It s Like Going through an Earthquake : Anthropological Perspectives on Depression among Latino Immigrants

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1 J Immigrant Minority Health (2007) 9:17 28 DOI /s ORIGINAL PAPER It s Like Going through an Earthquake : Anthropological Perspectives on Depression among Latino Immigrants Igda E. Martínez Pincay Peter J. Guarnaccia Published online: 28 September 2006 C Science+Business Media, LLC 2006 Abstract Depression is one of the most prevalent mental illnesses in the community and is responsible for a significant amount of disability. According to epidemiological and primary care studies, Latinos suffer from depression at high rates. This paper examines in depth Latinos conceptions of depression and their attitudes towards and expectations of mental health treatment. The aim of this paper is to summarize several qualitative studies examining Latinos cultural understandings of mental health in general and depression in particular, as well as to obtain information about the barriers to care that this community experienced. The results are a compilation of findings from four different research projects in New Jersey and New York that examined diverse Latinos conceptions of mental health, treatment and barriers to care. Keywords Depression. Latinos. Immigration. Barriers to care. Attitudes towards treatment Es como perder su techo, perder todo, es como cuando uno ha pasado por un terremoto y perdió todo... es como una acumulación de pérdidas. [It s like losing the roof over your head, losing everything, it s as if one had gone through an earthquake and lost everything... it s an accumulation of losses.] I. E. Martínez Pincay ( ) Graduate School of Applied and Professional Psychology, Rutgers University, 152 Frelinghuysen Road, Piscataway, NJ , USA igda P. J. Guarnaccia Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA Introduction Depression is one of the most prevalent mental illnesses in the community and is responsible for a significant amount of disability. The quote above describes how one Latino immigrant who participated in our focus groups described the immigration process. At the same time, the quote can be read as a graphic description of how devastating and disabling depression can be and links the losses of immigration to the depression experience. According to epidemiological and primary care studies, Latinos suffer from depression at high rates [1 4]. However, recent studies have demonstrated the importance of distinguishing between Latino immigrants and those Latinos born in the U.S. While immigrant Latinos experience lower rates of depression than their U.S.-born compatriots and than non-hispanic Whites, they are also less likely to seek mental health services when they are depressed [5]. We chose to study depression not only due to its prevalence in the community, but also because there are clear, well-developed treatment guidelines for both therapeutic and medication interventions for depression. Yet studies consistently show that Latinos have very low rates of use of mental health services [6 13]. Immigrants are even less likely to use mental health services than U.S. born Latinos. When Latinos do seek help for mental health problems, they are more likely to do so in the general medical sector than in specialty mental health services. There are a wide range of barriers to seeking mental health care that have been identified in the Latino mental health literature [7, 9, 10, 12, 13]. These barriers can be organized into several dimensions: barriers in the service system, community-level barriers, barriers in the social networks of people in the community, and person-centered barriers. The most important system level barriers include

2 18 J Immigrant Minority Health (2007) 9:17 28 lack of health insurance, language barriers, immigration status, discrimination from the system and lack of information about services (especially in Spanish). Community centered barriers include the stigma of mental illness and the density of family and other support networks. Personcentered barriers include lack of recognition of mental health problems, stigma of mental illness, and a self-reliant attitude. Few studies have gone beyond identifying and confirming in correlational analyses this same set of barriers. They have not delineated the dimensions of these barriers nor have they looked at how Latinos in the community assess these barriers. Cooper and colleagues [14] report on one of the most comprehensive analyses of multi-ethnic patients perceptions of the acceptability of treatment for depression. Using data from three NIMH quality improvement interventions to improve the quality of depression care, they compared the attitudes of African-Americans, Hispanics and Whites towards depression treatment. Their sample consisted of 829 patients, of whom 73 were Hispanic. The investigators used a highly structured interview to assess attitudes towards depression care. They found that Hispanics, like African Americans, expressed lower acceptance of anti-depressant medication than Whites and more acceptance than Blacks of counseling services. They also found that Hispanics and African Americans were more likely to see medications as addictive and less likely to see them as effective compared to Whites. While Cooper and colleagues [14] argue that there is a need to understand attitudes and social norms towards treatment in more depth than can be captured using categorical responses on a structured questionnaire, their study relies on just such responses. Even so, their research represents one of the few studies to compare African American, Hispanic and White attitudes towards treatment in the same study using the same methods. Also, while their study is comparative, it only includes 73 undifferentiated Hispanics (across three different interventions) representing less than 10% of the total sample. The study was also limited because all of the Hispanics spoke English and were insured, limiting the diversity of the Hispanic sample and likely excluding most recent immigrants. This paper, along with the companion paper by Cabassa and colleagues [15], examines in more depth Latinos conceptions of depression and their attitudes towards and expectations of mental health treatment. The combined papers provide a fuller comparison among Latinos from diverse parts of the United States. The papers provide richer understandings of the concerns Latinos express about mental health treatment; insights that can inform both future research and clinical treatment. The aim of this paper is to summarize several qualitative studies examining Latinos cultural understandings of mental health in general and depression in particular, as well as to obtain information