Mental Illness in US Latinos Addressed in Survey, Outreach Efforts

Early findings from a national study are shedding light on differences in the type and prevalence of mental disorders in US-born and immigrant Latinos, as well as differences among Latinos from various countries of origin.

US-born Latinos experience more psychiatric disorders than their immigrant parents, according to the National Latino and Asian American Study (NLAAS), a nationally representative community household survey that estimates the prevalence of mental disorders and rates of mental health service use by Latinos and Asian Americans in the United States.

Using data from the NLAAS, Alegría and associates¹ examined lifetime and past-year prevalence rates of depressive, anxiety, and substance use disorders and overall psychiatric disorders in 4 Latino subgroups: Mexican, Puerto Rican, Cuban, and those of other Latino descent.

Immigrants appear to have lower rates of psychiatric disorders than third-generation Latinos in the United States, said Margarita Alegría, PhD, professor of psychiatry at Harvard Medical School and lead author of the article on prevalence. The lifetime prevalence of the selected psychiatric disorders for US-born Latinos is 36.8%, compared with 23.8% for foreign-born Latinos, and the past-year prevalence is 18.6% for those who were US-born and 13% for those who were foreign-born.²

The Latino portion of the NLAAS, Alegría told Psychiatric Times, is more comprehensive than some other national studies on Latinos and is particularly important because Latinos already account for 14% of the nation's total population and this will climb to 24% by 2050. The researchers used the World Health Organization's World Mental Health Composite International Diagnostic Interview to evaluate the prevalence rates of psychiatric disorders and conducted interviews in English or Spanish as needed.

Hypothesizing that contextual, social, and immigration factors may play significant roles in Latinos' risk of psychiatric disorders, the researchers examined possible correlates, including gender, ethnic subgroup, nativity, generational status, English-language proficiency, length of residence in the United States, and age at migration.

Differences by geographic origin
Overall lifetime psychiatric disorder prevalence estimates are similar for men (28.1%) and women (30.2%), but when subgroups were compared, differences emerged. Lifetime and past-year prevalence rates were highest for Puerto Ricans on the mainland.

"Puerto Ricans . . . tend to be higher in some disorders than the Cubans, Mexicans, or other Latino group, and they tend to have higher rates of anxiety disorders, in particular, posttraumatic stress disorder, compared to other ethnic groups," said Alegría, who also directs the Center for Multicultural Mental Health Research at Cambridge Health Alliance in Massachusetts.

Explanations for the elevated rates of past-year psychiatric disorders among Puerto Rican men and women in the report included the tendency to express illness symptoms differently from other Latinos; more exposure to traumatic events; higher rates of unemployment and underemployment than other US Latino groups; and overrepresentation of households headed by single women, who might be experiencing both gender role stress and separation from family members.

Relative to their Puerto Rican counterparts, Mexican men and women are less likely to have a history of depressive disorders and Cuban men are less likely to have a history of anxiety disorders or substance use disorders. Similarly, the odds of a history of substance use disorders are significantly lower for both Cuban and Mexican women than for Puerto Rican women.

Alegría explained that the lower rates of depressive disorders among Mexicans might be because they tend to be a very cohesive group that lives in enclaves throughout the United States. Consequently, they are able to sustain close relationships and not experience the erosion of family ties and networks.

Effects of acculturation
As Latinos acculturate to mainstream US society, their mental health seems to worsen. Proficiency in English was a marker for increased risk of psychiatric disorders, particularly depressive disorders, according to Alegría. In the analysis, she and her coauthors theorized that "attempts to assimilate to an economic and cultural ideal in the United States while retaining a minority status position may exert particular pressure on Latino men. This is an area requiring increased awareness in general practice settings wherein doctors may need information about the risk factors for depressive disorders affecting Latino men at higher levels of acculturation."

Another area warranting increased attention is substance use disorders, Alegría explained. In general, both Latino immigrant men and women are significantly less likely than US-born Latinos to have a history of substance use disorders (and thus, a history of overall psychiatric disorders). Alegría and her coauthors called for substance abuse programs to pay continued attention to environmental influences and interventions, particularly as regards third-generation Latinos.

