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Office of the Surgeon General (US); Center for Mental Health Services (US); National Institute of Mental Health (US). Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2001 Aug.

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Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General.

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Chapter 6 Mental Health Care for Hispanic Americans

Introduction

The Spanish language and culture are common bonds for many Hispanic Americans, regardless of whether they trace their ancestry to Africa, Asia, Europe, or the Americas. The immigrant experience is another common bond. Nevertheless, Hispanic Americans are very heterogeneous in the circumstances of their migration and in other characteristics. To understand their mental health needs, it is important to examine both the shared and unique experiences of different groups of Hispanic Americans.

One of the most distinguishing characteristics of the Hispanic-American population is its rapid growth. In the 2000 census, sooner than forecast, the number of Hispanics counted rose to 35.3 million, roughly equal to the number of African Americans (U.S. Census Bureau, 2001a). In fact, census projections indicate that by 2050, the number of Latinos will increase to 97 million; this number will constitute nearly one-fourth of the U.S. population. Projections for the proportion of Hispanic youth are even higher. It is predicted that nearly one-third of those under 19 years of age will be Hispanic by 2050 (Spencer & Hollmann, 1998). Persons of Mexican origin comprise the largest proportion of Latinos (almost two-thirds), with the remaining third distributed primarily among persons of Puerto Rican, Cuban, and Central American origin, as shown in Figure 6-1 (U.S. Census Bureau, 2001b). It is noteworthy that nearly two-thirds of Hispanics (64 %) were born in the United States (U.S. Census Bureau, 2000c).

Figure 6-1. Percent Distribution of Hispanic American Population by Subgroup: 2000.

Figure

Figure 6-1. Percent Distribution of Hispanic American Population by Subgroup: 2000.

Historical Context

To place the growth of the Latino population in context, it is important to review some of the historical events that have brought Latinos to the United States. Although the Spanish language and cultural influence form a bond among most Hispanics, many key differences among the four main Latino groups are related to the circumstances of their migration.

Mexicans have been U.S. residents longer than any other Hispanic subgroup. After the Mexican War (1846-1848), when the United States took over large territories from Texas to California, the country gained many Mexican citizens who chose to remain in their "new" U.S. communities. The considerable economic, social, and political instability during the Mexican Revolution (1910-1917) contributed to the growth of the Mexican population in the United States. Economic pressures and wars have propelled subsequent waves of migration. Both push factors (economic hardships in Mexico) and pull factors (the need for laborers in the United States) have affected the flow. The sheer numbers of people who have come to the United States-well over 7 million-as well as the fact that many arrive "unauthorized" (without documentation) distinguishes Mexican immigration (U.S. Census Bureau, 2000d).

Puerto Ricans began arriving in large numbers on the U.S. mainland after World War II as Puerto Rico's population increased. High unemployment among displaced agricultural workers on the island also led to large-scale emigration to the mainland United States that continued through the 1950s and 1960s. In the 1980s, the migration pattern became more circular as many Puerto Ricans chose to return to the island. One distinctive characteristic of Puerto Rican migration is that the second Organic Act, or Jones Act, of 1917 granted Puerto Ricans U.S. citizenship.

Although Cubans came to the United States in the second half of the 19th century and in the early part of the 20th century, the greatest influx of Cuban immigrants began after Fidel Castro overthrew the Fulgencio Batista government in 1959. First, an elite group of Cubans came, but emigration continued with balseros, people who make the dangerous crossing to the United States by makeshift watercraft (Bernal & Shapiro, 1996). Some of these immigrants, such as the educated professionals who came to the United States during the early phase of Cuban migration, have become well established, where-as others who arrived with few economic resources are less so. Unlike immigrants from several other countries, many Cubans have gained access to citizenship and Federal support through their status as political refugees (Cattan, 1993).

Central Americans are the newest Latino subgroup in the United States. Many Central Americans fled their countries por la situacion, a phrase that refers to the political terror and atrocities in their homelands Farias, 1994; Jenkins, 1991; Suarez-Orozco, 1990. Although the specific social, historical, and political contexts differ in El Salvador, Guatemala, and Nicaragua, conflicts in those countries led to a significant emigration of their citizens. About 21 percent of foreign-born Central Americans arrived in the United States between 1970 and 1979, and the bulk (about 70 %) arrived between 1980 and 1990 (Farias, 1994).

The circumstances that caused various Hispanic groups to migrate greatly influence their experience in the United States. Cubans fled a Communist government, and, as a result, the U.S. Government has provided support through refugee or entrant status, work permits (Gil & Vega, 1996), and citizenship. More than half (51 %) of Cuban immigrants have become U.S. citizens, compared to only 15 percent of Mexican immigrants (U.S. Census Bureau, 1998). Puerto Ricans, whether born on the mainland or in Puerto Rico, are by definition U.S. citizens and, as a result, have access to government-sponsored support services.

In contrast, many Central American immigrants are not recognized as political refugees, despite the fact that the war-related trauma and terror that preceded their immigration may place them at high risk for post-traumatic stress disorder (PTSD) and may make adjustment to their new home more difficult. Many Latinos who arrive without proper documentation have difficulty obtaining jobs or advancing in them and live with the chronic fear of deportation. Finally, many Mexicans, Puerto Ricans, Central Americans, and recent Cuban immigrants come as unskilled laborers or displaced agricultural workers who lack the social and economic resources to ease their adjustment.

Current Status

Geographic Distribution

Hispanics are highly concentrated in the U.S. Southwest (see Table 6-1). In 2000, 60 percent lived in five Southwestern States (California, Arizona, New Mexico, Colorado, and Texas). Approximately half of all Hispanic Americans live in two States, California and Texas (U.S. Census Bureau, 2001b). While many Southwestern Latinos are recent immigrants, others are descendants of Mexican and Spanish settlers who lived in the territory before it belonged to the United States. Some of these descendants, particularly those in New Mexico and Colorado, refer to themselves as "Hispanos." More recent immigrants from Mexico and Central America are drawn to the Southwest because of its proximity to their home countries, its employment opportunities, and its established Latino communities, which can help them find jobs.

Table 6-1. Percentage of Hispanic Americans in State Populations: 2000.

Table

Table 6-1. Percentage of Hispanic Americans in State Populations: 2000.

Outside the Southwest, New York, Florida, and Illinois are home to the largest concentrations of Hispanics. New York has 8.1 percent, Florida, 7.6 percent, and Illinois, 4.3 percent of all the Latinos estimated to reside in the United States in 2000 (U.S. Census Bureau, 2001b). Two-thirds of Puerto Ricans on the mainland live in New York and New Jersey, and two-thirds of Cuban Americans live in Florida (Population Reference Bureau, 2000).

