Immigration and Mental Health: Stress, Psychiatric Disorders and Suicidal Behavior Among Immigrants and Refugees (Psychiartry - Theory, Applications and Treatments)

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PSYCHIATRY – THEORY, APPLICATIONS AND TREATMENTS

IMMIGRATION AND MENTAL HEALTH: STRESS, PSYCHIATRIC DISORDERS AND SUICIDAL BEHAVIOR AMONG IMMIGRANTS AND REFUGEES

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PSYCHIATRY – THEORY, APPLICATIONS AND TREATMENTS

IMMIGRATION AND MENTAL HEALTH: STRESS, PSYCHIATRIC DISORDERS AND SUICIDAL BEHAVIOR AMONG IMMIGRANTS AND REFUGEES

LEO SHER AND

ALEXANDER VILENS EDITORS

Nova Science Publishers, Inc. New York

Copyright © 2010 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers‘ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Immigration and mental health : stress, psychiatric disorders, and suicidal behavior among immigrants and refugees / editors, Leo Sher, Alexander Vilens. p. ; cm. Includes bibliographical references and index. ISBN 978-1-61324-748-8 (eBook) 1. Immigrants--Mental health. I. Sher, Leo. II. Vilens, Alexander. [DNLM: 1. Emigrants and Immigrants--psychology. 2. Mental Health. 3. Acculturation. 4. Mental Disorders. 5. Stress, Psychological. 6. Suicide. WA 305.1 I33 2010] RC451.4.E45I46 2010 362.196'890086912--dc22 2010015602

Published by Nova Science Publishers, Inc. † New York

CONTENTS Preface

ix

Part I Suicidal Behavior Chapter 1

A Model of Suicidal Behavior among Immigrants with Psychiatric Disorders Leo Sher

1

Chapter 2

Immigration and Suicide: An Overview Brian Greenfield, Londa Daniel and Bonnie Harnden

Chapter 3

Immigrants and Suicidal Behavior: The Role of Gender Diana van Bergen and Sawitri Saharso

21

Chapter 4

Suicidal Behavior among Hispanic Immigrants in the United States Guilherme Borges, Liliana Mondragón and Joshua Breslau

37

Chapter 5

Suicidality and Acculturation in Hispanic Adolescents Andres J. Pumariega, Eugenio M. Rothe, Jeffrey Swanson, Charles E. Holzer, Arthur O. Linskey and Ruben Quintero-Salinas

57

Chapter 6

Suicide amongst Britain‘s Immigrant Population: Data Sources, Analytical Approaches, and Main Findings Peter J. Aspinall

Chapter 7

The Effects of Immigration on the Mental Health of Adolescents: Depression, Post-Traumatic Stress Disorder, Substance Abuse, Delinquent and Suicidal Behavior among Immigrant Youth Dana Galler and Leo Sher

9

71

87

Part II Acculturation and Mental Health Chapter 8

Acculturation and Mental Disorders among Immigrants Michael G. Madianos

Chapter 9

Immigration, Psychosocial Factors and Psychological Distress, with Focus on Perceived Control and Social Integration Odd Steffen Dalgard

101

113

vi

Contents

Chapter 10

Depression among Latinos in the United States Patricia Gonzalez and Monica Rosales

Chapter 11

Acculturation, Acculturative Stress, and Depression among Haitians in the United States Guerda Nicolas, Darren Bernal and Seth T. Christman

Chapter 12

Changes in the Psychological Well-Being of Immigrants: A ThreeYear Longitudinal Study of Immigrant Adolescents Including the Pre-Migration Period Eugene Tartakovsky

Chapter 13

Mental Health Problems among Immigrants in Israel Alexander M. Ponizovsky

Chapter 14

Epidemiology of Mental Health Problems among Immigrants. Case of Korean Immigrants in Brazil Sam Chun-Kang, Denise Razouk, Jair J. de Mari, Itiro Shirakawa and Luiza Beth Alonso

Chapter 15

Successful Use of Mental Health Migration Models: The New Zealand Experience Regina Pernice

133

149

163 187

209

223

Part III: Substance Abuse Chapter 16

Substance Use Disorder among Immigrants in the United States Sun S. Kim, David Kalman, Gerardo Gonzalez and Douglas Ziedonis

Chapter 17

Alcohol Drinking and Treatment among Immigrants from the Former Soviet Union (FSU) in Israel: Review of Recent Publications January 2007-June 2009 Shoshana Weiss

243

267

Part IV: Miscellaneous Chapter 18

The Motives for Migration Michal Sabagh and Barbara S. Okun

283

Chapter 19

The Social and Cultural Context of Immigration and Stress Katie Vasey and Lenore Manderson

295

Chapter 20

Post-traumatic Stress Disorder: Integration of Biological and Psychosocial Aspects María Dolores Braquehais Conesa and Leo Sher

313

Contents

vii

Chapter 21

Impulsivity: A New Concept for an Old Idea María Dolores Braquehais Conesa

Chapter 22

Not Just Another Pretty Face: The Cross-Cultural Perception and Social Ramifications of Facial Attractiveness Dana Galler

327

About the Editors

333

Chapter 23 Index

321

335

PREFACE Immigrants' journeys to a new nation have been among the most exciting and dignified of human endeavors. Immigrants are going to a new country for the best of intensions: the wish to improve their lives; the desire to leave countries whose governments they could not tolerate; and the eagerness to work for another country where individuals can live in freedom and dignity. Immigrants are an integral part of many societies, contributing both to the economy and diversity of their new countries. Immigration is usually very nerve-racking. Upon arrival to a new country immigrants are confronted with various stresses and adjustment problems in the receiving society. The pain, pressure and stress associated with immigration can come from all facets of life: language barriers, feeling of loneliness and marginality, homesickness, social role changes and identity crises, cultural differences, economic adversities, social discrimination and family troubles. There is a high prevalence of psychological distress among immigrants. This can lead to severe and long-lasting psychological and behavioral problems, including depression, anxiety, posttraumatic stress disorder, substance abuse, and a high risk for suicide. It has been suggested that immigrants are more likely to need psychiatric treatment than natives. Generally, there are two opposite viewpoints of immigrants‘ psychological health. The first one predicts higher psychological distress among immigrants, and the other argues that immigrants have better psychological health than natives. Some studies indicate the existence of positive migratory selection factors, i.e., the self-selection and selection effect of immigration policies motivate the mentally healthy people who can be characterized as having strong, optimistic and confident personalities, to migrate to other countries. Immigrants often face significant obstacles to receiving quality mental health care including financial difficulties, lack of insurance, the lack of culturally- and linguisticallyappropriate services, and mistrust of mental health providers. For example, in the U.S., a disproportionate number of immigrants work in low-wage jobs, in small firms, and in labor, service, or trade occupations, which are less likely to offer health benefits. This book is devoted to research on immigration and mental health. The contributors to this book are the leading international experts in psychiatry, psychology and sociology. We would like to acknowledge and thank all the contributors. Our task as the editors was greatly facilitated by their swift and positive response to our initial inquiry, and thereafter by producing their manuscripts diligently.

x

Leo Sher and Alexander Vilens

Leo Sher dedicates this book to the memory of his parents, Ivetta Sher and Alexander Sher. Alexander Vilens dedicates this book to his parents, Blyuma Vilenskaya and Naum Vilensky. We welcome comments from readers. Please, submit your comments via the website at www.internetandpsychiatry.com Leo Sher Alexander Vilens December 2009

PART I SUICIDAL BEHAVIOR

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 1

A MODEL OF SUICIDAL BEHAVIOR AMONG IMMIGRANTS WITH PSYCHIATRIC DISORDERS Leo Sher Columbia University and New York State Psychiatric Institute, New York, New York, USA

ABSTRACT The term "immigration" is usually used to denote international immigration. The United Nations considers a long term international migrant to be ―A person who moves to a country other than that of his or her usual residence for a period of at least a year (12 months), so that the country of destination effectively becomes his or her new country of usual residence.‖ Immigrants‘ voyages to a new land have been among the most exciting and noble of human endeavors [4]. It is the amazing courage to flee oppression, to leave behind everything that is familiar, and to chance the hostility of a completely alien culture in order to find freedom, opportunity, and a better life. Many and many immigrants and refugees, including Albert Einstein, Ernst B. Chain, Selman A. Waksman, Enrico Fermi, Sigmund Freud, Eric Fromm, Bertold Brecht, Jean Gabin, Charles de Gaulle, Thomas Mann, Jean-Jacques Rousseau, François-Marie Arouet (Voltaire), Victor Hugo, David Ben-Gurion and Henry A. Kissinger, have made a remarkable contribution to the welfare and happiness of mankind. The editors of this book, Leo Sher, M.D. and Alexander Vilens, M.S. are also immigrants. Immigration is difficult and stressful. Many immigrants suffer from psychiatric disorders and some immigrants attempt or commit suicide. In this chapter, I propose a model of suicidal behavior among immigrants with psychiatric disorders. All immigrants experience preimmigration, immigration and post-immigration stress. Immigrants are frequently depressed. Depression in immigrants is associated with anxiety, post-traumatic symptoms, alcohol and/or drug use/abuse/dependence, pessimism, and stress-related medical illnesses such as hypertension, metabolic syndrome, and diabetes. Psychiatric and medical problems, genetic make-up, childhood experiences, availability of a social support, cultural acceptability of suicide, the degree of pre-immigration, immigration, and post-immigration stress, and other factors determine the vulnerability for suicidal behavior among immigrants with psychiatric disorders. Suicidal acts can be attributed to

2

Leo Sher the coincidence of a trigger with a vulnerability for suicidal behavior. Triggers for suicidal behavior among immigrants include financial problems, relationship problems, mood instability (e.g., the onset of a major depressive episode), alcohol intoxication, abuse/assault, and acute medical illness. Suicide prevention among immigrants requires comprehensive, coordinated, and continuous health and mental health services for immigrant populations provided by culturally competent professionals.

INTRODUCTION The term "immigration" is usually used to denote international immigration. The United Nations considers a long term international migrant to be ―A person who moves to a country other than that of his or her usual residence for a period of at least a year (12 months), so that the country of destination effectively becomes his or her new country of usual residence. From the perspective ... of the country of arrival the person will be a long-term immigrant‖ [1]. The International Organization for Migration has reported that there are more than 200 million migrants around the world today [2]. Europe hosted the largest number of immigrants, with 70.6 million people in 2005, the latest year for which figures are available. North America, with over 45.1 million immigrants, is second, followed by Asia, which hosts nearly 25.3 million. Only Northern America and the former USSR have seen a sharp increase in their migrant stock between 1970 and 2000 (from 15.9 per cent to 23.3 per cent for Northern America and 3.8 per cent to 16.8 per cent for the Former USSR). In the latter case however, this increase has more to do with the redefinition of borders than with the actual movement of people. The United Nations found that, in 2005, there were nearly 191 million international migrants worldwide, 3 percent of the world population. Recent surveys by Gallup found roughly 700 million adults would like to migrate to another country permanently if they had the chance [3]. The United States is the top desired destination country. Nearly one-quarter (24%) of these respondents, which translates to more than 165 million adults worldwide, name the United States as their desired future residence. From the time of the nation's founding, immigration has been crucial to the United States' growth. James Madison (1751-1836), an American politician and political philosopher who served as the fourth President of the United States (1809–1817), and was one of the Founding Fathers of the United States, wrote, ―America was indebted to immigration for her settlement and prosperity. That part of America which had encouraged them most had advanced most rapidly in population, agriculture and the arts.‖ At the turn of the 21st century, the United States has experienced another great wave of immigration, the largest since the 1920s. Immigration has also been very important to the development of many other countries.

IMMIGRATION AS A HUMAN ENDEAVOR Every day, migrants leave their homelands behind for new lives in other countries. Immigrants‘ voyages to a new land have been among the most exciting and noble of human endeavors [4]. It is the amazing courage to flee oppression, to leave behind everything that is familiar, and to chance the hostility of a completely alien culture in order to find freedom,

A Model of Suicidal Behavior among Immigrants with Psychiatric Disorders

3

opportunity, and a better life. Every person, every family has a different story to tell about the reasons for and the circumstances surrounding their departure from their native country. Immigrants are moving to a new country for the best of motives: the desire to improve their lives; the urge to leave countries whose governments they could not abide; and the willingness to work for another country where individuals can live in freedom and dignity. Many and many immigrants and refugees, including Albert Einstein, Ernst B. Chain, Selman A. Waksman, Enrico Fermi, Sigmund Freud, Eric Fromm, Bertold Brecht, Jean Gabin, Charles de Gaulle, Thomas Mann, Jean-Jacques Rousseau, François-Marie Arouet (Voltaire), Victor Hugo, David Ben-Gurion and Henry A. Kissinger, have made a remarkable contribution to the welfare and happiness of mankind. The editors of this book, Leo Sher, M.D. and Alexander Vilens, M.S. are also immigrants.

Figure 1. A model of suicidal behavior among immigrants.

4

Leo Sher

A MODEL OF SUICIDAL BEHAVIOR Immigration is difficult and stressful [5-7]. An old Italian story posted in today's Ellis Island museum puts it this way: "I came to America because I heard the streets were paved with gold. When I got here, I found out three things: First, the streets were not paved with gold. Second, they weren't paved at all. Third, I was expected to pave them." The sociocultural and political characteristics of the country of origin and the immigration social policy of the host country play an important role in the acculturation process of immigrants. Many immigrants suffer from psychiatric disorders and some immigrants attempt or commit suicide [5-12]. In this chapter, I propose the following model of suicidal behavior among immigrants with psychiatric disorders (Figure 1): 1. The future immigrants consist of the two groups: a) individuals without psychiatric disorders; and b) individuals with psychiatric disorders. Possibly, many individuals who did not have psychiatric disorders in their countries of origin but develop psychiatric conditions and exhibit suicidal behavior in a new country had certain maladaptive personality traits and/or some degree of psychiatric pathology and/or suicidal tendencies before immigrating to the new country [10]. However, it is very possible that practically healthy persons may develop psychiatric conditions and exhibit suicidal behavior as a result of immigration-related chronic stress. 2. All future immigrants experience pre-immigration stress. Pre-immigration stress is frequently related to traumatic experiences, loss of home, livelihood, social position, family, friends, community, homeland, familiar language, feeling of an uncertain future and doubts whether the decision to emigrate/immigrate is correct. Preimmigration stress can have a direct effect on mental and physical health status immediately after arrival to a new country. 3. All immigrants experience immigration stress. The process of relocation is difficult for many people. Immediately upon arrival to a new country, immigrants frequently become targets for abuse, cruelty and corruption. For example, in 1900, on Ellis Island, the main U.S. immigration center at that time, immigration officials demanded bribes from immigrants who appeared to have money; if the bribe was questioned, or slow in coming, an immigrant was detained [13]. Other immigration officials would admit pretty young women on the condition that the women make sex with them. Railroad agents sold tickets at inflated prices. Immigrants were compelled to buy box lunches they didn't want for many times their value. Employees at the Money Exchange simply lied about the exchange rates and then pocketed the difference. Some American immigration inspectors were issuing fake certificates of citizenship for a fee and splitting the profits with ship officers. I think that in other countries and in other times the experience of immigrants was quite similar. 4. Post-immigration stress is frequenlty very severe. Immigrants often face difficulty adjusting to their new home in a new country for many reasons, including coping with trauma experienced in their native country, overcoming cultural and language barriers, and encountering discrimination [5-7,11,12]. The effects of immigration on psychological and social well-being are especially profound for certain populations,


5

including children, women, individuals with disabilities, and those with limited financial resources. Many immigrants are often forced to take low-qualified jobs, even though they have the training and education for professional jobs. They cannot sustain their former economic and social status, which can lead to psychological distress. Language barriers often force otherwise intelligent immigrant children and adolescents to study at one to two grades lower than their peers [12], creating a situation which can be potentially demoralizing. A combination of pre- and post-immigration stressful situations can lead to severe and long-lasting psychological and behavioral problems, including depression, anxiety, posttraumatic stress disorder, alcohol and/or drug abuse, and a high risk for suicide. Immigrants who experienced more stressful life events presented progressive deterioration in psychological well-being [14]. Post-immigration experience is affected by health related social policy and political factors. For example, U.S. immigration policy programs in the 1960‘s and 1970‘s took a good care of the Cubans fleeing the Castro regime and Cubans were among the healthiest of all Latino groups in the U.S.A. [15]. 5. Immigrants are frequently depressed [5,7,16]. Depression in immigrants is associated with anxiety, post-traumatic symptoms, alcohol and/or drug use/abuse/dependence, pessimism, and stress-related medical illnesses such as hypertension, metabolic syndrome, and diabetes. For example, a higher prevalence of impaired lipid metabolism in immigrants in comparison with native population has been observed [16]. A recent study has shown that immigrants who experience downward social mobility are at elevated risk for major depression [17]. Depression in immigrants is related to discrimination. It‘s a vicious cycle: a) discrimination leads to or aggravates depression, and b) depressed immigrants are easier targets for discrimination. Depressive disorders are associated with a negative bias in information processing [18]. Depressed immigrants are more likely to remember negative than positive emotional information. This may negatively affect their ability to adjust to the new environment. Substance abuse may be more pronounced if the immigrants acculturate into a more permissive society, abandoning the more traditional or conservative values of their former culture [19]. Genetic factors and childhood experiences play an important role in the pathophysiology of psychiatric conditions in immigrants. 6. Psychiatric and medical problems, genetic make-up, childhood experiences, availability of a social support, cultural acceptability of suicide, the degree of preimmigration, immigration, and post-immigration stress, and other factors determine the vulnerability for suicidal behavior among immigrants with psychiatric disorders. The suicidal process may be different for individuals of immigrant background compared to people living in the host country. The theory of anomie (lack of social regulation) suggests that it is not poverty that causes suicide, but rather declines in socioeconomic status that produce anomie and result in suicide

6

Leo Sher

[20]. Thus, immigrant populations that are accustomed to low (or high) socioeconomic status may not be negatively affected by the continuance of this status in their new host country. 7. Triggers for suicidal behavior among immigrants include financial problems, relationship problems, mood instability (e.g., the onset of a major depressive episode), alcohol intoxication, abuse/assault, and acute medical illness. 8. Suicidal acts can be attributed to the coincidence of a trigger with a vulnerability for suicidal behavior [21,22]. Suicidal acts include suicide attempts and suicides. Many individuals with depression and/or other psychiatric disorders have suicidal thoughts but they never attempt suicide [22]. Immigrants typically evidence higher suicide rates than those found in their countries of origin and/or in the host country into which they have migrated [8,9]. For example, in Sweden, a significant overrepresentation of immigrants has been reported in the total cases of suicide [8]. It is of interest to note that ethnic immigrant groups subjected to more negative ethnophaulisms, or hate speech, were more likely to commit suicide [23].

IMMIGRANTS AND MENTAL HEALTH SERVICES Despite the critical need for mental health services, immigrants face significant obstacles to receiving quality mental health care including financial difficulties, the lack of culturallyand linguistically-appropriate services, and mistrust of mental health providers [2,3]. Suicide prevention among immigrants requires comprehensive, coordinated, and continuous health and mental health services for immigrant populations provided by culturally competent professionals. It is important to recognize psychiatric disorders in these populations. Social and legal help should also be provided. Suicide prevention hotlines where immigrants can speak their native language may be very important. Special attention should be given to immigrants and refugees who experienced traumatic circumstances including exposure to war and natural disasters, human trafficking, physical, sexual and emotional abuse. Suicide prevention in this high-risk population should include treatment of medical and neurological disorders.

CONCLUSION The recognition of the full professional equality of immigrants, their social acceptance and respect for their vocational and cultural aspirations may be the best protections against mental health problems among immigrants. It is critical to create a welcoming environment where immigrants can realize their potential and succeed.


7

REFERENCES [1]

[2] [3]

[4]

[5] [6] [7] [8]

[9] [10]

[11] [12]

[13] [14]

[15] [16] [17]

United Nations. Recommendations on Statistics of International Migration New York, 1998, p. Box 1. http://unstats.un.org/unsd/publication/SeriesM/SeriesM_ 58rev1E.pdf Accessed November 19, 2009 International Organization for Migration. http://www.iom.int/jahia/Jahia/aboutmigration Accessed November 19, 2009 Esipova N, Ray J. 700 million worldwide desire to migrate permanently. November 2, 2009. http://www.gallup.com/poll/124028/700-Million-Worldwide-Desire-MigratePermanently.aspx Accessed November 19, 2009 Schoolland K. Courage, Fear, and Immigration: The Significance of Welcoming Newcomers in a Free Economy. Julian Simon Memorial Lecture. Liberty Institute, New Delhi, India. January 10, 2005. http://www.idfresearch.org/ semImmigration.pdf Accessed May 23, 2009 Al-Issa I, Tousignant M. Ethnicity, Immigration, and Psychopathology. New York: Springer, 2004. Portes A, Rumbaut A. Immigrant America: A Portrait. 3rd edn. Berkely, CA: University of California Press, 2006. American Psychological Association. The Mental Health Needs of Immigrants. http://www.apa.org/ppo/ethnic/immigranthealth.html Accessed May 23, 2009 Ferrada-Noli M, Åsberq M, Ormstad K, and Nordström P. Definite and undetermined forensic diagnoses of suicide among immigrants in Sweden. Acta Psychiatrica Scand. 2007; 91(2): 130-135. Burvill PW. Migrant suicide rates in Australia and in country of birth. Psychol. Med. 1998; 28: 201–8. Sher L. On the role of neurobiological and genetic factors in the etiology and pathogenesis of suicidal behavior among immigrants. Med. Hypotheses 1999; 53(2): 110-1. Bhugra D: Migration, distress and cultural identity. Brit. Med. Bull. 2004; 60: 129-141 Sun S, Fung, WW, Kwong K. A Study on Mental Health of New Arrival Children for Their First Two Years of Settlement in Hong Kong. Hong Kong: City University of Hong Kong and Christian Action, 2000. History of Ellis Island. http://www.ohranger.com/ellis-island/history-ellis-island Accessed November 19, 2009. Slonim-Nevo V, Mirsky J, Rubinstein L, Nauck B. The impact of familial and environmental factors on the adjustment of immigrants: A longitudinal study. Journal of Family Issues 2009; 30(1): 92-123. Vega W A, Amaro H. Latino outlook: good health, uncertain prognosis. Ann. Rev. Pub. Health 1994; 15: 39-67. Tselmin S, Korenblum W, Reimann M, Bornstein SR, Schwarz PE. The health status of Russian-speaking immigrants in Germany. Horm. Metab. Res. 2007; 39(12): 858-61. Nicklett EJ, Burgard SA. Downward social mobility and major depressive episodes among Latino and Asian-American immigrants to the United States. Am. J. Epidemiol. 2009;170(6):793-801.

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[18] Harmer CJ, O'Sullivan U, Favaron E, Massey-Chase R, Ayres R, Reinecke A, Goodwin GM, Cowen PJ. Effect of acute antidepressant administration on negative affective bias in depressed patients. Am. J. Psychiatry 2009;166(10): 1178-84. [19] De La Rosa M. Acculturation and Latino adolescents' substance use: a research agenda for the future. Subst. Use Misuse 2002;37(4):429-56. [20] Durkheim E. Suicide: a study in sociology. Transl. by Spalding JA, Simpson G. London, Routledge and K. Paul, 1952. [21] Sher L. A model of suicidal behavior in war veterans with posttraumatic mood disorder. Med. Hypotheses 2009;73(2):215-9. [22] Sher L, Oquendo MA, Mann JJ. Risk of suicide in mood disorders. Clin. Neurosci. Res. 2001; 1(5):337-344. [23] Mullen B, Smyth JM. Immigrant suicide Psychosom. Med. 2004;66(3):343-8.


ISBN 978-1-61668-503- 4 © 2010 Nova Science Publishers, Inc.

Chapter 2

IMMIGRATION AND SUICIDE: AN OVERVIEW Brian Greenfield,1 Londa Daniel2 and Bonnie Harnden2 1. McGill University Faculty of Medicine and Montreal Children‘s Hospital, Montreal, Quebec, Canada 2. Concordia University, Montreal, Quebec, Canada

ABSTRACT Introduction: The assessment of patients contemplating suicide requires a specific skill set. When immigrants are involved, the complexity increases. Method: This article presents an overview of cultural issues concerning suicide, examining cultural differences among several countries of origin and tracking the impact of those disparities as immigrants adapt to the host culture through the first and subsequent generations. Results: Although suicide may be universally considered a final common pathway of distress, its acceptability, manifestations and execution vary widely across cultures. When individuals from disparate cultures immigrate to a host country, their suicide rates and methods gradually assume a profile similar to those of the host culture, mediated by acculturative stress, the process of acculturation and by risk factors (eg never having been married, drug use and rejection by the host culture) and protective elements (eg maintenance of traditional family relationships, belonging to an ethnic community, living in a large city and being married). Consideration is given to the Canadian Inuit, faced with problematic integration into the mainstream culture and particularly high suicide rates, to provide perspective on similar challenges and therapeutic matters in relation to suicidal immigrants. A case example highlights some of these characteristics. Conclusion: Although commonalities can be found between cultures in their attitudes toward suicide and the stresses associated with immigration, assessment of immigrants who are suicidal must be considered on an individual basis and superimposed on a sound clinical interview.

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Brian Greenfield, Londa Daniel and Bonnie Harnden

INTRODUCTION This chapter is an overview of suicide in the North American immigrant population. Some components inform clinicians about cultural factors that are relevant during assessment and treatment, while others guide researchers to literature supporting differences in suicide among immigrant populations. The term ‗immigrant population‘ refers to a heterogeneous cohort of diverse cultural backgrounds who have relocated for a range of different reasons and have lived in the host country for varying amounts of time. An exhaustive review of each group is beyond the scope of this chapter, which provides a framework clinicians can apply in assessing and that treating this population. What follows is a description of suicide rates, acculturation and acculturative stress (processes that influence the mental health of immigrants), protective and risk factors, cultural attitudes towards suicide, methods of suicide, suicide within aboriginal populations and a discussion of the applicability of cultural factors to diagnosis and treatment.

DIFFERENCES IN IMMIGRANT SUICIDE RATES Most of our current knowledge of suicide – statistics, predictors and protective and risk factors – has been derived from research with resident populations in industrialized (mainly North American and European) nations, and thus we know very little about the applicability and relevance of this literature to North American immigrant populations. Research on these groups, however scarce, indicates that significant differences in suicide tendencies may exist in comparison to non-immigrant populations. Within Canada and the US, suicide rates differ among cultural groups. Aboriginal and Inuit people are most likely to commit suicide, followed by non-Hispanic Caucasions, Hispanics, non-Hispanic Blacks and, least of all, Asian and Pacific Islanders [1]. In general, first generation immigrants demonstrate particularly low rates, resembling rates typical of their country of origin [2], with later generations demonstrating increased frequencies more comparable to North American trends [3]. Differences also exist by gender and age, following trends typical of the country of origin [4]. In the North American population, the suicide gender ratio is four men to every woman, reversing to 2:7 in many immigrant populations where women are more likely to commit suicide. Furthermore, suicide risk peaks in adulthood for Canadian-born populations, whereas in other groups, such as Chinese-Canadians, the elderly are at highest risk [4].

ACCULTURATION AND THE GENERATION EFFECT Acculturation describes the process of change that occurs as a result of exposure to a different culture [5]. It is responsible for change at both the individual and group levels. Individually, psychological changes occur, reflecting host society attitudes and behaviours. Collectively, cultural customs, economics and politics grow more similar to those of the host country. Acculturative stress describes the psychological difficulties which arise during the acculturation process [6]. For many, this process includes financial problems, discrimination,

Immigration and Suicide: An Overview

11

language difficulties, separation from family and alienation from traditional cultural beliefs. Elevated blood pressure, a stress response to this process noted in immigrant populations, remains higher than normal for as long as 15 years following immigration [7]. The cooccurring phenomena of acculturation and acculturative stress seem to play separate roles in affecting the likelihood of suicide.

Acculturative Stress Although acculturative stress is associated with economic and sociological hardships, some immigrants nonetheless have better mental health and lower suicide rates than even the host population, as has been documented in the Hispanic immigrant population [8] and in a variety of youth immigrant populations [9]. Although the process of immigration is unquestionably inherently stressful, some have questioned the utility of the term acculturative stress given that first-generation immigrants could have lower rates of mental illness and suicide than the host population [6]. When it does have negative consequences, acculturative stress seems to decrease with time spent in the host country. For instance, first-generation immigrant populations living in the US for over 20 years have a lower risk of committing suicide than the same cohort living in the US for only 10 years [10]. These findings imply that negative effects of acculturative stress may become less salient over time and suicide risk thus decreases. This effect has also been documented in immigrant populations in Britain, with suicide rates of long-term firstgeneration residents lower than those for recent immigrants [11]. Thus, despite the lower suicide rates of first-generation immigrants compared to the native population, acculturative stress may nevertheless have a role to play. It may be that the initial lower suicide rates are more reflective of suicide factors in the culture of origin than the absence of mental stress during the immigration process.

Acculturation The process of acculturation seems to play a different role in the psychological wellbeing of second- and later-generation immigrants as compared to first-generation immigrants. Concerns appear to shift from acculturative stressors, such as moving and adjusting to new cultural norms, to reconciling conflicts between heritage and host culture, while stressors such as prejudice and stereotyping persist. An example of this is the Latin-American population, which has higher rates of mental illness and suicide in second- and later-generation immigrants. These later generations may be less protected by the strong family and community bonds characteristic of Mexican culture, for example, rendering them more susceptible to mental illness and suicide [3]. Hence, although acculturation has certain advantages (eg overcoming language barriers, increased employment opportunities, acceptance within the host culture), it is disadvantaged by ‗dissimilation‘ (estrangement) from the heritage culture [12].

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PROTECTIVE AND RISK FACTORS Researchers have identified a number of factors that either protect against, or constitute risk for, suicide.

Protective Factors Protective factors which have been theorized to account for the observed low rates of mental illness in immigrant groups include maintenance of traditional family relationships, belonging to an ethnic community, living in a large city and being married. Mexican and other Latino immigrant populations are likely to have especially strong family ties, as seen in traditional Mexican culture [13], and these relationships may be responsible for low suicide rates within these groups [14]. It is possible that the lower suicide rates observed among nonHispanic Black, Asian and Pacific Islander immigrants as compared to the US Caucasian population [1] may be due to similarly protective family relationships. Trovato and Jarvis [15] found that immigrant cultures differ in the extent to which they experience ‗community completeness‘, which is described as belonging to, and feeling supported within, a community. This feeling may play an important role in suicide prevention in different cultures. Immigrant groups in Canada with low levels of community completeness, such as the Welsh, Scots, Germans and Americans, tend to have higher rates of suicide, and groups with high levels of community completeness, such as the Italians, Portuguese and Irish, have lower suicide rates [15]. Emile Durkheim‘s early work, Suicide [16], offers an anthropologic perspective to account for the importance of community and social networking as protective against suicide. He maintained that the observed differences in suicide rates between cultures inversely reflected the level of social integration, such that individuals manifesting strong social bonds pose a lower risk than those with less developed social networks. In keeping with Durkheim‘s work, immigrant populations are advised to build community and social bonds via assimilation into the host country‘s culture or maintenance of ties with other immigrants sharing the same culture. In support of this theory, researchers have noted that living in a large city is protective against suicide. Canada‘s three largest cities, Toronto, Montreal and Vancouver, where more than 60% of Canada‘s immigrant population lives, have the lowest immigrant suicide rates, supporting the notion that ethnic community plays a powerful role in preventing suicide in immigrant populations [4]. Being married [17] is also generally a predictor of lower suicide rates and is particularly protective in immigrant populations. Kposowa, McElvain and Breault [10] found that single immigrants were 4.4 times more likely, and divorced or separated immigrants were 3.7 times more likely, to kill themselves than married immigrants. This finding might relate to the value placed on family versus autonomy in other cultures and to a feeling of loneliness and alienation often accompanying the immigration process.


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Risk Factors Acculturation, lack of an ethnic community, never having been married (or being divorced) and drug use may pose particular risks for suicidal behaviour in certain immigrant populations. Conversely, low drug use among first-generation Mexican immigrants [18] may account for lower rates of suicide in immigrant groups as compared to the host population, a relationship that was also observed by Greenfield et al [19] in a variety of immigrant youth populations. In later immigrant generations, rates of drug use increase significantly, paralleling the rates of suicide, though they still remain lower than the rates of the host population and lower than those recorded in the general Mexican population [18]. Pena et al [3] similarly found that drug use among Mexican immigrants may mediate the relationship between generation status and suicide, such that drugs (cocaine, inhalants, LSD, PCP, ecstasy, mushrooms, speed, ice, heroin or non-prescription pills) were closely related to suicidal behaviour in later-generation immigrants. Knowledge of the relationship between drug use and suicidal behaviour can inform clinicians, who would thus be advised to inquire about drug-use patterns and initiate early intervention as a component of suicide prevention in at-risk immigrant populations. Suicide risk is dependent upon level of rejection of immigrant groups by the host population and can be measured by the level of hate speech, or ‗ethnophaulisms‘, directed toward immigrant populations. Mullen and Smyth [20] found that European immigrant groups in the US that were subject to higher rates of ethnophaulisms were more likely to commit suicide, further underlining the role that host culture plays in determining suicide rates within ethnic groups. Given the financial stressors inherent in the immigration process, one might intuitively anticipate that immigrant populations would have higher levels of mental illness, poor-quality health care and increased suicide rates. This would be consonant with Hollingshead and Redlich [21], who documented a higher prevalence of schizophrenia among lowsocioeconomic-level populations. However, it has been demonstrated that, despite socioeconomic stressors, Mexican immigrant populations do not experience greater rates of mental illness [13]. Durkheim‘s theory of anomie (lack of social regulation) [16], posits that it is not poverty that causes suicide, but rather declines in socioeconomic status that produce anomie and result in suicide. Thus, immigrant populations that are accustomed to low (or high) socioeconomic status may not be negatively affected by the continuance of this status in their new host country. The clinician might therefore be advised to inquire about status or income changes during assessment.

CULTURAL ACCEPTABILITY OF SUICIDE Cultural attitudes toward suicide may protect or pose risk and can be examined from both religious and non-religious perspectives. In highly religious communities, suicide rates may be affected by attitudes that condemn or reward suicide. For instance, the Hindu faith is characterized by understanding and acceptance of suicide and Asian-Hindu immigrants to the US have has a correspondingly high rate of suicide compared to Asian immigrants practising the Islamic faith [22]. Similarly, Mexican [23] and African [24] immigrant populations both

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demonstrate strong religious affiliation and low rates of suicide. But the relationship between religion and suicide is not always this simple and requires a further examination of the country, politics, religious practice and manner in which the population adheres to particular religious values. For example, even countries practicing the same religion may have different suicide rates, so that Catholic countries such as Austria and France have high rates of suicide while others such as Ireland, Spain and Italy have low rates [25]. Rates can even differ within the same country and religion; Irish rural areas have demonstrated a more substantial increase in suicide rates than urban areas during a recent decade [26]. Others have examined non-religious cultural attitudes towards suicide. In the Japanese culture, suicide is a respected, serious act, yet suicide rates are very low among the Japanese immigrant population [27], possibly resulting from other predominating protective factors. Reynolds, Kalish, and Farberow [28] observed differences in attitudes towards suicide in four different cultural groups within the US: Japanese-American, Mexican-American, CaucasianAmerican and African-American. In response to the question ‗What kind of individuals commit suicide?‘, Japanese-Americans were significantly more likely to choose ‗cowardly‘, whereas both African- and Mexican-Americans were more likely to opt for ‗crazy‘ and Caucasian-Americans favoured ‗emotionally upset‘, again highlighting cultural attitudes toward suicide. Such differences may reflect variation in cultural expression of suicide rather than differences in underlying affect. It is possible that individuals in all cultures are driven to suicide by the same emotional experience (distress, guilt, sadness), but that cultural acceptability acts as a lens through which the emotion is interpreted and managed. Differences in cultural acceptability may lead to the enlistment of different attitudes to defend against the same negative affect.

METHOD OF SUICIDE First-generation immigrant populations within North America tend to choose methods of suicide that are influenced by their cultural heritage. Method is determined by cultural traditions and attitudes, availability of resources [29], country of origin, location within a given country and gender. For instance, traditional customs in Japan led to the popularity of ritual disembowelment (cutting the abdomen from left to right), which emerged as a means to preserve honour and respect when warriors were about to be killed by an enemy. Due to changes in cultural norms and availability of resources, this custom was eventually superseded; hanging and taking pills are now the most common methods [27]. In Switzerland, firearms, which constitute a symbol of respect for the military, are eschewed as a method of suicide in favour of the most common practice, inhalation of toxic gas [30]. Within the Chinese population, methods differ according to location and availability of resources. In Hong Kong, jumping from a height was the most common method, whereas in Taiwan, poisoning was most frequent [31]. In the Indian subcontinent, both men and women commit suicide through poisoning with agrochemicals, a readily accessible resource [32]. In South Africa, choice of method is dependent upon ethnicity and gender rather than location or resources. African and Indian men have high rates of hanging and women commit suicide


15

most commonly by fire. Among the Caucasian population, men commit suicide most often with firearms and women choose poisoning [33]. There are also differences among cultures within North America. The most common method of suicide for Caucasian North Americans is by staged motor-vehicle accident, followed by poisoning, firearms and jumping from a height [1]. African-Americans use more violent methods compared to Caucasian-Americans, who have relatively higher rates of taking pills or toxic gases [34]. It has been postulated that these differences are driven by increased exposure to violence, lower socioeconomic status and increased availability of firearms within the African-American community [34]. Understanding suicide profiles in the country of origin, how those trends become manifest after transition to the host country can be evaluated. Lester [31] observed that recent Asian immigrants were influenced by suicide trends from their heritage culture and were more likely to choose hanging than Caucasian-Americans or African-Americans, consistent with the popularity of hanging in Chinese culture. However, as immigrant groups assimilate into the host culture, they are more likely to use methods prevalent in their adopted country. Burvill, McCall, Woodings and Stenhouse [35] have also found that although recent immigrants (from England, Scotland and Ireland) to Australia used methods that were common in their heritage culture, they were more likely to adopt Australian methods as their residency lengthened. Similarly, Lester [32] noted that Indian immigrants in other nations tend to switch from using poisoning with pesticides (popular in India) to hanging, perhaps reflecting a lack of availability of pesticides in the host countries or indicating how immigrants are influenced by the norms of the host culture.

SUICIDE AND ACCULTURATION WITHIN THE INDIGENOUS POPULATION There may be commonalities in the acculturation process between the Inuit and immigrant populations and, given the high suicide rate among Canadian Inuit, an examination of the factors contributing to that rate might increase understanding of risk factors in immigrants. Indigenous populations generally have higher rates of suicide than both Caucasian and immigrant populations [36]. Ihe Inuit population in Canada, for instance, demonstrates elevated patterns of suicide, with rates five times as great as those of the general population. In northern Quebec, this difference is even greater, with suicide rates among Inuit youth 20 times as great as those across the rest of Quebec [37]. Poor health care, poverty and lack of community control are some of the proposed factors accounting for that elevated rate. Heightened rates of indigenous suicide may also be due to conflict between Inuit and the majority North American culture; pressure to acculturate produces stress and alienation from heritage culture and loss of protective cultural traditions [38]. Especially high rates of suicide occur in communities that have high levels of acculturation (pressure to adopt the Caucasian culture) and are poorly integrated into social networks [39-40]. Several other risk factors associated with the Inuit population resemble those of immigrant groups and are worthy of mention. Drug and alcohol abuse are highly correlated with suicide and are prevalent among aboriginal youth with a proclivity to the use of solvents [37]. Lack of help-seeking behaviour is a particular obstacle in treating this population, as the

16


embarrassment and stigma of treatment can easily lead to its avoidance and the denial of a need for help [41]. Other risk factors include parental history of drug or alcohol abuse, suicidal behaviour in a close friend, presence of mental illness and alienation from community and family. Addressing these risk factors is paramount during interviews of suicidal patients from various cultures.

APPLICABILITY TO DIAGNOSIS AND TREATMENT Many factors contribute to the decision to commit suicide during the immigration process and they do not lend easily to an equation or diagnostic formula. Clinicians must first consider the general risk factors for suicide, gender, age, marital status, family history, previous attempts and substance abuse [42]. A thorough individual evaluation (and, in a paediatric setting, a family assessment as well) would then be required, searching for and attempting to repair weaknesses in interpersonal communication styles, which may render individuals vulnerable to distress. Superimposed upon this clinical template, clinicians may then consider cultural risk and protective factors for assessment and treatment. Such factors include norms of the heritage culture, attitudes towards suicide, the process of acculturation, the duration of stay in the host country and differentiation between the first and second generations. Also of relevance in this interview process is the manner in which symptoms are expressed in a given culture. For instance, Chinese immigrants are known to express depressive symptoms somatically rather than psychologically [43]. In such cultures, where somatic complaints are more socially acceptable than emotional problems, less distinction is made between organic functioning and emotion, such that physical ailments may serve as markers of mental illness such as depression and are thus also important in assessing suicidal risk. Furthermore, development of the therapeutic alliance, a factor that has consistently been one of the strongest predictors of treatment outcome [44], may be especially aided by knowledge of, and respect for, cultural differences. It is also important to consider who should be included in the assessment and treatment of a patient. When dealing with clients from Asian cultures, where high value is placed on family and interdependence, treatment may be facilitated by the inclusion of family members [45]. When other cultures view mental illness as unacceptable, thereby causing the patient to feel shame and guilt, inclusion of the family may actually hinder treatment. It is thus essential to consider individual circumstances when deciding which family members should be involved in the interview.

CASE EXAMPLE T is an 18-year-old girl from China who presented to an urban university hospital emergency room (ER), accompanied by her elder brother, with a complaint of stomach-aches. A psychiatric examination was requested by the paediatrician, as the patient frequently cried during examination, was guarded when questioned concerning possible suicidality and no organic aetiology was detected. Psychiatric assessment revealed that the patient had been


17

depressed during the previous two years and had frequently considered suicide, without having made attempts. She lived with her natural parents and brother. Despite discouragement from the paternal grandparents, the father, a successful businessman, had married the mother, who suffered from a long-standing gambling addiction. The mother had been increasingly indulging her addiction during the previous two years, with her husband fully aware of the problem but relatively helpless to stop her, thus rendering her less emotionally and physically available to the family. The patient, whose depression had worsened during that time, had no active plans to kill herself, but stated that her preferred choice would be by poisoning or overdose of overthe-counter medication in her home‘s medicine cabinets. Several clinical concerns were addressed during six sessions of crisis intervention with the family. The first ER assessment was focused on reinforcing the father‘s supervision of the patient, securing cleaning products and medications under lock-and-key and ensuring supervision of the patient after school and during weekends. The patient and family were also helped to understand the patient‘s somatic symptoms as cries for help, which needed to be taken seriously. The parents indicated that they were aware of the patient‘s physical suffering during recent years, but had felt they could address that themselves through consultation with Chinese friends. They now appreciated understanding that the emotional distress was masquerading as somatic complaints. During subsequent sessions, the patient revealed the stresses created by parental pressure for academic success. The parents indicated their perspective that, through study and hard work, the patient was more likely to become ‗successful‘ and ‗somebody‘. Household discussions thus focused on school-related activities, and no mention was made of the financial stresses induced by the mother‘s addiction. When this theme was aired, the father finally revealed that his long working hours were partially driven by a need to reimburse substantial debt incurred by the mother‘s habit and his further concerns that fatigue resulting from his heavy schedule could harm his own health, which worried the patient. Therapeutic efforts were focused on empathizing with the patient‘s academic struggles and with the family‘s stresses induced by the mother‘s gambling, the father‘s work load and the immigration process, validating their respective problems, and facilitating the mother‘s enrolment in a gambling rehabilitation program. The patient‘s clinical status was monitored and the impact of cultural issues on symptomatic presentation and evolution evaluated. A key therapeutic asset was understanding how Chinese parents function in a ‗cultural hierarchy‘, tending to predominantly interact with the oldest ‗parentified‘ child, who is then empowered to provide surrogate parenting to the younger siblings, with an expectation that the patient‘s illness would be healed by a ‗cultural collectivity‘. The patient‘s mother, burdened by her gambling habit, was less available to provide an example to the patient‘s brother, who was accordingly compromised in his ability to provide care for the patient, who then increasingly turned toward the host culture for solace and support, further distancing her from her parents. In common with dysfunctional families in the host culture, relationship issues, notably the mother‘s gambling, had never been addressed, there was pressure for the children to succeed academically, emotional issues were not recognized and the therapist used empathy and validation to produce therapeutic results. Of greater specificity to the Chinese culture, this family felt there was no pathway for receiving outside help, trying through their network of friends to deal with the patient‘s complaints. The mother and father directed their parenting to the oldest child, indirectly entrusting him with parenting the patient.

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CONCLUSION Although literature on immigrant populations tends to homogenize these communities, it would appear on closer examination that there may be further stratification among these groupings, such that each assessment must be considered individually. Assessment of suicidal patients is a complex process comprising individual and social risk factors. The complexity of that process is compounded by the multiplicity of risk factors inherent in the immigration experience over the generations. An awareness of these issues is essential in conducting interviews of immigrant populations and enriches them for all involved.

