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Medication Treatment of Mental Disorders in American Hispanics

Medication Treatment of Mental Disorders in American Hispanics. Humberto Marin, M.D. UMDNJ/Robert Wood Johnson Medical School Department of Psychiatry Piscataway, NJ. Hispanics in the U.S.: Highlights. 41.3 million Estimated Hispanic population as of July 1, 2004

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Medication Treatment of Mental Disorders in American Hispanics

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  1. Medication Treatment of Mental Disorders in American Hispanics Humberto Marin, M.D. UMDNJ/Robert Wood Johnson Medical School Department of Psychiatry Piscataway, NJ

  2. Hispanics in the U.S.: Highlights • 41.3 million Estimated Hispanic population as of July 1, 2004 • 1 Of every two people added to the U.S. population between July 1, 2003 and July 1, 2004 were Hispanic • 102.6 million Projected Hispanic population as of July 1, 2050 • 11 Number of states with at least half a million Hispanic residents • 43% Proportion of New Mexico’s population that is Hispanic • 7.6 million Number of Hispanic voters in the 2004 presidential election (47% of Hispanics) • 1.1 million Number of Latin American veterans (about 53,000 Hispanics on active duty in 2003) U.S. Census Bureau. Hispanic Heritage Month 2005--September 15-October 15. Press release, July 15, 2005

  3. Percent Distribution of Hispanics by Type: 2002 Source: Current Population Survey, March 2002, PGP-5

  4. Hispanics in New Jersey, 2000: Similar to to National Percentage

  5. Characteristics of Hispanic Americans Ramirez RR. We the People: Hispanics in the United States. US Census Bureau, issued December 2004. DeNavas-Walt C, Proctor BD, Mills RJ. Income, Poverty, and Health Insurance in the United States: 2003. US Census Bureau, issued August 2004.

  6. Open network. Reliance on a large number of people with weak connections to each other Closed networks. Strong ties, small membership, high degree of cultural homogeneity Strong maintenance of personal identity and emotional support Barriers to problem solving because of the lack of “bridges” to outside networks The Hispanic Networks Escobar JI, Randolph ET. The Hispanic and social networks. In: Becerra RM, Karno M, Escobar JI, eds. Mental health and Hispanic Americans. New York: Grune & Stratton; 1982:41-57.

  7. Hispanic Americans who have described themselves as Pew Hispanic Center/Kaiser Family Foundation. 2002 National Survey of Latinos: Summary of Findings. Menlo Park, California: Henry J. Kaiser Foundation, December 2002.

  8. Genetic Pool of Hispanic Subgroups Hanis CL, Hewett-Emmett D, Bertin TK, et al. Origins of U.S. Hispanics. Implications for diabetes. Diabetes Care 1991;14:618-627.

  9. The Stress of Acculturation: Immigration and Lifetime Prevalence Vega, W.A.; Kolody, B.; Aguilar-Gaxiola, S.; Alderete, E.; Catalano, R.; and Caraveo-Anduaga, J. Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Archives of General Psychiatry, 55(Sep):771-778, 1998.

  10. Grant BF, Stinson FS, Hasin DS, et al. Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic Whites in the United States. Archives of General Psychiatry 2004;61:1226-1233.

  11. Grant BF, Stinson FS, Hasin DS, et al. Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic Whites in the United States. Archives of General Psychiatry 2004;61:1226-1233.

  12. SALSA Prevalence of Depression (%)(CES-D > 16) Gonzalez HM, Haan MN, Hinton L. Acculturation and the prevalence of depression in older Mexican-Americans: baseline results of the Sacramento Area Latino Study on Aging. Journal of the American Geriatrics Society 2001;49(7):948-953.

  13. Some risk factors influencing mental disorders and their treatment in Hispanics CDC. Early Release of Selected Estimates Based on Data From the January-September 2004 National Health Interview Survey (Released 3/2005). Grant BF, Dawson DA, Stinson FS, et al. The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991-1991and 2001-2002. CDC. National Diabetes Fact Sheet, United States, 2003.

