Global Mental Health: Focus on Latino Populations

Javier I Escobar MDAssociate Dean for Global Health and

Professor of Psychiatry and Family Medicine, UMDN-Robert Wood Johnson

Medical SchoolSeptember 2011

Local Health

International Health

Global Health

“Health problems, issues, and concerns transcend national

boundaries, may be influenced by circumstances or

experiences in other countries, and are best addressed by

cooperative actions and solutions.”

The Institute of Medicine

GLOBAL HEALTH

US Commitment to Global Health

• The President asked congress to spend $ 63 billion over the next six years on a broader Global Health

strategy that would reshape previous policy.

• According to the President, this US global health investment is an important component of the national security “smart power strategy”, where the power of America’s development tools can build the capacity of government institutions and reduce the risk of conflict before it gathers strength.

• It has been also recommended that Global Health should become the pillar of US Foreign Policy*

*Institute of Medicine report released on 12/22/2008

We are in a Global AgeUS Medical Schools are developing programs in Global Health (Harvard, Johns Hopkins, Michigan, NYU and

many others)NIH Institutes opening Global Health’s Offices.Major Universities require significant time abroad for undergraduates (Harvard, Princeton, etc.).

“If you are going to come to Harvard College it would be very good to have a passport” William Kirby, Dean of the Faculty of Arts and Sciences (Guardian Unlimited, April 27, 2004)

NIH AND GLOBAL HEALTH

• The new director of NIH, Francis Collins, listed Global Health as one of his top four priorities at the Institute• Collins plans to expand research efforts

to include diseases endemic to developing nations and increase research collaboration with those countries, to alter the world’s view of the United States, “by emphasizing its role as a doctor rather than a soldier”

NIMH INTERNATIONAL ACTIVITIESIn 2004, there were 184 NIMH-funded research

projects that included an international component, only a handful of these (5 or less) taking place in Latin America.

By 2009, the director reported that there were 200 projects with an international component.

In 2010, first RFA to create “International Hubs” (one of them in Latin America)

In 2011, second RFA for “International Hubs”**We are submitting application that includes UMDNJ and sites in Colombia, Mexico, Argentina and Peru.

US Medical Schools and Hospitals Expanding

OverseasWeill Cornell Medical Center: Cornell Medical

School in Qatar

Duke University: Duke Medical School in Singapore

Johns Hopkins: Two Hospitals in the United Arab Emirates and one in Singapore

Cleveland Clinic: Hospital in Abu Dhabi

University of Pittsburgh (UPMC): Oncology centers in Greece, Turkey, Germany, South Korea

Why “Global Health” in Places Like New Jersey or

Zaragoza Spain?

Latinos in New Jersey

050,000

100,000150,000200,000250,000300,000350,000400,000

Source : U.S. Census, 2000

Latinos in New Brunswick48% of all residents

23

8 7 73

26

18

7

0

5

10

15

20

25

30

Source: New Brunswick Community Health Survey, Center for State Health Policy, 2004

Mexican C/S American

Dominican Puerto Rican

Not US citizen

84% 63% 62% 0

Spanish at home

99% 87% 94% 51%

Adult uninsured

70% 51% 39% 23%

Adult MH (fair/poor)

41% 23% 43% 25%

Anxiety symptoms

6% 11% 8% 10%

Depression symptoms

12% 13% 13% 22%

Source: New Brunswick Community Health Survey, Center for State Health Policy, 2004

Latinos in New Brunswick

1.2%1.2%12%2.4%3.5%4.7%4.8%5%

9%

13%

8%

44%

Country Origin of Latino Patients Recruited in a Primary Care Study at Eric B. Chandler Clinic, in New Brunswick (Escobar J.I., et al Annals of Family Medicine, 2007)

Concentration of Foreign-born Immigrants in Zaragoza

Delicias, Casco Viejo

A. Fullaondo, P. Garcia, www.enhr2007rotterdam.nl

Immigrants in Zaragoza (2006)

Rumania24%

Ecuador17%

Otros Varios36%

Marruecos8%

Colombia7%

China 4%

Argelia4%

Total Population =660,895Immigrants =65,012

Immigrants in Zaragoza, Spain Zaragoza = the smallest among Spanish Metropolis. 2001 = 14,583 (2%) 2005 = 53,492 (8%) 2006 = 65,012 (10%) 2008 = 92,491 (12%) 2010 = 108,373 (>15%) Immigrants account for >90 % of the demographic

growth in the city. More than one fourth of all immigrants come from

Ecuador and Colombia. Other immigrant groups (Asians and other Europeans) have been on the increase recently.