REFERENCES [1]

[2] [3]

[4] [5] [6] [7]

[8]

[9] [10] [11] [12] [13]

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control: Web-based Injury Statistics Query and Reporting System. 2006. Retrieved from: http://www.cdc.gov/ncipc/wisqars. Sainsbury P, Barraclough B: Differences between suicide rates. Nature 1968; 220:1252. Pena JB, Wyman PA, Brown CH, Matthieu MM, Olivares TE, Hartel D, Zayas LH: Immigration generation status and its association with suicide attempts, substance use, and depressive symptoms among Latino adolescents in the USA. Prev. Sci. 2008; 9: 299-310. Malenfant EC: Suicide in Canada's immigrant population. Health Rep. 2004; 15:9-17. Berry JW, Phinney JS, Sam DL, Vedder P: Immigrant youth: acculturation, identity, and adaptation. Appl. Psychol. 2006; 55:303-332. Rudmin F: Constructs, measurements and models of acculturation and acculturative stress. Int. J. Intercult. Relat. 2009; 33:106-123. Steffen PR, Smith TB, Larson M, Butler L: Acculturation to western society as a risk factor for high blood pressure: a meta-analytic review. Psychosom. Med. 2006; 68:386397. Vega WA, Kolody B, Aguilar-Gaxiola S, Alderete E, Catalano R, Caraveo-Anduaga J: Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Arch Gen. Psychiatry 1998; 55:771-778. Harker K: Immigrant generation, assimilation, and adolescent psychological well-being. Soc. Forces 2001; 79:969-1004. Kposowa AJ, McElvain JP, Breault KD: Immigration and suicide: the role of marital status, duration of residence, and social integration. Arch Suicide Res. 2008; 12:82-92. Bhugra D, Baldwin DS, Desai M, Jacob KS: Attempted suicide in West London, II. Inter-group comparisons. Psychol. Med. 1999; 29:1131-1139. Yinger JM: Toward a theory of assimilation and dissimilation. Ethn. Racial. Stud. 1981; 4:249-264. Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Anderson K: Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic whites in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen. Psychiatry 2004; 61:1226-1233.


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[14] Locke TE, Newcomb MD: Psychosocial predictors and correlates of suicidality in teenage Latino males. Hisp. J. Behav. Sci. 2005; 27:319-336. [15] Trovato F, Jarvis GK: Immigrant suicide in Canada: 1971 and 1981. Soc. Forces 1986; 65:433-457. [16] Durkheim E: Suicide: a study in sociology. Translated by Spalding JA, Simpson G. London, Routledge and K. Paul, 1952. [17] Stack S: Suicide: a 15-year review of the sociological literature. Part II: modernization and social integration perspectives. Suicide Life Threat Behav. 2000; 30:163-176. [18] Swanson JW, Linskey AO, Quintero-Salinas R, Pumariega AJ, Holzer CE, 3rd: A binational school survey of depressive symptoms, drug use, and suicidal ideation. J. Am. Acad. Child Adolesc. Psychiatry 1992; 31:669-678. [19] Greenfield B, Rousseau C, Slatkoff J, Lewkowski M, Davis M, Dube S, Lashley ME, Morin I, Dray P, Harnden B: Profile of a metropolitan North American immigrant suicidal adolescent population. Can. J. Psychiatry 2006; 51:155-159. [20] Mullen B, Smyth JM: Immigrant suicide rates as a function of ethnophaulisms: hate speech predicts death. Psychosom. Med. 2004; 66:343-348. [21] Hollingshead AB, Redlich FC: Schizophrenia and social structure. Am. J. Psychiatry 1954; 110:695-701. [22] Ineichen B: The influence of religion on the suicide rate: Islam and Hinduism compared. Mental Health, Religion and Culture 1998; 1:31-36. [23] Hovey JD: Acculturative stress, depression, and suicidal ideation in Mexican immigrants. Cultur Divers Ethnic Minor Psychol. 2000; 6:134-151. [24] Walker RL: Acculturation and acculturative stress as indicators for suicide risk among African Americans. Am. J. Orthopsychiatry 2007; 77:386-391. [25] Dublin LI: Suicide: a sociological and statistical study. New York, Ronald Press, 1963. [26] Kelleher MJ, Keeley HS, Corcoran P: The service implications of regional differences in suicide rates in the Republic of Ireland. Ir.Med. J. 1997; 90:262-264. [27] Iga M, Tatai K: Characteristics of suicides and attitudes toward suicide in Japan, in Suicide in Different Cultures. Edited by Farberow NL. Baltimore, MD, University Park Press, 1975. [28] Reynolds DK, Kalish RA, Farberow NL: A cross-ethnic study of suicide attitudes and expectations in the United States, in Suicide in Different Cultures. Edited by Farberow NL. Baltimore, MD, University Park Press, 1975. [29] Marzuk PM, Leon AC, Tardiff K, Morgan EB, Stajic M, Mann JJ: The effect of access to lethal methods of injury on suicide rates. Arch Gen. Psychiatry 1992; 49:451-458. [30] DeCatanzaro D: Suicide and self-damaging behavior: a sociobiological perspective. New York, Academic Press, 1981. [31] Lester D: The epidemiology of suicide in Chinese populations in six regions of the world. Chinese Mental Health Journal 1994; 7:25-36. [32] Lester D: Suicide in emigrants from the Indian subcontinent. Transcult Psychiatry 2000; 37:243-254. [33] Meer F: Race and suicide in South Africa. London, Routledge and K. Paul, 1976. [34] Stack S, Wasserman I: Race and method of suicide: culture and opportunity. Arch Suicide Res. 2005; 9:57-68.

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[35] Burvill PW, McCall MG, Woodings T, Stenhouse NS: Comparison of suicide rates and methods in English, Scots and Irish migrants in Australia. Soc. Sci. Med. 1983; 17:705708. [36] Leenaars AA: Suicide among indigenous peoples: introduction and call to action. Arch Suicide Res. 2006; 10:103-115. [37] Kirmayer LJ, Boothroyd LJ, Hodgins S: Attempted suicide among Inuit youth: psychosocial correlates and implications for prevention. Can. J. Psychiatry 1998; 43:816-822. [38] Berry JW: Acculturation and adaptation: health consequences of culture contact among circumpolar peoples. Arctic Med. Res. 1990; 49:142-150. [39] Bagley C: Poverty and suicide among native Canadians: a replication. Psychol. Rep. 1991; 69:149-150. [40] Van Winkle NW, May PA: Native American suicide in New Mexico, 1957-1979: a comparative study. Hum. Organ. 1986; 45:296-309. [41] Freedenthal S, Stiffman AR: Suicidal behavior in urban American Indian adolescents: a comparison with reservation youth in a southwestern state. Suicide Life Threat Behav. 2004; 34:160-171. [42] Kaplan HI, Freedman AM, Sadock BJ, editors. Comprehensive textbook of psychiatry. 3rd ed. Baltimore, MD, Williams and Wilkins, 1980. [43] Tseng WS, Asai M, Liu JQ, Wibulswasdi P, Suryani LK, Wen JK, Brennan J, Heiby E: Multi-cultural study of minor psychiatric disorders in Asia: symptom manifestations. Int. J. Soc. Psychiatry 1990; 36:252-264. [44] Horvath AO, Symonds BD: Relation between working alliance and outcome in psychotherapy: a meta-analysis. J. Couns. Psychol. 1991; 38:139-149. [45] Lin KM, Inui TS, Kleinman AM, Womack WM: Sociocultural determinants of the help-seeking behavior of patients with mental illness. J. Nerv. Ment. Dis. 1982; 170:7885.



Chapter 3

IMMIGRANTS AND SUICIDAL BEHAVIOR: THE ROLE OF GENDER Diana van Bergen1 and Sawitri Saharso2 1

2

The Netherlands Institute for Social Research, The Hague; VU University Amsterdam and University Twente, The Netherlands

ABSTRACT Ethnicity plays a major role in the rates and risk factors of suicidal behavior. While ethnocultural factors increasingly receive attention of suicidologists, the relevance of the intersections of ethnicity and gender are yet to be recognized. In this chapter, we review findings on the role that gender has for suicidal behavior of immigrants. We focus in particular on suicidal behavior of immigrant women and discuss gender specific risk factors. In addition, we summarize the indicators that exist cross culturally for the relevance of Durkheim‘s fatalistic suicide to understanding women‘s suicidal behavior.

INTRODUCTION Over the past decades, numerous empirical studies in suicidology have contributed to the knowledge of the epidemiology and risk factors of suicidal behavior. These studies have revealed remarkably consistent patterns of suicidal behavior according to gender. Females worldwide show higher rates of suicidal ideation and non-fatal suicidal behavior compared to males. A gender paradox emerges: across the globe, females are more suicidal, since they are more likely to report suicidal ideation and suicide attempts; however males are more likely to die by suicide [1, 2]. Hence, gender has a substantial predictive impact on suicidal behavior. Although suicide attracts most of the attention, it is statistically an infrequent phenomenon. Across cultures, non-fatal behavior is unequivocally found more often in females [3]. Since females worldwide outnumber men regarding this behavior, there is urgency in suicidology to focus on females. In spite of abundant evidence of the relevance of gender on suicide behavior, many studies fail to integrate gender as a crucial factor for detecting risk factors and origins of suicidal behavior [1]. Another shortcoming is that most studies conducted in the

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Diana van Bergen and Sawitri Saharso

west fail to recognize that the suicidal process may be different for individuals of immigrant background. Furthermore, the intersection of ethnicity and gender and its impact to suicidology in particular are an area of neglect. For example, the major role that depression plays towards the suicidal process has gained univocal support in the west and is taken for granted. Depression is to be more prevalent in females compared to males in the west [2]. However, depression is sometimes suggested to be less relevant to suicide in females in non western cultures for instance in India and China [4, 5]. In addition, research that has addressed ethnicity as a focus of interest often fails to include gender. For instance, a large study on immigrant and suicidal behavior in Canada by Clarke et al [6] showed that Franco-Europeans and native Inuit population had high suicide risk compared to other ethnicities due to alcohol abuse. A study from the US [7] showed how anti social behavior was linked to suicide for whites more than for blacks. Gender was not mentioned in these studies, which obscures whether differential patterns exist for immigrant men compared to immigrant women. In order to make a contribution to the lacunae that exist on the role of gender, in this chapter we accumulated a number of findings of suicidal behavior in immigrants in relation to gender, with special attention to immigrant females. We first examine the role of the gender paradox in the epidemiology of immigrants‘ suicidal behavior. Next we discuss important risk factors that are influenced by gender. Lastly, we want to specifically address the role of Durkheim‘s archetype of fatalistic suicide [8], which has an important explanatory power for immigrant women of Asian background, who make up a substantial part of the immigrant population in western Europe as well as the United States.

THE GENDER PARADOX IN SUICIDAL BEHAVIOR The gender paradox in suicidal behavior has been validated cross culturally in the US and Europe, for many immigrant as well as non immigrant groups [9-13]. Females exceed on rates of non fatal suicidal behavior and males on suicide rates. The gender ratio generally observed in suicide in the US and Europe is about 3-4 to 1 for males compared to females. However, in many non western countries, for instance Hong Kong, Sri Lanka and India, the gender differences are much smaller, often less than 2:1. Moreover, in rural China and Batman province in Turkey, the suicide rates of young women exceed that of men [2, 14]. Patterns and rates of suicidal behavior of first generations of immigrants seem to be replicated in the host countries and sometimes increase in the second generation of immigrants [12, 15, 16]. Support for this thesis can be found in South Asian immigrant young women who have high rates of fatal and non fatal suicidal behavior worldwide [17] and similar high rates in their countries of origin [18-19]. For instance, In the province of Nickerie in Surinam (which has predominantly a South Asian immigrant population), hospital registration has shown a rate of attempted suicide of 4.0 per 1,000 for South Asian females [20], which is remarkably similar to the registered high rates of South Asian-Surinamese females in The Hague, The Netherlands (4.2 per 1,000) [11]. South Asian young females are overrepresented compared to majority females among those who attempt suicide as well as those who die from suicide in The UK, Singapore, Fiji and The Netherlands [11, 17, 21, 22]

Immigrants and Suicidal Behavior: The Role of Gender

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In the US, Latino, African American as well as Asian youth have been found to have increased rates of fatal as well as non fatal suicidal behavior compared to those of European descent. In adults, however, this appears not to be the case [23]. In all ethnic groups in the US, females‘ rates of non fatal suicidal behavior exceed that of males; the gender ratio being 3:1 on average. Regarding suicide statistics, an average ratio of 5:1 (males to females) has been reported for youth cross culturally in the US [9]. A worrisome finding of the past decade has been the increase of suicide among young men of African American descent. A similar increase could not be found in African American women [24]. However, although African American women have low rates of suicide, their rates of suicidal behavior are as high as of European –American women [25]. Research from Sweden indicated increased suicide rates in immigrant females but not males of non western origin (excluding the Middle East), when compared to Swedish native population. In addition, male and female immigrant youth of eastern European and western descent in Sweden had increased odds for suicide compared to Swedish majority youth [12]. Regarding non fatal suicidal behavior in Sweden, immigrants, both with a non western background as well as immigrants of other European descent, had increased rates of non fatal suicidal behavior compared to Swedish majority (with the exception of Southern European immigrants). Yet, the female immigrant rate of non fatal suicidal behavior was higher than the rate of immigrant males [13]. A study from The Netherlands showed heightened propensity for suicide in Turkish and Surinamese young men in the age band 30-45 in The Netherlands compared to white Dutch majority men [10]. Another study from the Netherlands showed that Turkish young immigrant women have high rates of non fatal suicidal behavior, four times higher compared to Dutch majority women, whereas South Asian–women in the UK as well as in the Netherlands have high rates of both fatal and non fatal suicidal behavior [11, 21, 22, 26]. In short, research of immigrants from Europe and the US confirm that females are more suicidal than males, yet men die more often by suicide. Examples of India, China and Turkey indicate that there are exceptions to this pattern, which is underscored by findings of South Asian immigrant women in the UK and The Netherlands who have high risk of suicide. One explanation for the gender paradox that has gathered much support, is that the choice of less lethal methods of females is likely to be responsible for the non fatality their acts. The female choice of self poisoning reflects culturally determined gender preferences that result in a higher likelihood of a non-fatal outcome. A study by Denning, Conwell, King and Cox [27] showed that men and women with equal intent to die choose methods of suicidal behavior that vary in lethality, with men turning to more lethal methods than women. In western countries, women predominantly use self poisoning (with-over the counter prescribed medicine with low lethality) [2]. Hence, this suggests that if women would turn to more lethal methods, they would quickly exceed the number of suicides by men. The likelihood of this scenario is underscored by examples can from rural China, Surinam and southern Indian states, where suicides by women are as frequent or higher compared to male suicides [4, 19, 20]. However, males are overrepresented in urban suicides in China. The methods used for suicidal behavior by women in the countryside in these countries are highly lethal (i.e. pesticides), notably more lethal than the methods commonly used by female suicide attempters in the west and in the urban areas of non-western countries. The choice of suicide method is often replicated via the cultural memory of immigrants and thereby exported to the host country. Evidence for this mechanism is found among South

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Asian immigrant women. Indian women in the UK sometimes choose burning as a method [28]. The choice of method reflects the acceptability of self-immolation as observed by women, but not by men, in India [29]. South Asian-Surinamese women in The Netherlands frequently use acid as a means to their suicidal behavior, which is comparable to the choice of method for suicide in their regions of origin in Surinam [20]. This shows how gender and culture influence the availability, familiarity and acceptability of a certain method [3].

GENDER AND LETHAL INTENT As a result of the gender ratio in suicide, suicide is often perceived as a male problem. Simultaneously, non fatal suicidal behavior has often been framed as attention seeking and inept [2]. Dahlen and Canetto [30] and Stillion [31] demonstrated that North American males evaluated suicidal behavior more negatively compared to suicide. Since women are overrepresented in suicide attempts, it is women in particular who are prone to these negative evaluations. Also, it is often assumed that women's suicidal behavior is non-medically serious and has a low suicidal intent. However, numerous studies have shown that a lethal intent is present as often in females as in males and that the acts of women are medically serious as often as that of male attempters [2, 32]. Regarding differences between immigrant and non immigrant females, little research is available. However, a study in the Netherlands that compared the lethal intent of immigrant women in three immigrant groups (South AsianSurinamese, Turkish and Moroccan women) to majority Dutch women showed that a lethal intent was in fact mentioned more often by immigrant females compared to majority Dutch women [33]. Regarding the communicative aspects of suicidal behavior, the motives of suicidal behavior with an external focus e.g. ―I wanted others to know how much pain I felt‖ are more often mentioned by females than by males in a WHO study of more than 10 European countries [34]. While this may seem paradoxical, the external focus does not occur at the expense of a lower lethal intent in women. It has already been established that individuals who demonstrate suicidal behavior employ different motives simultaneously and some of them may seem contradictory [35]. In sum, the research on gender, method and intent of suicidal behavior suggests that suicidal immigrant females have similar or stronger lethal intent compared to majority groups and compared to males, yet also their behavior may more often be a means of communication to their environment in comparison to males. However, further research is needed into gender aspects of communication in attempted suicide in immigrant groups. Their choice of methods in general, protects women from dying by suicide, but specifically immigrant women from regions of origin where highly lethal methods are used are prone to replicate this choice of method and die more often also in the western countries they have migrated to.

GENDER AND DEPRESSION Research into the contribution of psychiatric disorders acknowledged depression to be the most common risk factor for suicidal behavior. An estimated two thirds of all suicide


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attempters of white western background have a depressive illness [36]. However, it is also documented in the literature that up to one third will not qualify for a psychiatric diagnosis [37]. This indicates that depression is not a sufficient or necessary condition for suicidal behavior. Research on western populations indicated that depression is more often seen in women than in men. While depression is the most common risk factor for suicidal behavior in both men and women, it happens twice as often in women than men. Theories on differential socialization suggest that males and females may learn to use different methods of coping with life and respond differently to stress [38, 39]. Their upbringing directs girls toward internalization rather than externalization of psychological disturbance [38]. Socialization permits female adolescents fewer outlets for the release of aggression than males [40]. One empirical foundation for this is the fact that adolescent girls are more often depressed than boys [38], whereas boys score much higher on externalizing disorders e.g. conduct disorders. The higher prevalence of depression in women is correlated to an earlier age of first onset (rather than to persistence or recurrence of the disorder), with the gender difference first emerging in puberty, occurring simultaneously with a likewise gender difference in the emergence of suicidal ideation and suicide attempt [41, 42]. The propensity to internalize as passed on in socialization seems indicative of suicidal behavior as more of an appropriate way for a female to respond to severe stress or difficulties, in comparison to males [10]. It was validated [43] that the gender skewness in depression as observed in whites, is present in all immigrant groups they studied in the US (blacks, Puerto Rican, Mexicans and Cubans) and varied from 3.4 to 1.8 : 1 (females to males). Epidemiology of depression that focused on ethnicity showed that many immigrant groups in the US do not have elevated risk for depressive disorder compared to whites in the US. For example, most Hispanic groups and Asians report lower rates of depression than whites, and blacks report a similar rate as whites. Only Puerto Ricans report a higher rate of depression compared to whites [43]. Remarkably, Puerto Ricans and Mexican Americans of both genders, and Cuban American females as well as black females have lower suicide rate than expected on the basis of their depression rate. From this study, it can be derived that the relationship between depression and suicidal behavior cross culturally is not straightforward. Moreover, it is known that the elevated incidence rate of suicide attempts by adolescent girls is not maintained into young adulthood, whereas depression maintains to be gender skewed throughout the life course [44]. Depression is therefore unlikely to be the crucial or sole mediating factor to account for gender differences in suicidal behavior. This is supported by research that showed how the gender differences in self-reported rates of suicidal behavior among adolescents was not eliminated even when depression was controlled for [39]. This preposition has also been validated across ethnicities. Liu, Chen. Cheung and Yip [45] conducted a cross cultural comparison between suicide in Hong Kong and Victoria, Australia. Hong Kong has very small gender differences in the suicide ratio, whereas Victoria has a ratio of 1:3. (females to males). The gender differences in the prevalence of psychiatric disorders i.e. depression could not explain the gender differential in the suicide rates. It was observed that the most skewed gender ratio was observed in the groups of suicide attempters without a history of psychiatric illness. In addition, research in immigrant groups in western Europe showed that depression may be less relevant as a risk factor in immigrant women compared to the majority group. In a study by Bhugra, Desai and Baldwin [26], depression was less often mentioned by Asian

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women in the UK in samples of suicide attempters compared to white British women. In similar vein, when three groups of immigrant females of South Asian-Surinamese, Turkish and Moroccan background in The Netherlands were compared to Dutch majority women with a history of suicidal behavior, rates of depression were found to be to be lower in immigrant women [33]. At the same time, Turkish immigrants of both genders in all age bands in the Netherlands have higher rates of depression [46]. While it may seem plausible that this vulnerability is reflected in the rates of Turkish young men who have increased suicide risk in the Netherlands, this has not been empirically tested yet [10]. One possible suggestion is underreporting of depression in immigrants who have a history of suicidal behavior. However, it is also plausible that cultural meanings are involved in the understanding and experience of depression across different ethnic groups. Some findings support this preposition. A study by Fenton and Sadiq [47] in the United Kingdom indicated how symptoms such as a loss of meaning in life and loss of sense of personal worth, frequently associated with depression, were not easily found in the accounts of South Asian women of the first generation. This could be explained as a result of a difference in selfconception, which does not match a similar emphasis placed on the individual as commonly seen in white western individuals. This study suggests that vigilance is needed when applying western understandings of depression cross culturally. Hence, the explanatory power of psychiatric risk factors such as depression for the gender difference in suicidal behavior seems ambiguous. Social and cultural stressors are expected to contribute to the suicidal behavior of women in this group. Therefore we shift our attention to social and cultural causes of suicidal behavior from a gender perspective.

RISKS IN THE SOCIAL ENVIRONMENT: MARRIAGE AND ABUSE Research has consistently shown that social support is a crucial protective factor against suicide and suicidal behavior. Marriage is often mentioned as an institution that provides social support and as such expected to be a buffer against suicide. A large scale study [48] demonstrated that across Europe, suicide attempters were disproportionately divorced or single according to WHO registration in the 1990s and early twenty-first century. However, gender complicates these findings. Models that account for gender have found that divorce increases the suicide risk predominantly in men. In women divorce does not have a similar substantial influence in suicide [49, 50]. Moreover, in some non western countries evidence found that suicide seem to be more common in married young women. In Pakistan, Khan and Reza [51] found that suicides are more common in married women less than 30 years of age. In addition, in rural China and rural Turkey, researchers report on very high suicide rates in young married women who live with their in-laws [52, 53]. Further evidence for the role of marriage as a risk factor comes from studies in rural India [54] and Iran [55] Domestic stressors, imprisonment at home, physical abuse, and denigration by the in-laws or husband have been reported to characterize the lives of young women who attempt suicide [51, 53, 56]. For females in particular, the quality of the marital bond appears more important than the marital status.


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Over the past decades suicidologists have examined how adversities that take place in a marriage and family context constitute a risk for suicidal behavior of females and their propensity to suicidal behavior. Research into the role of sexual and physical abuse unanimously shows that these experiences play a crucial role as risk factors for suicidal behavior, while sexual abuse is known to happen more often to females than to males [57]. Between 20 to 50 per cent of women reported to have been sexually abused within a population sample of suicide attempters [58, 59]. Physical abuse is also found to constitute a risk to suicidal behavior [60], yet appears to have less impact than sexual abuse in relation to suicidal behavior [61]. Although women may also be involved as perpetrators of domestic violence, women are more likely to be victims of domestic violence incidents that involve serious injury and death. They are also more likely have suicidal ideation when they are in those circumstances [62]. Abuse often goes together with family conflict, low care by parents or parent psychopathologies which are established risk factors for suicidal behavior. It could be hypothesized that those individuals who have a history of abuse are perhaps suicidal because of these co-founding factors. However, there is strong support for a relationship between abuse and suicidal behavior, even when variables such as the above mentioned that are likely to co-occur in families with abusive parents are controlled for [63] as well as when psychopathology of the individual is taken into account [64]. The vulnerability to suicidal behavior after abuse has been validated cross culturally and validated for immigrant populations [33, 59, 65]. Salander Renberg, Lindgren and Osterberg [59] established the association of sexual abuse to suicidal behavior in ten European countries, whereas Anderson, Tiro Price, Bender and Kaslow [65] validated the impact of sexual and physical abuse on suicidal behavior of African American women. Further evidence regarding the role of sexual and physical abuse in Turkish, Moroccan and SouthAsian Surinamese immigrant women in The Netherlands was found by van Bergen, van Balkom, Smit and Saharso [33]. Several studies demonstrated the impact of abuse for Asian women in the UK who attempted suicide [66, 67, 68]. The risk of both suicidal ideation and suicide attempt progresses according to the extent of the abuse, whether be it sexual or physical. [57]. This finding has also been validated cross culturally. African American women who suffered multiple forms of abuse had 2-4 times more vulnerability to suicide attempts compared to those women who reported a single form of abuse [65]. Immigrant status may be an aggrandizing factor in the abuse that takes place. In particular when an individual has migrated to the west for marriage purposes, there may be no family support system available in the host country. Moreover, the immigrant will be unfamiliar with the health care system as well as the language spoken in the host country. In addition, in particular immigrant women may find themselves in a position where they are financially dependent on the husband and in-laws [66]. These are factors that may have prolonged effect on the abuse since immigrant women to whom this happens are unlikely to seek or find assistance [69]. Immigration policies are yet another complicating factor. When a spouse is dependent on the partner residing in the host country before marriage, a divorce may mean loss of residence permit [70]. Some countries (for instance the Netherlands) are more lenient and are willing to grant the abused partner a residence permit even though the criteria for an independent residence permit are not met. An additional risk is that in some immigrant communities the possibility of marriages between family members exists (e.g. a marriage between cousins). For instance, this occurs

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among immigrants who come from Pakistan, India, Kurdistan, Afghanistan and Turkey. These marriages render women in particular vulnerable to suicidal behavior when their relationship is characterized by domestic violence and abuse. Women who would disclose the abuse to their families or to the in-laws are sometimes not believed or simply expected to bear the abuse and the consequences. A woman‘s own family may ask of her to bear the abuse since they are the direct kin of the husband‘s parents and want to maintain close family relations. This was for instance found in a study of Turkish and Moroccan female suicide attempters [33]. In addition, if sexual abuse also means a loss of virginity, and when physical abuse is undertaken by relatives or the husband, disclosure will result in squandering of family honor in many Asian and North African cultures. This precipitates pressure on women to remain silent about the abuse that has taken place. Yet, it has been established that abused women who receive no treatment tend to experience greater maladjustment in adult life, which renders them more vulnerable to suicidal behavior in the future [71].

DURKHEIM’S FATALISTIC SUICIDE AND IMMIGRANT WOMEN The findings of the risk factors of domestic violence, physical abuse and sexual abuse warrant that oppressive conditions have a profound impact on suicidal behavior. Since these aspects have a strong gender component, and the risks they carry of suicidal behavior in immigrant women are significant, we will theorize their relevance further. Durkheimian theories of suicide, which provide a deeper understanding of suicidal behavior beyond risk factors, are beneficial to this. Durkheim argued that a seemingly individual act as suicide is constraint to a greater or lesser extent by the moral forces of social life [8]. According to Durkheim, the variation in the suicide rate could be explained by the extent of social integration and regulation in a social group in society. Social integration refers to the degree, to which people are attached, bonded or connected to each other. By regulation, Durkheim meant the extent to which society has control and guidance over the motivations and values of its individual members. In short, when extreme positions on either of these aspects developed, this would lead, he expected, to suicide. While lack of social integration seems better qualified to explain the suicidal behavior of (majority) men, overregulation seems to be more appropriate to explain the suicidal behavior of minority women. When individuals experience extremely high levels of regulation in their social world, Durkheim theorized this could result in being excessively controlled by social-cultural prescriptions and lead to a fatalistic suicide. Fatalistic suicide occurs as a result of an oppressive context where harsh moral demands prevail, and are upheld through force [72-,73]. Individuals who are faced with a severe lack of agency, develop a sense of powerlessness. When norms are considered external, demanding and obtrusive and fail to be internalized by the individual, a sense of alienation and dehumanization is created. The individual does not experience having meaningful relations and lacks a sense of connectedness and may thus subsequently enter a suicidal process. The patterns of suicidal behavior of women in many (immigrant) cultures around the world, we would like to suggest, can best be explained as (near) instances of fatalistic suicide. Davies and Neal [53] investigated the suicides of young women in rural China and described these as a case of fatalistic suicide, mostly because of the restricted sex roles for women.


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Central to these restrictions is the practice of marrying off daughters by all-powerful families. These daughters subsequently lived in unhappy marriages under the tyranny of their motherin-law, who expected total compliance and denigrated their daughter-in-law. Suicide rates for Chinese young women are much lower in the cities, which underscores that the risk for suicidal behavior is associated with the rural family system, as well as demonstrating the pivotal role of the method commonly employed in rural China, i.e. pesticide poisoning. Additional evidence for cases of fatalistic suicide of women comes from Iran. Pridemore and Aliverdinia [74] examined and validated the association between female suicide rates and multiple measures of social control of women through studying several provinces in Iran. High rates of suicide were found in areas with greater social regulation of the lives of women and stronger traditional tribal cultures. They concluded therefore that hyper regulation is correlated with higher suicide rates for females in Iran. Fatalistic suicide also described the circumstances of many South Asian, Turkish and Moroccan immigrant women with a history of suicidal behavior in the Netherlands [33]. The ability and right to act autonomously with regard to strategic life choices [75] was more limited for Turkish and Moroccan women and to some extent South Asian women. Strategic life choices refer to spouse choice, sexuality, freedom of movement, education and participation in the labor market. Cultural images of females were found that valued subordination to the family and husband, female self-sacrifice and honor protection, While their young women sometimes took pride in it that they were able to live up to the image of the ‗enduring wife‘, these cultural images also hampered women‘s change toward more autonomy, and were in the end detrimental to their self image. Yet simultaneously, the internalization of these cultural images of ‗enduring wife‘ and avoiding the image of ‗the girl gone astray‘ was the key to understanding why many minority women endured their hardship. Honor of women and their family were at stake here. Migration seemed to worsen the scope for autonomy, in the sense that disruption of the extended family system, marital stress and acculturative stress of parents increased control and the demand on the young immigrant women of these ethnic groups to take up caretaking roles. Although the fatalistic suicide seems relevant especially in non western countries, it also has been found to apply to young women in a few European cases. Beratis [76] reports of Greek female suicide attempters, whose behavior is described as ‗a quest for autonomy‘ (76, pp.165). Girls‘ behavior in the study was restricted in the sense that they were not allowed to go outside the house alone, instructed not to talk to anyone the parents did not know, and were only allowed to have a very minimal social life of their own. In sum, fatalistic suicide seems to be a highly relevant theoretical concept for understanding the suicidal behavior of females. Women most notably from some regions in Asia confronted with an absence or struggle over crafting one's own life course that is characteristic for fatalistic suicide. These circumstances have been observed also after migration. The pressure by the family members, the husband and parents (in law) to ensure a woman abided by cultural norms lead to distress and vulnerability to suicidal behavior. The relevance of fatalistic suicide for women also undermines the idea that strong community bonds or an ethnically dense populated neighborhood are always protective against suicidal behavior, as Trovato [77] and Neeleman and Wessely argued [78]. Travato [77] showed that immigrant groups in Canada with strong degrees of community cohesiveness share reduced odds in their incidence of suicide. Neeleman and Wessely in the UK [78] found that, although belonging to an ethnic minority group at national level heightens the propensity to suicidal

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behavior, when a specific ethnicity minority group hold up a majority position within a neighborhood in London this is protective of their suicide rate. However, neither of these studies reported on the rates of (non fatal) suicidal behavior of young women. Gender could have thrown a different light on the results. When a majority group has a dominant position in an area and is close knitted (cohesive) while simultaneously its culture values chastity behavior and honor of women, as is the case in many Asian cultures, social control, lack of freedom of movement and scrutiny of women‘s behavior will increase. Social integration and cohesion is hence is not necessarily always protective for women, because of the over guidance and strict control over women by community members this encompasses.

CONCLUSION Despite the overwhelming impact and predictive power of gender in suicidal behavior, knowledge of suicidal behavior of immigrants in relation to gender is scarce. The intersecting and predicting role of gender and ethnicity in suicidal behavior needs to receive more attention in suicidology. Since women are predominantly more at risk compared to men, there is urgency for more research of suicidal behavior in immigrant women. In this chapter, we have addressed some of the gender issues that are important areas of future research. We highlighted risk factors of physical and sexual abuse in the contexts of family (in-law) and marriage. These findings indicate the relevance of Durkheimian thought that marriage is protective only when it is not over or under regulating and only when it provides social integration rather than alienation [8]. In many cases for women this is not necessarily so, and the family and marriage may precipitate a risk rather than protection against suicidal behavior. Those immigrant women in particular for whom physical and sexual abuse are contextualized amidst honor traditions and cultural values of female chastity, are vulnerable to suicidal behavior. On the basis of previous empirical work [33], we observed that immigrant women of Turkish, Moroccan and South Asian-Surinamese background were fortunately not frozen in unrewarding and oppressive lives forever; shifts toward more autonomy and rejection of harmful notions of gender and honor did eventually happen. This has important implications for health care and prevention programs. Women would benefit from empowering techniques for dealing with harmful practices of silencing their selves and denial of their autonomy. Clearly, this is not analogue to the assumption that immigrant women should necessarily exit their family and cultural environment once they ask for equal rights. Many immigrant women are not in favor of such an exit strategy; rather they wish to improve their situation within their cultural milieu [79]. Beyond doubt, in the domain of sexual and reproductive life that is central in many cultures, women‘s role is often pivotal [80]. The sphere of sexuality and reproduction is a crucial theme in cultural practices since it enables the continuity of the ethnic group. As a result, it is women in particular who are considered to be ‗the guardians of the collectivity‘s identity and honor and who demarcate with their behavior the moral boundaries of their group‘ (80, pp 25). In addition, cultural traditions and sometimes the re-invention of traditions are often used as ways of legitimizing the control and oppression of women in situations in which individual men as well as the collectivity feel threatened by others.


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Discrimination and poverty in immigrant groups in the host society may increase a sense of moral advantage compared to the majority group regarding immigrant women‘s honor and chastity, and hence increase protection of women. Thus, improving the social economic position of immigrants may be beneficial to the decrease of control exercised over women. It is important that cultural images of women of ‗enduring wife‘ and ‗the girl gone astray‘, that contribute to the tolerance of living unrewarding lives, are counteracted. If our societies want to engage successfully in the prevention of suicidal behavior of young minority women, critique should be expressed of these cultural images of women and reflections upon how these images can be questioned at community level as well as in immigrant families. If this would be pursued, the personal, social and economic costs associated with suicidal behavior in immigrant communities and society at large could hopefully be decreased in the future.

REFERENCES [1]

Canetto, SS, Sakinofsky II: The gender paradox in suicide. Suicide and Life Threatening Behavior 1998; 28(1):1-23. [2] Beautrais, AL: Women and suicidal Behavior. Crisis, the Journal of Crisis Intervention and Suicide Prevention; 2006: 27 (4):153-6. [3] Canetto, S.S: Women and suicidal Behavior. A cultural Analysis. American Journal of Orthopsychiatry: 2008; 78(2):259-66. [4] Law S, Liu P: Suicide in China: unique demographic patterns and relationship to depressive disorder. Current Psychiatry Reports 2008; 10(1):80-6. [5] Pearson V, Phillips MR, He F, Ji H: Attempted suicide among young rural women in the People's Republic of China: possibilities for prevention. Suicide and Life Threatening Behavior: 2002; 32(4):359-69. [6] Clarke DE, Colantonio A, Rhodes AE, Escobar M: Pathways to suicidality across ethnic groups Psychological Medicine: 2008; 38(3):419-31. [7] Castle K, Duberstein PR, Meldrum S, Conner KR, Conwell Y: Risk factors for suicide in blacks and whites: an analysis of data from the 1993 National Mortality Followback Survey. American Journal of Psychiatry 2004; 161(3): 395-7. [8] Durkheim E: Suicide. New York: The Free Press 1952 [First Published in 1898) [9] Joe S, Canetto SS, Romer D. Advancing prevention Suicide and Life Threatening Behavior 2008; 38(3):354-62. [Review] . [10] Garssen, J, Hoogenboezem J, Kerkhof AJFM: Zelfdoding onder migrantengroepen en autochtonen in Nederland. Nederlands Tijdschrift voor Geneeskunde 2006; 150(39): 2143-2149 [in Dutch]. [11] Burger I, Van Hemert AM, Bindraban CA, Schudel WJ Parasuïcide in Den Haag: Meldingen in de jaren 2000-2004. Epidemiologisch Bulletin 2005: 40(4), pp. 2-8 [in Dutch]. [12] Hjern A, Allebeck P. Suicide in first- and second-generation immigrants in Sweden: a comparative study. Social Psychiatry Psychiatric Epidemiology 2002; Sep; 37(9): 4239.

32


[13] Jablonska B, Lindberg L, Lindblad F, Hjern A: Ethnicity, socio-economic status Psychological Medicine 2009; 39(1):87-94. [14] Oto R, Altindag A, Ozkan M: Suicide in Batman, southeastern Turkey. Suicide and Life Threatening Behavior 2005; 35(4): 478-482. [15] Sorenson SB, Shen H.: Youth suicide Suicide and Life Threatening Behavior 1996;26(2):143-54. [16] Group for the Advancement of Psychiatry: Suicide and Ethnicity in the United States 1989, New York: Bruner/ Mazel Publishers, pp. 72-94. [17] Patel SP, Gaw A. Suicide among immigrants from the Indian subcontinent: A review. Psychiatric Services 1996; 47(5): 517-521. [18] Banerjee G, Nandi DN, Nandi S, Sarkar S, Boral GC, Ghosh G: The Vulnerability of Indian Women to Suicide. The Indian Journal of Psychiatry 1990: 32 (4): 305-308. [19] Aaron R, Joseph A, Abraham S, Muliyil J, George K, Prasad J, Minz S, Abraham VJ. Bose A: Suicides in young people in rural southern India. The Lancet 2004; 3; 363(9415): 1117-1118. [20] Graafsma, T: Characteristics of Suicides and Attempted Suicides in Nickerie, Years 2004-2008. Unpublished Communiqué of the Nickerie Suicide Prevention Program WINgroup and LMSZN, 2009; Nickerie Province, Surinam [21] Garssen, J, Van der Meulen A: Overlijdensrisico's naar Herkomstgroep: Daling en Afnemende Verschillen. 2008; Den Haag, The Netherlands: Centraal Bureau voor de Statistiek [in Dutch]. [22] Neeleman J, Wessely S: Ethnic minority Psychological Medicine 1999; 29(2):429-36. [23] Baca-Garcia E, Perez-Rodriguez MM, Mann JJ, Oquendo MA. Suicidal behavior Psychiatry Clinical North America 2008; 31(2):317-31 [Review]. [24] Joe S, Marcus SC: Datapoints: trends by racePsychiatric Services 2003;54(4):454. [25] Nisbet PA: Protective factors for suicidal black females. Suicide and Life Threatening Behavior 1996; 26(4):325-41. [26] Bhugra D, Desai M, Baldwin DS: Attempted Suicide in West London, 1 Rates Across Ethnic Communities. Psychological Medicine 1999; 29: 1125-1130. [27] Denning DG, Conwell Y, King D, Cox C: Method choice, intent, and gender Suicide and Life Threatening Behavior 2000: 30(3):282-8. [28] Raleigh VS, Balarajan, R: Suicide and self burning Indians and West Indians in England and Wales. British Journal of Psychiatry 1992; 156: 46-50. [29] Vijayakumar L: Altruistic suicide in India. Archives of Suicide Research 2006; 8(1): 7380. [30] Dahlen, ER Canetto SS: The role of gender and suicide precipitant in attitudes toward nonfatal suicidal behavior. Death Studies 2002; 26:. 99-116 [31] Stillion J: Through a Glass Darkly. Edited by Canetto SS, Lester D. Women and Suicidal Behavior 1995; New York, USA: Springer Publishing: 71-85 [32] Nordentoft, M, Branner J: Gender differences in suicidal intent and choice of method among suicide attempters. Crisis, the Journal of Crisis Intervention and Suicide Prevention 2008; 29(4):209-212. [33] Van Bergen DD, Smit, JH, van Balkom AJLM, Saharso S: Suicidal behaviour of young immigrant women Ethnic and Racial Studies 2009; 32 (2): 302 – 322


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[34] Hjelmeland H, Knizek B, Nordvik H: The communicative aspect of nonfatal suicidal behavior - Are there gender differences? Crisis, the Journal of Crisis Intervention and Suicide Prevention 2002; 23(4): 144-155 [35] Leo D, Burgis S, Bertolote JM, Bille Brahe U, Kerkhof AJFM: Definitions of suicidal behavior: lessons learned from the WHo/EURO multicentre Study. Crisis, The Journal of Crisis Intervention and Suicide Prevention 2006; 27(1): 4-15. [36] Van Heeringen, K. The neurobiology of suicide and suicidality, A review, Canadian Journal of Psychiatry 2003; 48(5); 292-300. [37] Murphy GE: Why women are less likely than men to commit suicide. Comprehensive Psychiatry 1998; 39: 165-75. [38] Nolen-Hoeksema S: Sex Differences in Depression. 1990; Stanford, USA: Stanford University Press. [39] Wichstrom R: Explaining the Gender Difference in Self-Reported Suicide Attempts: A Nationally Representative Study of Norwegian Adolescents. Suicide and LifeThreatening Behavior 2002: 32: 101-116. [40] Vanatta, R.: Adolescent gender differences in suicide related behaviors. Journal of Youth and Adolescence 1997; 26 [41] Fergusson DM, Woodward LJ, Horwood LJ: Risk factors and life processes associated with the onset of suicidal behaviour during adolescence Psychological Medicine 2000: 30(1):23-39. [42] Kessler RC. Berglund P, Borges, G, Nock M. Wang PS: Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003. Journal of the American Medical Association 2005; 293: 2487-2495 [43] Oquendo MA, Ellis SP, Greenwald S, Malone KM, Weissman MM, Mann JJ. Ethnic and sex American Journal Psychiatry 2001; 158(10):1652-8. [44] Lewinsohn PMR, Seeley J: Psychosocial Risk Factors for Future Adolescent Suicide Attempts. Journal of Consulting and Clinical Psychology 1994; 62: 297-305. [45] Liu KY, Chen EY, Cheung AS, Yip PS: Psychiatric history modifies the gender ratio of suicide: an East and West comparison. Social Psychiatry Psychiatric Epidemiology 2009;44(2):130-4. [46] Van Oort, FA, Joung IMA, Van der Ende J, Mackenbach JP, Verhulst, FCA, Crijnen AM: Development of ethnic disparities in internalizing and externalizing problems from adolescence into young adulthood. Ethnicity and Health 2007; 48(2): 176-184. [47] Fenton, S, Sadiq-Sangster F: Culture, relativism and the expression of mental distress: South Asian women in Britain. Sociology of Health and Illness 1996; 18(1): 66-85 [48] Schmidtke, A, Lohr C: Socio-demographic variables of suicide attempters. Edited by De Leo D, Bille Brahe U, Kerkhof AJFM, Schmidtke: Suicidal Behavior. Theories and Research Findings 2004; Gottingen, Germany: Hogrefe and Hubers Publishers, pp.8193. [49] Kposowa AJ, McElvain JP, Breault KD: Immigration and suicide Archives of Suicide Research 2008; 12(1):82-92. [50] Pescosolido BA, Wright ER: Suicide and the role of the family over the life course. Family Perspective 1990; 24-58 [51] Khan MM, Reza H: Gender differences in nonfatal suicidal behavior in Pakistan: Significance of sociocultural factors. Suicide and Life Treatening Behavior 1998; 28(1):62-68.

