Ethnic variation in the prevalence of depression and anxiety in primary care: A systematic review and meta-analysis

Psychiatry Research 195 (2012) 91–106

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Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

Review article

Ethnic variation in the prevalence of depression and anxiety in primary care: A systematic review and meta-analysis Ilaria Tarricone a,⁎, Elisa Stivanello b, Francesca Poggi a, Vanessa Castorini a, Maila Valentina Marseglia a, Maria Pia Fantini b, Domenico Berardi a a b

Institute of Psychiatry, University of Bologna, Viale Pepoli 5, 40123 Bologna, Italy Department of Medicine and Public Health, University of Bologna, Via San Giacomo 12, 40127 Bologna, Italy

a r t i c l e

i n f o

Article history: Received 15 April 2010 Received in revised form 12 April 2011 Accepted 18 May 2011 Keywords: Anxiety Depression Ethnic groups Emigration and immigration

a b s t r a c t Primary care plays a key role in the detection and management of depression and anxiety. At present it is not clear if the prevalence of depression and anxiety in primary care differs between migrants and ethnic minorities (MI) and natives and ethnic majorities (MA). A systematic review and a meta-analysis of studies comparing the prevalence of depression and anxiety in MI and MA in primary care were performed. Studies were identified by searching MEDLINE, PsychINFO, EMBASE and through hand-search. We included 25 studies, most of which had a relatively small sample size. Significant variations were found in the prevalence of anxiety and depression across studies. Pooled analyses were carried out for 23 studies, based on randomeffects models. Pooled RR of depression and anxiety in MI were 1.21 (95% CI 1.04–1.40, p = 0.012) and 1.01 (95% CI 0.76–1.32, p = 0.971), with high heterogeneity (I² = 87.2% and I² = 73%). Differences in prevalence rates among studies can be accounted for by inclusion criteria, sampling methods, diagnostic instruments and study design. Further research on larger samples and with culturally adapted instruments is needed to estimate the prevalence of depression and anxiety in MI seeking help for these disorders. © 2011 Elsevier Ireland Ltd. All rights reserved.

Contents 1. 2. 3.

Introduction . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Characteristics of studies included . . . . . . . . . 3.2. Prevalence of depression . . . . . . . . . . . . . . 3.3. Prevalence of anxiety . . . . . . . . . . . . . . . 3.4. Risk factors for anxiety and depression . . . . . . . 3.4.1. Risk factors for depression: 9 studies . . . . . . . . 3.4.2. Risk factors for anxiety disorders: 5 studies . . . . . 3.5. Help-seeking behaviour, identification and treatment 4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Limitations . . . . . . . . . . . . . . . . . . . . 4.2. Conclusions and clinical implications . . . . . . . . Acknowledgement . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . .

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1. Introduction

⁎ Corresponding author at. Tel. + 39 051 6584247; fax: + 39 051 521030. E-mail address: [email protected] (I. Tarricone). 0165-1781/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2011.05.020

Depression and anxiety are an important burden worldwide and are the single largest contributors to years lived with disability by adults across the world (Sartorius et al., 1993; WHO, 2001; Lloyd, 2009). Primary care (PC) plays a key role in the detection and management of

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I. Tarricone et al. / Psychiatry Research 195 (2012) 91–106

depression and anxiety and forms the first step on the pathway to psychiatric care for people with depression and anxiety (WHO, 2001). In the last years, progress has been made in identifying and treating depression and anxiety at the primary care level. Since migrants and ethnic minorities (MI) are becoming a substantial part of the populations of Western countries, identification and management of depression and anxiety in these populations in the primary care setting is an important issue. Several studies have pointed out that both migrants and ethnic minorities are at higher risk of developing mental disorders, the former due to problems experienced during and after the migration process and the latter due to social and environmental difficulties (Bhugra, 2005). The increasing risk of mental disorders among migrants and ethnic minorities compared to natives and ethnic majorities is nowadays well established for severe mental disorders, and particularly for psychotic disorders (King et al., 1994; Bhugra et al., 1997; Harrison et al., 1997; Morgan et al., 2006; Coid et al., 2008). Depression and anxiety prevalence rates among migrants and ethnic minorities are more controversial: epidemiological studies conducted in the community have not revealed higher rates of depression or anxiety in migrants and ethnic minorities in Western countries (Nazroo, 1998; Sproston and Nazroo, 2002; Bhugra, 2004), while qualitative studies showed an elevated level of psychological distress in migrants and ethnic minorities, and an increasing trend in emergency room admissions for psychiatric problems and suicide attempts (Beliappa, 1991; Jacob et al., 1998; Schraufnagel et al., 2006). However, because of differences in the use of health services, in perceived needs (Fassaert et al., 2009) and problems of cultural and financial accessibility, results from population-based studies might not be directly transferable to the primary care setting. While evidence from the literature indicates that around 1/5 of patients seeking help and treated in a primary care setting are suffering from depression or anxiety (Sartorius et al., 1993; Meltzer et al., 1995; Singleton et al., 2001), at present studies on the prevalence of depression and anxiety in primary care attenders belonging to ethnic minorities and migrants are scanty. Estimating the prevalence of depression and anxiety in these populations at primary care level may contribute to better identification of the real extent of the problem and is the first step towards tailoring services. The primary objective of our study is to provide an up-to-date overview and meta-analysis of prevalence rates of depression and anxiety at primary care (PC) level in migrants and ethnic minorities (MI), compared with natives and ethnic majorities (MA). We also included secondary findings reported in the studies identified, such as differences between MI and MA in risk factors of depression and anxiety, help seeking behaviour and case identification by General Practitioners (GPs). 2. Methods A literature review was conducted. A study was considered eligible if: - it was carried out in a primary care setting, - the sample included adult patients, - the study provided the prevalence (or numerators and denominators) of any type of depressive and/or anxiety disorders (or symptoms) for migrants and ethnic minorities (MI) and natives and ethnic majorities (MA) groups in the country where the study was conducted. - it was published in English as a full report. We excluded studies providing prevalence data on depression and anxiety in specific groups not representative of the general population (e.g. patients with specific physical illnesses, such as diabetes or hypertension). Studies were identified by searching three electronic databases: MEDLINE, PsychINFO, EMBASE and using ad hoc developed search strategies (see Supplementary Material). The search was supplemented by references provided by personal bibliographies of the investigators and by hand searching content pages of journals considered relevant to the topic (e.g., Transcultural Psychiatry and Ethnic & Health, International Journal of Social Psychiatry, Research on Social Work Practice, Psychiatric Research, etc.). The search was run in June 2008 and updated in July 2010. Two reviewers (FP and VC) independently checked the title and abstract of all identified records and subsequently read the full text of articles screened to assess their

eligibility. In case of disagreement between the two reviewers, the controversy was resolved by a third researcher (IT). We considered different aspects of the sample selection procedure that could bias the results, including specific inclusion or exclusion criteria (e.g. only English speaking), the method of ethnic group classification (census information, self-report or third party reports), the use of validated diagnostic interviews or self-report instruments and consideration of potential confounders. We also calculated the power of the studies to detect differences in prevalence between MI and MA. Using a predefined data extraction sheet, the following data were extracted for each study: year and country of publication; study design; setting; classification strategy for ethnic definition (census information, self-report or third-party report); sample source, size and characteristics (age, gender, language, ethnic group distribution and migrant status), screening and diagnostic tool used; prevalence of depression or anxiety, OR or prevalence difference (unadjusted or adjusted) with confidence intervals (CI) and P value; other results including risk factors, help seeking behavior and problems of identification. Prevalence estimates and 95% confidence intervals were calculated if not reported in the articles Proportions were compared using the χ² or Fisher's exact test. The significance level was set at p = 0.05. If at least three studies reported prevalence data, their results were pooled in a meta-analysis. The DerSimonian–Laird method based on a random effects model was used to estimate pooled RR of anxiety and pooled RR of depression for all MI and MA (DerSimonian and Laird, 1986). We conducted a chisquare test of heterogeneity for RR of depression and RR of anxiety among all studies and within different subgroups. We considered I² b 25% to indicate low heterogeneity and I² N 75% to indicate high heterogeneity (Higgins and Green, 2008). Statistical analyses, including power analysis, were carried out by using STATA 10, Texas.