Most Important Global Health Problems

NowadaysCommunicable, Maternal, Perinatal and Nutritional Conditions

Non-communicable Diseases (Chronic Diseases; Mental

Disorders)

Injuries

Other (Obesity, Violence, etc.)

LIFE EXPECTANCY AND INCOME

THE WORLDWIDE BURDEN

HISTORY OF EMERGING INFECTIONS

610 Influenza644 Leprosy900 Smallpox1348 Plague 1495 Syphilis1510 Scarlet Fever 1546 Typhus 1557 Malaria1567 Smallpox

YEAR DISEASE

History of Emerging Infections

1973 Rotavirus1977 Ebola Virus1977 Legionnaire’s Disease1981 Toxic Shock Syndrome1982 Lyme Disease1983 HIV-AIDS1983 Helicobacter Pylori1991 Multi Drug Resistant

(MDR) TB 1991 Epidemic Cholera1994 Cryptosporidium1998 Hong-Kong Bird Flu1999 West Nile Virus2001 Anthrax2003 SARS2006 Extremely Drug Resistant (XDR) TB)

WNV Activity 9/ 04 T=1386 Deaths 35

West Nile Virus in the US

AIDS Pandemico AIDS undoubtedly was one of the most devastating diseases that emerged during the 20th century.

o From 1981 to the end of 2004, about 25million people world-wide have succumbedto HIV infections.

o The pandemic is expected to progresswell into the 21th century.

InfluenzaAn agent of great concern

globally is influenza virus.Influenza virus is known to cause epidemics as early as the 1500’s, and pandemics have been described as early as 1889.The most extensive pandemic ever known is the pandemic of influenza of 1918-1919, which killed more 20 million people.

Ref Business Week, April 14, 2003

Malaria

TrachomaTrachoma is an infectious eye

disease. the result of infection of the eye with Chlamydia trachomatis.

Trachoma is the leading cause of blindness in the world (Africa, China, Thailand, Mexico, Brazil, Ecuador). In the USA = Native Americans and the Appalachian Region • Globally, 84 million people suffer from active

infection and nearly 8 million people are visually impaired as a result of this disease. ...

TrachomaInfection spreads from person to person, and is frequently passed from child to child and from child to mother, especially where there are shortages of water, numerous flies, and crowded living conditions.Infection often begins during infancy or childhood and can become chronic. If left untreated, the infection eventually causes the eyelid to turn inwards, which in turn causes the eyelashes to rub on the eyeball, resulting in intense pain and scarring of the front of the eye. This ultimately leads to irreversible blindness, typically between 30and 40 years of age.

WHO’s SAFE

SurgeryAntibioticsFacial CleansingEnhanced Hygiene

NCS in the Global Front• Most people nowadays die from non-

communicable diseases (NCS) once associated with wealth such as cancer, heart diseases, diabetes, etc.

• In 2008, 36 million deaths or 63% of all deaths worldwide, were due to NCS.

