Anxiety in the Latino Community DIVERSITY IMPACT 2012

1. Anxiety in the Latino CommunityDIVERSITY IMPACT 2012 Felicia Heyward CFNP 90 KatrinMoskowitz CFNP 91

2. Clinic Scenario Maria Sanchez, a 34 year old married, mother of four young children, comes to your office for a complaint of headaches. She tells you she hasn’t been able to sleep. She works full time as a house mom, takes care of her sick mother-in-law who lives with her. She cooks all the meals every night and handles all household duties. Her husband is looking for full time work and spends most days doing odd jobs. She finds that she can't keep from worrying "about everything" and she has been unable to control this worry. Although on the surface she appears outgoing, she dreads being in social situations.

3. General Anxiety Disorder • Generalized anxiety disorder is characterized by persistent, excessive, and unrealistic worry about everyday things. • The exact cause of GAD is unknown but research has shown that there is evidence that biological factors, family background, and life experiences, particularly stressful ones, play a role. • GAD affects 6.8 million adults, or 3.1% of the U.S. population, in any given year. Women are twice as likely to be affected. • People with the disorder, which is also referred to as GAD, experience exaggerated worry and tension, often expecting the worst, even when there is no apparent reason for concern. They anticipate disaster and are overly concerned about money, health, family, work, or other issues. • Source: Schmucker, W.W., (2008).

4. Diagnostics:(Should be discussed with patient prior to ordering) • EKG to assess for arrhythmias and tachycardia • Pulmonary function tests for asthma patients to rule out respiratory compromise • Labs that may need to be done include: • CBC • CMP • Thyroid levels—T3, T4 and TSH • Blood Glucose/Hgb A1C • Urinalysis and urine pregnancy • Urine drug toxicology screen • Prolactin • Folic acid • Parathyroid levels • Aldosterone •  Source: March,P.D. & Schub, T., (2011)

5. Differential Diagnoses for General Anxiety Disorder • Cardiac Conditions • Central Nervous System disorders • Hyperglycemia/Hypoglycemia • Hyperparathyroidism • Hyperthyroidism • Medications • Nutritional problems • Pheochromocytoma • Respiratory disorders • Stimulants (caffeine) • Temporal lobe epilepsy • Vestibular dysfunctions • Acute situational anxiety • Adjustment reaction • Alcohol and drug dependencies • Borderline personality disorder • Delirium • Dementia • Depression • Dysthymia • Factitious disorder • Generalized anxiety disorder • Malingering • Panic disorder • Phobias • Posttraumatic Stress Disorder • Psychosis • Schizophrenia • Somatization disorder Source: Schmucker, W.W. (2008). Medical Diagnoses Psychiatric Disorders

6. Combination Therapy Options for Anxiety Disorders Source: Prescriber’s Letter, (2012).

7. Patient Safety Issues An indication for hospital treatment would be a patient with suicidal or homicidal ideations. These patients hold a threat to themselves or others and need to be under supervision. Another reason for hospitalization would be alcohol or drug abuse requiring treatment. Many times patients self treat with other substances that maybe need to be ceased before appropriate therapy can begin. • Source: Anxiety disorder, 2011.

8. Common stigmatisms in the Latino communityfor patients with mental illness • A recent of 200 depressed and low income Latinos in Los Angeles showed that greater than 50% felt that depressed people were not trustworthy and would be unwilling to socialize with someone who is depressed. • When Latinos think mental illness, they often think…………. LOCO! • Family members shrug off mental illness as nervious(or “nerve problems”). • By not taking care of the physical issues they will become mentally “crazy”. • Hispanic patients may view mental health problems as a sign of weakness, and these problems may carry stigma as with many cultures. • Consequently, physical symptoms may be a more appropriate conduit for support. Hispanics have a high incidence of mental health problems, particularly depression, anxiety, and substance abuse. • Source: HealthWatch, 2012.

9. Cultural and Spiritual beliefs may impact treatment. • Religion is very important to Latino community. • Many turn to Espiritualistaswhich are folk healers. • Many feel that they have to resolve issues themselves as not to be a burden. • Many Hispanic patients tend to avoid disagreeing or expressing doubts to their health care provider about the treatment they are receiving. They may even be reluctant to ask questions or admit they are confused about their medical instructions or treatment. • Associated with this is a cultural taboo against expressing negative feelings directly. This taboo may manifest itself in a patient's withholding information, not following treatment orders, or terminating medical care. • The desire for a personalismoprovider -patient relationship. • Lack of trust because of provider rotations within the clinics. • Source: : U.S. Department of Health and Human Services (USDHHS), 2012