3. Results The literature search identified 541 articles, of which 181 were retrieved after screening titles and abstracts. Fig. 1 shows a flow chart of the studies included and excluded. After reviewing the full text, 25 articles were included. Of these, 20 compared the prevalence of depression among different ethnic groups (Zung et al., 1988; Hoppe et al., 1989; Lofvander and Papastavrou, 1993; Hearn et al., 1998; Shaw et al., 1999; Van Hook, 1999; Jackson-Triche et al., 2000; Olfson et al., 2000; Cooper et al., 2001; Arroll et al., 2002; Rollman et al., 2002; Bhui et al., 2004; Gallo et al., 2005; Gilgen et al., 2005; GoodyearSmith et al., 2005; Shvartzman et al., 2005; Grubaugh et al., 2006; Huang et al., 2006a, 2006b; Grubaugh et al., 2008) and 12 that of anxiety (Hoppe et al., 1989; Shaw et al., 1999; Olfson et al., 2000; Bhui et al., 2004; Thulesius et al., 2004; Goodyear-Smith et al., 2005; Weissman et al., 2005; Grubaugh et al., 2006; Johnson et al., 2007; Liebschutz et al., 2007; Brenes et al., 2008; Grubaugh et al., 2008). 3.1. Characteristics of studies included As reported in Table 1, the 25 studies were published between 1988 and 2008: 16 were conducted in the US, 3 in the UK, 1 in Israel, 2 in Sweden, 2 in New Zealand, and 1 in Switzerland. Eleven studies focused specifically on prevalence rates of depression and anxiety disorders in PC (Zung et al., 1988; Hoppe et al., 1989; Shaw et al., 1999; Jackson-Triche et al., 2000; Olfson et al., 2000; Arroll et al., 2002; Bhui et al., 2004; Weissman et al., 2005; Grubaugh et al., 2006; Liebschutz et al., 2007; Grubaugh et al., 2008); the other studies also presented prevalence figures but were focused on help-seeking behavior (Van Hook, 1999; Cooper et al., 2001; Gilgen et al., 2005) and identification and treatment of depression and anxiety disorders in PC (Lofvander and Papastavrou, 1993; Hearn et al., 1998; Rollman et al., 2002; Thulesius et al., 2004; Gallo et al., 2005; Goodyear-Smith et al., 2005; Shvartzman et al., 2005; Huang et al., 2006a; Huang et al., 2006b; Johnson et al., 2007; Brenes et al., 2008). Twenty-one had a one-phase design, and four had a two-phase design (Table 1). Sample sizes ranged from 76 to 21,504. Five studies had a power N80% of detecting significant differences among all groups (Jackson-Triche et al., 2000; Rollman et al., 2002; Gallo et al., 2005; Huang et al., 2006a; Liebschutz et al., 2007); in three studies (Hearn et al., 1998; Goodyear-Smith et al., 2005; Huang et al., 2006b) the power was N80% for only some comparisons. Participants were consecutive attenders of primary care clinics or were randomly

I. Tarricone et al. / Psychiatry Research 195 (2012) 91–106

643 records identified through database searching: - 58 Psychoinfo - 350 Pubmed - 235 Embase

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23 additional records identified through other sources

541 records after duplicates removed 360 records excluded 181 records screened

Reasons: - other target/no pevalence (209) - no english (11) - no primary care setting (39) - review/editorial (44) - children/adolescent (23) - no comparison (19) - specific population (15)

179 fulltext articles assessed for eligibility 155 full-text articles excluded 25 studies included in qualitative synthesis

Reasons: - other target/no prevalence (47) - no primary care setting (35) - review/editorial (7) - no comparison (64)

- 20 depression - 12 anxiety

23 studies included in metaanalysis -20 depression -10 anxiety

Fig. 1. Flow diagram of the search and selection process for studies included in the analyses.

recruited from GP databases or sign-in log lists (Table 1). Two studies (Van Hook, 1999; Grubaugh et al., 2008) focused on women and one on women with post-partum depression (Hearn et al., 1998). Six studies included only English-speaking patients (Hearn et al., 1998; Jackson-Triche et al., 2000; Cooper et al., 2001; Arroll et al., 2002; Goodyear-Smith et al., 2005; Liebschutz et al., 2007), one included only Hebrew-speaking patients (Shvartzman et al., 2005) and one only Swedish-speaking patients (Thulesius et al., 2004). The strategy used to classify ethnicity or migrant status was reported in 19 studies: in most cases ethnicity was self-reported by study participants; in one case (Shaw et al., 1999) it was based on a census using the generic labels of African Caribbean and White European. As reported in Table 1, Black MI were evaluated in 17 studies: 15 studies reported data on Afro-Americans and two on Afro-Caribbeans living in the UK; seven studies described Hispanic MI in the US; five

studies Asian MI in the US (3 studies) or UK (2 studies); other MI evaluated in the studies were Bosnians, Greeks, Middle East immigrants, Maori, Pacific Islanders Turks (Table 1). One study did not report the ethnic composition of the immigrants MI evaluated (Thulesius et al., 2004). Only five studies clearly defined migrant status of the sample as “first generation migrants” (Lofvander and Papastavrou, 1993; Thulesius et al., 2004; Gilgen et al., 2005; Shvartzman et al., 2005; Liebschutz et al., 2007). Sixteen studies used standardized diagnostic interviews to make a diagnosis according to DSM III, IV or ICD 10 criteria (Hoppe et al., 1989; Shaw et al., 1999; Jackson-Triche et al., 2000; Olfson et al., 2000; Cooper et al., 2001; Rollman et al., 2002; Bhui et al., 2004; Shvartzman et al., 2005; Weissman et al., 2005; Grubaugh et al., 2006; Huang et al., 2006a, 2006b; Johnson et al., 2007; Liebschutz et al., 2007; Brenes et al., 2008; Grubaugh et al., 2008). One of these studies used a

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Table 1 Study characteristics and main results. Authors, year of Study design, setting and publication, country sample source, research diagnostic tool and criteria Zung et al., 1988 USA

Depression Sample size, ethnic composition, gender, age, Outcome ethnic definition

Cross-sectional

1537

Consecutive attenders of 2 large primary care clinics in Durham, NC serving urban, lower-middle class population Zung self-rating depression scale