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[52] Davies C, Neal M: Durkheimian Altruistic and Fatalistic Suicide. Edited by Pickering W.F.S and Walford Geoffrey 2000 Durkheim’s Suicide, a Century of Research and Debate; pp. 36-53 [53] Bağlı M, Sev'er A: Suicide, suicide theories, suicide rates, female suicides, Turkish women, gender and suicide, patriarchy and women's health, poverty and suicide. Women's Health and Urban Life: An International and Interdisciplinary Journal 2003; 2(1): 60-84. [54] Kumar V: Burnt wives. A study of suicides. Burns 2003; 29:31-25. [55] Rastegar, A, Joghataei MT, Adli YR, Zadeh YA, Alaghehbandan R: Epidemiology of suicide by burns in the province of Isfahan, Iran. Journal of Burn Care and Research 2007; 28: 307-311. [56] Pearson V, Liu M: Ling's death Suicide and Life Threatening Behavior 2002: 32(4):347-58 [57] Fergusson DM, Mullen PE: Childhood Sexual Abuse: An evidence-based perspective. 1999; Thousand Oaks, USA: Sage Publishers. [58] Coll, X, Law F, Tobias A, Hawton K, Tomas J: Abuse and deliberate self-poisoning in women: a matched case-control study. Child Abuse and Neglect 2001; 25(10): 12911302a. [59] Salander-Renberg E, Lindgren S, Osterberg I: Sexual abuse and suicidal behavior. Edited by De Leo D, Bille Brahe U, Kerkhof AJFM, Schmidtke A: Suicidal Behavior. Theories and Research Findings 2004; Gottingen, Germany: Hogrefe and Hubers Publishers, pp. 185-197 [60] Enns MW, Cox BJ, Afifi, TO, De Graaf R, Ten Have M, Sareen J: Childhood adversities and risk for suicidal ideation and attempts: a longitudinal population-based study. Psychological Medicine 2006; 36(12): 1769-1778. [61] Brodly BS, Stanley B: Adverse childhood experiences and suicidal behavior. Clinical Psychiatry North America 2008; 31(2): 223-235. [62] Fergusson DM, Horwood LJ, Ridder E: Partner violence and mental health outcomes in a New Zealand birth cohort. Journal of Marriage and Family 2005; 67: 1103-1119 [63] Brown J, Cohen P, Johnson JG, Smailes EM: Childhood abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality. Journal of the American academy of child and adolescent psychiatry 2005; 38(12), 1490-1496. [64] Molnar BE, Berman LF, Buka SL: Psychopathology, childhood sexual abuse and other childhood adversities: relative links to subsequent suicidal behaviour in the US. [Review]. Psychological Medicine 2001;31(6): 965-977. [65] Anderson PL, Tiro JA, Price AW, Bender MA, Kaslow NJ: Additive impact of childhood. Suicide and Life Threatening Behavior 2002;32(2): 131-138. [66] Chantler K, Burman E, Batsleer J, Bashir C: Attempted Suicide and Selfharm. South Asian Women. Project Report. Commisioned by Manchester, Salford and Trafford Health Action Zone; 2001. [67] Chew-Graham C, Bashir C, Chantler K, Burman E, Batsleer J: South Asian Women, Psychological Distress and Self Harm: Lessons for Primary Care Trusts. Health and Social Care in the Community 2002; 10 (5): 339-347. [68] Bhardwaj A: Growing up Young, Asian and Female in Britain: A Report on Self Harm and Suicide. Feminist Review 2001; 68: 52-67.


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[69] Raj A, Silverman JG: Immigrant South Asian women at greater risk for injury from intimate partner violence. American Journal of Public Health 2003; 93(3):435-7. [70] Van Walsum S, Spijkerboer T: Women and immigration law: New variations on classical feminist themes. 2006; London: Routledge-Cavendish. [71] Leitenberg H, Greenwald E, Cado S: A retrospective study of long-term methods of coping with having been sexually abused during childhood. Child Abuse and Neglect 1992; 16(3):399-407. [72] Bearman S: The Social Structure of Suicide. Sociological Forum 1991; 6 (3): 501-24. [73] Pearce F: The Radical Durkheim. 1998; London: Unwin Hyman Ltd. [74] Aliverdinia A, Pridemore WA: Women's fatalistic suicide in Iran: a partial test of Durkheim in an Islamic Republic. Violence Against Women 2009: 15(3):307-20. [75] Kabeer N: Resources, agency, achievements: reflections on the measurement of women's empowerment. Sidastudies, Discussing Women's Empowerment - Theory and Practice 2001; 3: 17-57. [76] Beratis S. Factors associated with adolescent suicidal attempts in Greece Psychopathology 1990; 23(3):161-168. [77] Trovato, F: Suicide and ethnic factors in Canada. International Journal of Social Psychiatry 1986; 32: 55-64. [78] Neeleman J, Wilson-Jones C, Wessely S. Ethnic density Journal of Epidemiology Community Health 2001; 55(2):85-90. [79] Van Bergen DD. Suicidal behavior of young migrant women in The Netherlands. A comparative study of minority and majority women. 2009; VU university Amsterdam [PhD ]thesis, [80] Yuval Davis N: Gender and Nation. 1997; London: Sage Publications.



Chapter 4

SUICIDAL BEHAVIOR AMONG HISPANIC IMMIGRANTS IN THE UNITED STATES Guilherme Borges1,3, Liliana Mondragón1 and Joshua Breslau2 1. National Institute of Psychiatry, México City, México 2. UC Davis School of Medicine, Sacramento, California, USA 3.Universidad Autonoma Metropolitana, México City, México

ABSTRACT At the end of 2002 it was estimated that there were about 33 million Hispanics in the US, 14.5 million being non natives (about 60 % from Mexico) and 75% Hispanics being either immigrants or children of immigrants. This review covers the research published within the last 20 years on the experience of people of Hispanic background regarding suicide ideation and attempt when they first come to the US (first generation) looking for improvements in their standard of living through better jobs and more social opportunities, and as immigrants get settle and have US-Born children (second generation) and grand-children (third generation and so on). We also introduce new research regarding suicide ideation and attempt among return migrants and the families that the immigrants leave behind in their homeland. The current research in this area is limited in number and scope of interest, with most studies focusing on the simple ethnicity comparison. The research is basically cross-sectional and has produced results that are inconsistent in several key points. Currently, we do not know if Hispanics have rates of suicide ideation and attempts that are higher (or lower) when compared to Whites in the US. Evidence is more consistent on four other points. First, there is evidence that immigrants of Mexican origin who immigrated while youths (12 years or less) have rates of suicide ideation and attempt that are higher than similar persons who remained in their home country (i.e. Mexican non-migrants). Second, immigrants have crude lower prevalence of suicide ideation and attempt (both lifetime and 12-month) when compared to US-Born Hispanics of the same ethnicity, especially if they immigrated at older ages. Third, there is some evidence that Hispanics with more US-Born parents to have higher crude prevalence of suicide attempt when compared to US-Born Hispanics with no USBorn parents, but this was not always supported in multivariate analyses. Fourth, all studies showed that the preference in the use of English was positively associated with

38

Guilherme Borges, Liliana Mondragón and Joshua Breslau ideation, and suicide attempt, but associations between language use and attempts did not reach statistical significance. Research efforts that combine populations and information from sending and receiving countries and expand the number of groups under comparison to cover as many specific migratory experiences as possible are needed. This effort will require much more complex research designs that will call for true international collaboration.

INTRODUCTION Over the past 20 years, studies of suicidality have found differences between Hispanics and other ethnic groups in the US and differences among foreign-born and US-born Hispanics in the prevalence of suicidal ideation and suicide attempts [1;2]. These patterns have significant implications for reducing the impact of suicide attempts and preventing suicide. Hispanics are the largest ethnic minority group in the US, comprising about 14% of the 2005 US population. They are also the fastest growing group, projected to comprise 29% of the US population in 2050 (http://pewhispanic.org/files/reports/85.pdf, accessed August 14, 2009). More than two-thirds are either foreign-born (40%) or have at least one foreign-born parent (28%)[3]. More recently, research has begun to examine the relationship between migration and suicidality in greater detail, recognizing diversity within migrant groups and complex transnational effects of migration in sending as well as receiving countries. The goal of this review is to examine existing research on the epidemiology of migration between Latin America and the United States and suicidality, characterized by suicidal ideation and suicide attempts, in order to identify patterns with implications for prevention as well as gaps in existing knowledge. The category of ‗Hispanic‘ in the US lumps together people with origins in any of the 45 countries of Latin America and the Caribbean, each of which has its own internal ethnic divisions. People of Mexican origin make up over 60% of US Hispanics, but no other single country contributes as much as 10%. Because of this diversity, studies in the US that use national samples of Hispanics or of immigrants are likely to reflect patterns among Hispanics of Mexican origin. Regional studies, on the other hand, reflect the diversity of regional Hispanic populations, with much higher numbers of people of Mexican origin in the West and Southwest and higher numbers of Caribbean and South American origin in the South and Northeast. Sociological studies have shown that migration is not simply a collection of individual moves, but an institutionalized transnational multi-generational network linking communities in both countries across the border. Epidemiological research has begun to take the potential transnational impacts of migration into account through studies of the impact of migration on health in the countries of origin of immigrants. Migrant networks, through which transnational connections are established and maintained over time are not merely pathways for the movement of people, but also for the movement of goods, money, and social behaviors. For example, the Mexican-born population of the US accounts for nearly 10% of the total Mexican-born population (in Mexico or the US). About one-third of the population living in Mexico have a family-member who is living in the US. Migration may have many impacts on health. Some health problems, such as malaria [4], may arise from exposures directly tied to the actual process of migration.

Table 1. Studies on suicidality and Hispanics immigrants, 1988-2009

First author Sorenson Sorenson Moscicki Petronis

Year 1988 1988 1988 1990

REF#text [9] [10] [11] [12]

Study name LA-ECA ECA ECA ECA

Swanson YRBSS

1992 1993

[13] [14]

YHBS

Vega Roberts

1993 1995

[15] [16]

Ungemack Hovey Crosby Kessler Blum

1998 1998 1999 1999 2000

[17] [18] [19] [20] [21]

Olvera Tortolero King Borowsky Powell Pirkis

2001 2001 2001 2001 2001 2003

[22] [23] [24] [25] [26] [27]

NHSDA Oquendo Guiao O'Donnell

2003 2004 2004 2004

[28] [29] [30] [31]

Kessler Borges Brook Waldrop Roberts

2005 2006 2006 2007 2007

[32] [33] [34] [35] [36]

HHANES ICARIS NCS NLSAH

MECA NLSAH NLSAH NHSDA HHANES NLSAH NCS, NCSR NCS-R HCC TH2K

Study Population USB-MEX, MIG-MEX WHI-HIS-ALL WHI-HIS- MEX WHI-HIS-ALL USB-MEX, MEX in MEXICO WHI-HIS-ALL WHI-CUB,NIC,HISOTH WHI-HIS- MEX USB-HIS-ALL, MIGHIS-ALL HIS-ALL NON HIS-HIS-ALL WHI-HIS-ALL WHI-HIS-ALL WHI-HIS, USB-HIS MIG-HIS WHI-HIS-MEX WHI-HIS-PRI WHI-HIS-ALL WHI-HIS-ALL WHI-HIS-ALL WHI-HIS- MEX, USBMIG-HIS CUB, MEX, PRI WHI-HIS-ALL BLK-HIS WHI-HIS-ALL WHI-HIS-ALL NON HIS-HIS-ALL WHI-HIS WHI-HIS- MEX

Ideation (Y/N) Y Y N N

Plan (Y/N) N N N N

Attempt (Y/N) Y Y Y Y

Age group (ADOL/ADU) ADU ADU ADU ADU

Comparison ACC ETH ETH ETH

TIME LIFETIME LIFETIME LIFETIME LIFETIME

Y Y

N Y

N Y

ADOL ADOL

MG-NMIG ETH

LAST WEEK 12 MONTHS

Y Y

N N

Y N

ADOL ADOL

ETH ETH, ACC

LIFETIME 12 MONTHS

Y Y Y Y Y

N N Y N N

Y N N Y Y

ADU ADOL ADU ADU ADOL

NAT, ACC AMI ETH ETH ETH

LIFETIME LIFETIME 12 MONTHS LIFETIME LIFETIME

Y Y Y N N N

N N N N N N

N N Y Y Y Y

ADOL ADOL ADOL ADOL ADU ADOL

ETH, NAT ETH ETH ETH ETH ETH

LIFETIME 2 WEEKS 6 MONTHS 12 MONTHS 12 MONTHS 12 MONTHS

Y N Y Y

N N N Y

Y Y N Y

ADOL ADU ADOL ADOL

ETH, NAT ETH ETH ETH

12 MONTHS LIFETIME 12 MONTHS 12 MONTHS

Y Y Y Y N

Y N N N N

Y N N Y Y

ADU ADU ADU ADOL ADOL

ETH ETH ETH ETH ETH

12 MONTHS 12 MONTHS 12 MONTHS 2 WEEKS LIFETIME

Table 1. Studies on suicidality and Hispanics immigrants, 1988-2009 (Continued)

First author Fortuna Freedenthal YRBSS Peña Borges

Year 2007 2007 2007 2008 2008

REF#text [37] [38] [39] [40] [41]

Study name NLAAS NHSDA YHBS NLSAH NCS-NCS-2

Study Population HIS-USB, HIS-FB WHI-HIS-ALL WHI-HIS-ALL USB-HIS, MIG-HIS WHI-HIS-MEX

Ideation (Y/N) Y Y Y N Y

Plan (Y/N) N N Y N N

Attempt (Y/N) Y Y Y Y N

Age group (ADOL/ADU) ADU ADOL ADOL ADOL ADU

Borges

2009

[42]

MNCSCPES

USB-MEX, MIG-MEX REL

Y

Y

Y

ADU

Comparison GEN, ACC, AMI ETH ETH NAT , GEN ETH NAT, TSP, AMI, RMI,FMI,MGNMIG

TIME LIFETIME 12 MONTHS 12 MONTHS 12 MONTHS 10 YEARS

LIFETIME

Study Populations: Whites (WHI), Cubans (CUB), Mexicans (MEX), Puerto Ricans (PRI), Nicaraguans (NIC),Hispanics other ethnicity besides Cuban, Puerto Ricans or Mexicans (HIS-OTH). Hispanics without any ethnicity distinction (HIS-ALL), US-Born (USB), Foreign-Born (FB), Migrants (MIG), Relatives of migrants (REL), Adolescents (ADOL), Adults (ADU). Non-Hispanics (NON HIS), Blacks (BLK). Comparisons are: Ethnicity (ETH), Nativity (NAT), Age at immigration (AMI), Acculturation (ACC). Generation (GEN), Return migrants (RMI), Family of Migrants (FMI), Migrants-Non-migrants (MG-NMIG). The Epidemiologic Catchment Area study. Los Angeles (LA-ECA); Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. The National Comorbidity Study (NCS); Hispanic Health and Examination Survey (HHANES). The National Comorbidity Study Replica (NCS-R); The Epidemiologic Catchment Area study. (ECA) The National Comorbidity Study 2 (NCS-2); The National Longitudinal Study of Adolescent Health (NLSAH) The National Latino and Asian American Population Survey (NLAAS); The Injury Control and Risk Survey (ICARIS) The Mexican National Comorbidity Survey (M-NCS); National Household Survey on Drug Abuse (NHSDA) The Teen Health 2000 (THK2); Healthcare for Communities (HCC) Collaborative Psychiatric Epidemiology Surveys (CPES); The National Youth Risk Behavior Survey (YRBS)

Suicidal Behavior among Hispanic Immigrants in the United States

41

Others, such as cancer [5] or multiple sclerosis [6], may arise from specific environmental exposures that are rare in one environment and common in another. Suicidality is yet more complex because it involves changes in social context which determine the availability of means and norms regarding suicidality as well as broader changes in employment, close social ties and support groups. This review examines evidence from large general population surveys that report specific rates of suicide ideation and attempts among Hispanics in the US as assessed using standardized epidemiological instruments [7;8], the first of which were conducted almost 20 years ago. Evidence from these studies is organized by the specific comparisons that are informative with respect to the different segments of the migration process among the different affected populations. Organizing the evidence in this way provides a basis for assessing the strength of current knowledge about the impact of migration on suicidality and identifying gaps in our knowledge that should be addressed in future research.

WHAT DO WE KNOW ABOUT HISPANIC IMMIGRATION AND SUICIDALITY? We searched for peer-reviewed population based research publications within the last 20 years that reported prevalence rates or odds ratio estimates for suicide ideation and/or suicide attempts among Hispanics. Clinical samples were not included. The resulting publications are listed in Table 1. The table lists all publications so that studies with multiple publications are listed with multiple entries. The publications are classified by the study population, the outcomes that were reported, the age group, the specific comparison of interest in the study, and the time-frame in which the outcomes were assessed. Study population describes the ethnic, national origin, or nativity of the sample using the following categories: (Whites (WHI), Cubans (CUB), Mexicans (MEX), Puerto Ricans (PRI), Nicaraguans (NIC),Hispanics other ethnicity besides Cuban, Puerto Ricans or Mexicans (HIS-OTH), Hispanics without any ethnic sub-division (HIS-ALL), US-Born (USB), Foreign-Born (FB), Migrants (MIG), Relatives of migrants (REL), Non-Hispanics (NON HIS), Blacks (BLK)). Age groups included in the sample are classified as Adolescents (ADOL) or Adults (ADU). The comparisons of interest, which are explained in detail below, are classified as: Ethnicity (ETH) (Whites Vs Hispanics), Nativity (NAT) (US-Born Vs Foreign-Born Hispanic), Age at first immigration (AMI) among the Foreign-Born, Acculturation (ACC) among the US-Born and the Foreign-Born, Generation (GEN) among the US-Born, Return migrants (RMI), Family of Migrants (FMI) and Non-migrants (NMIG) among Hispanics.

(#1) Ethnicity: Overwhelmingly, the most common focus of the papers listed in Table 1 is ethnic comparison, i.e a comparison of suicide ideation and/or attempts between Whites and some group of Hispanics. 27 of the 34 report such an ethnic comparison and 24 report only ethnic comparisons. Graphs 1-2 present the results of lifetime and 12-month prevalence of suicide ideation (Graph1) and suicide attempt (Graph 2) by ethnicity.

42

Guilherme Borges, Liliana Mondragón and Joshua Breslau

The goal of these graphs are to review results in groups of pairs (or more) ethnicities by each research dataset (for example, Whites Vs Hispanics in the YRBS [14], Whites Vs


43

Mexican-Americans in the ECA [11], etc.) and not to compare the results across different datasets as some studies used different definitions of suicidality, time frame, or age groups (adolescents and adults). No research reported results for both adults and adolescents but some do provide results for both ideation and attempts. The simple prevalences of Graph 1 show inconsistent results for lifetime and 12-month suicide ideation. There is only one report of adult lifetime suicide ideation from the ECA [10] with higher prevalence of ideation among Whites. For lifetime ideation among adolescents, Vega [15] and Blum [21] reported higher prevalence among Whites from grades 9-12, but lower prevalence among Whites grades 7-8, and Olvera [22] reported a much higher lifetime prevalence of ideation among Hispanics adolescents relative to Whites. For 12-month prevalence of ideation, the two studies among adults show both a higher prevalence among Whites [19] and a lower prevalence [34]. More research is available among adolescents for 12-month ideation, and the results also show higher prevalence among Whites [19;24;28;36] and lower prevalence among Whites [14;16;23;31;34;39]. A similar picture of both higher [10] and lower [11] prevalence of lifetime suicide attempt in White adults and among White adolescents ([36] higher prevalence among Whites and [15] lower prevalence among Whites) emerged. In contrast, a consistent higher 12-month prevalence of suicide attempt among Hispanics was apparent in Graph 2, even when compared to Blacks [31]. Table 2. Estimates of risk of suicide ideation and attempt according to ethnicity status in the United States. Odds ratios (OR) and confidence interval are for Hispanics. Reference group is Whites.

Ref# [33] [32]

12 month Odds Ratio and 95% Confidence Interval 0.9 (0-5-1.6) 0.8 (0.5-1.4)

3.1 (1.09-8.81)

[31] [35] [16] [23] New Mexico [23] Texas

1.37 (0.89-2.11) 0.97 (0.71-1.33) 2.10 (1.6-2.6) 1.79 (1.40-2.28) 1.83 (1.39-2.41)

[12] [11]

0.33 (0.05-2.0) 0.56 (0.26-1.20)

[26] [32]

2.41 (1.47-3.94) 1.20 (0.5-2.8)

Adolescents [36]

0.70 (0.41-1.20)

[16] [27] [36] [35]

3.10 (1.09-8.81) 0.73 (0.45-1.16) 1.11 (0.46-4.76) 0.75 (0.34-1.64)

Ideation Adults

Ref# [20] [41]

Adolescents [22]

Attempt Adults

Lifetime Odds Ratio and 95% Confidence Interval 0.9 (0.6-1.4) 1.0 (0.7-1.15)

See Table 1 for description of studies. #26 is a matched case-cross over for suicide attempt hospitalization. #41 is on a 10 years follow-up. #31 ideation and attempts are lumped. #23 and #35 are on 2 weeks period. Reference group is Whites.

44


Odds ratios (OR) and 95% Confidence Intervals (CI) (OR, lower CI-upper CI) are reported in a number of papers. We summarized these results in Table 2. As apparent from this table, the vast majority of results for both adults and adolescents, tend to suggest null results; there is no statistically significant difference in the age and sex adjusted risk of suicide ideation and suicide attempt between Hispanics and Whites. In some groups, such as studies on 12-month ideation among adolescents, two studies found higher risk among Hispanics [16;23], but two suggested null results [31;35]. For lifetime attempts, two studies in adults [11;12] and one in adolescents (36) suggest lower risk among Hispanics that does not reach statistical significance. In summary, research has not found a consistent pattern of differences in risk for suicidal ideation or suicide attempts between Hispanics and Whites in the US, whether these comparisons are made with respect to overall prevalence or age and sex adjusted odds ratios.

(#2) Non-Migrant Natives in Home Country Vs Current Migrants The overall contribution of migration related factors to ethnic differences in suicidality are likely to result from multiple distinct processes. The first of these to consider is the effect of migration on suicidality among migrants themselves. This has been a surprisingly difficult issue to study. As Stillman et al [43] put it ―to truly understand the effect of migration on mental health one must compare the mental health of migrants to what their mental health would have been had they stayed in their home country‖. However, the best comparison group for this purpose is the population from which migrants emigrated. Very few studies have been able to make such a comparison, in large part due to the difficulty of sampling sufficient numbers in both the sending and receiving countries and assessing suicidality using the same methodology with both groups. To the best of our knowledge, there are only two studies that have made such a comparison, both comparing Mexicans in Mexico with Mexicans in the US, one among adolescents [13] and one among adults [42]. Swanson [13] compared a group of Hispanic students (overwhelmingly of Mexican origin) in schools of Texas, with Mexicans students living in the State of Tamaulipas, Mexico, with respect to suicidal ideation. The one-week prevalence of suicide ideation was about twice as high in the US sample (23.43%) than in the Mexican sample (11.57%) (p=0.001). The report from Borges et al [42] compared the lifetime prevalence of suicide ideation and attempts in Mexicans with no migration background living in Mexico (ideation=6.7%; attempt=2.3%) with Mexican immigrants currently living in the US (ideation=7.8%; attempt=2.9%). The authors found a higher risk for ideation for the migrants among those that migrated before the age of 12 years (OR=1.84, 1.09-3.09) and a higher but non-significant OR (1.88, 0.92-3.83) for attempt in the same group of early aged migrants, while those that immigrated at age 13 or older had no increase in ideation or attempt.

(#3) Nativity A larger number of studies have compared foreign-born and US-born Hispanics, using data from studies conducted in the US. Since this comparison is based on the respondents


45

place of birth we refer to it as a ‗nativity comparison‘. Graph 3 presents for the four studies that reported nativity comparison of lifetime prevalence among adults and two studies that reported a nativity comparison of 12-month prevalence among adolescents. In this graph the main comparison of interest is between the USB-FB pair from a similar ethnic group from the same study (for example, US-Born Mexicans Vs the Mexican Foreign-Born in the ECA).

46


The findings across studies are very consistent: The foreign-born of an ethnic group have lower prevalence of suicide ideation and suicide attempt when compared to the US-born of the same ethnic group, both in adults and adolescents. The difference between the lifetime prevalence of ideation for the USB-FB comparison was significant in Ungemack [17] and Fortuna [37], and for attempt in Fortuna [37] and Peña [40]. In summary, all surveys have showed lower prevalence of suicide ideation and attempt among FB-Hispanics when compared to a US-Born Hispanics. Fewer reported hypothesis tests (p values) or ORs. Among those, it seems that it is not just being Foreign-Born what is associated with lower prevalences, but also the age of entry (older ages have lower risk) into the US (see also below on ―age at migration‖).

(#4) Generation The nativity comparison can be broken down in several different ways in order to further describe differences in suicidality associated with migration. Researchers have been interested in comparisons among Hispanics with respect to their distance from their country of origin, as indicated by the number of generations separating them from migration or behavioral indicators of the extent to which they have adopted the culture of their host society. A goal of these studies has been to understand the environmental factors which occur after arrival in the US that contribute to suicidality. In demography first generation usually refers to Foreign-Born persons and second generation to US-Born persons. These comparisons were presented in the section just above under Nativity (#3). By generation analyses in the Latino suicidality-migration studies, we refer to possible differences in the second and the following generations (parents and grandparents nativity). Only two studies exist so far that reported such associations, one in adolescents [40] and one in adults [37] (Graph 4, right hand). In both, there was a tendency for Hispanics with more US-Born parents to have a higher crude prevalence of suicide attempt when compared to US-Born Hispanics with no US-Born parents. Nevertheless, multivariate analyses by Peña (40) found that the OR was only slightly higher among those of third and higher generation (1.25, 0.59-2.64), and Fortuna [37] found that those with no USBorn parents were at higher risk compared with those with at least 1 US-Born parent (OR=2.2, 95% CI 0.9-5.5 ,authors own calculations) . Disaggregated analyses from Fortuna [37] found that compared to those that were FB-Hispanics and arrived at ages 7 or older, only those US-Born with at least one US-Born parent had higher OR of suicide ideation (OR=1.7, 1.1-2.8). The Nativity (#3) and Generation (#4) analyzes above have been able to further specify two exposure variables: age at migration and acculturation. Age at first migration is used as there is a hypothesis that some exposures (usually conceptualized as the socialization process) happens mainly (or only) at an early age, in the context of primary schooling. So, only immigrants that arrived before schooling are truly exposed to this segment of the American environment. The concept of acculturation has multiple meanings and scales. By far, the most common operationalization of this concept is though some measure of English language skills or preference. There is, certainly, some overlap between these concepts. Duration of residence in the US has also been used in other areas of psychiatric epidemiology, but up to this moment it has not been reported in suicidality and migration studies among Hispanics.


47

Age at Migration Graph 4 shows the studies that reported crude prevalence of suicide ideation and attempts by age of first immigration into the US. Two studies of suicide ideation among adults reported that the lifetime prevalence of ideation was lower among Hispanic migrants [37] and Mexicans migrants [42] that arrived at later ages in the US, and higher among those that immigrated at earlier ages. A similar trend was found for suicide attempt. The only study among adolescents reported median values on a scale of suicide ideation and reported the same trend: lower values among those that immigrated at older ages , but without statistical significance [18]. According to Fortuna, when lifetime ideation and attempts were compared between those that arrived within 0-6 years of age and those that arrived at 7 or more years, the ORs were 1.7 (0.8-3.6) for ideation and 1.4 (0.5-3.6) for attempts. Borges et al [42] reported that those that arrived at early ages, less that 12 years old, had significant higher ideation (p=0.007) but not higher prevalence of attempt (p=0.243) when compared to those that arrived at 13 and more years. Borges et al [42] also provided ORs: compared to those US-Born Mexicans, Foreign-Born Mexicans that arrived at 12 years or less had an OR of 1.18 (0.74-1.86) for suicide ideation and OR=0.96 (0.40-2.25) for suicide attempt; the ORs for those Foreign-Born Mexicans that arrived at age 13 and older were, in the same order, 0.52 (0.28-0.93) and 0.49 (0.15-1.59). The reference groups vary widely among the studies, with little theoretical justification for selecting the specific age cut-points. In summary, even when most studies found a relationship in the expected direction, with those that arrived in the US at early ages showing higher lifetime prevalence of ideation and attempt, multivariate analyses of these authors failed to find increased risks in all groups and outcomes.

48


Acculturation Some studies attempt to directly assess distance from culture of origin at an individual level using acculturation scales. These scales assess behaviors, preferences and attitudes that are more or less like those presumed to characterize the culture of origin, such as language use, friendships with people of the same culture, food choices, and attitudes towards marrying people of other ethnicities. Often a single measure, such as language use, is used to assess acculturation in lieu of a full acculturation scales. Measures of acculturation have the advantage of being more direct, but they are also limited in that they do not help locate specific exposures that might lead to the differences they help identify. Only one study reported associations between a true scale of acculturation and suicidality [9], while three studies reported on the use of English language as a surrogate of acculturation [16;17;37]. The only study with adolescents [16] did not report prevalence rates, but in multivariate analyses those that used English at home were more likely to report suicidal ideation when compared to those adolescents that did not us English at home (OR = 1.4, 95% CI 1.0-1.9). Graph 5 shows prevalence as reported by three studies. Two studies [17;37] showed higher prevalence of ideation and attempt among those more fluent in English, while in Sorenson [9] the US-Born low in acculturation was the group with higher rates of ideation and attempt. Two studies provided more detailed analyses. Fortuna [37] showed that those who spoke more English as a child had higher risk of ideation (OR=1.7, 1.1-2.8) and Ungemack [17] found the difference of suicide ideation between those that had the interview in English compared to the interview in Spanish to be of statistical significance (p1980 Author (s)

Year of Publication (1981)

Age range >20

Ethnic group Mexican Americans in USA M+F Greeks in USA M+F

Instrument

Results

Acculturation Rating Scale for Mexican Americans Greek Immigrant Acculturation Scale

Mexican Americans in USA M+F US Hispanics M+F

Acculturation Rating Scale for Mexican Americans Acculturation Scale

Greek Cypriots in England M+F Mexican Americans in USA M+F Greek Cypriots in England M+F Third world immigrants in Norway M+F

Greek Immigrant Acculturation Scale (modified) Acculturation Scale

No relation between severity of psychopathology and acculturation The more acculturated manifested higher degree of psychological impairment Acculturation was associated with increased rate of psychiatric disorders Acculturation was associated with higher frequency of drinking Highly acculturated males were found to be mentally impaired Acculturated younger Mexican-Americans were found to be more distressed The less acculturated manifested a higher level of psychological distress Acculturation stress was found to exist among children although having to migrate or being born in Norway was not related to mental health status Low acculturation among Hawaiians did not correlate with any measure of psychosocial pathology Most newly arrived Amerasians experience acculturative stress Women who were the heaviest alcohol drinkers were also the least acculturated Respondent highly acculturated during their stay in the host country were found to be mentally impaired during their repatriation in their native country

1.

Cuellar et.al [24]

2.

Madianos [7]

(1984)

20-59

3.

Burham et al. [25]

(1987)

>18

4.

Caetano R. [26]

(1987)

18-65

5.

Mavreas and Bebbington [42] Kaplan and Marks [27]

(1990)

18-64

(1990)

30-74

7.

Adamopoulou [43]

(1990)

16-65

8.

Sam and Berry [44]

(1995)

10-17

9.

Streltzer et al. [58]

(1995)

19-65

Hawaiians and not Hawaiians M+F

Na Med Hawai‘i Scale

10.

Nwadiora and Mc Adoo [46]

(1996)

30-55

Amerasians M+F

11.

Hines et al. [29]

(1998)

18-29

12.

Madianos et al. [47]

(1998)

39-75

African American women M+F Greeks former immigrants repatriated in rural area of Greece M+F

Refugee Acculturation Stress Inventory Acculturation Adaptation to US mainstream Society Scale Greek Immigrant Acculturation Scale

13.

Ortega et al. [30]

(2000)

15-54

6.

Hispanics in USA from Nat.

Greek Immigrant Acculturation Scale (modified) Acculturation Questionnaire

Acculturation rating Scale

The more acculturated were more likely to

Acculturation and Mental Disorders among Immigrants Comorbidity study M+F AsianAmerican adolescents M+F

14.

Hahm et al. [31]

(2003)

12-17

15.

Mc Lachlan et al.[45]

(2004)

19-65

Irish in Dublin M+F

Acculturation and Social Change Questionnaire

16.

Oppedal et al. [46]

(2004)

14-17

Acculturation and Ethnic Identity Crisis Scale

17.

Lau et al.[32]

(2005)

Immigrant adolescents in Oslo, Norway M+F American families Mexican

18.

Virta et al. [59]

(2004)

Structured Questionnaire

19

Kim et al. [33]

(2006)

Turkish adolescents in Norway and Sweden M+F Korean American families

20.

Campos et al. [60]

(2008)

25-55

Females Hispanics in California


21.

Madianos et al. [34]

(2008)

20-60

Immigrant Acculturation Scale

22.

Karriker-Jaffe and Zemore [49]

(2009)

>18

Foreign immigrants in Athens, Greece M+F Mexicans in USA M+F

23.

Gul and Kolb [50]

(2009)

21-24

Turkish patients in Germany M+F

Acculturation Questionnaire

14-16

Acculturation Questionnaire

Structured Interview



105

exhibit higher prevalence of mental disorders and substance use The odds of alcohol use were 11 times greater in the highly acculturated group The more acculturated were getting better in terms of their mental health Ethnic identity crisis was positively correlated with all psychiatric problem categories More conduct problems occurred in families in which the adolescent member was more aligned with traditional culture than the paren Poorer adaptation and mental health of Turks in Norway was related to lower degree of Turkish identity Maternal acculturation moderated the relation between mother‘s reports of maternal acceptancerejection and young adolescents report of their psychological adjustment Low acculturation was not a significant predictor of mental health but had a protective effect with regard to substance abuse High acculturation level was correlated with low number of depressive symptoms Men at high levels of acculturation were more likely to be drinkers but only if they had above average income Depression was related with high level of acculturation when other family members had conflicts of adaptation

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Michael G. Madianos

5. A REVIEW OF SELECTED STUDIES ON ACCULTURATION AND MENTAL HEALTH In table 1 several studies on the relationship between acculturation and mental health in immigrant groups in USA and Europe are presented. These studies have been published since 1980 and these were carried out in representative immigrant groups of all ages with the use of standarardized instruments. Out of 23 studies only one reported no relation between severity of psychopathology detected in the sample and the level of acculturation. In more than half (60%) of the publications listed in table 1, high levels of acculturation of their samples were found to be related to the increased prevalence of psychopathological symptoms or specific psychiatric problems or disorders mainly depression and alcohol abuse. Only five studies reported that low levels of acculturation were found to be linked with high prevalence of mental disorders. For the rest of the studies, the investigators of three studies reported that high levels of acculturation were related with well-being and in one study low level of acculturation was found to be related with better mental health.

DISCUSSION Several investigators confirmed the hypothesis that the process of acculturation is causing stress related mental disorders [7, 25-27, 30, 42, 46-50]. The acculturation stress induced psychopathological mechanism has already been described. However the inverse relationship between acculturation level and demoralization (anxiety and depressive symptoms) has been reported by several others. Adamopoulou et al. [43] reported that the less acculturated Greek Cypriots living in London, England, manifested a higher level of psychopathological disturbance. Sam and Berry [44] examined the relationship between acculturation and emotional disorders among young immigrants in Norway and found out that a stressful acculturative experience alone could account for only 1% of the self-reported depressive symptoms. Another study explored the role of acculturation on alcohol consumption and risky sexual behavior among African American women [29]. The results indicated that women who were the heaviest drinkers were also the least acculturated. However, risky sexual behaviour was related to high acculturation levels. Two other studies reported that higher levels of acculturation are linked to better mental health status. McLachlan et al. [45] found a significant relationship between temporal higher acculturation and better mental health of Irish general population individuals. Lau et al. [32] tested the acculturation gap-distress hypothesis by examining whether parent-adolescent acculturation gaps were associated with greater risk of problems among Mexican American families. Greater discrepancies in children‘s acculturation compared to their parents‘ acculturation were not found to be related to increased conduct problems. More frequent conduct disorders were prevalent in families in which the youth was less acculturated than the parent.

Acculturation and Mental Disorders among Immigrants

107

In a recent study with foreign immigrants living in a greater Athens area the main finding was that the higher the degree of acculturation of the immigrant individuals, the lower the number of CES-Dscale depressive symptoms were suffering [34, 51]. It seems that better mental health of immigrants is linked to the adoption of an ―integration‖ mode of acculturation, rather than the rejection of the host culture [21, 52, 53]. Nevertheless the phenomenon of acculturation is a multidimensional and a complex one. It may affect health behaviors and well being as a consequence of continuous striving efforts of the immigrant, coping with the immigration traumatic experiences, like discrimination, racism and poverty, change or loss of identity as well as lack of social support, exposure to different beliefs, cultural values and norms, concerning also particular patterns of health behaviours (drinking, smoking, taking illicit drugs). The question is to what extend the various components of the acculturation process could be beneficial and protective for the immigrant individual and his/her family members? According to the bidimensional model of the acculturation process of Berry [28], several variables at both group and individual levels, could be considered as protective from the acculturation stress. At immigrant group level, the sociocultural structure of country of origin may play important role in the group process of acculturation. For example if the country of origin is of that of collectivist society where people from birth onwards are cohesively integrated living in a protective environment from aggression from outsiders, building a collective ethnic identity, group inter-dependence and solidarity, sharing stable family ties and friendships and the host country is of that of individualist one, supporting autonomy, selfsufficiency and respecting the rights of others, in a spirit of liberarism, the immigrant coming from traditionalism to individualism and liberarism, probably will face several difficulties to be adapted first and then acculturated. The ideal case is that both native and host countries to be of the same sociocultural structure and congruent. At individual level, the moderator/ protective variables before acculturation could be considered sociodemographic factors, younger age, higher education, voluntary immigration, pre-migration political status e.g. non traumatic exposure, knowledge of the host language, motivation for immigration being preacculturated e.g. preacceptance of the way of life of the host country. The moderator/protective variables during the acculturation process could include length of stay in the host country the financial security, bilingualism, family solidarity and support, living in high ethnic-density neighborhood (avoiding alienation), biculturarism (feeling comfortable from both cultures) and therefore being part of both cultures, preventing marginalization which leads to symptoms of distress. There is little doubt that there are cultural variables with a beneficial effect on health and mental health of the immigrant exposed to a different dominant culture. However some of them are uncontrolled. There are variables unavoidable in terms of their effect like the one of the sociostructural dissonance of the native and host societies. We don‘t choose the place to be born and raised. Another case is of that of the pre-migration trauma. Furthermore several ―protective‖ variables during the acculturation process are to be questioned. To live in ethnicdensity-neighborhoods is not always linked with better wellbeing. Ethnic enclaves are often transformed into slums or ghettos where poverty, unemployment, poor housing conditions and high crime are prevalent. On the other hand there are studies showing that the incidence rate of schizophrenia for immigrants was significantly increased in low ethnic density neighborhoods [54, 55].

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The issue of family solidarity and support is unquestionable. However it is not surprisingly that there are very traditional families demanding unbearable sacrifices from their members, raising reaction from non fanatics or the local community e.g. forced marriage in young ages. Moreover, the prevention of acculturation stress is affected by the complexities of culture and health related social policy and political factors. The Cubans in the 60‘s and 70‘s fleeing the Castro regime, in USA were well taken care by the US immigration policy programs and Cubans were among the most healthy of all Latino groups in USA [56]. It is basic to understand the context in which ongoing cultural and socioeconomic changes take place and the dynamics that reproduce according to the complexities of the dominant culture settings in which immigrants find themselves. Nevertheless cultural identity is one of the key determinants of mental health status of immigrant individuals. The question is how protective is the adoption of both cultural identities, of that of native and the host culture. Biculturism as cultural orientation could be, to a certain degree, beneficial to immigrants coping process with the strain. Biculturism is a common phenomenon exceeding the personal attitude of the immigrant and covers greater parts of both cultures mainly in the areas of language (both languages often spoken) folklore (ethnic food and music are fashionable) and traditional rituals (spiritual healing, psychic activities are accepted). Biculturism progressively leads to segmented assimilation. The segmented assimilation theory [57] refers to diverse patterns of adaptation, whereby the immigrant adopts the attitudes and cognitive style (values, beliefs) and consequently behaviours of divergent cultural group. For example second generation minority group follow a standard pattern of acculturation-assimilation to middle class majority group. The question is if this kind of acculturation process has a non deleterious effect on health and immigrant.

CONCLUSION In sum acculturation process is linked with the mental health status of the exposed immigrants in the host culture. Several studies confirmed that acculturation process is related to stress related mental disorders under certain psychological, social, political and ecological (the immigrant group density) conditions as well as the social support system and policy. However this view is not unidimensional. Other investigators provided the view that acculturation could be beneficial for the well being of the immigrant. More and better research is obviously required to explore the role of acculturation on mental health of immigrants and how the various components of culture interrelate with historical, political, social, economic factors in the formation of acculturation stress and the incidence of depression or anxiety disorders on any psychopathological pattern of behaviour. Additionally the research findings are needed to provide a reliable evidence for the organization of social policy programs to prevent socioculturally driven phenomena e.g. isolation, marginalization or racism and how deliver culturally responsive mental health care for immigrant populations.


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REFERENCES [1] [2]

[3] [4] [5] [6] [7] [8] [9]

[10] [11] [12]

[13] [14] [15]

[16] [17]

[18]

[19]

Odegaard O: Emigration and insanity: a study of mental disease among Norwegian born population of Minessota. Acta Psychiat. et Neurol. 1935; 4 (suppl): 1-206. Malzberg B, Lee E S: Migration and mental disease. A study of first admissions in hospitals for mental disease: New York (1939-1941). New York, New York Social Services Research Council, 1955. Murphy H B: Social change and mental health. Milbank Mem. Fund Quart 1965; 39: 385-399. Dohrenwend B P, Dohrenwend B S: Social status and psychological disorder. New York: J. Wiley, 1969. Cochrane R, Stopes-Roe M: Psychological symptom levels in Indian immigrants to England: comparison with native English. Psycholo. Med. 1981; 11: 319-327. Bebbington P E, Hurry J, Tennant C: Psychiatric disorders in selected immigrant groups in Camberwell. Social Psychiatry 1981; 16: 43-51. Madianos M: Acculturation and mental health of Greek immigrants in USA. In Social Psychiatry. Edited by Hudoin V New York, Plenum Press, 1984, pp 549-558 Burvil P W: Immigration and mental disease. Austr. New Zeal. J Psychiatry 1973; 12: 49-55. Haldin J: Prevalence of mental disorder in an urban population in central Sweden in relation to social class, marital status and immigration. Acta Psych. Scand. 1985; 71: 117-127. Fichter M, Elton M, Diallina M: Mental illness in Greek and Turkish adolescents. Eur Arch Psychiatry Clin. Neuroscience 1988; 237: 125-134. Cochrane R, Bal S S: Migration and schizophrenia: an examination of five hypotheses. Social Psychiatry 1987; 22: 180-191. Shrout P E, Canino G, Bird H R, Rubio-Stipev M, Bravo M, Burnam M A: Mental health status among Puerto Ricans, Mexican Americans and non-Hispanic whites. Amer. J. Com. Psychol. 1992; 20: 726-752. Escobar J: Immigration and mental health: why are immigrants better? Arch Gen. Psychiatry 1998; 55: 781-782. Bhugra D: Migration and depression. Acta Psychiat. Scand. 2003; 418 (suppl): 62-67. Grant B F, Stinson F S, Masin D S, Dawson D A, Chou S P, Anderson N K: Immigration and lifetime prevalence pf DSM-IV Psychiatric disorders among Mexicans-Americans and non-Hispanic whites in the United States: results from the National Epidemiologic survey on alcohol and related conditions. Arch Gen. Psychiatry 2004; 61: 1226-1233. Bhugra D: Migration, distress and cultural identity. Brit. Med. Bull. 2004; 60: 129-141. Claassen M, Axcoli M, Berhe T, Priebe S: Research on mental disorders and their care in immigrant populations: a review of publications from Germany, Italy and the UK. Eur. Psychiat. 2005; 20: 540-549. Breslau J, Chang D F: Psychiatric disorders among foreign-born and US-born Asian Americans in a US national survey. Soc. Psychiatry and Psychiatr. Epi. 2006; 41: 943950. Opler M: Culture and Mental Health. New York, Macmillan, 1959.

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[20] Koranyi E K, Kerrenyi A B, Sarwer-Foner G I: Adaptive difficulties of some Hungarian immigrants: The process of adaptation and acculturation. Compr. Psychiatry 1963; 4: 47-57. [21] Fabrega H: Social psychiatry aspects of acculturation and migration: a general statement. Compr. Psychiatry 1969; 10: 314-326. [22] Nachson I, Druguns J G, Broverman I K, Philips L: The reflection of acculturation in psychiatric symptomatology: a study of an Israeli guidance clinic population. Soc. Psychiatry 1972; 75: 109-118. [23] Padilla A M: Acculturation: Theory, Models and some findings. Westview, Press Boulder Co, 1980. [24] Cuellar I, Lorwen C H, Naron N: (1981) Evaluation of a bilingual bicultural treatment program for Mexican American psychiatric inpatients. In Explorations in Chicago psychology. Edited by Baron A, New York, Praeger, 1981, pp 165-186. [25] Burnam A, Hough P L, Karno M, Escobar J L, Telles C: Acculturation and lifetime prevalence of psychiatric disorders among Mexican Americans in Los Angeles. J. Health and Soc. Beh. 1987; 28: 89-102. [26] Caetano R: Acculturation and drinking patterns among US Hispanics. Brit. J. Addiction 1987; 82: 789-799. [27] Kaplan M, Marks G: Adverse effects of acculturation: Psychological distress among Mexican American young adults. Soc. Sci. Med, 1990; 31:1313-1319. [28] Berry J W: Immigration, acculturation and adaptation. Applied Psychology: An International Review 1997; 46: 5-18. [29] Hines A M, Snowden L R, Graves K L: Acculturation, alcohol consumption and AIDS related risky sexual behaviour among African American women. Women’s Health 1998; 27: 17-35. [30] Ortega A N, Rosenheck R, Alegria M, Desai, R A: Acculturation and the lifetime risk of psychiatric and substance use disorders among Hispanics. J. Nerv. Ment. Dis. 2000; 188: 736-740. [31] Hahm H C, Lahiff M, Guterman N B: Acculturation and parental attachment in AsianAmerican adolescents‘ alcohol use. J. Adol. Health 2003; 33: 119-129. [32] Lau A S, Mccabe K M, Yeh M, Garland A F, Wood P A, Hough R L: The acculturation gap-distress hypothesis among high risk Mexican-American families. J. Fam. Psycho.l 2005; 12: 361-375. [33] Kim E, Cain K, Mccubbin M: Maternal and parental parenting, acculturation, and young adolescents. Psychological adjustment in Korean American families. J. Child Adol. Psychiat. Nurs 2006; 19:112-129. [34] Madianos M, Gonidakis F, Ploubidis D, Papadopoulou E, Rogakou E: Measuring acculturation and symptoms of depression of foreign immigrants in the Athens area. Int. J. Soc. Psychiat. 2008; 54: 338-349. [35] Redfield R, Linton R, Herskovits M: Memorandum on the study of acculturation. Amer. Anthropologist 1936; 38: 149-152. [36] Park R E: Human migration and the marginal man. Am. J. Sociol. 1928; 33: 881-893. [37] Berry, J W: Acculturation as varieties of adaptation. In Acculturation: Theory, models and some findings. Edited by Padilla A, Colorado, Westview Press, 2000. [38] Berry, J M: Phinney L S , Sam D L, Vedder P: Immigrant youth: acculturation, identity and adaptation. Applied Psychol: Intl. Rev. 2006; 55: 302-332.


