Javier I. Escobar

Immigration and Mental Health: Mexican Americans in the United States

&NA; The Hispanic population in the United States continues to expand rapidly due primarily to a large flow of immigrants from Mexico. Historical observations of disadvantage in the immigrant population, when compared to the native population, had helped to shape prevailing theories on immigration and mental health. However, data emerging from new research on Mexican Americans have come to challenge the old idea that immigrants are necessarily disadvantaged. The goal of this article is to review these new studies critically, to draw conclusions concerning the relationship between immigration and psychopathology, and to offer potential explanations for the major findings. We review five recent large‐scale studies that examined the prevalence of mental disorders among Mexican‐born immigrants and U.S.‐born Mexican Americans in the United States. Results of these studies are inconsistent with traditional tenets on the relationship among immigration, acculturation, and psychopathology. They show that Mexico‐born immigrants, despite significant socioeconomic disadvantages, have better mental health profiles than do U.S.‐born Mexican Americans. Possible explanations for the better mental health profile of Mexican immigrants include research artifacts such as selection bias, a protective effect of traditional family networks, and a lower set of expectations about what constitutes success in America. The elevated rates of psychopathology in U.S.‐born Mexican Americans may be related to easier access to abused substances and an elevated frequency of substance abuse among the U.S.‐born.

Whether medically unexplained or not, three or more concurrent somatic symptoms predict psychopathology and service use in community populations

OBJECTIVESnTo examine the frequency of somatic symptoms in a community population of various ethnic backgrounds and to identify correlates of these symptoms such as psychopathology, use of services, and personal distress.nnnMETHODSnUsing a 14-symptom inventory with interviewer probes for somatic symptoms, we determined the presence of general physical symptoms (GPS) in a sample of 4864 white, Latino, and Asian US community respondents. Medically edited verbatim interview responses were used to decide whether or not physical symptoms would qualify as medically unexplained physical symptoms (MUPS). We then assessed the association between GPS and MUPS and psychiatric disorders, psychological distress, and use of services, in both unadjusted and multivariate regression analyses.nnnRESULTSnOne-third (33.6%) of the respondents reported at least one GPS and 11.1% reported at least one MUPS within the last year. 10.7% of respondents had three or more GPS and 1.5% had three or more MUPS. Three or more GPS and MUPS were positively associated with depressive, anxiety, and substance use disorders; service use; and psychological distress in unadjusted comparisons. In multivariate regressions, GPS persisted as a significant predictor, but there was no significant independent effect of MUPS, after controlling for GPS and other covariates.nnnCONCLUSIONSnRegardless of the presence or absence of medical explanations, physical symptoms are an important component of common mental disorders such as depression and anxiety and predict service use in community populations. These results suggest that three or more current GPS can be used to designate a case and that detailed probes and procedures aimed at determining whether or not physical symptoms are medically unexplained may not be necessary for classification purposes.

Somatic symptom disorder: An important change in DSM

This paper describes the rationale for the new diagnosis of somatic symptom disorder (SSD) within DSM5. SSD represents a consolidation of a number of previously listed diagnoses. It deemphasizes the centrality of medically unexplained symptoms and defines the disorder on the basis of persistent somatic symptoms associated with disproportionate thoughts, feelings, and behaviors related to these symptoms. Data are presented concerning reliability, validity, and prevalence of SSD, as well as tasks for future research, education, and clinical practice.

Overcoming barriers to reducing the burden of affective disorders

Affective disorders impose a substantial individual and societal burden. Despite availability of efficacious treatments and practice guidelines, unmet need remains high. To reduce unmet need and the burden of affective disorders, information is needed on the distribution of burden across stakeholders, on barriers to reducing burden, and on interventions that effectively reduce burden at the levels of practice, community, and policy. This article provides the report of the Working Group on Overcoming Barriers to Reducing the Burden of Affective Disorders, for the National Institute of Mental Health Strategic Plan on Mood Disorders. We review the literature, identify key gaps, and recommend new research to guide national efforts to reduce the burden of affective disorders.