White (MA) 773

Black (B) 764

% female 68.7

Hoppe et al., 1989 USA

Two-week prevalence moderate-severe depressive symptoms One-year prevalence of minimal or greater depressive symptoms One-year prevalence of moderate-severe depressive symptoms Major depression or dysthymia

p

MA: 23% (95% CI 9.9–42.3)a 0.02

Mexican American (H) 168 Black (B) 22

B: 13.6% (95% CI, 2.9–34.9)a MA: 31.6% (95% CI 12.6– 56.6)

0.02

H: 9.8% (95% CI 5.3–16.2)

M ANH

Generalized anxiety disorder -Female

MA: 9.1% (95% CI, 6–16)

NS

B: 14.3% (95% CI 0.4–57.9) Cross-sectional

100

Mild depression

Consecutive first time attenders of a Stockholm suburban general practice

Greek (G): 50

Moderate depression

Sweden (Ma): 50 Mean age: 45.4

Severe depression Mild depression – Female Moderate depression – Female Severe depression Mild depression – Male Moderate depression – Male Severe depression – Male

B: 4.5% (95% CI 0.1–22.8)a MA: 10.5% (95% CI 1.3–33.1) H: 5.3% (95% CI 2.2–10.6) B: 0

B: 13.3% (95% CI, 1.6–40.5)

H: 11.1% (95% CI 3.2–26.1)

Ethnic definition: NA

NS

MA: 6% (95% CI 4.4–7.9) B: 6% (95% CI 4.4–7.9) b

H: 10.1% (95% CI 6.0–15.7)a MA N H

% female 67

MA: 10% (95% CI 2.1-26.5)a H: 6.5% (95% CI 3.3–11.4)a

MA: 21% (95% CI 18.1–24.0) B: 23% (95% CI: 20.1–26.2)

Anglo (Ma) 30

Comprehensive Psychopatological Rating scale (CPRS)

Generalized anxiety disorder

MA: 5.7% (95% CI 4.2–7.6) B: 6.2% (95%CI 4.5–8.1)

Random sample of attenders of Family Health Center, San Antonio, Texas Diagnostic interview schedule – structured interview (DIS)

Major depression or dysthymia – Male

Lofvander and Papastavrou, 1993 Sweden

p

MA: 14.9% (95% 12.4–17.6) B: 17% (95% CI 14.4–19.9)

220

Mean age 42.0 (S.D. 17.4) % female 75.6 Ethnic definition: Self reported

% (95% CI)

MA: 20.6% (95% CI 17.8–23.6) NS B: 23.2% (95% CI 20.2–26.3)

Cross-sectional

Major depression or dysthymia – Female

Outcome

Generalized anxiety disorder–Male

MA: 9.1% (95% CI, 1.6–16) H: 11.1% (95% CI 3.2–26.1) B: 14.3% (95% CI 0.4–57.9) b

b

MA: 10% (3.3–21.2)a G: 24% (13.1–38.2)a MA: 0 (0–.7.1)a G: 12% (4.5–24.3)a

NS

0 MA: 13.9% (4.7–29.52) G: 16% (5.5–33.7) MA: 0 (0–9.7) G: 13% (3.6–29.8) 0 MA: 0 (0–23.2) G: 36.8% (16.3–61.6) MA: 0 (0–23.2) G: 10.5% (1.3–33.1) 0

NS NS

0.027

0.038

0.013 NSb NS

I. Tarricone et al. / Psychiatry Research 195 (2012) 91–106

Ethnic definition: NA

Two-week prevalence of minimal or greater depressive symptoms Two-week prevalence minimal-mild depressive symptoms

Anxiety % (95% CI)

Table 1 (continued) Authors, year of Study design, setting and publication, country sample source, research diagnostic tool and criteria

Depression Sample size, ethnic composition, gender, age, Outcome ethnic definition

Hearn et al., 1998 UK

Cross-sectional

176

English speaking mothers attending 7 practices for their postnatal examination in the Bolton area Edimburgh Postnatal depression Scale (EPNDS)

Caucasian (Ma): 162

Shaw et al., 1999 UK Two-phase cross-sectional

Postnatal depression

p = 0.0003

Afro-Caribbean (AC): 2 Middle Eastern (ME): 1 Ethnic definition: NA 864

ME: 100% (95% CI 2.5–100)

White Europeans (Ma) 275

II phase: ICD-10 clinical diagnosis

African Caribbeans (AC) 337 Mean age AC 49.5 (S.D. = 14.8)

Weighted one-month prevalence of depressive disorders Weighted one-month prevalence of depressive disorders –Female Weighted one-month prevalence of depressive disorders –Male

W 51.3 (S.D. = 13.5) % female: 53 II phase: 230 White Europeans (Ma) 103 African Caribbeans (AC) 127 Ethnic definition: Based on 1991 census 321

MA: 9% (95% CI ,6–12)

NS

AC: 13% (95% CI, 10–16)

b0.05

difference 4% (95% CI 0–8)

NS

Weighted one-month prevalence of anxiety Weighted one-month prevalence of anxiety – Female

MA: 9% (95% CI, 6–12)

b0.05

Weighted one-month prevalence of anxiety: –Male

difference 6% (95% CI 2–10),

AC: 3% (95% CI, 1–5)

AC: 19% (95% CI 14–25) difference 8% (95% CI 1–15)

AC :5% (95% CI, 2–8) difference 5% (95% CI − 1–11) MA: 7% (95% CI, 3–11) AC: 0 difference 7% ( 95% CI 4–10),

NS

b0.05

MA: 7.5% (95% CI 3.7–13.4) NSb H: 8.6% (95% CI 3.5–17.0)

Hispanic (H) 81 Afro-American (B) 76 Native American (NA) 6 Asian-American (AS) 5 Mean age 39 (18–75) Ethnic definition: Self reported I phase: 21504

B: 6.6% (95% CI 2.2–14.7)

White (MA) 16989

p

MA: 10% (95% CI, 5–15)

White (Ma) 133

MD

% (95% CI)

MA: 11% (95% CI 6–16),

MA: 7% (95% CI, 3–10) AC: 4% (95% CI, 1–7) difference 3% (95% CI − 2– 8)

Current prevalence MD – Female

Outcome

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I phase: General health questionnaire (GHQ)

Jackson-Triche et al., Two-phase cross-sectional 2000 USA Consecutive English speaking (Wells et al., 1989) attenders of 3 Health care systems (large multispeciality group, Health Maintenance Organization, solo practice: family practice, internal medicine, cardiology, diabetology,

MA: 13.0% (95% CI 8.2– 19.1) AS: 54.5% (95% CI 23.4– 83.2) AC: 50% (95% CI 1.3–98.7)

I phase: 612 completed the screening

Consecutive English or Spanish speaking women attending 4 Florida primary medical clinics located in rural and medium size communities serving low income families Medical Outcomes Services (MOS)

p

Asian (AS): 11

Random sample from family health services authority lists of 4 general practices in Central Manchester

Van Hook, 1999 USA Cross-sectional

Anxiety % (95% CI)

MA: 3.4% (95% CI, 3.1–3.7)/ b0.05 AS b MA, adj °3.7% B, H B : 3.7%(95% CI 3.0–4.5)/ adj 3.1%

95

(continued on next page)

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Table 1 (continued) Authors, year of Study design, setting and publication, country sample source, research diagnostic tool and criteria endocrinology) I phase: 8-item screener for MD and dysthymia II phase: Diagnostic interview schedule (DIS)

Depression Sample size, ethnic composition, gender, age, Outcome ethnic definition Afro-American (B) 2535 Hispanic (H) 1009 Asian-American (AS) 527 Other (O) 446