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[39] Ruesch J A, Jacobson A, Loeb M B: Acculturation and illness. Psychological Monographs. Washington DC, American Psychological Association, 1948. [40] Figuerido J: The law of sociocultural demoralization. Soc. Psychiatry 1983; 18: 73-78. [41] Link B, Dohrenwend B P: Formulation of hypotheses about the true prevalence of demoralization in United States. In Mental Illness in the United States. Edited by Dohrenwend B P, Dohrenwend B S, Schwartz M, Gould M, Link B. New York, Praeger, 1980, pp 114-130. [42] Mavreas V, Bebbington P: Acculturation and psychiatric disorder: a study of Greek Cypriot immigrant. Psychol. Med. 1990; 20: 941-951. [43] Adamopoulou A, Garyfalos G, Bouras N, Kouloumas G C: Mental health and primary care in ethnic groups Greek Cypriots in London: a preliminary investigation. Int. J. Soc. 1990; 36: 244-251. [44] Sam D L, Berry I W: Acculturative stress among immigrants in Norway. Scand J Psychol 1995; 36: 10-24. [45] McLachlan M, Smyth C, Breen F, Madden T: Temporal acculturation and mental health in modern Ireland. Intl. J. Soc. Psychiatry 2004; 50: 345-350. [46] Nwadiora E, McAdoo M: Acculturative stress among Amerasian refugees: gender and racial differences. Adolescence 1996; 31: 477-487. [47] Madianos M, Bilanakis N, Liakos A: Acculturation, demoralization and psychiatric disorders among repatriated Greek migrants in a rural area. Eur. J. Psychiatry 1998; 12: 95-108. [48] Oppedal B, Roysamb E, Heyerdahl S: Ethnic group, acculturation and psychiatric problems in young immigrants. J. Child Psychol. Psychiatry 2005; 46: 646-660. [49] Karriker –Jaffe K J, Zemore S E: Associations between acculturation and alcohol consumption of Latino men in the United States. J. Stud. Alcohol. Drugs 2009; 70:2731. [50] Gul V, Kolb S: Acculturation, bicultural identity and psychiatric morbidity in young Turkish patients in Germany. Turk. Psykiyatri Derg. 2009; 20: 138-143. [51] Radloff LS: The CES-D scale: a self report depression scale for research in the general population. Appl. Psychol. Measur. 1977; 1: 385-401. [52] Szapoeznik J, Kurtiness W: Acculturation biculturation and adjustment among Cuban Americans. In Acculturation: theory models and some new findings. Edited by Padilla A, Boulder, Co, Westview Press, 1980, pp 80-89. [53] Gaviria F M, Richman J, Flaherty J: Migration and mental health in Peruvian society. Towards a psychological model. Soc. Psychiatry 1986; 21: 193-199. [54] Boydell J van Os J, Mc Kenzie K, Allardyce J, Goel R, Mc Greadie R G, Murray, R M: Incidence of Schizophrenia in ethnic minorities in London: ecological study into interactions with environment. BMJ 2001; 323: 1336-1338. [55] Veling V, Sysser E, Van Os J, Mackenbach J, Selten J P, Hock H W: Ethnic density of neighbourhoods and incidence of psychotic disorders among immigrants. Am. J. Psychiat. 2007; 65: 66-73. [56] Vega W A, Amaro H: Latino outlook: good health, uncertain prognosis. An. Rev. Pub. Health 1994; 15: 39-67. [57] Zhou, M. Segmental assimilation: Issues, controversies and recent research on the new second generation. Int. Migration Rev. 1997; 31: 975-1008.

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[58] Streltzer J, Rezentes W C, Araki M: Does acculturation influence psychosocial adaptation and well-being in Native Hawaiians? Int. J. Soc. Psychiat. 1996; 42: 28-37. [59] Virta E, Sam D L, Westin C: Adolescents with Turkish background in Norway and Sweden: a comparative study of their psychological adaptation. Scand. J. Psychol. 2004; 45: 15-25. [60] Campos M D, Podus D, Anglin M D, Warda U: Mental health need and substance abuse problem risk: acculturation among Latinas as a protective factor among Calworks applicants and recipients. J. Ethn. Subst. Abuse 2008; 7: 268-291.



Chapter 9

IMMIGRATION, PSYCHOSOCIAL FACTORS AND PSYCHOLOGICAL DISTRESS, WITH FOCUS ON PERCEIVED CONTROL AND SOCIAL INTEGRATION Odd Steffen Dalgard Norwegian Institute of Public Health, Oslo, Norway

ABSTRACT Background: Studies have shown that immigration may be associated with good as well as poor mental health, depending on the social context, and that various social and psychosocial variables may act as explanatory factors. Aims of the study: To investigate the relationship between psychosocial variables and psychological distress in immigrants in Oslo, Norway, with special focus on perceived control and social integration. Methods: The study was based on data from a community survey in Oslo, and encompassed 13992 Norwegian born, 1118 Western immigrants and 1619 Non-western immigrants. Psychological distress was measured by a 10 items version of Hopkins Symptom Check List (HSCL-10), perceived control by scales of generalized self-efficacy and powerlessness, and social integration by an index based on four items: Knowledge of the Norwegian language, reading Norwegian newspapers, visits by Norwegians and receiving help from Norwegians. Information on paid work, household income, marital status, social support and conflicts in intimate relationships was also included in the study. Results: Compared to the Norwegian born and the Western immigrants, the Nonwestern immigrants had a higher prevalence of psychological distress, and they were more often without paid work, had lower household income, weaker social support and more negative life events, perceived less control, and were less socially integrated. When adjusting for these factors, the increased prevalence of psychological distress in the Nonwestern immigrants compared to the Norwegian born was substantially reduced, perceived control having an independent effect. Social integration was associated with good mental health in Non-western men but not in Non-western women.

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Odd Steffen Dalgard Conclusion: Lack of perceived control over own life situation, and in men, lack of social integration, contributes to increased prevalence of psychological distress in Nonwestern immigrants, and should be addressed in preventive work. In Non-western women the role of social integration is more complex, and one should be more cautious in expecting rapid social integration in these women.

INTRODUCTION Migration and its impact on mental health has been subject for studies for several decades, and the first classical studies were carried out before the second world war [1, 2]. Whereas the first studies were based on hospital statistics, the later studies have been based on surveys, with or without the use of clinical interviews. Anxiety, depression and post traumatic stress disorder (PTSD have been the indicators of mental health in most of the recent studies. The term ―psychological distress‖ is often used, in the sense of anxiety/depression which may be on the clinical or subclinical level. In recent years there has been a growing interest in the study of international migration and its impact on mental health, parallel with the trend of increasing migration between countries, especially from low-income to high-income countries [3]. The global problem of refugees has also been an important subject for recent psychiatric research. Most of the studies of international migration have reported higher rates of psychological distress among immigrants compared to the native population [4, 5, 6], but there are exceptions [7, 8]. Obviously, migration by itself does not represent a threat to mental health; it depends on the social context, and the conditions under which the migration takes place. Different mechanisms have been put forward to explain associations between migration and mental health. Stress, in the sense of an unbalance between challenges and the normal coping mechanisms, is a central concept in most of these explanations. To the extent migration leads to increased stress, either by increase in stress-leading events (stressors) and/or by weakening of coping resources, the risk of mental health problems increases. Premigration stressors are not so often studied as post-migration stressors, and if studied, this is mainly by retrospection. Especially in refugees, traumatic events in the country of origin, like imprisonment and torture, are shown to increase the rate of mental health problems [9]. But also post-migration stressors, like somatic illness, family conflicts, economic problems and unemployment, especially in migrants from low-income to high-income countries, contribute to mental health problems in immigrants [3, 10, 11]. Social isolation and lack of social support are other risk factors [12], increasing stress by reducing the coping abilities of the immigrants. In the present study, a special focus will be on two factors that may affect the mental health of immigrants, perceived control over own life situation and social integration, factors that in different ways may be connected with stress. To the knowledge of the author, perceived control has not been the explicit subject for prior research in this field, whereas the research on social integration has given somewhat inconsistent results.

Immigration, Psychosocial Factors and Psychological Distress…

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Perceived Control It is known for long time that perceived lack of control increases psychological distress [13], and it is suggested that lack of control is an important mediator between low socioeconomic status and mental health problems [14]. Consequently, it is not unlikely that lack of perceived control could contribute to mental health problems also in other socially marginalized groups, like immigrants, in particular those coming from countries with a different culture. Perceived lack of control may be defined and measured in somewhat different ways, for instance as sense of powerlessness or low self-efficacy. A sense of powerlessness develops when coping is not successful, and the individual feels that nothing can be done to relieve a stressful life situation. The feeling of powerlessness or helplessness, which is often associated with low self esteem, is by different authors described as a burden on health, mental as well as somatic [15, 16, 17, 18, 19, 20]. With the growing interest in the relationship between social inequality and health, the concept of powerlessness has taken on greater importance [21]. Self- efficacy, as defined by Bandura in 1977, is the subjective assessment of what one ―can do‖, and hence affects how people feel and think about the future. A low sense of selfefficacy is associated with helplessness and pessimistic thoughts about one‘s own development and accomplishments [22] , whereas a strong sense of self-efficacy motivates the individual to perform more challenging tasks, investing more effort, and for greater persistence in attempting to obtain desired goals [23].

Social Integration By social integration is usually meant the adaptation of the norms and values of the ―main stream‖ majority culture by the minority group, especially with respect to language, daily costumes and social behavior In some studies social integration is associated with good mental health, in others with mental health problems. In this literature ―social integration‖ and ―acculturation‖ have often been used interchangeably, even if there may be differences in the content of these concepts [24]. Different measures of degree of social integration or acculturation have been used, the most widely used probably being the learning of the language of the host country. Other indicators have been share of cultural values with the host population and use of host media. Several community studies in U.S. have indicated that social integration is associated with increased health problems, rather than the opposite. In one study immigrants of Hispanic ethnic origin had a lower prevalence of psychiatric disorder than the host population, and the prevalence was increasing by increasing integration in terms of learning the English language [8]. In a community study in United Kingdom, immigrants from India, Pakistan, Bangladesh and China had lower prevalence of anxiety and depression than the host population, whereas the Irish had higher rates [25]. Among the Pakistani and Bangladeshi groups who spoke fluently English, the prevalence of anxiety was doubled, whereas there was almost no difference for the Indians. Likewise, in a study of Greek immigrants in New York, those who were most ―Americanized‖, in terms of sharing American values and customs, had the highest score on psychological distress [26]. Other studies indicate that social integration is positive for mental health. As an example, a study from a recently established neighborhood in Oslo,

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where the same method of measuring integration as in the study from New York was applied, showed that the best integrated immigrants had the best mental health [27]. Likewise, in a study of Pakistani immigrants in U.K. [28], depression was associated with lack of fluency in English, and the same was the case in a study of immigrants in Australia [29]. In Canada Vietnamese refugees, and students from other Asian countries, had better mental health the more contacts with Canadians and Canadian culture [30]. As a conclusion then, social integration may be associated with good as well as poor mental health, depending on the social context. There are different contextual factors that might influence the association between social integration and mental health. One important factor seems to be the size of the immigrant community [31]. If the immigrant group is small compared to the host community, it is likely that the pressure towards integration will be strong, and consequently that lack of integration generates stress and mental health problems. If, on the other side, the immigrant group is relatively big, there will be less need for integration, since the group may develop it‘s own ethnic subculture. Another factor likely to affect mental health and social integration among immigrants is the attitudes of the host population towards the new-comers. Do they represent a pluralistic or multicultural ideology, with attendant tolerance for cultural diversity, or is there an ideology in favor of assimilation, with pressures to conform to a single cultural standard [30]? If there is an ideology in favor of assimilation, it is of importance how fast the new-comers are expected to assimilate, and there is some evidence that a pressure towards fast assimilation increases the risk of mental disorder, and that a pluralistic community is best for the mental health of immigrants [31]. A third factor playing an important role for social integration, is the cultural distance between the immigrants and the host population. If the cultural gap is wide, eventually with conflicting values, integration may be difficult. Especially in relation to immigration to Western countries from Asia or Africa, the conflict between individualistic and collectivist cultures is of relevance [32]. Individualistic society, then, is one where the ties between individuals are relatively loose, and everyone is expected to look after himself /herself and his/her immediate family, whereas collectivism refers to a type of society to which people from birth onwards are integrated into strong cohesive in-groups, especially family and kinship, which throughout their lifetime continues to protect them an demand unquestionable loyalty [33]. Not all individuals being alike, this means than an individualistic person from a collectivist culture may adjust easily to an individualistic society, and vice versa. The possibility of gender differences in the process of social integration is barely mentioned in the literature referred to above, as if men and women of the same ethnic origin have more or less the same problems in relating to the new cultural environment. This is not necessarily so, and in a qualitative study of elderly Indian women in Canada, there are examples of cultural conflicts which seem to hit women stronger than men [34]. The traditionally strong position of the elderly women in the family, not least in the function of mother-in-law is eroded, and their inability to transmit their culture and traditions to next generation, is felt as a loss and a source of sadness. Limited facility with the English language and household responsibility make it difficult for them to take part in the social life, and social isolation is likely to be a bigger problem for them than for men. Conflict with social norms, threats to the self and/or loss of identity could also be sources of distress, relatively stronger in the nonwestern immigrant women than men.


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To which extent the contrasting associations between social integration and mental health may be explained by the factors mentioned above, is not certain. However, it seems important in future research to take them all into consideration when investigating the relationship between social integration and mental health.

Aims of the Present Study The aims of the present study is to investigate the distribution of social and psychosocial risk factors in different immigrant groups compared to the Norwegian- born in Oslo, and to explore to which extent these factors explain the differences in psychological distress between the immigrants and the Norwegian- born. Special emphasize will be put on the role of perceived control and social integration. Some of the results are presented in prior publications [35, 36].

METHODS The Scene According to Statistics Norway, more than 7 % of the population of Norway consists of immigrants, and this constitutes almost 20% of the population of Oslo. Of the immigrants 52% comes from Africa or Asia (12% and 40%), the rest from Eastern Europe (16%), the Nordic counties (15%) the rest of Western Europe (10%) and America/Oceania (7%).

Sample The University of Oslo, National Health Screening Service of Norway (now the National Institute of Public Health), and Oslo Municipality jointly organized a general health survey known as the Oslo Health Study in 2000-2001. The study subjects were all the inhabitants of Oslo born in 1970, 1960, 1955, 1940/41 and 1924/25. The details on the methodology are described elsewhere [37]. Of the 40,888 in the sample, only 18,770 (45.9%) participated in the study. However, the weighted prevalence estimates of self-rated health and other analysed variables differed only slightly between attendees and the target population, and the association measures were found to be less influenced by the self-selection [37]. Among the responders 13992 were born in Norway, 1025 in Western Europe, North America and Australia (Western countries) and 1928 from Eastern Europe, South America and countries in Africa and Asia (Eastern countries). Data about country of birth was missing for 1825. Among the immigrants from ―Eastern countries‖ 259 came for Eastern Europe, 605 from the Indian subcontinent, 340 from South East Asia, 293 from Africa, 318 from the Middle East, and the rest (113) from other countries. In the analysis refugees (217) were not included, which gives a total analyzed sample of 15 723, split in three major groups according to place of birth: Norway (13992), Western countries (1118) and Non-Western countries (1619).

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Instruments The Oslo Health Study questionnaire was translated into the following 11 languages other than Norwegian: Albanian, Arabic, English, Farsi, Serbo-Croatian, Somalian, Spanish, Tamil, Turkish, Urdu and Vietnamese. The variables used in the present study are the following:

Mental Health A 10-items version of Hopkins Symptom Check List [38] was used as a measure of psychological distress. Each item was rated on a scale of 1 (not at all) to 4 (extremely) during the past week. In contrast to the 25 items Hopkins Symptom Check List (HSCL-25), where symptoms can be subdivided into depression and anxiety categories [39], the HSCL-10 provides a measure of global psychological distress. The internal consistency of the scale was high in the sample (Cronbach‘s alpha=0.89), and there were no difference with respect to this between the Norwegian born and the immigrant groups. In most of the analyses the distress score was dichotomized with cut off point 1.85 , which has been shown to correspond to the conventional cut-off point of 1.75 in HSCL-25 (38). Non-responders to HSCL-25 were unevenly distributed across the migratory groups, 4,3% of the Norwegian born, 6,2% of the immigrants from Western Europe/America and 20,5% of the immigrants from ―other countries‖ being non-responders. This means that especially the last group of immigrants is substantially reduced when comes to analyses including this variable. Social Support Social support was measured by two questions from the Oslo social support scale [40], one about number of close confidants, and the other about perceived positive interest and concern from other people. These questions have high face validity, and high predictive validity with respect to psychological distress. Negative Life Events To measure negative life events, a 12 items inventory of threatening experiences, developed by Brugha et al. [41] was used in the screening questionnaire. This inventory is developed by rating negative life events by two different methods in the same sample, i.e. an inventory developed by Tennants and Andrews [42], and a semi structured interview developed by Brown and Harris [17]. The inventory categories including most of the negative events in the interview representing marked or moderate threat, were identified. Very rare events were excluded. In an independent study the 12 items inventory, recording negative life events during the last 6 months, was associated with a significant increase in the risk of developing depression. The inventory is especially recommended for use in connection with depression, when the more costly use of semi-structured interview cannot be afforded. Perceived Control Control was measured by two instruments, generalized self-efficacy, developed by Jerusalem et al. [43], and the power-powerlessness factor in the Empowerment scale developed by Rogers et al. [44]. The two scales differ considerably in their content. Whereas


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the generalized self efficacy scale measures the confidence in being able to control challenging environmental demands by means of taking adaptive actions, the powerlessness scale measures the sense of power in a community context. Whereas generalized self efficacy is known to be relatively stable over time, and related to personality traits, like extraversion and optimism, less is known about powerlessness in the Empowerment scale. However, it is reason to believe that the powerlessness scale is more sensitive to the actual life situation, and hence measures a state rather than a trait. Examples of questions from the self-efficacy scale are:   

I always manage to solve difficult problems if I try hard enough I am confident that I could deal efficiently with unexpected events Thanks to my resourcefulness, I know how to handle unforeseen situations

Examples of questions from the powerlessness scale are:   

You cannot fight city hall When I am unsure about something, I usually go along with the group Experts are in the best position to decide what people should do and learn

The scales of generalized self efficacy and powerlessness both showed high internal consistency in the sample, Cronbach‘s alpha being respectively 0.90 and 0.67. The rationale for expecting the control variables to explain differences in psychological distress between Norwegian born and immigrants, is that lack of control, as measured in the study, has a negative effect on mental health in both groups. This is not necessarily so. As put forward by Rothbaum et al. [45], one may distinguish between primary and secondary control. Whereas primary control is to bring environment into line with one‘s wishes, secondary control is to bring oneself into line with the environmental forces. Both types of control may be adaptive, dependent on the circumstances. In the present study, the two indicators of control obviously measure primary control. It might be, then, that for the Norwegian born, lack of primary control is associated with a sense of failure and psychological distress, whereas for immigrants, because of their more difficult life situation, lack of primary control is not that bad, and rather an expression of a realistic assessment of the situation. If this is so, one should expect a higher correlation between the measures of control and psychological distress in the Norwegian born than in the immigrants. However, this was not so. The Pearson correlations between Powerlessness and psychological distress in respectively Norwegian born, Western immigrants and Non-western immigrants, were .30, .31 and .39. For generalized self-efficacy the correlations were –.31, -.35 and – .25. So it seemed that primary control was equally important for mental health in Norwegian born as in immigrants, and that it was meaningful to explore to which extent this type of control explains the differences in psychological distress.

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Social Integration Four items were used as indicators of integration into the Norwegian community:    

Knowledge of the Norwegian language Reading Norwegian newspapers last year Visit by Norwegians last year Help/support from Norwegians last year

The first item had 5 response alternatives from ―very good‖ to ―bad‖, and the other items had 4 response alternatives from ―daily‖ to ―never‖. An index was established by summarizing the scores of each item (Cronbach‘s alpha: 0.57), high score meaning high acculturation.

Socio-Demographic Data The analyses also included data about gender, age, marital status, household income and paid work. Information on family income was gathered from register data. Information about employment was based on the question: Are you in paid work?

The response alternatives were dichotomized into to two groups: ―In full-time or parttime paid work‖, ―not in paid work‖. Marital status was dichotomized in married/cohabitant and the rest.

Statistical analyses Testing of significance: The differences in distribution of categorical variables were tested by Chi-square (table 1 and figure 1), and of continuous variables by ANOVA (table 2). Correlations between variables were tested by Pearson correlations, two-tailed (table 3). Logistic linear regression analyses were used to estimate the associations between psychological distress (HSCL-10) and place of birth, when adjusting for various predictors, presenting Odds ratios and 95% confidence intervals (tables 4 and 5). Steps of analyses: The distribution of socio-demographic and psychosocial variables and the correlations between variables are presented for the total sample. The analyses of associations between place of birth and psychological distress, when adjusting for sociodemographic and psychosocial variables, with the exception of social integration, are based on the Norwegian born and the Non-western immigrants. When social integration is included, the analyses are based on the Western and Non-western immigrants.

RESULTS Distribution of socio-demographic and psycho-social variables The distribution of socio-demographics variables is shown in table 1.

Immigration, Psychosocial Factors and Psychological Distress… Table 1. Socio-demographic variables Age < 45 years

Married

Household income 1.85), with adjustment for various predictors.

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Associations between Immigration (Non-Western Immigrants Versus Norwegian Born) and Psychological Distress, with Adjustment for Socio-Demographic and PsychoSocial Variables The associations between place of birth and psychological distress, with adjustment for various combinations of variables, are shown in table 4. The results are based on four logistic regression analyses (model 1- 4). The results for men and women are put together, as the results were similar in both genders. When adjusting for gender and age (model 1), Non-western immigrants had a significantly increased level of psychological distress (Odds ratio 1.76, 95 % confidence interval 1.63-1.89) compared to the Norwegian born. When also adjusting for household income, paid work and marital status (model 2), the association between place of birth and psychological distress was reduced (Odds ratio 1.50, 95 % confidence interval 1.33-1.39). 25

23.5 21.4

20

15 12.5

Western countries 10

Non-western countries

10 7.2

6.3 5

0 Low integration

Medium integration

High integration

30 26.8

26.6 24

25 20.8 20 15.4

Western countries

15

Non-western countries 9.6

10

5

0 Low integration

Medium integration

High integration

Figure 1. Social integration and psychological distress (HSCL-10>1.85). Percent

Adjusting for confidants, social support and negative life events (model 3), reduced the association further (Odds ratio 1.35, 95 % confidence interval 1.18-1.56). When finally


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adjusting also for powerlessness (model 4), the association between place of birth and psychological distress was even further reduced, but was still statistically significant (Odds ratio 1.17, 95 % confidence interval 1.01- 1.36). In the final model, all variables were independently associated with psychological distress, not being in paid work and feeling of powerlessness emerging as the strongest risk factors.

Associations between Immigration (Non-Western Versus Western Immigrants) and Psychological Distress, with Special Focus on Social Integration The relationship between social integration and psychological distress in immigrants from Non-western and Western countries is shown in figure 1. In Western immigrants, men and women, the prevalence of psychological distress was lowest in the group with highest integration, and the same was true for male immigrants from Non-western countries. In the well integrated male immigrants the prevalence of psychological distress was not much higher than among the Norwegian born men (6.6 %), whereas the well integrated female immigrants from Western countries in fact had somewhat lower prevalence than the Norwegian born women (12.5 %) . For women from Non-western countries, however, there was no difference in prevalence of psychological distress across social integration. Irrespective of integration these women had a high prevalence of psychological distress. The lacking effect of social integration on psychological distress in women from Non-western countries was repeated in logistic regression analysis (data not shown). Whereas there were significant associations between social integration and psychological distress in women from Western countries (p=, 04), and men from Nonwestern countries (p= .06), when adjusting for age, there was no such association in women from Non-western countries (p= .49). The multiplicative interaction between gender and psychological stress with respect to psychological distress in Non-western immigrants was close to significance (p= .06). When adjusting for social integration, the association between place of birth and psychological distress in men from Non-western countries was substantially reduced (OR from 2.67 to 2.28), whereas the reduction in Non-western women was small (OR from 2.53 to 2.43). Association between Social Integration and Psychological Distress in Non- Western Immigrants The association between social integration and psychological distress (HSCL-10>1.85) in Non-western immigrants, when adjusting for various predictors, is shown in Table 5. When only adjusting for age (model 1), there is, as we already know, a significant association between social integration and psychological distress in men, but not in women. When adjusting for household income and not paid work (model 2), the association between social integration and psychological distress in men is reduced below the level of significance, and further reduced when also adjusting for powerlessness (model 3). In women the pattern is different. When adjusting for household income and not paid work, there is positive association between social integration and psychological distress, and when also adjusting for powerlessness there is a significant positive association, i.e. psychological distress increases by increasing social integration.

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Odd Steffen Dalgard Table 5. Logistic regression analyses Predictors

Men

Women

Integration Income Not paid work Powerlessness Nagelkerke Square Integration Income Not paid work Powerlessness Nagelkerke Square

Model 1

Model 2

Model 3

OR 95% CI

OR 95% CI

OR 95% CI

.88 ( .77-1.00)

.96 ( .83-1.11) .61 ( .44- .85) 1.55 ( .60-3.95)

.029

.116

.99 ( .85-1.16) .65 ( .46- .92) 1.22 ( .43-3.42) 3.35 (1.61-6.99) .198

1.03 ( .94-1.15)

1.13 ( .99-1.30) .85 ( .67-1.07) 1.64 ( .78-3.45)

.025

.060

1.19 (1.02-1.37) .88 ( .69-1.14) 1.54 ( .69-3.45) 3.33 (1.71-6.49) .146

DISCUSSION Immigrants from Non-western countries had a higher score on psychological distress than the Norwegian born and the immigrants from Western countries. The immigrants from Nonwestern countries reported less close confidants, less social support and more negative life events than the Norwegian born, and they had lower household income and were less often in paid work. Between the Western immigrants and the Norwegian born the differences were small. When adjusting for the socio-economic and psychosocial factors, the difference in psychological distress between the Non-western immigrants and the Norwegian born was substantially reduced, indicating that these factors to a considerable extent explained the increased level of psychological distress in the Non-western immigrants.

Perceived Control With respect to the indicators of perceived control, a sense of powerlessness was more prevalent in the Non-western immigrants than in the other groups, whereas this was not the case for generalized self-efficacy. When adjusting for sense of powerlessness, in addition to socio-demographic and other psychosocial variables, the associations between place of birth and psychological distress was further reduced, indicating that sense of powerlessness in itself contributed to the difference in psychological distress between the Non-western immigrants and the Norwegian born. It is in agreement with our hypothesis that perceived lack of control, in the sense of a feeling of powerlessness, emerged as an explanatory factor for the increased level of psychological distress in Non-western immigrants. But it is not clear if the perceived lack of control in Non-western immigrants reflected their actual life situation, or was rather an expression of their habitual attitude towards life, probably linked to personality traits. However, it seems less likely that the last was true, since these immigrants were coming from


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countries far away, and had showed initiative and courage by leaving their country of birth. This certainly does not indicate that they felt without control, at least not the men, when they decided to emigrate; it rather indicates that the reported lack of control was a consequence of a difficult and a stressful life situation in their new home country . The finding that the reported lack of control was closer to a state than a trait, was also to some extent supported by the finding that generalized self- efficacy, which is probably closer to a trait than sense of powerlessness [46], was not associated with immigration..

Social Integration Non-western immigrants were less socially integrated into the Norwegian community than the Western immigrants, and they reported a higher level of psychological distress. However, only in men this explained some of the increased level of psychological distress in the Non-western immigrants. The reason for this seemed to be that social integration in Nonwestern men was positive for mental health, whereas this was not the case in women. The positive effect in men seemed to be mediated by household income and paid work, since the effect of social integration was reduced substantially when adjusting for these variables. In women, social integration was negatively associated with mental health when adjusting for household income and paid work, indicating that the negative effect had been covered up by these other associated variables. There may be several reasons for the different effects of social integration in men and women from non-Western countries. One possibility is that women, with their central role in the family, to a greater extent than men are challenged by cultural values different from their own. It is not unlikely that the conflicts between the collectivistic values in most of the nonWestern countries and the individualistic values in the Western countries [32] are more strongly felt by immigrant women. Another explanation may be that social integration in women in some instances is met by negative sanctions from men of their own ethnic group. It is well known, that for instance Muslim women are not always stimulated by their families to adopt the Norwegian language and Norwegian costumes, rather to the contrary, and are expected to stay apart from the Norwegian community. All together, the attempt of these women to integrate into the Norwegian community may easily lead to conflicts with social norms, threats to the self and/or loss of identity, which could be a burden on mental health, at least temporary. One reason for the seemingly positive effect on mental health of social integration among Non-western men in the present study, may be the relative small size of the immigrant groups in Oslo. The size is too small to provide the immigrants with a subculture, where they can spend most of their time, even getting paid work, without much contact with the host community. Different from the big groups of Mexican immigrants in California [7] and of Greeks in New York [26], where social integration was associated with poor mental health, the Non-western immigrants in Oslo will have great problems in getting paid work without good knowledge of the Norwegian language of the host country, which in itself is an important indicator of social integration. For the Non-western women the situation is somewhat different, with less pressure towards paid work, and probably stronger ties to their own ethnic group.

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Another possible explanation of the positive effect of social integration on the mental health of the Non-western men in Oslo, is that Norway up to recently has been a culturally homogenous country, with strong pressure towards assimilation. In Norway there has been a strong pressure on immigrants to adopt Norwegian language and Norwegian customs, in spite of the public policy being ―integration‖ rather than ―assimilation‖. Even if the immigrants may keep important elements of their own culture, they are expected to adjust rather quickly to the Norwegian society. So integration is the best way to avoid conflicts with the Norwegian culture, which may be good for mental health, but the price may be conflicts within their own culture, which is probably most strongly felt by the Non- western women. The study has weaknesses which makes it difficult to draw firm conclusions. First, it is problematic that the response rate in the survey was low (45.9%). However, as mentioned earlier, in a study of the sample, where socio-demographic register data, also for the nonparticipants, were taken into consideration, the prevalence rates of self-rated health, including mental health, was not much changed by self-selection (Søgaard et al., 2004). Even so, one may question the representativeness of the sample, especially when comes to psychological distress, because of the relatively low response rate for this variable in the immigrants. This implies that one should be cautious drawing conclusions about prevalence rates of psychological distress in the sample, whereas one may feel more confident with respect to the findings related to associations between variables. Even if the questions in the questionnaire were translated into the native languages of the immigrants, one may doubt if the questions about stress and psychosocial conditions have the same validity in different cultures. Further research into this problem is of great importance for cross-cultural comparisons in this field. Another weakness of the study is the cross-sectional design, which makes it difficult to draw conclusion about causality. In principle, the increased prevalence of psychological distress among the immigrants could simply reflect that they had poorer mental health before entering Norway. That pre-migration stressors, like imprisonment, war experiences and torture, contribute to the excess morbidity of refugees, is documented by another study of the same sample (Thapa et al., 2005). Even here, however, post-migration factors seemed to be more important than pre-migration factors for mental health. Also with respect to non-refugee immigrants, whom the present study is dealing with, it is likely that pre-migration factors play a certain role.

CONCLUSION Together with low household income, unemployment, weak social support and negative life events, perceived lack of control contributes to the increased prevalence of psychological distress in Non-western immigrants. In accordance with this, empowerment should be an important part of preventive work in these immigrants. Lack of social integration is an important risk factor for mental health in men from Non-western countries living in Oslo, whereas this is not so for women from these countries. This indicates that from a mental health point view one should be cautious in expecting a rapid social integration of these women.


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ACKNOWLEDGMENTS The author is grateful to the Oslo Health Study 2000-2001 who have provided the data and made them ready for statistical analysis.

REFERENCES [1] [2] [3]

[4] [5]

[6]

[7]

[8]

[9]

[10]

[11] [12]

[13] [14]

Ødegård Ø. Immigrant and Insanity- a study of mental disease among the Norwegianborn population in Minnesota. Acta Psychiat. Neur. Scand. 1932, Suppl 4. Malzberg B. Social and Biological Aspects of Mental Disease. Utica, New York: State Hospitals Press, 1940. Thapa, SB, Dalgard, OS, Claussen B, Sandvik L, Hauff E. Psychological distress among immigrants from high- and low-income countries: findings from the Oslo Health Study. Nord. J. Psychiatry 2007; 61: 459-465. Khavarpour, F, Rissel, C. (1997). Mental health status of Iranian migrants in Sydney. Australia, N. Z. J. Psychiatry 1997; 31: 828 – 34. Bengi-Arslan, L FC. Verhulst, FC., Crijnen, AAM Prevalence and determinants of minor psychiatric disorder in Turkish immigrants living in The Netherlands. Soc Psychiatry Psychiatr. Epidemiol. 2002; 37: 118-24. Miyasaka, LS., Otsuka, K, Tsuji, K, Atallah AN, Kunihiro, J, Nakamunar, Yet al. !!!!! Mental health of two communities of Japanese-Brazilians: a comparative study in Japan and in Brazil. Psychiatry Clin. Neurosc. 2002; 56: 55-64. Vega, WA, Kolody, B, Aguilar-Gaixola, S, Alderete, E, Catalano, R, CaraveoAnduaga. Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Arch Gen. Psychiatry, 1998; 55: 771-778. Ortega, AN, Rosenheck, R, Algeria , M, Desai, RA. Acculturation and the lifetime risk of psychiatric and substance use disorders among Hispanics. J. Nerv. Ment. Dis. 2000; 188: 728-35. Hauff, E, Vaglum, P. Vietnamese boat refugees: the influence of war and flight traumatization on mental health on arrival in the country of resettlement. A community cohort study of Vietnamese refugees in Norway. Acta Psychiatr. Scand. 1993; 88: 62-8. Dalgard, OS, Sandanger, I, Sørensen, T(1998). Mental health among immigrants in Oslo, Norway, in Social psychiatry in a global perspective . Edited by Varma K, Masserman CM, Malhotra, A and Malik, SC. New Dehli: Macmillan Indian Limited, 1998, pp 107-112 Lie, B. A 3-year follow-up study of psychosocial functioning and general symptoms in settled refugees. Acta Psychiatr. Scand. 2002; 106: 415-25. Simich, L, Beiser, M, Mawani, FN. Social support and the significance of shared experience in refugee migration and resettlement. Western J. Nurs Research 2003; 25: 872-891. Lazarus, RS. Psychological stress and coping process. New York: McGraw-Hill,1966 Stansfeld, SA, Head J, Marmot, MG. Explaining social class differences in depression and well-being. Soc. Psychiat. Psychiatr. Epidemiol. 1998; 33: 1-9.

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[15] Seligman, MEP. Helplessness: On depression, development and death. San Francisco: Freeman, 1995 [16] Brown GW and Harris T The social origins of depression. London: Tavistock Publications, 1978. [17] Seeman, M. and Lewis, S. Powerlessness, health and mortality. A longitudinal study of older men and mature women. Soc. Sci. Med. 1995; 41: 517-525 [18] Syme, S.L. Rethinking disease: where do we go from here? Ann. Epidemiol. 1996; 6: 463-468 [19] Marmot MG, Bosma H, Heminway H, Brunner, Stansfeld S. Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet 1997; 349: 235-239 [20] McCubbin, M (editor.). Pathways to health, illness and well being: From the perspective of power and powerlessness. J. Community Appl. Soc. Psychol. 2001; 11 (2) [21] Kawachi, I. and Kennedy, BP. Income inequality and health. Pathways and mechanisms. Health Services Research 1999; 34: 215-227 [22] Schwarzer R. and Fuchs R. Self efficacy and health behaviour, in Predicting health behaviour. Edited by Rutter M and Norman P. Buckingham: Open University Press, 1966, pp 163-196 [23] Locke EA. and Latham GP. A theory of goal setting and task performance. Englewood Cliffs N J: Prentice Hall, 1990 [24] Hunt LM, Schneider S, Comer B. Should ―acculturation‖ be a variable in health research? A critical review of research on US Hispanics. Soc. Sci. and Med. 2004; 59: 973-986 [25] Nazroo J. Etnicity and mental health. London: P.S.I., 1997 [26] Madianos M. Acculturation and mental health of Greek immigrants in USA, in. Social Psychiatry. Edited by Hudolin. NY, USA: Plenum Publishing Company, 1984, pp 549557 [27] Dalgard OS, Sandanger I, Sørensen T. Mental health among immigrants in Oslo, Norway, in Social psychiatry in a global perspective. Edited by Varma VK, Masserman CM, Malhorta A and Malik SC. New Dehli: Macmillan India Limited, 1998, pp.107112 [28] Husain N, Creed F, Tamenson B. Adverse social circumstances and depression in people of Pakistani origin in the U.K. Br. J. Psych. 1977; 171: 434--438 [29] Minas H. Migration and mental health. Melbourne: Transcult Psych Unit Report, 1999 [30] 30 . Berry JW and Kim U. Acculturation and mental health, in Health and cross-cultural psychology, towards applications. Edited by Dasen P, Berry JW, Sartorius N. London: Sage publications 1988, pp. 207-238 [31] Murphy HBM. Migration, culture and mental health. Psychol. Med. 1977; 7: 677-684 [32] Bhugra D. Migration and mental health. Acta Psychiatr. Scand. 2004; 109: 243-258 [33] Hofstede G. Cultures consequences. Beverly Hills, CA: Sage, 1980 [34] Choudhry UK. Uprooting and resettlement experiences of South Asian immigrant women. Western J. Nurs Research 2001; 23: 376-393 [35] Dalgard, OS, Thapa, SB, Hauff, E, McCubbin, M and Syed, HR. Immigration, lack of control and psychological distress: Findings from the Oslo Health Study. Scand. J. Psychol. 2006; 47: 551-558


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[36] Dalgard, OS, Thapa, SB. Immigration, social integration and mental health in Norway, with focus on gender differences. Clin. Pract. Epidemiol. Ment. Health 2007, 3: 24. [37] Søgaard AJ, Selmer R, Bjertness E, Thelle D. The Oslo Health Study: The impact of self-selection in a large, population based survey. Int. J. Equity Health 2004, 3: 3 [38] Strand BH, Dalgard OS, Tambs K, Rognerud M. Measuring mental health of the Norwegian population: a comparison of the instruments SCL-25, SCL-10, SCL-5 and MHI-5 (SF-36). Nord. J. Psychiatry 2003; 57: 113-118 [39] Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L. The Hopkins Symprom Checklist (HSCL): a self-report symptom inventory. Behav. Sci. 1974; 19: 1-15 [40] Dalgard, OS, Dowrick, C, Lehtinen, V, Vasquez-Barquero JL, Casey P, Wilkinson, G, Ayuso-Mateos, JL, Page, H, Dunn, G. Negative life events, social support and gender difference in depression. A multinational community survey with data from the ODIN study. Soc. Psychiatry Psychiatr Epidemiol. 2006; 41: 444 - 451 [41] Brugha T, Bebbington PE, Tennant C, Hurry J. The list of threatening experiences: a subset of 12 life event categories with considerable long-term contextual threat. Psychol. Med. 1985; 15: 189-194 [42] Tennant C, Andrews G. A scale to measure the cause of life events. Aust. N. Z. J. Psychiatry 1977; 11: 163-167. [43] Jerusalem, M., Scwarzer, R. (1992). Self-efficacy as a resource factor in stress appraisal process, in Self-efficacy: Thought control of action. Edited by Schwarzer, R. Washington, DC: Hemisphere, 1992, pp. 195-213 [44] Rogers, ES, Chamberlin, J, Ellison, ML, Crean, BA. A consumer-constructed scale to measure empowerment among users of mental health services. Psychiatr. Serv. 1997; 48: 1042-1047. [45] Rothbaum, F, Weisz, JR, Snyder, SS. Changing the world and changing the self: A twoprocess model for perceived control. J. Pers. Soc. Psychol. 1982; 42: 5-37. [46] Eriksen, HR., Ursin, H. Social inequalities in health: Biological, cognitive and learning theory perspectives. Norw. J. Epidemiol. 2002; 1: 33-38



Chapter 10

DEPRESSION AMONG LATINOS IN THE UNITED STATES Patricia Gonzalez1 and Monica Rosales2 1

2

San Diego State University, San Diego, California, USA City of Hope National Medical Center, Duarte, California, USA

ABSTRACT Depression is a major public health concern that places significant burden on the lives of Latino individuals, their families, and society. Latinos comprise a growing and diverse population making up the largest ethnic minority group in the U.S. This chapter provides an overview of the impact of demographic, immigration, acculturation, and social factors on depression among U.S. and non U.S. born Latinos. The review of the literature illustrates the complex nature of the relationships among these factors across Latino groups. Given the distinct immigration patterns and cultural backgrounds of Latinos, we recommend that research examine differences between Latino groups to determine how these differences shape depression outcomes. The main findings described in this chapter provide pertinent information about the correlates of depression and can guide interventions aimed at reducing depression risk among Latinos.

INTRODUCTION Depression is a major public health concern in the United States (U.S.) that places significant burden on the lives of individuals, families, and society. More specifically, major depression is the most common psychiatric disorder in the U.S. with an estimated 17% lifetime prevalence in the general population [1, 2]. In any given year, major depression afflicts approximately 6.7% of the U.S. population 18 years of age and older [2]. Findings from NHANES data (2005-2006) indicate that in any 2 week period, 5.4% of Americans 12 years of age and older, experienced depression [3]. In 2000 Latinos comprised 13.3% of the U.S. population [4]), becoming the largest ethnic minority group in the U.S. [5]. In 2002, of the total U.S. Latino population, the largest group

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was of Mexican origin (66.9%) followed by Central and South American (14.3%), Puerto Rican (8.6%), Cuban (3.7%) and other Latinos (6.5%) [4]. Given that two in five U.S. Latinos are immigrants, greater understanding of Latino immigrants‘ mental health status is increasingly important [6]. Despite the fact that Latino immigrants represent a growing U.S. population they continue to remain ignored in the literature [7]. This chapter describes depression among Latino immigrants and U.S. born Latinos by presenting; (1) a synthesis of existing evidence concerning the relationship between demographic variables and depression (2) the impact of immigration on depression; (3) the impact of acculturation and social stressors associated with depression; and (4) the limitations of current literature and recommendations for future research.

Prevalence of Depression Although a few national (e.g., HHANES, NIMH Epidemiologic Catchment Area Program, Mexican American Prevalence and Services Study), community, and primary care studies have included Latino samples (mainly Mexican Americans), the rate and risk factors of major depression have been primarily studied among non-Latino Whites. Existing data indicates that in 2006, Latino adults 50 years of age and older reported higher rates of mental distress (13.2%) compared to non Latino Whites (8.3%) and non Latino Blacks (11.1%) [8]. Further, Latino adults were more likely to report current depression (11.4%) compared to non Latino Whites (6.8%) and non Latino Blacks (9%) [8]. NHANES data indicate that in 20052006, 6.3% of Mexican Americans 12 years of age and older reported current depression compared to 4.8% among non Latino Whites [3]. Table 1 presents a summary of the studies reviewed, some of which are discussed in this chapter. As mentioned earlier research on Latino immigrants is limited and empirical findings on depression among Latinos to date have been inconsistent [9, 10]. For example, some studies have reported: 1) higher depression levels among Latinos compared with non-Latino Whites [11]; 2) higher depression among Latino immigrants compared to U.S. born Latinos [12]; and 3) some studies have reported lower depression levels among Latino immigrants [5, 13] compared to their U.S. born counterparts.

