salud mental en paises latinoamericanos

8/10/2019 Salud mental en paises latinoamericanos

1/79

Global Mental Health: Focus onLatino Populations

Javier I Escobar MDAssociate Dean for Global Health and

Professor of Psychiatry and Family Medicine,

UMDN!obert "ood Johnson Medical #chool#e$tember %&''


2/79

(ocal Health

InternationalHealth

GlobalHealth


3/79

)Health $roblems, iss*es, andconcerns transcend national

bo*ndaries, may be infl*enced by

circ*mstances or e+$eriences inother co*ntries, and are best

addressed by coo$erative actions

and sol*tions-

The Institute of Medicine

GLOBAL HEALTH


4/79

US o!!it!ent to GlobalHealth

. /he President as0ed con1ress to s$end 2 34 billionover the ne+t si+ years on a broader Global Healthstrate1y that 5o*ld resha$e $revio*s $olicy

. Accordin1 to the President, this U# 1lobal healthinvestment is an im$ortant com$onent of the nationalsec*rity )smart $o5er strate1y-, 5here the $o5er ofAmerica6s develo$ment tools can b*ild the ca$acity of1overnment instit*tions and red*ce the ris0 of conflict

before it 1athers stren1th

. It has been also recommended that Global Healthsho*ld become the $illar of U# Forei1n Policy7

"Institute of Medicine #epo#t #eleased on $%&%%&%''(


5/79

"e are in a Global A1eU# Medical #chools are develo$in1

$ro1rams in Global Health 8Harvard,Johns Ho$0ins, Michi1an, N9U andmany others:NIH Instit*tes o$enin1 Global Health6s;fficesMa


6/79

7IH A72 GLOBALHEALTH

. /he ne5 director of NIH,Francis >ollins, listed Global Healthas one of his to$ fo*r $riorities at

the Instit*te. >ollins $lans to e+$and research efforts to

incl*de diseases endemic to develo$in1nations and increase research collaboration5ith those co*ntries, to alter the 5orld6svie5 of the United #tates, )by em$hasi?in1its role as a doctor rather than a soldier-


7/79

7IMH I7TE87ATIO7AL ATI9ITIES

In %''51 the#e -e#e $(5 7IMHfunded #esea#ch

p#o;ects that included an inte#national co!ponent1 onl*a handful of these 3< o# less6 ta=in+ place in LatinA!e#ica>

B* %''?1 the di#ecto# #epo#ted that the#e -e#e %''p#o;ects -ith an inte#national co!ponent>

In %'$'1 fi#st 8FA to c#eate )Inte#national Hubs.3one of the! in Latin A!e#ica6

In %'$$1 second 8FA fo# )Inte#national Hubs.""/e a#e sub!ittin+ application that includes UM27@ and sites inolo!bia1 Meico1 A#+entina and Pe#u>


8/79

US Medical Schools and HospitalsEpandin+ O,e#seas

"eill >ornell Medical >enter@ >ornell Medical#chool in atar

D*0e University@ D*0e Medical #chool in #in1a$ore

Johns Ho$0ins@ /5o Hos$itals in the United ArabEmirates and one in #in1a$ore

>leveland >linic@ Hos$ital in Ab* Dhabi

University of Pittsb*r1h 8UPM>:@ ;ncolo1y centers inGreece, /*r0ey, Germany, #o*th Borea


