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Depression, Co-morbidities, and Access To Treatment in Hispanic Populations

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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Depression, Co-morbidities, and Access To Treatment in Hispanic Populations

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  1. 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

  2. Disclosures • Advisory Board: Wyeth, Eli Lilly, Neuronetics • Grant Support: CNS Response, NIH

  3. 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 more likely to discontinue treatment Treatment of Depression in Hispanics U.S. Department of Health and Human Services, 2001 Sanchez-Lacay JA, et al. 2001 Blanco C, presented 2001 Data on file, Forest Laboratories

  4. Distribution of the Hispanic Population U.S. Census Bureau 2000

  5. 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 Summary of Findings: Unequal Treatment, a 2001 Report by the Institute of Medicine Smedley BD, et al. 2002

  6. 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 Access for Hispanics Ramirez RR, de la Cruz CG 2003 Kaiser Family Foundation 2004 Vega WA, Alegria M 2001

  7. Hispanic Population Living Below the Poverty Level vs. US Population U.S. Department of Health and Human Services 2001 U.S. Census Bureau 2000

  8. Uninsured Hispanics by Country of Origin Kaiser Family Foundation 2004

  9. Proportion of Hispanics Lacking Insurance on the Rise Ruiz P 1997

  10. 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 • Anglo-oriented acculturation Moscicki EK, et al. 1989

  11. 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 under-pathologization of individuals Stigma of mental illness, denial of mental health problems and values of self-reliance may influence Hispanics’ decisions to seek care Norms of Expressing Disorder 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

  12. CULTURE Clinician Patient Therapeutic Alliance Adherence Expectations (Placebo response) Health belief Personal Experiences Lin KM, Smith MW 2000

  13. Depression Includes Both Emotional and Physical Symptoms 2.0 Santiago 1.5 Rio de Janeiro Groningen 1.0 No. of Psychological Symptoms Paris Ankara Manchester Athens Seattle Mainz Ibadan Berlin 0.5 Verona Bangalore Shanghai Nagasaki 0.0 0.5 1.0 1.5 0.0 No. of Physical Symptoms Simon et al. NEJM. 1999;341:1329-35.A

  14. Major Depression Includes Physical, Emotional and Cognitive Symptoms American Psychiatric Association. DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

  15. Chronic Painful Physical Symptoms Are Common in People with Depression 43.4% 40 * 35 27.6% 30 25 (%) CPPS 17.1% 20 15 10 5 0 General Population Major DepressiveDisorder >1 Depressive Symptoms 18,980 subjects from 5 European countries by telephone interviews 16.5% at least 1 depressive symptom; 4.0% full diagnosis of major depression Ohayon & Schatzberg Arch Gen Psychiatry. 2003;60:39-47.

  16. 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 Common Physical Symptoms Cassano P, Fava M. J Psychosom Res. 2002;33:849-57.

  17. Somatic Symptoms and Psychiatric Disorders Kroenke K, et al. 1994

  18. Full Recovery Remission Recurrence No Depression Relapse Relapse Response Symptoms Severity Syndrome Progression to disorder Acute Continuation Maintenance Treatment Phases Time Phases of Treatment Adapted from: Kupfer, et al. J Clin Psychiatry. 1991;52:28-34.

  19. 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

  20. Depression: Response vs. Remission HAM-D17 Scores Depression 15 Response: 50% reduction in baseline HAM-D score or HAM-D  15 Remission: HAM-D Score  7 “Virtually Complete Symptom Resolution” 7 HAM-D17 Scores (total possible score = 56)

  21. Antidepressants are Generally Helpful in Reducing Chronic Pain 100 75 Percentage With Pain Relief on Taking Treatment 50 25 Diabetic neuropathy Postherpetic neuralgia 0 100 25 0 50 75 Percentage With Pain Relief on Taking Placebo 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 McQuayet al BMJ. 1997;314:763-4. unlabeled or investigational uses

  22. Treatment of Neuropathic Pain Conditions with Antidepressants Number Needed to Treat TCA (mainly amitriptyline) 2–3 SNRI (mainly venlafaxine) 4–5 SSRI (fluoxetine, citalopram) 7 or more NRI (reboxetine) insufficient NaSSA (mirtazapine) reliable data unlabeled or investigational uses Sindrup SH, et al. Basic Clin Pharmacol Toxicol. 2005;96:399-409.

  23. Venlafaxine SSRI Placebo Efficacy for the Treatment of MDD: Venlafaxine vs SSRI vs Placebo 50 ¶║ * † 40 § 30 * † ‡ Remission rate (%) ‡ 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.

  24. 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 Duloxetine 80 mg/day Duloxetine 60 mg/day Duloxetine 40 mg/day Duloxetine 20 mg/day Placebo Study 1 Study 2 Study 3 2 0 -2 -4 Least Squares Mean Change -6 b b a -8 c b a a -10 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) a Significant 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. Goldstein DJ, et al. Psychosomatics. 2004;45:17-28.

  25. 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 Summary

  26. 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 depression with physical symptoms • Serotonin and norepinephrine are shared biochemical mediators in modulating depression, including physical symptoms of depression

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