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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2006.087197
DISENTANGLING MENTAL HEALTH DISPARITIES |
Margarita Alegría, Norah Mulvaney-Day, Maria Torres, Shan Gao, and Vanessa Oddo are with the Center for Multicultural Mental Health Research, Cambridge Health Alliance, Harvard Medical School, Somerville, Mass. Meghan Woo is with the School of Public Health, Harvard University, Boston, Mass.
Correspondence: Requests for reprints should be sent to Margarita Alegría, PhD, Cambridge Health Alliance, Center for Multicultural Mental Health Research, 120 Beacon St, 4th Floor, Somerville, MA 02143 (e-mail: malegria{at}charesearch.org).
ABSTRACT
Objectives. We examined correlates and rates of past-year mental health service use in a national sample of Latinos residing in the United States.
Methods. We used data from the National Latino and Asian American Study, a national epidemiological household survey of Latinos.
Results. Cultural factors such as nativity, language, age at migration, years of residence in the United States, and generational status were associated with whether or not Latinos had used mental health services. However, when the analysis was stratified according to past-year psychiatric diagnoses, these associations held only among those who did not fulfill criteria for any of the psychiatric disorders assessed. Rates of mental health service use among those who did not fulfill diagnostic criteria were higher among Puerto Ricans and US-born Latinos than among non–Puerto Ricans and foreign-born Latinos.
Conclusions. Rates of mental health service use among Latinos appear to have increased substantially over the past decade relative to rates reported in the 1990s. Cultural and immigration characteristics should be considered in matching mental health services to Latinos who need preventive services or who are symptomatic but do not fulfill psychiatric disorder criteria.
Underuse of mental health services among Latinos residing in the United States is a concern in both research and practice.1–6 Studies conducted in the 1990s showed that fewer than 1 in 11 Latinos with a mental disorder sought specialty mental health services and that fewer than 1 in 5 obtained general services for mental health problems.7 Rates were even lower among Latino immigrants.4
Compounding the problem for Latinos is the limited availability of bilingual clinicians,8 possibly resulting in less accurate diagnoses and mismatches between treatment needs and resources.9 Studies indicate that US residents limited in English-language proficiency are less likely to seek and receive needed mental health services.10,11 Therefore, linking mental health service use and satisfaction with services to immigration characteristics and ethnicity is critical in planning service delivery.
Some of the estimates of Latinos’ mental health service use come from large national surveys12–15 that have not considered the heterogeneity of this population or from regional studies4,16 that have focused on a single Latino subgroup. Other national studies assessing mental health service delivery have provided disaggregated rates among different Latino subgroups17,18 using symptom measures rather than structured diagnostic batteries to determine need.
Although factors such as differences in ethnic group memberships,16,17,19 English language proficiency,10 and immigration status4 have been suggested as correlates of Latino mental health service use, they are typically not evaluated in most national studies. Most research has described Latinos in a "general population" context without addressing differences in service delivery within specific subpopulations. Yet, seminal studies of mental health service use among Mexican Americans4 and Cuban refugees in South Florida16 show the importance of immigration characteristics on service use.
In this study, we used data from the National Latino and Asian American Study (NLAAS), provided by the Center for Multi-cultural Mental Health Research at the Cambridge Health Alliance, to examine patterns and correlates of past-year mental health service use among Latinos residing in the United States, along with their perceptions of whether the care they received was helpful and their level of satisfaction with the care received. To our knowledge, this investigation is one of the few to date to examine ethnic group, immigration status, generational status, and English-language proficiency as correlates of service use and satisfaction with services in a national sample of Latinos.
METHODS
Participants and Sample Design
As described in detail elsewhere,20,21 the NLAAS, conducted from May 2002 through December 2003, was a nationally representative survey of Latino and Asian Americans residing in the United States. Participants were individuals aged 18 years or older who were of Latino or Asian descent and whose primary language was English, Spanish, or 1 of 3 Asian languages. The analyses conducted for this study focused on the NLAAS Latino sample (n=2554), which consisted of 4 ethnic subgroups determined according to respondents’ self-reported ethnicity (via the same ethnicity question used in the 2000 census22): Cuban (n=577), Puerto Rican (n=495), Mexican (n=868), and "other" (n=614).
