Hispanic immigrants in the USA: social and mental health perspectives

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Hispanic immigrants in the USA: social and mental health perspectives Renato D Alarcón, Amrita Parekh, Milton L Wainberg, Cristiane S Duarte, Ricardo Araya, María A Oquendo Lancet Psychiatry 2016; 3: 860–70 Mayo Medicine School, Mayo Clinic, Rochester, MN, USA (R D Alarcón MD); Universidad Peruana Cayetano Heredia, Lima, Peru (R D Alarcón); Dasra, Mumbai, India (A Parekh MSW); New York State Psychiatric Institute, Columbia University, New York, NY, USA (M L Wainberg MD, C S Duarte PhD); London School of Hygiene & Tropical Medicine, London, UK (R Araya PhD); and Department of Psychiatry, Columbia University Medical Center, New York, NY, USA (M A Oquendo MD) Correspondence to: Dr María A Oquendo, Department of Psychiatry, Columbia University Medical Center, 1051 Riverside Drive, New York, NY 10032, USA [email protected]

Hispanic immigration in the USA and its effect on many areas of US society are of great relevance to health care, public health, mental health, and medical and social sciences. In this report, we review and discuss pertinent literature on causes, procedures, and eventual outcomes of Hispanic migration waves throughout the last four decades. Hispanic immigrants do not constitute a monolithic group, despite the clear predominance of Mexican and Mexican-American segments. Common features of Hispanic immigrants include a younger average age, higher presence of married households, and lower educational levels than the overall US population. Differences within the Hispanic immigrant population are present in naturalisation figures, English language fluency, occupational and income status, health insurance coverage, and sense of accomplishment in the host society. We examine most of these aspects in the context of the so-called Hispanic paradox, presented as both a cause and a result of a heavily discussed acculturative process. We investigate prevalence and other data on depression, anxiety, substance abuse, and psychotic syndromes, with emphasis on the need to do further neurobiological, epigenetic, and sociocultural research in the Hispanic population.

Introduction Immigration is one of the most powerful social phenomena in the contemporary world.1 Throughout history, the population of the USA has frequently changed because of waves of immigrants from practically every region of the world. This Review will focus on the immigration process as experienced by Hispanic men and women (panel 1), examining relevant sociodemographic data as well as epidemiological and clinical psychopathology studies. We present evidence of the heterogeneity of the US Hispanic immigrant community, thus emphasising a feature whose impact has been ignored or, at best, minimised by public and mental health officers, agencies, and political decisionmaking authorities. We also discuss the acculturative experience and critically assess the so-called Hispanic paradox. We conclude with reflections on the public and mental health implications of the immigration process. Geographically, Hispanic immigrants in the USA come from Mexico, twenty other countries in the Caribbean region, Central and South America, and Spain itself2 (table). They live mostly in the southwest, along most of

the west coast, and in south Florida. Since the late 1990s, Hispanics in the USA (35·6% of whom are foreign born)3–5 have consistently constituted just over half of the total foreign-born population. According to the 2013 census, 54 million Hispanics were living in the USA, which constituted 17% of the total population and the largest minority in the country.6,7 Historically, Mexicans have always been the largest subgroup (33 million, or 63% in 2013, including Mexican-Americans) and growth of the immigrant population in 2015 was led by 740 000 Mexicans.8 The other Hispanic subpopulations include Cuban, Puerto Rican, Central American and Caribbean, South American, and Spanish people. Hispanics are the youngest ethnic group (median age 27·6 years) in the USA, whereas non-Hispanic white people are the oldest (42·3 years). The elderly Hispanic subpopulation makes up one of the largest proportions of the so-called baby-boomers (11%) projected to be almost 13% in 2060, when Hispanics will constitute 31% of the total US population.9 Additional demographic and socioeconomic data about the Hispanic subpopulations are presented in panel 2.