about the barriers to care that this community experienced. The results presented in this paper are a compilation of findings from four different research projects in New Jersey and New York that were carried out to examine diverse Latinos conceptions of mental health, treatment and barriers to care. Methods We chose focus groups as the method of data gathering because it is an excellent qualitative methodology for exploring group ideas about an issue and eliciting the perspectives of people in the community [16]. We were bolstered in our approach by a paper on the needs of people with psychotic disorders that took a similar perspective in a cross-national study of psychiatric services users needs for care [17].In order to get beyond the same list of issues and barriers already identified in the Latino mental health literature, we felt that it was important to more fully discuss with a diverse group of Latinos their understandings of depression and their assessments of different treatment alternatives. By conducting multiple focus groups in different sites with diverse Latino populations, we could identify cultural diversity and crosscultural similarities among Latinos. Each study was designed separately and therefore not designed to parallel each other. In this paper we are integrating the findings across the four studies. Focus group participants Focus group participants were recruited from various sites for the multiple studies. All were community samples recruited through a range of community mental health and social service agencies as well as community resources such as churches and day care centers. Overall there were 94 participants in 12 different groups throughout New Jersey and New York City. This is a larger sample than the number of Hispanics in three national quality improvement interventions [14]. The focus groups consisted of a diverse group of Latinos in terms of country of origin, time in U.S., age, and education (please see Table 1). A total of 12 focus groups are included in this paper. Five of the focus groups (40 participants, total) were from Study 1 and were held within New Jersey to assess conceptions of mental health, treatment and barriers to care. These focus groups consisted primarily of females (72%). Two groups were held with Puerto Ricans (37.5%) and Dominicans (7.5%), 2 groups were held with Mexicans (currenly says 1), and one group was held with Cubans (22.5%). The groups were also varied in terms of urban/rural community settings. The participants in these groups ranged in age from 20 to over 60 and had been in the United States anywhere from less than one year to over 20 years. These participants

3 J Immigrant Minority Health (2007) 9: Table 1 Demographics Study 1 (NJ): 5 FG Study 2 (NY): 3 FG Study 3 (NJ): 2 FG Study 4 (NJ): 2 FG N Gender (% female) Age range Over Country of Origin (%) Diverse Latino Groups Diverse Latino Groups Puerto Rico No majority From any One group No majority From any One group Dominican Republic Mexico 32.5 Cuba 22.5 Time in U.S. Range <1 year to over 20 years Minimum average 25 years 1 to 10 years 1 to 28 years came mostly from low income backgrounds and had not used mental health services. Participants received a gift basket for their time. Three focus groups (22 participants) came from Study 2 and were conducted in New York City to assess concepts of mental illness in the elderly Latino population [18]. These focus groups included mostly females (68%). The participants were either Puerto Rican (50%) or Dominican (50%), were over the age of 65 and had lived in the United States for a minimum average of 25 years. Participants were paid $35 for their time. Two focus groups (14 participants) were from Study 3, a study of community concerns regarding health and mental health services. These groups were carried out in a small urban community in central New Jersey. Participants in these groups were community members who agreed to attend the group in a community health clinic. They were mostly females, ranged in age from 24 to 64 and had been in the U.S. between 1 and 10 years. This group was rather diverse and had no majority of participants from any one Latino subgroup. The remaining two focus groups were from Study 4 and included 18 Spanish-speaking adult primary care patients (94% females). Members of the group came from a wide range of Caribbean, Central and South American countries, reflective of the current Latino community as the two focus groups described above. They ranged in age from 28 to 71, with a mean age of 46. These participants had been in the United States between one and 28 years, with an average number of years in the US of approximately 10. Overall, their average age of arrival in the US was 36. Conduct of the focus groups All of the groups were held in Spanish; they were all led by the second author and the majority of the groups were facilitated by the first author. The focus group leader led the discussions while the facilitator took notes and completed the transcripts of the groups. The focus group leader used a focus group agenda with several general questions to guide the focus group discussion. The general tone of the discussions revolved around questions such as: (a) What is mental health? (b) What is depression? (c) What is mental health treatment? (d) What barriers do you face when you try to seek care? (e) What ideas do you have about seeking help? (f) What ideas do you have about mental health providers? Appendix A contains a more detailed list of questions used to guide the focus groups. It is important to emphasize that all questions are never asked in a focus group. The questions in Appendix A were used as a guide for the range of topics to be discussed, but not necessarily asked in the specific form or the same order as they appear in the appendix. The two groups from Study 4 employed a vignette approach to assess participants recognition of depression and their ideas about what kinds of help a person with those problems should receive. The vignette also led participants to assess barriers to seeking treatment. The vignette is included in Appendix B. The vignette was designed so that new information was introduced in stages throughout the focus group and then participants were asked to respond to that new information. This approach was used in these two groups alone because they were a part of a larger study that used the vignette design for a comparative study across Puerto Rico, New Jersey, and Texas. The meetings lasted approximately 90 minutes and were hosted by community agencies that were comfortable, familiar, and easily accessible to the community participants. Audiotape recordings of each focus group meeting were transcribed by the facilitator and reviewed by the focus group leader.