9/79

"hy )Global Health- in Places

(i0e Ne5 Jersey or Cara1o?a#$ain


10/79

(atinos in Ne5 Jersey

#o*rce @ U# >ens*s, %&&&


11/79

(atinos in Ne5 r*ns5ic0 of all residents

Sou#ce: 7e- B#uns-ic= o!!unit* Health Su#,e*1ente# fo# State Health Polic*1 %''5
http://rds.yahoo.com/_ylt=A0geu7nwzJ5Jx.wAi7ZXNyoA;_ylu=X3oDMTB0Ym1vN2ZwBHNlYwNzYwRjb2xvA2FjMgR2dGlkA0gyNTlfMTMw/SIG=1hvvvlgeg/EXP=1235230320/**http%3A//images.search.yahoo.com/images/view%3Fback=http%3A%2F%2Fsearch.yahoo.com%2Fsearch%3Fei%3DUTF-8%26p%3Drutgers%2Blogos%26w=522%26h=685%26imgurl=www.logoshak.com%2F~asgsport%2Fimages4%2FRutgers_4.gif%26size=51kB%26name=Rutgers_4.gif%26rcurl=http%3A%2F%2Fwww.logoshak.com%2F~asgsport%2Fshak.html%26rurl=http%3A%2F%2Fwww.logoshak.com%2F~asgsport%2Fshak.html%26p=rutgers%2Blogos%26type=gif%26no=2%26tt=77%26oid=b8775a4671381374%26tit=Rutgers_4.gif%26sigr=11bjtcork%26sigi=11gjh31ob%26sigb=11no1vd9h


12/79

Me+ican >#American

Dominican P*erto !ican

Not U#citi?en

34 3% &

#$anish at

home

K L'

Ad*lt*nins*red

K& L' 4 %4

Ad*lt MH8fair$oor:

' %4 4 %L

An+ietysym$toms

3 '' '&

De$ressionsym$toms

'% '4 '4 %%

Sou#ce: 7e- B#uns-ic= o!!unit* Health Su#,e*1ente# fo# State Health Polic*1 %''5

(atinos in Ne5 r*ns5ic0


13/79

ount#* O#i+in of Latino Patients8ec#uited in a P#i!a#* a#e Stud* at

E#ic B> handle# linic1 in 7e- B#uns-ic=8Escobar JI, et al Annals of Family Medicine, %&&K:


14/79

>oncentration of Forei1nborn Immi1rants in Cara1o?a

Delicias, >asco ie


15/79

Immi1rants in Cara1o?a 8%&&3:

/otal Po$*lation 33&,LImmi1rants 3L,&'%


16/79

Immi1rants in Cara1o?a, #$ain

Cara1o?a the smallest amon1 #$anish Metro$olis %&&' ',L4 8%: %&&L L4,% 8: %&&3 3L,&'% 8'&:

%&& %,' 8'%: %&'& '&,4K4 8O'L: Immi1rants acco*nt for O& of the demo1ra$hic 1ro5th in

the city

More than one fo*rth of all immi1rants come from Ec*adorand >olombia ;ther immi1rant 1ro*$s 8Asians and otherE*ro$eans: have been on the increase recently


17/79


18/79

LIFE EPETA7C A72 I7OME


19/79

/HE ";!(D"IDE U!DEN

E E


20/79

HI#/;!9 ;F EME!GINGINFE>/I;N#

3'& Infl*en?a3 (e$rosy

&& #mall$o+'4 Pla1*e'L #y$hilis'L'& #carlet Fever'L3 /y$h*s'LLK Malaria'L3K #mall$o+

9EA! DI#EA#E


21/79

History of Emer1in1 Infections'K4 !otavir*s'KK Ebola ir*s'KK (e1ionnaire6s Disease'' /o+ic #hoc0 #yndrome'% (yme Disease'4 HIAID#

'4 Helicobacter Pylori'' M*lti Dr*1 !esistant

8MD!: /'' E$idemic >holera' >ry$tos$oridi*m

' Hon1Bon1 ird Fl*' "est Nile ir*s%&&' Anthra+%&&4 #A!#%&&3 E+tremely Dr*1 !esistant 8QD!: /:


22/79


23/79

/est 7ile 9i#us in the US


24/79


25/79

InfluenDa

An a1ent of 1reat concern1lobally is infl*en?a vir*s

Infl*en?a vir*s is 0no5n to ca*see$idemics as early as the 'L&&6s, and$andemics have been described as earlyas '

/he most e+tensive $andemic ever

0no5n is the $andemic of infl*en?a of'''', 5hich 0illed more %& million$eo$le


26/79

Ref Business Week, April 14, 2003


27/79

Mala#ia


28/79

T#acho!a

/rachoma is an infectio*s eyedisease the res*lt of infection

of the eye 5ith >hlamydia trachomatis

T#acho!ais the leadin1 ca*se

of blindness in the 5orld 8Africa, >hina, /hailand, Me+ico,ra?il, Ec*ador:

In the U#A Native Americans and the

A$$alachian !e1ion

. Globally, million $eo$le s*ffer from active infectionand nearly million $eo$le are vis*ally im$aired as ares*lt of this disease


