DEPRESSION & HISPANICS:EPIDEMIOLOGICAL, SOCIOECONOMIC

& CULTURAL CONSIDERATIONS

PEDRO RUIZ, M.D.

Professor & Interim ChairDepartment of Psychiatry & Behavioral SciencesUniversity of Texas Medical School at Houston

President (2006-2007)American Psychiatric Association

President Elect (2008-2011)World Psychiatric Association

DISCLOSURE

Nothing to Declare

USA POPULATIONUSA POPULATION (IN MILLIONS)

2000 1990

TOTAL 281.4 100% 248.8 100%

WHITE 194.6 69.2% 188.3 75.7%

HISPANIC 35.3 12.5% 22.4 9.0%

BLACK 33.9 12.1% 29.3 11.8%

ASIAN 10.5 3.7% 7.0 2.8%

NATIVE AMERICAN 2.1 0.7% 1.8 0.7%

OTHER 0.5 0.2% N/A N/A

TWO OR MORE RACES 4.6 1.6% N/A N/A

SOURCESOURCE: : U.S. CENSUS BUREAU, 1990, 2000.U.S. CENSUS BUREAU, 1990, 2000.

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

PROJECTED GROWTH OF POPULATION BY ETHNICITY

0

10

20

30

40

50

60

70

Whites Hispanics Blacks Asians AmericanIndians

Per

cen

t

1990

2000

2050

U.S. Census Bureau 1999.

$41,994$39,530

$28,953 $27,883

$0

$10,000

$20,000

$30,000

$40,000

$50,000

Median Family Income Levels

Total US PopulationCubansPuerto RicansMexicans

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

MEAN INCOME LEVEL OF HISPANICS VS. USA POPULATION

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. USA POPULATION

1997 USA HOUSEHOLD 1997 USA HOUSEHOLD STATUSSTATUS

FEMALEFEMALE

MARRIEDMARRIED HEADEDHEADED

(%) (%)(%) (%)

WHITEWHITE 80.980.9 14.214.2

ASIANASIAN 78.578.5 13.213.2

BLACKBLACK 45.545.5 46.746.7

HISPANICHISPANIC 68.268.2 24.424.4

MEXICAN AMERICANMEXICAN AMERICAN 72.272.2 20.220.2

PUERTO RICANPUERTO RICAN 54.354.3 39.439.4

CUBAN AMERICANCUBAN AMERICAN 76.976.9 16.916.9

CENTRAL & SOUTH AMERICANCENTRAL & SOUTH AMERICAN 65.265.2 26.826.8

SOURCESOURCE: U.S. Census Bureau, 2000.: U.S. Census Bureau, 2000.

DEPRESSION RELATED ANNUAL COSTS IN THE UNITED STATES

16,000 SUICIDES

565,000 HOSPITAL ADMISSONS

2.1 BILLION OF TOTAL DIRECT COSTS

10 BILLION OF INDIRECT MORBIDITY COSTS

4 BILLION OF LOST OF PRODUCTIVITY COST

16 BILLION IN TOTAL COSTS

SOURCE: Clinical Practice Guidelines No. 5: Depression in Primary Care, Volume 2. Rockville, Maryland, U.S. Department of Health & Human Services, Public Health Service, Agency for Health Care Policy, AHCPR Publication No. 93.0551, 1993.

ECA LIFETIME GENDER RATES OF MOOD DXECA LIFETIME GENDER RATES OF MOOD DX

DISORDERDISORDER FEMALEFEMALE MALEMALE F/M RATIOF/M RATIO

ALL AFFECTIVE DXALL AFFECTIVE DX 10.2 10.2 5.2 5.2 2.0 2.0

DYSTHYMIC DXDYSTHYMIC DX 4.1 4.1 2.2 2.2 1.9 1.9

MAJOR DEPRESSIONMAJOR DEPRESSION 7.0 7.0 2.6 2.6 2.7 2.7

MANIC EPISODEMANIC EPISODE 1.4 1.4 1.1 1.1 1.3 1.3

SOURCESOURCE: M.M. Weisman, et al., Free Press, 1991.: M.M. Weisman, et al., Free Press, 1991.

DEPRESSION RECURRENCE PROBABILITYDEPRESSION RECURRENCE PROBABILITY

RECURRENCERECURRENCE

AFTER FIRST EPISODEAFTER FIRST EPISODE 50-60%50-60%

AFTER SECOND EPISODEAFTER SECOND EPISODE 70% 70%

AFTER THIRD EPISODEAFTER THIRD EPISODE 90% 90%

AFTER DYSTHYMIC DXAFTER DYSTHYMIC DX 10% 10%

SOURCESOURCE: DSM-IV, 1994.: DSM-IV, 1994.

TWELVE MONTH PREVALENCE OF MOOD & ADDICTIVE DISORDERS IN MALES

0

2

4

6

8

10

12

United States Mexico

Pe

rce

nt

Depression

DysthymiaMania

AlcoholDrugs

Vega WA, et al. In press.