Panel 1: Definitions The term Hispanic throughout the article designates, for the most part, individuals who have migrated to the USA from Central and South American countries (including Mexico and Brazil) and Spain or their ancestors (if they have lived in the USA for generations), who identify themselves as such and share language, religion and other cultural features. Different studies may refer to one or many of these characteristics. The authors consider also the term Latino as describing the same (used in some of the bibliographic references) as synonymous. Finally, non-Hispanic whites is a label frequently used in epidemiological and other research works to generally identify American-born individuals, also known as Caucasians.

860

Number, in millions (2000–12) Mexican

17–30

Growth (2000–12) 54%

% of Hispanic population (2013) 65%

South American

1·4–2·8

50%

Cuban

1·2–1·8

44%

6·3% 4·8%

Puerto Rican

3·4–4·6

36%

12·1%

Central American

6·1–8·3

14%

5·7%

Caribbean

3·9–4·0

8%

4·9%

Spanish

0·1–0·6

600%

1·5%

Other or unknown

··

··

1·9%

Table: Hispanic immigrant subpopulations in the USA,2–5 total Hispanic immigrant population in 2013 was 54 million

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Panel 2: Demographic and socioeconomic data on the total US Hispanic population (2012–13)4–7,10,11 Population statistics • Population size, July 1, 2013: 54 million (17% of total US population) • Growth, July 1, 2012, to June 30, 2013: 1·1 million (2%) • Population projection for 2060: 128·8 million (31% of total US population) • States with Hispanic populations of 1 million or more: Arizona, California, Colorado, Florida, Illinois, New Jersey, New York, and Texas • State with the largest population: California (14·7 million) • State with the highest proportion of Hispanic people among total population: New Mexico (47·3%) • County with the largest population: Los Angeles, CA (4·8 million) • Number of states with Hispanic people as the largest ethnic minority: 22 • Median age: oldest (Florida), 46·5 years; youngest (California), 33·4 years Family status and education • Number of Hispanic households in the USA: 11·9 million • Proportion of Hispanic people who speak only Spanish at home: 73·9% (38·3 million) • Proportion of Hispanic households that consist of married couples: 62·4% (total US population, 73·2%); highest, Cubans (64%); lowest, Caribbeans (18%) • Proportion of Hispanic households that consist of married couples with children younger than 18 years: 58·5% (total US population, 40·3%)

The reasons and routes of Hispanic immigration to the USA Economic factors Poverty and scarce employment opportunities are probably the main reason for migration of Hispanics,8,9 most of whom join the US labour force, often at the lowest income level.12 The long, arduous, and emotionally painful journey is also expensive, as a result of high payments demanded by the so-called coyotes: organised gang-like groups assisting immigrants to illegally cross the border between Mexico and the USA.

• Proportion of Hispanic children living with two parents: 65·1% (total US population, 68·5%) • Proportion of Hispanic population who are enrolled in elementary and high school: 23·3% • Proportion of Hispanic population who graduate high school: 64% • Proportion of Hispanic population who are enrolled in university: 6·8% (1·8 million) • Proportion of Hispanic population who have a bachelor’s degree: 13·8% (4 million) • Proportion of Hispanic population (aged >25 years) who have an advanced degree: 4·5% (1·3 million) Employment history and economic status • Median income: US$39 005—South Americans, $49 741; Mexicans, $35 254 (US-born non-Hispanics, $83 369) • Proportion of Hispanic population living in poverty (income <$23 000 for a family of four): 25·6% • Proportion of Hispanic married couples with children younger than 18 years at home, both spouses employed: 43·1% (total US population, 58·0%) • Proportion of Hispanic population older than 16 years who are in the labour force: 67·1% • Proportion of Hispanic population older than 16 years who are working in management, business, science, or arts occupations: 19·5% • Percentages are out of the total Hispanic population in the USA, unless otherwise stated

motivated immigrants also come from Central America (Nicaragua, Guatemala, El Salvador) and South America (Chile, Venezuela, Bolivia, Ecuador). Similarly, many Colombian immigrants migrated to the USA because of the instability of almost four decades of civil war between the government, guerrilla groups, and paramilitary groups in Colombia, fostered by narcotictraffic organisations.14 Another pervasive factor is homophobic violence that has forced hundreds to seek asylum in the USA; however, once in the USA, they can continue to experience the same rejection by the Hispanic communities and sectors of the host society.15–20

