Ladson Hinton

Acculturation and the Prevalence of Depression in Older Mexican Americans: Baseline Results of the Sacramento Area Latino Study on Aging

OBJECTIVE: HTo determine the association between acculturation, immigration, and prevalence of depression in older Mexican Americans.

Practice constraints, behavioral problems, and dementia care: primary care physicians' perspectives.

ObjectivesTo examine how practice constraints contribute to barriers in the health care of persons with dementia and their families, particularly with respect to behavioral aspects of care.DesignCross-sectional qualitative interview study of primary care physicians.SettingPhysicians’ offices.ParticipantsForty primary care physicians in Northern California.MeasurementsOpen-ended interviews lasted 30–60 minutes and were structured by an interview guide covering clinician background and practice setting, clinical care of a particular patient, and general approach to managing patients with AD or dementia. Interviews were transcribed and themes reflecting constraints of practice were identified through a systematic coding process.ResultsRecurring themes (i.e., those present in ≥25% of physician interviews) included insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams. Physician narratives suggest that these constraints may lead to delayed detection of behavior problems, “reactive” as opposed to proactive management of dementia, and increased reliance on pharmacological rather than psychosocial approaches.ConclusionPhysicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex, because of time and reimbursement constraints as well as other perceived barriers. Our results suggest that more effective educational interventions (for families and physicians) and broader structural changes are needed to better meet the needs of the elderly with dementia and their families now and in the future. Without these changes, dementia care is likely to continue to fall short.

Working with culture: a qualitative analysis of barriers to the recruitment of Chinese-American family caregivers for dementia research.

The National Institutes of Health ismaking efforts to increase the representation ofminority elders in aging research. While it is oftennoted that cultural barriers may make the recruitmentof minority elders into research more difficult,relatively little empirical exists to support thisclaim. The purpose of this study was to identifysociocultural barriers to recruitment that emergedduring a four-year study of dementia caregiving amongChinese families in the Boston area. Morespecifically, this paper examines how culturallyshaped conceptions of health, aging, and dementiaimpacted the recruitment process. This paper is basedon a qualitative analysis of interviews with 23Chinese families and extensive fieldnotes generated byproject ethnographers and interviewers. The followingthemes emerged in this analysis: 1) dementia-relatedchanges were construed as a normal part of the agingprocess rather than a disease, making it moredifficult to identify dementia-affected elders and torecruit families, 2) research participation was viewedas potentially harmful because it can lead toexcessive worry 3) Alzheimers disease carries asocial stigma among Chinese, leading families to shunformal diagnosis and research participation, and 4)practitioners viewed research as an intrusion offeringno direct benefit to participants.

Reexamining the Relationships Among Dementia, Stigma, and Aging in Immigrant Chinese and Vietnamese Family Caregivers

Prior literature emphasizes that Asian Americans with dementia may be particularly vulnerable to the stigma of chronic and severe mental illness. However, there is a dearth of empirical research to support this claim. This study examines the relationship of stigma and dementia in 32 qualitative interviews with Chinese and Vietnamese family caregivers. Stigma was a common theme in the interviews (91%). Further analysis revealed two sources: the stigma of chronic and severe mental illness and a stigma reflecting negative stereotypes of aging or the aged. Chinese and Vietnamese cultural views of normal aging are not unitary but accommodate different trajectories of aging, some more and some less desired. When applied to persons with dementia, a “normalized” but negative trajectory of aging carried with it significant stigma that was distinct from but in addition to the stigma of chronic and severe mental illness. Older Chinese and Vietnamese with dementia are thus at risk of experiencing multiple stigmas that include but go beyond the stigma associated with chronic and severe mental illness.

Pathways to dementia diagnosis: evidence for cross-ethnic differences.