Although specific subgroups of Latinos are associated with specific geographical regions, important demographic shifts have resulted in the increased visibility of Latinos throughout the United States. From 1990 to 2000, Latinos more than doubled in number in the following six states: Arkansas (170 %), Nevada (145 %), North Carolina (129 %), Georgia (120 %), Nebraska (108 %), and Tennessee (105 %) (U.S. Census Bureau, 2000c). Of the six States, Nevada is the only one located in a region with traditionally high concentrations of Latinos. Thus, in addition to growing in numbers, Hispanic Americans are spreading throughout the United States.

Family Structure

Latinos are often referred to as family oriented (Sabogal et al., 1987). It is important to note that familism is as much a reflection of social processes as of cultural practice (Lopez & Guarnaccia, 2000). Specifically, the shared experience of immigrating to a new land or of experiencing difficult social conditions in one's homeland can promote adherence to family ties. In many cases, family connections facilitate survival and adjustment.

The importance of family can be seen in Hispanic living arrangements. Although family characteristics vary by Latino subgroups, as a whole, Latinos, like Asian Americans and Pacific Islanders, are most likely to live in family households and least likely to live alone. In addition, children (especially the females) tend to remain in the family until they marry. Nearly 30 percent of both white and black households consisted of a single person in 1998, compared to just 14 percent of Hispanic households (Riche, 2000). Almost two-thirds (63 %) of Hispanic family households included children under age 18 in 1999, while fewer white families (47 %) and black families (56 %) included children (U.S. Census Bureau, 2001).

Education

Overall, Hispanics have less formal education than the national average. Of Latinos over 25 years of age, only 56 percent have graduated from high school, and only 11 percent have graduated from college. Nationally, 83 percent and 25 percent of the same age group have graduated from high school and college respectively (U.S. Census Bureau, 2000b). Hispanics' educational attainment is related to their place of birth. In 1999, only 44 percent of foreign-born Hispanic adults 25 years and older were high school graduates, compared to 70 percent of U.S.-born Hispanic adults (U.S. Census Bureau, 2000b). The dropout rate for foreign-born Hispanics ages 16 to 24 is more than twice the dropout rate for U.S.-born Hispanics in the same age range (Kaufman et al., 1999).

A recent study of middle school Latino students questions why foreign-born adolescents and adults have the worst educational outcomes (C. Suarez-Orozco & M. Suarez-Orozco, 1995). The study concluded that recent immigrants from Mexico and El Salvador had at least the same, or in some cases greater motivation to achieve than white or U.S.-born Mexican American students. (See also M. Suarez-Orozco, 1989.)

It is not clear how to reconcilethese data on motivation with the national picture of poor educational outcomes for many Latino immigrants. One explanation may be that the high dropout rate reflects a large number of youth and young adults with little education who come to the United States to work, not to attend school (National Center for Education Statistics, 2000). Another explanation may be that many Latino immigrants who attend school lose their motivation over time, given the social, linguistic, and economic difficulties they face. Some may even turn to involvement in urban gangs (Vigil, 1988).

The educational achievement of three of the main Hispanic subgroups reveals further variability. Cubans have the highest percentage of formally educated people. Of persons over 25 years of age, 70 percent of Cuban Americans have graduated from high school, whereas 64 percent of Puerto Ricans and 50 percent of Mexican Americans have graduated from high school (U.S. Census Bureau, 2000d). Moreover, one-fourth of Cuban Americans have graduated from college, which is identical to the college graduation rate of Americans overall. In contrast, Puerto Rican and Mexican-origin adults have lower college graduation rates, 11 percent and 7 percent respectively. Although Latinos as a group have poorer educational outcomes than other ethnic groups, there is sufficient variability to offer hope for improving Latinos' educational success.

Income

The economic status of three of the main subgroups parallels their educational status. Cuban Americans are more affluent in standing than Puerto Ricans and Mexican Americans, as reflected in median family incomes (Cubans, $39,530; Puerto Ricans, $28,953; Mexicans, $27,883), the percentage of persons below the poverty line (Puerto Ricans, 31 %; Mexicans, 27 %; Cubans, 14 %) and the unemployment rates of persons 16 years and older (Puerto Ricans, 7 %; Mexicans, 7 %; Cubans, 5 %) (U.S. Census Bureau, 2000d). The current income levels of the Latino subgroups are also related to the political and historical circumstances of their immigration. Elite Cuban immigrants have contributed in part to the relatively strong economic status of Cuban Americans. Their experience, however, stands in stark contrast to that of Mexican Americans, Puerto Ricans, and Central Americans, most of whom came to the United States as unskilled laborers.

Physical Health Status

Infant mortality is one sensitive indicator of a population's health. Hispanic Americans have lower infant mortality rates than do white Americans. For most groups, infant mortality tends to be related to the educational level of mothers. For example, white infants born to mothers with fewer than 12 years of education are 2.4 times as likely to die as those born to mothers with 16 or more years of education. Although Cubans and Puerto Ricans show this general pattern, the pattern is not so prominent for Mexican Americans or immigrants from Central America. Furthermore, although Mexican Americans and African Americans have similar socioeconomic profiles, infant mortality among Mexican Americans is less than half that of African Americans. Mexican American women who were born in Mexico are less likely to give birth to a baby of low birthweight than are U.S.-born Mexican American women (Becerra et al., 1991). This difference is partially explained by the fact that Mexican-born women are less likely to use cigarettes and alcohol than Mexican American women who were born in the United States (Scribner & Dwyer, 1989).

Other statistics show that Latinos in the United States suffer from more health disorders than white Americans. Latinos are twice as likely as whites to die from diabetes (Department of Health and Human Services, [DHHS], 2000). Although they comprised only 11 percent of the total U.S. population in 1996, Latinos had 20 percent of the new cases of tuberculosis in the United States that year. Latinos also exceed whites in rates of high blood pressure and obesity.

Health indicators for Puerto Rican Americans are worse than such indicators for other Latinos. According to the results of a nationally representative interview conducted in English and Spanish, Puerto Rican Americans reported more days in which they had to restrict their activities due to health disability, more days spent in bed, and more hospitalizations than did Mexican Americans and Cuban Americans (National Health Interview Survey, 1992-1995, see Hajat, 2000).

The Need for Mental Health Care

Historical and Sociocultural Factors That Relate to Mental Health

Historical and sociocultural factors suggest that, as a group, Latinos are in great need of mental health services. Latinos, on average, have relatively low educational and economic status. In addition, historical and social subgroup differences create differential needs within Latino groups. Central Americans may be in particular need of mental health services given the trauma experienced in their home countries. Puerto Rican and Mexican American children and adults may be at a higher risk than Cuban Americans for mental health problems, given their lower educational and economic resources. Recent immigrants of all backgrounds, who are adapting to the United States, are likely to experience a different set of stressors than long-term Hispanic residents.

