Descriptions of depression and depression treatment in older Hispanic immigrants in a geriatric collaborative care program.

OBJECTIVES: To explore experiences with depression and depression treatment among older Hispanic immigrants participating in a collaborative care program of psychotherapy and antidepressant medication. METHOD: Semi-structured, in-depth interviews were conducted with 14 older Spanish-speaking Hispanic immigrants with major depression who participated in a collaborative care program within a public sector specialty geriatric clinic in Los Angeles, CA. RESULTS: Findings revealed that participants used various idioms to describe their experiences with depression, and that depression had a strong impact on functioning. Other findings indicated that depression was caused by various psychosocial problems, antidepressants were helpful in reducing depression, and that bilingual psychotherapists provided a welcoming and safe environment to express emotions and find solutions to problems. CONCLUSION: Results revealed participants' experiences with depression and the impact of participating in a collaborative care intervention for depression. Findings from this project should be used to inform future geriatric interventions for older Hispanic immigrants in the USA.

Barriers to depression treatment among low-income, Latino emergency department patients.

Low-income and Latinos use the emergency department (ED) as a primary source of care. Also, the depression prevalence in ED patients is high, making the ED a compelling venue for depression screening and intervention. This study examined barriers and facilitators to depression treatment among low-income, predominantly Latino ED patients. We conducted telephone interviews with 24 ED patients (18-62 years of age, 79 % female) who dropped out of a depression treatment intervention. Using grounded theory, we analyzed perceptions of depression and treatment, and barriers and facilitators to mental health treatment. Although most patients acknowledged signs of depression, there was a lack of readiness to seek help. Patients reported negative perceptions about anti-depressant medication, even if they had no previous use. Barriers to treatment included transportation concerns, employment/unemployment, patient-provider issues, and immigrant documentation. Identified facilitators included consistent provider advice and "talking." This study introduced new misunderstanding and miscommunication barriers.

Measuring Latinos' perceptions of depression: a confirmatory factor analysis of the Illness Perception Questionnaire.

This study examined the psychometric properties of the Revised Illness Perception Questionnaire adapted for a clinical sample of low-income Latinos suffering from depression. Participants (N = 339) were recruited from public primary care centers. Their average age was 49.73 years and the majority was foreign born females of either Mexican or Central American descent. Confirmatory factor analysis was used to test the factor structure of this measure. Construct and discriminant validity and internal consistency were evaluated. After the elimination of three items because of low factor loadings (< .40) and the specification of seven error covariances, a revised model composed of 24 items had adequate goodness-of-fit indices and factor loadings, supporting construct validity. Each of the subscales reported satisfactory internal consistency. Intercorrelations between the 5 illness perception factors provided initial support for the discriminant validity of these factors in the context of depression. The establishment of the psychometric properties of this adapted measure will pave the way for future studies examining the role illness perceptions play in the help seeking and management of depression among Latinos.

Research issues for improving treatment of U.S. Hispanics with persistent mental disorders.

This article reports on the outcome of an expert consensus meeting in August 2005 sponsored by the National Institute of Mental Health, which assembled 15 senior researchers with a background in treatment and services research with the Hispanic population. The purpose of the workshop was to identify research issues most pertinent for improving quality and effectiveness of treatment for Hispanics experiencing persistent mental disorders, defined as psychiatric syndromes that are of sufficient severity and duration to cause long-term impairment in social and occupational functioning and significant disability. The spectrum of ideas and recommendations advanced at the one-day meeting was wide and overlapping; therefore, the rich body of material was subsequently organized into five topics: diagnosis, quality of care and culturally appropriate services, psychosocial intervention development, psychopharmacologic interventions, and access to care. Although the authors recognize that the review was broad and the agenda presented is ambitious and in many instances generalizes to priority areas in overall mental health services and treatment research, the recommendations are intended to stimulate research for addressing the unique problems and research deficits that affect Hispanics with persistent mental disorders.

