William A. Vega, PhD

Provost Professor

Executive Director

Latino Health and Faculty Development Conference

Stanford University, July 22, 2010

Brain Reward Pathways

Source: Messing RO. In: Harrison’s Principles of Internal Medicine. 2001:2557-2561.

•The VTA-nucleus accumbens pathway is activated by all drugs of dependence including alcohol

•This pathway is important not only in drug dependence, but also in essential physiological behaviors such as eating, drinking, sleeping, and sex

Ventral tegmental area (VTA)

Nucleus accumbens

genomegenomeprotein expressionprotein expression

neural circuitsneural circuits

DRUGSDRUGSsocialsocial

conductconduct

Systems operating in the etiology ofdrug addiction and mental illnesses Systems operating in the etiology ofdrug addiction and mental illnesses

MENTAL MENTAL ILLNESSESILLNESSES

Pathways for interactions among levels:

Social groups composed of individuals

Individuals composed of physiological

systems

Physiological systems composed of cells

Cells composed of molecules (DNA)

Only 1 in 10 people who use illicit drugsbecome

dependent on them

Genetic susceptibility to complex disease

usually results from joint effects of many genes,

each with a small to moderate effect and often

with interaction among themselves (e.g.

regions) and the environment.

IOM (2006)

“Schinka et al. have identified a functional Schinka et al. have identified a functional polymorphism within the opioid receptor polymorphism within the opioid receptor gene as a gene as a general general risk gene for substance risk gene for substance dependence. Substance abuse and dependence. Substance abuse and dependence phenotypes that emerge only dependence phenotypes that emerge only after exposure to the environment.”after exposure to the environment.”

Licinio, J (2002) Gene-environment interactions in Molecular Psychiatry.

Molecular Psychiatry 7:123-124

Tsuang et al. (2001) The Harvard twin study of substance abuse. Harvard Rev. Psychiatry 9:267-279

Cooper, R.S. (2003) Gene-environments interactions and the etiology of common complex disease. Ann Inter Med 139:437-440

Lower heart rate variability Slow recovery from exercise Elevated cortisol levels related to

accelerated cell aging Greater risk of metabolic syndrome Effects on hormonal regulation

(hypothalamic-pituitary-adrena axis) Increased risk for depression

Although there are (temporary) exceptions, such as the immigrant paradox, having better income and education is protective against most diseases and mental illnesses in the U.S.

Paradox affects weathering over time and immigrants have similar disability and chronic disease levels as U.S. born

Reasons: more persistent life stress, fewer resources available for avoiding impact of personal problems and unhealthy behaviors

SOCIOECONOMIC STATUS RACE/ETHNICITY SOCIAL NETWORKS/SOCIAL SUPPORT PSYCHOSOCIAL WORK ENVIRONMENT COMMUNITY ENVIRONMENT IOM (2006)

Long range impacts of social determinants and low socioeconomic mobility

Organization of human services to support optimal human development

Role of research in promoting change The role of social determinants in changing

public policy

Females: Alcohol Abuse/Dependence Rate by Parental Risk, Nativity, Time in Country, Age, and Language Preference

Only 3 subgroups show any effect of parental risk factors:• Female US born English all or most (high acculturation): 20% vs 2% (p < 0.001),• Female US born Spanish/English (low acculturation): 10% vs 2% (p = 0.04).• Female immigrant 13+ y Age 18–44 Spanish/English (high acculturation): 9% vs 2%

(suggestive but NS)

Females: Alcohol Abuse/Dependence Rate by Parental Risk, Nativity, Time in Country,

Age, and Language Preference

0

5

10

15

20

25

Female immigrant

<13y (all ages)Spanish

all the time

Female immigrant

<13y(all ages) Spanish/English

Female immigrant

13+y Age 45-59 Spanish

all the time

Female immigrant

13+y Age 45-59 Spanish/English

Female immigrant

13+y Age 18-44 Spanish

all the time

Female immigrant

13+y Age 18-44 Spanish/English

Female US born

(all ages)Spanish/English

Female US born

(all ages)English

all or most

%

One or more parental risk factors No parental risk factors

Ph

enot

ype

Exposure

Mexico USA

GVP

GVA

GVP

Context Dependence: Gene-Environment Interaction Model

Adapted from Cooper, R.S. (2003). Annals of Internal Medicine, 139:437-440

GVA = Gene Variant AbsentGVP = Gene Variant Present

GVA

Males: Alcohol Abuse/Dependence Rate by Parental Risk, Nativity, Time in Country, Age, and Language Preference

Males: Alcohol Abuse/Dependence Rate by Parental Risk, Nativity, Time in Country,

Age, and Language Preference

0

10

20

30

40

Male immigrant <13y

(all ages)Spanish

all the time

Male immigrant <13y

(all ages) Spanish/English

Male immigrant 13+y

Age 45-59 Spanish

all the time

Male immigrant 13+y

Age 45-59 Spanish/English

Male immigrant 13+y

Age 18-44 Spanish

all the time

Male immigrant 13+y

Age 18-44 Spanish/English

Male US born

(all ages)Spanish/English

Male US born

(all ages)English

all or most

%

One or more parental risk factors No parental risk factors

Only 2 subgroups have a significant effect of parental risk factors:

•Male immigrant <13y Spanish/English (high acculturation): 20% vs 5% (p = 0.01),

•Male US born Spanish/English (low acculturation): 33% vs 9% (p < 0.001).

Age significant for immigrant 13+ y (p = 0.01); NS for US born and immigrant <13y.