• In late September 2011 a high level summit of the United Nations will be addressing this problem

Complex Global Health Problems:

Mental DisordersAddictionObesityViolenceInjuries

Leading Causes of Disability Around The World (Cost in Billions of US Dollars)

DepressionAnemiaFalls

AlcoholCOPD

Bipolar

Congenital Defects

Arthritis

Schizophrenia

$0.00 $10.00 $20.00 $30.00 $40.00 $50.00World Health Organization, 1996

Obesity

Violence

Addiction

DALYs Lost Due to High-Risk Drinking by Disease Category and Region (2001)

6.5 5.32.8

10.3

3.2 4.5

3.11.5

1.7

1.5

1.10.5

0.0

4.0

8.0

12.0

Europe/ Central

Asia

Latin America/Caribbean

Sub-Saharan

Africa

E. Asia/ Pacific

South Asia

High-Income

Countries

InjuryChronic Disease

Mill

ions

of

DAL

Ys

Notes: Numbers are rounded.Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 47.3

9.7

6.8

4.5

11.8

3.75.6

The WHO ranking of the world’s health care systems

1. France2. Italy3. San Marino4. Andorra5. Malta6. Singapore7. Spain8. Oman9. Austria10.Japan11.Norway12.Portugal13.Monaco14.Greece15.Iceland16.Luxembourg17.Netherlands18.United Kingdom

19.Ireland20.Switzerland21.Belgium22.Colombia23.Sweden24.Cyprus25.Germany26.Saudi Arabia27.United Arab Emirates28.Israel29.Morocco30.Canada31.Finland32.Australia33.Chile34.Denmark35.Dominica36.United States of America

WHO Health Report, 2000

Total Health Expenditures as % of GDP, 2002-2005

1. Marshall Islands (19%)

2. USA (>14%)3. Niue 4. Timor-Leste5. Micronesia6. Kiribati7. Maldives 8. Malawi9. Switzerland10.France (10%)11.Germany (10%)

40.Spain (7-8%)41. United Kingdom

(7-8%)60.Colombia (7-8%)

Source = WHO

Disability Adjusted Life Expectancy at Birth

1. Japan2. Australia3. France4. Sweden5. Spain6. Italy7. Greece8. Switzerland9. Monaco10. Andorra11. San Marino12. Canada

13. Netherlands14. United Kingdom15. Norway16. Belgium17. Austria18. Luxembourg19. Iceland20. Finland21. Malta 22. Germany23. Israel24.United States of

America

Source, WHO, 1999

RWJMS Office of Global Health

Located at CAB Suite 7038o Javier I Escobar MD, Associate Dean for Global Healtho Aparna Kalbag MD, PhD, Post Doctoral Fellowo Rachel Werner, AdministrativeAssistanto Steering Committee: Sunanda Gaur MD (Pediatrics), Robert Like MD; Sonia Garcia-Lambauch MD; Karen Lin MD (Family

Medicine), Charletta Ayers MD (OB & Gyn); Abel Moreyra MD (Medicine/Cardiology), Shannon O’Hearn MS3,

Minyoung Yang MS3, Peter Murr MS-2, Rhea Itoop MS-2, Shazia Mehmood MS-2

RWJMS Medical Students’ Interest in

Global Healtho 21% of RWJMS 2012 Class Were Born Outside

the United States

o Over 20 students in the entering class have participated in international service activities prior to medical school on four different continents

o Over 1/3 of first year medical students express interest in having an international experience during medical school

LATIN AMERICA:COLOMBIA--CES Medical School, Medellín --Universidad de Antioquia, Medellín --Universidad de los Andes, Bogota(Dr. Javier I Escobar)BRAZIL --Brazil, Cross Cultural project with Pediatrics (Dr. Moorthy); --Universidad de Sao Paulo (Dr. Pat Williams, Pediatrics)ARGENTINA--Universidad de la Plata (Dr. Abel Moreyra Medicine/Cardiology)--Universidad de Buenos Aires; Departamento de Salud, San Salvador de JujuyMEXICO--Instituto Mexicano de Psiquiatria--Universidad Popular Autónoma del Estado de Puebla (UPAEP)--Universidad de OaxacaPERU--Universidad Cayetano Heredia, LimaCOSTA RICA--International Health Central American Institute Foundation, San José