29/79

T#acho!aInfection s$reads from $erson to $erson,

and is fre=*ently $assed from child to childand from child to mother, es$ecially 5herethere are shorta1es of 5ater, n*mero*sflies, and cro5ded livin1 conditions

Infection often be1ins d*rin1 infancy or

childhood and can become chronic If left*ntreated, the infection event*ally ca*sesthe eyelid to t*rn in5ards, 5hich in t*rnca*ses the eyelashes to r*b on the eyeball,res*ltin1 in intense $ain and scarrin1 of the

front of the eye /his *ltimately leads toirreversible blindness, ty$ically bet5een4&and & years of a1e

/HOs SAFE

Su#+e#*AntibioticsFacial leansin+Enhanced H*+iene


30/79

7S in the Global F#ont

. Most $eo$le no5adays die from noncomm*nicable diseases 8N>#: onceassociated 5ith 5ealth s*ch as cancer,heart diseases, diabetes, etc

. In %&&, 43 million deaths or 34 of alldeaths 5orld5ide, 5ere d*e to N>#

. In late #e$tember %&'' a hi1h levels*mmit of the United Nations 5ill beaddressin1 this $roblem


31/79

o!ple Global Health

P#oble!s@Mental Disorders

Addiction;besity

iolenceIn


32/79

Leadin+ auses of 2isabilit* A#ound The /o#ld3ost in Billions of US 2olla#s6

"orld Health ;r1ani?ation, '3


33/79

Obesit*

9i l


34/79

9iolence


35/79

Addiction


36/79

2ALCs Lost 2ue toHi+h8is= 2#in=in+ b*2isease ate+o#* and8e+ion 3%''$6

Millionsof

2ALCs

Notes@ N*mbers are ro*nded

#o*rce@ Disease >ontrol Priorities in Develo$in1 >o*ntries, second edition, %&&3, /able K4

?>4

>(

5>(

>4


37/79

h 0 f h ld


38/79

/he "H; ran0in1 of the 5orld6shealth care systems

' France

% Italy4 #an Marino AndorraL Malta3 #in1a$oreK #$ain

;man A*stria'& Ja$an'' Nor5ay'% Port*1al'4 Monaco' Greece

'L Iceland'3 (*+embo*r1'K Netherlands' United Bin1dom

' Ireland%& #5it?erland%' el1i*m%%>olo!bia%4 #5eden% >y$r*s

%L Germany%3 #a*di Arabia%K United Arab Emirates% Israel% Morocco4& >anada

4' Finland4% A*stralia>hile4 Denmar04L Dominica>United States of A!e#ica

"H; Health !e$ort, %&&&

l H l h E d


39/79

/otal Health E+$endit*res as of GDP, %&&%%&&L

' Marshall Islands 8':

%> USA 3$564 Ni*e

/imor(esteL Micronesia3 BiribatiK Maldives

Mala5i #5it?erland'& France 8'&:'' Germany 8'&:

$ain 8K:' United Bin1dom 8K

:

3&>olombia 8K:

#o*rce "H;

Di bilit Ad< t d (if


40/79

Disability Ad


41/79

8/@MS Office of Global Health

(ocated at >A #*ite K&4o Javier I Escobar MD,Associate Dean for Global Healtho A$arna Balba1 MD, PhD, PostDoctoral Fello5

o !achel "erner, AdministrativeAssistanto #teerin1 >ommittee@#*nanda Ga*r MD 8Pediatrics:, !obert (i0e MD #oniaGarcia(amba*ch MD Baren (in MD 8Family Medicine:,

>harletta Ayers MD 8; R Gyn: Abel Moreyra MD8Medicine>ardiolo1y:, #hannon ;6Hearn M#4, Minyo*n19an1 M#4, Peter M*rr M#%, !hea Itoo$ M#%, #ha?iaMehmood M#%


42/79

8/@MS Medical StudentsInte#est in Global Health

o %' of !"JM# %&'% >lass "ere orn ;*tsidethe United #tates

o ;ver %& st*dents in the enterin1 class have$artici$ated in international service activities$rior to medical school on fo*r differentcontinents

o ;ver '4 of first year medical st*dents e+$ressinterest in havin1 an international e+$erienced*rin1 medical school