Dysthymia

II phase: 2195 Ethnic definition: Self reported

Any depressive symptoms

Subtreshold depression

Olfson et al., 2000 USA

One-month prevalence MD

H: 4.8% (95% CI 3.5–6.3)/ adj 3.5% AS: 0.9% (95% CI 0.3–2.8)/ adj 0.8% O: 3.6 /adj 3.1 MA:3.1% (95% CI 2.8–3.4)/ adj 3.4% B: 3.9% (95% CI 3.2–4.5)/ adj 3.2 H: 6.8% (95% CI 5.4–8.6)/ adj 5.0% AS: 0.9% (95% CI 0.3–2.2) b/ adj 0.8 Other: 7.0% /adj 5.7% MA: 5% /adj 5.4 (95% CI 4.7–5.0) B:6% adj 5 (95% CI 5.1–7.0) H: 9.4%/adj 6.9 (95% CI 7.7–11.4) AS:1.6%/adj 1.4 (95% CI 0.6–3.0) Other: 7.5%/adj 6.2 (95% CI 5.1–10.2) MA: 14.5% /adj 15.3 (95% CI 1.3–1.6) B:18.5% adj 15.7 (95% CI 17.0–20.1) H: 20.6%/adj 16.3 (95% CI 18.2–23.1) AS:12.9%/ adj 11.4 (95% CI 10.2–16.1) Other: 18.1%/adj 15.7(95% CI 14.7–22.1) MA: 9.5%/adj 9.9 (95% CI 9.1–10.0) B:12.6% adj 10.7 (95% CI 11.3–13.9) H: 11.2%/adj 9.1 (95% CI 9.3–13.3) AS:11.3%/ adj 10.4 (95% CI 8.8–14.4) Other: 10.7%/adj 9.4 (95% CI 8.0–14.0) °adj for age, gender, site, income MA: 11.8 (95% CI: 0.4–23.2)

Cross-sectional

1007

Consecutive English or Spanish speaking attenders of urban general medicine practices in New York

White, non Hispanic (Ma) 34

H: 22.3 (95% CI 19.3–25.3)

Hispanic (H) 736 Black, non Hispanic (B) 219 Other (O) 18

B: 9.6 (95% CI 5.7–13.5) O: 5.3 (95% CI 0.0–16.3)

p

Outcome

% (95% CI)

p

One month prevalence of panic disorder

MA: 5.9 (95% CI: 0.0–14.2) H: 9.5 (95% CI 7.4–11.7)

NS

b 0.05 AS b all other groups

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Any depressive disorder

Anxiety % (95% CI)

NS

NS

One month prevalence of GAD

B: 5.0 (95% CI 2.1–7.9) O: 5.3 (95% CI 0.0–16.3) MA: 11.8 (95%

Table 1 (continued) Authors, year of Study design, setting and publication, country sample source, research diagnostic tool and criteria PRIME-MD Patient Health Questionnaire 9 (PHQ)

Depression Sample size, ethnic composition, gender, age, Outcome ethnic definition

Anxiety % (95% CI)

p

Outcome

% female: 75.0

Cooper et al., 2001 USA

Cross-sectional English speaking attenders of a urban university PHC Centers for Epidemiologic studies depression scale (CES-D) Structured Clinical Interview for DSM-IV (SCID-IV)

Arroll et al., 2002 Cross-sectional New Zealand Consecutive English speaking patients N 16 years attending an Auckland general practice Beck depression Inventory (BDI)

Afro-American (B): 27 MD

I phase: 7802 Caucasian (MA): 6586 African-American (B): 1216 II phase: 573 Caucasian (MA): 446 African-American (B): 127 Ethnic definition: Self reported 253

6 months prevalence of MD

Non Maori (MA): 189

Maori (Mao): 64

Median age: 45 years Ethnic definition: Self reported

Two-phase cross-sectional

I phase: 503

Consecutive attenders of 5 general practices in London I phase : GHQ-12 and Amritsar Depression Inventory (ADI) II phase : Clinical Interview Schedule, Revised (CIS-R)

English (MA) 251 Punjabi (P) 252 II phase: 379

English (MA) 180

MA: 17% (95% CI 7.3–30.0) B: 22% (95% CI 8.6–42.2)

NS

MA: 56% (95% CI 40.2–69.3)

Mean age: 34.8 % female: 72 Ethnic definition: Self reported

% female: 65

Bhui et al., 2004 UK

Dysthymia Minor depression

B: 74% (95% CI 53.7–88.8) MA: 4% 95% CI (0.5–14.0) B: 0% (95% CI 0–12.8) MA: 3.7% (95% CI 3.3–4.2)

0.001

I. Tarricone et al. / Psychiatry Research 195 (2012) 91–106

Rollman et al., 2002 Two-phase cross-sectional USA Attenders of an academically affiliated urban primary care clinic I phase : PRIME-MD (self administered part) II phase : Prime –MD (mood module)

p

CI: 0.4–23.2) H: 16.2 (95% CI 13.5–18.9) B: 10.5 (95% CI 6.4–14.6) O: 15.8 (95% CI 0.0–33.9)

Mean age: 53.2

Ethnic definition: Self reported 76 White (Ma): 49

% (95% CI)

AA: 7.2% (95% CI 5.8–8.8)

Current mild mood disturbance Current Borderline clinical depression Current Moderate depression Current Severe depression: Current Extreme depression: Current Depression

Weighted prevalence depression

MA: 13% (95% CI 8.7–18.9) Mao: 21% (95% CI 12.5– 33.4) MA: 5% (95% CI 2.2–8.8) Mao: 2% (95% CI 0.4–8.4)

NS

MA: 5% (95% CI 2.6–9.5)

Mao: 6% (95% CI 1.7–15.2) MA: 4% (95% CI 1.8–8.2) Mao: 3% (95% CI 0.4–10.8) MA: 1% (95% CI 0–5.6) Mao: 0% (95% CI 0.01–2.9) MA: 15% (95% CI 10.0–20.7) Mao: 11% (95% CI 4.5–21.2) MA: 18% 0.02 P: 28.8%

Weighted prevalence depression female

NSb

Adj° OR P vs MA = 1.73 (95% CI 1.08–2.8) Unweighted prevalence MA: 16.7% (95% CI 12.3–21.9) P: 27.4% (95% CI 21.9– 33.3)a MA: 19.5% (95% CI 12.8–

0.002

Weighted prevalence anxiety

MA: 8.3%

0.04

P: 2.5% Adj° OR P vs MA = 0.37 (95% CI 0.14–0.97) a Adj for age, gender, employment, social class, marital status, number of body systems affected by physical illness Unweighted prevalence 97

(continued on next page)

98

Table 1 (continued) Authors, year of Study design, setting and publication, country sample source, research diagnostic tool and criteria

Depression Sample size, ethnic composition, gender, age, Outcome ethnic definition

Mean age:

Cross-sectional Random sample of Hebrew speaking registered patients of 3 urban primary care clinics of Beer.Sheva Mini International Neuropsychiatric Interview (MINI)

Gallo et al., 2005 USA

PTSD

MA : 8% I : 18%

95% CI: NA

Ethnic definition: Self reported

Adj°OR : 3.8 (95% CI 1.4–10.2) °Adj for gender, QoL, period since trauma, rape)

2507 Israeli (MA): 753

MD

MA: 6.3% (95% CI 4.7–8.4)

