Review article Acta psychiatr. scand. 1987:75:1-10 Key words epidemiological methods, health survey, cultural characteristics Social epidemiology of mental disorders A review of Latin-American studies N. de Almeida-Filho Department of Preventive Medicine, Faculty of Medicine of the Federal University of Bahia. Brazil ABSTRACT - This paper reviews the literature about the relationships between cultural change and psychopathology produced by Latin American researchers. With the analysis of 22 epidemiological studies, the author shows how culture has been traditionally viewed by social psychiatric research in Latin America as an independent variable associated with the prevalence of mental disorders. Two basic approaches have been analyzed: one of anthropological origin and the other based on sociological explanations. The hypotheses of cultural shock, stress of acculturation and cultural marginalization belong to the first approach, while the second one is manifested by the notions of urban stress, life change, social support and goal-striving stress. Methodological issues were brought about to evaluate the results on the association of cultural processes and psychopathology available in contemporary socio-psychiatric research in Latin America. Received June 7, 1986; accepted for publication July 18, 1986 The health consequences of economic development have frequently been ignored in epidemiological research in Third World countries. Most comprehensive analyses of the problem have approached health indicators at a national or regional level, and the bulk of research on this issue does not attach much importance to individual-level outcomes, such as the psychopathological effects of modernizing experiences. The social epidemiology of mental disorders in Latin America seems to be an intriguing exception to this overall pattern. The basic question of social psychiatric research in our continent can be stated as follows: in these countries, is poor mental health due to modernizing pressures which require rapid and difficult acculturation, including the migratory attraction to urban centers (in itself a life-crisis event) or is it due to changes in the economic system, which expels labor without providing sufficient employment opportunities for the full reincorporation of these social groups within a modernized productive process? This paper is an attempt to present the scientific literature about the relationships between social factors and mental health/illness that has been produced in Latin America. With this aim, I have covered not only material published in indexed scientific periodicals, but also papers appearing in regional publications as well as unpublished manuscripts. As a result, I have reviewed two papers based on clinical impressions, three “anthropological” studies, one investigation of mental hospital first admission, three small scale studies and 13 community surveys. A summary on methods and results of these studies is provided below, by classifying them into three categories: “pre-epidemiological” studies, community surveys of the first phase (1950-1970) and epidemiological studies of the second phase (1970-present). Finally, an evaluation of this body of literature is presented, particularly in terms of theoretical models adopted to explain research findings from the studies covered by the present review. 2 N. DE ALMEIDA-FILHO “Pre-epidemiological” studies In 1956, Seguin (1) reported that a large number of mountain Indians were referred to a Peruvian psychiatric service after having passed through several clinical sections without being diagnosed and treated. In his account, those patients shared three characteristics: they were Indians, they had recently migrated, and they had problems in adjusting to city life. The clinical picture included several non-specific body symptoms (he listed up to 15 symptoms, classified into five groups: circulatory, gastrointestinal, respiratory, rheumatic and neurological), plus depression and anxiety. According to Seguin, the patients were young men and women, aged 15 to 25, most of them Indians, but also a few mestizos; the symptoms generally appeared following a short period of latency after the patients arrived in the city of Lima. Seguin labeled it the “psychosomatic disadaptation syndrome”, and submitted that it was “only a particular and quite exaggerated case of the very common picture of homesickness or nostalgia”, and that the syndrome should be an example of “flight into illness” (1). Fried (2), elaborating on Seguin’s clinical findings, suggested a “sociocultural stress” interpretation for the etiology of the illness. He reasoned that mental ill health was already shown to be “statistically correlated with migration”, and provided the following explanation for the etiology of that “syndrome”: “Since immigrants in Europe and America are reported as having excessively high rates of physical and mental illnesses, Indian migrants who come from Andean regions and must endure special psychological stress, must be even more susceptible (0 illness. If urban European immigrants in urban American centers can experience rejection and social isolation, then the rural, very backward, illiterate Indian coming to Lima must overcome even greater cultural barriers” ( 2 ) . “Anthropological” studies were also conducted in Lima, Peru (3-5). Initially, these authors tried to refute the traditional view of the migrant as a victim of extreme biological, social and