Political and social factors Voluntary or government-sanctioned exile, escape from death threats, police persecution, judicial sentences or jail terms, oppressive life under authoritarian regimes, increasing violence, property loss, financial or business pressures, and strong ideological disagreements are the main political factors leading to migration.12 The best known examples of these political factors in action are the Cuban exiles, both the original group in the early 1960s, and the wave of less wealthy marielitos in the 1980s.13 Politically www.thelancet.com/psychiatry Vol 3 September 2016

Natural disasters Earthquakes, volcanic eruptions, river and sea floods, and other natural disasters that are quite frequent in Central and South America, can trigger the decision to migrate.21 In many cases the decision is determined more by the event’s emotional impact than by financial or occupational losses. Nevertheless, the migration experience might be different for a businessman from Chile than for a villager from Guatemala or Ecuador, for example. 861

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Family reasons A large number of immigrants’ close family members remain in their country of origin, often financially supported by the wages of those who migrate. Once more or less established in the USA, the immigrant asks them to come to reunite. Parents, grandparents, siblings, spouses, and children are usually the recipients of these calls. This pattern of migration has increased in the last two to three decades.22

Professional reasons A minority of Central American, South American, and Spanish immigrants to the USA are professionals at different levels of training or with established careers, who decide to extend their training, upgrade their job opportunities, or seek a better income. Academics, physicians, engineers, economists, technologists, and teachers following this path usually arrive in possession of, or with firm possibilities of obtaining, a job.10

Sociodemographic, occupational, and integration features of Hispanic immigrants Hispanic immigrant groups are generally younger (median age, 34·7 years) than the total US working-age population. Mexicans are less likely to complete high school than other Hispanic immigrants and individuals born in the USA (eg, 40% vs 83% among South Americans, and 73% among Caribbeans), mostly because, on average, Mexican immigrants have not yet reached eighth grade by the time they arrive in the USA, and because a low proportion of Mexican immigrants enrol in school in the host country. By contrast, a high proportion of Cuban immigrants had a high school diploma and a college degree (61·7% and 19·2%, respectively); but these figures are still lower than in non-Hispanics (75% and 31·9%).2,6,23 In 2010, compared with other Hispanic immigrant subgroups and the US-born population, immigrants born in Mexico were most likely to be married (58%), whereas those born in the Caribbean were most likely to be separated or divorced (18%), and 38% of other Central Americans were never married.5 Hispanic householders were more likely than US-born householders to be women with no husband present, and to have a larger family size (mean number of people, four).3,5,23 Only 32% of the whole Hispanic immigrant population were naturalised US citizens in 2010. The proportions of naturalised citizens varied broadly between Hispanic subpopulations: from 56% of those born in Cuba to 21% of those from Honduras.4 Mexicans, the largest Hispanic immigrant group, had the second smallest proportion of naturalised citizens. In a study by the Pew Research Center from 2013,23 61% of first-generation Hispanic immigrants (ie, those born outside the USA) identified themselves as being from their country of origin, whereas only 8% considered themselves American. However, only 38% of the second generation identified 862