Key Issues for Understanding the Research

Much of our current understanding of the mental health status of Latinos, particularly among adult populations, is derived from epidemiological studies of prevalence rates of mental disorders, diagnostic entities established by the Diagnostic and Statistical Manual of Mental Disorders(DSM; American Psychiatric Association, 1994). The advantage of focusing on rates of disorders is that such findings can be compared with and contrasted to findings from studies in other domains (e.g., clinical studies) using the same diagnostic criteria. In addition, diagnostic entities are now often associated with specific pharmacological and psychosocial treatments.

Although there are several advantages to examining DSM-based clinical entities, there are at least three disadvantages. One limitation is that individuals may experience considerable distress-a level of distress that disrupts their daily functioning-but the symptoms associated with the distress fall short of a given diagnostic threshold. Thus, if only disorder criteria are used, some individuals' need for mental health care may not be recognized. A second disadvantage is that the current definitions of the diagnostic entities have little flexibility to take into account culturally patterned forms of distress and disorder. As a result, disorders in need of treatment may not be recognized or may be mislabeled. A third limitation is that most of the epidemiological studies using the disorder-based definitions are conducted in community household surveys. They fail to include nonhousehold members, such as persons without homes or those who reside in institutions. Because of these limitations, it is important to broaden the review of research on mental health needs to include not only studies that report on disorders, but also studies that report on symptoms, symptom clusters, culturally patterned expressions of distress and disorder, and high-need populations not usually included in household-based surveys.

Mental Disorders

Adults

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.

Older Adults

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

Mental Health Problems

Symptoms

The early epidemiological studies of Latinos examined the number of symptoms, not the number of mental disorders, reported by groups of Hispanic Americans, and in some cases compared them to the number of symptoms reported by white Americans. Much of this research found that Latinos had higher rates of depression or distress than whites Frerichs et al., 1981; Roberts, 1981; Vernon & Roberts, 1982; Vega et al., 1984. In a large-scale study of Hispanics, Cuban Americans (Narrow et al., 1990) and Mexican Americans (Moscicki et al., 1989) were found to have lower rates of depressive symptoms than Puerto Ricans from the New York City metropolitan area Moscicki et al., 1987; Potter et al., 1995. In another line of inquiry, Latina mothers who have children with mental retardation were found to report high levels of depressive symptomatology (Blacher et al., 1997a, 1997b).

It is important to note that measures of symptoms may reflect actual disorders that may not be measured in a given study, as well as general distress associated with social stressors but not necessarily associated with disorders. Two studies provide evidence that depressive symptom indices used with Latinos tend to measure distress more than disorder. In one study, rates of depressivesymptoms were found to be similar among poor Puerto Ricans living in New York City and in Puerto Rico (Vera et al., 1991), even though earlier analyses indicated different rates of major depression for the two samples Canino et al., 1987; Moscicki et al., 1987. In the second study, symptoms of depression were less related to diagnosis of depression for those Hispanics who were economically disadvantaged than for those Hispanics more socially advantaged (Cho et al., 1993). If an index of depressive symptoms were an indicator of both general distress and disorder, then that index would have been related to a diagnosis of depression for both economically advantaged and disadvantaged samples. An understanding of the interrelation of psychological distress, specific mental disorders, and social conditions would help shed light on how distress and disorder are moderated by social factors. (See Box 6-2 as an example of how the social world relates to family mental health problems.)

Box 6-2: Rebellious teenager and father's mal trato

Javier (age 16)

Javier Reyes Balan, a 16-year-old boy, was referred by his school for persistent truancy. Nine years ago, his mother, father, and four younger siblings moved from Michoacan, Mexico, to San Diego, California, to better their economic situation. Javier was bilingual and served as the family interpreter in their dealings with outside institutions. He preferred to speak English and was clearly more savvy about American values and ways than his parents.

Mr. Reyes began the session by complaining bitterly about Javier's unruly behavior, lack of cooperation with his mother, and lack of respect toward his parents. Mrs. Reyes appeared to agree with her husband's view of Javier, although she protested that she didn't need much help around the house.

An inquiry about Mr. Reyes's occupation revealed that he had hoped to start his own small business as a car mechanic after moving from Mexico. He had not succeeded and was supporting the family precariously with occasional small jobs. He was proud of his competence and honesty as an automobile mechanic. But now he refused to work in a company under an Anglo-American foreman who would subject him to mal trato. In his view, "they [Americans] don't respect us Mexicans, and when you turn around they exploit you." The father's position in the family appeared to be debilitated by his unemployment.

Source: Falicov (1998), pp. 128-129.

Somatization

The expression of distress through somatic symptoms has been observed in many groups, including Latinos (Escobar et al., 1987). Early research, influenced by psychodynamic theory, suggested that the expression of psychic distress via bodily complaints reflected limited psychological development. Current perspectives, however, accept somatic and psychological forms of expressing distress as equally valid. The two modes of expression are thought to mirror the sociocultural context; they do not necessarily reflect a lack of insight or psychological sophistication. The critical questions today concern how social and cultural processes shape the expression of distress that emphasizes the soma, the psyche, or both (Kirmayer & Young, 1998).

Some research has examined the extent to which Latinos express physical symptoms, particularly in comparison to whites. Many of these studies have used symptom indices derived from the diagnostic interview used in the ECA studies. According to these studies, Mexican American women, particularly those over age 40, are more likely to report somatic symptoms; however, no differences were found between Mexican American and white men (Escobar et al., 1987). In an additional study, Puerto Rican men and women had higher rates of somatic symptoms than Mexican American and non-Hispanic men and women (Escobar et al., 1989).

A group of primary care patients that included Central American immigrants, Mexican immigrants, U.S.-born Mexican Americans, and whites were assessed for psychiatric disorders and somatization. After controlling for education and income differences, the immigrants reported fewer psychiatric disorders but higher rates of somatic symptoms when compared with the U.S.-born sample (Escobar et al., 2000). However, a more recent study questions the validity of those findings (Villasenor & Waitzkin, 1999), arguing that differences in use of health care services, different cultural understandings of the questions, and differences in socioeconomic status lead to spurious reports of somatic symptoms. For example, symptoms could have been considered "medically unexplained" because Latinos failed to receive adequate medical care and did not receive a diagnosis from a physician. Because high levels of somatic symptoms are related to disability (Escobar et al., 1987), research in this area is most important. Of particular significance are service factors (accessibility to care) and cultural factors (the meaning of physical and mental health) as they relate to somatization and distress.

Culture-Bound Syndromes

DSM-IV recognizes the existence of culturally related syndromes, referred to in the appendix of DSM as culture-bound syndromes. Relevant examples of these syndromes for Latinos are susto (fright), nervios (nerves), and mal de ojo (evil eye). One expression of distress that is most commonly associated with Caribbean Latinos but has been recognized in other Latinos as well is ataques de nervios Guarnaccia et al., 1989). Symptoms of an ataque de nervios include screaming uncontrollably, crying, trembling, and verbal or physical aggression. Dissociative experiences, seizure-like or fainting episodes, and suicidal gestures are also prominent in some ataques. In one study carried out in Puerto Rico, researchers found that 14 percent of the population reported having had ataques (Guarnaccia et al., 1993). Furthermore, in detailed interviews of 121 individuals living in Puerto Rico (78 of whom had had an ataque), experiencing these symptoms was related to major life problems and subsequent psychological suffering (Guarnaccia et al., 1996). Clinical and ethnographic studies of individuals living in Boston and New York City also report observations of ataques, which in some instances required treatment (Guarnaccia et al., 1989; Liebowitz et al., 1994.

