEXUS OF CULTURALLY COMPETENT (INDIVIDUALIZED) CARE MODELS • THE HEALTH CARE ORGANIZATION AS THE WEBWORK CONTROLLING ACCESS, PROCESSES OF CARE AND PRACTICE INNOVATIONS, AND OUTREARCH TO PATIENTS AND COMMUNITY

35. Four Levels of ChangeRequired • Clarifying national aims for improvement • Changing the care, itself • Changing the organizations that deliver care • Changing the environment that affects organizational and professional behavior

36. Access • Spanish-speaking Latinos less likely to have physician visits, flu shots, or mammograms than English speaking Latinos or non-Latino whites. (Fiscella) • Children whose parents speak Spanish less likely to have usual source of care than English speaking Latinos or non-Latino whites. (Weinick) • Spanish speakers who could not communicate with their physicians less likely to be discharged from the ER with a follow-up appointment. (Sarver) Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the insured. Med Care 2002;40:52-9.

37. Comprehension • Spanish speakers less likely to be discharged from the ER with an understanding of their medications, special instructions, and plans for follow-up care (Crane) • Spanish-speaking Latinos more likely to report problems with communication than English-speaking Latinos (Commonwealth Fund 2002 Health Care Quality Survey) • Spanish speakers who needed but didn't receive an interpreter were at much higher risk for not understanding discharge medications. (Andrulis in toolkit/Appendix A) Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med 1997;15:1-7.

38. Quality • Speaking a primary language other than English was an independent predictor of patient-reported drug complications. (Ghandi) • Spanish speaking patients less likely to receive standard of care (prompt surgery) in cholecystitis. (Diehl) Ghandi TK, Burstin HR, Cook EF, et al. Drug complications in outpatients. JGIM 2000;15:149-154.

39. Satisfaction • Patients whose primary language was not English significantly less likely to want to return to same ER for future care (Carrasquillo) • Patients who needed but didn't receive an interpreter in the ER were less satisfied with the care they received, as well as less satisfied with their physician. (Baker) Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. JGIM 1999; 14: 82-87.

40. Cost • Pediatric patients with a language barrier had higher charges ($38) and longer stays (20 min) than those without language barriers. (Hampers 1999) • Pediatric patients who needed, but didn't receive, a professional interpreter had higher test costs and were the most likely to be admitted to the hospital (compared to patients who could speak directly with their doctors, and patients who had a trained interpreter). (Hampers 2002) Hampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE. Language barriers and resources utilization in a pediatric emergency department. Peds 1999; 103(6): 1253-1256.

43. In Practice, Minorities are Over- and Under-Medicated • Repeated studies have shown that African Americans tend to receive significantly higher doses of antipsychotics than Caucasians • On the other hand, Hispanics and Asians seem likely to receive lower antipsychotic doses than Caucasians • African and Hispanic Americans are more likely to receive depot antipsychotics than Caucasians • African and Hispanic Americans seem more likely to receive typical antipsychotics than Caucasians

44. Future