Factors Associated with Depression Several factors have been linked to depression among Latino immigrants. In particular, the variability in depression rates is influenced by socio-demographic factors (e.g., education, income, and sex), nativity (U.S.-born, non-U.S. born), acculturation, perceived social support, and feelings of deprivation. Moreover these factors tend to be linked to ethnicity [14]. Together these factors would suggest that Latinos may be at an elevated risk for depression compared to Whites.

Table 1. Depression Studies Reviewed Authors

Study Purpose

Sample/location

Examined the effects of psychosocial risk and protective factors on depressive symptoms among agricultural workers from Mexico working in California Examined depression prevalence among U.S. Latinos across ethnicity, nativity, generational status, Englishlanguage proficiency, length of residence in the U.S. and age at migration

1,001 Participants Sex: 500 Males, 501 Females Ages 18-59 Rural California 2554 Participants Sex: 1127 Males, 1427 Females Nationally representative U.S. sample

Breslau, AguilarGaxiola, Borges, Castilla-Puentes, Kendler, MedinaMora, Su, and Kessler (2007)

Examined whether migrants have higher risk for onset and persistence of mental disorders after they migrate to the U.S., the period during which environmental stressors could have an impact

Crockett, Iturbide, Torres Stone, McGinley, Raffaelli, and Carlo (2007) Cuellar, Bastida, and Braccio (2004)

Examined acculturative stress, psychological functioning, social support, and coping style in Mexican American college students

Alderete, Vega, Kolody, AguilarGaxiola (1999)

Alegria, Mulvaney-Day, Torres, Polo, Cao, and Canino (2007)

Compared mental well-being between Mexican immigrants and U.S. born Mexican Americans

Country of Birth/Immigration status Mexican Immigrants (n=1001)

Depression measure

Findings

CES-D

Time in US did not increase risk of depressive symptoms. Acculturation was a significant mental health risk factor.

Immigrants (n=1630) U.S. born (n=924) Latino groups: Mexican (n=868) Puerto Rican (n=495) Cuban (n=577) Other (n=614)

World Mental health Survey Initiative version of the WMH-CIDI

Subsample of the US National Comorbidity Survey Replication (NCSR), and Mexicans, the Mexican National Comorbidity Survey

Mexican Immigrants (n=75) Mexican residents (n= 2326)

Compositie International Diagnostic Instrument ( v3)

148 Participants Sex: 49 Males, 99 Females Age: 18-30 Texas and California 353 Participants Sex: Males (25.8%), Females (74.2%) Age: 45-88; M=63; Texas

Mexican Immigrants (17%) Mexican Americans (83%)

CES-D

Mexican Immigrants (n=148) Mexican Americans (n=205)

Depressive Symptom Scale

Puerto Ricans had the highest overall psychiatric prevalence rate among Latino groups. Mexican origin Latinos were less likely to have a history of depression. Latino immigrants less likely than U.S.-born Latinos to have a history of overall psychiatric disorders. Immigrants had significantly higher lifetime and 12 month prevalence of mood disorders than the Mexican sample, with a lifetime prevalence of any mood disorder twice as high among immigrants as Mexican residents, and a 12-month prevalence close to three times as high among immigrants as Mexican residents. Acculturative stress was associated with higher anxiety and depression. Parental support buffered acculturative stress effects on anxiety and depressive symptoms. No differences in depression scores between Mexican Americans and Mexican immigrants were observed.

Table 1. Depression Studies Reviewed (Continued) Authors

Study Purpose

Finch, Kolody and Vega (2000)

MAPSS Investigated the direct and moderating connections between perceived discrimination, acculturative stress, and mental health Assessed differences between U.S. born Mexican Americans and Mexico-born immigrants in depression using community data

3,012 Participants Age: 18-59 Fresno, California

1244 Participants U.S. born: Male (46%) Female (54%) Age: Mean=38 Los Angeles, California

Mexican Immigrants (n=706) Mexican Americans (n=538)

CES-D

Gonzalez, Haan, and Hinton (2001)

Examined the association between acculturation, immigration, and depression among older Mexican Americans.

1663 Participants Sex: 695 Males, 968 Females Ages: Mean=70.6; 60100 Northern California

CES-D

Gonzalez and Gonzalez (2007)

Examined the association among acculturation and native status in the prevalence of depression

Beck Depression Inventory-II

Women and low acculturated individuals were more likely to report depressive symptoms.

Hovey (2000)

Examined the relationship among acculturative stress, depression, and suicidal ideation as well as predictors of depression and suicidal ideation among Mexican immigrants

153 Participants Sex: 61 Males, 91 Females Age: Mean = 25; 18-56 Southern California 114 Participants Sex: 38 Males, 76 Females Ages: Mean=34; 17-77 Los Angeles, California

U.S. born (n=831) Immigrant ( n=832) Mexican Immigrants (89%) Other country Immigrants (11%): Central America (67%) South America (20%) Caribbean (13%) Mexican American (n= 57) Mexican Immigrants (n=96) Mexican Immigrants (n=114)

CES-D

Mexican immigrants who experienced more acculturative stress, family dysfunction, and ineffective social support had higher levels of depression.

Golding and Burnam (1990)

Sample/location

Country of Birth/Immigration status Mexican Americans (n=1,124) Mexican Immigrants (n=1,888)

Depression measure CES-D

Findings Discrimination was directly related to depression, but this effect was moderated by country of birth, English-language acculturation, sex, and country of education variables. Higher depressive symptoms were observed among Mexican Americans compared to Mexican immigrants. Not being married, lack of marital support (for married), and less relatives were associated with depressive scores. Immigrants and less acculturated Latinos had higher prevalence of depression compared to U.S. born Latinos and more acculturated Latinos.

Authors

Study Purpose

Hovey (2000a)

Examined the relationship among acculturative stress, depression, and suicidal ideation among Central American immigrants

Kessler, McGonagle, Zhao, Nelson, Hughes, Eshlemann, Wittchen, Kendler (1994)

Presents lifetime and 12 month prevalence of 14 DSM-III-R psychiatric disorders from the National Comorbidity Survey

Miranda and Umhoefer (1998)

Examined differences in depression among low acculturated, bicultural, and high acculturated Latinos

Salgado de Snyder, Cervantes, and Padilla (1990)

Examined the relationship between gender, ethnicity, psychological stress and generalized distress among immigrant Latinos and US born Mexican Americans

Vega, Kolody, Aguilar-Gaxiola, Alderete, Catalano and CaraveoAnuduaga (1998)

Compared psychiatric morbidity for immigrant and native-born adults of Mexican origin with rates for the U.S. national population from the NCS and from Mexico City, Mexico

Sample/location 78 Participants Sex: 14 Males, 64 Females Age: Mean=38.5; 17-75 Los Angeles, California Sex: 49.1% Males, 50.9% Females Age: 15-54 75% White 11.9% Black 8.6% Hispanic 4.5% Other 282 Participants Sex: 138 Males, 175 Females Ages: Mean=31 Georgia

593 Participants Sex: 293 Males, 300 Females Age: Immigrant Mean=24; U.S. born Mean=22 Los Angeles, California 3012 Participants Sex: 1496 Males, 1516 Females Age: 18-59 Fresno, California

Country of Birth/Immigration status Immigrants (n=78): El Salvador (71.1%), Guatemala (17.1), Honduras (9.2%), Nicaragua (2.6%) County of birth not reported

Depression measure CES-D

Central American immigrants with greater acculturative stress, family dysfunction, and lower social support were at greater risk for depression.

Composite International Diagnostic Interview (CIDI)

Over 17% of participants had a history of major depressive episode (MDE) in their lifetime, and more than 10% had an episode in the past 12 months. Latinos had higher prevalence of current affective disorders and compared to Whites. Less acculturated Latinos had slightly higher depression scores than high acculturated and bicultural Latinos. Bicultural Latinos had significantly higher social interest and lower depression scores.

U.S. born (n=81%) Immigrant (n=19%)= Mexico, Cuba, El Salvador, Chile, Puerto Rico, Panama, Argentina, Peru, Bolivia, Ecuador, Uruguay, Venezuela, Honduras, Guatemala, Paraguay Mexican American (n=329) Mexican Immigrants (n=138), Central American Immigrants (n=126),

BDI

Mexican American (n= 1202) Mexican Immigrant (n=1810)

Composite International Diagnostic Interview (CIDI) modified version

Note. Mexican American refers to individuals of Mexican origin born in the U.S. Mexican Immigrant refers to individuals of Mexican origin born in Mexico.

Findings

CES-D

Depression scores higher among Central American than Mexican immigrants and Mexican immigrants had higher scores than Mexican Americans. Among, immigrants, family conflict was associated with higher depressive symptoms. Mexican immigrants had lifetime rates similar to Mexican citizens. Mexican Americans (14.8%) had higher lifetime prevalence of a major depressive episode compared to Immigrants (5.2%). As Mexican immigrants acculturated their mental health worsened.

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Socio-economic Status Factors Education. The impact of education on depression has been examined primarily among White samples, while minimal research has examined the impact of education on depression among Latinos. The few studies that have included Latino samples have found lower education levels to be significantly associated with prevalence of major depressive disorder for Mexican American individuals [15, 16]. Education may provide immigrants with the resources to cope better in a new society. However, greater research attention is needed to clearly understand the impact of education on Latinos. Income. Higher rates of depression among Latinos compared to Whites may be due, in part, to Latinos‘ lower socioeconomic status (SES) [14]. Latinos in the U.S. regardless of citizenship status, tend to have lower SES than Whites [4]. Furthermore, there is a wide range of income levels among Latinos [17]. Studies have found that low SES increases Latinos‘ risk for depression [2, 18, 19]. More specifically, the SES - depression relationship may be mediated by stress, given that lack of financial resources may be perceived as stressful and depression may develop in the context of psychosocial stress. For example, lower SES levels may lead to problems meeting basic needs, which may place individuals at risk for depression. Thus, to the extent that Latinos face financial hardships, they may be at increased risk for depression [9]. Sex. Depressive symptoms tend to be higher for women than men [9, 20-23].Overall, women have been found to be twice as likely to develop depression compared to men. Further, sex has been found to be a risk factor among Mexican and Puerto Ricans [23, 24]. Several explanations may shed light on these findings. First, poverty, a risk factor for depression, is more prevalent among women than men [18]. Second, cultural differences in gender socialization may impact the magnitude of depression-sex differences [9]. For example, traditional Latino values that emphasize strength for males and submissiveness for females may increase the likelihood that Latinas express psychological distress through internalizing pathways such as depressive symptoms [9]. Yet another explanation for these sex differences may be attributed to differences in explanatory style. According to NolenHoeksema [25] when depressed, men tend to engage in extracurricular activities (i.e., sports). Women, on the other hand, tend to be less active and ruminate about the potential causes of their depression. Furthermore, individuals who engage in activities to distract themselves from their depressive mood appear to recover faster from depressive episodes than individuals who remain inactive and ruminate about the causes of their emotional state [25]. Immigration Factors As a group, Latinos face particularly stressful life situations [26]. Many are immigrants who enter the U.S. to work [26] and the vast majority do not speak English [27]. Overall, Latino immigrants endure numerous stressors that impact their mental health. For example, immigrants may experience the breaking of ties to family and friends in their country of origin, thus resulting in feelings of loss and a reduction in coping resources. Immigrants also experience stressful factors specific to their new environment including discrimination, language difficulty, lack of social and financial resources, and feelings of not belonging in the host society [28]. Despite the numerous stressors that Latino immigrants encounter, several studies report more favorable mental health outcomes [17, 23]. More precisely, the risk of major depression seems to be greater for U.S. born Latinos than for Latino immigrants.

Depression among Latinos in the United States

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Latino Groups Regional as well as national studies have begun to uncover differences in depression among Latino groups that may be accounted for by native status [29, 30]. A limitation of these studies is that the majority of them have involved depression estimates of a single Latino group, Mexican Americans in particular, in southwestern U.S. regions. Additionally, no major mental health studies to date have included other growing Latino groups (e.g., Dominican, Colombians, Ecuadorians) [31]. Emerging evidence suggests that depression patterns appear to vary by Latino group (e.g., Mexican, Puerto Rican, and Cuban). For example, Puerto Ricans have been found to have significantly higher lifetime rates of major depression episodes (9.24) than Mexican Americans (4.17) and Cubans (3.24) [32]. Puerto Ricans have also reported a greater number of psychiatric disorders than Mexican or Cuban Americans [29, 30]. Puerto Ricans experience the lowest SES of the major Latino groups [31, 33] which in part may explain their higher depression rates. Acculturation Acculturation as a contributing factor to Latinos‘ mental health has been examined [3436]. Acculturation refers to the process by which individuals adjust to a nonnative culture [37, 38]. Two theories of acculturation have been proposed. One theory is that acculturation is unidimensional ranging from not acculturated to acculturated [37, 39]. The second theory is that acculturation is bidimensional and emphasizes integration or biculturalism [37, 39]. Modern theories are more likely to embrace the latter conceptualization of acculturation suggesting that multiple cultural attachments are possible [35]. Given that U.S. Latinos may be at greater risk of suffering from mental health problems [33, 40], examining the relationship between acculturation and depression is warranted. However, research examining this relationship has revealed mixed and contradictory findings [13, 40, 41]. Some studies have found no association between acculturation and depression. For example, Falcon and Tucker [33] found no association between acculturation level and depression among Latinos (i.e., Puerto Rican, Dominican and other Latinos) residing in Massachusetts. In addition, Canabal and Quiles [42] found no association between depression and acculturation among Puerto Ricans. Several studies examining Mexican Americans and Mexican immigrants also report no association between acculturation level and depression [10, 13, 43]. Yet, other studies report that mental health deteriorates as acculturation level increases [44-46]. More specifically, associations between acculturation and depression have been highlighted in the literature. However, the results are unclear in that some studies report an association between higher acculturation levels and depression while others report lower acculturation levels to be associated with depression. Some studies with large population samples (e.g., NESARC, ECA, H-HANES) report an association between depression and length of time among Mexican immigrants, indicating that the longer they live in the U.S. the more likely they are to experience depression [47-49]. Similar results have been found for older Dominican immigrants [33]. The depression and acculturation link has also been examined among U.S. born and immigrant Latinos. A review that examined studies focusing on U.S. born and Latino immigrants (i.e., Mexican, Central American, Puerto Rican, Cuban) reported higher rates of depression among U.S. born Latinos compared to immigrants [50]. Similarly, higher

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depressive symptoms have been found among U.S. born Mexican Americans compared to Mexican immigrants [11, 48, 51]. Despite research suggesting that depression increases with time in the U.S., there are other studies that have reported the opposite. For example, higher depression rates have been reported among immigrants (Mexican, Central and South American) and less acculturated Latinos compared to U.S. born Latinos and more acculturated Latinos [10, 12].Similarly, island born Puerto Ricans have reported higher levels of depression than U.S. born Puerto Ricans [51].

Acculturative Stress A related yet distinct construct resulting from the acculturation process is acculturative stress [52, 53]. As immigrants adapt or acculturate to a new society, they may experience several changes and stressors [38, 52] that impact acculturative stress. These changes and stressors include factors such as language familiarity and use, cultural heritage, ethnic pride and identity, discrimination [38, 52], pre-immigration experiences, post migration acculturation experiences (e.g., immigration stress, feelings of not belonging in the host society) [52], degree of acculturation [38, 54] generational status, age [55], and familial factors such as severing ties with family and friends in the country of origin [38, 52, 56]. Acculturative stress has been linked to depression [36, 38, 44, 57]. For example, higher levels of acculturative stress have been found to be significantly associated to depression among Mexican origin Latinos residing in the U.S. [44, 58]. Studies examining the association between acculturative stressors and depression found that Mexican immigrants who experienced greater acculturative stressors (e.g., discrimination, immigration stress, family structure changes, separation from family, and feeling excluded because of ethnic background) also had higher depression levels [21, 46, 54, 57]. Similar findings have also been reported for Central American immigrants [21, 52]. Social and Emotional Support Past studies suggest a positive relationship between social support and mental health, including depression [23, 59-62]. The support received and required by different groups may come from different sources. For example, among Latinos, families may provide social and emotional support, which serves as a stress buffer [32, 44]. In the Latino culture, familismostrong feelings of attachment, shared identity, family loyalty- is emphasized [63]. Further, strong familial bonds fostered through family cohesion are expected to promote family support [22]. Thus, it is not surprising that the social and emotional support received from immediate and extended family has been linked to lower depressive symptoms [34, 44, 55, 64, 65]. Familial factors such as marital status, marital support, and number of relatives residing in the U.S. have been associated with lower levels of depression [11]. Among Mexican and Central American immigrants, family conflict has been associated with higher depressive symptoms [21]. Hiott et al. [46] found that among Mexican immigrant women, separation from family, which contributes to loss of social support, was associated with greater depressive symptoms. Moreover, among Mexican immigrants [57] and Central American immigrants [52], family dysfunction and ineffective social support have been found to be associated with higher levels of depression. Aranda, Castaneda, Lee, and Sobel [64] found that among Mexican immigrant and Mexican American men low social support from relatives predicted higher levels of depressive symptoms and among women lower partner


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social support predicted depressive symptoms. Similarly, family cohesion has been found to be associated with lower levels of psychological distress (e.g., depression) among Mexican, Puerto Rican, Cuban and other Latino immigrants residing in the U.S. [22].

Latino Health Paradox In spite of all the factors mentioned above, overall, Latinos appear to have better health outcomes compared to Whites [66], a phenomenon often described as the Latino health paradox. Several hypotheses have been offered to explain the paradoxical association between immigration status and depression, including selective migration, relative deprivation [10], and stress coping skills. The selective migration explanation predicts that individuals with good mental health are more likely to immigrate than those with poor mental health [5, 11]. In terms of stress coping skills, Latinos may employ healthier stress coping styles than Whites [26]. For example, one study found that Mexican immigrants tended to process stress in more adaptive ways than Whites [26]. Moreover, Mexican immigrants may retain culturally protective factors that may provide powerful sources of emotional resilience [9]. For example, the Latino cultural value of familismo, which places a strong emphasis on family relationships, may foster positive social support that protects individuals from depression [9]. This resilience may decrease as individuals become fluent in English or spend more time in the U.S. [9]. Although widely reported among Latino populations, inconsistent evidence exists regarding the generalizability of the Latino health paradox [29]. The relationship between nativity and depression risk, best established among Mexican Americans, may also extend to other Latino groups [17]. That being said, when examining depression, caution should be exercised in generalizing the Latino health paradox to all Latino groups [29]. Relative Deprivation. Another explanation for Latino immigrants‘ positive mental health may be attributed to immigrants‘ better psychological resources and lower expectations for income and employment status, which may account for lower depression rates relative to their U.S. born counterparts [11]. For example, Latino immigrants may experience economic hardships and inequality in their country of origin and in turn, these experiences may then decrease the likelihood of demoralization among Latino immigrants in their new environment and increase resignation to negative outcomes, resulting in lower depression risk. Expectations of the new country both in terms of personal and social gains must be matched by achievement in order for the individual to function well [67]. U.S. born Latinos, having higher expectations for status attainment, may be more distressed and experience a greater sense of deprivation and greater risk of psychiatric morbidity when they fail to meet their own expectations than their foreign born counterparts [5]. However, immigrants may have a differing viewpoint and set of expectations about what constitutes ―success‖ in America [23]. For example, since Puerto Ricans are U.S. citizens they may experience a greater sense of failed expectations if they are not economically successful (Alegria et al. 2007).

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CONCLUSION A synthesis and review of major findings was provided concerning depression among U.S. Latino immigrant groups as well as a brief table depicting some of the studies reviewed. The research to date is plagued with several limitations. First, researchers who investigate the determinants of depression in Latino immigrants tend to focus on social processes occurring after migration [68]. An examination of psychological influences operating prior to migration may help elucidate observed individual differences in the adaptation process [34]. Therefore, our understanding of the relationship between immigration and depression can be enhanced by comparing Latino immigrants to Latinos in their home countries. Second, grouping Latinos together and generalizing findings to all Latino groups will not suffice [32]. Several studies aggregate study results under the umbrella of Latino and do not stratify key variables (e.g., immigration status) by Latino group. However, Latinos are a heterogeneous group in several aspects such as by birth place, acculturation, and reasons for migrating [31, 36]. It is important to acknowledge this heterogeneity because these factors can contribute to Latinos‘ immigration and acculturation experiences in the U.S., which in turn influence their mental health. Guarnacia (2000) argues that using a general label to represent Latinos is inappropriate because factors as those just mentioned differ between Latino groups. For example, Hovey [52] suggests that greater levels of depression among Central American immigrants compared to Mexican immigrants may in part be due to preimmigration factors such as trauma experienced as a result of socio-political circumstances. Third, studies have been conducted primarily in states such as California and Texas and have focused on Latinos of Mexican origin [33, 35] and on those aged 20 to 64 years [33]. Delgado et al. [47] highlight the under-representation of Central and South Americans in the literature and the need for research with these populations to gain an understanding of their mental health. Thus, it is important to examine depression and its risk factors among Latino groups other than Mexican immigrants and Mexican Americans. Fourth, the existent studies have used assessment instruments that have been normed on White samples (CES-D and BDI-II). More research on the use, validity and reliability of depression scales is needed. What are the reliability and validity of currently available scales among Latino subgroups? Furthermore, acculturation is a unique construct that has not been operationalized or measured consistently across time and studies. It has been pointed out that proxy variables (e.g., use of the English language, ethnic identity, birthplace, and length of time in the U.S.) have been used to measure acculturation [69, 70]. Lara et al. [35] noted that their review of the literature revealed inconsistencies in the measurement of acculturation and stated the importance of this inconsistency in the interpretation of findings. These methodological differences (i.e., operationalization; domains measured) reflect the inconsistent and contradictory findings in acculturation research [40]. Further, whether acculturation has a positive or negative effect on Latinos‘ mental health depends in part on the way acculturation is measured [35]. Thus, while measuring acculturation is no easy task, its role as a contributing factor to depression among Latinos merits further examination. Given the substantial increase of Latinos from different countries in the U.S., the unfavorable effects of depression on overall well-being should continue to be examined. With the continued entry of Latino immigrants, and changes in public opinion about immigration, predicting how the U.S. will change with Latino culture is no easy task [53]. Thus, the


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relationship between depression and Latinos is a complex one influenced by multiple factors. A greater understanding of the correlates of depression among Latinos is essential for managing and facilitating depression treatment appropriately. The questions that remain are: what factors place U.S. born and immigrant Latinos at greater risk for depression? Which factors serve as protective factors against mental health problems? By broadening our understanding of the key risk factors across Latino groups we will be better able to address depression disparities.

REFERENCES [1]

Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen HU Kendler KS. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: 1994; [2] Kessler RC, Chiu WT, Demler O Walters EE. Prevalence, severity, and comorbidity of 12-moth DSM-IV disorders in the National Comorbidity Survey Replication: Archives of General Psychiatry 2005; 62: [3] Pratt LABrody DJ. Depression in the United States Household Population, 2005-2006: NCHS Data Brief 2008; 7: 1-7. [4] Ramirez RRDe la Cruz GP, The Hispanic Population in the United States: March 2002: Current population reports, U.S.C. Bureau, Editor. 2003: Washington, DC. p. P20-545. [5] Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP Anderson K. Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic Whites in the United States: Archives of General Psychiatry 2004; 61: 1226-1233. [6] Rios- Ellis B, Critical Disparities in Latino Mental Health: Transforming Research into Action. 2005, National Council of La Raza. p. 1-7. [7] Dunn MGO'Brien KM. Psychological Health and meaning in life: Stress, social support, and religious coping in Latina/Latino Immigrants: Hispanic Journal of Behavioral Sciences 2009; 31: 204-227. [8] CDC CfDaPaNAoCDD, The state of mental health and aging in America Issue Brief 1: What do the data tell us? 2008, CDC Atlanta. p. 1-12. [9] Mendelson T, Rehkopf DHKubzansky LD. Depression among Latinos in the United States: A Meta-Analytic Review: Journal of Consulting and Clinical Psychology 2008; 76: 355-366. [10] Gonzalez PGonzalez GM. Acculturation, Optimism, and Relatively Fewer Depression Symptoms among Mexican Immigrants and Mexican Americans: Psychological Reports 2007; 103: 566-576. [11] Golding JM Burnam MA. Immigration, stress, and depressive symptoms in a MexicanAmerican community: The Journal of Nervous and Mental Disease 1990; 17: 161-171. [12] Gonzalez HM, Haan MN Hinton L. Acculturation and the prevalence of depression in older Mexican Americans: Baseline results of the Sacramento area Latino study on aging. : Journal of the American Geriatrics Society 2001; 49: 948-953.

144


[13] Masten WG, Asidao CS, Jerome WW, Mosey L, Caldwell-Colbert AT, Medina MY, Hernandez G, Chapman R, Kirilla C Ervin S. Depression and acculturation in Mexican American and European American women: Anales de Psicologia 2004; 20: 15-21. [14] Plant EASachs-Ericsson N. Racial and ethnic differences in depression: the roles of social support and meeting basic needs: Journal of Consulting and Clinical Psychology 2004; 72: 41-52. [15] Riolo SA, Nguyen TA, Greden JFKing CA. Prevalence of depression by race/ethnicity: findings from the National Health and Nutrition Examination Survey III: Am. J. Public Health 2005; 95: 998-1000. [16] Chiriboga DA, Black SA, Aranda M Markides KS. Stress and depressive symptoms among Mexican American elders: Journal of Gerontology 2002; 57B: 559-568. [17] Lewis-Fernandez R, Das AK, Alfonso C, Weissman MM Olfson M. Depression in US Hispanics: diagnostic and management considerations in family practice: Journal of the American Board of Family Practice 2005; 18: 282-296. [18] Bruce ML, Takeuchi DTLeaf PJ. Poverty and psychiatric status: Archives of General Psychiatry 1991; 48: 470-474. [19] Cuéllar IRoberts R. Relations of depression, acculturation, and socioeconomic status in a Latino sample: Hispanic Journal of Behavioral Sciences 1997; 19: 230-238. [20] Vega WA Rumbaut R. Ethnic minorities and mental health: Annual Review of Sociology 1991; 17: 351-383. [21] Salgado De Snyder VN, Cervantes RCPadilla AM. Gender and ethnic differences in psychosocial stress and generalized distress among Hispanics: 1990; 22: 441-453. [22] Rivera FI, Guarnaccia PJ, Mulvaney-Day N, Lin JY, Torres M Alegria M. Family cohesion and its relationship to psychological distress among Latino groups: Hispanic Journal of Behavioral Sciences 2008; 30: 357-378. [23] Torres Stone R, Rivera FI Berdahl T. Predictors of depression among non-Hispanic Whites, Mexicans and Puerto Ricans: A look at race/ethnicity as a reflection of social relations: Race and Society 2004; 7: 79-94. [24] Moscicki EK, Locke BZ, Rae DsBoyd JH. Depressive symptoms among Mexican Americans: the Hispanic Health and Nutrition Examination Survey: American Journal of Epidemiology 1989; 130: 348-360. [25] Nolen-Hoeksema S. Sex differences in unipolar depression: Evidence and theory: Psychological Bulletin 1987; 101: 259-282. [26] Farley T, Galves A, Dickinson LM Diaz Perez MJ. Stress, coping, and health: A comparison of Mexican Immigrants, Mexican-Americans, and non-Hispanic Whites: Journal of Immigrant Health 2005; 7: 213-220. [27] Page RL. Acculturation in Mexican Immigrants: A concept analysis: Journal of Holistic Nursing 2006; 24: 270-278. [28] Hovey JD Magana C. Acculturative stress, anxiety, and depression among Mexican immigrant farmworkers in the Midwest United States: Journal of Immigration Health 2000; 2: 119-131. [29] Alegria M, Canino G, Shrout PE, Woo M, Duan N, Vila D, Torres M, Chen CMeng XL. Prevalence of mental illness in Immigrant and Non-Immigrant U.S. Latino Groups: American Journal of Psychiatry 2008; 1-10.


145

[30] Alegria M, Mulvaney-Day N, Torres M, Polo A, Cao Z Canino G. Prevalence of psychiatric disorders across Latino subgroups in the United States: American Journal of Public Health 2007; 97: 68-75. [31] Guarnaccia PJMartinez I, Comprehensive in-depth literature review and analysis of Hispanic mentalh health issues, in Changing Minds, Advancing Mental Health for Hispanics N.J.M.H. Institute, Editor. 2002. [32] Oquendo MA, Lizardi D, Greenwald S, E Weissman MM Mann JJ. Rates of lifetime suicide attempt and rates of lifetime major depression in different ethnic groups in the United States: Acta Psychiatrica Scandinavica 2004; 110: 446-451. [33] Falcon LM Tucker KL. Prevalence and correlates of depressive symptoms among Hispanic elders in Massachusetts: Journal of Gerontology 2000; 55B: 108-116. [34] Santos SJ, Bohan LMSanchez- Sosa JJ. Childhood family relationships, marital and work confliect, and mental health distress in Mexican Immigrants: Journal of Community Psychology 1998; 26: 491-508. [35] Lara M, Gamboa C, Kahramanian MI, Morales LSHayes Bautista DE. Acculturation and Latino health in the United States: a review of the literature and its sociopolitical context: Annu. Rev. Public Health 2005; 26: 367-397. [36] Marin H, Escobar JI Vega WA. Mental illness in Hispanics: A review of the literature: Focus 2006; 4: 23-37. [37] Rogler L, Cortes D Malgady R. Acculturation and mental health status among Hispanics: American Psychologist 1991; 46: 585–597. [38] Miranda AO Matheny KB. Socio-psychological predictors of acculturative stress among Latino adults: Journal of Mental Health Counseling 2000; 22: 306-317. [39] Cabassa LJ. Measuring Acculturation: Where we are and where we need to go: Hispanic Journal of Behavioral Sciences 2003; 25: 127-146. [40] Torres L Rollock DR. Intercultural Competence as a Moderator Between Acculturation and Depression Among Hispanics: Cultural Diversity and Ethnic Minority Psychology 2007; 13: 10-17. [41] Masten WG, Penland EANayani EJ. Depression and acculturation in MexicanAmerican women: Psychological Reports 1994; 75: 1499-1503. [42] Canabal MEQuiles JA. Acculturation and socioeconomic factors as determinants of depression among Puerto Ricans in the United States: Social Behavior and Personality 1995; 23: 235-248. [43] Cuellar I, Bastida EBraccio SM. Residency in the United States, subjective well-being, and depression in an older Mexica-origen sample: Journal of Aging and Health 2004; 16: 447-465. [44] Crockett LJ, Iturbide MI, Torres Stone RA, McGinley M, Raffaelli MCarlo G. Acculturative stress, social support, and coping: Relations to psychological adjustment among Mexican American college students: Cultural Diversity and Ethnic Minority Psychology 2007; 13: 347-355. [45] Heilemann MV, Coffey-Love M Frutos L. Perceived reasons for depression among low income women of Mexican descent: Arch Psychiatr Nurs 2004; 18: 185-92. [46] Hiott A, Grzywacz JG, Arcury TA Quandt SA. Gender differences in anxiety and depression among immigrant Latinos: Families Systems and Health 2006; 24: 137. [47] Delgado PD, Alegria M, Canive JM, Diaz E, Escobar JI, Kopelowicz A, Oquendo MA, Ruiz PVega WA. Depression and access to treatment among U.S. Hispanics: Review of

146

[48]

[49]

[50] [51]

[52] [53] [54] [55]

[56]

[57] [58]

[59] [60] [61] [62] [63] [64]

[65]

Patricia Gonzalez and Monica Rosales the literature and recommendations for policy research: FOCUS: The Journal of Lifelong Learning in Psychiatry 2006; 4: 38-47. Alderete E, Vega WA, Kolody B Aguilar-Gaxiola S. Depressive symptomatology: Prevalence and psychosocial risk factors among Mexican migrant farmworkers in California: Journal of Community Psychology 1999; 27: Vega WA, Kolody B, Aguilar-Gaxiola S, Alderete E, Catalano RCaraveo-Anduaga J. Lifetime Prevalence of DSM-III-R Psychiatric disorders among urban and rural Mexican Americans in California: Archives of General Psychiatry 1998; 55: 771-778. Escobar JI, Hoyos Nervi CGara MA. Immigration and mental health: Mexican Americans in the United States: Harvard Review of Psychiatry 2000; 8: 64-72. Torres-Stone R, Rivera FI Berdahl T. Predictors of depression among non-Hispanic Whites, Mexicans and Puerto Ricans: A look at race/ethnicity as a reflection of social relations: Race and Society 2004; 7: 79-94. Hovey JD. Acculturative stress, depression, and suicidal ideation among Central American immigrants: Suicide and Life-Threatening Behavior 2000a; 30: 125-140. Caplan S. Latinos, acculturation, and acculturative stress: A dimensional concept analysis: Policy, Politics, and Nursing Practice 2007; 8: 93-106. Finch B Vega W. Acculturation stress, social support, and self-rated health among Latinos in California: Journal of Immigrant Health 2003; 5: 109-117. Hovey JDKing CA. Acculturative stress, depression, and suicidal ideation among immigrant and second generation Latino adolescents.: Journal of the American Academy of Child and Adolescent Psychiatry 1996; 35: 1183-1192. Miranda AO, Estrada DFirpo-Jimenez M. Differences in family cohesion, adaptability, and environment among Latino families in dissimilar stages of acculturation: The Family Journal 2000; 8: 341-350. Hovey JD. Acculturative stress, depression, and suicidal ideation in Mexican Immigrants: Cultural Diversity and Ethnic Minority Psychology 2000; 6: 134-151. Shattell MM, Smith KM, Quinlan-Colwell A Villalba JA. Factors contributing to depression in Latinas of Mexican origin residing in the United States: Implications for nurses: Journal of the American Psychiatric Nurses Association 2008; 14: 193-204. Berkman LF. The role of social relations in health promotion: Psychosomatic Medicine 1995; 57: 245-254. Kawachi I Berkman LF. Social ties and mental health: Journal of Urban Health 2001; 78: 458-467. House JS, Landis KR Umberson D. Social relationships and health: Science 1988; 241: 540-545. Seeman TE. Social ties and health: Annals of Epidemiology 1996; 6: 442-451. Marin GMarin BV Research with Hispanic populations, ed. S. Publications. 1991, Newbury Park, CA. Aranda MP, Castaneda I, Lee P Sobel E. Stress, social support, and coping as predictors of depressive symptoms: Gender differences among Mexican Americans: Social Work Research 2001; 25: 37-48. Alderete E, Vega WA, Kolody B Aguilar-Gaxiola S. Lifetime prevalence of and risk factors for psychiatric disorders among Mexican migrant farmworkers in California: American Journal of Public Health 2000; 90: 608-614.


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[66] Morales LS, Kington RS, Valdez RO Escarce JJ. Socioeconomic, cultural, and behavioral factors affecting Hispanic health outcomes: Journal of Health Care for the Poor and Underserved 2002; 13: 477-503. [67] Bhugra D Ayonrinde D. Depression in migrants and ethnic minorities: Advances in Psychiatric Treatment 2004; 10: 13-17. [68] Grzywacz JG, Quandt SA, Early J, Tapia J, Graham CN Arcury TA. Leaving family for work: ambivalence and mental health among Mexican migrant farmworker men: Journal of Immigrant and Minority Health 2006; 8: 85-97. [69] Hunt LM, Schneider S Comer B. Should ―acculturation‖ be a variable in health research? A critical review of research on U.S. Hispanics: Social Science and Medicine 2004; 59: 973-986. [70] Heilemann M, Lee K Kury F. Strengths and vulnerabilities of women of Mexican descent in relation to depressive symptoms: Nursing Research 2002; 51: 175-182.



Chapter 11

ACCULTURATION, ACCULTURATIVE STRESS, AND DEPRESSION AMONG HAITIANS IN THE UNITED STATES Guerda Nicolas, Darren Bernal and Seth T. Christman University of Miami, Miami, Florida, USA

ABSTRACT Acculturation and Acculturative Stress have been shown to be important factors in understanding the mental health of immigrants and ethnically diverse groups. This study is the first examination of the role of acculturation, acculturative stress, and depression in the Haitian population residing in the United States. Results from the study revealed that age, gender, and acculturative stress accounted for significant variance in depression levels. Implications for practice and research are discussed.

INTRODUCTION The Surgeon General‘s Report on Mental Health and its Supplement report [1] highlighted the disparities that exist for ethnic and racial minority groups in need of mental health services. The report concluded that racial and ethnic minorities had less access to mental health services than Whites, were less likely to receive needed care, and when care was received, it was more likely to be of poor quality [1]. A number of barriers are reported to explain the underutilization of mental health services among ethnic minorities. Some of the most commonly identified barriers are: (1) socioeconomic status, (2) lack of knowledge about mental health services, (3) mistrust and fear of treatment, (4) different cultural ideas about illness and health, (5) lack of insurance, (6) immigration status, (7) stigma, (8) language, and (9) discrimination [2, 3, 4, 5]. Acculturation, defined as the extent to which a person identifies with his or her group of origin and its culture or with the mainstream dominant culture [6], has been studied among various ethnic groups in the U.S. For ethnic minorities, this means acculturating to the

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Guerda Nicolas, Darren Bernal and Seth Christman

dominant, White culture. Few studies have focused on the specific acculturation experiences of Blacks, and there is no known study focusing on the acculturation process of Haitians in the United States. Indeed, several studies have shown that acculturation and acculturative stress differ across different ethnic/cultural groups [7, 8] in a number of ways. In this chapter, we review the literature on acculturation and acculturative stress among ethnic minority immigrants in the U.S. and summarize the results of a project from a community sample of Haitian immigrants in the United States with respect to their acculturation and acculturative stress.

ACCULTURATION AND MENTAL HEALTH Acculturation is considered an interactive process between an individual and the dominant host culture [8, 9]. An individual‘s acculturation will depend on the degree of changes in attitudes, behaviors, cognitions, identity, and values resulting from contact with the dominant host culture [8]. More acculturated individuals will retain less of their native culture (i.e. language, values, beliefs, traditions) and experience more changes in thinking and behavior. For example, acculturation can be particularly difficult for Latinos because they maintain closer ties to their native country by preserving their language and cultural characteristics [10]. However, integrating their cultural beliefs with those of the dominant culture can be challenging, often becoming a significant stressor that places Latinos at risk for developing mental health problems [11]. Although some studies have argued that higher levels of acculturation are associated with higher levels of psychological distress and mental health problems, [12], this does not appear to be the case for Colombian immigrants [10]. With respect to this finding, it is important to recognize that many of the participants came to the Unites States at an older age. Therefore, unlike immigrants in the Balls et al. study [12], the participants may not have acculturated to the point of losing traditional cultural norms or the supportive family networks which are believed to guard against distress. Overall, these results support those of previous findings, mainly that there is a significant impact of acculturation and acculturative stress on mental health for Latinos, the effects of which have been found to be similar across different ethnic Latino groups. The relationship between acculturation and mental health status is complex. Numerous studies have shown a relationship between low levels of acculturation and mental health problems [13]. Low levels of acculturation and mental health problems may be explained in part by recent immigrants leaving their support systems and entering a new society, resulting in higher levels of psychological distress. Conversely, highly acculturated individuals may experience psychological stressors, such as the challenges of adjusting to the cultural values of the dominant society [14]. Latinos reporting high levels of acculturation also report greater levels of depressive symptoms [15], more psychopathological symptoms [16], and higher levels of chemical dependency [17].

Acculturation, Acculturative Stress, and Depression among Haitians…

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Acculturative Stress and Mental Health The term ―acculturative stress‖ refers to the stress that an individual experiences as they move away from their country of origins to another [18]). Some studies suggest that high levels of acculturative stress may place individuals at risk for developing psychological problems [19, 20]. Studies on acculturative stress show that it can lead to a number of healthrisks, including depression, anxiety, psychosomatic symptoms, suicidal ideation, and identity confusion [19, 20]. For Latinos, acculturative stress has been reported to negatively influence occupational functioning, decision making abilities, and physical health. Lacks of social support, English language competency, and socioeconomic status have all been found to increase acculturative stress in Latinos [21, 20]. It is evident from the cited studies that acculturative stress can have a negative impact on mental health in Latinos. Understanding the impact of acculturative stress among other ethnically diverse groups will assist in advancing the mental health field.

HAITIAN POPULATION IN THE UNITED STATES Although research has increasingly focused on racial minority families, very little attention has been paid to the rapidly increasing Black Caribbean communities in the United States. Data from the 1990 U.S. Census show that almost one million persons were of English-speaking, West Indian heritage, and that 6% of the Black population was foreignborn. With regard to specific Caribbean groups, data from the 2000 Census indicate that there were 419,317 foreign-born Haitians in the United States. It is estimated that 544,000 to 637,000 second-generation Haitians resided in the United States in 2001, with anywhere from 163,000 to 191,000 of those living in New York City [22]. After Jamaica, Haiti is the second largest source of Black immigrants to the United States [23], and Haitians comprise at least 8% of the population that researchers commonly classify as African Americans [23]. Despite the large number of Haitian immigrants in the United States, there is a dearth of information about the mental health of this group [24]. Considering the rapidly increasing number of Haitians immigrating to the United States and the paucity of research concerning them, it becomes important to investigate factors that influence the mental health of this group in order to ensure that efficacious mental health treatment and prevention methods are developed specifically for this population in the United States.

The Focus of the Chapter Acculturation and acculturative stress research to date has examined both the characteristics and the impact of these factors in the lives of many immigrant groups [19, 13]. Unfortunately, however, research has not yet examined these issues for Haitian immigrants, nor has it provided descriptive information on the characteristics and impact of acculturation and acculturative stress in the lives of Haitian immigrants. Therefore, the purpose of this study is to (a) report descriptive information about acculturation and acculturative stress of Haitian immigrants; (b) explore relationships between acculturation, acculturative stress and

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depression among Haitian immigrants; and (c) determine whether acculturation and acculturative stress predict depression for Haitian immigrants. This in-depth examination will provide mental health clinicians and researchers with data on the characteristics and impact of acculturation and acculturative stress for Haitian immigrants. Such results can elucidate strategies for treatment and research delivery for this population. Table 1. Demographics Characteristics and Percentage of Sample n

%

Female

90

60.4

Male

59

39.6

Less than high school

16

12

High school completion

65

43.3

Completed college or trade school

44

27.3

Graduate degree

19

12.7

Never married

42

28

Engaged

2

1.3

Cohabitating/common law marriage

2

1.3

Married

71

47.3

Separated

3

2

Divorced

23

15.3

Widow/widower

7

4.7

Work full-time

76

50.7

Work part-time

24

16

Homemaker

4

2.7

Disabled

3

2

Student (full and part-time)

4

2.7

Retired

3

2

Unemployed/seeking employment

33

22

No

133

89.3

Yes

16

10.7

Gender

Education

Marital status

Employment status

Born in the US


153

METHODS Participants The participants of the study consisted of a convenience sample of 149 Haitians residing in the United States. Table 1 summarizes the characteristics of the participants. Participants‘ ages ranged from 22 to 82 years, with a mean of 40.74 (SD = 12.66). The average age of arrival to the United States was 26.00 years (SD =11.98), with a range of 2 to 66 years. A majority of the sample (n = 106) resided in the United states for more than six years, as opposed to the smaller portion (n = 33) who arrived less than six years ago. The mean income of the participants was $21,750 (n = 117, SD = 16,062), with a range of $1,000 to $42,000. Just over half the sample (n = 82) spoke a combination of languages (English, Creole, French, and Spanish) at home, with the remaining participants (n = 67) speaking primarily Creole, English or French at home. The primary language used at home is not reflective of the language abilities of the participants, almost all of which were multilingual.

Measures Acculturative Stress. The Social, Attitudinal, Familial, and Environmental Acculturative Stress Scale (SAFE) is a 24-item scale used to measure acculturative stress in social, attitudinal, familial and environmental contexts, and includes perceived discrimination [21]. Responses on the SAFE scale are based on a 5-point Likert scale with options ranging from ―not stressful‖ to ―extremely stressful.‖ The range of total scale scores is from 0 to 120. Mena, Padilla, and Maldonao [26] reported an internal consistency reliability coefficient of .89 for the scale. Additionally, the reliability characteristics for the total scale have been shown in a variety of multiethnic populations, including a heterogeneous group of Latinos (α = .89; 27), African Americans (α = .87, 28), and Asian Americans (α = .89; 26). A Cronbach alpha of .92 was found for the sample of this study. Depression. The Center for Epidemiologic Studies Depression Scale (CES-D) is a 20item screening self-report of depressive symptoms present within the past week [29; 27]. The CES-D was designed to measure current levels of depressive symptomatology, especially depressive affect. The 20 items were selected by Radloff [29] from five previously used depression scales to represent every major component of depressive symptomatology. The components include: depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, loss of appetite, sleep disturbance, and psychomotor retardation. The scale can differentiate between clinical groups and general community groups. Though it is generally scored continuously, there are several cut-off scores for clinical depression with rational links between cutoff scores and a clinical diagnosis. The CES-D is recognized as a measure for assessing the number, type, and duration of depressive symptoms across gender, as well as race and age categories [30, 29, 31]. Responses are rated on a 4point scale, ranging from 1 (―rarely or none of the time‖) to 4 (―most or all of the time‖) and are summed to yield a total score. Total scores may range from 0 to 60 with higher scores signifying higher levels of depressive symptoms. A score of 16 or higher is used as a cut-off point for depressive symptoms [29]. High internal consistency has been reported, with

154


Cronbach‘s alpha coefficients ranging from .85 to .90 across studies with ethnic minorities [32, 29]. A Cronbach alpha of .88 was obtained for the present sample, which is similar to those obtained by Radloff [29] and Bernal [33] for immigrant populations.