There is value in identifying specific culture-bound syndromes such as ataques de nervios because it is critical to recognize the existence of conceptions of distress and illness outside traditional psychiatric classification systems. These are often referred to as popular, lay, or common sense conceptions of illness or illness behavior (Koss-Chioino & Canive, 1993). Some of these popular conceptions may have what appear to be definable boundaries, while others are more fluid and cut across a wide range of symptom clusters. For example, many people of Mexican origin apply the more general concept of nervios to distress that is not associated with DSM disorders, as well as to distress that is associated with anxiety disorders, depressive disorders (Salgado de Snyder et al., 2000), and schizophrenia (Jenkins, 1988). Though it is valuable for researchers and clinicians alike to learn about specific culture-bound syndromes, it is more important that they assess variable local representations of illness and distress. The latter approach casts a wider net around understanding the role of culture in illness and distress.

In the following quote, Koss-Chioino (1992) points out that a given presenting problem can have multiple levels of interpretation: the mental health view, the folk healing view (in this case, spiritist), and the patient's view. The same woman, during one episode of illness, may experience "depression" in terms of hallucinations, poor or excessive appetite, memory problems, and feelings of sadness or depression, if she presents to a mental health clinic; or, alternatively, in terms of "backaches," "leg aches," and "fear," if she attends a Spiritist session. However, she will probably experience headaches, sleep disturbances, and nervousness regardless of the resource she uses. If we encounter her at the mental health clinic, she may explain her distress as due to disordered or out-of-control mind, behavior, or lifestyle. In the Spiritist session she will probably have her distress explained as an "obsession." And if weencounter her before she seeks help from either of these treatment resources, she may describe her problems as due to difficulties with her husband or children (or to their having abandoned her). (p. 198)

In the treatment setting, integrating consumers' popular or common sense notions of health and illness with biomedical notions has the potential to enhance treatment alliances and, in turn, treatment outcomes Leventhal et al., 1997; Lopez, 1997.

Suicide

According to national statistics, Latinos had a suicide rate of approximately 6 percent in 1997 compared to a rate of 13 percent for the white population (DHHS, 1990). Overall, this lower rate suggests that Hispanic Americans are not demonstrating excess psychopathology through high rates of suicide. However, a national survey of 16,262 high school students in grades 9 through 12 found that Hispanics, both young women and young men, reported more suicidal ideation and specific suicidal attempts proportionally than whites and blacks. Over 10 percent of the Hispanics had attempted suicide, and 23 percent had considered the possibility of suicide (Centers for Disease Control and Prevention, 1998). Although this survey provided no data on actual suicides, these data suggest significant distress among Hispanic youth and are consistent with the several studies that found greater distress among Latinos than among largely white American youth.

High-Need Populations

Given that poverty is associated with homelessness and that many Hispanic American subgroups experience high rates of poverty, high rates of homelessness might be anticipated. However, the fact is that Hispanics are underrepresented among those without shelter (National Survey of Homeless Assistance Providers and Clients, 1996). Likewise, the need to place children in foster care is related to socioeconomic factors. Again, few Hispanic children are in the foster care system (DHHS, 1999). The fact that Hispanics are more likely to live with extended family members and with unrelated individuals suggests that family or friends may be taking care of those in need. Although Hispanics are relatively underrepresented among persons who are homeless or in foster care, they are present in high numbers within other vulnerable, high-need populations, such as incarcerated individuals, war veterans, survivors of trauma, and persons who abuse drugs or alcohol.

Individuals Who are Incarcerated

Low family socioeconomic status is associated with rates of chronic delinquency and crime Wadsworth, 1979; Farrington, 1987; Tracy et al., 1990; Werner & Smith, 1992. The socioeconomic status of a neighborhood also predicts delinquency; that is, neighborhoods with high rates of adult unemployment, overcrowding, poor housing, low-achieving students, and high rates of mobility are all associated with high rates of delinquency Rutter, 1979; Byrne & Sampson, 1986; McGahey, 1986; Schuerman & Kobrin, 1986. Given that many Latinos are poor and live within impoverished inner cities, relatively high rates of criminal involvement might be expected.

A larger proportion of Hispanic Americans (9 %) compared to white Americans (3 %) is incarcerated (Bureau of Justice Statistics, 1999). Among men, Hispanics are nearly four times as likely as whites to be in prison at some point during their lifetimes. Among women, less than 2 percent of Hispanics will enter prison compared to less than 1 percent of white women (Bureau of Justice Statistics, 1999). In addition, Hispanic youth make up 18 percent of juvenile offenders in residential placement (Bureau of Justice Statistics, 1999). Current epidemiological studies of incarcerated men and women include Hispanics and, in general, find that the rates of mental disorders among incarcerated individuals are higher than among community residents Teplin, 1994; Teplin et al., 1996. Few ethnic differences among Hispanic Americans, white Americans, and African Americans were found. For those that were found, the small subsample of Latinos raises questions about the reliability of the findings.

Vietnam War Veterans

High rates of post-traumatic stress disorder (PTSD) exist among Vietnam War veterans. In a national study of Vietnam veterans (Kulka et al.,1990), Hispanics were found to be at higher risk for war-related PTSD than their white counterparts. In a further examination of Kulka's work, Ruef and her colleagues (2000) found the risk for Hispanics also higher than that for black veterans, suggesting that the risk is not just related to minority status. In another recent reexamination of the Kulka study, Puerto Rican veterans in particular were found to have a higher probability of experiencing PTSD than were others with similar levels of war zone stress exposure (Ortega & Rosenheck, 2000). Because these differences in prevalence were not explained by exposure to stressors or acculturation and were not accompanied by substantial reductions in functioning, the authors suggest that differences in symptom reporting may reflect features of expressive style rather than different levels of illness. Another plausible factor in explaining the higher likelihood of experiencing PTSD is greater exposure to violence and trauma prior to entering the military (Bremmer et al., 1993).

Refugees

Many Hispanics, particularly Central Americans, have come to the United States as refugees, and only a small number of them were granted refugee status as defined by the U.S. Government. During the period of civil wars in Nicaragua, El Salvador, and Guatemala, an estimated 2 million Central Americans migrated to Mexico, the United States, and Canada. From 1990 to 1997, from 4 to 8 percent of the refugees who entered the United States legally were from Central America. Many others are believed to have entered the country through unauthorized channels. Although self-help groups and assistance centers were set up by religious organizations, these refugees did not have official U.S. Government sanction and thus received no U.S. Government resettlement benefits (Carillo, 1990).