Effectiveness of Collaborative Care for Depression in Public-Sector Primary Care Clinics Serving Latinos.

OBJECTIVE: Quality improvement interventions for depression care have been shown to be effective for improving quality of care and depression outcomes in settings with primarily insured patients. The aim of this study was to determine the impact of a collaborative care intervention for depression that was tailored for low-income Latino patients seen in public-sector clinics. METHODS: A total of 400 depressed patients from three public-sector primary care clinics were enrolled in a randomized controlled trial of a tailored collaborative care intervention versus enhanced usual care. Social workers without previous mental health experience served as depression care specialists for the intervention patients (N=196). Depending on patient preference, they delivered a cognitive-behavioral therapy (CBT) intervention or facilitated antidepressant medication given by primary care providers or both. In enhanced usual care, patients (N=204) received a pamphlet about depression, a letter for their primary care provider stating that they had a positive depression screen, and a list of local mental health resources. Intent-to-treat analyses examined clinical and process-of-care outcomes at 16 weeks. RESULTS: Compared with patients in the enhanced usual care group, patients in the intervention group had significantly improved depression, quality of life, and satisfaction outcomes (p<.001 for all). Intervention patients also had significantly improved quality-of-care indicators, including the proportion of patients receiving either psychotherapy or antidepressant medication (77% versus 21%, p<.001). CONCLUSIONS: Collaborative care for depression can greatly improve care and outcomes in public-sector clinics. Social workers without prior mental health experience can effectively provide CBT and manage depression care.

Disparities in depression treatment for Latinos and site of care.

OBJECTIVE: This study examined the impact of patient characteristics and source of care on differences between whites and Latinos in use and quality of depression treatment in managed primary care settings. METHODS: Data were examined for 1,175 patients (398 Latinos and 777 whites) in 46 managed primary care practices who screened positive for probable depressive disorder. Patient baseline assessments were used to compile sociodemographic and clinical characteristics and to derive variables for receipt of any depression care and depression care that met minimum guidelines (antidepressant use or specialty counseling) in the past six months. Clinics were classified by the percentage of their patient population that consisted of Latinos to determine whether patients in highly Latino clinics reported lower rates of care. Predictors of use and quality of depression care were examined by using logistic regression. RESULTS: Rates of receipt of any depression care and guideline-level depression care were low, and Latinos were less than half as likely as whites to receive such care, even after the analyses controlled for independent predictors (that is, younger age, higher educational level, current unemployment, more comorbid medical illness, and a diagnosis of a depressive or anxiety disorder). The likelihood of receiving any care or care that met guidelines did not significantly vary according to whether clinics served a low, moderate, or high percentage of Latinos. CONCLUSIONS: Disparities in depression care for Latinos were not attributable to sociodemographic and clinical characteristics, and they were not attributable to receiving care in clinics that served ethnically similar or dissimilar clientele. These findings suggest that other patient or provider factors may be responsible.

Disclosure of Use and Abuse of Controlled Substances Among Psychiatric Outpatients.

BACKGROUND: Prescription drug abuse is a serious health concern and is considered a nationwide epidemic. Patients often fail or refuse to disclose the use of controlled substances, leaving prescribers and pharmacies unaware of the potential for harmful drug interactions and risk of overdose. Psychiatric patients are especially vulnerable to controlled substance misuse. OBJECTIVES: To determine hazardous patterns of prescription drug use among psychiatric outpatients and to raise awareness about the importance of reviewing information provided by prescription drug monitoring programs (PDMPs). METHODS: The medical records of 150 patients attending the Adult Outpatient Psychiatric Clinic at the Los Angeles County+University of Southern California (LAC+USC) Medical Center from July 2012 through May 2013 were reviewed. Patient activity reports were generated from California's PDMP. Nondisclosure of controlled substance use was identified by a discrepancy between patient reporting of prescriptions according to the medical records and PDMP reports. A "pattern suggestive of prescription drug abuse" was defined as having one or more of the following: within-class prescriptions from multiple providers and/or within-class early refills or within-class overlapping prescriptions picked up within 10 days of each other. RESULTS: Of the 150 patients, 113 were found in California's PDMP database. Of these 113 patients, 81 had obtained 111 prescriptions for controlled substances in the past 12 months. Of these 111 prescriptions, 52 (47%) were not disclosed to the primary psychiatrist, of which 14 (27%) revealed patterns consistent with prescription drug abuse. CONCLUSIONS: Reviewing PDMP databases before prescribing controlled substances should be considered a standard prescribing practice to prevent abuse, diversion, and adverse medical outcomes.