Procedure Three Haitian community centers in the New England area were contacted as possible sites for recruitment of participants for the present study. The first author and her colleague met with the directors of the centers that provide services to Haitians. The three directors introduced the researchers to the staff members of their respective centers who had direct contact with Haitians in the community. In addition to the centers, community members were solicited by means of fliers, churches, beauty salons, referrals from previous participants, and radio announcements. In each case, interested participants contacted the researchers and scheduled a meeting for an interview. Once consent was obtained, research assistants conducted a semi-structured interview with the participant for approximately 90 minutes. During the interview, the previously described measures were administered. All of the meetings were conducted by trained research assistants either at the community centers, churches, or participants‘ homes. All of the interviews and documents were in English because funding was not available for translation into Haitian-Kreyol. At the end of the study, participants were compensated $25.00 for their involvement. The were provided with a letter specifically describing the purpose of the project, contact information for the researchers if any questions or concerns were to arise after the interview process, and a form to request results of the study upon completion of the study.

RESULTS Descriptive Statistics for Acculturation Our sample consisted of 149 Haitians of which 89.3% (n = 133) were born in Haiti and 10.6% (n = 16) were born in the United States. Of this population, a majority 92.6% (n = 138) reported that their parents were born in Haiti, leaving only 7.4% (n = 11) with at least one male parent born in the U.S. One-hundred percent (n = 149) of the respondents‘ mothers were born in Haiti and 98.6% (n = 147) of respondents‘ fathers were born in Haiti and 1.3% (n = 2) of fathers born in Cuba. The strong Haitian lineage was also demonstrated in grandmothers and grandfathers of the respondents, 98.7% (n = 147) and 97.3% (n = 145) respectively. The remaining grandparents in the sample were either both Jamaican and Haitian (n = 2) or both Cuban and Haitian (n = 2). Participants reported residing in the United States an average of 16.3 years with a range of 1 to 52 years. All but one of the male participants stated they spoke at least one other language in addition to English (See table 1 for more details information).


155

Descriptive Statistics for Acculturation Stress On average the participants obtained an average score of 55.44 on the SAFE scale. The range of the middle 25th to 75th percentile was 41.00 to 69.50 on the SAFE scale, with a low score of 3 and a high of 115. However, an item analysis of scale indicates that the participants were stressed by some areas. Overall, respondents stated that 54.6% of the time they were either extremely or very stressed that people they knew used drugs, opposed to 38% who stated this drug usage was somewhat, little, or not stressful at all. Respondents were not stressed about not having close friends around, with 54% stating it was a little stressful or not stressful in comparison to the 22% who stated it was at least somewhat stressful. Similarly, almost half of the participants (48%) stated they did not feel stressed by pressure to assimilate, opposed to 33.9% who found the pressure to assimilate at least somewhat stressful. In line with this response, half of the participants stated they were not bothered by having an accent or felt little stress about their accent, while 38.9% stated it was at least somewhat stressful to have an accent.

Gender Differences Independent sample t-tests examined the potential difference in the levels of reported acculturation stress and depression between Haitian men and women. The range for acculturation stress was 3 to 115. On average, female participants reported less acculturation stress (M = 60.91, SE = 2.87) than male participants (M=51.43, SE=2.29), t(148), p = .01, with a medium sized effect (r =.21). Female respondents reported higher levels of depression (M=18.21, SE=1.22) compared to males (M=13.06, SE=1.13), t(148), p < .01. This difference in depression had a medium sized effect (r = .25).

Relationship between Acculturation and Depression The scores on the depression measure ranged from 0 to 50. No significant difference was found between levels of acculturation stress and depression when comparing the 133 native born participants to the 16 who were born in the United States. Both men and women who lived in the United States for less than six years reported higher levels (M = 67.64, SE = 3.71) of acculturation stress than the group who resides in the U.S. more than 6 years (M = 51.82, SE = 2.10), t(138), p < 01. There was also a difference in depression between participants with less than 6 years spent in the U.S. (M = 18.09, SE = 1.47) and those who had resided in the U.S. for longer (M = 15.85, SE = 1.13), though this difference was not statistically significant ( p =.31). A medium-sized effect (r =.30) was found, however. Linear regression revealed the amount of time spent in the United States R2 = .289, F(1, 138) = 12.59, p < .001 accounted for 7.7% of the variance in acculturation stress. Regression analysis however did not reveal a significant effect of time spent in the US and depression levels R2 = .131, F(1, 128) = 2.23, p =.138. Similarly t-tests did not find a significant difference in acculturation stress and depression levels in native born versus first generation Haitians in the United States.

156


Relationships between Acculturative Stress and Depression Pearson correlations (two tailed) revealed a significant relationship between acculturation stress and depression r= .33, pU$ 12000.00 per year) and high educational level (61.7%; >12 years of schooling) for the Brazilian context. Almost all participants (96.6%) were religious.

Immigration Related Characteristics Most participants (65.1%) had emigrated young, at an age of up to 20 years, and almost half (47.5%) had been living in Brazil for up to 15 years. Majority (74.4%) understood and spoke Korean very well while fewer subjects (39.8%) did it in Portuguese. Almost all respondents (95.4%) were participating at some Korean immigrants association, especially religious ones (93.8%). Self-rated socioeconomic class was lower when compared to Koreans than to Brazilians: 15.7% rated themselves as high class compared to Brazilians while only 8% said the same compared to Koreans; low class, 4.3% compared to Brazilians and 9% compared to Koreans. About the resident country, almost all participants (98.5%) liked it even though 63.6% had perception of prejudice for being Korean. Related to inter-ethnic marriage, 70.4% were favorable for or indifferent and 29.6% was against it.

Frequency of Psychiatric Disorders The lifetime frequency of psychiatric disorders according to ICD-10 for the total sample is shown in Table 1. Nearly 42% of the sample had at least one lifetime mental disorder. The most prevalent disorder was substance (alcohol, tobacco, drug) use disorder (23.1%). The second most frequent was anxiety disorder (13%), followed by mood (8.6%), somatoform (7.4%), dissociative (4.9%), psychotic (4.3%) and eating (0.6%) disorders. Of all subjects, 9.6% had post-traumatic stress disorder. Excluding alcohol and tobacco use disorder, 26.2% had at least one lifetime psychiatric disorder. Of all respondents, 18.2% had at least one lifetime anxiety disorder or mood disorder. The number of subjects that sought any kind of medical assistance in the previous year was investigated. Of all participants, 22.5% obtained general medical service; 3.4% sought emergency services; and 1.9% used service of mental health professionals (psychiatrist, psychologist or social worker).

Variables Associated with Psychiatric Disorders The association of correlates with psychiatric disorders was studied after dividing the mental health problems into two groups: one, any lifetime psychiatric disorder but substance use disorder and another one, only substance use disorders. Gender was associated with both groups of disorders. Women were 1.8 times more likely than men to have any lifetime psychiatric disorder except substance use or dependence, and men were 5.8 times more likely to have substance use disorder. The gender was the only variable associated with substance use disorder.

Epidemiology of Mental Health Problems among Immigrants

215

Table 1. Frequency of ICD-10 psychiatric disorders among Korean immigrants in Brazil

ICD diagnosis

N (324)

%

Korea* (%)

Brazil† (%)

Any disorder

135

41.7

32.6

45.9

Any disorder but tobacco dependence

113

34.9

27.0

33.1

Any disorder but alcohol/tobacco use

85

26.2

13.2

Substance use disorder

75

23.1

Alcohol use disorder

42

13.0

16.8

Alcohol abuse

34

10.5

7.1

Alcohol dependence

19

5.9

9.8

Tobacco use disorder

51

15.7

11.1

Tobacco abuse

22

6.8

2.9

Tobacco dependence

29

9

10.2

Drug use disorder

4

1.2

0.25

Drug abuse

4

1.2

0.2

Drug dependence

2

0.6

0.05

Any anxiety/mood disorders

59

18.2

Any anxiety disorder

42

13.0

9.1

12.5

Generalized Anxiety disorder

15

4.6

2.3

4.2

Panic disorder

1

0.3

0.4

1.6

Any phobia

4

1.2

Agoraphobia

2

0.6

0.3

2.1

Specific phobia

1

0.3

5.2

4.8

Social phobia

1

0.3

0.2

3.5

Obsessive-compulsive disorder

-

-

0.8

0.3

Post-traumatic stress disorder

31

9.6

1,7

Any mood disorder

28

8.6

4.7

18.4

Depressive episode

20

6.2

4.1

16.8

Dysthymia

8

2.5

0.5

4.3

Depressive disorder (DE/dysthymia)

27

8.3

Bipolar disorder

1

0.3

0.2

1.0

Somatoform disorder

24

7.4

0.6

6.0

Dissociative disorder

16

4.9

27.3

5.5

25.0

1.1 24.0

8.4

18.1

2.2

216

Sam Chun-Kang, Denise Razouk, Jair J. de Mari et al. Table 1 (Continued)

ICD diagnosis

N (324)

%

Korea* (%)

Brazil† (%)

Psychotic disorder

14

4.3

1.2

1.9

Schizophrenia

5

1.5

0.2

Eating disorder

2

0.6

0.2

Bulimia nervosa

2

0.6

0.03

Anorexia nervosa

1

0.3

0.2

1.5

* Data from Ministry of Health and Welfare of Korea (24), N=6275, DSM-IV criteria. † Data from Andrade et al. (25), N=1464, ICD-10 criteria.

Among self-rated variables, those who had perception of prejudice for being Korean immigrants in Brazil and those who considered themselves as low socioeconomic class in relation to Korean community had more psychiatric problems: 2.8 and 2.7 times more likely than those who didn‘t rate themselves the same way. Other correlates such as age, marital status, occupation, family income, age at immigration, length of time in Brazil and knowledge of languages were not associated with mental health problems.

CONCLUSION This is the first study about the mental health of immigrants in Brazil using the WHOCIDI. Results show that Korean immigrants in Brazil have a rate of lifetime mental disorders (41.9%) that is between the prevalence in Korea (32.6%) and in Brazil (45.9%) (24, 25). The prevalence surveys in Korea and in Brazil used the same diagnostic instrument as this study (CIDI), but different diagnostic criteria: DSM-IV in Korea and ICD-10 in Brazil. A cautious comparison of results is recommended since ICD-10 criteria identify more cases of depression and fewer cases of anxiety disorders than the DSM criteria [26]. The population in this survey had higher rates in all categories of psychiatric diagnoses than Koreans in Korea. The rate of any lifetime disorder except alcohol and tobacco use disorder among immigrants was almost twice the rate for Koreans in their native country (26.2% vs 13.2%). This result is in agreement with other studies that demonstrated that the pattern of mental health among immigrants was unfavorable when compared to the population in their country of origin: Mexicans in the United States [3-5], Italians in Paris [6] and Japanese-Brazilians in Japan compared with those in Brazil [7]. The patterns of psychiatric disorders were not homogenous in the different diagnostic categories when compared to those in the Brazilian population: Korean immigrants have more psychotic (4.3% vs. 1.9%), dissociative (4.9% vs. 2.2%) and somatoform disorders (7.4% vs. 6.0%), fewer mood disorders (8.6% vs. 18.4%) and substance use disorders (23.1% vs. 27.3%), and a similar rate of anxiety disorders (13.0% vs. 12.5%). Studies about Afro-Caribbeans in Britain suggest that social and environmental adversities, such as unemployment, early separation from parents, inadequate housing, and experiences of racism, are risk factors for immigrants to develop a severe mental disorder


217

[11,12,27]. However, in the case of Korean immigrants in Brazil, social adversities may not be associated with the high rate of psychotic disorders, since 88.3% of the subjects have an annual income greater than U$12,000.00, which can be regarded as middle or high economic class in Brazil. A survey on 130 Japanese-Brazilian patients that went to Japan to work but had to come back to Brazil due to mental problems showed that 76.1% had a psychotic disorder. That study pointed out that experiencing a cultural change might be a stressful factor, which could explain the onset of the psychotic crises [28]. In the case of the participants in this survey, the experience of immigration might have increased their vulnerability, since immigration may precipitate the predominance of psychotic mechanisms by rupture of the balance between psychological conflicts and defenses [1]. The western definition of psychiatric disorders, with its emphasis on biological factors, may increase the rate of somatoform disorders in communities with culturally different symptoms [29-31], particularly among Asians, who show more physical complaints than psychological symptoms [32-34]. However, a higher frequency of somatoform disorders among immigrant Koreans than among nonimmigrant Koreans (7.4% vs. 0.6%) raises questions about the role of immigration on the onset of this psychiatric disorder. Substance use disorder was the most prevalent group of disorders in this study. Drug dependence rate was between the prevalence rate for Koreans in Korea and that for the Brazilian population. However, both tobacco (9%) and alcohol dependence rates (5.9%) were similar to the lower prevalence in the two populations: tobacco dependence, similar to that for Koreans in Korea (10.2% vs. 25% for Brazilians); and alcohol dependence, similar to that for Brazilians (5.5% vs. 9.8% for Koreans in Korea). These results differ from those found in a survey with elderly Koreans in Los Angeles, which showed similar rates of alcohol use disorder for immigrants (19.0%) and for the population of their native country (21.7%) (29,35). The results of our survey may have been affected by the religiosity of the subjects: most were Protestants (68.5%), whose religion has rules against substance use. The rate of mood disorders for immigrant Koreans (8.6%) is double the rate for nonimmigrant Koreans (4.7%) and less than half of that among Brazilians (18.4%). Comparing the findings of this study with those of other surveys, which used the same diagnostic instrument, our study subjects had a lower rate of mood disorders than MexicanAmericans (12.1%) (3) and Sardinians in Paris (17.6%; depressive episode) [6]. The comparison with Chinese-Americans revealed a similar rate of depressive episodes (6.2% vs. 6.9%), but a lower rate of dysthymia (2.5% vs. 5.2%) [36]. Surveys show that Asians have lower rates of mood disorders than Western people because they rarely report psychological complaints [33, 36, 37]. However, even considering this culturally different psychopathological pattern among Asians, Korean immigrants have more depressive disorders (8.3%, depressive episode/dysthymia) than other Asian communities in Brazil: Japanese-Brazilians (3.2%, using SRQ-20) [5] and Chinese-Brazilians (4.8%, using the Beck Depression Inventory) [34]. Although rates obtained by using different instruments are not easily compared, higher rates of mood disorders among this study subjects than in the population of their native country and in other Asian communities in Brazil may indicate higher vulnerability of this community to mood disorders. A higher rate of anxiety disorders among Korean immigrants than among Koreans in Korea (13% vs 9.1%) may be explained by the strikingly higher rate of PTSD among immigrants in this study (9.6% vs. 1.7%). The analysis of the CIDI section that corresponds to PSTD (section K) revealed that 35% of the subjects had suffered physical attack or assault;

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Sam Chun-Kang, Denise Razouk, Jair J. de Mari et al.

23% were involved in accidents with life risk; 20% had seen somebody being severely injured or killed; and 16% had been threatened with fire guns, kidnapped or secluded. Some studies report that immigrants are vulnerable to develop PTSD due to their feelings of helplessness [1, 31, 38]. Severe urban violence in São Paulo in addition to the stressful and traumatic experiences associated with migration may promote the onset of PTSD in immigrants. Comparative studies about urban violence and PTSD in both immigrant and nonimmigrant populations should investigate whether immigrants are suffering more violence and whether violent experiences lead to more PTSD among immigrants than among the general population. The percentage of study participants that sought mental health services (1.9% in the previous year) was lower than that found for Brazilians (7.7% in the previous month) [25] and much lower than the potential estimate of 25% according to the frequency of mental health problems found in this study [39]. The explanation for such low percentage may be cultural because mental problems are seen as ―mental weakness‖ or ―reason to be ashamed‖ [40]. This may also be assigned to difficulties in communication, because there are no public services available for culturally diverse populations. Strategies should be developed to bring adequate treatment to this population. This survey shows higher participation when the participants are contacted personally. The lowest refusal rate (4%) is found among those indicated by the interviewers and the highest refusal rate (96.6%), among those contacted at community churches through fliers. It indicates the importance of sampling method based on personal contact to promote higher participation among Asian immigrants. Some of the limitations of this survey are high refusal rate, low rate of participation of nonreligious population and difficulties/refusals to indicate friends, which made snowball design difficult. It may limit the generalization of results to the whole community of Korean immigrants in Brazil. Although this study worked with the best available number at the moment of the survey, further studies are required to control possible sample bias and to find more accurate rate of mental disorders for the immigrant community. Our results show that the prevalence of psychiatric disorders for Korean immigrants is greater than for Koreans in Korea and almost the same as for the Brazilian population. Furthermore, considering high religiosity of the subjects and protecting function of religion, the rate of mental disorders among the immigrants might be higher than that found in this study. The results of this survey, which revealed a more unfavorable pattern of mental health among immigrants than among the population in their native country, cannot be generalized to all immigrants in Brazil or to all Korean immigrants in other countries. However, attention from mental health authorities is required for a healthier integration of new immigrants, and the development of culturally sensitive mental health services for this population.

ACKNOWLEDGMENTS Special thanks to Caderno de Saúde Pública for the authorization of the use of the following article in this text: Kang S, Razzouk D, Mari JJ, Shirakawa I. The mental health of Korean immigrants in São Paulo, Brazil. Cad. Saúde Pública, 2009, vol. 25, n. 4, p. 819-826. ISSN 0102-311X.


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REFERENCES [1] [2] [3]

[4]

[5]

[6]

[7]

[8]

[9] [10] [11] [12]

[13] [14] [15] [16] [17] [18]

Grinberg LA, Grinberg R. Psicoanálisis de la migración y del exilio. Madrid: Alianza, 1984. Berry JW, Kim U, Mine T, Mod D. Comparative studies of acculturative stress. Int. Migration Rev, 1987; 21:491-511. Alderete E, Vega WA, Kolody B, Gaxiola SA. Effects of time in the United States and Indian ethnicity on DSM-III-R psychiatric disorders among Mexican Americans in California. J. Nerv. Ment. Dis, 2000; 188:90-100. Alderete E, Vega WA, Kolody B, Gaxiola SA. Lifetime prevalence of and risk factors for psychiatric disorders among Mexican migrant farm workers in California. Am. J. Public Health, 2000; 90:608-614. Vega WA, Kolody B, Aguilar-Gaxiola S, Alderete E, Catalano R, Caraveo-Anduaga J. Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Arch Gen. Psychiatry, 1998; 55:771-778. Carta MG, Kovess V, Hardoy MC, Morosini P, Murgia S, Carpiniello B. Psychiatric disorders in Sardinian immigrants to Paris: a comparison with Parisians and Sardinians resident in Sardinia. Soc. Psychiatry Psychiatr Epidemiol, 2002; 37:112-117. Miyasaka LS, Otsuka K, Tsuji K, Atallah AN, Kunihiro J, Nakamura Y, et al. Mental health of two communities of Japanese-Brazilians: a comparative study in Japan and in Brazil. Psychiatry Clin. Neurosci, 2002; 56:1:55-64. Zilber N, Lerner Y, Eidelman R, Kertes J. Depression and anxiety disorders among Jews from the former Soviet Union five years after their immigration to Israel. Int. J. Geriatr. Psychiatry, 2001; 16:993-999. Pope HG, Kullgren G, Caldera T. Migrations and manic-depressive illness. Compr. Psychiatry, 1983; 24:158-165. Grove W, Clayton PJ, Endicott J, Hirschfeld RMA, Andreasen NC, Klerman GL. Immigration and major affective disorder. Acta Psychiatr. Scand, 1986; 74:548-552. Wessely S, Castle D, Der G, Murray RM. Schizophrenia in the Afro-Caribbeans: a case-control study. Br. J. Psychiatry, 1991; 159:795-801. Hutchinson G, Takei N, Rahy TA, Bhugra D, Gilvarry C, Moran P, et al. Morbid risk of schizophrenia in first-degree relatives of white and African-Caribbean patients with psychosis. Br. J. Psychiatry, 1996; 169:776-780. Bagheri A. Psychiatric problems among Iranian immigrants in Canada. Can J Psychiatry, 1992; 37:7-11. Instituto Brasileiro de Geografia e Estatística. Censo 2000. Available at: http://www.ibge.gov.br/censo/. Accessed: May 15, 2002. Rosner B. Fundamentals of biostatistics. 4th ed. Belmont: Wadsworth, 1995. Biernarcki P, Waldorf D. Snowball sampling: problems and techniques of chain referral sampling. Sociol Methods Res, 1981; 10:141-163. Cornelius MA. Interviewing undocumented immigrants. Int. Migration Rev, 1982; 19:378-411. Quintana MIS. Performance of the Composite International Diagnostic Interview (CIDI/WHO) Version 2.1 in mental health services in Brazil [dissertation]. São Paulo: Universidade Federal de São Paulo, 2000.

220

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[19] Quintana MIS. Validity of Composite International Diagnostic Interview (CIDI/WHO) Version 2.1 in mental health services in Brazil. São Paulo: Universidade Federal de São Paulo, 2005. [20] Cho MJ, Hahm BJ, Suh DW, Hong JP, Bae JN, Kim JK, et al. Development of a Korean version of the Composite International Diagnostic Interview (K-CIDI). J. Korean Neuropsychiatr. Assoc, 2002; 41:123-137. [21] Robins LN, Wing J, Wittchen HU, Helzer JE, Babor TF, Burke J, et al. The Composite International Diagnostic Interview: an epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch Gen. Psychiatry, 1988; 45:1069-1077. [22] Wittchen HU, Robins LN, Cottler LB, Sartorius N, Burke JD, Regier D. Cross-cultural feasibility, reliability and sources of variance of the Composite International Diagnostic Interview (CIDI). Br. J. Psychiatry, 1991; 159:645-653. [23] World Health Organization. International statistical classification of diseases and related health problems. 10th revision. Geneva: WHO, 1992. [24] Ministry of Health and Welfare of Korea. Prevalence of DSM-IV psychiatric disorders in Korea. 2001. Available at: http://www.mohw.go.kr/databank. Accessed March 20, 2003. [25] Andrade L, Walter EE, Gentil V, Laurenti R. Prevalence of ICD-10 mental disorders in a catchment area in the city of São Paulo, Brazil. Soc. Psychiatr. Epidemiol, 2002; 37:316-325. [26] Wacker HR, Müllejans R, Klein KH, Battegay R. Identification of crises of anxiety disorders and affective disorders in the community according to ICD-10 and DSM-III-R by using the Composite International Diagnostic Interview (CIDI). Int. J. Methods Psychiatr. Res, 1992; 2:91-100. [27] Mallet R, Leff J, Bhugra D, Pang D, Zhao JH. Social environment, ethnicity and schizophrenia: a case-control study. Soc. Psychiatry Psychiatr. Epidemiol, 2002; 37:329-335. [28] Shirakawa I, Nakagawa D, Miyasaka LS. Emigration and mental disorders of Brazilians in Japan. J. Bras Psiquiatr, 2003; 52:73-78. [29] Lee CK, Kwak YS, Yamamoto J, Rhee H, Kim YS, Han JH, et al. Psychiatric epidemiology in Korea. Part I: Gender and age differences in Seoul. J Nerv Ment Dis, 1990; 178:242-252. [30] Villaseñor Y, Waitzkin H. Limitations of a structured psychiatric diagnostic instrument in assessing somatization among Latino patients in primary care. Med. Care, 1999; 377:637-646. [31] Mangado EO, Muelas NV, Suarez ML. Síndromes depresivos en la población inmigrante. Rev. Clin. Esp, 2005; 205:116-118. [32] Hsu LKG, Folstein MF. Somatoform disorders in Caucasian and Chinese Americans. J. Nerv. Ment. Dis, 1997; 185:382-387. [33] Chen JP, Chen H, Chung H. Depressive disorders in Asian American adults. West J. Med, 2002; 176:239-244. [34] Wang YP, Andrade LH, Gorenstein C. Validation of the Back Depression Inventory for a Portuguese-speaking Chinese community in Brazil. Braz. J. Med. Biol. Res, 2005; 38:1-10.


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[35] Yamamoto J, Rhee S, Chang DS. Psychiatric disorders among elderly Koreans in the Unites States. Commun. Mental Health J, 1994; 30-1:17-27. [36] Takeuchi DT, Chung RC, Lin KM, Shen H, Kurasaki K, Chun CA, et al. Lifetime and twelve-month prevalence rates of major depressive episodes and dysthymia among Chinese-Americans in Los Angeles. Am. J. Psyquiatry, 1998; 155:1407-1414. [37] Wang PY, Gorenstein C, Andrade LH. Patterns of psychopathological manifestations among ethnic Chinese living in Brazil. Eur. Arch Psychiatry Clin. Neurosci, 2004; 254:36-42. [38] Bhugra D. Migration and mental health: review article. Acta Psychiatr Scand, 2004; 109:243-258. [39] Almeida-Filho N, Mari JJ, Coutinho E, França JF, Fernandes JG, Andreoli SB, et al. Brazilian multicentric study of psychiatric morbidity: methodological features and prevalence estimates. Br. J. Psychiatry, 1997; 171:524-529. [40] Kramer EJ, Kwong K, Lee E, Chung H. Cultural factors influencing the mental health of Asian Americans. West J. Med, 2002; 176:227-231.



Chapter 15

SUCCESSFUL USE OF MENTAL HEALTH MIGRATION MODELS: THE NEW ZEALAND EXPERIENCE Regina Pernice Massey University, New Zealand

ABSTRACT This chapter outlines the development of theories and models which explain migrants‘ mental health and their successful application in New Zealand. The Social Selection Theory was the first theory proposed in the 1940s, but it soon proved to be unsatisfactory in explaining the relationship between immigration and mental health as it attributed the occurrence of mental health problems in the immigrant population to a predisposition of the individual to mental disorder. The alternative theory, the Social Causation Theory, was equally limited, in that it attributed mental illness to external stress alone. It became apparent in the 1960‘s that the two theories were not separable as a predisposition and the experience of stress both contribute to an increase of mental health problems. Therefore it became necessary to examine the multiple factors that comprise the process of immigration and the Multivariate Model of the Immigrant Adaptation Process was proposed in the 1970s. It took into consideration pre-migration conditions, post-migration factors in the society of settlement, the length of residence, and characteristics of individuals, and offered testable explanations of the relationship between immigration and mental health. Subsequent research using the Multivariate Model led to proposals with distinctly different patterns of the Length of Residence factor and also added new aspects to the model, e.g. the Circumstances of Migration (either forced or voluntary). This Multivariate Model had become very influential, provided the evidence needed to improve health and social services particularly for refugees. The most recent model, the bi-dimensional Acculturation Process Model explored the individual‘s attitude to acculturation (expressed by four adaptation styles) with two successful styles of adaptation to the host society and two styles detrimental to mental health. New Zealand‘s research, being focused for many years on the physical health effects of migration had neglected mental health research. The settlement of large numbers of Indochinese refugees prompted some exploration of mental health concerns using aspects of the Multivariate Model of the Adaptation Process. Despite a relatively large migration

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INTRODUCTION The earliest awareness of an excess of mental disorder among immigrants seems to have been by the superintendents of American asylums in the 1840‘s. Some blamed this phenomenon on the hard conditions the immigrants had to endure while others thought that immigration only attracted the destitute and unstable. In the subsequent hundred years data were collected to support each rival argument. The early literature dealt primarily with populations of institutions and compared the proportions of the foreign and native populations in mental hospitals. The authors estimated the numbers of the mentally ill among the foreign born, speculated about precipitating circumstances, examined claims that the mentally ill had been induced to emigrate from some particular countries and suggested procedures for more adequate screening at ports of entry into the United States. The early publications were relatively uncontroversial and apolitical. Later literature reflected the developing political pressures against the entrance of new immigrants, particularly against the influx of Eastern Europeans. Only a few articles contributed fundamentally to knowledge and formulated testable inferences. Their methodology has been criticised and, as Malzberg and Lee [1] pointed out, many authors committed an important statistical error since they did not take into account the different age distribution of the native born versus the foreign born population groups. Without correction, this factor would influence the ratio of mental illness making it spuriously high for the foreign born. Improvements were made in the quality of the data which was collected, but no suggestion of a viable theory occurred until Odegaard‘s work in the 1930‘s.

SOCIAL SELECTION THEORY Odegaard linked clinical observation to sound epidemiology. He came to the conclusion that, mainly in respect to schizophrenia, immigrants were liable to have an excessive incidence rate, because, in part, this disorder interferes with its victim‘s attachments to his native community and makes him disproportionately liable to emigrate [2]. Odegaard suggested that constitutional vulnerability to mental illness predisposes the person to migrate. The studies of Odegaard [2,3] were based on admission rates to mental institutions in Minnesota for Norwegian born immigrants compared with native Americans; and for the general population in Norway compared with returned migrants to Norway. The analysis took into account both the selection process operating in immigration (by comparing immigrants with the parent population), and the differentials emerging in the process of assimilation (by comparing immigrants with the indigenous population in the area of settlement). Odegaard found that the Norwegian born immigrants to the United States had a 30-50% higher admission rate than the American born. There was a higher admission rate for

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Norwegians born in Minnesota, than for the population of Norway. Returned migrants to Norway had twice as high an admission rate to mental institutions as the Norwegian general population. Odegaard concluded that he had found strong evidence that the high incidence of mental disorder in the immigrant population was due to the prevalence of certain psychopathic tendencies in the constitution of those who migrate. Social selection seemed the only possible explanation for this phenomenon. Odegaard‘s social selection theory was supported by Clark [4], Malzberg and Lee [1] and Mezey [5]. Clark standardised his data for social class, Malzberg and Lee looked at internal migration within the United States, while Mezey investigated personal characteristics of Hungarian refugees. All studies found a higher incidence of psychoses in the migrant population. The social selection theory, also called the premorbid personality theory [6], or the self selection theory [7], was soon considered too deterministic. Moreover, it ignored disorders other than the psychoses as well as the obvious hardships of immigrant life at that time.

SOCIAL CAUSATION THEORY Later researchers suggested an alternative theory, sometimes referred to in the literature as the external stress theory [6], the stress hypothesis, or the general hazard theory [7], all emphasising social causation. This theory implicated the severe stressors associated with migration as the precipitating factors of the immigrants‘ high incidences of mental disorder. These stressors included cultural changes and economic and social difficulties. It was supported by Ruesch et al. [8] and by the Manhattan study [9], both studies dealing with non-psychotic disorders in the community. Soon the social causation theory appeared equally simplistic and pessimistic and brought about a change in the nature of the question being asked. Instead of asking why migrants have a higher rate of mental disorder, it became necessary to ask under what conditions do they have these higher rates and researchers found it necessary to examine the multiple elements that comprise the process of migration.

MULTIVARIATE MODEL OF THE IMMIGRANT ADAPTATION PROCESS Goldlust and Richmond [10] after studying the native and foreign born population in Toronto, proposed a Multivariate Model of the Immigrant Adaptation Process. This model considered pre-migration conditions and characteristics, the situational determinants in the receiving society, and the length of residence in the society of settlement (see Figure 1).

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From Goldlust and Richmond, 1974. Figure 1. Multivariate Model of the Immigrant Adaptation Process.

Goldlust and Richmond emphasised the importance of individual characteristics of the immigrant by defining three elements within the immigrant‘s subjective state: (i) identification, involving modification of the sense of personal identity and the transference of loyalty (ii) internalisation, referring to the changes of attitudes and values that were part of the socialisation process, and (iii) level of satisfaction with various aspects of the immigrant‘s life relative to his or her pre-migration situation as compared with specific reference groups against which the immigrant measured himself/herself. Most researchers favoured the multivariate model of the immigrant adaptation process as it took into account pre-migratory and post-migratory factors, individual characteristics and the length of residence in the society of settlement. Several mental health workers such as Tyhurst [11], Cohon [12] and Sluzki [13], who worked with refugees and immigrants, had observed that refugees and immigrants go through different stages or phases during their resettlement and some of these phases were characterised by a higher level of mental health risk than others. Therefore they suggested that the length of residence in the receiving society significantly influences mental health levels and they suggested different time patterns of adaptation.


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LENGTH OF RESIDENCE IN THE SOCIETY OF SETTLEMENT Tyhurst [11] proposed a pattern of refugee adjustment dynamics which he called the Social Displacement Syndrome. He reviewed 27 years of clinical experience and field work with refugees in Canada and aimed at an all-inclusive picture of the psychological reactions of refugees. Four groups of refugees to Canada were studied: the displaced people, who arrived in the late forties and early fifties, the Hungarian refugees admitted in 1956, the Czechoslovakians who came in 1968, and the Asians expelled from Uganda in 1972. Tyhurst formulated three inter-related stages in the clinical phenomena that emerged among refugees, and considered that the general structure of these stages has been consistent for all refugee groups. The first stage or the initial period lasts about two to three months after arrival and consists of an ‗incubation period‘ that is symptom free and during which the refugee‘s outlook is often positive, even euphoric. This is followed after three months by the onset of a general disequilibrium in the refugee which reaches its peak six months after entry. This second stage is characterised by a cluster of symptomatology presented by (i) a range of paranoid behaviours from suspiciousness to acute paranoid psychotic episodes (ii) generalised hypochondriasis with pain as the central complaint and fatigue often being the earliest subjective symptom, and (iii) a mix of anxiety and depression with somatic complaints predominating. Tyhurst stated that the paranoia observed during this stage is mild and benign except in cases of refugees with concentration camp experience. The third stage of the Social Displacement Syndrome consists of a series of phenomena that are situation specific and affect the individual‘s sense of continuity of self, his orientation to place and time, with accompanying fluidity of mood, and at times vivid hallucinations related to the previous experience of flight. Another characteristic of this third stage is impairment of interpersonal and social skills manifested by contradictory tendencies of social withdrawal or hostility. Tyhurst did not suggest whether symptoms gradually ameliorated after reaching the peak after six months of residence in the society of settlement or when this might occur. Cohon [12] suggested a similar pattern of refugee adjustment but with different time intervals. In his analysis of data collected on 54 Indochinese refugee-clients treated in the San Francisco area, he noted that during the first year of residence in the United States the most frequent difficulties were related to socialisation as, for example, issues related to housing or other practical matters. From a mental health point of view, however, the first year of residence was symptom free. Beginning with the thirteenth month and slowly increasing in frequency, depression was the mental health problem diagnosed most often. For refugees who lived in the United States longer than two and a half years, severe depression was the problem of most concern, and was diagnosed in 92% of the cases. Therefore, the peak of presenting mental health problems occurred after two and a half years. Sluzki [13] proposed the Stage Model of the migratory process that applies to all migrants and not only to the displaced people or refugees. The model is ‗culture free‘, regardless of how culture-specific the styles of coping may be. In his investigation of

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immigrant families, Sluzki suggested that a period of overcompensation and euphoria, lasting some six months is followed by a period of major crisis, one in which the long-range responses to migration take place. This period of crisis can last for several years and might reach its peak from one to six years after arrival. Although Cohon [12] and Sluzki [13] generally support Tyhurst‘s [11] Social Displacement Model, there are some slight differences in the timing of these events. All three researchers confirm an initial symptom free period, for three months [11], six months [13] or one year [12]. In Tyhurst‘s Social Displacement Model the onset of crisis occurs after 3 months, reaching its peak at about 6 months, whilst Cohon found that problems increased after one year and that after two and a half years symptoms of depression were most severe. Sluzki stated that with immigrants and refugees the peak of the crisis could be found between one year and six years. None of the authors explicitly stated a drop of symptom levels after the crisis or the peak has been reached, although it appears that this is implied (see Figure 2).

Tyhurst, 1977; Cohon, 1979; Sluzki, 1986. Figure 2. Diagramatic representation of three different time patterns of adaptation.

Sluzki‘s description of the migrant‘s (refugee and immigrant) adaptation process was supported by Grinberg and Grinberg [14] in their work with immigrants to the United States. Other researchers however, such as Beiser [15] working with refugees and Flaherty et al. [16], investigating immigrant‘s mental health, suggested that migrants pass through prolonged periods of demoralization, which increase over time and reach a peak by the fourth or seventh year of residence in the country of settlement. A third response pattern of immigrants (not refugees) proposed a gradual improvement in mental health over time [17, 18]. Other aspects of the migration process which could explain the mental health consequences, were suggested by Murphy [19]. He agreed with Goldlust and Richmond‘s [10] multivariate model in general outline, but formulated it with slight differences in detail. He suggested additional factors of importance to migrants‘ mental health. He proposed that the mental health of a migrant group is determined not only by factors inherent in the,


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(i) society of origin (including personal characteristics), and by elements operating in the (ii) society of settlement, including the length of residence, but as well by (iii) circumstances of migration According to Murphy, all three sets of factors need to be considered if understanding and reduction of the level of mental disorder in any immigrant group is to be achieved.

(i) The Society of Origin The society of origin plays a crucial role in shaping the attitude of the individual and how emigration is perceived. In Europe, for example the Netherlands have, overall, encouraged emigration during the last 100 years, seeing it as an admirable act, requiring courage and the willingness to work hard. Under these circumstances a positive selection (that is, a selection of people likely to have no prior mental health problems) is likely to take place, whereas if emigration is looked upon as a desertion or a betrayal to the community, then negative selection is likely to occur. This view is based on personal observation by Murphy [19] who found that Dutch immigrants to Canada had lower rates of mental hospitalisation than immigrants from France. He speculated that France, with a lower birth rate and a greater need for soldiers, has been traditionally critical of emigration. Thus, negative selection could be a contributing factor for higher rates of mental disorders. The information provided to emigrants regarding conditions in the country of settlement is similarly relevant. Weinberg [20] and David [21] found a general consensus in the literature, namely, that emigrants who were prepared and well-briefed on their new sociocultural environment tended to adapt more readily than those who were ill-informed. The transition into the new society was better accomplished and, as a consequence, the incidence of mental disorder was lower. Consideration must be given, too, to the fact that certain societies seem to have a high predisposition for, and therefore a high incidence of, certain disorders, such as schizophrenia in the case of the Irish [22]. On these grounds it would be expected that the Irish immigrant population would show a higher rate of this condition than other immigrant groups. Similarly, a high incidence rate of peptic ulcers in the Japanese immigrant cannot be solely attributed to immigrant stress since Japan has the highest rate of this disorder in the world [23]. Furthermore, Nguyen [24] in accordance with Goldlust and Richmond [10] suggested that the immigrant‘s characteristics, his or her age, sex, educational level, social class and personality and the language and culture of the society of origin have to be considered, if one seeks to understand the mental health problems of any immigrant group.

(ii) The Society of Resettlement In the society of resettlement the factor most likely to affect mental health is the relative size of the immigrant‘s own minority group [7]. In Singapore, for example, where the Chinese population is divided by marked language differences, it was found that there was a

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strong inverse correlation between the size of the language group and the incidence of mental disorders [19]. Governments have tried to discourage the establishment of immigrant communities or ghettos. The ‗melting pot‘, a romantic American idea, was considered to be the ideal. It was hoped that both the native and the immigrant or refugee would be changed and merged into a new, supposedly stronger, alloy [25]. It was slowly recognised, however, that small resettlement communities had poorer mental health than larger ones [19]. Murphy‘s findings were consistent with the idea that ethnic enclaves are important for recently arrived refugees and immigrants, serving a mediating function between the newcomer and the host culture [26]. Thus, the model of assimilation considered then appropriate became cultural pluralism, and governments have encouraged it. It was hoped that the immigrants or refugees would adapt to the dominant cultural patterns, particularly in politics, play, education and work, while at the same time preserving their communal life and most of their culture. This meant, from the point of view of mental health, that migrants who were linguistically and culturally very different from the society of resettlement, should be encouraged to settle in large groups of the same origin. The greatest protection against mental health problems is not only the existence of large clusters of people of the same origin but, as well, the recognition of the full professional equality of migrants, their social acceptance and respect for their vocational and cultural aspirations [21]. Krupinski et al. [27] have shown that in Australia, central European professionals had quite abnormally high rates of mental breakdown which appeared to be linked to the fact that recognition of their professional qualifications was denied for many years. Vignes and Hall‘s [28] Louisiana study confirmed the findings of Krupinski et al., and called attention to the risk factors for psychopathology if there was status dislocation, loss of professional identity and the loss of employment status among heads of households. Another issue in the society of settlement is the experience of xenophobic hostility, directed by the population of the host country towards a particular immigrant group. Prejudice in the society of resettlement is felt strongly by some ethnic groups, especially when great distances in religious, ideological, and other cultural traits exist, or when there are obvious physical and anthropological differences [29]. The resulting discrimination, social isolation, and the sense of not belonging, can influence negatively the mental health status of refugees and immigrants. In the society of resettlement, factors such as remaining in one residence, closeness or distance from people of the same ethnic group, English language ability, the presence of relatives and support groups, an adequate social network, and satisfactory employment seem to affect the mental health of the immigrants. Westermeyer et al. [30] compared patient status with pre-migration and post-migration factors in a group of Hmong refugees to Minnesota. The findings suggested that remaining in one residence and greater distance from other Hmong, were significantly correlated with fewer emotional problems. However, the relative drop in occupation or social class, insufficient English language acquisition, and lack of relatives and support groups, were associated with higher symptom levels and patient status. Formal English instruction, however, was found to have only limited effects. Another universal risk factor for mental health problems mentioned in the literature is the lack of an adequate social network [31].


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(iii) The Circumstances of Migration The conditions of migration appear to influence the future psychological functioning of the immigrant. Of these conditions the most important is whether the migration has been forced or free. If it has been forced, as in the case of refugees, by real threat of persecution, famine or war, the trauma created by these experiences, and the fact that the migration has been undertaken without adequate preparation, can be the cause of considerable mental health problems. Researchers from all over the world have confirmed that refugees are more psychologically at risk than voluntary immigrants and usually experience significant levels of depression, anxiety and/or traumatic stress disorder [27, 32].

THE ACCULTURATIVE STRESS MODEL The most recent model to explain why there is an overrepresentation of migrants among those who experience mental health problems is the widely accepted bi-dimensional model of the acculturation process by Berry et al. [33]. The term acculturation refers to cultural change that results from prolonged and direct contact between two distinct cultural groups. In essence, acculturation occurs when a non-dominant ethnic group adapts to a dominant society [34]. Psychologically, adjusting to a new culture results in changes to the immigrant‘s values, behaviours, and beliefs toward the host country. The degree of acculturation stress experienced typically depends on the amount of behaviour change required during the adaptation process [35]. Berry divided the adjustment patterns of immigrants into four categories, based on two questions: ‗Is it considered to be of value to maintain my cultural identity and characteristics?‘ and ‗Is it considered to be of value to adapt to cultural identity and characteristics of the host country?‘ the answer to each question broadly defines the category each immigrant falls into: assimilation, integration, separation or marginalisation. Assimilation occurs when the immigrant abandons or rejects his/her traditional cultural conventions or identity and is absorbed into the dominant culture. Integration is when the immigrant maintains some of his/her cultural integrity, as well as adjusting their behaviour to become an integral part of the dominant societal framework. Separation is defined as the situation when the immigrant has no interest in building a tangible relationship with the dominant culture and holds onto his/her traditional culture. Finally, Marginalisation usually results from severe acculturation stress where, no longer acknowledging his/her cultural group and unable to adjust to the larger society, the immigrant in the adjustment process rejects both the old and the new culture. Conceptually, each acculturation style has far reaching consequences for the immigrant‘s psychological wellbeing. According to Berry [36] separation and marginalisation tend to be ineffective strategies in adjusting to a new culture as the societal issues the immigrant is confronted with remain unresolved, which may result in declining mental health. Berry argues that integration and assimilation result in the least stress on immigrants as they selectively adopt the mainstream culture. Integration is often seen in the bicultural individual who derives benefits from both population groups. For example, research by Niles [37] in Australia found that immigrant groups who preserved their values, traditions and culture (and

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thus maintained a strong ethnic identity) while partially adopting Australian culture in terms of language, education and societal norms, had a high sense of psychological well-being (see Figure 3).

Berry et al., 1989. Figure 3. Berry‘s four Acculturation Styles.