psychological stresses, and of migration itself as a source of such stresses. They argued that their data did not support the hypothesis that specific stresses of migration are responsible for the “psychosomatic disadaptation” which Seguin and Fried described. According to Mangin & Cohen: “We are dealing then with a con- dition of stress rather than the specific condition of migration, that leads to certain psychological phenomena. Thus, we might find that in the home area of the rural mountain group extreme stress of a variety other than migration would enable one to see the same basic picture that we reported as the ’migrant syndrome”’ (4). However, reasonable as this statement might appear, it is based on poor quality data and vague methodology. In addition to “traditional anthropological techniques such as observation, conversation and participation”, Mangin ( 3 ) applied the Cornell Medical Index to a convenience sample of 65 residents in a Lima “barriada” (squatter settlement). In a later paper, this same author presented a set of stories told by two rural migrants in response to selected TAT cards ( 5 ) . All of these papers purported to be preliminary results. Despite the authors’ claims that the material would be systematically analyzed, I failed to find final reports of these studies with definitive data analyses. In the late 1960’s, the Instituto Venezolano d e Accion Comunitaria conducted a small-scale survey with a stratified sample of 270 residents in a barrio of Caracas, Venezuela, inhabited predominantly by migrants from rural areas (6). The basic objective of that research was to study some demographic characteristics in relation to “subjective anomie”, and to feelings of Zogm (frustration). With this aim, they developed an adapted “aspirationachievement” questionnaire and translated Srole’s anomie scale. Among other results, they found that length of urban residence was positively correlated with feelings of logro and to subjective anomie, but not at significant levels. In addition, the results indicated that income was negatively correlated with both sociopsychological variables at borderline levels of significance. There was no association between any of these variables and migration taken alone. The authors did not report any controlled analysis for potential confounding factors nor did they try to relate their findings to any defined theoretical frame of reference. Two of the small-scale studies were completed in Santiago, Chile. Stephan & Stephan (7) dealt with the relationships between role differentiation, empathy, and neurosis among 60 lower class individuals, half of whom were migrants from rural areas. The authors did not present in detail the research instruments nor the sampling procedures. They EPIDEMIOLOGY OF MENTAL DISORDERS IN LATIN AMERICA found that both groups had similar levels of “empathy”, but the urban-born group scored higher in “role differentiation” and had lower rates of neurosis than the migrant group. No information about matching or controlled analyses for other variables was given. Years later, Willamson (8) applied a shorter version of Langner’s 22-item Scale to a “representative” sample of 111 middle class and 64 lower class individuals, to study the associations between socialization practices, social class and emotional disorders. His conclusions were that the lower class had disproportionately more socialization problems than the middle class, and that most symptoms were nearly twice as frequent for the lower as for the middle class. For both studies, the lack of methodological information prevents a better assessment of the quality of these data and the scientific value of these results. Finally, I should like to make a special mention of Brody’s investigation, reported in a 1973 book appropriately titled The Lost Ones (9), because it is perhaps the most eclectic theoretical treatment of the problem among all such studies conducted in Latin America. The research was based on a sample of 254 first admissions to an emergency hospital and two private asylums in Rio de Janeiro, Brazil, which was seriously biased by the arbitrary selection of sources of cases, and by the non-inclusion of patients who had received heavy sedation directly after admission. Two questionnaires, one “sociocultural” and the other psychopathological, were used in that collection of data. The analysis presented is highly descriptive, and many generalizations are made, based on comparisons of some demographic characteristics of the sample with the general population profile. In short, the author found a concentration of male, uneducated, “brown”, migrant, married, unemployed, and low socioeconomic status individuals in the hospital sample. Among migrants, it was found that recent arrivals were overrepresented in the sample. He also reported a higher proportion of married migrants than married nonmigrants among the patients, and speculated that unattached migrants would be more likely to remain anonymous, untreated or involved with the police instead of under psychiatric care (9). Given the methodological limitations of treated population studies in general, as well as the many problems with that sampling method in particular, 3 Brody’s theoretical interpretations were clearly beyond the explanatory reach of the reported results. For example, he suggested that a lack of social support from extended family members, as well as the hostility of neighbors and the pressure of unshared