Minor depression or only symptoms

I: 5.7% (95% CI 4.7–6.9) MA: 15.7% (95% CI 14.4– 17.9) I: 16.1% (95% CI 13.1–18.5)

NS

Not-Israeli (I): 1748

982

Consecutive English or Spanish attenders of a urban primary care clinic in New York City Life events checklist Post-traumatic stress disorder checklist-civilian version (PCL-C)

White/other, nonHispanic (MA): 48 Hispanic (H): 804 Black, non-Hispanic (B): 130 % female: 70 Ethnic definition: Self reported

Cross-sectional

338

Patients ≥65 years of 13 practices

White (MA): 221 Black (B): 117 % female: 76 Mean age: 75 Ethnic definition: Self reported

Significant depressive symptoms

MA: 62% (95% CI 55.2–68.4) 0.000 B: 40% (95% CI 30.4–48.7)

p

P: 2.4(95%CI 0.9–5.1)a

% female: 60

Cross-sectional

Centers for Epidemiologic studies depression scale (CES-D)

% (95% CI)

MA:6.8% (95% CI 4.0–10.6)

MA: 46 P: 45.5 Ethnic definition: Self reported 1113 Mean age: 46.6

Ethnic definition: Self reported

Weissman et al., 2005 USA

Outcome

One month prevalence PTSD Female

MA : 6.7 H : 15% B : 2.7%

One month prevalence PTSD Male

MA: 0 B: 6.3% H: 9.5% 95% CI: NA

b 0.05 I. Tarricone et al. / Psychiatry Research 195 (2012) 91–106

Shvartzman et al., 2005 Israel

Cross-sectional Consecutive Swedish speaking visitors to 10 health centres of one city and surrounding small towns and villages Post-traumatic Symptom Scale − 10 (PTSS-10)

p

27.8) P: 39.1% (95% CI 30.4–48.5) Adj°OR P vs MA = 2.74 (95% CI 1.48–5.08) °Adj for age, gender, employment, social class, marital status, number of body systems affected by physical illness

Punjabi (P) 209

Thulesius et al., 2004 Sweden

Anxiety % (95% CI)

Table 1 (continued) Authors, year of Study design, setting and publication, country sample source, research diagnostic tool and criteria

Depression Sample size, ethnic composition, gender, age, Outcome ethnic definition

Gilgen et al., 2005 Switzerland

146

Cross-sectional

Feeling sad in the previous month

Huang et al., 2006b USA

Grubaugh et al., 2006 USA

% female: 54 Mean age: 38.7 Ethnic definition: NA 1000

Anxiety

NS MA: 40.4% (95% CI 36.6–44.2) Mao: 47.1% (95% CI 35.1–59.4) Difference: 6.8 0.001 (95% CI: −22.7–36.2) PI: 56.2% (95% CI 47.7-64.5) Difference: 15.9 (95% CI: -1.9-33.7)

Current PTSD prevalence

MA: 11% (95% CI 8.2–14.1)

MA: 26% (95% CI 13.6–39.6)

Lifetime thoughts of self harm

Depression

Bo: 38% (95% CI 23.1–56.5) T: 14% (95% CI 6.9–25.8)

MA: 24.4% (95% CI 21.2– 27.8)

New Zealand European (MA): 676 Maori (Mao): 71

Mao: 26.1% (95% CI 16.8– 39.1) PI: 26.4% (95% CI 19.4– 34.4)

Multi item screening tool (MIST)

Pacific Island People (PI): 144 Other (O): 100

Difference (MA vs Mao): 1.7 (95% CI: −16.8–20.2) Difference (MA vs PI): 2.0 (95% CI: −12.9–16.9)

Mean age: 47 % female: 66 Ethnic definition: Self reported 3461

NS

Significant depressive symptoms

MA: 21.8% (95% CI 20.2– 23.4) AS: 15.2% (95% CI 13.0– 17.7)

b0.001

Clinically important depression Moderate depression

MA: 32.5 (95% CI 30.7– 34.4)c B: 30.4 (95% CI 26.8.–34.3) H: 30.0 (95% CI 27.1-33.0)

NS

African American (B): 808 Latino (H): 1253 Mean age: 38.1 % female: 83.7% Ethnic definition: NA

Moderately severe depression Severe depression

MA: 8.6 (95% CI 7.5–9.8)

713

Dysthymia

Consecutive patients from 5 general internal medicine clinics, 3 family practice clinics and 7 gynecology obstetrics outpatiens sitesa Patient Health Questionnaire 9 (PHQ-9) Cross-sectional

Non Hispanic, White (MA): 2520 Chinese American (AS): 941

Consecutive patients from 5 general internal medicine clinics, 3 family practice clinics and 7 gynecology obstetrics outpatient unitsa Patient Health Questionnaire 9 (PHQ-9)

Non Hispanic, White (MA): 3366

Cross-sectional

p

MA: 35% (95% CI 22.2–50.5) 0.008 Bo N T, S

Consecutive English speaking attenders of 20 urban Auckland GPs

Cross-sectional

% (95% CI)

Ethnic definition: NA 5427

B: 6.9 (95% CI 5.0–9.2) H: 8.7 (95% CI 7.0–10.7) MA: 4.5 (95% CI 3.7–5.4) B: 3.8 (95% CI 2.4–5.7) H: 3.9 (95% CI 2.7–5.3) MA: 3.0 (95% CI 2.3–3.7) B: 2.0 (95% CI 1.0–3.5) H: 1.8(95% CI 1.1–2.9) MA: 11% (95% CI 8.0–13.9)

0.03

I. Tarricone et al. / Psychiatry Research 195 (2012) 91–106

Huang et al., 2006a USA

Outcome

T: 55% (95% CI 41.7–67.5) Internal Swiss migrants (MA): 48 Bosnian (Bo): 36 Turkish/Kurdish (T): 62

Cross-sectional

p

Bo: 68% (95% CI 49.0–81.4) 0.03 Bo N T, MA

Consecutive outpatients aged ≥15 years of a university hospital and of 10 GPs in the area of Basel Explanatory Model Interview Catalogue (EMIC)

Goodyear-Smith et al., 2005 New Zealand

Anxiety % (95% CI)

NS before and after adjustment 99

(continued on next page)

100

Table 1 (continued) Authors, year of Study design, setting and publication, country sample source, research diagnostic tool and criteria

Mini International Neuropsychiatric Interview (MINI) Trauma Assessment for Adult Self Report Version (TAA) Clinician Administered PTSD scale (CAPS) Liebschutz et al., 2007 USA

Cross-sectional

Caucasian (MA): 460

Anxiety % (95% CI)

p

Outcome

AA: 13% (95% CI 9.5–18.2)

African-American (B): 253 Mean age: 61.2 % female: 7% Ethnic definition: Self reported 509

Consecutive English speaking primary care attenders at an urban university-affiliated outpatient department

White (W) 98

Composite International Diagnostic Interview (CIDI), PTSD module.