with their parents’ country of origin, and 37% declared themselves American.23 Trends in labour force growth and assignments differ widely among Hispanic subgroups. By 2010, 70% of Hispanic immigrants were working but represented only 11% of the total US labour force.11,24 Immigrants born in Mexico and Central American countries were the least likely (14%) among all region-of-birth groups to be in management, business, science, and arts occupations, and the most likely (31%) to work in service areas. Agriculture and manufacturing are the most frequent forms of employment for non-professional Mexican immigrants. Puerto Ricans were granted US citizenship in 1917, and therefore may not technically be considered immigrants. Those who have moved to the USA work in a broad spectrum of occupations: from jobs in cigar-making shops in the 1890s, munition factories and shipyards in the early 20th century, to textiles, garment, and leather factories and steel mills by the 1960s. Cuban refugees have unique characteristics: according to Cattan,25 many of them, in the early 1960s, started working in low-skilled, far less prestigious jobs than those they had back home. Over the years, however, a large proportion of Cuban Americans reached higher levels in the occupational hierarchy thanks to business or professional backgrounds and higher educational levels than other Hispanic subpopulations. In 2015, the occupational distribution among Cubans living in the USA most closely approximated that of non-Hispanics.11 Central and South American immigrants, who started to arrive in increasing numbers around the 1980s, have generally taken so-called white-collar jobs (ie, non-manual professions), given their middle-class backgrounds and higher level of education than those who arrived earlier, as was the case with Colombian immigrants.10,11 Spanish immigrants have followed the same track, whereas Dominican and other Caribbean immigrants have mostly taken manual work.24 In 1992, an average of 11% of the Hispanic labour force was unemployed; in 2015, seasonally adjusted Hispanic unemployment for men and women older than 20 years was 7%.11 Hispanic women were less likely than non-Hispanic women to be in the workforce. Puerto Rican men and women have continuously been the most affected by unemployment out of all Hispanic subpopulations.24,25 Median weekly earnings of Hispanics are much lower than those of US-born non-Hispanics, as they were in the 1990s; Mexican immigrants make a median annual income that is almost US$15 000 less than South American immigrants, and almost $50 000 less than non-Hispanic white householders at similar occupational levels.11,24,25 Berk and colleagues26 reported that 40% of the growth of the US population without health insurance between 1977 and 1992 was accounted for by Hispanics, with those of Mexican origin constituting more than half (27%). The average annual increase in uninsured Hispanics was www.thelancet.com/psychiatry Vol 3 September 2016

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9·7%, compared with only 2·3% in the uninsured non-Hispanic population. Of the Hispanic subpopulations, Mexicans had the greatest average annual increase (>10%), whereas Cubans had only a 1·1% increase. By 2010, 51% of Hispanic immigrants had some form of health insurance—mostly public—and among them, Caribbeans were the best covered (71%).27 In the early stages of the implementation of the Affordable Care Act, one in four foreign-born Hispanics residing in the USA still did not have health insurance,28 a situation that has improved considerably since.29 The main health problems in the Hispanic population of the USA, including causes of death, health disparities, and prevalence of depression and suicidal behaviours, are presented in panel 3.

Immigration and acculturation Redfield and colleagues30 stated that acculturation entails the phenomena that result “when groups of individuals having different cultures come into continuous firsthand contact, with subsequent changes in the original cultural patterns of either or both groups”. The process itself might trigger resistance to change (reactive acculturation), stimulate the emergence of new cultural forms (creative acculturation), or generate changes fully attained only after a long term (delayed acculturation).31 Berry32 noted that acculturation depends on factors in the society of origin, the society of settlement, and on features that exist before or arise during its course. In turn, rejection of the acculturation process has been named deculturation. Interculturation, a term mostly used by European social scientists, differs from acculturation and deculturation mostly because one of its postulated outcomes is the formation of new cultures.33 Acculturation factors in Hispanic immigrants are many and complex. The contextual changes and costs (financial and emotional) include separations, sequential immigration and concomitant shifting family roles, the loss of extended kin networks left in the country of origin, the transformation into dual-earner households, parental stress from new and demanding jobs, and decrease in family time spent together.34 An additional phenomenon is the so-called Americanisation of children and adolescents who, finding themselves alone at home, focus first on their past life in their country but then start to make attempts at independence to which the parents might initially respond with increased strictness. In the process, familismo, a strong value in Hispanic culture, based on family orientation, obligations, loyalty, and cohesion,35 might become a powerful asset to promote mutual help, assistance, and recreation. Other strategies emerge, including preserving cultural rituals and traditions to maintain pride about the country of origin and family group closeness, or parents’ acceptance of their children’s faster acculturation that improves communication with the surrounding environment, making the children www.thelancet.com/psychiatry Vol 3 September 2016

