As noted in previous chapters, researchers have conducted two large-scale studies to identify the rates of psychiatric disorders among adults in the United States. The first, the Epidemiologic Catchment Area Study (ECA) (Robins & Regier, 1991), examined rates of psychiatric disorders in five communities (N = 19,182): New Haven, Baltimore, St Louis, Durham, and Los Angeles. Investigators at the Los Angeles site conducted interviews in English and Spanish and oversampled Mexican Americans (N = 1,243), so that rates of psychiatric disorders in this subpopulation could be estimated (Karno et al., 1987). The second study, the National Comorbidity Study (NCS) (Kessler et al., 1994), examined psychiatric disorders in a representative sample of individuals living throughout the United States (N = 8,098), excluding Alaska and Hawaii. This survey included Hispanics (N = 719), but was conducted only in English; thus, Spanish-speaking Hispanics were not represented (Ortega et al., 2000).
The ECA study found that Mexican Americans and white Americans had very similar rates of psychiatric disorders (Robins & Regier, 1991). However, when the Mexican American group was separated into two sub-groups, those born in Mexico and those born in the United States, it was found that those born in the United States had higher rates of depression and phobias than those born in Mexico (Burnam et al., 1987). The NCS found that relative to whites, Mexican Americans had fewer lifetime disorders overall and fewer anxiety and substance use disorders. Like the Los Angeles ECA findings, Mexican Americans born outside the United States were found to have lower prevalence rates of any lifetime disorders than Mexican Americans born in the United States. Relative to whites, the lifetime prevalence rates did not differ for Puerto Ricans, nor for "Other Hispanics." However, the sample sizes of the latter two subgroups were quite small, thus limiting the statistical power to detect group differences (Ortega et al., 2000).
A third study examined rates of psychiatric disorders in a large sample of Mexican Americans residing in Fresno County, California (Vega et al., 1998). This study found that the lifetime rates of mental disorders among Mexican American immigrants born in Mexico were remarkably lower than the rates of mental disorders among Mexican Americans born in the United States. Overall, approximately 25 percent of the Mexican immigrants had some disorder (including both mental disorders and substance abuse), whereas 48 percent of the U.S.-born Mexican Americans had a disorder (Vega et al., 1998). Furthermore, the length of time that these Latinos had spent in the United States appeared to be an important factor in the development of mental disorders. Immigrants who had lived in the United States for at least 13 years had higher prevalence rates of disorders than those who had lived in the United States fewer than 13 years (Vega et al., 1998).
It is interesting to note that the mental disorder prevalence rates of U.S.-born Mexican Americans closely resembled the rates among the general U.S. population. In contrast, the Mexican-born Fresno residents' lower prevalence rates were similar to those found in a Mexico City study (e.g., for any affective disorder: Fresno, 8 %, Mexico City, 9 %) (Caraveo-Anduaga et al., 1999). Together, the results from the ECA, the NCS, and the Fresno studies suggest that Mexican-born Latinos have better mental health than do U.S.-born Mexican Americans and the national sample overall.
A similar pattern has been found in other sets of studies. One study examined the mental health of Mexicans and Mexican Americans who were seen in family practice settings in two towns equidistant from the Mexican border (Hoppe et al., 1991). This investigation found that 8 percent of the Mexican American participants had experienced a lifetime episode of depression, whereas only 4 percent of Mexican participants had. A group of earlier studies conducted in the mid-1980s also examined rates of depression in English- and Spanish-speaking Latinos, including Cuban Americans (N = 857) in Miami (Narrow et al., 1990); Mexican Americans (N = 3,118) in the Southwest (Moscicki et al.,1987); Puerto Ricans (N = 1,140) in New York City (Moscicki et al., 1987; and Puerto Ricans (N = 1,513) on the island Canino et al., 1987). One of the most salient findings is that Puerto Ricans from the island had lower rates of lifetime depression (4.6 %) than those from New York City (9 %) Canino et al., 1987; Moscicki et al., 1987.
The most striking finding from the set of adult epidemiological studies using diagnostic measures is that Mexican immigrants, Mexican immigrants who lived fewer than 13 years in the United States, or Puerto Ricans who resided on the island of Puerto Rico had lower prevalence rates of depression and other disorders than did Mexican Americans who were born in the United States, Mexican immigrants who lived in the United States 13 years or more, or Puerto Ricans who lived on the mainland. This consistent pattern of findings across independent investigators, different sites, and two Latino subgroups (Mexican Americans and Puerto Ricans) suggests that factors associated with living in the United States are related to an increased risk of mental disorders.
Some authors have interpreted these findings as suggesting that acculturation may lead to an increased risk of mental disorders e.g., Vega et al., 1998; Escobar et al., 2000; Ortega et al., 2000. The limitation of this explanation is that none of the noted epidemiological studies directly tested whether acculturation and prevalence rates are indeed related. At best, place of birth and number of years living in the United States are proxy measures of acculturation. Moreover, acculturation is a complex process (LaFromboise et al., 1993); it is not clear what aspect or aspects of acculturation could be related to higher rates of disorders. Is it the changing cultural values and practices, the stressors associated with such changes, or negative encounters with American institutions (e.g., schools or employers) that underlie some of the different prevalence rates (Betancourt & Lopez, 1993)? Before acculturation can be accepted as an explanation for this observed pattern of findings, it is important that direct tests of specific acculturation processes be carried out and that alternative explanations for these findings be ruled out. Longitudinal research would be especially helpful in identifying the key predictors of Latinos' mental health and mental illness.