family responsibilities, “contribute to a higher risk of mental hospitalization among recent than settled migrants into Rio de Janeiro” (9). With the type of research design and data analysis reported, it was impossible to calculate crude risk estimates, as well as relative risks for the different sociological variables suggested above. By the same token, Brody’s “refutation” of the social selection hypothesis - by identifying a wide array of factors, such as the breaking of social networks, loneliness, life change stress, urban environmental stress, marginalization, and lack of social support as more related to the patient’s illness than earlier predispositions - sounds weak and not logically connected with the study results. Community surveys of the first phase (1950-1970) The first community surveys on the relationships between migration, cultural change and mental disorders in Latin America were conducted in Peru, during the 19503, explicitly as an attempt to support Seguin’s clinical findings through epidemiological research. The results of these early studies are collected in a volume titled Estudios de Psiquiatria Social en el Peru (10). First, I will discuss, briefly, some of their methodological issues. The Cornell Medical Index was applied to a stratified sample of 239 residents in Mendocita, a medium-size barriada of Lima. The research team interviewed those individuals who had “indications of psychopathology”, in order to classify them diagnostically and collect “data about their social participation and their morale” (10). The authors did not report any revalidation studies of the research instrument nor the criteria used for the screening of the suspected population. Also, they applied the screening questionnaire to a random sample of 124 individuals drawn from a coastal village near Lima called Pachacamac, without further psychiatric examinations. The urban-rural comparisons, based only on the CMI results, revealed that the urban population had 4 N. DE ALMEIDA-FILHO higher levels of depression and aggressiveness, as well as “greater feelings of inadequacy, a tendency to go to pieces under stress, more distrust and a lack of confidence in personal relationships, and an extremely high incidence of alcoholism” (11). In discussing the findings of similar levels of anxiety in both samples, Rotondo used Redfield’s folk-urban continuum, pointing out that the village would not be at the extreme rural limit of the continuum, and suggested that “the high incidence of anxiety may be an indication of insecurity in relation to the cultural and social changes now taking place”. With regard to comparisons between migrants and nonmigrants within the urban slum sample, the authors found prevalence rates of epilepsy, depressive reactions, and psychosomatic disorders to be higher among migrants, and of psychoses and anxiety reaction to be more prevalent among nonmigrants. They classified the migrants as coastal or mountain in origin, and reported higher rates of all conditions but epilepsy to be greater among mountain peasants who emigrated to the city. O n the basis of the CMI results, Rotondo et al. (12) indicated that more severe symptomatology was related to constitutional selection, urban stress, cultural shock, goal-striving stress, and modal personality factors at once. This is summarized in their conclusion: “The worsening emotional symptomatology among peasants newly arrived to Lima, who have settled down in Mendocita, suggests a probable influence of negative factors which perhaps are related with the new living conditions and with the demands of an urban environment, where major stresses and uncertainties. are more present than in the simple and rural environment they come from. The disorientation, the detachment, the disappointment, are not unusual consequences of this urbanization phenomena. Many people who arrive in Lima bring with them, on the other hand, great aspirations which are not always materialized. We have identified a picture of emotional symptoms and inadequate attitudes in the migrant who came from the mountains which is not as frequent among shore-men and Lima-born. Such a symptom picture is formed by depressive manifestations, hypochondriac preoccupations, feelings of inadequacy, attitudes of fear and sensitivity, indecison, a clear necessity of dependency, and, unlike the other inha- bitants of Lima, a lower incidence of expressions of aggressiveness” (12). Ponce (13) conducted a more ambitious community survey on the same subject, also using the CMI as the basic data collection device. The study used a stratified subsample of 779 individuals drawn from the whole Lima-Calla0 area. The main objective was to study the housing, health and mental health conditions of inmigrants to that metropolitan area. In addition to an association between mental health and socioeconomic status (measured by an ecological classification of neighborhoods), Ponce reported that migrants had slightly worse mental health conditions than nonmigrants. Among migrants, those from the mountains and rural areas had higher rates of anxiety, depression and stress. With regard to length of urban residence, Ponce’s findings point to an increase in depression and anxiety and a decrease in stress levels along the time scale. For none of these results did the author present any significance-testing of the differences between rates, nor any controlled analysis for age, sex or other variables. However, he stratified his