A hierarchical classes analysis (HICLAS) of primary care patients with medically unexplained somatic symptoms

This study used a clustering model, Hierarchical Classes Analysis (HICLAS), to examine patient groupings in a multiethnic sample of 1456 patients using primary care services at a university-affiliated community clinic in southern California. Somatic symptoms, psychiatric diagnoses and disability were studied using a survey instrument that included portions of the Composite International Diagnostic Interview (CIDI), the Diagnostic Interview Schedule (DIS) and the RAND-MOS Short Form Health Surveys (SF-36) physical functioning dimension. HICLAS identified 11 clusters of patients with distinct patterns of medically unexplained somatic symptoms. These patient clusters varied with respect to psychiatric diagnoses and symptoms, gender, immigration status and disability. Results of this study suggest that the type of presenting symptom(s) and their various combinations may have diagnostic and prognostic value in primary care settings. These new findings may lead to further refinement of current diagnostic constructs for somatizing syndromes.

Putative psychotic symptoms in the Mexican American population: prevalence and co-occurrence with psychiatric disorders.

It is reported that Latin Americans describe culturally normative experiences or express putative psychotic symptoms in medical and mental health treatment settings that complicate the diagnostic process. Previous research reported that Latinos were more likely than European Americans and African Americans to have their diagnoses changed from schizophrenia to other disorders. This study describes the prevalence and likelihood of putative psychotic symptoms being expressed independent of any psychiatric disorder or co-occurring with common disorders such as depression or anxiety within a Mexican American population sample. Epidemiologic data of the Mexican American Prevalence and Services Survey (N = 3012) were used to contrast rates and patterns of putatively psychotic features among adults by demographic variables and diagnostic status using DSM-III-R criteria and receipt of treatment. Putative psychotic symptoms were reported by 17% of US-born and 7% of immigrants without disorders, and by 38% of US-born and 28% of immigrants with lifetime disorders, totaling 18% lifetime prevalence for the entire study population of Mexican Americans. First-rank Schneiderian symptoms were higher in those with a disorder compared with those without a disorder for both sexes. The results of this study indicate that putative psychotic symptoms are common among Mexican Americans, and their presence is a strong precautionary signal for evaluating clinicians to correctly distinguish whether putative psychotic symptoms are indicators of nonorganic psychoses or other psychiatric disorders, or are simply cultural expressions. Research is needed to identify the determinants of misdiagnosis in clinical practice, and guidelines are needed to assist clinicians.

Multisystem Component Phenotypes of Bipolar Disorder for Genetic Investigations of Extended Pedigrees

IMPORTANCEnGenetic factors contribute to risk for bipolar disorder (BP), but its pathogenesis remains poorly understood. A focus on measuring multisystem quantitative traits that may be components of BP psychopathology may enable genetic dissection of this complex disorder, and investigation of extended pedigrees from genetically isolated populations may facilitate the detection of specific genetic variants that affect BP as well as its component phenotypes.nnnOBJECTIVEnTo identify quantitative neurocognitive, temperament-related, and neuroanatomical phenotypes that appear heritable and associated with severe BP (bipolar I disorder [BP-I]) and therefore suitable for genetic linkage and association studies aimed at identifying variants contributing to BP-I risk.nnnDESIGN, SETTING, AND PARTICIPANTSnMultigenerational pedigree study in 2 closely related, genetically isolated populations: the Central Valley of Costa Rica and Antioquia, Colombia. A total of 738 individuals, all from Central Valley of Costa Rica and Antioquia pedigrees, participated; among them, 181 have BP-I.nnnMAIN OUTCOMES AND MEASURESnFamilial aggregation (heritability) and association with BP-I of 169 quantitative neurocognitive, temperament, magnetic resonance imaging, and diffusion tensor imaging phenotypes.nnnRESULTSnOf 169 phenotypes investigated, 126 (75%) were significantly heritable and 53 (31%) were associated with BP-I. About one-quarter of the phenotypes, including measures from each phenotype domain, were both heritable and associated with BP-I. Neuroimaging phenotypes, particularly cortical thickness in prefrontal and temporal regions as well as volume and microstructural integrity of the corpus callosum, represented the most promising candidate traits for genetic mapping related to BP based on strong heritability and association with disease. Analyses of phenotypic and genetic covariation identified substantial correlations among the traits, at least some of which share a common underlying genetic architecture.nnnCONCLUSIONS AND RELEVANCEnTo our knowledge, this is the most extensive investigation of BP-relevant component phenotypes to date. Our results identify brain and behavioral quantitative traits that appear to be genetically influenced and show a pattern of BP-I association within families that is consistent with expectations from case-control studies. Together, these phenotypes provide a basis for identifying loci contributing to BP-I risk and for genetic dissection of the disorder.