43/79

LATI7 AME8IA:OLOMBIA>E# Medical #chool, MedellSnUniversidad de Antio=*ia, MedellSn

Universidad de los Andes, o1ota8Dr Javier I Escobar:B8AJILra?il, >ross >*lt*ral $ro


44/79

ABOUT


45/79

OU7T8IES 9ISITE2OU7T8IES 9ISITE2

A8GE7TI7A

OLOMBIAOLOMBIA

OSTA 8IA

EUA2O8

GHA7A

I72IA

MCA7MA8

MEIO

HIMALACAS&7EPAL

SOUTH AF8IA

TIBET

2OMI7IA7 8EPUBLI

GUATEMALA

JAMBIA

SPAI7

S/ITJE8LA72>HINA


46/79

)8/@MS HAS GO7E GLOBAL.


47/79

OPPO8TU7ITIES A728ESOU8ES FO8

I7TE87ATIO7AL ME7TALHEALTH 8ESEA8H

ollabo#ations -ith Latin A!e#ica:


48/79

ollabo#ations -ith Latin A!e#ica:@a,ie# I Escoba# M2

Addiction in the Americas 8>I>AD ;A#: >ollaboration 5ith>osta !ica, Me+ico, arbados, Ur*1*ay, El #alvador, >hile,>olombia 8UMDNJ!"JM# as >oordinatin1 #ite:

NIMH>I!PAH;@ >ollaboration in Mental Health #ervices

!esearch and Ed*cation 8U#A, >anada, Me+ico, >olombia,>hile, ra?il, Per*, Jamaica:

NIMHF*nded Genetic #t*dy@ )i$olar Endo$henoty$es inPo$*lation Isolates- V U>(A, >olombia, >osta !ica

NIMH !'4 Mentorin1 Grant )>ritical!esearch Iss*es in (atino Mental Health-

#chi?o$hrenia #t*dy in Ar1entina


49/79

Outco!e of SchiDoph#enia Ac#ossultu#es 3/HO Stud* @ablens=* et al1 $??%6

0

20

40

Best Outcome Worst Outcome

Familial E+$ressed Emotion and !ela$se


50/79

Familial E+$ressed Emotion and !ela$seof #chi?o$hrenia

. %3 #t*dies in #everal>o*ntries

8En1land, U#A, #$ain,

Germany, Eastern

E*ro$e, Ja$an,

Me+ico:

. Percent !ela$sin1@

(o5 EE %%

Hi1h EE L&


51/79

AAI(A(E DA/A #E/#

/o#ld Mental Health Su#,e*s


52/79

L%

/o#ld Mental Health Su#,e*sPa#ticipatin+ ount#ies in the

A!e#icasount#* Sa!ple SiDe

ra?il L,&&&

>anada 4&,&&&>olombia L,&&&

>osta !ica L,&&&

Me+ico L,&&&

Per* L,&&&

United #tates %L,&&&

" ld M t l H lth # s


53/79

"orld Mental Health #*rveysPartici$atin1 >o*ntries

LegendParticipating countriesPending countriesNo Data

WHO 2003. All rights reserved

The boundaries and names shown and the designations used o n this map do not imply the expression of anyopinion whatsoever on the part of the World Health Organiation !on!erning the legal status of any !ountry"territory" !ity or area or of its a uthorities" or !on!erning the delimitation of its frontiers or boundaries.#otted lines on maps represent approximate border lines for whi!h there may not yet be full agreement.

U f bi d i i


54/79

Use of annabis and ocaine inSe,e#al ount#ies

Medina Mo#a et al1 %''<


55/79

HEA(/H DI#PA!I/IE#


56/79

(et6s remember the old U#AUB #t*dyins$ired by the #chi?o$hrenias that)5ere c*red


57/79

UBH STU2C 37 $?1%$?6Pe#cent /ith Se#ious Mental Illness

32e!entia1 SchiDoph#enia1 M221 Bipola#6

Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch GenPsychiatry, 60:6!"6##, $00

d h h


58/79

Pe#cent 2ia+nosed as SchiDoph#enia37K$?1%$?6

Mins=* S1 9e+a /1 Mis=i!en T1 Ga#a M1 Escoba# @I1 A#ch Gen Ps*chiat#*1':4551 %''