SummaryThe diagnosis of dementia often occurs well after the onset of the disease. Studies of help-seeking behavior may help illuminate why delays occur. Specific Aims(1) To describe pathways to diagnosis from the perspective of family caregivers and (2) to compare help-seeking patterns and experiences across three ethnic groups. MethodsSemi-structured qualitative interviews were conducted with 39 ethnically diverse family dementia caregivers. Interviews were coded for help-seeking events (initial help-seeking, referrals to secondary helpers, and site of final diagnosis), pathway types, and adverse experiences within the healthcare system along pathways to diagnosis. ResultsHelp-seeking was most often initiated by family members or formal care providers (ie, healthcare providers or social workers), usually in outpatient primary care settings but also elsewhere (eg, social service agencies, hospitals). “Secondary” formal helpers were often involved, usually through self-referral by families rather than by healthcare providers. While most families reported receiving a “final” diagnosis, a small minority of predominantly Chinese-American families did not. Four distinct pathways to diagnosis were identified and found to vary significantly (p < 0.03) across the three ethnic groups, which we label as smooth pathways, crisis events pathways, fragmented pathways, and dead-end pathways. Adverse experiences in the healthcare system were common and included unsatisfactory diagnosis disclosure and explanation, inadequate workup, uncaring or insensitive attitude, language barriers, and discrimination. ConclusionsCross-ethnic differences were found in both pathway types and in adverse experiences.

Dementia in fragile X-associated tremor/ataxia syndrome (FXTAS): Comparison with Alzheimer's disease†

Neurocognitive deficits in fragile X‐associated tremor/ataxia syndrome (FXTAS) involve attentional control, working memory, executive functioning, and declarative and procedural learning. To date, no studies comparing FXTAS with other dementias have been done. We characterize the dementia in FXTAS, comparing it with Alzheimers disease. Retrospective chart review of 68 adults (50 men, 18 women) with FXTAS. 20 men with FXTAS dementia were matched by age, gender, and education to patients with mild Alzheimers dementia (AD). Neuropsychological measures were compared between the two groups: Boston Naming Test (BNT), phonemic fluency (Controlled Oral Word Association Test), digit span forward (DSF) and backward (DSB). Comparisons were based on analysis of covariance and t‐tests to assess significant differences between groups. 50% of men with FXTAS and no women were cognitively impaired. On mean scores of verbal fluency (22.83 in FXTAS vs. 28.83 in AD, P = 0.112), working memory (DSB, 4.80 in AD vs. 5.41 in FXTAS, P = 0.359), and language (BNT, 48.54 in AD vs. 54.20 in FXTAS, P = 0.089), there were no significant differences. Digit span forward, measuring attention, was significantly higher in subjects with FXTAS dementia (8.59, vs. 7.10 in AD, P = 0.010). Individuals with FXTAS have significant cognitive deficits, on the order of those in AD although the cognitive profiles in these dementias are not similar. Further research is needed to outline the neuropsychiatric profile in FXTAS and the correlation of genetic markers with the progression and severity of cognitive loss.

Culture and Psychiatric Evaluation: Operationalizing Cultural Formulation for DSM-5

The Outline for Cultural Formulation (OCF) introduced with DSM-IV provided a framework for clinicians to organize cultural information relevant to diagnostic assessment and treatment planning. However, use of the OCF has been inconsistent, raising questions about the need for guidance on implementation, training, and application in diverse settings. To address this need, DSM-5 introduced a cultural formulation interview (CFI) that operationalizes the process of data collection for the OCF. The CFI includes patient and informant versions and 12 supplementary modules addressing specific domains of the OCF. This article summarizes the literature reviews and analyses of experience with the OCF conducted by the DSM-5 Cross-Cultural Issues Subgroup (DCCIS) that informed the development of the CFI. We review the history and contents of the DSM-IV OCF, its use in training programs, and previous attempts to render it operational through questionnaires, protocols, and semi-structured interview formats. Results of research based on the OCF are discussed. For each domain of the OCF, we summarize findings from the DCCIS that led to content revision and operationalization in the CFI. The conclusion discusses training and implementation issues essential to service delivery.