Comparing survey results
When asked about the lower prevalence of psychiatric disorders in Latino populations in the NLAAS compared with the National Comorbidity Study-Replication (NCS-R),³ Alegría explained that the NCS-R surveyed only English-speaking Latinos, possibly amplifying prevalence rates, and also used a smaller sample size (527 compared with 2554 in the NLAAS).

She added that prevalence data in both studies might be conservative, because certain symptoms of psychiatric disorders among immigrant populations (eg, ataque de nervios) would not be represented in the diagnostic batteries used with the general population.

"We have used other diagnostic batteries to detect the different expressions of illness, but did not discuss them in the current article," she explained. "We will be talking more about psychiatric diagnosis and culture in some upcoming papers."

Mental health service use
Alegría and her coauthors also used Latino data from the NLAAS to examine correlates and rates of past-year mental health service use for 11 psychiatric disorders.⁴

Compared with mental health service use in the 1990s, "rates of obtaining care are much higher than had been reported before," Alegría said, adding that the increased use is good news, since it implies "we are getting our message out" to the Latino community.

Another change, she said, is the increased use of specialty mental health services (eg, psychiatrists, psychologists, and other mental health professionals) compared with the general medical sector.

Some differences emerged regarding ethnic subgroups, nativity, generational status, insurance availability, and other factors. According to the analysis by Alegría and her coauthors, the rates of overall mental health service use and specialty service use were significantly higher among Puerto Ricans than in other subgroups. One in 5 Puerto Ricans (19.89%) reported going to a mental health specialist, general medical provider (eg, family doctor or nurse), or community resource (eg, clergy or self-help group) during the past year. This rate is higher than that of other ethnic subgroups (11.49% of Cubans, 10.08% of Mexicans, and 11% of other Latinos).

In comparison with US-born Latinos and those who were English-proficient, foreign-born Latinos and those who indicated that they spoke primarily Spanish reported less use of services overall and less use of specialty services.

Insurance coverage played a significant role in mental health service use. Use of specialty mental health services and of mental health services in the general medical sector was significantly lower among Latinos with no insurance coverage than in those with public or private insurance coverage.

Satisfaction with care
As part of the NLAAS study, participants were asked about their level of satisfaction with the mental health services they received and whether or not the service provider helped them. Immigrants who had resided in the United States for 5 years or less reported lower levels of satisfaction with mental health services than those who had lived here for more than 20 years.

Commenting on this, Alegría remarked that "there is a need to determine what recent migrants are looking for that they are not getting in treatment. My hypothesis is that for recent migrants to really navigate the system is very hard."

She recommended that case managers or patient advocates be used to help recent immigrants with seemingly tangential yet practically important issues, such as how to take the public transit system so they can get to appointments and how to access the service provider by telephone.

When Latino patients were asked in other studies why they were dropping out of treatment, Alegría said they complained that the care was too minimal, attending to only part of what they needed; was too medicalized; did not answer their concerns; and failed to give them skills to work with after leaving the office of the service provider.

"It is very important for clinicians to be aware of their own stereotypes" and to avoid making assumptions about patients, Alegría said. Psychiatrists and other mental health professionals, she added, need to spend time to hear the story of the person and to assess norms and values of these populations, particularly looking at which services and care approaches would help them most.

Outreach efforts
When questioned about outreach to US Latino populations, Alegría acknowledged the increased efforts of some pharmaceutical companies, advocacy groups, the media, and churches. As an example, she pointed to some churches serving Latino populations that are conducting screenings for depression and training clergy on how to recognize symptoms of psychiatric disorders and refer a congregant to specialty care (see "Model Mental Health Program").

References:

References:1. Alegría M, Mulvaney-Day N, Torres M, et al. Prevalence of psychiatric disorders across Latino subgroups in the United States. Am J Public Health. 2007;97:68-75.
2. National Institute of Mental Health. U.S.-born children of immigrants may have higher risk for mental disorders than parents. Available at: http://www.nimh.nih.gov/ press/immigrant_mentalhealth.cfm. Accessed January 31, 2007.
3. Breslau J, Aguilar-Gaxiola S, Kendler KS, et al. Specifying race-ethnic differences in risk for psychiatric disorder in a USA national sample. Psychol Med. 2006;36: 57-68.
4. Alegría M, Mulvaney-Day N, Woo M, et al. Correlates of past-year mental health service use among Latinos: results from the National Latino and Asian American Study. Am J Public Health. 2007;97:76-83.