Latino Patient with Depression Presenting to Primary Care

1
Latino Patient with Depression Presenting to
Primary Care

• Provided by Javier I Escobar, MD
• Presenters Theresa Miskimen, MD
• Esperanza Diaz, MD
• Presentation at the opening of the Clínica Latina
• RWJMS/UBHC
• July 19, 2006

2
Patient ID

• Hispanic female widow aged 56 years. She is the
  mother of 4 children aged 20 to 35 years and is a
  recent immigrant. She lives with her married
  daughter and speaks only Spanish. Her daughter is
  her interpreter.
• Chief Complaint at first primary care clinic
  visit
• severe weakness
• back pain
• joint pain

3

• Other somatic complaints identified on
  examination
• abdominal pain/flatulence
• headaches
• palpitations
• dizziness

4
Medical and Family History

• Medical History mild hypertension. She was
  prescribed a low-dose diuretic that she had not
  taken for several months
• Family History diabetes mellitus and
  hypertension (brother and sister)
• Physical examination showed nothing abnormal,
  except for slight obesity and mild hypertension
  (145/90 mm Hg). Laboratory assessments, including
  EKG, CBC, LFTs, and thyroid panel were normal

EKGelectrocardiogram CBCcomplete blood count
LFTsliver function tests.
5
Treatment Course

• The Primary Care Physician (PCP) saw pt with
  daughter serving as interpreter. PCP prescribed
  a low-dose ACE-inhibitor two month follow up
• Follow up visit daughter indicated mothers pain
  had continued, unresponsive to acetaminophen. In
  addition, she noted that her mother slept poorly
  and did not want to leave the house because of
  her physical problems. The PCP reassured the
  patient via her daughter

6

• Crisis few days later, the PCP received an
  urgent call from family indicating that the
  patient was in crisis. She was agitated, not
  sleeping, sobbing, eating little, and complaining
  of multiple pains
• The doctor suspected a psychiatric problem and
  asked the nurse at the clinic to assess the
  patient in an emergency visit

7
Crisis Assessment and Recommendations

• Screening tool PRIME-MD depression/anxiety
• Treatment recommendation benzodiazepine for
  sleep and psychiatric referral
• The family disagreed with the recommendation
  (The symptoms are not in her head!)
• Second opinion also suspected depression
• Psychiatric referral failed because the bilingual
  psychiatrist in practice nearby did not accept
  Medicaid patients

8
Course

• Symptoms continued to escalate with subsequent
  second crisis/brought to the emergency department
  of a university hospital
• Following physical clearance, a psychiatry
  resident diagnosed major depressive disorder
  (MDD) and started the patient on an
  antidepressant after explaining the diagnosis and
  reasons for the prescription to the family
• Follow up primary care clinic
• The patient hesitantly started taking the
  medication, but soon discontinued her treatment
  because it made her feel nauseous

9

• Case assignment Spanish-speaking APN
• Treatment recommendations trial another
  antidepressant, brief weekly visits, brief
  physicals
• Other interventions supportive therapy to talk
  about stressors psychoeducation depression can
  hurt
• Family intervention family sessions/encouraged
  family to endorse the treatment
• Update condition improved and after 6 to 8
  weeks, her symptoms were largely resolved
• She is now examined biannually for continuation
  treatment

10
Factors

• System Level Barrier
• Language
• Community Centered Barrier
• Stigma
• Provider Barrier
• Medicaid
• Access to Care
• primary care clinic