Nimodipine in the Treatment of Probable Alzheimer’s Disease

SummaryThe results of both in vitro and animal studies suggest that calcium dysregulation plays an important role in neuronal cell degeneration, and thus support the use of calcium antagonists for the treatment of Alzheimer’s disease (AD). The aim of this pooled analysis of 2 multicentre randomised trials was to assess the efficacy and tolerability of nimodipine administered for 6 months in a total of 1648 patients with probable AD. There were no statistically significant differences between nimodipine and placebo for any of the primary outcome variables. However, significant improvements in the secondary variable, Mini Mental State Examination (MMSE; p = 0.004) score, compared with the placebo group, were noted when the individual study data were pooled. Differences favouring nimodipine also emerged when patients were stratified according to their baseline MMSE scores. In more severely impaired patients (MMSE scores 12 to 18), nimodipine 180 mg/day was significantly superior to placebo for Alzheimer’s Disease Assessment Scale (ADAS) total (p = 0.01) and cognitive (p = 0.035) scores as well as MMSE total score (p = 0.006). Secondary analyses of these data indicated that patients with more severe cognitive disturbances, yet able to recall ≥ 1 word twice in succession (BSR test), demonstrated the greatest response to nimodipine 180 mg/day treatment. Nimodipine was well tolerated when administered at either 90 or 180 mg/day.In conclusion, although nimodipine did not significantly slow disease progression in the overall study population, patients with moderately severe dementia did appear to benefit from nimodipine treatment, especially those who performed well on the selective reminding test.

Role of psychiatric comorbidity in chronic Lyme disease

OBJECTIVEnTo evaluate the prevalence and role of psychiatric comorbidity and other psychological factors in patients with chronic Lyme disease (CLD).nnnMETHODSnWe assessed 159 patients drawn from a cohort of 240 patients evaluated at an academic Lyme disease referral center. Patients were screened for common axis I psychiatric disorders (e.g., depressive and anxiety disorders); structured clinical interviews confirmed diagnoses. Axis II personality disorders, functional status, and traits like negative and positive affect and pain catastrophizing were also evaluated. A physician blind to psychiatric assessment results performed a medical evaluation. Two groups of CLD patients (those with post-Lyme disease syndrome and those with medically unexplained symptoms attributed to Lyme disease but without Borrelia burgdorferi infection) were compared with 2 groups of patients without CLD (patients recovered from Lyme disease and those with an identifiable medical condition explaining symptoms attributed to Lyme disease).nnnRESULTSnAfter adjusting for age and sex, axis I psychiatric disorders were more common in CLD patients than in comparison patients (P = 0.02, odds ratio 2.64, 95% confidence interval 1.30-5.35), but personality disorders were not. Patients with CLD had higher negative affect, lower positive affect, and a greater tendency to catastrophize pain (P < 0.001) than comparison patients. All psychological factors except personality disorders were related to level of functioning. A predictive model based on these psychological variables was confirmed. Fibromyalgia was diagnosed in 46.8% of CLD patients.nnnCONCLUSIONnPsychiatric comorbidity and other psychological factors distinguished CLD patients from other patients commonly seen in Lyme disease referral centers, and were related to poor functional outcomes.

Psychophysiologic treatment for patients with medically unexplained symptoms: a randomized controlled trial.

BACKGROUNDnPatients presenting with medically unexplained physical symptoms (MUPS) typically present with significant distress and marked impairment in functioning and pose a unique challenge to health care providers. The purpose of this study was to examine the efficacy of a psychophysiological treatment (PT) for MUPS.nnnMETHODSnThirty-eight participants meeting criteria for subthreshold somatization disorder (abridged somatization) were randomly assigned to one of two conditions: (1) standard medical care augmented by a psychiatric consultation intervention (wait-list) or (2) a 10-session, manualized, individually-administered PT added to the psychiatric consultation intervention. Assessments were conducted at baseline, at midpoint (after four sessions), and after completing the last session. The primary outcome measure was the severity scale of the Clinical Global Impression Scale anchored for Somatic Symptoms (CGI-SD). Secondary outcome measures were responder status as determined by clinical ratings, self-report measures of mental and physical functioning.nnnRESULTSnAt the end of the trial, the severity (and frequency) of physical symptoms improved significantly more (p<0.05) in the intervention group. The average improvement in the CGI-SD was 0.80 points greater in the intervention group than in the wait-list group. PT was also associated with greater improvements in self-reported functioning and depressive symptomatology. The effect sizes at the final assessment point indicate that this intervention had a robust effect on complex somatic symptom presentations.nnnCONCLUSIONnFor patients with high levels of MUPS (abridged somatization), PT produces significant improvements in symptoms and functional status.