ABOUT 50 RWJMS MEDICAL STUDENTS WENT ABROAD

IN 2008-200960% = MS-II

25% = MS-III

15% = MS-IV

COUNTRIES VISITEDCOUNTRIES VISITED

ARGENTINA

COLOMBIACOLOMBIA

COSTA RICA

ECUADOR

GHANA

INDIA

MYANMAR

MEXICO

HIMALAYAS/NEPAL

SOUTH AFRICA

TIBET

DOMINICAN REPUBLIC

GUATEMALA

ZAMBIA

SPAIN

SWITZERLANDCHINA

“RWJMS HAS GONE GLOBAL”

OPPORTUNITIES AND RESOURCES FOR

INTERNATIONAL MENTAL HEALTH RESEARCH

Collaborations with Latin America:

Javier I Escobar MDAddiction in the Americas (CICAD - OAS) Collaboration with Costa Rica, Mexico, Barbados, Uruguay, El Salvador, Chile, Colombia (UMDNJ-RWJMS as Coordinating Site)

NIMH/CIR/PAHO: Collaboration in Mental Health Services Research and Education (USA, Canada, Mexico, Colombia, Chile, Brazil, Peru, Jamaica)

NIMH-Funded Genetic Study: “Bipolar Endophenotypes in Population Isolates” – UCLA, Colombia, Costa Rica

NIMH R-13 Mentoring Grant “Critical Research Issues in Latino Mental Health”

Schizophrenia Study in Argentina.

Outcome of Schizophrenia Across Cultures (WHO Study-- Jablensky et al,

1992)

0

20

40Best Outcome Worst Outcome

Familial Expressed Emotion and Relapse of Schizophrenia

• 26 Studies in Several Countries (England, USA, Spain, Germany, Eastern Europe, Japan, Mexico)

• Percent Relapsing: Low EE -- 22% High EE -- 50% 0

100

200

300

400

500

600

Low EE High EE

relapsed did not relapse

AVAILABLE DATA SETS

52

World Mental Health SurveysParticipating Countries in the

AmericasCountry Sample Size

Brazil 5,000Canada 30,000Colombia 5,000Costa Rica 5,000Mexico 5,000Peru 5,000United States 25,000

World Mental Health Surveys Participating Countries

LegendParticipating countriesPending countriesNo Data

WHO 2003. All rights reserved

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

Use of Cannabis and Cocaine in Several

Countries

0

2

4

6

8

10

Marihuana Cocaine

USA Canada Mexico South America Asia

Medina Mora et al, 2005

HEALTH DISPARITIES

Let’s remember the old USA/UK Study inspired by the Schizophrenias that “were cured just by crossing the Atlantic” (From the US to England)! --This led to structured instruments and diagnoses to diminish bias --

--However, diagnostic bias is here to stay!--

Diagnostic disparities

UBHC STUDY (N=19,219)Percent With Serious Mental Illness

(Dementia, Schizophrenia, MDD, Bipolar)

05

101520253035404550

Latinos Blacks Whites

Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003

Percent Diagnosed as Schizophrenia

(N=19,219)

0

2

4

6

8

10

12

14

Latinos (N=1531) Blacks (N= 6,475) Whites (N=10,339

Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003

IMMIGRATION: ADVANTAGE OR DISDVANTAGE?

Vega WA, et al. 1998; Alderete E, et al. 2000

ImmigrationAbout 50% of Latinos in the US are ImmigrantsHispanics born or living in the US appear to be at a greater risk for mental disorders than counterparts born or living in their native countriesStress of trying to integrate into US society, feelings of alienation and discrimination may increases risk for some disordersLonger time of residence in US and younger age at entry increase risk for immigrantsProtective effects of strong cultural and familial ties may weaken when living in the USLonger residence in US and younger age at immigration increase risk (vulnerable period?)

White vs Black vs. Hispanics

NCSR 299/5124 English

Non-Hispanic Whites

NESARC 1541/23,622

English/Spanish

Mexican Origin ECANCSMAPSSNESARC

706/538319/581810/1202227/2331

English/SpanishEnglishEnglish/SpanishEnglish/Spanish

Puerto Rican NCSNESARC

54/16434/563

EnglishEnglish/Spanish

Hispanics NLAAS 1630/924 English/Spanish

Ethnic Groups Study Immigrants/USA

Language

YES

YES

YES YES YES YES NO NO NO?