Using conjoint analysis to assess depression treatment preferences among low-income Latinos.

The authors examined the feasibility of conjoint analysis for measuring the depression treatment preferences of low-income, low-literacy Latino primary care patients. Forty-two patients with depression (58 percent of those eligible for the study) completed a survey about preferences for treatment and strategies to reduce barriers to care. They preferred combined counseling and medication to either approach alone and preferred individual over group treatment but did not show a significant preference for treatment setting. The odds of treatment acceptance were increased by the availability of telephone appointments, bus passes, and help with making appointments. Although further validation is required, conjoint analysis appears to be feasible for assessing preferences regarding depression treatment in this underserved population.

Racial-ethnic composition of provider practices and disparities in treatment of depression and anxiety, 2003-2007.

OBJECTIVES: This study explored whether racial and ethnic disparities in the treatment of depression and anxiety are associated with provider-level factors. METHODS: This study analyzed 58,826 office-based adult outpatient visits to primary care physicians and psychiatrists. Data were from the National Ambulatory Medical Care Survey, 2003-2007. Outcomes included counseling and referral for counseling, antidepressant prescription, and any care for depression or anxiety. The analyses of treatment outcomes were not limited to visits with a depression or anxiety diagnosis. RESULTS: Compared with visits to primary care physicians by whites, such visits by blacks and Hispanics were less likely to result in antidepressant prescription or in any care for depression or anxiety; primary care visits by Hispanics were also less likely to result in counseling. Compared with visits to psychiatrists by whites, such visits by blacks were less likely to result in an antidepressant prescription. The majority of visits to both primary care physicians and psychiatrists by blacks and Hispanics were to practices serving a high percentage of nonwhite patients. However, racial and ethnic disparities in care that were especially evident in primary care settings persisted after the analyses controlled for whether visits were to settings with a high or low percentage of nonwhite patients. CONCLUSIONS: Disparities in care for depression and anxiety in primary care continue and are not fully accounted for by less care being provided in settings that nonwhites frequent. Physician bias, resource issues, and patient factors may all play a role in the diagnosis and treatment of depression and anxiety.

Efficiency in mental health practice and research.

Limited financial resources, escalating mental health-related costs and opportunities for capitalizing on advances in health information technologies have brought the theme of efficiency to the forefront of mental health services research and clinical practice. In this introductory article to the journal series stemming from the 20th NIMH Mental Health Services Research Conference, we first delineate the need for a new focus on efficiency in both research and clinical practice. Second, we provide preliminary definitions of efficiency for the field and discuss issues related to measurement. Finally, we explore the interface between efficiency in mental health services research and practice and the NIMH strategic objectives of developing improved interventions for diverse populations and enhancing the public health impact of research. Case examples illustrate how perspectives from dissemination and implementation research may be used to maximize efficiencies in the development and implementation of new service delivery models. Allowing findings from the dissemination and implementation field to permeate and inform clinical practice and research may facilitate more efficient development of interventions and enhance the public health impact of research.

Effectiveness of collaborative care in addressing depression treatment preferences among low-income Latinos.