4 20 J Immigrant Minority Health (2007) 9:17 28 Analysis of the focus groups All of the focus groups were transcribed for review and analysis. After debriefing each focus group and comparing general notes, each transcript was read over several times and a basic content analysis was performed by each member of the research team. Each coder created a list of major themes that arose in the groups and these lists were compared in team meetings. Consensus on key themes from the coding was obtained through discussion and elaboration on each coder s conceptualization of the construct being discussed in the focus group. Based on the content analyses and on the specific transcripts, the principal investigators identified key themes that emerged from the focus groups. Finally, quotations from the transcripts were selected to better illustrate the core themes. Results What is mental health? In most of the focus groups, we decided it was important to understand how participants conceptualized mental health before we discussed mental illness. Throughout the focus groups, participants defined mental health as being dependent on the quality and quantity of social relationships and supports available to an individual. Mental health was described as being able to live a good life [una vida buena]; to be able to function in and contribute to society. There was also a strong emphasis on being able to live a tranquil life [una vida tranquila]. To better understand these concepts, we asked them what made up a good life. Para mi una buena vida sería llevar una vida de tranquilidad, sentirse con un poco de salud, que es lo principal, y...sentirse para mi bienestar con su familia unida y vivir tranquilo. [A good life would be living a tranquil life, being in good health, that s the most important... to feel a sense of well-being about my family s unity and to live peacefully]. In many of the comments, ideas about the centrality of social relationships, especially family relations, emerged as keys to mental health. Para mi la buena vida sería una buena unión familiar y poder compartir con los demás cualquier necesidad que haya. [For me a good life would be to have good family unity and to be able to share with others whatever necessity there might be.] Other important aspects of mental health included being in control of one s emotions and not being aggressive. Participants linked mental health to staying away from vices, particularly not abusing alcohol or drugs. In addition, one of the key roles of the family is to protect and nurture children and one of the major challenges for immigrants is to protect and support their children in the complex and difficult transition to moving to the United States. Families fear that their children will not be safe in the urban centers in the U.S. where many immigrants live and that they will become American too quickly. Para mi la buena vida es conservar las amistades y creer en Dios, alejarnos de vicios y mantener nuestros hijos fuera de peligro. [For me, a good life is maintaining friendships and believing in God, staying away from vices and keeping our children out of danger.] Mental health is intimately tied to spirituality; to believing in and seeking God s protection in life. What is depression? We then turned our attention to asking participants to describe or recognize depression, depending on the approach of the focus group. We were struck that in all the groups and across Latino ethnicities, depression was widely recognized among Latinos as a mental health problem. Participants in the focus groups recognized both emotional and somatic aspects of depression. Cuando una persona esta triste, esta nostálgica, se pone a llorar fácilmente, esta muy cansada y no sabe por que, no tiene ganas de hacer nada. Uno no tiene amigos, no tiene familia, ni nada. Le hace falta más la familia. [When a person is sad, is nostalgic, s/he cries easily, feels very tired and doesn t know why, s/he has no desire to do anything. One doesn t have friends, doesn t have family or anything. When you feel like this, you miss your family even more.] Uno ha perdido su identidad. Es una persona adolorida, que está triste, está enojada. No se quiere ni peinar, no se quiere ni bañar. Esa persona no es la que era un mes antes. [One has lost one s identity. It is a person in great pain, who is sad, who is angry. One doesn t want to comb one s hair nor bathe. This person isn t the same as the person s/he was a month earlier.] These descriptions are very representative of how Latinos across our focus groups discussed depression. Many of the elements could come right out of a standard diagnostic manual, as they describe affective, behavioral and interpersonal aspects of depression. Related to the intense sociality of Latinos, being alone or isolated from others was seen as very damaging to one s mental health. Participants tended to view isolation as a cause

5 J Immigrant Minority Health (2007) 9: for depression, rather than the loneliness being the result of depression. La soledad también. La soledad hace mucho daño. Por eso uno debe compartir con otras personas porque una sola en la casa es triste. [Loneliness, too. Loneliness is very harmful. That is why one should share with other people, because being home alone is sad.] In addition to being a response to social isolation, depression was seen as resulting from social stressors and losses, such as: the death of a family member, the loss of a job and financial stresses, and traumatic events like those of September 11, son momentos emocionales de estrés porque le he puesto caso a esas dos muertes tan queridas; se fue mi mamá y mi esposo junto y de repente que yo no esperaba que fueran a morir.... Y no me encontraba con ello, y nunca se me había muerto una persona que fuera de mi familia... Ya yo estoy en una mejor etapa pero al principio si me dió diabetes, me dió depresión. [They are emotional and stressful moments because I focused on those two deaths of my loved ones. My mother and my husband died at the same time. They were sudden and unexpected deaths. No one from my family had ever died before.... Now I m in a better place, but at first, I suffered from diabetes and depression.] Interestingly, participants, particularly those who were older, connected depression to diabetes. We were struck with the consistency across Latinos in how they viewed depression. The next definition, however, is culturally specific to the groups we did with Mexican American immigrants. Mexican immigrants were intensely aware of the difficult jobs available to them, particularly if they were undocumented. In a state like New Jersey, with a high cost of living, it was common for men (and women) to work more than one job to make ends meet. Both men and women discussed the stresses produced by these work situations. They saw depression as intimately tied to alcohol use. Women also saw this cycle as including domestic violence directed at them. [Los hombres] se deprimen, ellos buscan el alcohol para escaparse y no deprimirse. Tienen que hacerse a cargo de la familia acáytambién mandarle dinero a la familia allá. Conseguir trabajo aquí es difícil. [Men get depressed. They seek out alcohol to escape and not get depressed. They are responsible for their family here and also have to send money to their family there, and finding work here is difficult.] This quote also highlights the pressure on immigrants here to support family in their home countries. Some participants would say they worked one job to support their family here and the second to support family back home. Barriers to seeking help Participants were very articulate about the barriers they confronted when seeking help. Focus group participants were asked what barriers they encountered when seeking help; based on their responses we created a list of the most commonly mentioned barriers: stigma of mental illness, problems with health insurance or financial concerns, transportation to and from mental health providing agencies, their own immigration status and fear of being discovered, lack of knowledge of where to go for help, language and other cultural barriers, the relative coldness of providers, and a lack of understanding of what mental health treatment involves. It was as if they had read the research literature on barriers to mental health services for Latinos and were providing us a summary of that research! [Nosotros] inmigramos, y nos encontramos con muchas barreras como el idioma, no tenemos papeles, no tenemos información de muchas cosas, no sabemos cuales son nuestros derechos... la vida aquí es muy difícil. Estamos muy aisladas aquí. [We immigrate here and find ourselves with many barriers: such as language, we don t have papers, we don t have information about many things, we don t know what our rights are...life here is very difficult. We are very isolated here.] Nosotros como Hispanos no tenemos donde recurrir. Y cuando no hablamos inglés es otro obstáculo grandísimo. [As Hispanics we don t have anywhere to turn to. And when we don t speak English it is another huge obstacle.] Tiene miedo a lo que va a pasar, a lo desconocido.... Que van a preguntar, que va a pasar? Tiene miedo a discutir, a investigar... [One is afraid of what will happen, of the unknown.... What are they going to ask, what s going to happen? One is afraid, to discuss, to investigate...] The major stigma of seeking mental health services is the fear that they will be considered crazy (loco) or might really be crazy if they need these services. One poignant example in the groups was a woman who was in treatment for her depression. She recounted that when she came back from therapy, she overheard her neighbors on the next stoop saying to each other, Ay, aqui viene la loca. [Oh, here comes the crazy woman.] At the same time participants recognized the unjustness of such assumptions and the need for educational interventions in the Latino community to combat the stigma of mental illness.