1 NESARC. 2 from M. Medina-Mora et al., in press.

U.S.1

Mexico2 Immigrants U.S. born

Alcohol abuse 0.4 1.0 8.7

Alcohol dependence

0.5 1.7 11.0

Drug abuse 0.0 0.6 5.2

Drug dependence 0.1 0.3 3.2

Nicotine dependence

0.9 1.5 9.8

1 NESARC. 2 from M. Medina-Mora et al., in press.

U.S.1

Mexico2 Immigrants U.S. born

Alcohol abuse 4.9 15.4 25.2

Alcohol dependence

8.8 9.6 19.4

Drug abuse 2.3 1.8 12.0

Drug dependence 0.7 0.5 4.5

Nicotine dependence

2.2 5.1 10.2

Any alcohol abuse/dependence with or without drug dependence, and a co-occurring non-addictive DSM-IV disorder

Total for immigrant women 0.68%,men 5.25%

Total for U.S. born women 7.33%, men 16.22%

Drugs: Costa Rica 15, Mex. 10, U.S. 29

Alcohol: Costa Rica 20, Mex. 19, U.S. 34

Any Sub A/D: Costa Rica 25,Mex. 23, U.S. 45

Crabbe, JC (2002) Genetic contributions to addiction. Annu Rev Psychol 53:435-62

Every system is perfectly designed to achieve

exactly the results it gets.

“In other words it sure didn’t get this way by accident”

Bill Vega

“The First Law of Improvement” from Donald

Berwick

Access to care in a cost-control environment

Reconfiguring a fragmented health care system

Poor coordination of payers to providers for safety net populations

Low visibility and high stigma of mental health providers and treatments

Low availability of linguistically competent staff or translators

Low availability of co-ethnic specialists

Most mental health problems presented in primary care where behavioral health specialists are not available and providers are not disposed to offer treatment

Current levels of practicing mental health professionals: 29 Hispanics per 100,000 vs. 173 European Americans per 100,000

The Chain of EffectThe Chain of Effectin Improving Cultural Competencein Improving Cultural Competence

Macro-system regulationsregulationsStandards of care, enforcement accountability

Research knowledgeknowledgeModel testing and develop-ment, efficacy and effective-ness trials, scaling up

Organizational Context

processes of processes of carecare

Policy development and implementation

Clinical SkillsClinical Skills

Design Concepts for practice standards, clinical culture, upskilling staff and continuous quality improvement

THE REGULATORY COMMUNITY IMPOSING STANDARDS AND

ACCOUNTABILITY FOR SYSTEMS OF CARE (INCLUDING FEDS,

LICENSURE AND ACCREDITING BODIES)

THE RESEARCH COMMUNITY PROVIDING THEORY,

IMPLEMENTATION MODELS, AND EVIDENCE OF EFFECTIVENESS

THE INDIVIDUAL AS THE NEXUS OF CULTURALLY COMPETENT

(INDIVIDUALIZED) CARE MODELS

THE HEALTH CARE ORGANIZATION AS THE WEBWORK

CONTROLLING ACCESS, PROCESSES OF CARE AND PRACTICE

INNOVATIONS, AND OUTREARCH TO PATIENTS AND COMMUNITY

Clarifying national aims for improvement

Changing the care, itself

Changing the organizations that deliver care

Changing the environment that affects organizational and professional behavior

Spanish-speaking Latinos less likely to have physician visits, flu shots, or mammograms than English speaking Latinos or non-Latino whites. (Fiscella)

Children whose parents speak Spanish less likely to have usual source of care than English speaking Latinos or non-Latino whites. (Weinick)

Spanish speakers who could not communicate with their physicians less likely to be discharged from the ER with a follow-up appointment. (Sarver)

Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the insured. Med Care 2002;40:52-9.

Spanish speakers less likely to be discharged from the ER with an understanding of their medications, special instructions, and plans for follow-up care (Crane)

Spanish-speaking Latinos more likely to report problems with communication than English-speaking Latinos (Commonwealth Fund 2002 Health Care Quality Survey)

Spanish speakers who needed but didn't receive an interpreter were at much higher risk for not understanding discharge medications. (Andrulis in toolkit/Appendix A)

Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med 1997;15:1-7.

Speaking a primary language other than English was an independent predictor of patient-reported drug complications. (Ghandi)

Spanish speaking patients less likely to receive standard of care (prompt surgery) in cholecystitis. (Diehl)

Ghandi TK, Burstin HR, Cook EF, et al. Drug complications in outpatients. JGIM 2000;15:149-154.

Patients whose primary language was not English significantly less likely to want to return to same ER for future care (Carrasquillo)

Patients who needed but didn't receive an interpreter in the ER were less satisfied with the care they received, as well as less satisfied with their physician. (Baker)

Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. JGIM 1999; 14: 82-87.

Pediatric patients with a language barrier had higher charges ($38) and longer stays (20 min) than those without language barriers. (Hampers 1999)

Pediatric patients who needed, but didn't receive, a professional interpreter had higher test costs and were the most likely to be admitted to the hospital (compared to patients who could speak directly with their doctors, and patients who had a trained interpreter). (Hampers 2002)

Hampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE. Language barriers and resources utilization in a pediatric emergency department. Peds 1999; 103(6): 1253-1256.

Repeated studies have shown that African Americans

tend to receive significantly higher doses of

antipsychotics than Caucasians

On the other hand, Hispanics and Asians seem likely to

receive lower antipsychotic doses than Caucasians

African and Hispanic Americans are more likely to

receive depot antipsychotics than Caucasians

African and Hispanic Americans seem more likely to

receive typical antipsychotics than Caucasians