sample by the socioeconomic ecological classification, which resulted in a clear excess of cases in the lower strata for both migrant and nonmigrant groups. In his discussion, Ponce emphasized that “there was a clear relationship between economic level and reactions of maladaptation, which are more intense in the lower economic levels”, and that poverty should be considered “an aggravating factor for the adaptation process” (13). In additon, he states that the “cultural contrast” is also a basic element in the relationship, given that maladaptive reactions are more severe for those who came from the mountains and from rural areas than for city-born individuals. Unlike the preceding studies, this author did not develop or indicate a defined conceptual framework to explain his findings. The Harvard Project on the Social and Cultural Aspects of Development provided some data on the relationships between social factors and mental health in two Latin-American countries. Its basic findings were summarized by Inkeles & Smith in a 1970 paper (14). They applied a battery of questionnaires, including a Psychosomatic Symptoms Test, to selected samples of rural cultivators, urban migrants, urban service workers and industrial EPIDEMIOLOGY OF MENTAL DISORDERS IN LATIN AMERICA workers in six countries: Argentina, Chile, East Pakistan, India, Nigeria, and Israel. The basic hypothesis being tested was that “modernizing” experiences, and eventually “individual modernity”, were related to psychological maladjustment. In general, the authors concluded that their results gave virtually no support to the assertion that education, urban experience, factory work, mass media contact, and individual modernity in developing countries are regularly associated with increased psychic stress. The comparisons between psychosomatic symptom scores of newly settled migrants and of rural dwellers revealed no significant differences. Among factory workers, the rural-urban origin also was not related to higher psychological stress levels, even after matched comparisons by education and length of factory experience. When they compared non-industrial workers with rural dwellers, they found that the former had higher stress levels in all six countries. Making this last point, they conclude: “Indeed, taking all the measures into account, moving in itself seems to be neither here nor there with regard to psychic health. Perhaps the critical factor is whether or not your post-migratory status permits you to become integrated into a stable, meaningful and rewarding role in your new environment. In this connection, it is revealing to consider the fate of those who migrated to the city but did not succeed in finding the higher paying, more secure, and generally more prestigious jobs represented by those in industry. It seems, then, that it is much less the fact of moving, and more the kind of reward the migrant wins after his move, which determines the presence or absence of psychosomatic symptoms” (14). Several other surveys carried out in Latin-American urban areas did not directly deal with the issue of social factors and mental illness, even though they provided valuable information on the overall unequal distribution of these conditions. Since the objective of these studies was to generate preliminary data to be used to plan community mental health programs, the authors did not attempt to integrate their findings into any explanatory frame of reference (15-20). Epidemiological studies of the second phase (1970-present) Coutinho (21) completed an epidemiological study 5 of psychiatric disorders in Maciel, a small slum of Salvador, Brazil, with a census of all residents (approximately 1600 individuals) in the area. He employed a 38-item screening instrument developed specifically for that research, which was previously tested for validity. Cases indicated as suspect by the questionnaire score were interviewed by the author for diagnostic purposes. Coutinho reported an extremely high prevalence of mental illness, around 49%, mostly alcoholism and neurosis (both with a rate of 23%), with higher specific rates for females, unmarrried, uneducated, and migrants. The differences for the migrant-nonmigrant comparison, however, were not statistically significant. The author oriented the interpretation of his findings toward a mixed cultural disintegration and “culture of poverty” approach (21). The most recently reported research on the problem conducted in Peru was more concerned with the relations between social environmental stresses and illness in general, but it included emotional symptoms as well (22). The researchers took a stratified random sample of 325 adults, all from the lower socioeconomic class, who lived in the town of Cocachacra in southern Peru. They applied to that sample a health questionnaire adapted from the Cornell Medical Index and from the KaiserPermanente Medical Questionnaire, translated into Spanish and Quechua. No validation or reliability testing procedures were reported. Dutt & Baker (22) reported higher levels of emotional symptoms for migrants compared with nonmigrants, and, among migrants, those who came from mountain areas had higher rates than those who came from low-altitude environments. These differences were significant for men but not for women, and for older males but not for youngsters. Among low-altitude migrants, the time since migration was positively correlated to stress levels, while the opposite was true