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

Pedro L. Delgado, MDDielmann 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

U.S. Department of Health and Human Services, 2001

Sanchez-Lacay JA, et al. 2001

Blanco C, presented 2001

Data on file, Forest Laboratories

Treatment of Depression in Hispanics

• 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

4

Mexican58%

South American

4%

All Other Hispanic

17%

Cuban4%

Central American

5%

Puerto Rican10%

Dominican2%

Spaniard0%

U.S. Census Bureau 2000

Distribution of the Hispanic Population

5Smedley BD, et al. 2002

Summary of Findings: Unequal Treatment, a 2001 Report by the

Institute of Medicine • 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

6Ramirez RR, de la Cruz CG 2003

Kaiser Family Foundation 2004

Vega WA, Alegria M 2001

Access for Hispanics

• 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

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12%14%

31%

27%

0%

10%

20%

30%

40%

% Below the Poverty Line

Total US Population

Cubans

Puerto Ricans

Mexicans

U.S. Department of Health and Human Services 2001U.S. Census Bureau 2000

Hispanic Population Living Below the Poverty Level vs. US Population

8

0

5

10

15

20

25

30

35

40

45

50

Mexican Puerto Rican Cuban CenteralAmerican

SouthAmerican

Kaiser Family Foundation 2004

Uninsured Hispanics by Country of Origin

9Ruiz P 1997

0%

10%

20%

30%

40%

50%

60%

1977 1987 1997

Private Health Insurance Medicaid or Medicare Uninsured

Proportion of Hispanics Lacking Insurance on the Rise

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Moscicki EK, et al. 1989

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

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Norms of Expressing Disorder

• 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

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

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Expectations(Placebo response)

Clinician Patient

Adherence

CULTURE

TherapeuticAlliance

Health belief

Personal Experiences

Lin KM, Smith MW 2000

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Depression Includes Both Emotional and Physical Symptoms

Simon et al. NEJM. 1999;341:1329-35.A

No

. of

Ps

yc

ho

log

ica

l S

ym

pto

ms

0.0

0.5

1.0

1.5

2.0

1.51.00.50.0

GroningenParis Ankara

AthensMainz

Manchester

Rio de Janeiro

Santiago

BerlinBangalore

NagasakiShanghai

SeattleIbadan

Verona

No. of Physical Symptoms

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Major Depression Includes Physical, Emotional and Cognitive Symptoms

Physical Emotional CognitiveWeight change Depressed mood Impaired

concentration

Fatigue, loss of energy

Guilt/worthlessness

Suicidal ideation

Insomnia/hypersomnia

Diminished pleasure/interest

Psychomotor retardation or

agitation

Pain/Somatic complaints

Anxiety

American Psychiatric Association. DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

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Chronic Painful Physical Symptoms Are Common in People with Depression

Ohayon & Schatzberg Arch Gen Psychiatry. 2003;60:39-47.

*

0

5

10

15

20

25

30

35

40

>1 Depressive Symptoms

Major DepressiveDisorder

(%)

CP

PS

43.4%

17.1%

GeneralPopulation

27.6%

18,980 subjects from 5 European countries by telephone interviews16.5% at least 1 depressive symptom; 4.0% full diagnosis of major depression

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Common Physical Symptoms

• 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

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

Somatic Symptoms and Psychiatric Disorders

0

10

20

30

40

50

60

70

80

90

Any Disorder Mood Anxiety

0 Symptoms

3-5 Symptoms

6+ Symptoms

Kroenke K, et al. 1994

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Phases of Treatment

Adapted from: Kupfer, et al. J Clin Psychiatry. 1991;52:28-34.

MaintenanceContinuationAcute

Full Recovery

Seve

rity

Time

Response

RelapseRecurrence

Treatment Phases

Symptoms

Remission

Syndrome

Relapse

Progression

to disorder

No Depression

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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

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Depression: Response vs. Remission

HAM-D17 Scores

15

7

Response: 50% reduction in baseline HAM-D score or HAM-D 15

Remission: HAM-D Score 7

“Virtually Complete Symptom Resolution”

Depression

HAM-D17 Scores (total possible score = 56)

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Antidepressants are Generally Helpful in Reducing Chronic Pain

McQuay et al BMJ. 1997;314:763-4.

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

Pe

rce

nta

ge

Wit

h P

ain

Re

lief

on

Ta

kin

g T

rea

tme

nt

Percentage With Pain Relief on Taking Placebo

50

25

75

100

00 25 50 75 100

Diabetic neuropathyPostherpetic neuralgia

unlabeled or investigational uses

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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) insufficientNaSSA (mirtazapine) reliable data

Sindrup SH, et al. Basic Clin Pharmacol Toxicol. 2005;96:399-409.

unlabeled or investigational uses

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Efficacy for the Treatment of MDD: Venlafaxine vs SSRI vs Placebo

1 2 3 4 6 80

50

40

30

20

10

Week of treatment

Rem

issio

n r

ate

(%

) Venlafaxine

SSRI

Placebo

*

* †‡

* †

* †

‡

¶ ║

§

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.

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Duloxetine 80 mg/day Duloxetine 60 mg/day Duloxetine 40 mg/day Duloxetine 20 mg/day Placebo

Duloxetine Versus Placebo in MDD With Painful Physical Symptoms

Goldstein DJ, et al. Psychosomatics. 2004;45:17-28.

-12

-10

-8

-6

-4

-2

0

2

0 1 2 3 4 5 6 7 8 9

b

bb

b

ca

aa

a

0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9

Treatment (Weeks)

Le

ast

Sq

ua

res

Mea

n C

han

ge

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.

Study 1 Study 2 Study 3

• 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

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Summary• 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

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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