6 22 J Immigrant Minority Health (2007) 9:17 28 En la cultura Hispana, piensan que ir a ver a un psicólogo es cosa de locos. Es la parte de ignorancia, saber entender y saber donde pedir ayuda. [Inthe Hispanic culture, they think that going to a psychologist is only for people who are really crazy. It s due in part to ignorance, not being able to understand and not knowing where to go for help.] This next quote illustrates not only the insurance and financial problems Latinos face in getting mental health care, but the lack of sensitivity of public mental health services in dealing with these issues. Nunca la cojí la conserjería porque yo dije, pero si ellosmelaestán ofreciendo y yo fui y yo me presenté. Pero me dijeron, No, el seguro de su esposo no cubre eso. Necesita $250 de down. [I never received the counseling. They were offering me the counseling and I went and presented myself. But then they said, No, your husband s insurance doesn t cover this; we need a $250 down payment.] While this list of barriers is very similar to those identified in mental health services research, these quotes make the barriers more real, palpable, and provide a sense of the texture of how they are experienced in the Latino community. Attitudes toward treatment When asked how they felt that depression should be treated, the focus group participants generally agreed that depression is a consequence of difficult life circumstances, and therefore not always an illness. This is one of the key reasons why Latinos do not often seek mental health services right away. Given the myriad stresses in the lives of Latino immigrants, it is not difficult to find reasonable explanations for why one might be deeply sad, feel lost and disoriented, experience life as overburdening, be tired all the time, and express a sense of hopelessness about the future. To decide that the feelings and bodily experiences that are often associated with the challenges of being a Latino immigrant in the U.S. have gone on too long and are too disabling so that mental health treatment might be indicated is a difficult process. Often the social networks that would help make that decision are disrupted by the immigration process itself, and those family members who are here are often also working long hours and may not be aware or be able to be sensitive to the problems a person is facing. Latinos often expressed a strong value for trying to deal with problems on one s own [hay que poner de su parte] before seeking professional help. This value is a further reason why a delay in seeking help is the norm, not the exception. At the same time, participants expressed the strong opinion that one should seek help if the problem grows to be out of one s control. In addition, many participants felt they would try remedies already known to them before going to mental health services. Nosotros los Hispanos, nos hemos acostumbrado en los remedios caseros...la medicina en realidad no es muy receptiva. [We Hispanics have become accustomed to using home remedies...in reality, medications are not very well received by the Hispanic community.] Participants preferred to seek out a talking cure first if they were to go to mental health services. Participants indicated a need to unburden oneself [desahogarse] and thus thought talking to a professional would be most beneficial. Participants reported strong negative reactions towards medications; medications are only for people who are severely mentally ill. To most participants, medications are seen as a last resort and then only as a temporary solution until one gains control of oneself; though others believed that if one reached the point of needing medications, then it would be necessary for life. Como último recurso, siempre se trata de buscar ayuda profesional, pero a veces de necesidad usas medicamentos a pesar de la ayuda, algo que se usa siempre, no por un día. [As a last resort, we always try to seek professional help. But sometimes out of necessity one uses medications in spite of the counseling. If it gets to the point that you need medicine, it is medicine that you use always, not just for one day.] Many expressed a fear of potential side effects and the addictive potential of psychiatric medications. The fear of addiction to psychiatric medications is very strong. Members of the community tended to use models of sleeping pills and coffee to understand medicines; in these models people need more and more sleeping pills or coffee over time to have an effect, and it is difficult to stop taking the pills or drinking the coffee. Attitudes towards providers Most focus group members explained that they seek help from primary care providers because they are not aware of mental health as a specialty service. Language barriers and cultural clashes in understanding the style of mental health treatment in the United States are also an issue. Participants explained that providers need to be accessible, need to build trust [confianza] with their clients, and need to treat people with respect [respeto]. Participants clearly needed more orientation to how psychotherapy is often carried out in the U.S. Their expectations were in line with the strong emphasis on sociality in Latino culture; that if I unburden myself and

7 J Immigrant Minority Health (2007) 9: share my emotions with you, I will get a warm and emotional response in turn. One participant shared one experience of going to a therapist: Yo he ido a unos cuantos psicoterapias...yo fui a uno que se sentaba y me decía habla y parecía que le estaba hablando a una pared. Pero el de ahora habla, da sus opiniones, se ve que esta interesado en conocerme a mi. El trata de obtener mi confianza y así me hace sentir más cómoda... [I ve gone to several psychotherapists... I went to one who sat down and said talk and it felt like I was talking to a wall. But the one I see now talks, gives his opinions, I can tell that he is interested in getting to know me. He tries to obtain my trust and thus makes me feel more comfortable...] Lo que pasó es que yo llegaba y el me escucha y está con el reloj. Y yo le estoy platicando todo lo que yo siento, lo que pasó, todo. Y el me dice, Bueno te espero en la próxima cita. Era todo lo que me decía. [everyone laughs] Yo ya no voy. Yo no tengo tiempo para perder así. [What happened is that I arrived [at therapy] and he listened to me and he was looking at his watch. And I was telling him everything I felt, everything that had happened. And he said, I ll wait for you at our next appointment. That was all he said. [everyone laughs] I don t go anymore. I don t have time to waste like that.] In reaction to comments such as this one, the conversation turned to what community members expect from therapy. One person described how the first session should be: La primera sesión debe ser individual para que se recobre su autoestima, se siente confianza. Ya después, buscar una terapia en grupo será loúltimo, ya cuando una persona está superando su