for mountain migrants, regardless of sex differences in both cases. The authors examined three possible hypotheses and concluded that poor living conditions and selective migration did not explain their results. The remaining hypothesis, that a “change of physical and cultural environment may be detrimental to health and the more extreme the change, the more serious the health loss”, was considered as the most plausible one (22). Santana (23) reported preliminary results of an- 6 N. DE ALMEIDA-FILHO other epidemiological study of mental disorders conducted in Salvador, Brazil, with a representative sample of 1.500 adults living in an urban squatter settlement. The author employed the QMPA (Adult Psychiatric Morbidity Questionnaire) as the study screening instrument, which was tested for sensitivity and specificity by means of a 2-step study. As a second phase of the data-collection, psychiatrists double-blindly interviewed all suspects identified by the instrument and a sub-sample of the non-suspected. Santana found an overall prevalence of psychiatric disorders of 20%, with neurosis (14.5%) and alcoholism (3.5%) as the most frequent diagnoses. Among specific findings, females, older, less educated, and lower class showed higher prevalence rates. In relation to migration, the finding that migrants have higher rates than nonmigrants, even controlling for age and sex, and that recent arrivals have higher rates than late arrivals, did not reach statistical significance. The author argued that sociocultural theories were not adequate to explain her results, which should be better interpreted through concepts of political economy. While she pointed to several important issues, mainly with respect to epidemiological problems of the survey approach in epidemiological studies of mental disorders, Santana did not elaborate a clear theoretical model to deal with the problem of political and economic factors involved with phenomena of mental ill health (23). Micklin & Leon (24) reported perhaps the most sophisticated of all large-scale specific studies on the association between social factors and psychological disturbance in Latin America which was carried out in the Colombian city of Cali. They applied to a multistage sample of 681 respondents, all aged between 20 and 59 years, employed or seeking work, a questionnaire on occupational and residential history, as well as a Spanish translation of Langner’s 22-item scale. The study’s independent variables received detailed definitions, with the distinction of “migrant status”, classified according to six life-cycle intervals, from “migrant type”, classified by size of place of residence. In addition, they also defined “social mobility types”, based on a cross-classification of respondents’ and fathers’ occupational status, with five categories. The findings of this study clearly indicate that sex, educational level and social mobility experience were associated with levels of psychiatric disturbance as measured by the symptom index. Females, illiterate, and lower class people had the highest scores. In terms of social mobility, Micklin & Leon found that the stable upper class had the lowest mean scores, while among the mobiles, skidders showed the highest levels. Females consistently had more symptomatology than males throughout all the social mobility categories. The findings on migration are far more complicated to analyze. There were no clear-cut differences in scores by migrational status, once controlled for life-cycle interval of migration. With regard to the type of migration, the authors found that, for definitive moves, which implied urban residence from ages 5. and 1.5 to present, individuals of rural origin consistently had higher scores in the symptom scale. Migrants from other large urban areas had the lowest score levels, regardless of the life-cycle of migration. Analyses of variance of these findings indicated that when “all variables were considered simultaneously, however, the effect of migration on psychiatric disturbance virtually disappears. Sex, educational attainment and social mobility type, in that order, emerge as the important determinants of average symptom scores” (24). Although they had suggested, in their presentation of the problem, that mobility should be treated as a subcategory of social change, the authors discussed their findings only in terms of methodological problems in the research design and in the data analysis, with references to its implications for “primary prevention” and for future research in the field. Almeida-Filho (25) investigated the relationships between social factors and mental health in the same sample studied by Santana (23) in Bahia, Brazil. He found stress levels to be higher among migrants than nonmigrants, and among individuals outside the labor market (unemployed and underemployed) compared with those regularly working. In addition, there was no association between stress levels and the time of urban residence or the cultural background. After controlling for combined and isolated effects of nine potential confounding factors through covariance analyses, only the hypotheis of a positive association between placement into labor force and mental health was not falsified. The author concluded that “geographical mobility EPIDEMIOLOGY OF MENTAL DISORDERS IN LATIN AMERICA as a life-change or as a culture-change may not be the basic process of interest for the study of social factors and mental illness in