  14. Odds Ratio for ED (95% Confidence Interval) NHANES III White 1.00 Hispanic 1.89 (1.22-2.93) African American 1.03 (0.74-1.45) Other 0.67 (0.29-1.47) Christopher S. Saigal, MD, MPH; Hunter Wessells, MD; Jennifer Pace, BS; Matt Schonlau, PhD; Timothy J. Wilt, MD, MPH; for the Urologic Diseases in America Project.Predictors and Prevalence of Erectile Dysfunction in a Racially Diverse Population. Archives of Internal Medicine 2006;166:207-212.

  15. Hispanic Americans:Access to Mental Health Care

  16. No Health insurance coverage among persons under 65 years of age by selected characteristics: United States, 2002 Age Under 18 years 18-24 years 25-34 years 35-44 years 45-54 years 55-64 years Percent of poverty level Below 100 percent 100-149 percent 150-199 percent 200 percent or more Race and Hispanic origin White only, not Hispanic Asian only Black only, not Hispanic American Indian and Alaska Native only Hispanic (total) Mexican Other Hispanic Cuban Puerto Rican Percent NOTES: Percents by poverty level, Hispanic origin, and race are age adjusted. Persons of Hispanic origin may be of any race. Asian and American Indian and Alaska Native races include persons of Hispanic and non-Hispanic origin. See Data Table for data points graphed, standard errors, and additional notes. SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey. Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

  17. Health Insurance Status 1996 (%) Monheit AC. Vistnes JP. Race/ethnicity and health insurance status: 1987 and 1996. Medical Care Research & Review 2000:57 (Suppl 1):11-35.

  18. Private Health Insurance Coverage, Age <65, 1984-2002 National Center for Health Statistics. Health, United States, 2004 Hyattsville, Maryland: 2004.

  19. Use of health care services by Hispanic subgroups Weinick RM, Jacobs EA, Cacari Stone L, et al. Hispanic healthcare disparities - challenging the myth of a monolithic Hispanic population. Medical Care 2004;42:313-320

  20. Access to mental health services among women in California, CWHS 2001 Kimerling R, Baumrind N. Access to specialty mental health services among women in California. Psychiatric Services 2005:56:729-734.

  21. Help Seeking for Mental Health Problems: Mexican Americans (%) (Vega et al., 2001)

  22. Linguistic Barriers for Hispanic Americans

  23. Difficulty communicating with health care providers because of language (%) Pew Hispanic Center/Kaiser Family Foundation. 2002 National Survey of Latinos: Summary of Findings. Menlo Park, California: Henry J. Kaiser Foundation, December 2002.

  24. Unadjusted relative risk for decreased health care use (non-Hispanic white = 1) Fiscella K, Franks P, Doescher MP, et al. Disparities in health care by race, ethnicity, and language among the insured. Medical Care 2002;40:52-59

  25. Psychiatry Resident’s Race and Ethnic Identification Census of Psychiatry Residents 2003-2004. American Psychiatric Association, November 2004

  26. Total Physicians by Race/Ethnicity-2003 AMA, Minority Affairs Consortium, last updated Feb 02, 2005

  27. Physicians who speak Spanish per 100,000 Spanish-speakers with limited English-proficiencyCalifornia, 2001 Yoon J, Grumbach K, Bindman AB. Access to Spanish-speaking physicians in California: supply, insurance, or both. J Am Board Fam Pract 2004;17:165-172.