depresión. [Thefirst session should be individual so that the person can recover his/her self esteem, can feel confidence and trust. Then later, seeking group therapy would be the last thing, when one is in the process of overcoming one s depression.] Overall, many could identify the benefits of talk therapies and why they can be helpful. Porque uno se desahoga. Si uno platica, uno llora y llora y llora y hay alguien que le escucha a uno, y uno saca todo, pues saca todo y desahoga el alma. Uno necesita llorar. [Because one unburdens oneself. If one talks, then cries and cries and cries and there is someone who can listen and one gets it all out, well one gets it all out, and unburdens one s soul. One needs to cry.] Discussion This paper, along with the paper by Cabassa and colleagues [15], provides rich context to the growing quantitative studies concerning different ethnic groups attitudes towards mental health treatment generally and depression care more specifically. The first important finding is that Latinos recognize and label depression clearly. It is not tenable to argue that Latinos do not recognize depression and do not have terms for it. Many of the descriptions of depression from our focus group participants clearly mirrored the symptoms of depression incorporated in DSM-IV. Their descriptions integrated emotional and physical symptoms of depression, not prioritizing the psychological over the somatic, as DSM-IV does. Participants descriptions of depression also included social dimensions of the experience, especially isolation or loneliness. In this sense, depression is a sociosomatic experience among Latinos [19, 20]. This tight linking of depression to life s problems, what Finkler [21] describes as life s lesions, means that many Latinos do not initially see depression as an illness, but rather as a consequence of the many disruptions caused by the immigration process and challenges that Latino immigrants face in surviving in the U.S. Latinos do see the experiences associated with depression as serious and needing help, but not necessarily mental health care. That Latinos may emphasize the more somatic aspects of depression when seeking help in primary care can be seen as more a strategic decision than a lack of awareness or insight into the emotional components of depression. Their own and providers expectations that you come to the clinic with physical symptoms shape how they report their problems. The stigma in the community against mental health problems also leads Latinos to defend against the possibility that they may be labeled as crazy because they are seeking mental health services. In their home countries, particularly in rural areas, the paucity of mental health services also means that people are not used to and are not familiar with mental health treatment. Social and emotional problems are more likely dealt with in the family, church and alternative medical sectors in Latinos home countries. All of these factors combine to influence Latinos presentation of self when they come to primary care and even mental health services. Latinos, even fairly recent immigrants, are painfully aware of the many barriers they face to getting primary care and mental health services for depression. In our focus groups, they listed many of the factors that have been regularly identified in the services literature: lack of insurance, costs of treatment and medications, lack of Spanish-speaking staff, stigma, concerns about immigration status, and many others. What comes through as different in the focus groups from reading the research literature is that these factors are all

8 24 J Immigrant Minority Health (2007) 9:17 28 intertwined and connected to the particular circumstances and life experiences of Latino immigrants. That is, these are not a series of separate factors to be put into a regression model to identify the most important barriers to care. Rather, all of these factors come together in the lives of Latino immigrants as a result of their social and economic positions in the U.S. From the perspective of Latino immigrants, all the factors stem from the same sets of issues the kinds of work and wages they can find in the U.S., the uncertainties produced by their immigration status, the discrimination they experience because of who they are and how they speak, the multiple demands of supporting family here and family there, and the separation from supportive social networks. While the confluence of all these factors seem overwhelming, it is also important to remember that research indicates that immigrants as a group have better mental health than U.S.-born Latinos [5]. But for those Latino immigrants who do develop depression, both the sources of the depression and the barriers to care are multiply determined. Several studies have now found that Latinos are more supportive of psychotherapeutic interventions than other minorities and less receptive to medications than European (currently says that) Americans. Our focus groups further elucidate these findings and provide meaning to them within Latino cultural frameworks. The preference for psychotherapy results from several factors. The cultural idea of the value of unburdening oneself [desahogarse] as an important aspect of maintaining emotional health makes psychotherapy seem attractive [20]. The idea that depression is a result of stressors in the social world also means that social interventions make sense to Latinos. Building more supportive social relationships fills a need for Latino immigrants who have often lost those relationships in the process of immigration. To the extent that therapy provides a context for sharing emotions and for building new supportive relationships, it fits with Latinos conceptions of depression and how to cope with it. Medications, on the other hand, are less congruent with Latinos models of depression. Medications signal that the person s problems are a disorder, not a problem in living, and open the person to community stigmatization as someone who is loco. Medications also signal long term disability and an inability to care for oneself. That these assumptions about medication do not fit with the medical model make them no less influential in the community. Medications also pose the threat of addiction. In part this arises from community models of other substances that are addictive like caffeine in coffee, nicotine in cigarettes, and older anxiolytics. Awareness of the difference in addictive potential and side effective profiles of the newer anti-depressants are limited in the Latino community. The challenge is to provide psychoeducation about anti-depressants in the Latino community without appearing to be overly promoting medications for depression. Limitations This study involved a series of focus groups composed of community members in various heavily populated Hispanic areas of New York and New Jersey. While our sample was larger than in many other studies, it was not random, but was based on