Don't Worry, Be Feliz

Psychiatrist Isabel Lagomasino is breaking down the barriers that keep low-income Latinos with depression from getting much-needed treatment.

by Kathleen O'Neil

Isabel Lagomasino wants people to be happy.

So it seems natural that, as a clinical psychiatrist, she has chosen to target one of the major causes of unhappiness: depression. According to the National Institute of Mental Health, depression affects about 10 percent of the American adult population every year, and is the leading cause of disability in the United States and developed countries around the world.

“Depression is one of the most prevalent mental illnesses, yet it has effective treatments, so people can improve,” says Lagomasino, M.D., M.S.H.S., a visiting professor in the Department of Psychiatry and Behavioral Sciences at the Keck School of Medicine of USC.

Unfortunately, many people do not get treatment for their depression and continue to suffer. For the past eight years, Lagomasino has been working to understand what comes between people and the treatment that can help them. She is focusing her studies on minorities, particularly Latinos, who are among the least likely to seek help for depression.

Lagomasino developed her interest in depression in minorities while participating in a psychopharmacology training program at Harvard Medical School’s Massachusetts General Hospital, where she worked with patients in public health clinics.

She began to recognize that many people who came in for physical illnesses also were showing signs of depression, but were not receiving a clinical diagnosis or treatment.

She noticed that some health-care providers downplayed the symptoms of depression in Latino patients by saying that was “just the way they are.” Lagomasino, who is Cuban-American, knew that depression is not a characteristic of Latino heritage.

She found that research indicated that depression rates are higher in people with poor socio-economic conditions. And yet, low-income Latinos are among the least likely to recognize depression, seek care for it or get treatment.

A 2001 report by the U.S. Surgeon General on the mental health of minorities stated that Latinos have less access to mental health care, receive poorer quality care when they do get treated and are rarely included in research. As a result, even though they have rates of depression similar to other racial groups, after controlling for socioeconomic differences, it turns out that they suffer more disability as a result of the illness.

“The depressed patients were so sick by the time they came to the clinic because most weren’t getting proper mental health care,” Lagomasino says. “The barriers occur at all different levels—with patients, providers and health-care systems.”

Latinos tend not to recognize depression as an illness, partly because of a strong cultural stigma against mental illness. They are more likely to attribute their decreased energy level, stress and other symptoms to external factors, such as lack of money or other problems over which they have no control.

If they do recognize that they are depressed, they are less likely to know where to seek treatment. They frequently go to their general health-care providers rather than to mental health professionals. And often, the health-care programs lack the resources to provide treatment for depression, especially the psychotherapy options that Latinos tend to prefer instead of medications.

Lagomasino has been trying to find ways around these barriers. In 1997, while at UCLA, she and co-researcher Megan Dwight-Johnson, M.D., M.P.H., joined a study led by Kenneth Wells, M.D., M.P.H., that sought to improve mental health care for all patients in managed primary-care clinics. The five-year Partners in Care trial enrolled more than 1,300 patients diagnosed with depression in 46 participating clinics across the United States. The participating clinics educated their patients and providers about depression and dedicated a staff person to act as a depression care specialist. The researchers then compared those clinics to clinics without special mental health services.

They found that the education and intervention program resulted in significantly improved mental health care for patients, with more appropriate dosing of antidepressant medication and a higher level of counseling.

The researchers also compared African-American and Latino study participants with white participants and found that while all three groups received the same level of improved care, the African Americans and Latinos were more likely to have improved mental health as a result. Without intervention, however, minorities were more likely to not seek appropriate care and to remain depressed.

Building on the Partners in Care findings, Lagomasino and Dwight-Johnson are currently working on a four-year study of depressed patients in public-sector, primary-care clinics.

“The public-sector, primary-care clinics are overwhelmed, so they focus on physical ailments rather than depression,” Lagomasino says. “And the specialized public mental health centers lack the budget to treat everyone, so they’re often limited to taking care of the severely mentally ill patients, such as ones with schizophrenia or who are suicidal. As a result, many people with depression go without treatment.”

With funding from the National Institute of Mental Health, Lagomasino and Dwight-Johnson, along with USC School of Pharmacy associate professor Joel Hay, Ph.D., USC School of Social Work professors Kathleen Ell, D.S.W., and Lawrence Palinkas, Ph.D., and clinical project manager Jennifer Green, M.S.W., in the Keck School Department of Psychiatry and Behavioral Sciences, as well as researchers from UCLA and the RAND Corporation, will set up a model intervention program in three Los Angeles public health clinics.

The intervention is designed to improve the diagnosis and care of depressed minorities, who make up the majority of patients at the public clinics. Patients will be screened for depression and offered a choice of on-site psychotherapy or antidepressant medication treatment.

Lagomasino and her colleagues aim to develop a better understanding of the types of treatments and services that patients want and the care that clinics feel they can provide. Ultimately, Lagomasino hopes to make the intervention program affordable and easy to maintain so it can become a permanent part of each clinic’s operations after the study has ended. “We need to figure out how to make treatments more available to a larger number of minority patients who can most benefit from the increased care,” she says.