Because Central American refugees often experienced the systematic violation of human rights in their own countries (Farias, 1994), they are at high risk for mental disorders such as PTSD and depression. Adults attending three schools in Los Angeles were examined for symptoms of PTSD and depression (Cervantes et al., 1989). Half of the Central American participants reported symptoms that were consistent with a diagnosis of PTSD. In comparison with recent Mexican immigrants, a greater proportion of Central American refugees reported symptom clusters of PTSD (50% versus 25%) (Cervantes et al., 1989). In another study, 60 percent of adult Central American refugee patients were diagnosed with PTSD (Michultka et al., 1998). Central American immigrant children seeking care at refugee service centers also had high rates of PTSD (33 %) (Arroyo & Eth, 1984). Thus, Central American refugees who have been exposed to trauma have a high need for mental health care.

Individuals with Alcohol and Drug Problems

Studies have consistently shown that rates of substance abuse are linked with rates of mental disorders Kessler et al., 1996: Ross et al., 1988; Rounsaville et al., 1991. Most studies of alcohol use among Hispanics indicate that rates of use are either similar to or slightly below those of whites (Kessler et al., 1994). However, two factors influence these rates. First, gender differences in rates of Latinos' use are often greater than the gender differences observed between whites. Latinas are particularly unlikely to use alcohol or drugs (Gilbert, 1987). In some cases, Latino men are more likely to use substances than white men. For example, in the Los Angeles ECA study, Mexican American men (31 %) had significantly higher rates of alcohol abuse and dependence than non-Hispanic white men (21 %). In addition, more alcohol-related problems have been found among Mexican American men than among white men (Cunradi et al., 1999).

A second factor associated with Latinos' rates of substance abuse is place of birth. In the Fresno study (Vega et al., 1998), rates of substance abuse were much higher among U.S.-born Mexican Americans compared to Mexican immigrants. Specifically, substance abuse rates were seven times higher among U.S.-born women compared to immigrant women. For men, the ratio was 2 to 1. U.S.-born Mexican American youth also had higher rates of substance abuse than Mexican-born youth (Swanson et al., 1992).

Strengths

The study of mental disorders and substance abuse among Latinos suggests two specific types of strengths that Latinos may have. First, as noted, Latino adults who are immigrants have lower prevalence rates of mental disorders than those born in the United States. Among the competing explanations of these findings is that Latino immigrants may be particularly resilient in the face of the hardships they encounter in settling in a new country. If this is the case, then the identification of what these immigrants do to reduce the likelihood of mental disorders could be of value for all Americans. One of many possible factors that might contribute to their resilience is what Suarez-Orozco and Suarez-Orozco (1995) refer to as a "dual frame of reference." Investigators found that Latino immigrants in middle-school frequently used their families back home as reference points in assessing their lives in the United States. Given that the social and economic conditions are often much worse in their homelands than in the United States, they may experience less distress in handling the stressors of their daily lives than those who lack such a basis of comparison. U.S.-born Latinos are more likely to compare themselves with their peers in the United States. Suarez-Orozco and Suarez-Orozco argue that these Latino children are more aware of what they do not have and thus may experience more distress.

A second factor noted by the Suarez-Orozcos that might be related to the resilience of Latino immigrants is their high aspiration to succeed. Particularly noteworthy is that many Latinos want to succeed in order to help their families, rather than for their own personal benefit. Because the Suarez-Orozcos did not include measures of mental health, it is not certain whether their observations about school achievement apply to mental health. Nevertheless, a dual frame of reference and collective achievement goals are part of a complex set of psychological, cultural, and social factors that may explain why some Latino immigrants function better than Latinos of later generations.

A second type of strength noted in the literature is how Latino families cope with mental illness. Guarnaccia and colleagues (1992) found that some families draw on their spirituality to cope with a relative's serious mental illness. Strong beliefs in God give some family members a sense of hope. For example, in reference to her brother's mental illness, one of the informants commented: We all have an invisible doctor that we do not see, no? This doctor is God. Always when we go in search of a medicine, we go to a doctor, but we must keep in mind that this doctor is inspired by God and that he will give us something that will help us. We must also keep in mind that who really does the curing is God, and that God can cure us of anything that we have, material or spiritual. (p. 206)

Jenkins (1988) found that many Mexican Americans attributed their relatives' schizophrenia to nervios, a combination of both physical and emotional ailments. An important point here is that nervios implies that the patient is not blameworthy, and thus family members are less likely to be critical. Previous studies from largely non-Hispanic samples have found that both family criticism (for a review see Bebbington & Kuipers, 1994) and family blame and criticism together (Lopez et al., 1999) are associated with relapse in patients with schizophrenia. Mexican American families living with a relative who has schizophrenia are not only less likely to be critical, but also those who are Spanish-speaking immigrants have been found to be high in warmth. This is important because those patients who returned from a hospital stay to a family high in warmth were less likely to relapse than those who returned to families low in warmth (Lopez et al., 1998). Thus, Mexican American families' warmth may help protect the relative with schizophrenia from relapse. The spirituality of Latino families, their conceptions of mental illness, and their warmth all contribute to the support they give in coping with serious mental illness.

Although limited, the attention given to Latinos' possible strengths is an important contribution to the study of Latino mental health. Strengths are protective factors against distress and disorder and can be used to develop interventions to prevent mental disorders and to promote well-being. Such interventions could be used to inform interventions for all Americans, not just Latinos. In addition, redirecting attention to strengths helps point out the overemphasis researchers and practitioners give to pathology, clinical entities, and treatment, rather than to health, well-being, and prevention.

Availability, Accessibility, and Utilization of Mental Health Services

Availability of Mental Health Services

Finding mental health treatment from Spanish-speaking providers is likely to be a problem for many Spanish-speaking Hispanics. In the 1990 census, about 40 percent of Latinos reported that they either didn't speak English or didn't speak English well. Thus, a significant proportion of Latinos need Spanish-speaking mental health care providers. Presently there are no national data to indicate the language skills of the Nation's mental health professionals. However, a few studies reveal that there are few Spanish-speaking and Latino providers. One survey of 1,507 school psychologists who carry out psychoeducational assessments of bilingual children in the eight States with the highest percentages of Latinos found that 43 percent of the psychologists identified themselves as English-speaking monolinguals (Ochoa et al., 1996). In other words, a large number of English-speaking-only psychologists are evaluating bilingual children; this becomes a problem when these children's English language skills are limited.

Available clinical psychology human resources data indicate that Latinos comprise an extremely small portion of practicing psychologists. In fact, in a recent national survey of 596 licensed psychologists with active clinical practices who are members of the American Psychological Association, only 1 percent of the randomly selected sample identified themselves as Hispanic, whereas 96 percent identified themselves as white (Williams & Kohut, 1999). Another survey found that there were 29 Latino mental health professionals for every 100,000 Latinos in the U.S. population. For whites, the rate was 173 white providers per 100,000 (Center for Mental Health Service [CMHS], 1999). Clearly, Latino consumers have limited access to ethnically and linguistically similar providers.