convenience samples from a range of communities and service and community agencies. It reflects the diversity of Latinos in the Northeast, but not in other parts of the country. In addition, our sample consisted primarily of females, so the content herein might not accurately reflect the Latino male sample though some gender differences were noted in the group discussions. This oversampling could be due to various factors including the higher prevalence of depression among women, the fact that women are more likely to seek services than men, and that the samples were recruited from community social service or community health agencies. Future studies should work to include more men in their samples. It is important to note that despite the different methodologies across the focus groups, the themes that arose across groups were strikingly similar. Experiences in the service system are also reflective of services in New York and New Jersey, which are uneven in their efforts to develop service adaptations to meet the needs of the rapidly growing and diversifying Latino community in these areas. Improving care for depression With regards to therapies, especially psychotherapies, the results of this study clearly emphasize that therapists need to orient Latino patients to the process of mental health treatment. Latinos are not aware of the professional codes of conduct that govern relationships between therapists and consumers. The interpersonal models that Latinos bring to therapy are based on traditional models of relationships among family and friends. Building the therapeutic alliance is especially important when working with Latinos. It should include an orientation towards the treatment in general as well as an explanation of specific treatment approaches, the therapeutic model and the goals for treatment. The more the Latino client can be involved in this process, the more confianza is built between the therapist and client. Psychoeducation about medication is also critically important. Addressing issues of the negative side effects and consequences of medication is essential. Having the therapist or doctor explain the difference between everyday models of the addictiveness of some substances and how antidepressants actually work and that the medicine can be stopped may help people to more readily accept the medicines as a form of treatment. Providing consumers with realistic estimates of how long it will take for the medications to produce therapeutic effects and what the likely course of treatment is

9 J Immigrant Minority Health (2007) 9: will also help to prevent misconceptions and patient dropout. Recent research has shown that depression treatment in primary care combining therapy and medications is particularly effective for Latinos both in the U.S. and in Latin America [22, 23]. Needs for community intervention Based on the barriers to help seeking described in the various focus groups, several culturally competent intervention programs are necessary to make mental health services accessible to the Latino community. For example, there is a need for programs to help new Latino immigrants adjust to life in the U.S., this could help to prevent the onset of depression. In addition, programs to reduce the stigma of mental illness and mental health care in the Latino community would significantly increase help seeking behaviors. More psychoeducation about mental health and its treatment would encourage the Latino community to be psychologically savvy; this could help community members to be their own advocates for appropriate treatments. Finally, there is a need for more public information in Spanish about where to get mental health help and how to access such care. These kinds of interventions are supported both by our findings and those of Cabassa and colleagues [15] in a different context with a different mix of Latinos. Clinical and research implication Based on the findings presented in this paper, one can see that community members echo ideas set forth by cross-cultural mental health practitioners about how to more effectively serve the Latino community. Mental health providers working with Latino clients should learn to address the concerns expressed by these community members including the stigma of mental illness, the fear of both the unknown structure of therapy and the unknown effects of psychotropic medications in short, professionals need to become culturally competent. In addition, researchers can learn to adapt their research strategies to the cultural values and norms within the population they wish to study. For example, we used the focus group method, where you gather around a table, usually with some refreshments, and talk about things that are important to you, a style that is culturally acceptable within the Latino community and emphasizes values such as personalismo. We end this paper with a call to action for the mental health fields to become more involved in reaching out, educating, and helping the Latino community. As one focus group participant so aptly phrased it, Qué hace uno cuando hay un problema? Se preocupa. Pero para resolver hay que quitarle el pre y ocuparse! [What do you do when you have a problem? You worry and become preoccupied with it. But to resolve a problem, you have to take off the pre and take care of it (that is become occupied in finding the solutions to the problem)!]. APPENDIX A: Focus group guide concerning mental health and mental health services (Studies 1 and 2) 1. Para Uds, que es salud emocional o salud mental? [For you, what is emotional or mental health?] Como saben Uds. que una persona es sana mentalmente? [How do you know when someone is mentally healthy?] Que debe hacer una persona para mantener su salud emocional? [What should someone do to maintain their emotional health?] 2. Que tipos de problemas (enfermedades) de salud mental hay? [What types of mental health problems (illensses) are there?] Como saben Uds. que una persona tiene un problema (una enfermedad) de salud mental? [How do you know when someone has a mental health problem (illness)?] 3. Cuales son las reacciones de gente en la comunidad acerca de personas con problemas de salud mental? [How do people in the community react to people with mental health problems?] 4. Que debe hacer una persona que padece de un problema de salud mental? [What should someone do if they suffer from a mental health problem?] Que tratamientos conocen Uds. para problemas (enfermedades) de salud mental? [What treatments do you know for mental health problems (illnesses)?] Cuales de esos tratamientos piensan Uds. son mas efectivos? [Which of these treatments do you think are most effective?] Que puede hacer la familia de una persona con un problema de salud mental? [What can the family of a person with a mental health problem do for them?] 5. Que problemas encuentran personas con problemas de salud mental en buscar ayuda? [What problems do people with mental health problems encounter in seeking help?]