Third World social formations. Indeed, the fundamental process that should be taken into account in such research is the process of formation of an urban labor force and a reserve industrial army, essential conditions for the dependent capitalist development in those countries” (25). Some critical points The review of literature presented above provokes the easy conclusion that we are facing a confused picture, with a wide variety of methodologies producing contradictory results. In addition, one may think that scientific research into the relationships between social factors and mental illness has failed to contribute to the development of a coherent set of theories on the subject matter. But these conclusions are too easy and simple, and they may well be equivocal. A closer look at the overall content of this body of literature reveals not only some consistent findings, but also structured (even though sometimes not explicit) systems of explanation at the basis of such research. In other words, there is an order in that “disorder”. The investigations reviewed above had basic methodological problems, which ranged from several kinds of sampIing biases to the use of nonvalidated translations of foreign symptom scales as a measurement of individual mental health status. From this perspective, two af the most methodologically sophisticated studies (14,24) had similar sampling bias, insofar as both did not include urban unemployed or underemployed in their samples. On the other hand, only the Brazilian investigations (20,21,23,25) employed screening questionnaires especially developed for their socio-cultural context, as well as tested for validity and reliability. In addition, except for Inkeles & Smith (14), Micklin & Lion (24) and Almeida-Filho ( 2 5 ) , these studies did not control for the effect of potentially confounding factors. All these investigations had crosssectional designs, which severely limited the validity of their conclusions. In terms of theory, how did researchers in this field treat their findings? How did they arrange them into logical structures of explanation? A 7 superficial content analysis of this body of scientific literature made possible the identification of nine basic factors that have been regarded as causes, determinants, or independent variables in this research. As these factors are not mutually exclusive, different combinations of them have been used by some authors to build their proposed models of sociocultural causation of mental illness. They are here tentatively classified as part of a “sociologism” or a “culturalism” orientation. As part of a “sociologism” orientation, I include the notions of urban stress, goal-striving stress, life change, social support, and labeling. As explanations oriented by a “culturalism” approach to the problem, I will consider the notions of nostalgia (loss of culture), marginal man, cultural shock, and acculturation. The idea of urban stress is intimately connected with an ecological paradigm, as developed by the so-called Chicago school of human ecology, during the 1930’s. For these authors, the urban environment can be a source of many stressors that would make a normal personality development impossible, and would provoke abnormal behavioral responses. According to Faris & Dunham (26), in some areas in the inner city, social life “is terrifically harsh, intensely individualistic, highly competitive, extremely crude, and often violently brutal, and consequently more personalities have difficulty in coping with it.” Applying this interpretation to explain higher rates of mental disorders among migrants to urban areas, one could say that people who migrate tend to live in those deprived urban areas, the slums, where they become easy targets for those psychosocial stressors produced by such a “morbid” environment. Among Latin American studies, Rotondo ( l l ) , Brody (9), and Coutinho (24) employed this hypothesis without adequate connections to their respective frames of reference. From a critical standpoint, on the one hand, such an explanation indicates an abstract and loosely defined entity, the urban environment, as a source of determinants of psychopathology; on the other hand, it does not seek the basic conditions which forced the poor to get settled down, and to remain in what are, to follow their argument, the most unhealthy of all places. The notions of goal-striving stress, life change, social support and labeling will not be discussed here in detail because they have not been very influ- 8 N. DE ALMEIDA-FILHO ential in research covered by this review. Stephan & Stephan (7) and the IVAC survey (6) direct their analyses toward a goal-striving model, while only Micklin & Leon (24) mention the issue of life change in their explanation of mental health levels. Lack of social support and labeling phenomena were considered by Brody (9) as related to the risk of mental hospitalization among underprivileged social groups. The idea that psychopathology could be related to the experience of suddenly broken ties with the culture of origin was developed mainly among European authors, who were more concerned with labor immigration into certain countries like France, West Germany and Switzerland (27). In the literature sampled here, Seguin is the only one who explicitly mentioned this factor as a basic explanation for the etiology of his “migrant psychosomatic syndrome”. The notion “cultural marginality” was first proposed by anthropologists