59/79

IMMIG8ATIO7:A29A7TAGE O82IS29A7TAGE

I!!i ti


60/79

9e+a /A1 et al> $??( Alde#ete E1 et al> %'''

I!!i+#ation

Abo*t L& of (atinos in the U# are Immi1rantsHis$anics born or livin1 in the U# a$$ear to be at a1reater ris0 for mental disorders than co*nter$artsborn or livin1 in their native co*ntries#tress of tryin1 to inte1rate into U# society, feelin1sof alienation and discrimination may increases ris0 forsome disorders(on1er time of residence in U# and yo*n1er a1e atentry increase ris0 for immi1rantsProtective effects of stron1 c*lt*ral and familial tiesmay 5ea0en 5hen livin1 in the U#(on1er residence in U# and yo*n1er a1e at immi1rationincrease ris0 8v*lnerable $eriod:


61/79

'% M th P l f M d d Addi ti


62/79

'% Month Prevalence of Mood and AddictiveDisorders in Males 8e1a et al, 'K:

12 month Substance Abuse/Dependence Rate by Nativity


63/79

12-month Substance Abuse/Dependence Rate by Nativity,Age at Time of Enty into !S,

and "esent Age

0

10

1

20

10 20 30 40 0 !0

Age #yeas$

Age 0#1! at $ntr% &' Age 1(#24 at $ntr% &'

Age 2) at $ntr% &' &' *orn

.U>S> bo#n si+nificantl* diffe#ent 3pN '>''$6 f#o! each i!!i+#ant +#oup3cont#ollin+ fo# se and p#esent a+e6>

. I!!i+#ants A+e '$ at Ent#* US ,s A+e $4%5 at Ent#* US si+nificantl*diffe#ent 3pK '>'%6 fo# p#esent a+e $(%5>

e1a "A, et al In $ress

Prevalence of >*rrent Dia1noses in Immi1rants and


64/79

Prevalence of >*rrent Dia1noses in Immi1rants andNative orn in #$ain 8N'L&& each:7

7Garcia>am$ayo et al, %&''

PX&&&'

U h lth H bit i P t


65/79

Unhealth* Habits in P#e+nant/o!en

Modified f#o! 9e+a et al1 $??

$' Cea# A+eEducation Ad;usted


66/79

$' Cea# A+eEducation Ad;ustedo#ona#* Hea#t 2isease Mo#talit* 8is=

fo# MeicanA!e#ican Adults

Sunduist Q /in=leb* A! @ Public Health1 (?:4%4'1 $???

ultu#al G#adient and


67/79

ultu#al G#adient andBlood P#essu#e

Socioecono!ic Status

Steffen P81 @ou#nal of Beha,io#al Medicine1 %?:


68/79

a#dio,ascula# Pa#ado in7e- @e#se*

8Moreyra et al, $resented at GHE>,>*ernavaca, Me+ico, Abril %&'&:

/able ' >linical >haracteristics


69/79

/able ' >linical >haracteristics7@ $??5%''4

HospitaliDed AMI

Hispanic

nK$1$'

/hites

nK$?'1$5%

n 36 >A+e1 * 4 R $4

2iabetes Mellitus1 n 36 ?>%" %?>$

8enal 2isease1 n 36 $$>" $$>


70/79

8Interventions:

7@ $??5%''4Hos$itali?ed AMI

Hispanic

nK$1$'

/hites

nK$?'1$5%

Ad;usted

O8&H8

3?%$ $(>5? '>?5 3'>?'

'>??6

'>'

ABG1 n 36 (>5% (>($ '>?( 3'>?$

$>'46

'>4%

. His$anics had lo5er ad?''>??1 pK'>'61

. b*t similar rates of revasc*lari?ation@

V b* ABG 3O8 '?(1 I '>?$$>'41 pK'>4%

/able % M*ltivariable Ad


71/79

8Mortality:7@ $??5%''4Hos$itali?ed AMI

Hispanic

nK$1$'

/hites

nK$?'1$5%

Ad;usted

O8&H8

3?4 '>(( 3'>(

'>?6

N'>'''

$

' 2a* 2eath $> $4>$ '>?< 3'>?'