There are several factors that contribute to and determine acculturation style, with social and economic contexts (including host country attitudes towards the immigrant) playing a major role [34]. Without adequate social or cultural support, immigrants can face numerous mental health problems, often related to unemployment, poverty, substandard housing, prejudice, discrimination and lack of health care services and education. Moreover, acculturative experiences can often exacerbate the effect of daily stressors. These additional stressors are especially potent for immigrants who experience a great distance between the cultural norms of their former country and the society of settlement [35]. When the difference is significant, and the immigrant is unable to cope with the cultural changes and acquisition of language skills, the experiences can often lead to severe acculturation stress during the resettlement period [34]. Age also has an impact on the acculturation process, with older immigrants clinging to their traditional past and resisting the cultural norms of the host country [38]. The extent of acculturative stress and coping strategies differ between individuals, and thus determines the long-term outcomes of each immigrant. More recent research adopting a bidimensional approach did not make the a priori assumption of a typology [39, 40, 41]. In these studies, each acculturation dimension was first used to predict psychological adjustment separately. Findings from these immigrant studies suggested that in general, acculturation towards the host culture held adaptive implications and more positive mental health outcomes whilst acculturation towards the heritage culture held maladaptive implications. However, Cheung-Blunden and Juang‘s [42] study with young girls and their parents from Hong Kong found that acculturation towards Chinese (majority) culture was related to adaptive implications, whereas acculturation towards western (minority) culture was related to poorer adaptation and mental health problems. They


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suggested that the bicultural composition (e.g., status, prestige, strength of cultural networks of each culture) should be incorporated into acculturation theory to better understand adjustment implications across a wide range of contexts. The mental health migration theories and models, developed and extensively tested in predominantly immigrant nations of North America, have stimulated and guided researchers in other nations to raise awareness of migrant mental health issues and to initiate improvements in health and social services.

THE NEW ZEALAND EXPERIENCE New Zealand is a small nation of migrants. Its distance from major land masses resulted in it being one of the last countries to be inhabited. Ancestors of the Maori settled some 800 years ago from the Pacific. European colonisation did not commence until midway through the 19th Century but since then active immigration policies have been pursued to encourage further immigration. These policies were highly selective, favouring Europeans, especially migrants from the United Kingdom [43]. However, the 1987 changes in immigration policy and in particular the introduction of the 1992 point system provided highly skilled migrants from all parts of the world the opportunity to settle in New Zealand. The objectives of policies in the late 20th and early 21st century have always fallen into two main categories: those serving specific national interests, such as needed highly skilled staff resources for economic development and those of a humanistic nature, such as family reunification and acceptance of refugees. This resulted in a multicultural population with large ethnic minority groups. According to the latest 2006 census New Zealand has 4 million inhabitants and of these 14% identify as Maori, 9.2% as Asian, 6.6% are from the Pacific nations, 67.6% are of European descent, close to 1% identify as from the Middle East, Latin America and Africa and about 1.6% chose the ‗other‘ category [44]. Migrant research in New Zealand had focused on physical health with several researchers investigating the general health of the immigrant population. For example, such conditions as coronary and hypertensive heart disease, high blood pressure and ulcers have been clearly associated with immigration [45]. An early study by Eastcott [46] revealed a high rate of lung cancer among British immigrants and both Jackson et al. [47] and Sutherland et. al. [48] reported high rates of diabetes and asthma among the Polynesian population. Prior [45] reported that the health problems of the Vietnamese, Cambodians and Lao refugees to New Zealand, such as tuberculosis and worm infestations, were assessed, starting in 1978 and treated prior to settlement. However, ―…the exploration and examination of immigrant mental health had been grossly neglected in New Zealand‖ p. 94 [45]. The resettlement of large numbers of Indochinese refugees (nearly 10,000) during the late 1970s and 1980s provided the stimulus for the first systematic mental health research in the country [49]. Researchers looked for tested theories and models, overseas findings and experience with mental health measures [such as: 50, 51, 52] guided and inspired research designs leading to results that would inform the implementation of specific services for refugee and immigrant resettlement in New Zealand. The first study on mental health of migrants in the country by Pernice [53], Pernice and Brook [54, 55, 56] explored aspects of the Multivariate Model of the Immigrant Adaptation

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Process, in particular the relationship between mental health levels of Indo-Chinese refugees, immigrants from the Pacific Nations and British migrants and their pre-migration (demographic) characteristics, their length of residence, the circumstances of migration, and their post-migration experiences in New Zealand society. The findings indicated that the demographic characteristics such as age, gender, marital status and educational level had little influence on emotional distress, whereas discrimination in their daily life in New Zealand, experienced by both the Indochinese refugees and the immigrants from the Pacific nations was the crucial post-immigration factor associated with high symptom levels. Also the test of Sluzki‘s [13] length of residence did not support the influence of such stages on mental health, as no euphoric period or a time-linked mental health crisis were evident. The most definite aspect of the findings was the rejection of the concept of a euphoric period among the whole population of migrants. The hypothesis that the circumstances of migration (being a refugee or immigrant) would affect mental health and that refugees would experience more emotional distress than migrants was only supported when refugees were compared with British immigrants. Both Indochinese refugees and the immigrants from the Pacific nations had poor mental health. However, the incidence of clinical depression and clinical total emotional distress was higher among refugees which supported findings from international research [32]. Cheung [57], a psychiatrist in the South Island of New Zealand, investigated Cambodian refugees who presented with depression and post-traumatic stress disorder (PTSD). He discussed why traumatised Cambodians somatise their mental health problems and the difficulties involving them in Western style psychotherapy. A study of 223 Cambodians by Cheung and Spears [58] explored the psychiatric and physical health status, the pattern of health care service use and problems encountered with local health services. Their findings indicated that 15.7% had severe mental health problems but less than 3% of the refugees had ever attended any mental health services. Most participants had used traditional services in their home country but very few had used them in New Zealand. Over half of the refugees reported problems with use of health services. As these studies indicated, New Zealand‘s mental health research in the late 1980s and early 1990s focused on mental health of refugees and immigrants (as comparison groups) and predominantly investigated experiences in the society of settlement, including the length of residence, as opposed to pre-migration characteristics. Consideration of these findings encouraged a revision of service provision in New Zealand which resulted in an extension of refugee support agencies in all major cities of the country, where programmes used volunteer sponsors for each refugee family. In 1997 additional specialist clinics were established in Wellington and Auckland. These Refugees as Survivors (RAS) centres‘ main mission is to provide those who experienced torture and trauma with access to free and appropriate mental health services. Therefore these are examples of the practical successes that have been achieved by the awareness of refugees‘ special needs. This awareness by policy makers and health providers was in turn informed by migrant mental health research. Later mental health studies shifted their attention to voluntary immigrants and focused on aspects important to adjustment to life in New Zealand [59, 60, 61, 62]. Abbott et al.‘s [59, 60] community survey of 271 Chinese migrants (the majority from Hong Kong and Taiwan), used the Acculturative Stress Model (which identifies four adaptation styles) to assess their preferred adjustment strategies and mental health levels. The findings indicated that the bicultural or integration style provided the optimal path to adaptation with most respondents having neither major adjustment nor mental health problems supporting overseas research


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[33, 36]. The authors concluded that the prevalence rates of mental disorder were similar to those found in 1994 in surveys of the general population. However, major predictors of psychiatric morbidity included unemployment, low English proficiency, shorter residency in the country and younger age. Migrants‘ employment status also appeared to be a major mental health issue for the highly skilled Asian migrants who had been attracted via New Zealand‘s point system immigration policy in 1992 and 1995. Therefore Pernice et al. [61, 62] collected mental health data from Chinese (from the People‘s Republic of China), Indian and South African skilled immigrants and their employment status over five years, spanning Sluzki‘s length of residence stages. The research, built on the post-migration aspects of the Multivariate Model of the Immigrant Adaptation Process, found that mental health levels during the participants first year and a half in the country were no better for the employed than for the unemployed. Migrants in both employment categories experienced poor mental health similar to those in a previous study of the general long-term unemployed population in New Zealand [63]. For those migrants who were employed, this could be due to underemployment, occupational stress or dissatisfaction or to a combination of these factors. Poor mental health was equally evident among migrants from all three national origins. This situation persisted particularly over the first two data collection periods with slightly improved mental health levels during the following three years [62]. While most South Africans were successful in finding employment from the beginning, compared to the Indians and Chinese, this did not prevent them from having poor mental health. This may in part have been a result of the South Africans having different motivational factors driving their migration (e.g. feeling more ‗pushed‘ out of their country of origin rather than being ‗pulled‘ by the attraction of settling in New Zealand) . No positive relationship could be established between mental health and duration of residence. However, the generally poor mental health of the three groups of participants (particularly during the first year and a half in New Zealand) supports neither the concept of a euphoric/optimistic initial period nor a subsequent crisis period as proposed by Sluzki‘s [13] Stage Model. Instead, a different trend was observed with poor mental health in the first year and a half and slightly improved but still poor mental health thereafter [62]. While there are not many, specifically mental health studies, among the large number on various aspects of immigration to New Zealand, they have provided the knowledge base for some successful advances in support services to migrants, in particular for refugees. The more recent research on skilled migrants highlighted that post-migration factors such as employment status are not a clear determinant of mental health. Pre-migration aspects also need to be considered as the original Multivariate Model of the Immigrant Adaptation Process, developed in North America over 30 years ago, would have predicted.

CONCLUSION This chapter outlines theories and models of migration and its relationship to mental health and puts these into the context of the New Zealand experience. It describes the shift away from the Social Selection and Social Causation theories to a Multivariate Model of the

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Immigrant Adaptation Process. This model proposed in the 1970s became the most influential and tested model in North America and it inspired mental health research with refugees and migrants in many Western countries, including New Zealand. It took into consideration the characteristics of the individual, pre-migration conditions and postmigration factors in the society of settlement including the migrant‘s length of residence. Subsequent research tested various aspects of this model and the relationship of each aspect to migrant mental health. Some researchers suggested new factors to be of significance to the adaptation process. Others focused predominantly on settlement issues in the host society, with the latest model proposing individual characteristics such as his/her choice of adaptation style to the country of settlement. New Zealand‘s mental health researchers also explored and tested aspects of the Multivariate Model of the Adaptation Process starting in the late 1980s. The main focus has been post-migration settlement issues in New Zealand society, with both refugees and immigrants. Their research significantly contributed to an understanding of migrant mental health and to the successful implementation of improved service provision. Therefore the New Zealand experience has affirmed the experience elsewhere by determining that the use of theoretical frameworks from the mental health migration models has been a productive research avenue leading to better migrant service provision in New Zealand.

REFERENCES [1]

Malzberg B, Lee ES: Migration and Mental Disease. A study of First Admissions to Hospitals for Mental Disease: New York 1939-1944. New York, Social Science Research Council, 1956. [2] Odegaard O: Emigration and mental health. Mental Hygiene 1936; 20: 546-553. [3] Odegaard O: The distribution of mental diseases in Norway. Acta Psychiatrica Neurologica 1945; 20: 247-252. [4] Clark RE: The relationship of schizophrenia to occupational income and occupational prestige. American Sociological Review 1948; 13: 325-353. [5] Mezey AG: Psychiatric illness in Hungarian refugees. Journal of Mental Science 1968; 106: 618-627. [6] Eitinger L: The incidence of mental disease among refugees in Norway. Journal of Mental Science 1959; 105: 326-338. [7] Sanua VD: Immigration, migration and mental illness: a review of the literature with special emphasis on schizophrenia, in Behavior in New Environments. Adaptation of Migrant Populations. Edited by Brody EB. Beverly Hills, Sage, 1969, pp 291-352. [8] Ruesch J, Jacobson A, Loeb MB: Acculturation and Illness. American Psychological Association Monograph 1948. [9] Srole L, Langner TS, Michael ST, Opler MK, Rennie TA: Mental health in the metropolis. New York: McGraw Hill, 1962. [10] Goldlust J, Richmond AH: A multivariate model of immigrant adaptation. International Migration Review 1974; 8: 193-225. [11] Tyhurst L: Psychosocial first aid for refugees. (An essay in social psychiatry). Mental Health and Society 1977; 4: 319-343.


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[12] Cohon JD: A Preliminary Analysis of Indochinese Refugee Mental Health Clients. San Francisco, International Institute of San Francisco. Indochinese Mental Health Project 1979. [13] Sluzki CE: Migration and family conflict, in Coping with Life Crises. Edited by Moos RH. New York, Plenum, 1986, pp 277-288. [14] Grinberg L, Grinberg R: Psychoanalytic Perspectives of Migration and Exile. New Haven, Yale University Press, 1989. [15] Beiser M: Influences of time, ethnicity and attachment on depression in Southeast Asian refugees. American Journal of Psychiatry 1988; 145: 46-51. [16] Flaherty JA, Kohn R, Levav I, Birz S: Demoralization in Soviet-Jewish immigrants to the United States and Israel. Comprehensive Psychiatry 1988; 29: 588-597. [17] Scott WA, Scott R: Adaptation of Immigrants: Individual Differences and Determinants. Oxford, Pergamon Press, 1989. [18] Tran TV, Manalo V, Nguyen VTD: Nonlinear relationship between length of residence and depression in a community-based sample of Vietnamese Americans. International Journal of Social Psychiatry 2007; 53(1): 85-94. [19] Murphy HBM: Migration, culture and mental health. Psychological Medicine 1977; 7: 677-684. [20] Weinberg A: Mental health aspects of voluntary migration. Mental Hygiene 1954; 39(3): 450-566. [21] David HP: Involuntary international migration: adaptation of refugees, in Behavior in New Environments. Adaptation of Migrant Populations. Edited by Brody EB. Beverly Hills, Sage, 1969, pp 73-95. [22] Murphy HBM: Alcoholism and schizophrenia in the Irish: A review. Transcultural Psychiatric Research Review 1975; 12: 116-139. [23] Stocks P: Indications of a possible association between peptic ulcer and vascular lesions of the central nervous system. British Journal of Preventive and Social Medicine 1968; 22: 206-211. [24] Nguyen SD: Mental health services for refugees and immigrants. The Psychiatric Journal of the University of Ottawa 1984; 9(2): 85-91. [25] Stein BN: The refugee experience: Defining the parameters of a field study. International Migration Review 1981; 15(1): 320-330. [26] Brody EB: Introduction, in Behavior in New Environments. Adaptation of Migrant Populations. Edited by Brody EB. Beverly Hills, Sage, 1969, pp 13-21. [27] Krupinsky J, Stoller A, Wallace L: Psychiatric disorders in East European refugees now in Australia. Social Science and Medicine 1973; 7: 31-49. [28] Vignes AJ, Hall RCW: Adjustment of a group of Vietnamese people to the United States. American Journal of Psychiatry 1979; 136: 424-444. [29] Lazarus J, Locke BZ, Thomas DS: Migration differentials in mental disease. Milbank Memorial Fund Quarterly 1963; 41: 25-39. [30] Westermeyer J, Vang TF, Neider J: Migration and mental health among Hmong refugees. Association of pre- and post-migration factors with self-rating scales. The Journal of Nervous and Mental Disease 1983; 171(2): 92-96. [31] Yamamoto J, Satele A: Samoans in California. Psychiatric Journal of the University of Ottawa 1979; 4: 349-352.

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Regina Pernice

[32] Williams CL, Berry JW. Primary prevention of acculturative stress among refugees. American Psychologist 1991; 46: 632-641. [33] Berry JW, Kim U, Power S, Young M, Bujaki M: Acculturation attitudes in plural societies. Applied Psychology: An International Review 1989; 38: 185-206. [34] Ekbald S, Kohn R, Jansson B: Psychological and clinical aspects of immigration and mental health, in Clinical Methods in Transcultural Psychiatry. Edited by Okpaku S. Washington, DC, American Psychiatric Press, 1998, pp 42-66. [35] Schmitz PG: Psychological aspects of immigration, in Cross-cultural Topics in Psychology. Edited by Alder LL, Gielen UP. Westport, CT, Praeger, 2001, pp 229-243. [36] Berry JW: Acculturation and adaptation: a general framework, in Mental Health of Immigrants and Refugees. Edited by Holtzman WH, Bornemann TH. Austin, Texas, Hogg Foundation for Mental Health, 1990, pp 90-102. [37] Niles FS: Stress, coping and mental health among immigrants to Australia, in Merging Past, Present and Future in Cross-cultural Psychology. Edited by Lonner W, Dinnel D, Forgays D, Hayes S. Lisse, The Netherlands, Swets and Zeitlinger, 1999, pp 293-307. [38] Ghaffarian S: The acculturation of Iranian immigrants in the United States and the implications for mental health. Journal of Social Psychology 1998; 138: 645-675. [39] Costigan CL, Su TF: Orthogonal versus linear models of acculturation among immigrant Chinese Canadians: a comparison of mothers, fathers and children. International Journal of Behavioral Development 2004; 28(6): 518-527. [40] Nguyen HH, Messe LA, Stollak GE: Toward a more complex understanding of acculturation and adjustment. Journal of Cross-cultural Psychology 1999; 30(1): 5-31. [41] Ryder AG, Alden LE, Paulhus DL: Is acculturation unidimensional or bidimensional? A head-to-head comparison in the prediction of personality, self-identity, and adjustment. Journal of Personality and Social Psychology 2000; 79: 49-65. [42] Cheung-Blunden VL, Juang LP: Expanding acculturation theory: are acculturation models and the adaptiveness of acculturation strategies generalizable in a colonial context? International Journal of Behavioral Development 2008; 32(1): 21-33. [43] King M: The Penguin History of New Zealand. Auckland, NZ, Penguin Books (NZ), 2003. [44] Statistics New Zealand: QuickStats about New Zealand‘s Population and Dwellings: 2006 Census. Wellington, Department of Statistics, 2007. [45] Prior I: Immigrants and health: a selective review and suggestions for future research, in New Zealand and International Migration. A Digest and Bibliography No1. Edited by Trlin AD, Spoonley, P. Palmerston North, NZ, Massey University, Department of Sociology, 1986, pp 81-96. [46] Eastcott DF: The epidemiology of lung cancer in New Zealand. Lancet 1956; 1: 37-39. [47] Jackson RT, Beaglehole R, Rea HH, Sutherland DC: Mortality from asthma: a new epidemic in New Zealand. British Medical Journal 1982; 285: 771-774. [48] Sutherland DC, Beaglehole R, Fenwick J, Jackson RT, Mullins P, Rea HH: Death from asthma in Auckland: circumstances and validation of causes. New Zealand Medical Journal 1984; 97(769): 845-848. [49] Abbott M: Introduction, in Refugee Resettlement and Wellbeing (based on the first National Conference on Refugee Mental Health in New Zealand). Edited by Abbott M. Auckland, Mental Health Foundation, 1989, pp 3-11.


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[50] Mollica RF, Lavelle JP: The Trauma of Mass Violence and Torture: An Overview of the Psychiatric Care of the Southeast Asian Refugee (Report). Boston, Indochinese Psychiatry Clinic, St. Elizabeth‘s Hospital, 1986. [51] Mollica RF, Wyshak G, Marneffe D, Tu B, Yang T, Khuon F, Coelho R, Lavelle J: Hopkins Symptom Checklist-25. Manual. Cambodian, Laotian and Vietnamese Versions. Boston, Indochinese Psychiatry Clinic, St. Elizabeth‘s Hospital, 1986. [52] Mollica RF, Wyshak G, Marneffe D, Khuon F, Lavelle J: Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. American Journal of Psychiatry 1987; 144(4): 497-500. [53] Pernice R: Chapter 12. Refugees and mental health, in Refugee Resettlement and Wellbeing (based on the first National Conference on Refugee Mental Health in New Zealand). Edited by Abbott M. Auckland, Mental Health Foundation, 1989, pp 155160. [54] Pernice R, Brook J: Relationship of migrant status (refugee or immigrant) to mental health. International Journal of Social Psychiatry 1994; 40(3): 177-188. [55] Pernice R, Brook J: The mental health pattern of migrants: is there a euphoric period followed by a mental health crisis? International Journal of Social Psychiatry 1996; 42(1): 18-27. [56] Pernice R, Brook J: Refugees‘ and immigrants‘ mental health: Association of demographic and post-migration factors. Journal of Social Psychology 1996; 136(4): 511-519. [57] Cheung P: Somatisation as a presentation in depression and post-traumatic stress disorder among Cambodian refugees. Australian and New Zealand Journal of Psychiatry 1993, 27: 422-428. [58] Cheung P, Spears G: Illness aetiology constructs, health status and use of health services among Cambodians in New Zealand. Australian and New Zealand Journal of Psychiatry 1995; 29: 257-265. [59] Abbott MW, Wong S, Williams M, Au M, Young W: Chinese migrants‘ mental health and adjustment to life in New Zealand. Australian and New Zealand Journal of Psychiatry 1999; 33: 13-21. [60] Abbott MW, Wong S, Williams M, Au M, Young W: Recent Chinese migrants‘ health, adjustment to life in New Zealand and primary health care utilization. Disability and Rehabilitation 2000; 22(1/2): 43-56. [61] Pernice R, Trlin AD, Henderson AM, North N: Employment and mental health of three groups of immigrants to New Zealand. New Zealand Journal of Psychology 2000; 29(1): 24-29. [62] Pernice R, Trlin AD, Henderson AM, North N, Skinner M: Employment status, duration of residence and mental health among skilled migrants to New Zealand: results of a longitudinal study. International Journal of Social Psychiatry 2009; 55(3): 272287. [63] Pernice R, Long N: Long-term unemployment, employment attitudes and mental health. Australian Journal of Social Issues 1996; 31(3): 311-326.

PART III: SUBSTANCE ABUSE



Chapter 16

SUBSTANCE USE DISORDER AMONG IMMIGRANTS IN THE UNITED STATES Sun S. Kim1, David Kalman1,2, Gerardo Gonzalez1 and Douglas Ziedonis1 1. University of Massachusetts School of Medicine, Worcester, Massachusetts, USA 2. Edith Nourse Memorial Veterans Administration Medical Center, Bedford, Massachusetts, USA

ABSTRACT The purpose of this chapter is to describe substance use disorders among immigrants based on a review of literature conducted in the United States. This chapter consists of three parts: the first part covers the definition of substance use disorders and a brief description of biological and psychosocial aspects of addiction; the second part is a review of empirical literature; and the third part is conclusion of the chapter. Thirty two studies of U.S. immigrants are reviewed. About 65.0% (13/20) of the studies with adults and 50.0% (6/12) of the studies with adolescents were conducted exclusively with Hispanics; studies with other immigrants are scarce. Findings are consistent across subgroups of Hispanics, with the exception of Puerto Ricans, that immigrants are less likely to have substance use disorders than U.S. natives. Due to lack of studies with African and Asian immigrant groups, findings are inconclusive about these groups. The majority of studies with African, Asian, and European Americans report findings in aggregated data of all groups without ethnic-specific information on subgroups. Acculturation is the variable that has been most frequently studied in relation to substance use disorders among immigrants. Importantly, the level of acculturation is strongly associated with sociodemographic factors (e.g., gender and age), and socioeconomic factors (e.g., education and family income). More studies are needed to determine how to modify maladaptive processes contained in some trajectories of acculturation into American culture that may increase substance use, especially among female immigrants and their female offspring. In addition, future research should focus on developing interventions that are designed to foster the retaining of protective cultural norms against substance use prevalent of an ethnic group within the immigrant community.

Sun S. Kim, David Kalman, Gerardo Gonzalez et al.

244

INTRODUCTION Substance use disorders are chronic, often relapsing, diseases that are characterized by compulsive drug-seeking and drug-taking behaviors, despite negative consequences. It is a leading suicide risk factor [1-3] and has been a serious public health problem across nations. With health care costs attributable to alcohol, tobacco and other illicit drug use estimated annually at more than 100 billion dollars, substance use disorder is a leading health problem in the United States (US) [4]. According to the National Epidemiologic Survey on Alcohol and Related Conditions conducted in 2001-2002, the 12-month prevalence of any substance use disorders (excluding nicotine) was 9.35% (19.4 million); the prevalence rates of alcohol and drug use disorders were 8.46% (17.6 million) and 2.00% (4.2 million adult Americans), respectively [5]. More recently, the National Survey on Drug Use and Health in 2008 reports that about 22.2 million Americans aged 12 years or older, or 8.9% of the population, can be considered to have a substance use disorder (including alcohol and illicit drugs) [6]. Between 2002 and 2008, there was almost no change in number of persons with substance abuse or dependence (22.0 million in 2002 and 22.2 million in 2008). Studies on substance use disorders among immigrants are scarce and findings have been inconsistent due to heavy reliance on convenience samples. Most studies report findings in an aggregated format by race or language use such as Spanish-speaking without ethnic-specific information. Although substance use among immigrants tend to be less common than among U.S. natives, estimates of substance use disorders and types of substances abused most frequently may vary by race and ethnicity. The purpose of this chapter is to describe substance use disorders among immigrants in the US based on a review of empirical literature that report rates of substance use disorders. The chapter consists of three parts:   

Part I. Definition and Etiologies of Substance Use Disorders Part II. Review of Studies on Substance Use Disorders among U.S. Immigrants Part III. Conclusion

In this chapter, we first define substance use disorders, using the current classification of the Diagnostic and Statistical Manual fourth edition text revised (DSM-IV TR) [7] and then provide an overview of substance use disorders, describing pertinent biological and psychosocial etiological factors. We then describe how ethnic and racial differences in biological systems that contribute to, or protect from, problematic substance use. We then present a review of the extant literature in substance use disorders among immigrants in the US. Finally, we conclude the review with some recommendations for future studies.

PART I. DEFINITION AND ETIOLOGIES OF SUBSTANCE USE DISORDERS Substance use disorders include abuse and dependence. According to the American Psychiatric Association [7], substance abuse is defined as a maladaptive pattern of substance use during 12 months leading to clinically significant impairment or distress as manifested by recurrent substance use despite its negative consequences in the user‘s life. Abuse is

Substance Use Disorder among Immigrants in the United States

245

considered the less severe version of substance use disorders with fewer symptoms of the overall syndrome of dependence. Substance dependence is the more severe version of substance use disorders and includes other symptoms of tolerance, withdrawal, and compulsive drug seeking behavior. The dependent user has an intensive desire for the substance ("craving") and needs more of the substance to achieve the effect that a lesser amount induced in the past (―tolerance‖). When use is interrupted, the dependent user experiences withdrawal symptoms that include negative emotions and physiological changes, which often leads to relapse to use. In this chapter, the term ―drug addiction‖ is used interchangeably with ―substance dependence‖ as they are in the DSM-IV TR [7].

Biological Explanation of Addiction Biological theories of addiction explicate that individuals initially consume substances for the ability of the agents to produce a pleasurable effect (that is, reward) and that dependence develops as a function of the time and recurrent drive for reward [8]. This idea of positive reinforcement by drugs with abuse liability has been widely seen as a primary factor behind substance abuse and dependence. Drugs of abuse are generally classified into different categories, including cannabinoids, depressants (i.e., ethanol), stimulants (i.e., nicotine, amphetamines and cocaine), hallucinogens (for example, lysergic acid diethylamide [LSD] and ecstasy) and inhalants (i.e., toluene and nitrous oxide) [9]. Although these drugs often produce differential behavioral effects and have diverse pharmacological profiles and withdrawal symptoms, they all act on one common feature the mesocorticolimbic dopamine (DA) activity in the brain [10, 11]. The mesocorticolimbic dopamine activity. The mesocorticolimbic system, which is implicated in the rewarding properties of both natural stimuli (for example, food, drink and sex) and addictive drugs, consists of DA projections from cell bodies in the ventral tegmental area to limbic structures of the mesolimbic pathway that include nucleus accumbens (NAcc), the amygdala, ventral striatum, and hippocampus, and cortical areas of the mesocortical pathway including the prefrontal cortex, the orbitofrontal cortex and the anterior cingulate. The mesolimbic pathway is involved in the acute reinforcing effects of drugs and various conditioned responses related to craving and relapse, whereas changes in the mesocortical pathway mediate the conscious drug experience, drug craving and a loss of behavioral inhibition that results in compulsive drug-seeking and drug-taking behaviors [9]. The enhancement of DA secretion in the NAcc is a common effect of different pharmacological classes of drugs of abuse: opiates, cocaine, amphetamine, ethanol, nicotine and cannabinoids. This effect can result from direct action on dopaminergic neurons as is the case with nicotine, cocaine, and amphetamine or an indirect effect as is the case with ethanol and opioids. Noradrenergic and serotonergic neurons. Findings from animal studies suggest that DA is not the only neurotransmitter involved in addiction. Noradrenergic (norepinephrine containing) receptors and serotonergic (serotonin containing) systems are also involved [12]. For example, in genetic studies, dopaminergic transporter (DAT)-knockout mice continue to experience DA release in the reward circuit in response to stimulants and consequently still self-administer cocaine [13, 14]. In contrast, α1b-adrenergic receptor-knockout mice do not show behavioral sensitization to d-amphetamine [15], nor increased DA release in the NAcc [16]. This suggests that norepinephrine contributes to stimulant effects independently of the

246


DAT. The serotonergic system appears to be involved in the regulation of impulse-control mechanisms related to craving and relapse rates [17].

Racial and Ethnic Differences in Biological Factors Not everyone who experiments with drugs that have abuse ability will become dependent on them and this individual difference in addiction vulnerability has been explicated in large by gene-environment interplay. Attempts to identify genes conferring susceptibility to addictive diseases have been undertaken via a range of research designs including adoption and twin studies [18-26]. Adoption studies consistently find greater similarities between substance abuse phenotypes with biological relatives than with adopted family members. Genetic studies have found moderate to high genetic influences on addiction that account for 30 to 70% of the total variance [20]. It has also been suggested that genetic vulnerability is influenced by gender, age and ethnicity [24]. Very limited studies exist that examine genetic differences in substance use by racial and ethnic groups and most have focused on alcohol and nicotine dependence. For example, the importance of genetic factors in the development of alcohol dependence has been well established [27]. A protective relationship has been found between alcohol dehydrogenase (ADH2*2) and alcoholism in Asians [28] and Jews [29]. A liver enzyme, Cytochrome P450 2A6 (CYP2A6), with alleles associated with slow nicotine metabolism, has been reported more frequently with Asian populations (15-20%) than European and Middle East populations (less than 1%) [30, 31]. Others also found that Japanese smokers have lower active genotypes of the CYP2A6 enzyme than white counterparts [32]. However, significant genetic differences exist within the Asian population: Japanese and Koreans living in Japan presented significant differences (p < 0.005) in the activity of CYP2A6 enzyme [33]. More recently, genome-wide association (GWA) studies with substance dependent individuals have been conducted within and across racial and ethnic groups. For example, there was a significant association of polymorphisms in the melanocortin receptor type 2 (MC2R or ACTH receptor) gene with heroin addiction in 272 subjects including Caucasians, Hispanics, and African Americans [34]. The researchers found a significant association (p = 0.0004) of the allele – 184A with a protective effect from heroin addiction in Hispanics.

Psychosocial Explanations of Substance Use among Immigrants Psychosocial stress model explains drug addiction and relapse in light of the interaction between biological and psychosocial factors [35-37]. Stress is generally defined as any disruption of homeostasis from internal and external challenges [38]. To return to homeostasis, people respond by the activation of two adaptive systems: first, stress activates the hypothalamic–pituitary–adrenal axis through the release of corticotrophin-releasing factor (CRF) and second, stress activates the sympathetic nervous system resulting in the release of epinephrine. The release of CRF results in release of adrenocorticotropin hormone [ACTH] into general circulation. ACTH then acts on the adrenal cortex resulting in release of glucocorticoids into blood. While the high concentration of glucocorticoids act in a negative feedback fashion to terminate the release of CRF, it also stimulates the release of epinephrine


247

from the adrenal medulla by regulating the level of the enzyme, phenylethanolamine-Nmethyltransferase, which controls the synthesis of epinephrine from norepinephrine [39]. Acculturative stress model versus Assimilation model. Immigrants are confronted with a variety of problems upon arrival in a new society. Language difficulties, cultural differences, ethnic discrimination, family separations, and loss of social networks, valued social roles, identities, and occupational positions are but a few of the challenges that are often faced by immigrants [40]. The acculturative stress model suggests that the stress caused by cultural conflict at point of destination and lack of social and economic resources for coping may result in substance use and substance use disorders [41-43]. Studies of immigrants from Latin America to the US indeed have found an association of acculturative stressors with psychological distress and substance use disorders [44-46]. In contrast, the assimilation model suggests that as immigrants adopt the customs and practices of the host society, their patterns of substance use will also begin to parallel those of their new environment [47, 48].

Conceptual Definitions of Acculturation and Other Related Terms ―Assimilation‖, ―enculturation‖, and ―socialization‖ are some other terms that have been used interchangeably with ―acculturation‖, which creates confusion. Instead of ―acculturation‖, the term ―assimilation‖ had been used for a while to depict the process or an outcome of adaptation of a group of racial/ethnic minority groups to the dominant group [4951]. Scholars then believed that immigrants were destined to lose completely the traits of their original cultures and to be absorbed into the dominant culture. This belief was based on an idea that the host society consists of the basic homogeneity of Anglo-Saxon culture and that immigrants could conform to social and cultural norms within a national framework [52]. Hence, the end product of assimilation was frequently conceived as a situation of complete conformity to the majority society at all cultural, social, and economic levels. Many scholars who are themselves descents of immigrants, however, argue that the assimilation theory is incongruent with so called ―salad bowl‖ reality in which ethnicity seems to be persistent across generations [52]. In line with this, Berry and colleagues [53] proposed a multidimensional model of acculturation that has been widely accepted in studies of immigrants across disciplines. They suggested that immigrants living in a multicultural society face two fundamental issues: (1) the value of retaining one's own cultural identity and customs and (2) the value of adopting the culture and custom of the host society. Depending upon answers to the two questions, people can select one of four modes: (1) assimilation mode whereby one relinquishes one's cultural identity by moving into the host culture, (2) integration mode, which entails maintaining relationships with both the culture of origin and the host culture, (3) separation mode whereby one maintains relationships only with one‘s culture of origin, and (4) marginalization mode in which relationships are lost with both the culture of origin and the host culture [54-56]. Integration mode is considered the ideal option, whereas marginalization mode in which the greatest acculturative stress is to be found is the most maladaptive one. Acculturation has also been viewed as synonymous with enculturation. Cavalli-Sforza and Feldman [57] proposed that enculturation and acculturation are identical phenomena with one exception: the behavior to be learned belongs to one's own cultures in the former case, while in the latter case it belongs to another culture. Socialization also has been viewed as

248


synonymous with acculturation. For example, Spiro [58] argued that the values and beliefs one holds are constructed to a greater degree by social experience and social heritage than an individual's private experience. Thus, he placed emphasis on social interaction that involves acquiring knowledge and internalizing values. Berry et al. [53], however, disagreed with Spiro‘s view by arguing that enculturation and acculturation are the processes whereby a person gradually learns culture and then incorporates into one‘s core values and beliefs; whereas, socialization refers to the process by which institutions deliberately shape one‘s values and beliefs.

PART II. REVIEW OF STUDIES ON SUBSTANCE USE DISORDERS AMONG U.S. IMMIGRANTS Table 1 summarizes findings of 32 studies on substance use disorders among U.S. immigrants [41, 48, 59-88]. These studies were identified with key words such as ―immigrants AND substance use―, ―immigrants AND substance use disorders‖, and ―immigrants AND alcohol use disorders‖ from a computer search on databases of healthrelated literature such as PubMed, Social Sciences Citation Index, and Cumulative Index to Nursing and Allied Health Literature. A total of 93 research articles published through June 30, 2009 were retrieved from a combination of computer search of the databases and manual search from the list of references in selected articles. We found 32 articles (34.4%) that met our inclusion criteria. To be included, the study had to be conducted with a representative sample or a large number of subjects (N ≥ 1000) and must provide information on subject characteristics, particularly, nativity (U.S. born vs. foreign born) and/or generation status (immigration, first, and second generation). A total of 25 studies that simply reported prevalence rates of alcohol and/or tobacco use were not included; yet, studies (n = 13) with immigrants on any illicit drug use were all included due to paucity of such studies.

Prevalence of Substance Use Disorders among Immigrants in the US Among the 32 studies listed in Table 1, all but three [41, 65, 72] reported findings with aggregated data without racial or ethnic classifications. Of the three with disaggregated data, one was conducted with adults and two were with adolescents. Most studies reported that immigrants had lower lifetime prevalence of substance use disorders than U.S.-born natives of the same national origin. This finding had been consistent across studies with adolescents as well as across studies with adults of all racial and ethnic groups except for Puerto Ricans [48, 64]. Immigrants had a later age of onset for substance use and also had a lower propensity for progression from substance use to disorders. However, further analysis presented a different picture when substance use was compared among immigrants by their length of residency in the US. There was a trend toward equality in risk for substance use disorders between immigrant adults and U.S. natives after 15 years of residence [41, 48] and between immigrant adolescents and U.S. natives after 5 to 10 years of residence [65, 68]. The trend was often understood as a result of the maladaptive process of acculturation or assimilation to the American norm of substance use.

Table 1. Studies on Substance Use among Immigrants in the United States by Race and Ethnicity Age Group

Citation

Study Location

Group Origin

Major Findings

Adults

Alegria et al., 2006 [62]

Nationwide

Puerto Rican Cuban

U.S.-born non-Hispanic Whites and Cuban Americans reported higher alcohol and drug use disorders as compared with their foreign-born counterparts. For Puerto Ricans, there was no difference in alcohol use


Nationwide

Hispanic

Self-perceived high social standing in the U.S. community was associated with decreased likelihood of reporting any substance use disorders in the past 12 months (ORa = 0.3, p < 0.05). Coming to the US after age 25 did offset the elevated risk of substance use from exposure to neighborhood disadvantage.


Nationwide

Hispanic

U.S.-born Latinos except Puerto Ricans reported higher rates for substance use disorders than Latino Immigrants. No differences were found between foreign-born and U.S.-born Puerto Ricans.

Amaro et al., 1990 [79]

Nationwide

Mexican, Puerto Rican Cuban

Use of marijuana and cocaine was higher among U.S.-born Hispanics of all groups than among those who were born outside the US. Regardless of ethnicity, drug use was highest among English-speaking Hispanics than among those who were bilingual Hispanics, whose drug use in turn was higher than among those who were primarily Spanish- speaking.

Borges et al., 2006 [61]

Nationwide

Mexican

Borges et

Tijuana,

Mexican

The prevalence of alcohol dependence was 4.8% for the Mexicans, 4.2% for the Mexico-born immigrants, and 6.6% for U.S.-born Mexican immigrants. High acculturation was associated with higher risks of alcohol use disorders for women; however, unexpectedly, high acculturation was associated with lower risks for men. Migrants who had worked in the US and returned to Mexico were more

al., 2009

Ciudad Juarez,

likely to have used alcohol, marijuana or cocaine in their life-time and in the

[66]

and Monterrey,

past 12 months, and were more likely to develop a substance use disorder

disorders but there were differences in any drug use disorders.

Mexico Breslau et al., 2007 [87]

Nationwide

compared with others in the general population of Mexico. Black, Hispanic,

Immigrants had lower lifetime risk of substance use disorders than natives.

White

Risk was equally large for natives who were children of immigrants as for natives of subsequent generations.

Table 1. Studies on Substance Use among Immigrants in the United States by Race and Ethnicity (Continued) Age Group

Citation

Study Location

Group Origin

Major Findings

Burnam et

Los Angeles,

Mexican

Lifetime prevalence rates of alcohol and drug use disorders were higher for

al., 1987

CA

high acculturated or native Mexican Americans than for low acculturated or

[78] Caetano et al., 2008

Mexican immigrants. Texas

Mexican

Acculturation was related to lower rates of alcohol use disorders among men and a higher frequency of heavy episodic drinking among women. those who are ‗‗very Mexican,‘‘ ‗‗bicultural Mexican,‘‘ or ‗‗bicultural Anglo‘‘

[85]

are more at higher risk for alcohol abuse and ⁄ or dependence compared with ‗‗very Anglo ⁄ Anglicized‘‘ men. For women, acculturation level did not predict alcohol use disorders. Chae et al.,

Nationwide

2008 [80]

Chinese,

U.S.-born Asian Americans were more likely to report lifetime history of

Filipino, Vietnamese, Other Asian alone Biracial/Mixed

alcohol abuse/dependence than foreign-born Asian Americans. Controlling for sociodemographic characteristics, Asian Americans who reported experiencing unfair treatment had higher odds of lifetime history of alcohol abuse/dependence disorders (OR = 5.26, CI = 0.23 to 0.90).

Finch et al., 2003 [81]

California

Mexican

Employment frustration resulting from labor market exclusion and discrimination were significantly related to past-year alcohol abuse and dependence.

Grant et al, 2004 [69]

Nationwide

Mexican White

Harrison and Sidebottom, 2009 [82]

Minnesota

Black American Indian Asian, Hispanic White Biracial/Multiracial

Foreign-born Mexicans and Whites were at lower risk (p < 0.05) of DSM-IV substance use disorders compared with their U.S.-born counterparts. The rate of any drug use disorders for U.S.-born Mexican Americans was 8.3 times greater than for foreign-born, while for Whites the ratio was about 2.4:1.0 between U.S.-born and foreign-born. Pre-pregnancy alcohol and drug use was much higher among U.S.-born women than immigrant women regardless of race/ethnicity. American Indians had the highest rates of the use among all racial/ethnic groups. U.S.-born African Americans had the higher use rates than U.S.-born Asian Americans or Hispanics.

Age Group

Citation

Study Location

Group Origin

Major Findings

Johnson et al., 2002

Nationwide

not disaggregated

Immigrants were less likely to report past-year and lifetime use of alcohol and drugs than those born in the US. Lifetime prevalence generally

[41] Ojeda et al.,

increased with longer length of residence in the US. Nationwide

2008

Hispanic,

The odds of lifetime substance use by Hispanic and White immigrants were

White

lower than for U.S.-born Whites. Hispanic Immigrants' odds of lifetime

[71]

substance use were lower than for U.S.-born Latinos. Hispanic immigrants reported lower use of cigarettes, marijuana, and LSD than did White immigrants.

Ortega et al,

Mexican,

Mexican Americans were less likely than Whites to have any substance use

2000

Nationwide

Puerto Rican,

disorders. No significant findings were found for Puerto Ricans or other

[48]

Other Hispanic,

Hispanics compared with Whites. Acculturation predicted greater risk of

White

having a substance use disorder for all Hispanic groups. Cumulative exposure to traumatic events was a strong predictor of drug dependence. The exposure was lower among immigrants than natives. This difference appeared to contribute importantly toward accounting for observed nativity differences in drug dependence among Hispanic women. Binge drinking and alcohol dependence were higher in rural areas than in urban areas. However, drug use and drug-related problems were similar in both areas. Rural residents were more likely than urban residents to be recent immigrants and to have lower incomes and educational attainment. Co-occurring lifetime rates of substance use disorders with non-substance

Turner et al., 2006 [86]

South Florida

Cuban Other Hispanic

Spence et al., 2007 [83]

Texas

Hispanics, mostly Mexican

Vega et al.,

California

Mexican

2003 [73] Vega et al.,

Youth

use psychiatric disorders were 12.3% for the U.S.-born Mexican Americans Nationwide

Hispanic

and were 3.5% for Mexican immigrants. Compared to US-born Hispanics, foreign-born Hispanic were less likely to

2009

have dual diagnoses (OR = 0.234, p ≤ 0.0001) or any substance disorder

[76]

(OR = 0.261, p ≤ 0.0001), if they reported any lifetime substance use.

Blake et al., 2001 [65]

Massachusetts

Not disaggregated

Compared with U.S.-born youths, immigrant youths (particularly those living in the US for 6 years or less) reported lower lifetime and recent alcohol and marijuana use (p < 0.001). There was no difference in use of other illegal drugs between the two groups.

Table 1. Studies on Substance Use among Immigrants in the United States by Race and Ethnicity (Continued) Age Group

Citation

Study Location

Group Origin

Major Findings

Brindis et al. 1995

California

Hispanic White

Hispanic students engaged in a greater number of risk-taking behaviors than native Whites. Greater proportions of native-born Hispanic students,

[84]

as compared to Hispanic immigrants, reported use of alcohol and marijuana, whereas Hispanic immigrants were more at risk for unintended pregnancy and self-violence.

Dierker et, al. 2006 [88]

San Juan, Puerto Rico New Haven, CT

Puerto Rican

DSM-IV nicotine dependence was strongly associated with attentiondeficit-hyperactivity-disorder (ADHD) (OR = 20.1, CI = 2.39–169.12), alcohol abuse/dependence (OR = 19.5, CI = 1.98–190.86) and drug abuse/ dependence (OR = 57.3, CI = 8.86–370.5). Yet, the association between ADHD and nicotine dependence was significant only for the San Juan site

Frank et al., 2007 [67]

California

Asian, Black, Hispanic, White

Hispanic adolescents were less likely to engage in substance use than White adolescents. Yet, third-generation Hispanics were not different from Whites. Asians demonstrated lower risk of substance use compared to Whites. There was no difference in substance use between Black and White adolescents

Gfroerer and Tan, 2003 [68]

Nationwide

not disaggregated

Prevalence rates of substance use were lower among foreign-born youths than among U.S.-born youths (p < 0.05), especially for youths aged 16 to 17 years. Foreign-born youths who had been in the US for less than 5 years had lower prevalence than did U.S.- born youths. The rates of use for foreign-born youths in the US for 10 or more years were not different from the rates for U.S.-born youths.

Khoury et

Florida

Black, Cuban

Compared to Black and foreign-born Hispanics, White and U.S.-born

Other Hispanic, White

Hispanics had the highest lifetime and past-year prevalence rates of substance use. Cuban American girls had higher lifetime prevalence rates for alcohol use than girls in the other ethnic groups. Cuban American boys had the largest percentages of alcohol heavy use, whereas White boys had the largest percentages of heavy cigarette smoking and other illicit drug use.