10. Barriers to care • Lack of health insurance (According to a 2006 American Psychological Association survey, nearly 1/3 of all Latinos had no health insurance in comparison to 10% of Whites.) • Underinsured (Only 41% of those insured, had mental health benefits compared to 65% of Whites and 63% African Americans.) • Time for care (Many Latinos have manual labor or service jobs that require odd hours, long shifts, and overtime.) • Language Barrier (Shortage of Spanish speaking psychiatrists, psychologists, and therapists. There are on 29 Latino mental health professional to every 100,000 Latinas compared to 173 White providers per 100,000 whites.) • Cultural Stressors (Cultural transition caused by immigration, acculturation, and biculturalism. These stressors are often manifest in feelings of irritability, anxiety, helplessness, and despair. Hispanics may mourn the loss of family, friends, language, and culturally determined values and attitudes. These reactions are not signs of individual pathology, but rather normal responses to the often-disruptive process of change.) Source: USDHHS, 2012.

11. Different points of View • Health care professionals • Work within the structured medicine • Physical and mental health separated • Latinos/Hispanics • Synergistic point of view • Spirit (espiritu), body, and mind – continuum of care • Source:USDHHS, 2012

12. What are the education needs of these patients? • Patients need to be educated about their illness, treatment options, that treatments may be needed long term, and expectations. • Educate patients that some people do better with cognitive behavior therapy, while others do better with medication. • Still others do better with a combination of the two. • Many patients with anxiety add a natural medicine along with their conventional treatment. (Follow up care needs to include a thorough assessment of all medications – prescribed and alternative) • Caution patients that many of the natural products can be sedating and could be unsafe to use before driving or performing other dangerous tasks. • Sources: National Institute of Mental Health (2012) & • Prescriber’s Letter (2012)

13. Nurse Leader in Latino Mental Health Dr. Jeanne-Marie Stacciarini, PhD, RN Brazilian Native Assistant Professor at the University of Florida College of Nursing Received the Research in Minority Health Award from Southern Nursing Research Society. Honored for research on the mental health of rural Latinos and her mentorship of minority students. Her research focuses on restoring the strong Latino cultural belief of “familismo” or rebuilding family bonds to promote mental wellness. Research: Dr. Stacciarini research interests are in the area of mental health promotion among minorities, community-based participatory research for minorities and international population. Area of expertise: Dr. Stacciarini has clinical expertise in Psychiatric Nursing and Mental Health. Education: Dr. Stacciarini received her BSN in Nursing at the Catholic University of Goiás (Brazil). She received her master in Psychiatric Nursing and Mental Health at the University of São Paulo/ College of Nursing RibeirãoPreto and her PhD in Psychology at the University of Brasilia (Brazil). During her PhD she received a Fulbright Scholarship and came to the US as a visitor scholar at the Psychology department/University of Massachusetts. Source: University of Florida, 2012

14. References • Anxiety disorder. (2011). Essential Evidence Plus. Retrieved from http://www.essential evidenceplus.com.ezproxy.midwives.org/content/ebmgebm/729. • Healthwatch (2012).CNN. Retrieved from http:www.cnnhealthwatch.com • March, P.D, & Schub, T.(2011). Generalized Anxiety Disorder in Women. CINAHL Nursing Guide, Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=nrc&AN=5000002773&site=nrc-live. • National Institute of Mental Health (2012). Generalized Anxiety Disorder (GAD): When Worry Gets Out of Control. Retrieved from http://www.nimh.nih.gov/health/publications/generalized-anxiety-disorder-gad/complete-generalized-anxiety-disorder-gad-when-worry-gets-out-of-control.shtml • Prescriber's Letter. (2009). Natural medicines in the clinical management of anxiety, 8(29), #08029. Retrieved from http://prescribersletter.therapeuticresearch.com.ezproxy.midwives.org/ce/ceCourse.aspx?cs=FRONT~CEPDA&s=PRL&pv=1&pc=08-29&quiz=1

15. References Schmucker, W.W. (2008). Anxiety Disorders. In T.M. Buttaro, J. Trybulski, P.P. Bailey, & J. Sandberg-Cook (Eds.), Primary Care: A collaborative practice (3rd ed., pp.1378-1383). Philadelphia, PA: Mosby Elsevier. Shearer, S.L. (2011). Generalized Anxiety Disorder. Essential Evidence Plus. Retrieved from http://www.essentialevidenceplus.com.ezproxy.midwives.org/content/eee/623 The Providers Guide to Quality and Culture (2012). U.S. Department of Health and Human Services (USDHHS). Retrieved from http://erc.msh.org/mainpage.cfm?file=5.2.0f.htm&module=provider&languag e=english