Ethnic Differences in the Prevalence of, and Predictors for Anxiety, Depression, and Somatic Distress in Long-Term Survivors of Hematopoietic Cell Transplantation (HCT): A Report from the Bone Marrow Transplant Survivor Study (BMTSS)
Authors: Sun Can-Lan , Francisco Liton , Baker K. Scott , Forman Stephen J. , Bhatia Smita 
Published: October 2019

Abstract
Hispanics are the largest minority group in the US, constituting 14% of the entire population. Compared to non-Hispanic whites, Hispanics are conceivably at a higher risk for adverse mental health outcomes, due to socioeconomic, cultural, and language barriers as well as barriers within the healthcare system. Depressive symptoms and psychological distress are frequently observed in HCT survivors. But little is known regarding the ethnic differences in the magnitude and nature of psychosocial distress experienced by long-term HCT survivors. The purpose of this study was to determine the prevalence of and risk factors for psychosocial distresses in Hispanic HCT survivors as compared with non-Hispanic white HCT survivors. BMTSS, a collaborative effort between City of Hope National Medical Center and University of Minnesota, examined self-reported psychosocial distresses in individuals who underwent HCT between 1976 and 1998, and survived two or more years. Psychosocial distress was measured using the 18-item Brief Symptom Inventory (BSI-18). This measure provides a global severity index and symptom-specific subscales for depression, somatization, and anxiety. Participants were considered to have had psychosocial distress if they scored in the highest 10% of population norms on any of the 3 symptom-specific subscales or the global index. Logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). The current study included 984 HCT survivors; 443 had received autologous HCT and 541 allogeneic HCT for hematological malignancies (463 leukemia, 286 lymphoma, and 135 other). Median length of follow-up from HCT to study participation was 7.4 years (range 2, 27.8). Of the 984 survivors, 825 (83.8%) were self-reported non-Hispanic whites, while 159 (16.2%) were Hispanics. Median age at study participation was 44.5 years (range, 18.2–73.0) for whites and 41.5 years (range 20.0–67.4) for Hispanics, and median follow-up for was 7.3 years (range 2.0–27.8) and 8.0 years (range 2.5–25.2), respectively. When compared with non-Hispanic whites, Hispanics were significantly less likely to have completed high school (55.1% vs. 96.6%, p<0.001), and to be currently insured (75.9% vs. 93.7%, p<0.001). Hispanics were significantly more likely to have undergone allogeneic HCT (67.9% vs. 52.5%; P<0.01); to report their current health as fair or poor (25.8% vs. 17.9%, p=0.02); and to report a low household income (<=$20k: 45.4% vs. 10.0%, p<0.001). There were no differences between the two ethnic groups with respect to gender, risk of relapse at HCT, exposure to total body irradiation (TBI), and chronic graft vs. host disease. Overall, 21% of the long-term HCT survivors experienced at least one adverse mental health symptom (anxiety [6%], depression [11%], somatization [15%] and global index [10%]). Univariate analysis revealed that Hispanics were more likely to report mental health problems, and this was most apparent for the monolingual Spanish-speaking Hispanics. After adjustment for age at HCT, gender, type of HCT, primary diagnosis, time since HCT, exposure to TBI, current health status, and current insurance status, Hispanics were 3.4 times as likely as non-Hispanic whites to report anxiety (95% CI, 1.8–6.3). The comparable risks were 1.99 (1.2–3.3) for depression, 1.5 (0.95–2.5) for somatization and 3.13 (1.9–5.3) for global distress. However, adjustment for education, household income and language spoken, resulted in a mitigation of the ethnic differences in mental health problems, and the residual differences between non-Hispanic whites and Hispanics were statically non-significant (OR=1.94 [0.9–4.4] for anxiety, 0.86 [0.4–1.7] for depression, 1.09 [0.6–2.0] for somatization, and 1.82 [0.9–3.6] for global distress). Poor current health was significantly associated with increased risk of mental health problems (OR=11.3 [4.1–31.2] for anxiety, 4.5 [2.5–8.1] for depression, 12.4 [7.0–22.0] for somatization, and 13.0 [6.2–27.5] for global distress). This study demonstrates that mental health problems are prevalent in long-term HCT survivors, and that the differences in magnitude of mental health problems reported by non-Hispanic whites and Hispanics are a function of differences in socioeconomic status and ability to communicate in English.