concerned with the issue of mental disorders and acculturation processes (28). Basically, this notion attempts to explain psychological problems of persons caught between two cultural systems, through stresses and anxieties related to this experience of double rejection. Among the Latin-American studies, Fried’s “sociocultural stress” and Brody’s explanation of the mental illnesses of Black migrants to Rio de Janeiro seem to be oriented by such a theory of the “marginal man”. Nonetheless, both interpretations, loss of culture and cultural marginality, are not part of the main stream of scientific research in this particular field. Undoubtedly the dominant paradigm in this literature has been the notion of culture change, and its correlate, modernization. As a result, in the literature concerned with the social and psychological consequences of modernization, predominantly produced by anthropologists, a general trend has been set, in which the notion of culture has been ascribed the status of a basic variable in causal models (29). Cassel et al. (30) give a model of health implications of cultural change which is perhaps paradigmatic of such an approach. These authors are explicitly concerned with acculturation as manifested by geographical moves from a rural traditional context to a modern industrial society. They assume that a traditional folk culture provides the rural migrant with a “design for living quite appropriate to the so- cial situation of the folk community, but a culture adapted to rural life may increase rather than decrease the stresses of the rural migrant to an urban situation” (30). This model holds that rural-urban migration may lead to cultural incongruency, depending upon the “fit” between the migrant’s culture and his new social situation. Such incongruities, in turn, tend to arouse excessive stress on the migrant’s affiliative network and on the individual personality that may or may not be absorbed by either system. In summary, the theory states that the nonabsorption of those “sociocultural stresses” is associated with the onset of psychiatric and psychosomatic symptoms. Although most of the research on the subject carried out in Latin America assumed theoretical models based on the notion of modernization (1,2,9-13,21,22), none made explicit such an elaborate model as Cassel et al. (30). The Peruvian studies did mention a cultural shock mechanism to account for the higher rates of psychological disorders among mountain Indian migrants to the cities. Caravedo et al. (10) went further in suggesting a conflict between modal personality traits and the urban culture, while Ponce (13) used the expression “cultural contrast” to describe better the preconditions of the cultural shock phenomenon. Indeed, cultural shock implies the notions of adaptation and cultural distance, in that large differences in symbolic patterns would lead to uncertainty and unpredictability, with the subsequent arousal of levels of anxiety and stress in the individual. In this sense, cultural shock is viewed as a consequence of the migration process (which therefore is taken as a change of cultures instead of a culture change), and it is regarded as the immediate determinant of psychiatric disturbance. On the other hand, the failure in finding a clean positive association between psychopathology and migration after controlled analyses led some authors to suggest alternative interpretations. Micklin & Leon (24), who initially considered migration as a life crisis causally related to psychological maladaptation, pointed out that insertion in the urban SOcia1 mobility system would be the main factor involved in being emotionally disturbed under such circumstances. In relation to this issue, Inkeles & Smith (14) made a similar suggestion. Despite indicating that, in this particular aspect, the problems of EPIDEMIOLOGY OF MENTAL DISORDERS IN LATIN AMERICA modernization in developing societies could be better interpreted as a process of formation of an urban labor force instead of a cultural change process, these authors did not present any theoretical model to explain their findings. Other authors (23,31), have proposed a comprehensive model for better understanding of such processes. According to them, the so-called development process places increasing numbers of the traditional population into a market economy, as a result of the penetration of capitalism into the rural sector. Following upon such changes, social classes may lose their position in the social structure, and their members, therefore, may undergo a process of absorption by the new emerging classes or be displaced from the new social order, and both moves may be simultaneous with geographical population movements. For Almeida-Filho (31), particularly in relation to the manner of insertion into the modern productive system, the condition of being displaced from the labor force implies, for the individual, extreme uncertainty and social stress, with temporary or permanent repercussions at a psychological level. Conclusion The present review shows an unexpected concentration of scientific efforts around the same basic question, the psychosocial outcomes of economic development in a given geographic area. This fact may be explained by the massivity and pervasiveness of the process of socio-economic change in Latin America, compelling social scientists as well as epidemiologists to try to understand better the health consequences of such social phenomena. It is also revealing that, in this area of research, the paucity in methodology has been somewhat balanced by a wide variety of theoretical approaches. In any event, despite all weaknesses, difficulties and lack of exchange with scientists in developed countries, social epidemiologic research in Latin America can undoubtedly contribute to the overall advancement of the field of psychiatric epidemiology. In this regard, I hope that the present review will be able to disclose to epidemiologists of developed countries some of the questions, problems and findings generated by Latin American researchers. 