Advantages Immigrants?

Epidemiological Studies in USA

12 Month Prevalence of Mood and Addictive Disorders in Males (Vega et al,

1997)

USA MEXI CO0

5

10

Depression

Dysthymia

Mania

Alcohol

Drugs

12-month Substance Abuse/Dependence Rate by Nativity, Age at Time of Entry into US,

and Present Age

0

5

10

15

20

10 20 30 40 50 60Age (years)

%

Age 0–16 at Entry US Age 17–24 at Entry USAge 25+ at Entry US US born

•U.S. born significantly different (p < 0.001) from each immigrant group (controlling for sex and present age).

•Immigrants Age 0–16 at Entry US vs Age 17–24 at Entry US significantly different (p = 0.02) for present age 18–24.

Vega WA, et al. In press

Prevalence of Current Diagnoses in Immigrants and Native Born in Spain (N=1500 each)*

*Garcia-Campayo et al, 2011

P<.0001

Unhealthy Habits in Pregnant Women

05

1015202530354045

LatinWomen

White,US- born

Positive for Drugs Positive for Alcohol Smokers

Modified from Vega et al, 1993

10 Year Age-Education Adjusted Coronary Heart Disease Mortality Risk for Mexican-American Adults

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

MALES FEMALES

US-born Spanish US-born English Mexico-born

Sundquist & Winkleby Am J Public Health, 89:723-730, 1999

Cultural Gradient and Blood Pressure

95

100

105

110

115

120

125

Low Middle High

Whites Latin Immigrants

Socioeconomic StatusSteffen PR, Journal of Behavioral Medicine, 29: 501-510, 2006

Average Systolic Blood Pressure

Cardiovascular Paradox in New Jersey

(Moreyra et al, presented at GHEC, Cuernavaca, Mexico, Abril 2010)

Table 1. Clinical Characteristics NJ 1994-2007 Hospitalized AMI

Hispanicn=13,106

Whitesn=190,142

n (%) 6.5% 93.6%Age, y 67 + 15* 71 + 14

Hypertension, n (%) 69.7%* 63.7%Diabetes Mellitus, n (%) 39.2%* 29.1%

Renal Disease, n (%) 11.3%* 11.5%

• Hispanics were younger (67 years vs. 71 years), • more likely to have

– hypertension (70% vs. 64%), – and diabetes (39% vs. 29%),

• all differences significant, p<0.0001.

Table 2. Multivariable Adjusted Associations (Interventions)

NJ 1994-2007 Hospitalized AMI

Hispanicn=13,106

Whitesn=190,142

AdjustedOR/HR

(95% CI)

Adjusted

p valuePCI, n (%) 21.21% 18.49% 0.94 (0.90-

0.99)0.03

CABG, n (%) 8.42% 8.81% 0.98 (0.91-1.07)

0.72

• Hispanics had lower adjusted rates of percutaneous interventions:– (PCI) (OR 0.94, CI 0.90-0.99, p=0.03),

• but similar rates of revascularization:– by CABG (OR 098, CI 0.91-1.07, p=0.72.

Table 2. Multivariable Adjusted Associations (Mortality)

NJ 1994-2007 Hospitalized AMI

Hispanicn=13,106

Whitesn=190,142

AdjustedOR/HR

(95% CI)

Adjusted

p valueIn-Hospital

Death 12% 14.7% 0.88 (0.83-

0.93)<0.00

0130 Day Death 13.6% 17.1% 0.95 (0.90-

0.99)0.047

1 Year Death 22.8% 27.6% 0.98 (0.94-1.01)

0.23

• Hispanics had lower:• In-hospital (HR 0.88, CI 0.83-0.93, p<0.001) and • 30-day mortality (HR 0.95, CI 0.90-0.99, p=0.047), • But at one year the survival difference was no longer

significant (HR 0.98, CI 0.94-1.01, p=0.23).