The NLAAS weighted sample was similar to the 2000 census population but included more US immigrants and more individuals with low incomes. Possible reasons for these discrepancies have been discussed elsewhere20 (see Heeringa21 and Alegría et al.20 for detailed descriptions of the sample design and weighting methods). The final weighted response rate for the Latino sample was 75.5%.
All study materials were translated into Spanish via a standard translation and back-translation protocol. Half of the participants had limited English proficiency and requested the interview in Spanish. The study procedures were explained in the respondents’ preferred language, and written informed consent was obtained in the respondents’ preferred language (see Pennell et al.23 for a detailed description of the data collection procedures of the NLAAS).
Measures
In the development of the instruments used in the NLAAS, existing measures were adapted and new culturally relevant measures were created.24 Sociodemographic measures assessed included age, gender, and insurance coverage (private, public, no coverage, other). Immigration and cultural characteristics included Latino ethnicity (Cuban, Puerto Rican, Mexican, or other Latino descent), nativity status (US-born or foreign-born), years of residence in the United States (0–5, 6–10, 11–20, 21 or more, US-born), English-language proficiency (self-rating of ability to speak, read, and write English25), age at time of immigration (12 years or less, 13–17 years, 18–34 years, 35 years or older, US-born), and generational status (not born on US mainland [first generation], US-born with at least 1 parent foreign-born [second generation], respondent and both parents born on US mainland [third generation or later]).
The categories for age at time of immigration were selected to represent life cycle differences across infancy and childhood (aged 0–12 years), adolescence (aged 13–17 years), early adulthood (aged 18–34 years), and later adulthood (aged 35 years or older). With respect to the years of residence variable, the "5 years or less" category was important because some health programs require that immigrants reside in the United States for more than 5 years before becoming eligible for coverage. In the case of both age at migration and length of residence, categories were selected to ensure a sufficient number of cases across all ethnic subgroups.
Psychiatric disorder prevalence rates were evaluated with the diagnostic interview of the World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (CIDI),26 a fully structured diagnostic instrument administered by trained lay interviewers and based on criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.27 The diagnoses in earlier versions of the English and Spanish CIDI diagnostic assessments were consistent with the diagnoses made independently by trained clinical interviewers.28,29 Here we report past-year prevalence rates for 11 disorders: dysthymia, major depressive disorder, agoraphobia, social phobia, generalized anxiety disorder, posttraumatic stress disorder, panic disorder, drug abuse, drug dependence, alcohol abuse, and alcohol dependence.
Service Use
All NLAAS respondents were asked a battery of questions to ascertain the types of mental health services they used in the preceding 12 months. Three composite categories were used to represent the service sectors included. The specialty mental health sector included psychiatrists, psychologists, counselors, and social workers seen in mental health settings; other mental health professionals; and mental health hotlines. The general medical sector consisted of general practitioners, family doctors, nurses, occupational therapists, and other health professionals seen for mental health problems. The "any service" sector included all specialty and general medical services, religious or spiritual advisors, counselors or social workers in non–mental health settings, and herbalists, chiropractors, spiritualists, self-help groups, and Internet support groups. Past-year service use was defined as at least 1 visit to a service provider within the preceding 12 months.
Satisfaction
Two satisfaction variables were created: level of satisfaction with services received (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied) and helpfulness of services received (whether the service provider helped a lot, some, a little, or not at all). Respondents were considered satisfied if they responded that they were "very satisfied" or "satisfied" with their provider and were considered to have received helpful services if the provider helped them "a lot." Our choice of these categories was driven by concerns about social desirability, which can deter respondents from reporting that they are not satisfied with the care they received. Therefore, neutral reports of satisfaction or reports that treatment helped "some" were not included within the satisfied or helpful categories.
A respondent could report use of multiple types of mental health services within each broad service category (specialty, general medical, or any service). To rate satisfaction with services in these cases, we identified the service in each broad category to which the respondent made the greatest number of visits during the 12-month period. The satisfaction variables for this service were then used as the indicator of level of satisfaction and helpfulness for the entire service category.