9 Acknowledgement This paper was originally written when the author was a Rockefeller Foundation Fellow at the Department of Epidemiology of the UNC School of Public Health at Chapel Hill. Berton Kaplan, Sherman James and Nancy Scheper-Hughes gave helpful criticisms and editorial help on an earlier manuscript. An anonymous reviewer of APS An contributed much to the present version of the paper. References 1. Seguin C . Migration and psychosomatic adaptation. Psy- chosom Med 1956:18404-410. 2. Fried J. Acculturation and mental health among migrants in Peru. In: Opler, M. (ed.) Culture and mental health. New York: Macmillan, 1959:113-121. 3. Mangin W. Mental health and migration to the cities: a Peruvian case. Ann New York Acad Sci 1960:94:911-917, 4. Mangin W., Cohen, J. Cultural and psychological characteristics of mountain migrants to Lima, Peru. Sociologus 1964:14:81-)3H. 5 . Mangin, W. Tales from the Barriadas. In: Mangin, W. (ed) Peasants in cities. Boston: Houghton Mifflin, 1970:55-61. 6. Instituto Venezoelano de Accion Comunitaria. Estudio sobre bairros de Caracas, Ediciones del Consejo Municipal, 1968. 7. Stephan W. Stephan C. Role differentiation, empathy and neurosis in urban migrants and lower class residents at Santiago - Chile. J Pers SOCPsycho1 1971:19:1-6. 8. Williamson R. Socialization, mental health and social class. A Santiago sample. SOCPsychiatry 1976: 1169-74. 9. Brody E. The lost ones. Social forces and mental illness in Rio de Janeiro. New York: International University Press, 1973. 10. Caravedo B., Rotondo H., Mariategui J . Problems de salud mental en el area urbana de Mendocita. In: Caravedo B, Rotondo H . , Mariategui J, eds. Estudios de Psiquiatria Social en el Peru, Lima: Ediciones des Sol, 1963:13-18. 11. Rotondo H. Psychological and mental health problems of urbanization based on case studies in Peru. In: Hauser P, ed. Urbanization in Latin America. New York: Columbia University Press, 1961:249-257. 12. Rotondo H., Mariategui J . , Bambaren C., et al. Personalidad basica, migracion y salud mental. Bol OPAS, 1962: 52(2):140- 142. 13. Ponce 0. Migracion interna a la metropolis. Lima: lmprenta de la Universidad de San Marcos, 1970. 14. Inkeles A., Smith D. The fate of personal adjustment in the process of modernization. Int Comp Sociol 1970:3277-291. 15. Horwitz J. lnvestigaciones epidemiologicas acerca de la morbilidad mental en Chile. Revista del servicio nacional de salud, 1958:3277-291. 16. Moya L., Marconi J., Horwitz J., et al. Estudios de Prevalencia de Desordenes Mentales en al Area Norte de Santiago de Chile. Acta Psiquiatr Psicol Am. Lat 1969:15: 137-148. 17. Leon C. Prevalencia de Transtornos Mentales en un Sector 10 18. 19. 20. 21. 22. 23. 24. 25. N. DE ALMEIDA-FILHO Urbano de Cali. Revista Columbiana de Psiquiatria. 1967:224-36. Tarnopolski A., Caetano R., Leva I., et al. Prevalenceof psychiatric morbidity in an industrial suburb of Buenos Aires. SOCPsychiatry 1977: 1275-88. Gonzalez M. Epidemiologia de 10s transtornos mentales en Bogota - Primera etapa. Acta Psiquiatr Psicol Am Lat 1978:2493-95. Almeida-Filho N., Santana V., Coutinho D., et al. Prevalencia de desordens mentais em una area industrial da regiao metropolitana de Salvador. Aspectos Metodologicos e Achados Preliminares. Universitas, 1983:3259-72. Coutinho D. Prevalencia de doencas mentais em uma comunidad marginal: um estudo do Maciel. Master's Thesis, University of Bahia, Brazil, 1976. Dutt J., Baker P. Environment, migration and health in Southern Peru. SOCSci Med, 1978: /2:29-38. Santana V. Estudo epidemiologico das doencas mentais em um bairro de Salvador. Master's Thesis, University of Bahia, Brazil, 1978. Micklin M., Leon C. Life change and psychiatric disturbance in the South American city: effects of geographic and social mobility. J Health Soc Behav 1978:/992-107. Almeida-Filho N., The psychosocial costs of development: lahor, migration and stress in Bahia, Brazil. Latin America Research Review 1982: /7(3):9 1 - 1 18. 26. Faris R., Dunham W. Mental disorders in urban areas. Chicago: University of Chicago Press, 1939. 27. Zwingman C. Uprooting and related phenomena: a descriptive bibliography. Geneva: World Health Organization, 1976. 28. Berry J . Acculturation as varieties of adaptation. In: Padilla A. ed. Acculturation: theory, models and some new findings. Boulder: Westerview, 1980:9-26. 29. Murphy HBM., Migration, culture and mental health. Psychol Med 1977: 7677-684. 30. Cassel J., Patrick R., Jenkins D. Epidemiological analysis of the health implications of culture change: a conceptual model. Ann N.Y. Acad Sci 1960:84939-943. 31. Almeida-Filho N. Urbanizacao e doenca mental. Revista da Associacao Psiquiatrica de Bahia. 1980: 1( 1):61-78. Address: Naomar de Afmeida-Filho, M.D. Departamento de Medicina Preventiva FMUFBA Rua Padre Feijo, 29-4th Floor Canela - Salvador - Bahia Brazil CEP 40000