Children and Youth
Most epidemiological studies of Latino children and adolescents have been conducted with symptom indices and problem behavior checklists, not diagnostic instruments. Efforts to study diagnostic entities among Latino children in community samples have been limited. In one study carried out in Puerto Rico, psychiatrists administered a standard diagnostic instrument, the Diagnostic Interview Schedule for Children (DISC), and found high rates of mental disorders (49 %) among Puerto Rican children who had previously been identified as having significant behavioral problems. However, the rate dropped to 18 percent when a diagnosis with some associated impairment was required (Bird et al., 1988). The importance of including impairment as a criterion for disorders in children was established in another recent study. Children living in Georgia, Connecticut, New York, and Puerto Rico were assessed to establish rates of mental disorders; the Puerto Rican children had rates comparable to the multiethnic sample from the U.S mainland (Shaffer et al., 1996). For all groups, rates of disorders dropped dramatically when impairment was required as part of the diagnosis.
An examination of studies of mental health problems reveals a generally consistent pattern: Latino youth experience a significant number of mental health problems, and in most cases, more problems than whites. Studies of child mental health problems typically used versions or portions of a popular screening instrument, the Childhood Behavior Checklist (CBCL, Achenbach & Edelbrock, 1983). Glover and colleagues (1999) found that Hispanic children in middle schools, specifically Mexican-origin youth from Texas, reported more anxiety-related problem behaviors than white students. In addition, Hispanic sixth- and seventh-graders from a Southwestern city reported more delinquency-type problem behaviors than white students (Vazsonyi & Flannery, 1997). Youth in Puerto Rico were also found to have a significantly higher total problem score (35% versus 20%) and prevalence rate of "cases" (36% versus 9 %) than a three-State sample comprised primarily of whites (Achenbach et al., 1990). A study of Hispanic 10- to 16-year-old boys in Dade County, Florida, was the only exception. This investigation did not reveal any differences in total problem behaviors when comparing Hispanic, non-Hispanic white, and African American boys (Vega et al., 1995).
Studies of depressive symptoms and disorders also revealed more distress among Hispanic children and adolescents, particularly among Mexican-origin youth. This was evident in a community study in Las Cruces, New Mexico (Roberts & Chen, 1995), as well as in a national study within the 48 coterminous States (Roberts & Sobhan, 1992). In both these investigations, Mexican American adolescents reported more depressive symptoms than did white adolescents. In a recent study that used a self-report measure of major depression among middle school (grades 6-8) students in Houston, Texas, Mexican American youth were found to have a significantly higher rate of depression than white youth (12 % versus 6 %) (Roberts et al., 1997). These findings held even when level of impairment and sociodemographic factors were taken into account.
A large-scale survey of primarily Mexican American adolescents in schools on both sides of the Texas-Mexico border revealed high rates of depressive symptoms, drug use, and suicide (Swanson et al., 1992). Like the adult epidemiological studies, this investigation found that living in the United States is related to elevated risk for mental health problems. More Texas youth (48 %) reported high rates of depressive symptoms than did Mexican youth (39 %). Also, youth residing in Texas reported more illicit drug use in the last 30 days (21 %) and more suicidal ideation (23 %) than youth residing in Mexico.
Together the data indicate that Latino children and adolescents are at significant risk for mental health problems, and in many cases at greater risk than white children. At this time, it is not clear why a differential rate of mental health problems exists for Latino and white children. Special attention should be directed to the study of Latino youth, as they may be both the most vulnerable and the most amenable to prevention and intervention.
Few studies have examined the mental health status of older Hispanic American adults. A study of 703 Los Angeles area Hispanics age 60 or above found over 26 percent had major depression or dysphoria. Depression was related to physical health; only 5.5 percent of those without physical health complications reported depression (Kemp et al., 1987). Similar findings associated chronic health conditions and disability with depressive symptoms in a sample of 2,823 older community-dwelling Mexican Americans (Black et al., 1998). The findings from in-home interviews of 2,723 Mexican Americans age 65 or older in Southwestern communities revealed a relationship between low blood pressure and higher levels of depressive symptomatology (Stroup-Benham et al., 2000). These data are somewhat difficult to interpret. Given the fact that somatic symptoms (e.g., difficulty sleeping and loss of appetite) are related to poor health, these studies could simply document that these somatic symptoms are elevated among older Hispanics who are ill. (See Box 6-1, an illustration of the importance of considering the physical problems of older Latinos. This is one of many cases that Celia Falicov, 1998, uses to illustrate how the social and cultural world of Latino families expresses itself in clinical domains.) On the other hand, presence of physical illness is also related to depression. Taken together, these findings indicate that older Hispanics who have health problems may be at risk for depression. Furthermore, a recent study suggests that the risk for Alzheimer's disease may be higher among Hispanic Americans than among white Americans (Tang et al., 1998).
Box 6-1: Emotional or physical problems?
Mrs. Corrales (age 70)
Mrs. Corrales, a 70-year-old Puerto Rican, was referred to a mental health clinic by her local priest. Mrs. Corrales had no friends within the urban barrio. She had migrated from Puerto Rico eight years earlier to live with her two sons and her 45-year-old single and mildly developmentally impaired daughter. Two years before she came to the clinic, her sons had moved to a nearby city in search of better jobs. Mrs. Corrales remained behind with her daughter, who spoke no English and did not work. Among other questions, the Latin American therapist asked her if she was losing weight because she had lost her appetite, to which she quipped: "No, I've lost my teeth, not my appetite! That's what irks me!" Indeed, Mrs. Corrales had almost no teeth left in her mouth. Apparently, her conversations with the priest (an American who had learned to speak Spanish during a Latin American mission and was sensitive to the losses of migration) had centered on the emotional losses she had suffered with her sons' departure. The priest thought this was the cause of her "anxious depression." Though well meaning, he had failed to consider practical issues. Mrs. Corrales had no dental insurance, did not know any dentists, and had no financial resources.
Source: Falicov (1998), p. 255