10 26 J Immigrant Minority Health (2007) 9:17 28 Que problemas tiene en identificar servicios apropriadas? [What problems do they have in identifying appropriate services?] Que problemas tienen en usar estos servicios? [What problems do they have in using those services?] Focus group questions about educational campaign A nosotros, nos interesa desarollar un programa para educar a la comunidad Latina acerca de la salud mental. [We would like to develop a program to educate the Latino community about mental health.] 1. Que medios de comunicacion serian mejores para ese programa de educacion? (radio, television, periodicos, etc.) [What forms of communication would work best for the educational program? (radio, television, newspapers, etc.)] 2. Utilizaria Ud. un numero 800 para informacion acerca de donde encontrar servicios de salud mental? [Would you use an 800 number for information about how to find mental health services?] 3. Que mensajes deberiamos presentar acerca de salud mental en la comunidad Latina? (Informacion acerca de enfermedades, estigma, recursos o tratamientos, etc.) [What messages should we present about mental health in the Latino community? (Information about illnesses, stigma, resources, treatments, etc.)] Appendix B: Vignette on recognizing depression and attitudes towards treatment (Study 4) Voy a comenzar por hablarles de un paciente, una mujer que llamaremos Marta, de 38 años, divorciada con 2 hijos de 11 y13años. Marta expresa que durante el último año se ha sentido muy triste. Indica que se le hace difícil dormir, tiene poco apetito, llora a menudo, y no puede realizar sus tareas. Ella ha tenido que visitar al médico para dolores de cabeza, estomacales y de los músculos. [I am going to begin by telling you about a patient, a woman we will call Marta, who is 38 years old, divorced and has two children who are 11 and 13 years old. Marta says that during the past year she has felt very sad. She has had trouble sleeping, had little appetite, cries often and cannot get her tasks done. She has had to visit her doctor for headaches and pains in her stomach and muscles.] Qué piensan Uds. que esta pasando con Marta? [What do you think is going on with Marta?] STOP HERE AND DISCUSS AFTER EACH QUES- TION Qué tipo de ayuda necesita (Marta)? [What type of help does Marta need?] Los doctores piensan que Marta está deprimida. Al preguntarle si considera que ha necesitado ayuda profesional para algún problema emocional, dice que no. [The doctors think that Marta is depressed. When they ask her if she thinks she needs professional help for an emotional problem, she says no.] Qué esta ocurriendo con Marta que a pesar de lo mal que se siente, no reconoce que tiene un problema emocional? [What is happening with Marta, that although she feels really ill, she does not recognize that she has an emotional problem?] Por qué personas como Marta se deprimen? [Why do people like Marta get depressed?] Qué otras razones contribuyen a que personas como Marta se depriman? [What are some other reasons why people like Marta might become depressed?] Cuándo debe uno buscar ayuda para la depresión? [When should one seek help for depression?] Qué tipo de ayuda debe buscar Marta para su depresión? [What type of help should Marta seek for her depression?] A pesar de que se siente mal con problemas físicos y psicológicos y que el doctor le ha dicho que esta deprimida, Marta no busca ni ha entrado en tratamiento para la depresión. [In spite of how badly she feels due to her physical and psychological problems, and that the doctor has told her she is depressed, Marta does not seek nor enter treatment for depression.] Qué razones podría tener Marta para no buscar ayuda? [What reasons might Marta have for not seeking help?] Luego de pasar otro año en que los períodos de depresión han ido aumentando, Marta ha pensado en algunas ocasiones en buscar ayuda, pero no lo ha hecho. [During another year in which her periods of depression have increased, Marta has thought about seeking help on some occasions, but still has not gone.] Qué se podría hacer para que alguien como Marta busque la ayuda que necesita? [What could be done so that someone like Marta would seek the help she needs?] Marta decide que desea recibir ayuda profesional pero se ha encontrado con muchos problemas en conseguir tratamiento. [Marta decides that she would like professional help, but she encounters many barriers in obtaining treatment.] Cuáles problemas consideran ustedes que hacen difícil que las personas consiguen tratamiento?

