“It`s Like Going through an Earthquake”: Anthropological

J Immigrant Minority Health (2007) 9:17–28
DOI 10.1007/s10903-006-9011-0
ORIGINAL PAPER
“It’s Like Going through an Earthquake”: Anthropological
Perspectives on Depression among Latino Immigrants
Igda E. Martı́nez Pincay · Peter J. Guarnaccia
Published online: 28 September 2006
C Springer 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. Martı́nez Pincay ()
Graduate School of Applied and Professional Psychology,
Rutgers University, 152 Frelinghuysen Road,
Piscataway, NJ 08854-8085, USA
e-mail: igda [email protected]
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
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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
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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
J Immigrant Minority Health (2007) 9:17–28
Table 1
19
Demographics
N
Gender (% female)
Age range
Country of Origin (%)
Puerto Rico
Dominican Republic
Mexico
Cuba
Time in U.S. Range
Study 1 (NJ): 5 FG
Study 2 (NY): 3 FG
Study 3 (NJ): 2 FG
Study 4 (NJ): 2 FG
40
72
20–60
22
68
Over 65
37.5
7.5
32.5
22.5
<1 year to over 20
years
50
50
14
90
24–64
Diverse Latino Groups
No majority From any One group
18
94
28–71
Diverse Latino Groups
No majority From any One group
1 to 10 years
1 to 28 years
Minimum average 25
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)
(b)
(c)
(d)
(e)
(f)
What is mental health?
What is depression?
What is mental health treatment?
What barriers do you face when you try to seek care?
What ideas do you have about seeking help?
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.
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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.
ticipants 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.
Results
What is depression?
What is mental health?
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.
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 serı́a 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 serı́a 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. ParSpringer
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
J Immigrant Minority Health (2007) 9:17–28
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, 2001.
. . . 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 habı́a 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 acá y también mandarle dinero a la
familia allá. Conseguir trabajo aquı́ es difı́cil. [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
21
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 aquı́ es muy difı́cil.
Estamos muy aisladas aquı́. [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
grandı́simo. [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.
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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. [In the
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 cojı́ la conserjerı́a porque yo dije, pero si
ellos me la están 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
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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 dı́a. [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
J Immigrant Minority Health (2007) 9:17–28
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 decı́a “habla” y parecı́a 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 ası́
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 decı́a. [everyone
laughs] Yo ya no voy. Yo no tengo tiempo para perder
ası́. [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 lo último, ya cuando
una persona está superando su depresión. [The first
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.]
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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
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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.
Springer
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
J Immigrant Minority Health (2007) 9:17–28
25
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].
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)!].
Needs for community intervention
APPENDIX A: Focus group guide concerning mental
health and mental health services (Studies 1 and 2)
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
1. Para Uds, que es salud emocional o salud mental?
[For you, what is emotional or mental health?]
r Como saben Uds. que una persona es sana mentalmente?
[How do you know when someone is mentally healthy?]
r 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?]
r Que tratamientos conocen Uds. para problemas (enfermedades) de salud mental?
[What treatments do you know for mental health problems (illnesses)?]
r Cuales de esos tratamientos piensan Uds. son mas efectivos?
[Which of these treatments do you think are most
effective?]
r 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?]
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J Immigrant Minority Health (2007) 9:17–28
r Que problemas tiene en identificar servicios apropriadas?
[What problems do they have in identifying appropriate
services?]
r 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
y 13 años. Marta expresa que durante el último año se ha
sentido muy triste. Indica que se le hace difı́cil 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.]
r ¿Qué piensan Uds. que esta pasando con Marta?
[What do you think is going on with Marta?]
STOP HERE AND DISCUSS AFTER EACH QUESTION
r ¿Qué tipo de ayuda necesita (Marta)?
Springer
[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.]
r ¿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?]
r ¿Por qué personas como Marta se deprimen?
[Why do people like Marta get depressed?]
r Qué otras razones contribuyen a que personas como Marta
se depriman?
[What are some other reasons why people like Marta might
become depressed?]
r Cuándo debe uno buscar ayuda para la depresión?
[When should one seek help for depression?]
r ¿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 fı́sicos 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.]
r Qué razones podrı́a tener Marta para no buscar ayuda?
[What reasons might Marta have for not seeking help?]
Luego de pasar otro año en que los perı́odos 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.]
r ¿Qué se podrı́a 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.]
r ¿Cuáles problemas consideran ustedes que hacen difı́cil
que las personas consiguen tratamiento?
J Immigrant Minority Health (2007) 9:17–28
[What types of problems do you think make it hard for
people to access treatment?]
r ¿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,]
r ¿Cómo reaccionarı́a su familia? sus amigos?
[How would her family react? Her friends?]
r ¿Deberı́a 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 oı́do hablar
de varios tratamientos para la depresión.
[Now Marta has decided to seek help. She has heard of
various treatments for depression.]
r ¿De qué tratamientos han oı́do 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:]
r ¿tomar pastillas por seis meses?
[taking pills for six months?]
r ¿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.]
r ¿Porque personas como Marta no terminan sus tratamientos?
[Why do people like Marta terminate their treatment?]
r ¿Donde prefieren Uds. recibir tratamiento para la depresión?
[Where would you prefer to receive treatment for your
depression?]
27
r ¿De quienes prefieren Uds. recibir tratamiento?
[From whom would you prefer to receive treatment?]
r ¿Hay otro comentario que Uds. quieren hacer acerca de
este asunto?
[Is there anything else that you would like to say about
this topic?]
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