  28. U.S. Medical School Faculty, 2001 (%) AMA, Minority Affairs Consortium, last updated Sep 13, 2004

  29. Treatment of Mental Disordersin Hispanic Americans

  30. Pharmacokinetics of Psychotropics in Hispanics • Nortriptyline: no differences between Hispanics and Caucasians (Gaviria et al., 1986) • Tiagabine: no differences between Hispanic and non-Hispanic patients (Samara et al., 1998) • Haloperidol: similar profiles for Caucasian- and African-Americans, unique profile for Chinese. Hispanics differed from Caucasian/African Americans only at dosages higher than 40 mg/day (Jann et al., 1993)

  31. Hispanics and CYP2D6 Lam YWF, Casto DT, Dunn JF. Drug metabolizing capacity in Mexican Americans. Clinical Pharmacology and Therapeutics 1991;49:159. Mendoza R, Wan Y-J Y, Poland RE, et al. CYPD2D6 polymorphism in a Mexican American population. Clinical Pharmacology and Therapeutics 2001;70:552-560.

  32. Hispanics and CYP3A4 Paris PL, Kupelian PA, Hall JM, et al. Association between a CYP3A4 genetic variant and clinical presentation in African-American prostate cancer patients. Cancer Epidemiology, Biomarkers and Prevention 1999;8:901-905

  33. Hispanics and Haloperidol Metabolism Lam YWF, Jann MW, Chang W-H, Yu H-S, Lin S-K, Chen H, Davis CM. Intra- and inter-ethnic variability in reduced haloperidol to haloperidol ratios. Journal of Clinical Pharmacology 1995;35:128-136.

  34. In STEP-BD, Hispanics are about 4-5 % of the sampleIn STAR-D and CATIE the Hispanic share is 12-13% of the sampleSachs G & Liberman J. Communications at the 2005 APA and NCDEU meetings Atlanta, GA,and Boca Raton, FL, May & June 2005

  35. Participants in clinical trials submitted to the FDA, 1995-1999 (%) Evelyn B, Toigo T, Banks D, et al: Participation of racial/ethnic groups in clinical trials and race-related labeling: a review of new molecular entities approved 1995-1999. Journal of the National Medical Association 93(12, suppl.):18S-24S, 2001

  36. Ethnicity and Adherence in Schizophrenia Opolka JL, Rascati KL, Brown CM, et al. Role of ethnicity in predicting antipsychotic medication adherence. Annals of Pharmacotherapy 2003;17:625-630

  37. Medication Adherence in Hispanics

  38. Hispanics:Expectations About Mental Treatment

  39. Caregivers’ Agreement with Professional Label of Severely Mentally Ill Patients (Guarnaccia et al., 1992)

  40. Caregivers’ Agreement with Professional Label of Severely Mentally Ill Patients (Guarnaccia et al., 1992)

  41. Caregivers’ Expectation of Cure (%) (Guarnaccia et al., 1992)

  42. 1st recommendation If you feel you need an interpreter, ask for an in situ professional interpreter

  43. “Be aware of personal bias and countertransference, and keep in mind that a Hispanic patient is first and foremost an individual. Do not let cultural-specific information obscure the individual patient, which can occur if the healthcare provider treats the information stereotypically and acts as if all members of an ethnic category must behave and believe in the same fashion.” A. Hardwood 2nd recommendation

  44. 3rd recommendationHispanic Patients Are Mis- and Underdiagnosed • It has been shown for decades that minority bipolar patients are more likely to be misdiagnosed as schizophrenic • Minority patients in primary care are less likely to have their depression diagnosed and treated • Studies with elderly veterans have shown that minorities are less likely to receive a diagnosis of schizophrenia than Caucasians • Minority veterans with a diagnosis of schizophrenia receive less visits than Caucasians with the same diagnosis

  45. And They Are Also Overdiagnosed • Minority veterans are more likely than Caucasians to receive a diagnosis of substance disorder • Minority veterans with a diagnosis of substance disorder have more visits than Caucasians with the same diagnosis

  46. 4th Recommendation With Hispanic Americans, use the same dosing guidelines you use in the mainstream population

  47. 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

  48. 5th Recommendation When choosing medications, remember that Hispanic and African Americans are at higher risk for some significant adverse effects

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