11 J Immigrant Minority Health (2007) 9: [What types of problems do you think make it hard for people to access treatment?] Qué recomendaciones tienen para resolver estos problemas? [What recommendations do you have for solving those problems?] Si Marta decide buscar ayuda, [If Marta did decide to seek treatment,] Cómo reaccionaría su familia? sus amigos? [How would her family react? Her friends?] Debería Marta contarle a sus compañeros de trabajo que está buscando ayuda por un problema emocional? Por qué?, Por qué no? [Should Marta tell her colleagues at work that she is seeking help for an emotional problem? Why should she or shouldn t she?] Ya Marta ha decidido buscar ayuda. Ella ha oído hablar de varios tratamientos para la depresión. [Now Marta has decided to seek help. She has heard of various treatments for depression.] De qué tratamientos han oído hablar Uds.? [What treatments (for depression) have you heard of?] Hay varias alternativas para tratar la depresión. Qué cosas positivas (buenas) o negativas (malas) le ven ustedes a cada tratamiento que mencionaba antes?: [There are various alternatives for treating depression. What positive (good) and negative (bad) things have you heard about each of the treatments you mentioned above:] REVIEW EACH TREATMENT MENTIONED ABOVE Qué cosas positivas (buenas) o negativas (malas) le ven ustedes a: [What positive (good) and negative (bad) things do you see with:] tomar pastillas por seis meses? [taking pills for six months?] reunirse en grupo con un profesional de ayuda una vez semanal por tres meses? [going to a weekly therapy group with a professional for three months?] Marta empezó pero no terminó el tratamiento. [Marta began but did not finish treatment.] Porque personas como Marta no terminan sus tratamientos? [Why do people like Marta terminate their treatment?] Donde prefieren Uds. recibir tratamiento para la depresión? [Where would you prefer to receive treatment for your depression?] De quienes prefieren Uds. recibir tratamiento? [From whom would you prefer to receive treatment?] Hay otro comentario que Uds. quieren hacer acerca de este asunto? [Is there anything else that you would like to say about this topic?] References 1. Moscicki EK, Rae D, Regier DA, Locke BZ: The Hispanic Health and Nutrition Examination Survey: Depression among Mexican- Americans, Cuban-Americans, Puerto Ricans: In Gaviria M, Arana JD, editors. Health and Behavior: Research Agenda for Hispanics. Chicago: University of Chicago at Illinois; Kessler R, McGonagle KA, Zhao S, Nelson CD, Hughes M, Eshleman S, Wittchen HU, Kendler KS: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the national comorbidity survey. Arch Gen Psychiatry 1994; 51: Chung H, Teresi J, Guarnaccia P, Meyers BS, Holmes D, Bobrowitz T, Eimicke JP, Ferran E: Depressive Symptoms and Psychiatric Distress in Low Income Asian and Latino Primary Care Patients: Prevalence and Recognition. Comm Ment Health J 2003; 39: Minsky S, Vega W, Miskimen T, Gara M, Escobar J: Diagnostic patterns in Latino, African American and European American psychiatric patients. Arch Gen Psychiatry 2003; 60: Vega WA, Kolody B, Aguilar-Gaxiola S, Alderate E, Catalano R, Carveo-Anduaga J: Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Arch Gen Psychiatry 1998; 55: Briones DF, Heller PL, Chalfant HP, Roberts AE, Aguirre- Hauchbaum SF, Farr WF Jr: Socioeconomic status, ethnicity, psychological distress, and readiness to utilize a mental health facility. Am J Psychiatry 1990; 147: Hough RL, Landsverk JA, Karno M, Burnam MA, Timbers DM, Escobar JI, Regier DA: Utilization of health and mental health services by Los Angeles Mexican Americans and non-hispanic whites. Arc Gen Psychiatry 1987; 44: Wells KB, Hough RL, Golding JM, Burnam MA, Karno M: Which Mexican-Americans underutilize health services? Am J Psychiatry 1987; 144: Pescosolido BA, Wright ER, Alegria M, Vera M: Social networks and patterns of use among the poor with mental health problems in Puerto Rico. Med Care 1998; 36: Vega WA, Kolody B, Aguilar-Gaxiola S, Catalano R: Gaps in service utilization by Mexican Americans with mental health problems. Am J Psychiatry 1999; 156: Peifer K, Hu T, Vega W: Help seeking by persons of Mexican origin with functional impairments. Psych Services 2000; 51: Vega WA, Alegria M: Latino mental health and treatment in the United States: In Aguirre Molina M, Molina C, Zambrana R, editors. Health Issues in the Latino Community. San Francisco: Jossey-Bass, 2001: U.S. Department of Health and Human Services: Mental Health: Culture, Race, and Ethnicity A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Services, Office of the Surgeon General, Cooper LA, Gonzales JJ, Gallo JJ, Rost KM, Meredith LS, Rubenstein LV, Wang NY, Ford DE: The acceptability of treatment

12 28 J Immigrant Minority Health (2007) 9:17 28 for depression among African-American, Hispanic and White primary care patients. Med Care 2003; 41: Cabassa L, Lester R, Zayas LH: It s like being in a labyrinth: Hispanic immigrants perceptions of depression and attitudes towards treatment. J Immigrant Minority Health, DOI: /s (this issue). 16. Morgan DL, Krueger RA: The Focus Group Kit. Thousand Oaks, CA: Sage Publications; Wagner LC, King M: Existential needs of people with psychotic disorders in Porto Alegre, Brasil. British J Psychiatry 2005; 184: Berkman CS, Guarnaccia PJ, Diaz N, Badger LW, Kennedy GJ: Concepts of mental health and mental illness in older Hispanics. J Immigrant Refugee Serv 2005; 3: Kleinman A: Social Origins of Distress and Disease: Depression, Neurasthenia and Pain in Modern China. New Haven: Yale University Press; Jenkins J, Cofresi N: The sociosomatic course of depression and trauma: A cultural analysis of suffering and resilience in the life of a Puerto Rican woman. Psychosom Med 60: Finkler K: Physicians at Work, Patients in Pain: Biomedical Practice and Patient Response in Mexico. Boulder, CO: Westview Press; Miranda J, Duan N, Sherbourne C, Schoenbaum M, Lagomasino I, Jackson-Triche M, Wells KB: Improving care for minorities: Can quality improvement interventions improve care and outcomes for depressed minorities? Results of a randomized, controlled trial. Health Serv Res 2003; 38: Araya R, Graciela R, Fritsch R, Gaete J, Rojas M, Simon G, Peters TJ: Treating depression in primary care in low-income women in Santiago, Chile: A randomised controlled trial. Lancet 2003; 361:

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