Black/African American (B) 300

Current PTSD prevalence

Lifetime PTSD prevalence

Other (O) 71

Cross-sectional Patients scheduled for visits to primary care clinics in Charleston, South

p

AA: 17% (95% CI 12.2–21.8) NS after adj

Hispanic/Latino (H) 40

Johnson et al., 2007 USA

% (95% CI)

I generation immigrant (I): 140 Not I generation immigrant (MA): 359 Mean age: 42 % female: 50.7 Ethnic definition: Self reported 295 Caucasians (MA): 216

One-year Panic disorder prevalence

MA: 25% (95% CI :20.7–29.9)/ adj° : 21% (95% CI : 17–26) I : 17% (95% CI :11.3–24.4)/ adj° : 13% (95% CI : 8–20) MA: 38% (95% CI :32.8 –43.12)/ adj° : 36% (95% CI : 31–42) I : 24% (95% CI :17.4 –32.2 ) b/ adj° : 22% (95% CI : 15–30) °Adj for for age, gender, income employment. marital status

MA : 11.6% (95% CI 7.6–16.6) B : 20.3% (95% CI 12.0–30.8)

NS

0.046 after adjustment

0.004 0.006 after adjustment

NS

I. Tarricone et al. / Psychiatry Research 195 (2012) 91–106

Random sample from master list of patients from 4 Veterans Affairs primary care clinics Short Form Health Survey (SF36)

Depression Sample size, ethnic composition, gender, age, Outcome ethnic definition

Table 1 (continued) Authors, year of Study design, setting and publication, country sample source, research diagnostic tool and criteria Carolina PRIME MD Panic Outcome Module

Brenes et al., 2008 USA

Grubaugh et al., 2008 USA

PD Module of the Structured Clinical Interview for DSM-IV (SCID-IV) Cross-sectional

Depression Sample size, ethnic composition, gender, age, Outcome ethnic definition

Anxiety % (95% CI)

p

African-Americans (B): 79 Mean age: 54.1 % female: 66.4% Ethnic definition: Self reported 1111

MA: 27.3% (95% CI 18.8– 37.1)

Short Form Health Survey (SF36)

Caucasian (MA) 99

B: 34.5% (95% CI 24.5–45.7) b

Mini International Neuropsychiatric Interview (MINI) Trauma Assessment for Adult Self Report Version (TAA) Clinician Administered PTSD scale (CAPS)

Afro-American (B) 84

OR B vs MA: 1.41 (95% CI: 0.75–2.64) Adj° OR B vs MA: 1.27 (95% CI: 0.65–2.46) °Adj for age

Mean age: 50 Ethnic definition: Self reported

NS

% (95% CI)

p

GAD

MA: 11.2% (95% CI 9.0–13.8) B: 14.2% (95% CI 10.7–18.0) b

NS

PTSD – Femaled

MA: 6.6% (95% CI 2.9–14.0)

NS before and after adjustment

Other anxiety (panic disorder, agoraphobia, GAD, social anxiety) – Female

B: 14.3% (95% CI 7.6–23.6)

OR B vs MA: 2.36 (95% CI 0.83–6.72) adj °OR B vs MA: 1.75 (95% CI 0.75–5.20) MA: 21.2% (95% CI 13.6–30.6) B: 26.2% (95% CI 17.2–39.9) b OR B vs MA: 1.32 (95% CI:0.67–2.71) adj OR B vs MA: 1.16 (0.57–2.39) °Adj for age

NA: not available/not clear. AS Asian American; B: Black, African American; Bo: Bosnian; G: Greek; H Hispanic, Mexican American; MA: majority ethnic group, Caucasian, White, non Hispanic, non Immigrant; ME: Middle East; Mao: Maori; O: other; I: Immigrant; P: Punjabi; Pi: Pacific Island people; T: Turkish. NS = non significant; MD = major depression; GAD = generalized anxiety disorders; PTSD = post-traumatic stress disorder. a Data obtained by working out the original data of the author. b CI or p value calculated from the original data of the author. c Part of the White group was included in both Huang et al., 2006a, and Huang et al., 2006b. d Part of the study population was potentially included in both Grubaugh et al., 2006, 2008.

I. Tarricone et al. / Psychiatry Research 195 (2012) 91–106

White (MA) 720 Consecutive attenders of 1 universityaffiliated family medicine clinic and 1 university-affiliated internal medicine clinic Patient Health Questionnaire 9 (PHQ-9) Afro-American (B) 383 Mean age: 50.12% female: 73.2 Ethnic definition: Self reported Random sample of female attenders of 183 MD or dysthymia – 4 Veterans Affairs primary care clinics Femalec

Outcome

101

102

I. Tarricone et al. / Psychiatry Research 195 (2012) 91–106

culturally adapted diagnostic interview (Bhui et al., 2004). The other studies did not use diagnostic interviews, but only screening questionnaires to assess the presence of depressive or anxiety symptoms; Gilgen et al., 2005 used a data collection instrument for cross-cultural research which combines epidemiological and ethnographic research approaches. 3.2. Prevalence of depression We found 20 articles reporting prevalence data on current depression (from depressive symptoms to severe major depressive disorder). Seventeen studies reported prevalence data for both genders and three for women only. We found a great variation in depression rates among studies, both in MI and MA. In the 12 studies using diagnostic standardized interviews, Depression (Major depression, Dysthymia or Minor Depression) rates in MA ranged from 3% for severe depression (Huang et al., 2006b) to 32.5% for clinically significant depression (Huang et al., 2006b); depression rates in MI ranged from 0% for Major Depression (Cooper et al., 2001), to 74% for Minor Depression (Cooper et al., 2001). In the eight studies that did not use standardized diagnostic interviews , depression rates in MA ranged from 0 for severe depression (Lofvander and Papastavrou, 1993) to 62% for clinically significant symptoms (Gallo et al., 2005) and to 68% for sadness (Gilgen et al., 2005) in MI. Out of the 20 studies on depression (Table 1), 10 reported for at least one rate a significant difference between MI and MA: four studies reported higher prevalence rates in MA (Hoppe et al., 1989; JacksonTriche et al., 2000; Gallo et al., 2005; Huang et al., 2006a) and six reported higher prevalence rates in MI (Lofvander and Papastavrou,

1993; Hearn et al., 1998; Rollman et al., 2002; Bhui et al., 2004; Gilgen et al., 2005; Grubaugh et al., 2006). In the meta-analysis of the 20 studies, the pooled relative risk of depression in MI compared to MA was 1.21 (95% CI 1.04–1.40, p b 0.012) (Fig. 2). A high heterogeneity was found within studies (I2 = 87.2%). This heterogeneity persisted after excluding studies carried out in the elderly (N64 years, Gallo et al., 2005) and women (Hearn et al., 1998; Van Hook, 1999; Grubaugh et al., 2008). It also persisted when the metaanalysis was run after excluding studies that did not use standardized diagnostic interviews (I2 = 88.7%), studies conducted in the US (I2 = 81.5%) or those considering only data of black MI vs MA (I2 = 82.9%), or of immigrant MI vs MA (I2 = 83.8%). Heterogeneity was low when considering studies published from 2000 on and carried out on English-speaking attenders (pooled RR: 1.25, p b 0.001; 95% CI: 1.17– 1.33; I 2 = 0). In the meta-analysis of the eight studies not using standardized diagnostic interviews, the pooled relative risk of depression in MI compared to MA was 1.48 (95% CI 1.07–2.06, p = 0.017; I 2 = 78.7%). Meta-analysis of the 12 studies using diagnostic interviews led to a RR very similar to the one for all 20 studies on depression (RR = 1.18, 95% CI 0.99–1.40; p = 0.061, I 2 = 88.7%). 3.3. Prevalence of anxiety We found 12 studies with prevalence data on current anxiety (anxiety or more specifically panic disorders or GAD or PTSD). Ten studies reported prevalence data on both genders and two on women only. Among the 10 studies that used standardized diagnostic interviews, the rate of anxiety (GAD, Panic Disorders, PTSD) ranged from

N.