ONE-YEAR PREVALENCE OF MAJOR DEPRESSION AMONG USA ETHNIC

GROUPS

0

1

2

3

4

5

6

7

8

Whites MexicanAmericans

CubanAmericans

PuertoRicans

Pre

vale

nce

(P

er 1

00 P

erso

ns)

Oquendo MA, et al. 2001

DEPRESSION RATES AMONG PUERTO RICANS ON THE ISLAND VS. NEW

YORK

0%

2%

4%

6%

8%

10%

Puerto Ricans on the Island Puerto Ricans in New York City

Canino GJ, et al. 1987Moscicki EK, et al. 1987

Moscicki EK, et al. 1989Kemp BJ, et al. 1987Vega WA, et al. 1998

U.S. Department of Health and Human Services 2001

WHY ARE HISPANICS AT INCREASED RISK

FOR DEPRESSION? Risk factors include: Female gender Medical comorbidity Substance abuse Longer time in US residence and younger age at immigration Poverty Job loss

USA SUICIDE RATES ACCORDING TO AGE & USA SUICIDE RATES ACCORDING TO AGE & SEXSEX

RATES PER 100,000 POPULATIONRATES PER 100,000 POPULATION

AGE GROUPAGE GROUP TOTALTOTAL MALEMALE FEMALEFEMALE

15-1915-19 10.010.0 17.317.3 4.14.1

20-2420-24 15.615.6 27.427.4 5.25.2

25-3425-34 15.215.2 25.425.4 6.46.4

35-4435-44 14.614.6 23.523.5 7.77.7

45-5445-54 15.615.6 25.125.1 9.09.0

55-6455-64 16.716.7 28.628.6 8.48.4

65-7465-74 18.518.5 35.335.3 7.37.3

74-8474-84 24.124.1 57.157.1 7.07.0

ALL AGESALL AGES 12.312.3 21.521.5 5.65.6

SOURCE:SOURCE: U.S. Census, 1987. U.S. Census, 1987.

MEXICO SUICIDE RATES ACCORDING TO AGE & SEXMEXICO SUICIDE RATES ACCORDING TO AGE & SEX

RATES PER 100,000 POPULATIONRATES PER 100,000 POPULATION

AGE GROUPAGE GROUP TOTALTOTAL MALEMALE FEMALEFEMALE

15-2415-24 1.31.3 1.91.9 0.70.7

25-3425-34 1.21.2 1.81.8 0.50.5

35-4435-44 1.21.2 2.22.2 0.30.3

45-5445-54 1.21.2 1.91.9 0.40.4

55-6455-64 1.41.4 2.52.5 0.30.3

65-7465-74 1.71.7 3.33.3 0.10.1

74 & OVER74 & OVER 1.61.6 2.92.9 0.50.5

ALL AGESALL AGES 0.70.7 1.11.1 0.30.3

SOURCE:SOURCE: WHO, 1973. WHO, 1973.

ANNUAL SUICIDE RATE RELATIVE TO ONE-YEAR PREVALENCE OF MAJOR DEPRESSION

AMONG USA ETHNIC GROUPS

0

20

40

60

80

100

120

Whites MexicanAmericans

CubanAmericans

PuertoRicans

Nu

mb

er

of

su

icid

es

pe

r y

ea

r p

er

ca

se

of

ma

jor

de

pre

ss

ion

pe

r y

ea

r (x

10

-4) Males

Females

Oquendo MA, et al. 2001

RISK FACTORS FOR COMPLETED SUICIDEOlder males

Prior history of suicide attempt

Major depression

Substance abuse/dependence

Salib E, Green L 2003Smith JC, et al. 1985

Hoppe SK, Martin HW 1986Shai D, Rosenwaike I 1988

Maser JD, et al. 2002Hagnell O, et al. 1981

Derose KP, Baker DW 2000 Lewis-Fernandez R, Kleinman A 1995

Rogler LH 1996Ruiz P, Ruiz PP 1983

Guarnaccia PJ, et al. 1992

ISSUES THAT INFLUENCE HISPANICS’ ADHERENCE TO TREATMENT

PROGRAMSAlthough adjusted adherence rates in Hispanics likely are similar to Caucasians, the reasons for nonadherence differ and include: Poor doctor-patient communication

Lack of cultural sensitivity of the program

Hispanics’ negative attitudes toward health care providers

Limited provider responsiveness to familial and cultural context of treatment

Aguilar-Gaxiola SA, et al. 2002Vega WA, et al. 1999

Lewis-Fernandez R, Kleinman A 1995Rogler LH 1989

Lawson HH, et al. 1982

ISSUES THAT INFLUENCE HISPANICS’ ADHERENCE TO TREATMENT PROGRAMS

(CONT.) Social isolation and poor transportation

Disappointment at not receiving pharmacologic treatments

Unfulfilled expectation of prompt resolution of problem

Hispanics’ preference for alternative strategies to medical

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

1999 USA UNINSURED 1999 USA UNINSURED POPULATIONPOPULATION

ETHNIC GROUP %

HISPANIC 33.4

BLACK 21.2

ASIAN 20.8

WHITE 11.0

OTHER 13.6

SOURCE: U.S. Census Bureau, 2000.