'>??6

'>'54

$ Cea# 2eath %%>( %4> '>?( 3'>?5

$>'$6

'>%

. Hispanics had lo-e#:

. Inhospital 3H8 '>((1 I '>('>?1 pN'>''$6 and. 'da* !o#talit* 3H8 '>?'5461

. But at one *ea# the su#,i,al diffe#ence -as no lon+e# si+nificant3H8 '>?(1 I '>?5$>'$1 pK'>%6>


72/79

The Latino Pa#ado:


73/79

The Latino Pa#ado:Mo#talit* 3HaDa#d 8atios6 Latinos ,s> 7on Latino /hites

in the US 37LMS 2ata6

Abrai%o"&an'a et a( AJP) *+++Abrai%o"&an'a et a( AJP) *+++

Potential Eplanations fo# Mental


74/79

pHealth )Ad,anta+es. of I!!i+#ants in

the US Measu#e!ent E##o#L

!isinte#p#etation ofuestionslan+ua+e Q t#anslation issues

c#osscultu#al eui,alence

8esponse BiasLsocial desi#abilit*1 social

app#o,al1 acuiescence

)Sal!on. Effect

Selecti,e Mi+#ation

Healthie# Habits

0in net-o#=s and Fa!il*

Suppo#tL


75/79

Ad,anta+es of Bilin+ualis!

o ilin1*al $eo$le 8FrenchEn1lish:obtain better res*lts ine+ec*tion tests, have betterco1nitive fle+ibility, betterability to ne1otiate abstract

conce$ts than monolin1*al$eo$le'

o #imilar res*lts have beenobserved in the case of His$anicori1in $eo$le in the United#tates %,4

'Peal and (ambert, '3% %!*mba*t and Ima ' 4Portes 'K:


76/79

I!!i+#ation and Ps*chosis:The Epe#ience in En+land

o '3&6s@ )Hi1h $revalence of #chi?o$hreniain >aribbean Immi1rants to the UB- 8':

o '&6s@ )#chi?o$hrenia is ' times hi1her amon1 >aribbeanimmi1rants than in the 1eneral UB $o$*lation 8%: and this also

a$$lies to the second 1eneration born in En1land84:

o '&6s@ #t*dies 5ith more methodolo1ical so$histication alsosho5ed an e+cess of schi?o$hrenia 8F:and mania 8L: amon1>aribbean immi1rants Ho5ever, other st*dies sho5ed sli1ht orno differences 83:

o %&&&6s /he AE#;P st*dy calls immi1ration )a ris0 factor for

$sychosis8K:

$Sha#ple* et al1 %''$ % Ha##ison et al1 $?(( Ha##ison et al1 $??4 5/essel* et al1

$??$


77/79

pa#ibbean Mi+#ation to

the United 0in+do!o Disadvanta1es and travails of lac0 $eo$le and ethnic

minorities in En1lando Afro>aribbeans are more li0ely to be arrested or be

trans$orted by the $olice, to be admitted to $sychiatricservices a1ainst their 5ill and to be loc0ed or confined

o )Dia1noses of $sychosis made by "hite $sychiatrists onAfro>aribbeans are based on the notion that the$erson is stran1e, *ndesirable, bi?arre, a11ressive anddan1ero*s-

8alei+h and Al!ond $??


78/79

o!!ents on Studies Associatin+Ps*chosis -ith Mi+#ation

o /here is ethnic variation in the $resentation of $sychoticsym$toms '

o Doc*mented bias in the dia1nosis $f certain ethnic1ro*$s 8African Americans in U#A: %

o /he dia1nosis of Afro>aribbeans in En1land is $ossiblyd*e to a similar biaso #t*dies of Afro>aribbeans in Jamaica do not sho5 an

e+cess of $sychotic disorders 4o /he res*lts of the old north American st*dies and the

more recent E*ro$ean st*dies relatin1 mi1ration and$sychosis may be d*e to these biases

$9e+a /A1 Le-isFe#nandeD 81 u##ent Ps*chiat#ic 8epo#ts1 %''(1 $':%%%%(%Mins=* S1 9e+a /1 Mis=i!en T et al1 A#ch Gen Ps*chiat#*1 %''1 ':455Hic=lin+ F/1 So#el E 3eds61 I!a+es of Ps*chiat#*: The a#ibbean1 Stephenson Litho P#ess1 @a!aica1 %''li i l #t di

salud mental en paises latinoamericanos

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