N.

majority

minority

Study

group

group

RR (95% CI)

Weight

Zung, 1988

773

764

1.13 (0.93, 1.36)

6.55

Hoppe, 1989

30

190

0.45 (0.21, 0.97)

2.46

Lofvander, 1993

50

50

3.60 (1.45, 8.94)

1.94

Hearn, 1998

162

14

4.41 (2.41, 8.07)

3.30

Shaw, 1999

275

337

1.44 (0.90, 2.28)

4.26

Van Hook, 1999

133

157

1.14 (0.80, 1.64)

5.13

Jackson-Triche, 2000

16989

4515

1.26 (1.17, 1.36)

7.22

Olfson, 2000

34

973

1.62 (0.64, 4.12)

1.88

Cooper, 2001

49

27

1.28 (1.07, 1.52)

6.65

Arroll, 2002

189

64

0.74 (0.34, 1.61)

2.42

Rollman, 2002

6586

1216

1.95 (1.54, 2.46)

6.19

Bhui, 2004

251

252

1.64 (1.16, 2.30)

5.28

Gallo, 2005

221

117

0.63 (0.50, 0.81)

6.09

Gilden, 2005

48

98

1.67 (1.10, 2.53)

4.65

Goodyear-Smith, 2005

673

211

1.09 (0.84, 1.41)

5.98

Shvartzman, 2005

753

1748

0.98 (0.83, 1.15)

6.76

Grubaugh, 2006

458

253

1.55 (1.06, 2.27)

4.93

Huang, 2006a

2520

1572

0.93 (0.84, 1.02)

7.13

Huang, 2006b

2520

941

0.70 (0.59, 0.83)

6.71

Grubaugh, 2008

99

84

1.27 (0.82, 1.96)

4.48

1.21 (1.04, 1.40)

100.00

%

Overall (I-squared = 87.2%, p = 0.000) NOTE: Weights are from random effects analysis

.112

1

8.94

Fig. 2. Forest plot of RR for the effect of MI group compared with MA group on the prevalence of depression.

I. Tarricone et al. / Psychiatry Research 195 (2012) 91–106

2.5% in (Bhui et al., 2004) to 26% (Grubaugh et al., 2008) in MI, and from 6.6% (Grubaugh et al., 2008) to 25% (Liebschutz et al., 2007) in MA. Five of 12 studies (Shaw et al., 1999; Bhui et al., 2004; Thulesius et al., 2004; Goodyear-Smith et al., 2005; Liebschutz et al., 2007) found statistically significant differences in prevalence rates, with all but Thulesius et al. (2004) and Goodyear-Smith et al. (2005) reporting higher rates in MA. The pooled relative risk of anxiety in MI compared to MA in 10 studies providing complete data was 1.01 (95% CI: 0.76–1.34, p = 0.971) (Fig. 3), with substantial heterogeneity among studies (I2 = 73.0%). Subgroup analyses according to the use of standardized diagnostic tools or country of publication (US, non-US) did not identify a specific source of heterogeneity. Heterogeneity within studies persisted after excluding studies carried out in women or considering only data of black MI vs MA. Pooled analyses on specific diagnostic groups did not reveal any significant differences between MA and MI. 3.4. Risk factors for anxiety and depression Among the 25 studies identified, 10 studies reported results in terms of risk factors for depression (9 studies) or anxiety disorders (5 studies). 3.4.1. Risk factors for depression: 9 studies Among studies comparing rates of depression in men and women, only five reported results for MI (Hoppe et al., 1989; Lofvander and Papastavrou, 1993; Shaw et al., 1999; Bhui et al., 2004; Gilgen et al., 2005). In the Hoppe et al. study (1989) depression was more prevalent in women than men only in MA. The studies conducted in the UK emphasized a higher prevalence of depression among women and this excess of depression among women was found in ethnic mino-

103

rities, both in the Afro-Caribbean sample (Shaw et al., 1999) and in the Punjabi sample (Bhui et al., 2004). Lofvander and Papastavrou (1993) observed this risk factor in Swedish MA, but not in Greek MI, where men were at higher risk. Gilgen et al. (2005) found that Bosnian men were more likely than Bosnian women to report sadness. MI men evaluated by these two studies (Lofvander and Papastavrou, 1993; Gilgen et al., 2005) have been exposed to high degree of social difficulties during migration and adaptation process in the host country. Some studies described other risk factors of depression in MI: stressful life events, mostly related to financial losses (Jackson-Triche et al., 2000); physical impairment (Bhui et al., 2004); two or more children, the lack of close family ties, low integration at the family level (Hoppe et al., 1989); episodes of physical violence (van Hook, 1999). Length of stay in Israel was associated with depression in the Shvartzman et al. (2005) study but length of stay in the UK was unrelated with depression in the study by Bhui et al. (2004). In the study by Gilgen et al. (2005), the migration history was found to impact on illness experience; particularly, Bosnian migrants perceived their past war experience and their uncertain present situation as the cause of their current illness.

3.4.2. Risk factors for anxiety disorders: 5 studies The Hoppe et al. study (1989) showed that in MI (but not in Anglo MA) anxiety disorders in men were about twofold compared with women; on the contrary, Shaw et al.'s study (1999) reported higher rates in women than in men and this disproportion was particularly relevant among Afro-Caribbean MI. Weissman et al. (2005) reported that gender differences within Hispanics disappeared after controlling for education and marital status. African-American MI were more likely than Caucasian MA to have experienced combat exposure or physical assault (Grubaugh et al.,

N.

N.

majority

minority

Study

group

group

RR (95% CI)

Weight

Hoppe, 1989

30

190

0.63 (0.19, 2.11)

3.94

Shaw, 1999

275

337

0.33 (0.16, 0.67)

7.76

Olfson, 2000

34

973

1.32 (0.63, 2.76)

7.55

Bhui, 2004

251

252

0.35 (0.14, 0.88)

5.82

Goodyear-Smith, 2005

674

214

1.32 (1.13, 1.54)

15.64

Grubaugh, 2006

458

253

1.23 (0.82, 1.85)

12.07

Liebschutz, 2007

359

140

0.68 (0.46, 1.03)

12.11

Johnson, 2007

216

79

1.75 (0.99, 3.10)

9.59

Brenes, 2008

720

383

1.25 (0.91, 1.73)

13.43

Grubaugh, 2008

99

84

1.43 (0.95, 2.15)

12.09

1.01 (0.76, 1.32)

100.00

%

Overall (I-squared = 73.0%, p = 0.000)

NOTE: Weights are from random effects analysis

.141

1

7.1

Fig. 3. Forest plot of RR for the effect of MI group compared with MA group on the prevalence of anxiety.