Kaiser Family Foundation 2004

UNINSURED HISPANICS BY COUNTRY OF ORIGIN

HISPANIC HEALTH INSURANCE COVERAGE & HEALTH CARE UTILIZATION

PHYSICIAN NO PHYSICIAN

ANNUAL VISITS ANNUAL VISITS

MEXICAN AMERICAN 3.7 33%

MAINLAND PUERTO RICAN 6.0 20% CUBAN AMERICAN 6.2 25%

SOURCE: Trevino FM. et al., JAMA, 265(2):233-237, 1991.

1999 USA HEALTH UNINSURED 1999 USA HEALTH UNINSURED POPULATIONPOPULATION (TOTAL POPULATION: 274.1 MILLION)(TOTAL POPULATION: 274.1 MILLION)

(TOTAL POOR POPULATION: 32.3 MILLION)(TOTAL POOR POPULATION: 32.3 MILLION)

MILLIONMILLION %%

TOTAL UNINSURED POPULATIONTOTAL UNINSURED POPULATION 42.6 15.5 42.6 15.5

TOTAL UNINSURED POOR POPULATIONTOTAL UNINSURED POOR POPULATION 10.4 32.2 10.4 32.2

ETHNICITYETHNICITY %% % POOR% POOR

WHITEWHITE 11.0 11.0 28.0 28.0

BLACKBLACK 21.2 21.2 28.1 28.1

ASIAN ASIAN 20.8 20.8 41.7 41.7

HISPANICHISPANIC 33.4 33.4 43.7 43.7

ORIGINORIGIN

NATIVE BORNNATIVE BORN 13.5 13.5 28.4 28.4

FOREIGN BORNFOREIGN BORN 33.4 33.4 56.1 56.1

SOURCESOURCE: U.S. Census Bureau, 2000.: U.S. Census Bureau, 2000.

1999 USA CHILDREN & 1999 USA CHILDREN & ADOLESCENTSADOLESCENTS (TOTAL 72.3 MILLION)(TOTAL 72.3 MILLION)

INSUREDINSURED 62.3 MILLION62.3 MILLION 86.1% 86.1%

NOT INSUREDNOT INSURED 10.0 MILLION10.0 MILLION 13.9% 13.9%

ETHNIC GROUPETHNIC GROUP COVEREDCOVERED NOT COVEREDNOT COVERED

WHITEWHITE 91.1% 91.1% 8.9% 8.9%

ASIANASIAN 83.3% 83.3% 16.7% 16.7%

BLACKBLACK 82.1% 82.1% 17.9% 17.9%

HISPANICHISPANIC 72.8% 72.8% 27.2% 27.2%

SOURCESOURCE: U.S. Census Bureau, 2000.: U.S. Census Bureau, 2000.

1999 USA POOR CHILDREN & 1999 USA POOR CHILDREN & ADOLESCENTSADOLESCENTS

(TOTAL: 12.1 MILLION) (TOTAL: 12.1 MILLION)

INSUREDINSURED 9.3 MILLION9.3 MILLION 76.9%76.9%

UNINSUREDUNINSURED 2.8 MILLION2.8 MILLION 23.1%23.1%

ETHNICITYETHNICITY % UNINSURED% UNINSURED

HISPANICHISPANIC 32.0% 32.0%

ASIANASIAN 26.2% 26.2%

BLACKBLACK 18.7% 18.7%

WHITEWHITE 19.0% 19.0%

OTHEROTHER 4.1% 4.1%

SOURCESOURCE: U.S. Census Bureau, 2000.: U.S. Census Bureau, 2000.

HISPANIC AMERICAN HEALTH CARE MANPOWER

MEDICAL STUDENTSMEDICAL STUDENTS 2.0%2.0%

PHYSICIANSPHYSICIANS 5.4%5.4%

PSYCHIATRISTSPSYCHIATRISTS 4.6%4.6%

NURSESNURSES 3.0%3.0%

DENTISTSDENTISTS 2.2%2.2%

PHARMACISTSPHARMACISTS 2.2%2.2%

SOURCE:SOURCE: Ruiz P. Hosp. & Comm. Psych., 44(10): 958-962, 1993. Ruiz P. Hosp. & Comm. Psych., 44(10): 958-962, 1993.

SUMMARY

Multiple factors influence Hispanics’ encounter with mental health services, including:

Barriers in access, utilization, and quality of services resulting from financial and cultural factors

Cultural expressions of disorder

Beliefs about help-seeking

To attain compatibility, we need a knowledge base that integrates research, training and outreach and blends an understanding of circumstances that occur in both community systems and treatment systems where Hispanics live

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