Statistical Analyses
Data were weighted to adjust for differential probabilities of selection and nonresponse. We calculated weighted rates of past-year service use according to ethnic subgroup, nativity, language, immigration characteristics, and insurance status. In a supplementary analysis, we evaluated whether the associations between service use rates and the variables just mentioned changed after control for age and past-year prevalence of any psychiatric disorder. Then, across these same variables, we assessed subjective satisfaction with and perceived helpfulness of mental health services received according to service sector. We also compared weighted past-year rates of any service use across the same set of correlates, stratifying according to whether individuals had or had not experienced one of the psychiatric disorders assessed in the preceding 12 months.
We conducted significance tests for differences in service use rates across subgroups using design-based F tests. We performed the Wald test in pairwise comparisons as a supplemental analysis. Bonferroni corrections were used whenever multiple pairwise comparisons were made. Stata Survey Analysis procedures were used to account for the complex sampling design.30 (Stata uses a first-order matrix Taylor series expansion to produce variance estimators.3) We applied sampling weights (see Herringa21) in all analyses so that we could generalize results to the US Latino population as a whole.
RESULTS
Table 1
shows that rates of overall mental health service use and specialty service use were significantly higher among Puerto Ricans than among all other Latino subgroups (P < .01 after Bonferroni correction). One in 5 Puerto Ricans (19.9%) reported past-year mental health service use, in contrast to 1 in every 10 Mexicans (10.1%). In comparison with US-born Latinos and those indicating that they spoke primarily English, foreign-born Latinos and those indicating that they spoke primarily Spanish reported less use of services overall and less use of specialty services; however, there were no significant differences in general sector mental health service use. Among respondents born outside the United States, a higher percentage of those who had migrated to the country at age 12 years or younger (13.4%) or 35 years or older (14.5%) than between 18 to 34 years reported use of any mental health service and general medical services (P = .01).
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Differences in past-year service use rates were significant across years of residence in the United States. We found that those who had resided in the United States for less than 5 years had significantly lower service use rates than those who had resided in the country for 21 years or more (P < .03 after Bonferroni correction). Also, those who had resided in the country for 6 to 10 years had significantly lower rates than those who had resided in the country for 21 years or more (P < .03 after Bonferroni correction).
Significant differences in overall mental health service use, use of specialty services, and use of general medical services were observed in comparisons of first-generation and third-generation Latinos (P < .03 after Bonferroni correction). Overall mental health service use rates (P < .05 after Bonferroni correction), specialty service use rates (P < .01 after Bonferroni correction), and general medical service use rates (P < .05 after Bonferroni correction) were all significantly lower among those with no insurance coverage than among those in the other insurance groups.
We conducted supplementary analyses to determine whether age and presence of a past-year mental disorder played a role in the differences in service use rates observed across groups (data not shown). We fit a series of separate logistic regressions for each service sector in which all of the correlates (ethnic subgroup, nativity, language, immigration characteristics, and insurance status) were entered and age and presence of a past-year disorder were controlled. Results did not change significantly from those shown in Table 1
. After control for age and disorder status, the significance levels across ethnic groups, nativity, language, age at migration, years of residence in the United States, and insurance status remained the same as in the pairwise comparisons, except that the differences in use of any services and use of specialty services between first- and second-generation became significant (P<.05; data not shown).
We conducted a design-based F test (using the Rao–Scott Statistic) to evaluate whether there were differences in satisfaction with mental health services received according to ethnic subgroup, nativity, language, immigration characteristics, and insurance status. As shown in Table 2, there were significant differences in ratings of satisfaction with mental health services received across ethnic subgroups (P < .01) and years of residence in the United States (P = .01).
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Mexicans were less likely than those in the "other Latino" group to report satisfaction with mental health services received (P=.01 after Bonferroni correction). Immigrants who had resided in the United States for 5 years or less reported lower levels of satisfaction with mental health services received than those who had resided in the United States for more than 20 years (P=.04 after Bonferroni correction). In none of the service categories were significant differences in satisfaction observed among Latino service users according to nativity, language, age at migration, generational status, or insurance status (Table 2
).
Table 3 shows ratings of perceived service helpfulness among those who had received mental health services in the preceding 12 months. The only significant difference observed involved specialty services, for which perceived helpfulness ratings were distributed differently according to age at migration (Table 3). Pairwise comparisons showed that, relative to those who had arrived in the United States at age 12 years or younger or aged between 13 and 17 years, a higher percentage of those who had arrived in the country at age 35 years or older reported that specialty services helped them "a lot" (P < .05 after Bonferroni correction).