104

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2006, 2008) whereas the latter were more likely to report child sexual abuse (Grubaugh et al., 2008). 3.5. Help-seeking behaviour, identification and treatment Among the studies identified, seven give results on help-seeking behaviour and four on problem identification. Shaw et al. (1999) found no differences between African-Caribbeans and White Europeans in the help-seeking pattern; however AfricanCaribbeans were more likely to seek further support from a non-medical setting. Some studies (Cooper et al., 2001; Goodyear-Smith et al., 2005; Grubaugh et al., 2006; Grubaugh et al., 2008) likewise did not find significant differences in the use of health services or mental health services, or in the rate of patients seeking help for depression or anxiety among different ethnic groups. In the Van Hook study (1999), both MI and MA reported difficulties in access to care, mostly related to the separation between general medicine and mental health services. In this study, African American women were especially likely to report stigma as the main barrier to care. Differences in the help-seeking behavior were reported by Gilgen et al. (2005): help from GPs was sought most often by Bosnians, while in hospital outpatient departments by Turks and Swiss. In the Shaw et al. study (1999) mood and anxiety disorder detection by GPs appeared low, particularly in African Caribbeans: psychological problems were identified in 27% of African Caribbeans and in 52% of White Europeans. Brenes et al. (2008) also pointed out that, compared to African-Americans, White Americans had a higher chance of receiving medical treatment for anxiety and depression (66.7% vs 41%; p = 0.004) and of being referred to mental health specialists (50.0% vs 24.1%; p = 0.003). Rates of recent mental health treatment did not differ significantly across the ethnic groups in the study by Olfson et al. (2000). Older black patients were less likely to have been actively managed for depression in the six months prior to interview (Gallo et al., 2005). 4. Discussion This review of the international literature identified only a few studies reporting prevalence of depression and anxiety in ethnic groups and natives in a primary care setting. Our meta-analysis indicates a slightly greater risk of depression among migrants and ethnic minority groups (RR = 1.2); this risk is increased in the subset of studies that did not use diagnostic interviews (RR = 1.4). We found that heterogeneity within studies was low only when considering studies published from 2000 and carried out on English-speaking attenders (pooled RR: 1.25, p b 0.001; 95% CI: 1.17–1.33; I 2 = 0). As far as anxiety is concerned, no differences between MA and MI were found in the meta-analysis, with large heterogeneity among studies. We found that the prevalence of depression and anxiety displayed significant variations across studies, especially for depression prevalence rates, in line with WHO findings. The WHO estimated an overall prevalence of depression and anxiety of 24% in primary care, with a large variability among countries (WHO, 1992). A similar variability was found in a systematic review of population-based depression and anxiety prevalence studies among labour migrants (Lindert et al., 2009). One narrative review comparing prevalence rates of major depression between Latinos and White yielded inconsistent results (Lewis-Fernández et al., 2005). Our results indicate that female gender confers an increasing risk of depression in some but not all MI groups. This is only partially consistent with the results of a meta-analysis, conducted in Europe, showing that the risk of depressive disorder in women is about twice that of men (Fryers et al., 2004). Interestingly, the two studies (Lofvander and Papastavrou, 1993; Gilgen et al., 2005) showing higher risk of depression among MI men found high social distress among migrant groups (Greek migrants in North Europe and Bosnian refugees). Hoppe et al. (1989) did not find a higher prevalence of depression in MI women

and concluded that family ties may buffer the impact of environmental stressors, such as those associated with low socioeconomic status. In a few studies, higher susceptibility to depression and anxiety in ethnic minorities was associated with the presence of additional risk factors, such as a traumatic migration history, higher family and social burden, a high number of children, violence in the domestic setting, low integration and uncertain future (Hoppe et al., 1989; Van Hook, 1999; Gilgen et al., 2005). Thus, the role of potential risk factors for depression and anxiety in MI should be deeply evaluated in further studies. Our review also addresses help-seeking behavior, detection and treatment of anxiety and depression among migrants that other authors have highlighted (Gillam et al., 1989; Commander et al., 1997; Husain et al., 1997; Borowsky et al., 2000; Melfi et al., 2000). Because our review only included studies carried out in primary care, results cannot be generalized to people who did not access primary care services for economic, cultural or life event-related reasons. However, we found that almost all the studies reviewed did not report different help-seeking behavior among MI, while they reported a lower proportion of mood and anxiety disorders detected by GPs among MI. In the Bhui et al. (2001) study GPs were less likely to detect depressive disorders among Punjabi people compared to English people, even if there was no significant cultural difference in help-seeking behaviors and physical complaints. The authors of this study (Bhui et al., 2001) argued that Punjabi were less willing to express depressive ideas and this could hinder case detection. Shaw et al. (1999) argued that training of GPs is required to ameliorate cultural competence in case identification. 4.1. Limitations Some limitations related to the studies included in this review should be acknowledged. First, some of the studies were underpowered to detect differences in prevalence because of their small sample size. Second, the results of some studies may be influenced by crosscultural issues. One of these issues, raised by Kleinman (1980) and directly connected to the debate between psychiatry and anthropology, concerns the effective validity of standardized diagnostic interviews among non-western cultural groups. For instance, Alegría et al. (2008) found that the CIDI, used by Liebschutz et al., 2007, poses problems in assessing GAD and PTSD for Latinos. Other authors argued that the self-report screening instruments and the diagnostic interviews used in population studies may not be suitable for identifying depression and anxiety in ethnic minorities or migrants, who express their distress using particular idioms that need cultural competence to be recognized (Bhugra, 2005; Bhui et al., 2007). Bhui et al. (2004) pointed out that, although GHQ-12 is a well-established screening tool, it may prove to be not specific enough for South- Asian populations. Third, some studies include only individuals speaking the language of the natives or of the majority group, which may introduce a potential selection bias. The observed heterogeneity in prevalence rates and in ethnic differences among studies can be accounted for by inclusion criteria, sampling methods, diagnostic instruments and study design. The psychiatric problems investigated varied from symptomatic to severe disorders, with a focus on specific disorders (PTSD or dysthymia) or on the whole spectrum of anxiety and depression. The populations included differed in many respects. Studies were conducted in different countries, in urban or rural settings, from the late 1980s to late 2000s and in some cases were focused on specific populations (only among veterans for example). In addition, there was a high heterogeneity in the populations compared, between and within studies. For example, under the label ‘Black Caribbean native’ Shaw et al. (1999) included people coming from different Caribbean islands with different cultures or born in Africa; moreover, in some studies the majority group consisted of only English or Anglo-Americans, and in other had a broader meaning. Again the label ‘Latinos’, used by Van Hook (1999), subsumed different

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Hispanic American populations and people from different South American countries. The populations compared may not share the same risk factors for anxiety and depression. Ethnic minorities like Blacks in the US, that may have lived in the host country for centuries or like the Maori that are real natives, do not carry the burden of a personal migration history for example. Accessibility to primary health care or perceived needs might vary across the population included and explain part of the heterogeneity. 4.2. Conclusions and clinical implications Our study is the first to our knowledge to carry out a meta-analysis of the studies on the prevalence of depression and anxiety in MI compared to MA in primary care. The existing studies only allow one to draw tentative conclusion about the prevalence of depression and anxiety in migrants and ethnic minorities attending primary care facilities, but they do clearly suggest that primary care physicians should be aware that depression and anxiety in migrants and ethnic minorities are common problems. Further studies with an adequate sample size and culturally adapted instruments are warranted to investigate the prevalence of depression and anxiety and to improve doctors' awareness of psychiatric disorders, thereby facilitating the provision of appropriate care and avoiding unnecessary prescription of drugs and tests among migrants and minority groups attending primary care clinics. Supplementary materials related to this article can be found online at doi:10.1016/j.psychres.2011.05.020. Acknowledgement We thank Dr. Marco Menchetti for his comments on an earlier version of this paper.

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