OBJECTIVE: This study assessed treatment preferences among low-income Latino patients in public-sector primary care clinics and examined whether a collaborative care intervention that included patient education and allowed patients to choose between medication, therapy, or both would increase the likelihood that patients received preferred treatment. METHODS: A total of 339 Latino patients with probable depressive disorders were recruited; participants completed a baseline conjoint analysis preference survey and were randomly assigned to receive the intervention or enhanced usual care. At 16 weeks, a patient survey assessed depression treatment received during the study period. Logistic regression models were constructed to estimate treatment preferences, examine patient characteristics associated with treatment preferences, and examine patient characteristics associated with a match between stated preference and actual treatment received. RESULTS: The conjoint analysis preference survey showed that patients preferred counseling or counseling plus medication over antidepressant medication alone and that they preferred treatment in primary care over specialty mental health care, but they showed no significant preference for individual versus group treatment. Patients also indicated that individual education sessions, telephone sessions, transportation assistance, and family involvement were barrier reduction strategies that would enhance their likelihood of accepting treatment. Compared with patients assigned to usual care, those in the intervention group were 21 times as likely to receive preferred treatment. Among all participants, women, unemployed persons, those who spoke English, and those referred by providers were more likely to receive preferred treatment. CONCLUSIONS: Collaborative care interventions that include psychotherapy can increase the likelihood that Latino patients receive preferred care; however, special efforts may be needed to address preferences of working persons, men, and Spanish-speaking patients.

Racial and ethnic disparities in detection and treatment of depression and anxiety among psychiatric and primary health care visits, 1995-2005.

CONTEXT: Recent evidence questions whether formerly documented disparities in care for common mental disorders among African Americans and Hispanics still remain. Also, whether disparities exist mainly in psychiatric settings or primary health care settings is unknown. OBJECTIVE: To comprehensively examine time trends in outpatient diagnosis and treatment of depression and anxiety among ethnic groups in primary care and psychiatric settings. DESIGN AND SETTING: Analyses of office-based outpatient visits from the National Ambulatory Medical Care Study from 1995-2005 (n = 96,075). PARTICIPANTS: Visits to office-based primary care physicians and psychiatrists in the United States. MAIN OUTCOME MEASURES: Diagnosed with depression or anxiety, received counseling or a referral for counseling, received an antidepressant prescription, and any counseling or antidepressant care. RESULTS: In these analyses of 10-year trends in treatment of common mental disorders, disparities in counseling/referrals for counseling, antidepressant medications, and any care vastly improved or were eliminated over time in psychiatric visits. Continued disparities in diagnoses, counseling/referrals for counseling, antidepressant medication, and any care are found in primary care visits. CONCLUSIONS: Disparities in care for depression and anxiety among African Americans and Hispanics remain in primary care. Quality improvement efforts are needed to address cultural and linguistic barriers to care.

Atypical psychotic symptoms in a Hispanic population: diagnostic dilemmas and implications for treatment.

OBJECTIVE: To better characterize psychotic symptoms and their treatment in Hispanic populations. DESIGN: Chart review. SETTING: Chelsea MGH Health Center and Chelsea Counseling Center (both affiliates of the Massachusetts General Hospital). PARTICIPANTS: Forty-four Hispanic patients presenting with psychotic symptoms in the context of mood and anxiety disorders. MEASUREMENTS: Chart review focussed on diagnosis, description, and cataloguing of psychotic symptoms and review of treatment efficacy. RESULTS: All but two patients described some atypical psychotic symptoms (e.g., doorbells or telephones ringing, voices of children, and visual hallucinations of animals or relatives). Treatment varied; 34 percent received monotherapy (either neuroleptic, antidepressant, or anxiolytic); 61 percent received polypharmacy; of these, 48 percent received a combination of antidepressant and anxiolytic; 19 percent received antidepressant with neuroleptic; 14 percent received antidepressant with neuroleptic and anxiolytic. No regimen was significantly better than any other. CONCLUSIONS: Psychotic symptoms in Hispanic patients have been noted anecdotally to present differently from those described in other populations. Our review appears to support this observation. Clinicians who work with Hispanic patients should ask about these atypical psychotic symptoms. We provide speculation on the nature of these symptoms, review approaches to treatment, and make recommendations for further investigation.