Accessibility of Mental Health Services

The lack of health insurance is a significant barrier to mental health care for many Latinos. Although Hispanics comprise 12 percent of the U.S. population, they represent nearly one out of every four uninsured Americans Brown et al., 2000; Kaiser Commission, 2000. Nationally, 37 percent of Latinos are uninsured; this is more than double the percent for whites. These high numbers are driven mostly by Latinos' lack of employer based coverage: Only 43 percent of Latinos are covered through the workplace, compared to 73 percent of whites. Medicaid and other public coverage reaches 18 percent of Latinos. Citizenship and immigration status are other important factors that affect health insurance Brown et al., 1999; Hanson, 2001. For example, among Latino youth ages 0 to 17 years in immigrant families, only 47 percent of noncitizens were insured compared to 71 percent of citizens. Of children born to U.S.-born parents, 84 percent were insured. Compared to Asian Americans, African Americans, and white Americans children, Latino children were the least likely to be insured, regardless of citizenship. For example, noncitizen Latino children had a significantly lower percentage of being insured (47 %) than noncitizen Asian children (80 %). Thus, the lower rate of insurance coverage for Latinos is a function of ethnicity, immigration status, and citizenship status.

Utilization of Mental Health Services

Community Studies

The available studies consistently indicate that Hispanic community residents with diagnosable mental disorders are receiving insufficient mental health care. In the Los Angeles Epidemiologic Catchment Area (ECA) study, for example, Mexican Americans who had experienced mental disorders within the past six months were less likely to use health or mental health services than whites (11 % versus 22 %) (Hough et al., 1987). The study of Mexican Americans residing in Fresno County revealed similar results. Only 9 percent of those with mental disorders during the 12 months prior to the interview sought services from a mental health specialist. This rate was even lower for those born in Mexico (5 %) compared to those born in the United States (12 %) (Vega et al., 1999). Furthermore, Latinos are twice as likely to seek treatment for mental disorders in general health care settings as opposed to mental health specialty settings.

These studies suggest that among Hispanic Americans with mental disorders, fewer than 1 in 11 contact mental health care specialists, while fewer than 1 in 5 contact general health care providers. Among Hispanic American immigrants with mental disorders, fewer than 1 in 20 use services from mental health specialists, while fewer than 1 in 10 use services from general health care providers.

The National Comorbidity Study also found that Latinos used few mental health services, even though all those surveyed were fluent in English. For example, only 11 percent of those with a mood disorder and 10 percent of those with an anxiety disorder used mental health specialists for care.

Reports on the use of mental health services in Puerto Rico are much different. In one community survey (N = 1,551 adults), 85 percent of those with diagnosable disorders reported using mental health care specialists or health care providers (Martinez et al., 1991). In a second large survey focused on poor Puerto Ricans, 32 percent of those identified as needing mental health care received services in the previous year (Alegria et al., 1991). Like mainland Latinos, Puerto Ricans obtained mental health care from the general medical sector more often than from mental health specialists.

Whereas most studies of Latinos' use of mental health services have been largely descriptive in nature, there have been some studies to identify the processes that lead to accessing mental health care. One study carried out in Puerto Rico, for example, found that low economic strain was related to the use of specialty mental health care, suggesting that economic barriers may contribute to low use of mental health services (Vera et al., 1998). In addition, these investigators pointed out that predictors vary with regard to the specific aspect of help seeking under study, from recognizing a mental health problem to seeking care from health care providers in general and mental health care providers in particular (See Box 6-3). Another important process that may be associated with Hispanics' use of mental health services is stigma. Research is needed to examine the role of stigma as it relates to their accessing mental health care.

Mental Health Systems Studies

Several evaluations of Latinos' use of services in care systems during the 1980s have been published. Two were based on national data (Snowden & Cheung, 1990, for 1980-1981; Cheung & Snowden, 1990, for 1983; & Ryujin, 1999, for 1986), and two examined insured populations (Scheffler & Miller, 1989, for 1979-1981; Padgett et al., 1994, for 1983). Most show low use of inpatient services. The results for outpatient care were equivocal. Differences between studies of inpatient and outpatient service use could have resulted from the study of different Latino subgroups in each sample.

Complementary Therapies

Several national studies show that Americans from all ethnocultural backgrounds turn to alternative sources of health care, either self-administered or given by alternative providers, to complement the general health and mental health care that they receive from mainstream sources Astin, 1998; Eisenberg et al., 1998; Druss & Rosenheck, 2000. However, these studies have not included large enough samples of Latinos to give precise estimates of the use of complementary therapies by this group. The Hispanic Health and Nutrition Examination Survey (HHANES) found that only 4 percent of the Mexican American sample in five Southwestern States had reported consulting a curandero, herbalista, or other folk medicine practitioner within the prior 12 months (Higginbotham et al., 1990). However, some believe that the HHANES may not truly represent the extent of use among all Mexican Americans, because the methods the HHANES used tend to include individuals with higher education, higher income, and telephone access, while they tend to miss subgroups that are harder to reach (Skaer et al., 1996). In fact, studies of smaller subgroups of Mexican Americans have found that proportions ranging from 7 percent to 44 percent of the sample use curanderos and other traditional healers Risser & Mazur, 1995; Keegan, 1996; Skaer et al., 1996; Macias & Morales, 2000.

Box 6-3: Increasing use of services: Learning from the past

La Frontera Center

With the growing number and increasing spread of Latinos throughout the United States, some mental health systems are addressing for the first time how to reach Latinos in need of mental health care. To guide current efforts, there is some value in reflecting on how mental health centers in the 1960s first began to reach out to Latino communities. La Frontera Center, a mental health center located in South Tucson, Arizona, is well known for its success in making services available to Latinos (Preciado Martin, 1979).

When [La Frontera] first opened its doors, bilingual and bicultural social workers walked through the community introducing themselves and their services. In addition, service providers established collaborative working relations with other community organizations such as public health agencies, juvenile justice, public libraries, and the local Spanish-language radio station. For example, a depression prevention program was implemented in a public health well baby clinic where young mothers would bring their children for a free physical exam. A Spanish-speaking mental health worker would meet briefly with mothers and provide both educational and assessment services. When necessary, the mental health worker would refer the mother for an evaluation at the mental health center. The main point is that the center developed creative approaches to engage persons in need within their community context; clinic staff did not wait for potential consumers to walk through the clinic doors. Evidence of the same philosophy can be seen in more contemporary services as well, specifically those provided to caregivers of Latinos with Alzheimer's disease (Henderson et al., 1993).

Use of folk remedies is more common than consultation with a folk healer, however, and these remedies are generally used to complement mainstream care. A study of folk remedies for asthma in a mainland Puerto Rican community found that these remedies are well known and commonly used, even though the importance of receiving timely mainstream treatment was recognized (Pachter et al., 1995).