Summary of ResultsDespite higher prevalence of risk

factors and lower rates of PCI in Hispanics, the in-hospital and 30-day post AMI mortality is lower, but the difference fades at 1-year.

The Latino Paradox: Mortality (Hazard Ratios) Latinos vs. Non Latino

Whites in the US (NLMS Data)

0

0.2

0.4

0.6

0.8

1

Males FemalesMexican Puerto Rican CubanCentral/South Amer. Non-Latino Whites

Abraido-Lanza et al AJPH 1999Abraido-Lanza et al AJPH 1999

Potential Explanations for Mental Health “Advantages” of

Immigrants in the US Measurement Error?

misinterpretation of questions; language & translation issues; cross-cultural equivalence

Response Bias? social desirability, social approval, acquiescence

“Salmon” Effect

Selective Migration

Healthier Habits

Kin networks and Family

Support?

Advantages of Bilingualism

o Bilingual people (French/English) obtain better results in execution tests, have better cognitive flexibility, better ability to negotiate abstract concepts than monolingual people1

o Similar results have been observed in the case of Hispanic origin people in the United States 2,3

1-Peal and Lambert, 1962 2-Rumbaut and Ima 1988 3-Portes 1997)

Immigration and Psychosis: The Experience in England

o 1960’s: “High prevalence of Schizophrenia in Caribbean Immigrants to the UK” (1) o 1980’s: “Schizophrenia is 14 times higher among Caribbean

immigrants than in the general UK population (2) and this also applies to the second generation born in England (3)

o 1990’s: Studies with more methodological sophistication also showed an excess of schizophrenia (4) and mania (5) among Caribbean immigrants. However, other studies showed slight or no differences (6)

o 2000’s; The AESOP study calls immigration “a risk factor for psychosis (7)

1-Sharpley et al, 2001; 2- Harrison et al, 1988; 3-Harrison et al, 1997; 4-Wessely et al, 1991 5- Van Os et al, 1996; 6-Bughra et al 1997; 7- AESOPStudy Group 2002

Social Aspects of the Caribbean

Migration to the United Kingdom

o Disadvantages and travails of Black people and ethnic minorities in England.

o Afro-Caribbeans are more likely to be arrested or be transported by the police, to be admitted to psychiatric services against their will and to be locked or confined.

o “Diagnoses of psychosis made by White psychiatrists on Afro-Caribbeans are based on the notion that the person is strange, undesirable, bizarre, aggressive and dangerous”

Raleigh and Almond 1995; Fernando 1998; Hickling FW, Robertson-Hickling H, Hutchinson G, Migration and Mental Health, in Hickling FW, Sorel E (eds), Images of Psychiatry: The Caribbean, Stephenson Litho Press, Jamaica, 2005 (pages 153-177

Comments on Studies Associating Psychosis with

Migrationo There is ethnic variation in the presentation of

psychotic symptoms 1

o Documented bias in the diagnosis pf certain ethnic groups (African Americans in USA) 2

o The diagnosis of Afro-Caribbeans in England is possibly due to a similar bias.

o Studies of Afro-Caribbeans in Jamaica do not show an excess of psychotic disorders. 3

o The results of the old north American studies and the more recent European studies relating migration and psychosis may be due to these biases.

1-Vega WA, Lewis-Fernandez R, Current Psychiatric Reports, 2008, 10:223-228 2-Minsky S, Vega W, Miskimen T et al, Arch Gen Psychiatry, 2003, 60:637-6443-Hickling FW, Sorel E (eds), Images of Psychiatry: The Caribbean, Stephenson Litho Press, Jamaica, 2005

Reflexions on Immigration and Psychopathology

o Immigration is a risk factor with a high level of variability. o It is related to motivations for migrating, social

conditions, language, culture, acceptance of the immigrant in the new environment, employment, etc.

o Unfortunately, color of the skin continues to play a significant role (racism).

o Language is a critical factoro Resilience, personality, social support, are protective

factors.o Immigration may have an impact on certain psychiatric

disorders but not in others. o Epidemiological vs. Clinical Studies.