Patient Smartphone Ownership and Interest in Mobile Apps to Monitor Symptoms of Mental Health Conditions: A Survey in Four Geographically Distinct Psychiatric Clinics

Background Despite growing interest in mobile mental health and utilization of smartphone technology to monitor psychiatric symptoms, there remains a lack of knowledge both regarding patient ownership of smartphones and their interest in using such to monitor their mental health. Objective To provide data on psychiatric outpatients’ prevalence of smartphone ownership and interest in using their smartphones to run applications to monitor their mental health. Methods We surveyed 320 psychiatric outpatients from four clinics around the United States in order to capture a geographically and socioeconomically diverse patient population. These comprised a state clinic in Massachusetts (n=108), a county clinic in California (n=56), a hybrid public and private clinic in Louisiana (n=50), and a private/university clinic in Wisconsin (n=106). Results Smartphone ownership and interest in utilizing such to monitor mental health varied by both clinic type and age with overall ownership of 62.5% (200/320), which is slightly higher than the average United States’ rate of ownership of 58% in January 2014. Overall patient interest in utilizing smartphones to monitor symptoms was 70.6% (226/320). Conclusions These results suggest that psychiatric outpatients are interested in using their smartphones to monitor their mental health and own the smartphones capable of running mental healthcare related mobile applications.

Migration from Mexico to the United States and Subsequent Risk for Depressive and Anxiety Disorders A Cross-National Study

CONTEXT Migration is suspected to increase risk for depressive and anxiety disorders. OBJECTIVE To test the hypothesized increase in risk for depressive and anxiety disorders after arrival in the United States among Mexican migrants. DESIGN We combined data from surveys conducted separately in Mexico and the United States that used the same diagnostic interview. Discrete time survival models were specified to estimate the relative odds of first onset of depressive disorders (major depressive episode and dysthymia) and anxiety disorders (generalized anxiety disorder, social phobia, panic disorder, and posttraumatic stress disorder) among migrants after their arrival in the United States compared with nonmigrant Mexicans who have a migrant in their immediate family. SETTING Population surveys in the United States and Mexico. PARTICIPANTS Two thousand five hundred nineteen nonmigrant family members of migrants in Mexico and 554 Mexican migrants in the United States. MAIN OUTCOME MEASURES First onset of any depressive or anxiety disorder. RESULTS After arrival in the United States, migrants had a significantly higher risk for first onset of any depressive or anxiety disorder than did nonmigrant family members of migrants in Mexico (odds ratio, 1.42; 95% confidence interval, 1.04-1.94). Associations between migration and disorder varied across birth cohorts. Elevated risk among migrants relative to nonmigrants was restricted to the 2 younger cohorts (those aged 18-25 or 26-35 years at interview). In the most recent birth cohort, the association between migration and first onset of any depressive or anxiety disorder was particularly strong (odds ratio, 3.89; 95% confidence interval, 2.74-5.53). CONCLUSIONS This is, to our knowledge, the first study to compare risk for first onset of psychiatric disorder between representative samples of migrants in the United States and nonmigrants in Mexico. The findings are consistent with the hypothesized adverse effect of migration from Mexico to the United States on the mental health of migrants, but only among migrants in recent birth cohorts.

Antidepressant use in black and white populations in the United States

OBJECTIVE The study objective was to estimate the prevalence and correlates of antidepressant use by black and white Americans. METHODS Data from the Collaborative Psychiatric Epidemiology Surveys (CPES) were analyzed to calculate nationally representative estimates of past-year antidepressant use by black and white Americans ages 18 years and older (N=9,723). RESULTS Among individuals with depressive and anxiety disorders in the past year (N=516), black respondents (14.6%) had significantly lower (p<.001) antidepressant use than white respondents (32.4%). Depression severity was significantly associated with higher antidepressant use for white but not for black respondents. Psychiatric disorders and vascular disease significantly increased the odds of past-year antidepressant use. The increased prevalence of antidepressant use associated with vascular disease was independent of diagnosable psychiatric disorders. Among respondents not meeting criteria for depressive and anxiety disorders in the past year, lifetime depressive and anxiety disorders and vascular disease significantly increased the odds of antidepressant use. CONCLUSIONS Few white and fewer black Americans with depressive and anxiety disorders received antidepressant treatment. Higher depression severity was associated with more antidepressant use for white but not for black respondents. Antidepressant use was associated with medical conditions related to vascular disease, and these medical conditions were independent of coexisting psychiatric conditions. The results also indicate that many antidepressants are used for maintenance pharmacotherapy for depressive and anxiety disorders as well as common medical conditions associated with vascular disease.