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Because differences in rates of service use may, in fact, be driven by differences in the presence of disorders across groups, we stratified the sample according to presence or absence of past-year psychiatric disorders. As can be seen in Table 4
, no significant differences in service use were observed among those who had experienced a psychiatric disorder in the past 12 months according to ethnic group, nativity, language, or immigration characteristics. The only significant difference involved insurance status (P < .01), with uninsured individuals being less likely to use any type of service than those with either public or private insurance coverage (P < .02 after Bonferroni correction).
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However, among those who had not been diagnosed with a disorder in the past year, service use rates differed significantly according to ethnic group, nativity, language, length of residence in the United States, generational status, and insurance status. After conducting Bonferroni corrections, pairwise test results indicated that service use rates were higher among Puerto Ricans than among members of the other 3 ethnic subgroups (P<.01) and higher among US-born Latinos than among immigrants (P<.01). Among those with no disorder in the past year, lower rates of mental health service use were associated with Spanish language dominance (P<.01), 0 to 5 years (vs 21 years or more) of residence in the United States (P<.01), 6 to 10 years (vs 21 years or more) of residence in the United States (P<.01), first-generation (vs third-generation) status (P=.01), and lack of insurance coverage (vs public insurance coverage; P<.01).
As can be seen in Table 4, among Latinos who had met criteria for a psychiatric disorder in the preceding year, there was no association between the length of time they had resided in the United States or their level of fluency in English and their likelihood of using mental health services. Longer length of residence in the United States and greater English proficiency increased the likelihood that Latinos who had not met the criteria for a psychiatric disorder in the past year would report seeking care.
DISCUSSION
As a result of the diagnostic measures used, the representative samples of Latino subgroups included, and the substantial numbers of Spanish-speaking respondents, the NLAAS provides some of the most comprehensive data available on rates of mental health service use among Latinos. Our results show that cultural factors related to nativity, language, age at migration, years of residence in the United States, and generational status are linked to whether Latinos use mental health services. However, when the analysis was stratified according to past-year psychiatric diagnoses, these associations held only among those who did not fulfill the criteria for any of the psychiatric disorders assessed. Our data emphasize that, to provide a better understanding of differences in service use rates, it is important to account for differences across Latino groups in terms of the presence of psychiatric disorders. Cultural and immigration characteristics play a significant role in service use when mental health care appears to be discretionary.
Among Latinos who may need preventive services or who are symptomatic but have not been diagnosed with a disorder, ethnicity, nativity, language, and immigration characteristics are substantially related to whether or not they receive care. Restricted use of public insurance programs31 may explain the effects of these cultural factors on access to mental health care among undiagnosed Latino immigrants, whose dominant language is typically Spanish. Those with insufficient English proficiency may work in jobs less likely to offer insurance coverage.32,33 Language barriers may also make it more difficult for these individuals to complete insurance applications34 or engage in therapeutic processes such as psychotherapy.
The finding that foreign-born (vs US-born) Latinos and those who spoke primarily Spanish (vs English) reported significantly less use of specialty services but not general medical services for their mental health problems may also reflect lower levels of problem recognition among these groups. Research has shown that patients believe it is appropriate to talk to their general physicians about emotional distress, but sensitivity to the reactions of others appears to be elevated among Latinos seeking specialty care.35
Our findings confirm that, among Latinos either with or without mental illnesses, insurance coverage continues to play a significant role in mental health service use. Only 19.1% of uninsured Latinos used any type of service, even those with a psychiatric disorder; corresponding service use rates were 38.6% among those with private insurance coverage and 51.6% among those with public insurance coverage. This finding confirms that lack of insurance coverage continues to hinder Latinos’ access to mental health services.
Limitations
A number of limitations apply to this study. No information was available to validate self-reported measures of service use. There is evidence that self-reported measures of mental health service use overestimate administrative treatment data,36,37 suggesting that if there was bias in self-reporting, it may have been in the direction of overestimating service use. However, this possible biased recall would apply equally across the Latino subgroups assessed.