Integrating complementary care with traditional mental health care was an objective of a unique training project carried out in Puerto Rico (Koss-Chioino, 1992). Both espiritistas (Puerto Rican folk healers) and mental health providers participated in a program to enhance mutual understanding and communication. This model program included lectures and case presentations by experts representing both therapeutic perspectives, as well as visits to the healers' facility, or centro. The available evidence suggested that this program was most successful in helping both groups understand their differences, as well as in occasionally coordinating their treatments. Although mental health providers and folk healers do not often communicate with one another, this program demonstrated that the two systems of care have the potential to complement one another. Also, mental health service providers should be aware that in many places these complementary sources of care have been stigmatized by the church and by traditional medical practices. Therefore, some Latinos may be reluctant to disclose their participation in folk healing practices.

Children and Youth

Very few studies have addressed the use of mental health services by Latino children and youth. One exception is the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study (Lahey et al., 1996). Researchers obtained community-based probability samples of parent and youth pairs (N = 1,285) in four sites: New Haven, Connecticut; Atlanta, Georgia; Westchester County, New York; and San Juan, Puerto Rico. They also administered a structured diagnostic instrument to assess these children and adolescents. These investigators found that Puerto Rican youth used mental health services significantly less than children from the other sites did. Of those Puerto Rican youth with a diagnosable mental disorder, only 20 percent reported using mental health-related services (Leaf et al., 1996). This percentage is markedly lower than the percentages of youth receiving care at the other sites; they range from 37 to 44 percent.

This study made a unique contribution to the understanding of children's use of mental health services because it obtained a measure of unmet need that was based both on a diagnosis and on a significant degree of impairment, where impairment was related to key symptoms of the diagnosis (Flisher et al., 1997). Including a level of impairment in identifying need for mental health care is likely to reduce the risk of overestimating need. Using this measure, 13 percent of Hispanic children, compared to 16 percent of white children, were rated as having unmet need for care.

Researchers conducted another study of children's use of mental health care in two communities in Texas: Galveston and the lower Rio Grande Valley (Pumariega et al., 1998). Hispanics reported significantly fewer lifetime counseling visits than white youth (2 versus 4). Bui and Takeuchi (1992) also found evidence that Hispanics were underrepresented in the use of outpatient mental health facilities in Los Angeles County from 1983 to 1988. Specifically, they reported that although Hispanics under 18 years of age in Los Angeles County were 42 percent of the under-18-year-old population, only 36 percent of the adolescent caseload was Hispanic. Together these studies indicate that Latino youth use mental health facilities less than they might.

Appropriateness and Outcomes of Mental Health Services

Studies on Treatment Outcomes

Few studies on the response of Latinos to mental health care are available. Only three small studies of depression have been published. They investigated the care for depression given to unmarried Puerto Rican mothers with depressive symptoms (Comas-Diaz, 1981), to Mexican American women (Alonso et al., 1997), and to Puerto Rican adolescents (Rossello & Bernal, 1999). Although all found that those who were treated had favorable results, the sample sizes are far too small to establish the response of Latinos to care for depression.

Another study examined interventions for schizophrenia among Latinos. In this randomized study, members of low-income, Spanish-speaking families were more likely to suffer a significant exacerbation of symptoms in highly structured family therapy than in the less structured case management (Telles et al., 1995). The authors of this study speculated that these individuals may have found this highly structured treatment too intrusive.

Several preventive intervention studies have focused on Latino children and families Costantino et al., 1986, 1988; Szapocznik et al., 1989; Malgady et al., 1990; Lieberman et al., 1991. In these studies, mental health professionals provided culturally adapted preventive care to immigrant mothers and infants in San Francisco (Lieberman et al., 1991), Puerto Rican children and parents in New York City (Costantino et al., 1986), and families in Miami (Szapocznik et al., 1989). In general, the interventions resulted in short-term gains, but long-term follow-up evaluations to determine whether they actually prevented later mental disorders were not reported.

Two effectiveness studies examined treatment for depression among ethnically mixed samples of primary care patients with significant proportions of Latinos. In the first study, Miranda and Munoz (1994) investigated the effectiveness of group cognitive treatment for minor depression. Although analyses were not run separately for Latinos, who comprised 24 percent of the sample, the findings indicated that patients receiving the cognitive treatment improved significantly more than those who received no intervention or who watched a 40-minute videotape.

The second study was more ambitious. It was carried out in 46 primary care clinics across six managed systems of care (Wells et al., 2000). Two of the cities in the study, San Luis, Colorado, and San Antonio, Texas, have large Mexican American communities. Latinos comprised nearly a third (30 %) of the enrolled sample (N = 1,356). The purpose of the study was to assess the effects of programs to improve the quality of care for depression. Specifically, usual care was compared with two interventions, one for which medication was administered and closely followed for 6 or 12 months and the other for which local psychotherapists provided cognitive-behavior treatment ranging from 4 sessions for minor depression and related problems to 10-16 sessions for major depression. Although results broken down by ethnicity have yet to be published, the initial findings indicate that, relative to usual care, the quality improvement programs had significant effects on treatment process, clinical outcome, and even social outcomes such as employment.

Diagnostic and Testing Issues

Quality care requires valid diagnostic and clinical assessment. Several studies have found that bilingual patients are evaluated differently when interviewed in English as opposed to Spanish Del Castillo, 1970; Marcos et al., 1973; Price & Cuellar, 1981; Malgady & Costantino, 1998; however, the extent to which these factors result in misdiagnoses is not known. One small study examining records of patients with bipolar disorder (manic depressive illness) found that in the past, both African American and Latino patients were more likely to have been misdiagnosed as schizophrenic than whites (Mukherjee et al., 1983). Further research is needed to clarify how cultural and linguistic factors influence diagnoses Malgady et al., 1987; Lopez, 1988.

Psychological testing can also be affected by language and cultural factors. Of particular interest is testing that contributes to the diagnosis of mental retardation (e.g., cognitive intelligence tests), dementia (neuropsychological testing), and mental disorders (psychological tests such as the MMPI-2). The two main positions on testing are that (1) tests are biased against minority group members (e.g., Guthrie, 1998), and (2) there is no evidence of ethnic or cultural bias (Gottfredson, 1997). Cole (1981) refers to these positions as those of the reformers and the defenders. Most of the literature involves African Americans (e.g., Helms, 1992), and when Latinos are included, they are mostly English-speaking Latinos (e.g., Sandoval, 1979). However, the literature concerning Latinos and the particular challenge of assessing bilingual persons and those with limited English proficiency is growing (e.g., Jacobs et al., 1997).