Not disaggregated

Individuals who spoke English at home were more likely to use drugs during the preceding 3 months (OR = 1.28, p = 0.000) compared to those who spoke a language other than English at home.

al., 1996 [70]

Saint-Jean et al., 2008 [72]

Florida

Age Group

Citation

Study Location

Group Origin

Major Findings

Tonin et al., 2008 [59]

A southwestern state

Hispanic

Acculturation and gender interacted with attitudes towards drugs to predict current alcohol, inhalant, and marijuana use. The effects of attitudes on alcohol and inhalant use were stronger for girls compared to boys.

Vega and Gil, 2005] [74

Florida

Hispanic

Ethnic differences existed in rates and progression of tobacco use to other drug use or dependence, with African Americans and foreign-born Latinos having larger proportions of non-smokers and lower rates of persistent use compared to White Americans. The odds of progression to marijuana use or dependence by later adolescence were highest (OR = 4.9) among persistent smokers but not significant for foreign-born Latinos.

Vega et al.,

Nationwide

Hispanic

African Americans and Hispanic immigrants had lower risk of smoking

2007 [75]

a

OR: odd ratio.

initiation and tobacco dependence. However, adolescents who initiated smoking shared increased risk for substance use disorders and other psychiatric disorders regardless of race and ethnicity.

Warren et al., 2008 [77]

Arizona

Mexican

There was no difference in lifetime substance use prevalence between U.S.-born and foreign-born Mexican pre-adolescents. Mexican preadolescents who were reared in single, blended, nuclear, and extended families reported a similar prevalence of lifetime substance use.

Willgerodt and Thompson, 2006 [60]

Nationwide

Chinese, Filipino, White

Ethnicity did not predict substance use; however, generational status did among Chinese and Filipino adolescents. Substance use by generational status among Euro American adolescents was not compared due to the small number of first- and second-generations within the group.


254

Table 2. Group Differences in Substance Use Disorders by Nativity and/or Acculturation Ethnic Origin Mexican

Substance Use Disorders Alcohol

Any drugs

Cuban

Puerto Rican

Any substances Alcohol Any drugs Any substances Alcohol

Nicotine Any drugs Any substances Other Hispanics Hispanics

Asian

Any substances Alcohol Nicotine Marijuana and other drugs Any substances Alcohol

Black White

Any substances Alcohol

Any drugs

Any substances a

Author and Year Alegria et al., 2008 [63] Borges et al., 2006 [61] Burnam et al., 1987 [78] Caetano et al., 2008 [85] Grant et al., 2004 [69] Vega et al., 2003 [73] Alegria et al. 2008 [64] Borges et al., 2009 [66] Burnam et al., 1987 [78] Grant et al., 2004 [69] Vega et al. 2003 [73] Alegria et al. 2007 [63] Ortega et al., 2000 [48] Alegria et al. 2006 [62] Alegria et al. 2006 [62] Alegria et al. 2007 [63]

Differed by U.S. Nativity? Yes Yes Yes Yes Yes Yes Yes -a Yes Yes Yes -a No Yes Yes -a

Differed by Acculturation? -a Yesb Yesc Yesc only for men -a -a -a Yesd Yesc -a -a Noe Nof -a -a Noe

Alegria et al. 2006 [62] Alegria et al. 2008 [64] Dierker et al., 2006 [88] Dierker et al., 2006 [88] Alegria et al. 2008 [64] Dierker et al., 2006 [88] Alegria et al. 2007 [63] Ortega et al., 2000 [48] Alegria et al. 2007 [63] Ortega et al., 2000 [48] Vega and Gil, 2005 [74] Vega et al, 2007 [75] Vega and Gil, 2005 [74]

No No No No No No -a No -a Yes No Yes Yes

-a -a -a -a -a -a Noe Yesf Noe Yesf -a -a -a

Breslau et al., 2007 [87] Vega et al, 2009 [76] Chae et al. 2008 [80]

Yes Yes Yes

Yesb -a -a

Breslau et al., 2007 [87] Alegria et al. 2006 [62] Alegria et al. 2008 [64] Grant et al., 2004 [69] Alegria et al. 2006 [62] Alegria et al. 2008 [64] Grant et al., 2004 [69] Breslau et al., 2007 [87]

Yes Yes Yes Yes Yes Yes Yes Yes

Yesb -a -a -a -a -a -a Yesb

no reports were available for differences; b acculturation was measured by age at immigration and length of residency in the US; cacculturation was assessed on a composite measure of multi-items; d acculturation was measured by migration work experiences in the US; eacculturation was measured with age at immigration; facculturation was assessed with use of English vs. Spanish language;


255

Differences in Substance Use Disorders by Nativity and/or Acculturation Table 2 summarizes findings for racial or ethnic groups whose members demonstrated differences in substance use disorders by nativity status (natives vs. immigrants) and/or acculturation level (high vs. low). Although acculturation was often used to examine differences in substance use disorders within a racial/ethnic group, except for two studies [78, 85], the variable was usually assessed on a proxy measure such as language use [79] and age at immigration [63, 87]. The two studies used a composite measure of acculturation covering language used, media preference, food preference, ethnic identity, and other aspects of daily life. The findings for each racial/ethnic group are summarized below. Hispanic Americans. Hispanic Americans represent a diverse population with many ethnic groups, including Mexicans, Cubans, Puerto Ricans, different South and Central American Countries, and Spain. Mexican Americans had been studied most frequently (n = 11) and findings were consistent across studies: Mexico-born adults were less likely to have alcohol and drug disorders than U.S.-born Hispanic adults in general and U.S.-born Mexican adults in particular. However, Mexican immigrant youths did not differ in rates of substance use and substance use disorders from U.S.-born Mexican youths if they had been in the US for 10 or more years [68]. Mexican pre-adolescents also had similar lifetime prevalence of substance use regardless of their birth place [77]. Similar to findings for Mexicans, Cuban immigrant adults had lower prevalence rates of substance use disorders than their U.S.-born counterparts [62, 79]. Cuban American girls, particularly those born in the US, reported higher lifetime prevalence rates of alcohol use than girls in any other Hispanic groups [70]. Similarly Cuban American boys were more likely to report heavy alcohol use than boys in any other Hispanic groups. Spanish-speaking Mexican and Cuban American adults were less likely to use marijuana and cocaine than their English-speaking counterparts [79]. Unlike other groups of Hispanic origin, Puerto Ricans [48, 64] did not present any differences in substance use and/or its related disorders by their nativity status and/or acculturation level. Amaro and others [79], however, reported significant differences in marijuana and cocaine use between Spanish-speaking and English-speaking Puerto Rican adults although this latter study was conducted about a decade earlier than the two studies reporting no difference. Differences in acculturation measurement might have contributed to the inconsistency of findings across studies and more studies are needed before any conclusion can be drawn about Puerto Ricans. Of note, Alegria and others [63] reported that coming to the US after age 25 years seemed to offset the increased risk of substance use among Hispanic immigrants regardless of ethnic origin even after they had been exposed to neighborhood drug use. European Americans. European Americans had been studied second most frequently (n = 9) and findings were consistent across studies that European immigrants had lower rates of substance use disorders than their U.S.-born counterparts. However, no single study could be identified that had ethnic-specific information about any groups of the population. All the studies grouped all immigrants from Europe into a single racial category ―White‖ and the majority of the studies compared prevalence rates of substance use and/or substance use disorders for the group with those for Hispanic and/or other racial groups. The study by Breslau and colleagues was the only one reporting significant differences in substance use disorders among European immigrants by acculturation level [87].

256


African Americans. Four studies had specific information on substance use among African immigrants in the US [67, 70, 82, 87]. Most studies compared prevalence rates for the group with those for other racial/ethnic groups. Breslau et al. [87] found significant differences in this group by nativity status and acculturation level. Similar to findings for Hispanics and Europeans, African immigrants had lower rates of substance use disorders compared to U.S.-born African Americans. Findings were, however, inconclusive with regard to whether U.S.-born African Americans had lower rates of substance use and/or substance use disorders than U.S.-born European Americans or U.S.-born Hispanic Americans. Asian Americans. The study by Chae and others was the only one that presented specific information about Asian American adults [80]. In this study, Asian Americans who had a history of alcohol use disorders were disproportionately more often single, U.S.-born, male, and uninsured. Two studies had been conducted with Asian American adolescents: Asian immigrant youths were less likely to use any substances than U.S.-born Asian youths who in turn were less likely to drink alcohol or to smoke cigarettes than U.S.-born White youths [60, 67].

Gender Difference in Substance Use Disorders within the Immigrant Population For immigrants, substance use disorders are more common among males and, therefore, studies of substance use had been conducted primarily with male subjects. In the US – there are also gender differences in substance use disorders; however, percentages for alcohol, tobacco, and other drugs are much closer between males and females. Recent studies of women have brought attention to gender differences in biology related to substance abuse, epidemiology of the disorders, etiologic and treatment considerations, and psychiatric comorbidity [89]. In one study, it was found that women were more likely than men to (1) attribute the causes of alcohol and drug abuse to genetic disposition, family history or environmental stress, (2) perceive drugs as more powerful, (3) perceive a higher prevalence of substance abuse, and (4) believe prevention and treatment are more effective [90]. On the other hand, there was no significant difference in individual factors: men and women equally attributed lack of moral character and willpower as causes of substance abuse. There are many factors for the lower rate of substance use among females. Although many factors differentiate women from men, one factor of major importance is the societal response to women with substance use disorders. Women experience more social disapproval of substance use and are more stigmatized for the use than men [89]. The striking gender differences in substance use disorders that are often found in Asia and Latin America may be in part related to this societal factor. However, when female immigrants from these regions acculturate into American culture that has less strict gender-role proscription against female substance use; they and their female children are more likely to initiate substance use. This premise is supported in studies of substance use among immigrants. Vega and colleagues [91] found that the combined effect of U.S. nativity and acculturation on drug use, was greater among women (adjusted OR = 29.3) than among men (adjusted OR = 7.4). Similar findings are also reported in studies with Asian immigrants. Acculturated women are about five times more likely to smoke cigarettes compared to Asian culture-oriented women [92]. Regardless of racial and ethnic origin, there is a trend among boys and girls aged 12 to 17 years toward


257

comparable rates of initiation and use of alcohol, cocaine, heroin, and tobacco [93]. If this trend continues, over time there may be a narrowing of the male-to-female prevalence ratios of substance use in the older age groups.

Studies on Substance Use Disorders in Relation to Suicide among Immigrants An additional computer search was conducted to identify studies on substance use disorders in relation to suicide among immigrants. However, most of the studies were conducted with immigrants in European countries [94-96]. Studies with immigrants in the US were very limited. Most European studies reported higher suicide rates among immigrants, which was attributed, in part, to their higher rates of substance use. In contrast, studies with U.S. immigrants generally examined suicide in relation to acculturative stress or depression [97-101]. Only one study examined suicide in relation to substance use [3]. The study reported that among Latino adolescents, immigration generation status predicted the risk of suicide attempts, problematic alcohol use, repeated marijuana use, and repeated other drug use. However, the direct effects of generation status on suicide attempts became nonsignificant (0.11 and 0.15) for later-generations (second and third) when substance use variables were included in the model. The authors suggested that substance use mediate the effects of generation status on suicide attempts [3].

PART III. CONCLUSION More than half of the studies (19/32, 59.4%) were conducted exclusively with Hispanic group. The remaining studies also largely compared prevalence rates of substance use disorders between Hispanic and European Americans. Hispanic immigrants, except for Puerto Ricans, were less likely to have substance use disorders than U.S.-born Hispanics. Studies on African, Asian, and European immigrants in the US were extremely rare and hence, no conclusion can be drawn about them. It is crucial to examine whether African, Asian, and European immigrants follow the same trend toward increased risk of substance use disorders as that has been observed among immigrants of Hispanic origin in general. It would also be informative to better understand how gender moderates the process as discussed with smoking among Asian Americans [102]. There is a need to better understand rates of substance use, abuse, and dependence, and progression among immigrants in general and immigrants of African, Asian, and European ethnic subgroups. Except for Mexican, Cuban, and Puerto Rican, Hispanics from other ethnic origins were often grouped together as Hispanic others or other Hispanics without country of origin or racial specific information [48, 68]. Similar to Hispanics, immigrants from Africa, Asia, and Europe comprise complex and heterogeneous groups and information on correlates and comorbidities of substance use disorders within and across ethnic groups of the populations may help guide prevention and treatment interventions for respective ethnic groups. The arbitrary racial categorization of these groups may not have any biological or cultural implications in understanding of substance use and its related disorders.

258


Similar to studies with immigrants in other health areas, acculturation is the most predominant psychosocial and cultural variable in studies of substance use disorders among immigrants. Despite the continuous accumulation of health research on acculturation, the concept remains ambiguous and complicated. Researchers continue to debate whether acculturation is appropriate as an explicatory construct to account for differences in substance use disorders among immigrants. Many suggest a cautious interpretation in the effect of acculturation on substance use disorders because the variable has a strong interaction effect with other sociodemographic and socioeconomic factors. For example, Amaro and others [79] found significant interaction effects of language use that was used as a proxy measure of acculturation with education, sex, marital status, and place of birth. Instead of the ambiguous term acculturation, marginalization or downward social mobility may be the true underlying process whereby immigrants learn the dysfunctional behaviors of social outcasts in the host country. The relatively lower prevalence of substance use disorders among immigrants during first 15 years after migration to the US may be related to time needed for immigrants to be naturalized as a U.S. citizen. The threat of deportation may serve as powerful deterrents to experimentation with illicit substances and/or becoming dependent on substances [41]. It will be interesting to compare prevalence of substance use disorders among immigrants by U.S. citizenship and how much the citizenship alone can explain the difference when other confounding factors such as education and acculturation variables are adjusted for. It will be worthy to examine whether immigrants with U.S. citizenship are more likely to progress from substance use to abuse, and then to dependence compared with immigrants who don‘t have the citizenship. The latter group may be more likely to maintain the use within the socially acceptable limit or may be less likely to report use of any illicit substances. Future research in the following areas may help produce information necessary and crucial for the prevention and reduction of substance-related morbidity and mortality in immigrants and their offspring. First, there is a need for surveys with large representative samples of diverse subgroups of immigrant populations that yield ethnic- and gender-specific data for each group and compare findings by immigration generation status and acculturation level. It is also crucial to validate self-reported data with biochemical testing if possible because there is tendency to underreport substance use and its related disorders among immigrants because of the potential threat of greater legal sanctions among non-citizens as described above. In 2002, Johnson and colleagues indicated that validation studies of the quality of drug and alcohol self-reports among immigrant populations in the US and other countries have not been conducted [41]. We also failed to identify any studies that reported self-reports in conjunction with biochemical validation. Researchers should consider undertaking such validation with obtaining a Certificate of Confidentiality that guarantees exemption from any subpoenas of collected data. Second, researchers in future studies that examine substance use disorders in relation to acculturation must provide a conceptual definition of the term and utilize a standardized measure in order to enhance the credibility of findings and comparability across studies. Based on a review of 69 research articles between 1996 and 2002, Hunt and colleagues [103] expressed concerns that acculturation in health research seems to be based more on ethnic stereotyping than on objective representation of cultural differences. According to Olmedo, there are two key problems encountered in the definition of acculturation: (1) it rests on an a priori definition of culture, and (2) its contextual scope differs across disciplines [104].


259

Future studies on substance use disorders in relation to acculturation should assess the concept on a standardized measure that was based on a clear conceptual framework. The measure should also have sound psychometric properties with the ethnic group under investigation. Finally, more cross-cultural studies are urgently needed that explore cultural norms of certain ethnic groups that serve as protective factors against substance use. This information can be used to develop interventions designed to foster the retaining of these protective norms within the immigrant community. It will also be interesting to conduct studies with a cohort of immigrants who are followed over time since their arrival in the US with the purpose of investigating how their perceptions of substance use change over time, what factors are associated with such changes, and how these factors are associated with their actual use of substances.

REFERENCES [1]

[2]

[3]

[4] [5]

[6]

[7]

[8] [9]

Borges G, Angst J, Nock MK, Ruscio AM, Walters EE, Kessler RC: A risk index for 12-month suicide attempts in the National Comorbidity Survey Replication (NCS-R). Psychol. Med. 2006; 36(12): 1747-57. Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, Bruffaerts R, Chiu WT, de Girolamo G, Gluzman S, de Graaf R, Gureje O, Haro JM, Huang Y, Karam E, Kessler RC, Lepine JP, Levinson D, Medina-Mora ME, Ono Y, Posada-Villa J, Williams D: Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br. J. Psychiatry 2008; 192(2): 98-105. Pena JB, Wyman PA, Brown CH, Matthieu MM, Olivares TE, Hartel D, Zayas LH: Immigration generation status and its association with suicide attempts, substance use, and depressive symptoms among Latino adolescents in the USA. Prev. Sci. 2008; 9(4): 299-310. Horgan C, Skwara KC, Strickler G, Anderson L: Substance abuse: the nation‘s number one health problem, key indicators for policy, Update 2001. Brandeis University, 2001. Grant BF, Stinson FS, Dawson DA, Chou SP, Dufour MC, Compton W, Pickering RP, Kaplan K: Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen. Psychiatry 2004; 61(8): 807-16. Substance Abuse and Mental Health Services Administration: Results from the 2008 National Survey on Drug Use and Health: National Findings. U.S. Available at http://www.oas.samhsa.gov/NSDUH/2k8NSDUH/2k8results.cfm#1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Fourth edition text revised ed. Washington DC: American Psychiatric Association, 2000. Wise RA: Action of drugs of abuse on brain reward systems. Pharmacol. Biochem. Behav. 1980; 13 Suppl 1: 213-23. Feltenstein MW, See RE: The neurocircuitry of addiction: an overview. Br. J. Pharmacol. 2008; 154(2): 261-74.

260


[10] Di Chiara G, Imperato A: Drugs abused by humans preferentially increase synaptic dopamine concentrations in the mesolimbic system of freely moving rats. Proc. Natl. Acad. Sci. USA 1988; 85(14): 5274-8. [11] Wise RA: Neurobiology of addiction. Curr. Opin. Neurobiol. 1996; 6(2): 243-51. [12] Tassin JP: Uncoupling between noradrenergic and serotonergic neurons as a molecular basis of stable changes in behavior induced by repeated drugs of abuse. Biochem. Pharmacol. 2008; 75(1): 85-97. [13] Carboni E, Spielewoy C, Vacca C, Nosten-Bertrand M, Giros B, Di Chiara G: Cocaine and amphetamine increase extracellular dopamine in the nucleus accumbens of mice lacking the dopamine transporter gene. J. Neurosci. 2001; 21(9): RC141: 1-4. [14] Rocha BA, Fumagalli F, Gainetdinov RR, Jones SR, Ator R, Giros B, Miller GW, Caron MG: Cocaine self-administration in dopamine-transporter knockout mice. Nat. Neurosci. 1998; 1(2): 132-7. [15] Drouin C, Darracq L, Trovero F, Blanc G, Glowinski J, Cotecchia S, Tassin JP: Alpha1b-adrenergic receptors control locomotor and rewarding effects of psychostimulants and opiates. J. Neurosci. 2002; 22(7): 2873-84. [16] Auclair A, Cotecchia S, Glowinski J, Tassin JP: D-amphetamine fails to increase extracellular dopamine levels in mice lacking alpha 1b-adrenergic receptors: relationship between functional and nonfunctional dopamine release. 2002; 22(21): 9150-4. [17] Ciccocioppo R: The role of serotonin in craving: from basic research to human studies. Alcohol Alcohol 1999; 34(2): 244-53. [18] Hopfer CJ, Crowley TJ, Hewitt JK: Review of twin and adoption studies of adolescent substance use. J. Am. Acad. Child Adolesc. Psychiatry 2003; 42(6): 710-9. [19] Merikangas KR, Stolar M, Stevens DE, Goulet J, Preisig MA, Fenton B, Zhang H, O'Malley SS, Rounsaville BJ: Familial transmission of substance use disorders. Arch Gen. Psychiatry 1998; 55(11): 973-9. [20] Agrawal A, Lynskey MT: Are there genetic influences on addiction: evidence from family, adoption and twin studies. Addiction 2008; 103(7): 1069-81. [21] Derringer J, Krueger RF, McGue M, Iacono WG: Genetic and environmental contributions to the diversity of substances used in adolescent twins: a longitudinal study of age and sex effects. Addiction 2008; 103(10): 1744-51. [22] Xian H, Scherrer JF, Grant JD, Eisen SA, True WR, Jacob T, Bucholz KK: Genetic and environmental contributions to nicotine, alcohol and cannabis dependence in male twins. Addiction 2008; 103(8): 1391-8. [23] Uhl GR, Drgon T, Johnson C, Fatusin OO, Liu QR, Contoreggi C, Li CY, Buck K, Crabbe J: "Higher order" addiction molecular genetics: convergent data from genomewide association in humans and mice. Biochem. Pharmacol. 2008; 75(1): 98-111. [24] Le Moal M: Drug abuse: vulnerability and transition to addiction. Pharmacopsychiatry 2009; 42 Suppl 1: S42-55. [25] Uhl GR, Elmer GI, Labuda MC, Pickens RW: Genetic influences in drug abuse. In: Gloom FE, Kupfer DJ, eds. Psychopharmacology: the fourth generation of progress. New York: Raven Press, 1995; 1793-2783. [26] Ducci F, Goldman D: Genetic approaches to addiction: genes and alcohol. Addiction 2008; 103(9): 1414-28.


261

[27] Heath AC, Bucholz KK, Madden PA, Dinwiddie SH, Slutske WS, Bierut LJ, Statham DJ, Dunne MP, Whitfield JB, Martin NG: Genetic and environmental contributions to alcohol dependence risk in a national twin sample: consistency of findings in women and men. Psychol. Med. 1997; 27(6): 1381-96. [28] Li TK: Pharmacogenetics of responses to alcohol and genes that influence alcohol drinking. J. Stud. Alcohol. 2000; 61(1): 5-12. [29] Hasin D, Aharonovich E, Liu X, Mamman Z, Matseoane K, Carr LG, Li TK: Alcohol dependence symptoms and alcohol dehydrogenase 2 polymorphism: Israeli Ashkenazis, Sephardics, and recent Russian immigrants. Alcohol. Clin. Exp. Res. 2002; 26(9): 131521. [30] Oscarson M, Gullsten H, Rautio A, Bernal ML, Sinues B, Dahl ML, Stengard JH, Pelkonen O, Raunio H, Ingelman-Sundberg M: Genotyping of human cytochrome P450 2A6 (CYP2A6), a nicotine C-oxidase. FEBS Lett. 1998; 438(3): 201-5. [31] Oscarson M, McLellan RA, Gullsten H, Yue QY, Lang MA, Bernal ML, Sinues B, Hirvonen A, Raunio H, Pelkonen O, Ingelman-Sundberg M: Characterization and PCRbased detection of a CYP2A6 gene deletion found at a high frequency in a Chinese population. FEBS Lett. 1999; 448(1): 105-10. [32] Yoshida R, Nakajima M, Watanabe Y, Kwon JT, Yokoi T: Genetic polymorphisms in human CYP2A6 gene causing impaired nicotine metabolism. Br. J. Clin. Pharmacol. 2002; 54(5): 511-7. [33] Schoedel KA, Hoffmann EB, Rao Y, Sellers EM, Tyndale RF: Ethnic variation in CYP2A6 and association of genetically slow nicotine metabolism and smoking in adult Caucasians. Pharmacogenetics 2004; 14(9): 615-26. [34] Proudnikov D, Hamon S, Ott J, Kreek MJ: Association of polymorphisms in the melanocortin receptor type 2 (MC2R, ACTH receptor) gene with heroin addiction. Neurosci. Lett. 2008; 435(3): 234-9. [35] Dagher A, Tannenbaum B, Hayashi T, Pruessner JC, McBride D: An acute psychosocial stress enhances the neural response to smoking cues. Brain Res. 2009; 1293: 40-8. [36] Anderson KG, Ramo DE, Brown SA: Life stress, coping and comorbid youth: an examination of the stress-vulnerability model for substance relapse. J. Psychoactive Drugs 2006; 38(3): 255-62. [37] Brown SA, Vik PW, Patterson TL, Grant I, Schuckit MA: Stress, vulnerability and adult alcohol relapse. J. Stud. Alcohol. 1995; 56(5): 538-45. [38] Miller DB, O'Callaghan JP: Neuroendocrine aspects of the response to stress. Metabolism 2002; 51(6 Suppl 1): 5-10. [39] Wurtman RJ: Stress and the adrenocortical control of epinephrine synthesis. Metabolism 2002; 51(6 Suppl 1): 11-4. [40] Johnson TP: Alcohol and drug use among displaced persons: an overview. Subst. Use Misuse 1996; 31(13): 1853-89. [41] Johnson TP, VanGeest JB, Cho YI: Migration and substance use: evidence from the U.S. National Health Interview Survey. Subst. Use Misuse 2002; 37(8-10): 941-72. [42] Torres Stone RA, Meyler D: Identifying potential risk and protective factors among non-metropolitan Latino youth: cultural implications for substance use research. Journal of Immigrant and Minority Health 2007; 9(2): 95-107.

262


[43] Zamboanga BL, Schwartz SJ, Jarvis LH, Van Tyne K: Acculturation and substance use among Hispanic early adolescents: investigating the mediating roles of acculturative stress and self-esteem. J. Prim. Prev. 2009; 30(3-4): 315-33. [44] Kaplan MS, Marks G: Adverse effects of acculturation: psychological distress among Mexican American young adults. Soc. Sci. Med. 1990; 31(12): 1313-9. [45] Lara M, Gamboa C, Kahramanian MI, Morales LS, Bautista DE: Acculturation and Latino health in the United States: a review of the literature and its sociopolitical context. Annu. Rev. Public Health 2005; 26: 367-97. [46] Al-Issa I: Ethnicity, immigration, and psychopathology. In: Al-Issa I, Tousignant M, eds. Ethnicity, immigration, and psychopathology. New York: Plenum Press, 1997; 315. [47] Fosados R, McClain A, Ritt-Olson A, Sussman S, Soto D, Baezconde-Garbanati L, Unger JB: The influence of acculturation on drug and alcohol use in a sample of adolescents. Addict. Behav. 2007; 32(12): 2990-3004. [48] Ortega AN, Rosenheck R, Alegria M, Desai RA: Acculturation and the lifetime risk of psychiatric and substance use disorders among Hispanics. J. Nerv. Ment. Dis. 2000; 188(11): 728-35. [49] Gordon MM: Assimilation in American life. New York: Oxford University Press, 1964. [50] Gordon MM: Human race, class, and ethnicity. New York: Oxford University Press, 1978. [51] Park RE: Human migration and the marginal man. American Journal of Sociology 1928; 5: 881-893. [52] Borrie WD: The cultural integration of immigrants. Paris, France: UNESCO, 1959. [53] Berry JW, Poortinga YH, Segall MH, Dasen PR: Cross-cultural psychology: Research and application. New York: Cambridge University Press, 1992. [54] Berry JW: Acculturation as varieties of adaptation. In: Padilla A, ed. Acculturation: Theory, models, and some new findings Boulder, Colorado: Westview Press, 1980; 926. [55] Berry JW, Annis RC: Acculturative stress. Journal of Cross-cultural Psychology 1974; 5: 382-406. [56] Berry JW, Kim U, Power S, Young M, Bujaki M: Acculturation attitudes in plural societies. Applied Psychology: An International Review 1989; 38: 185-206. [57] Cavalli-Sforza L, Feldman MW: Cultural transmission and evolution: A quantitative approach. Princeton, NJ: Princeton University Press, 1981. [58] Sapiro ME: Culture and human nature. Chicago, IL: The University of Chicago Press, 1987. [59] Tonin SL, Burrow-Sanchez JJ, Harrison RS, Kircher JC: The influence of attitudes, acculturation, and gender on substance use for Mexican American middle school students. Addict. Behav. 2008; 33(7): 949-54. [60] Willgerodt MA, Thompson EA: Ethnic and generational influences on emotional distress and risk behaviors among Chinese and Filipino American adolescents. Research in Nursing and Health 2006; 29(4): 311-324. [61] Borges G, Medina-Mora ME, Lown A, Ye Y, Robertson MJ, Cherpitel C, Greenfield T: Alcohol use disorders in national samples of Mexicans and Mexican-Americans: The Mexican National Addiction Suvey and the U.S. National Alcohol Survey. Hispanic Journal of Behavioral Sciences 2006; 28(3): 425-449.


263

[62] Alegria M, Canino G, Stinson FS, Grant BF: Nativity and DSM-IV psychiatric disorders among Puerto Ricans, Cuban Americans, and non-Latino Whites in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J. Clin. Psychiatry 2006; 67(1): 56-65. [63] Alegria M, Shrout PE, Woo M, Guarnaccia P, Sribney W, Vila D, Polo A, Cao Z, Mulvaney-Day N, Torres M, Canino G: Understanding differences in past year psychiatric disorders for Latinos living in the US. Soc. Sci. Med. 2007; 65(2): 214-30. [64] Algeria M, Canino G, Shrout PE, Woo M, Duan N, Vila D, Torres M, Chen CN, Meng XL: Prevalence of mental illness in immigrant and non-immigrant U.S. Latino groups. American Journal of Psychiatry 2008; 165(3): 359-369. [65] Blake SM, Ledsky R, Goodenow C, O'Donnell L: Recency of immigration, substance use, and sexual behavior among Massachusetts adolescents. Am. J. Public Health 2001; 91(5): 794-8. [66] Borges G, Medina-Mora M, Orozco R, Fleiz C, Cherpitel C, Breslau J: The Mexican migration to the United States and substance use in northern Mexico. Addiction 2009; 104(4): 603-611. [67] Frank R, Cerda M, Rendon M: Barrios and burbs: residential context and health-risk behaviors among Angeleno adolescents. J. Health Soc. Behav. 2007; 48(3): 283-300. [68] Gfroerer JC, Tan LL: Substance use among foreign-born youths in the United States: does the length of residence matter? Am. J. Public Health 2003; 93(11): 1892-1895. [69] Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Anderson K: Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic whites in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen. Psychiatry 2004; 61(12): 122633. [70] Khoury EL, Warheit GJ, Zimmerman RS, Vega WA, Gil AG: Gender and ethnic differences in the prevalence of alcohol, cigarette, and illicit drug use over time in a cohort of young Hispanic adolescents in south Florida. Women Health 1996; 24(1): 2140. [71] Ojeda VD, Patterson TL, Strathdee SA: The influence of perceived risk to health and immigration-related characteristics on substance use among Latino and other immigrants. Am. J. Public Health 2008; 98(5): 862-8. [72] Saint-Jean G, Martinez CA, Crandall LA: Psychosocial mediators of the impact of acculturation on adolescent substance abuse. J. Immigr. Minor. Health 2008; 10(2): 187-95. [73] Vega WA, Sribney WM, Achara-Abrahams I: Co-occurring alcohol, drug, and other psychiatric disorders among Mexican-origin people in the United States. Am. J. Public Health 2003; 93(7): 1057-64. [74] Vega WA, Gil AG: Revisiting drug progression: long-range effects of early tobacco use. Addiction 2005; 100(9): 1358-1369. [75] Vega WA, Chen KW, Williams J: Smoking, drugs, and other behavioral health problems among multiethnic adolescents in the NHSDA. Addict. Behav. 2007; 32(9): 1949-56. [76] Vega WA, Canino G, Cao Z, Alegria M: Prevalence and correlates of dual diagnoses in U.S. Latinos. Drug Alcohol. Depend 2009; 100(1-2): 32-8.

264


[77] Warren JR, Wagstaff DA, Hecht ML, Elek E: The effects of Mexican origin family structure on parental monitoring and pre-adolescent substance use expectancies and substance use. Journal of Substance Use 2008; 13(4): 283-292. [78] Burnam MA, Hough RL, Karno M, Escobar JI, Telles CA: Acculturation and lifetime prevalence of psychiatric disorders among Mexican Americans in Los Angeles. J. Health Soc. Behav. 1987; 28(1): 89-102. [79] Amaro H, Whitaker R, Coffman G, Heeren T: Acculturation and marijuana and cocaine use: findings from HHANES 1982-84. Am. J. Public Health 1990; 80 Suppl: 54-60. [80] Chae DH, Takeuchi DT, Barbeau EM, Bennett GG, Lindsey JC, Stoddard AM, Krieger N: Alcohol disorders among Asian Americans: associations with unfair treatment, racial/ethnic discrimination, and ethnic identification (the national Latino and Asian Americans study, 2002-2003). J. Epidemiol. Community Health 2008; 62(11): 973-9. [81] Finch BK, Catalano RC, Novaco RW, Vega WA: Employment frustration and alcohol abuse/dependence among labor migrants in California. J. Immigr. Health 2003; 5(4): 181-6. [82] Harrison PA, Sidebottom AC: Alcohol and drug use before and during pregnancy: an examination of use patterns and predictors of cessation. Matern. Child Health J 2009; 13(3): 386-94. [83] Spence RT, Wallisch LS: Alcohol and drug use in rural colonias and adjacent urban areas of the Texas border. J. Rural Health 2007; 23 Suppl: 55-60. [84] Brindis C, Wolfe AL, McCarter V, Ball S, Starbuck-Morales S: The associations between immigrant status and risk-behavior patterns in Latino adolescents. J. Adolesc. Health 1995; 17(2): 99-105. [85] Caetano R, Ramisetty-Mikler S, Wallisch LS, McGrath C, Spence RT: Acculturation, drinking, and alcohol abuse and dependence among Hispanics in the Texas-Mexico border. Alcohol Clin. Exp. Res. 2008; 32(2): 314-21. [86] Turner RJ, Lloyd DA, Taylor J: Stress burden, drug dependence and the nativity paradox among US Hispanics. Drug and Alcohol Dependence 2006; 83(1): 79-89. [87] Breslau J, Aguilar-Gaxiola S, Borges G, Kendler KS, Su M, Kessler RC: Risk for psychiatric disorder among immigrants and their US-born descendants: evidence from the National Comorbidity Survey Replication. J. Nerv. Ment. Dis. 2007; 195(3): 18995. [88] Dierker LC, Canino G, Merikangas KR: Association between parental and individual psychiatric/substance use disorders and smoking stages among Puerto Rican adolescents. Drug and Alcohol Dependence 2006; 84(2): 144-153. [89] Brady KT, Randall CL: Gender differences in substance use disorders. Psychiatric Clinics of North America 1999; 22(2): 241-252. [90] Kauffman SE, Silver P, Poulin J: Gender differences in attitudes toward alcohol, tobacco, and other drugs. Soc. Work 1997; 42(3): 231-41. [91] Vega WA, Alderete E, Kolody B, Aguilar-Gaxiola S: Illicit drug use among Mexicans and Mexican Americans in California: the effects of gender and acculturation. Addiction 1998; 93(12): 1839-50. [92] Choi S, Rankin S, Stewart A, Oka R: Effects of acculturation on smoking behavior in Asian Americans: a meta-analysis. J. Cardiovasc. Nurs. 2008; 23(1): 67-73. [93] Greenfield SF, Manwani SG, Nargiso JE: Epidemiology of substance use disorders in women. Obstet Gynecol. Clin. North Am. 2003; 30(3): 413-46.


265

[94] Burke AW: Attempted suicide among Commonwealth immigrants in Birmingham. Int. J. Soc. Psychiatry 1978; 24(1): 7-11. [95] Kolves K, Sisask M, Anion L, Samm A, Varnik A: Factors predicting suicide among Russians in Estonia in comparison with Estonians: case-control study. 2006(6): 869-77. [96] Ott JJ, Winkler V, Kyobutungi C, Laki J, Becher H: Effects of residential changes and time patterns on external-cause mortality in migrants: results of a German cohort study. Scand. J. Public Health 2008; 36(5): 524-31. [97] Eshun S: Acculturation and suicide attitudes: a study of perceptions about suicide among a sample of Ghanaian immigrants in the United States. Psychol. Rep. 2006; 99(1): 295-304. [98] Borges G, Breslau J, Su M, Miller M, Medina-Mora ME, Aguilar-Gaxiola S: Immigration and suicidal behavior among Mexicans and Mexican Americans. Am. J. Public Health 2009; 99(4): 728-33. [99] Chung I: Changes in the sociocultural reality of Chinese immigrants: Challenges and opportunities in help-seeking behavior. Int. J. Soc. Psychiatry 2009. [100] Hovey JD: Acculturative stress, depression, and suicidal ideation in Mexican immigrants. Cultur. Divers Ethnic Minor Psychol. 2000; 6(2): 134-51. [101] Hovey JD: Acculturative stress, depression, and suicidal ideation among Central American immigrants. Suicide Life Threat Behav. 2000; 30(2): 125-39. [102] Kim SS, Ziedonis D, Chen KW: Tobacco use and dependence in Asian Americans: a review of the literature. Nicotine Tob. Res. 2007; 9(2): 169-84. [103] Hunt LM, Schneider S, Comer B: Should "acculturation" be a variable in health research? A critical review of research on US Hispanics. Soc. Sci. Med. 2004; 59(5): 973-86. [104] Olmedo EL: Acculturation: A psychometric perspective. American Psychologist 1979; 34: 1061-1070.



Chapter 17

ALCOHOL DRINKING AND TREATMENT AMONG IMMIGRANTS FROM THE FORMER SOVIET UNION (FSU) IN ISRAEL: REVIEW OF RECENT PUBLICATIONS JANUARY 2007-JUNE 2009 Shoshana Weiss Alcohol Research Unit, Nahariya, Israel

ABSTRACT This chapter attempts to cover the current state of alcohol use among immigrants from the Former Soviet Union (FSU) in Israel, as a continuation of a previous publication which reviewed studies published in the professional literature (mainly in Hebrew) and referred to an earlier period from the beginning of the 1990s until 2006. This chapter reviews studies published (also mainly in Hebrew) from January 2007 through June 2009 and describes alcohol use patterns and treatment among FSU immigrants. As in the previous review, the present review confirms the findings that alcohol use among FSU immigrants continues to be more prevalent than among the general Jewish-Israel society and that FSU immigrants continue to be over-represented in treatment programs. Recommendations for future research activities include the need for a special research focus on specific groups of FSU immigrants not covered in current Israeli research.

INTRODUCTION Israel is a country of immigrants. It was founded in 1948 as a Jewish state with about 650,000 Jewish citizens (35% Israeli-born). The Israeli Law of Return, passed by the Knesset (Israel parliament) in 1950, enables any person who has at least one Jewish grandparent to be eligible for automatic citizenship. In April 2009 the number of Jewish citizens in Israel was 5,593,000, and additional 320,000 were non-Arab non-Jewish citizens from the Former

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Soviet Union (FSU) that are not ―halachically‖ Jewish (according to Jewish religious law) and not registered as Jews [1]. Since the end of communism and the dissolution of the USSR, about one million Soviet Jews and halachically non-Jewish members of Jewish households from the European and Asian republics of the FSU took advantage of liberalized emigration policies, and immigrated to Israel. The wave of immigration from this region began in 1989 [2, 3], as seen in Table 1. The total number of FSU immigrants who came to Israel in the immigration wave since 1989 is 991,347 and non-Jewish immigrants make up about 30% of this total. As the number of citizens in Israel was about 7,400,000 (including Arab / Druze residents) in 2008, the FSU immigrants who arrived since 1989 constituted about 14% of the total Israeli population. Most of these immigrants arrived from the European republics of the FSU, mainly Russia and the Ukraine. This wave also brought groups from Bukhara and the Caucasus. This large number of newcomers for such a small country like Israel would be equivalent to about 40 million immigrants which the USA would have absorbed. It is worth noting that FSU immigration occurred at the same time as a smaller wave of Ethiopian immigrants who exhibited totally different socio-cultural profile and needs, and constitute only 1.4% of the entire population [4]. Immigration has been described as an earthquake that causes major disruptions in a person's life, and an uprooting that may lead to huge problems. Immigration is an experience that involves many losses and changes: loss of employment, social status, relationships, financial security, familiar physical environment, familiar language and more. Many books, articles and newspaper reports have been published about the characteristics of the FSU immigration to Israel and the life of the newcomers in the absorbing society [e.g. 5-11]. Table 1. Immigration to Israel from the FSU Year 1948-70 1971-88 1989 1990 1991 1992 1993 1994 1995 1996 1997

Number of FSU immigrants 20,872 164,579 12,932 185,277 147,839 65,093 66,145 68,079 64,848 59,048 54,621

Year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Number of FSU immigrants 46,032 66,848 50,817 33,601 18,508 12,383 10,130 9,431 7,469 6,643 5,603

Sources: Data are taken from references 2, 3.

Overall, the immigration from the FSU is rich in human resources, although a relatively large portion of immigrants are employed in blue-collar jobs, particularly those with higher education, because the small Israeli labor market became oversaturated with a large number of professionals. These immigrants share a rich cultural heritage expressed in the importance of their children learning Russian language and literature, and as well as maintaining exclusive social relations among the immigrants. However, poverty and low socio-economic

Alcohol Drinking and Treatment among Immigrants from the Former Soviet Union… 269 status, life in densely populated apartments (three generations together), violence and delinquency among young immigrants and high rates of school dropouts are all evident. The immigrants from the FSU differ from the Israeli-born population in having smaller family sizes, more single-parent families, and especially in a heavy alcohol drinking culture. FSU immigrants left a country with well-known very high rates of alcohol consumption and alcohol-related health and social problems [e.g. 12-17]. Immigrants to Israel arrived at a country with a lower alcohol consumption rate. The claim that "Jews do not drink" was widespread in the FSU. However, alcohol use can be affected by the "immigration experience": the separation from familiar social networks, changing of environmental conditions, concerns about family members left behind, language barriers, loss of valued social and occupational roles, lack of sufficient economic resources, cultural dissonance, difficulties in adjustment to the Israeli reality and bureaucracy, and the need to cope with stresses. In the case of FSU immigrants, studies conducted from the beginning of 1990s until 2006 [18], showed that they did not adopt the drinking customs of the host country (Israel) and their patterns of alcohol use did not reflect those of their new location. Given the magnitude of the changes in the immigrants‘ lives one could expect immigrants from the FSU to have increases in social, health and psychological problems that contribute to alcohol abuse and related alcohol problems [18, 19]. The previous review published in 2008 [18] summarized studies (mainly in Hebrew) by Israeli researchers as well as reports and theses from the early 1990s through 2006. It provided information in English about alcohol drinking patterns and problems in the FSU immigrant community in Israel. The review noted that alcohol drinking among FSU immigrants was more prevalent than among the general Jewish-Israeli society. FSU immigrants also were over-represented as patients in alcoholism treatment. This current chapter attempts to review studies and reports published in Hebrew and English from January 2007 through June 2009 in Israel or by Israeli researchers. This review continues to provide data that updates the current state of alcohol use and treatment among the FSU immigrants in Israel. Books and journals in academic and institutional libraries, treatment centers reports and the Knesset's Information Center protocols and reports were reviewed. Information available on the Internet was also reviewed in order to check whether there are any significant differences in the current period (January 2007-June 2009) compared to the earlier period of the 1990s to 2006. The assumption has been that earlier trends identified up until 2006 [e.g.20] continue, with higher rates of alcohol consumption among FSU immigrants as compared to Israeli adolescents and adults.

EPIDEMIOLOGICAL ASPECTS Eight epidemiological studies in 12 publications published in 2007-June 2009 dealing with alcohol consumption were identified, most written in Hebrew. It should be noted that in all Israeli studies, respondents were instructed to disregard ceremonial use of alcoholic beverages. Table 2 illustrates these studies among immigrants from the FSU. Five publications published in this period referred to studies carried out in previous years and their results are in accordance with the findings and trends identified in the previous

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review: FSU immigrants have higher rates of alcohol use and related problems in comparison to native-Israelis [18]. One study [21] conducted in 2003 and published in 2007 reviewed 12 to-18-year old (245 Israeli-born and 120 FSU-born) at-risk (detached) youth in alternative education and training programs, street "drop-in" centers and organized evening street activities in the southern region and northern Haifa. It noted that FSU youth reported a significantly higher level of liquor use in the previous month, as well as binge drinking in the last month (Table 3). ―Detached youth‖ is defined as a population of adolescents with varying degrees of social detachment, including those who neither work nor study, those who work and study in special educational settings or those who are formally listed as students, but rarely attend school. Table 2. Domain, year of publication, reference and language of publication of the reviewed studies among FSU immigrants published in 2007-June 2009 Domain

Year of publication

Reference

Local study in the southern region and northern Haifa among at-risk youth National epidemiology study for the Ministry of Health among adults Local study in the city of Haifa among youth in relation to terrorism Local study in the city of Beer-Sheba among youth

2007

21

Language of publication English

2007

22

English

2008

23

Hebrew

2007 2009

24 25

Hebrew English

Local study in the city of Beer-Sheba among older people Local study in the city of Reshon Lezion among youth National epidemiology study for the Anti-Drug Authority (IADA) among youth and detached youth National epidemiology study for IADA among youth in relation to negative life events

2009

26

English

2007

27

Hebrew

2007 2008 2008 2008

28 29 30 32

Hebrew Hebrew Hebrew Hebrew

Table 3. Percentage of alcohol use and binge drinking in previous 30 days among at-risk Israeli-born youth and FSU-born youth Alcohol used at least once Beer Wine Hard Liquor Binge drinking at least once *p=

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