Current work with the NLAAS also shows that the format of the service use questions and their location in the assessment battery may have significantly influenced reported rates of service use.38 The vulnerability of surveys to such conditioning effects, whereby latter segments of a survey instrument are influenced by experience gained in earlier segments,39 may lead to undercounting of rates of service use. Analyses of the NLAAS data are continuing to determine what impact these differences may have on overall service use estimates. However, the differences in service use rates across subgroups reported here are stable in that all Latino subgroups were administered the same version of the questionnaire.
Another limitation is that the NLAAS excluded institutionalized as well as homeless populations, so our results can be generalized only to the noninstitutionalized, nonhomeless Latino population. Finally, some severe disorders such as psychotic spectrum disorders were excluded from the NLAAS diagnostic battery, given that previous validation studies involving the CIDI have shown that lay-administered diagnostic instruments substantially overestimate prevalence rates of these disorders.40 As such, different service use rates might be found among Latinos with severe and persistent mental illnesses.
Conclusions
Rates of mental health service use among Latinos have substantially increased over the past 10 years relative to estimates from studies conducted in the 1990s. Our results indicating that 34% of Mexicans and 43% of Puerto Ricans who had met criteria for a diagnosis in the past year had used mental health services are consistent with findings obtained in a recent national sample41 of Puerto Ricans and Mexicans. In that study, 40% to 42% of Latinos classified as in need of care (according to symptom measures42) reported having received any mental health care in the previous 12 months. Our results also parallel rates found in the National Comorbidity Survey Replication sample (41% overall).6
Increases in rates of mental health service use, particularly among Latino immigrants, can be explained in several ways. In the past decade, public awareness of psychiatric disorders has increased, and the need to obtain care for these disorders has been publicized by the media.43–45 As a result, Latinos and other groups targeted by the media and the pharmaceutical industry may be less prone to stigmatize mental illness and more likely to seek help for mental health problems. There is evidence that rates of mental health treatment increased almost 3-fold46 from 1987 to 1997; moreover, during that period the percentage of patients who were prescribed anti-depressants rose from 37.5% to 74.5%, and such increases in prescription frequencies were particularly prevalent among Latino and African American patients.
An alternative explanation is that screening for mental illness has increased among primary care providers,47 augmenting identification of individuals with psychiatric illness for referral into mental health care. Such an increase in service use among Latinos seems unlikely to be caused by only public awareness or screening, however. Potential differences in the samples used in making past estimates as well as differences in definitions of need and service use could be responsible for increases in rates.
Our results are consistent with previous studies indicating that Latinos who have resided in the United States for 5 years or less are less likely than those who have resided in the country for longer periods to report being very satisfied with the mental health care they receive.18 Research and clinical practices have begun to recognize the importance of considering cultural variables as essential factors in treatment design.48 Research indicates that culture shapes treatment expectations and experiences. Reduced satisfaction with mental health care among those who have resided in the United States for short periods of time may reflect difficulties in merging clinical practice with patterns of engagement that are effective with recent immigrants.
Traditional psychotherapy values open verbal communication and tends to place individual goals before the collective.49 This practice may conflict with the traditional values of Latinos, who place individual goals below the goals of the collective and tend to perceive the disclosure of personal problems as bringing shame to family members. Therapists unaware of these values may not satisfy or be helpful to Latino immigrant patients50 who have a limited understanding of the American health system.51 Early orientation about what to anticipate from mental health treatment will empower recent immigrants to express their expectations and may promote a better match between patient and treatment.
Acknowledgments
The project was supported by the National Institutes of Health (grant U01 MH62209) and the National Center on Minority Health and Health Disparities (grant P20 MD000537).
We would like to thank William Sribney for his statistical assistance in the development of this article.
Note. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Center on Minority Health and Health Disparities.
Human Participant Protection
The institutional review boards of the Cambridge Health Alliance, the University of Washington, and the University of Michigan approved all recruitment, consent, and interviewing procedures for the National Latino and Asian American Study.
Footnotes
Contributors
M. Alegría originated the study and led the conceptualization, design, and all aspects of writing the article. N. Mulvaney-Day, M. Woo, and M. Torres assisted with drafting the article. M. Alegría, N. Mulvaney-Day, M. Woo, M. Torres, and S. Gao contributed to analysis and interpretation of the data. Statistical expertise was provided by S. Gao. All of the authors reviewed drafts and contributed to critical revisions of the article.
Accepted for publication May 12, 2006.
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