The lack of reliable and valid tests normed on contemporary samples of Latinos, both Spanish-speaking and English-speaking, is a significant obstacle to carrying out the appropriate assessment of Latinos Bird et al., 1987; Loewenstein et al., 1994; Velasquez et al., 1998. Two of the most widely used tests for diagnostic purposes are the Wechsler scales of intelligence and the MMPI-2. The available Wechsler test for Spanish-speaking adults, Escala Inteligencia de Wechsler para Adultos (EIWA), was published in 1968 and was based on a standardization sample of Puerto Rican islanders (Wechsler, 1968). Since then, two English language versions have been standardized and published (Wechsler, 1981, 1998).

The current Spanish language norms are significantly outdated, and available research has demonstrated their overestimating the level of functioning of some Spanish-speaking adults (e.g., Lopez & Taussig, 1991). The children's version of the WAIS, however, has been developed and standardized on a more contemporary sample of Puerto Rican island children (Wechsler, 1989). In the restandardization of the MMPI (MMPI-2; Butcher et al., 1989), little consideration was given to Latinos. Of the 2,600 who comprised the standardization sample, only 73, or 2.8 percent, were identified as Hispanic. This percentage reflected only one-third of the actual Hispanic representation in the Nation at that time. Both the EIWA and MMPI-2 demonstrate that some test publishers assign little importance to providing contemporary and representative norms of Latinos in the United States. This statement does not apply to all tests, since recent advances have been made in the development of language skills tests in Spanish and English (e.g., Woodcock & Munoz, 1993) and nonverbal tests (e.g., Bracken & McCallum, 1998, Naglieri & Bardos, 1999). At the very least, tests based on normative samples of U.S. adults or children should include subsamples of Latinos that accurately reflect their representation in the Nation. At best, Latinos should be oversampled so that tests of fairness can be carried out that attend to differences among sub-groups within the Hispanic American population as well as differences between Hispanic Americans and other racial and ethnic groups.

Evidence-Based Treatment

To determine whether there are disparities in mental health care, it is important to discover whether Latinos are as likely as white Americans to receive care that is consistent with guidelines established by recognized psychiatric and psychological organizations. Recent data suggest that Latinos are less likely than whites to receive treatment according to evidence-based guidelines. Evidence from a representative national sample suggests that many individuals with depression and anxiety do not receive appropriate care (Young et al., 2001); fewer Hispanics receive appropriate care (24 %) than do whites (34 %).

Another study examined the use of antidepressants among clients who had visited a general medical doctor (National Ambulatory Medical Care Surveys of 1992-1993 and 1994-1995). During the two time periods in the early 1990s that were evaluated, Latinos were less than half as likely as whites to have received either a diagnosis of depression or antidepressant medication (Sclar et al., 1999).

A few small preliminary studies have examined pharmacologic responses in Latino populations. In the research that does exist, data are often drawn from aggregate samples of several different Hispanic groups in attempts to characterize a typical Hispanic response (Mendoza & Smith, 2000. However, evidence of important genetic variation among subgroups (i.e., Mexican Americans, Puerto Ricans, and Colombians) implies that disaggregated data are needed before any ethnopsychopharmacological findings should be considered conclusive Hanis et al., 1991; Mendoza & Smith, 2000).

Cultural Competence

Sue and colleagues (1991) studied community mental health centers in Los Angeles in order to examine ethnically matched provider services versus nonmatched provider services. Ethnic match resulted in longer duration of treatment for Mexican Americans, as well as better patient response to treatment based on a global indicator of functioning. This suggests that ethnic match of provider and consumer can be important in providing services for some Latinos.

One limitation of ethnic match research is that there is no direct assessment of clinicians' cultural understanding or skills. Therefore, it is not clear if the cultural competence of practitioners is related to the positive findings of ethnic match. Direct study of cultural competence for Latinos is needed. Although there have been efforts to develop specific cultural competence guidelines for Latinos (Western Interstate Commission for Higher Education, 1996), most models that have been developed apply across ethnic groups.

Cultural competence has received widespread attention across the Nation. Some State and local policymakers now require cultural competence training for their practitioners. Federal agencies are supporting the development and implementation of guidelines (e.g.,CMHS, 2000). Despite the several models and the growing interest in cultural competence, much work needs to be done before cultural competence will positively impact mental health service delivery for Latinos and other ethnic groups. Currently, cultural competence is largely a set of guiding principles that lack empirical validation. Thus, an essential step in advancing culturally competent services for Latinos is to carry out research to test the guidelines, standards, or models proposed by these expert clinicians and administrators. Bernal et al. (1995) and Lopez et al. (in press) discuss multiple strategies to develop culturally informed interventions.

Conclusions

  1. The system of mental health services currently in place fails to provide for the vast majority of Latinos in need of care. This failure is especially pronounced for immigrant Latinos, who make the least use of mental health services. Latinos within known vulnerable groups are also of concern. Incarcerated Latinos, those who use excessive amounts of alcohol or drugs, and those exposed to violence, such as Central American refugees, are most likely to be in need of mental health care. There are many ways to improve services for Latinos, from reducing systemic barriers-especially financial barriers-to increasing the number of mental health professionals who are linguistically and culturally skilled. Also, because Latinos are more likely to seek mental health services in primary care settings, improving detection and care within the general health care sector is important.
  2. Latino youth are at a significantly high risk for poor mental health outcomes. Evidence suggests that they are more likely to drop out of school, to report depression and anxiety, and to consider suicide than white youth. Prevention and treatment are needed to address their mental health problems. Given the rapid expansion of this young population of Latinos, these interventions could have major implications for the ongoing health of the Nation's youth.
  3. Sociohistorical data suggest that there should be mental health differences among Latino sub-groups. Although the data are limited, there is some evidence that Central Americans do have greater problems than other Latino subgroups, especially with post-traumatic stress disorder. However, there is little evidence of Cuban Americans having lower rates of disorder than other Latino subgroups. The National Latino Asian American Study (NLAAS) now being conducted will be the first psychiatric epidemiological study to use a representative sample of the Nation's Latinos, which will enable researchers to test subgroup differences more systematically.
  4. In addition to the findings emphasizing the need for mental health care, a pattern of evidence for the strengths of Latino immigrants also emerges.Resilience is indicated by the lower rates of mental disorders for Mexican-born adults and children and island-born Puerto Rican adults compared with the rates for those born in the United States. Some of the ways in which Latinos cope with mental illness suggest strengths as well. The factors underlying these observed strengths are not clear, but they hold promise for identifying social and cultural patterns that promote mental health. These patterns could be particularly helpful in developing culturally sensitive interventions to prevent and treat the mental health problems that Latinos face.
  5. Mental disorders and distress can be interpreted on many levels, from the molecular aspects of neuroscience to the social world of consumers and families. Psychosis can be understood as the result of dysfunctions in neurotransmitters as well as the result of a deeply felt personal loss. To provide culturally responsive therapy for Latinos, it is critical that providers access the local world of their patients and their families. Doing so will suggest ways practitioners can integrate effectively the social and cultural context of their Latino patients with their own worlds to provide effective care.

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