Panel 3: Main health problems among Hispanic population in the USA (2012–13)6,10,26,28 • No health insurance: 29·1% • Leading causes of death: cancer, heart disease, unintentional injuries, stroke, diabetes, cirrhosis, chronic respiratory disease, Alzheimer’s disease, nephritis, pneumonia • Leading causes of health disparities: obesity, diabetes, periodontitis, HIV, teenage birth, no health insurance, colorectal cancer, high-risk occupations • Prevalence of depression in Hispanic women: 46%; Hispanic men: 19·6%. Caseness (duly diagnosed, following established criteria): Mexicans, 41% (US-born non-Hispanic white people, 16–18%) • Prevalence of attempted suicide in Hispanic girls aged <18 years: 14·9% (African-American girls, 9%; non-Hispanic white girls, 10·3%). Higher prevalence reported among US-born and long-term US residents than in recent Hispanic immigrants

cultural brokers on the basis of their acquired English language skills. Thus, biculturalism among the younger generation becomes a reachable objective and an effective ingredient in establishing relationships, delineating responsibilities, and acquiring tools for conflict resolution within the immigrant family and in its dealings with the host society.36,37 Studies of the relationship between acculturation and physical health (eg, obesity and sleep patterns)38 and between acculturation and addictive practices such as cigarette smoking and alcohol consumption by gender and age groups, have yielded mixed results.39–41 The level of acculturation seems to play a role in this context.42 For instance, highly acculturated women (those with proficient use of English language and a long length of residence in the USA) were more likely to be smokers and heavier drinkers than their less acculturated counterparts. As acculturation increased, participants were more likely to exercise regularly. Hispanic women aged 75 years and older tended to report healthier practices than younger Hispanic women, among whom cigarette smoking and obesity are prominent threats to improving health.38 From the psychopathological perspective, acculturative stress might reflect psychosocial features working against neurobiological vulnerabilities,43 and can be pathogenically connected with diagnoses such as anxiety disorders, suicidal behaviour, post-traumatic stress disorder, and alcohol and drug misuse.41,43 Among Hispanic immigrants, the onset can be non-specific, but within weeks or a few months anxious, depressive, cognitive, and somatic symptoms might emerge, leading to so-called role entrapment. This process, coupled with lowered labour performance and ineffective relationships with health professionals, can generate a pattern of chronicity.44 863

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The Hispanic paradox First described in 1986,45 the Hispanic paradox claims that Hispanic immigrants living in the USA have better overall health than non-Hispanic white people, despite several risk factors. Farley and colleagues,46 for instance, compared perceived stress, stress-coping strategies, and health-related quality of life between a rural sample of Mexican citizens living in the USA, Mexican-Americans, and non-Hispanic white people. They found that coping styles or features such as positive reframing, denial, and religion (mostly present in Mexican citizens and Mexican-Americans), could be predictors of better physical and mental health. However, Hispanic immigrants in disadvantaged neighbourhoods are more likely to drop out of school or not enrol in college, and use illicit drugs, reflecting the negative consequences of what is known as downward assimilation.47 In a nationally representative survey in the USA, Breslau and colleagues48 found that Mexican immigrants had a lower lifetime risk of anxiety, mood, impulse control, and substance use disorders than US-born individuals (Hispanics and non-Hispanics), yet in the case of mood and impulse control disorders, those who arrived in the USA at age 12 years or younger had the same risk as non-immigrants. Two distinct explanations were hypothesised for these risk differences: the early socialisation of immigrants who arrive in the USA as children, and post-migration factors for those who arrive as adolescents or adults. In a sample of 259 adult Mexican-Americans from three suburban communities in southern California, Griffith49 reported that Spanish-speaking probands had significantly fewer problems in social relations but, paradoxically, more anxiety problems than their English-speaking and bilingual counterparts. These more acculturated Mexican-Americans also had more family conflicts than less acculturated participants. Vega and colleagues,50 in a 12-month comparative prevalence study, reported that mood or anxiety disorders, and substance use disorders for Hispanic immigrant women and men were lower than those of US-born individuals (anxiety and mood disorders, 14·2% vs 27·8%; and substance use disorders, 12·6% vs 27·2%, respectively). Indeed, lower levels of past-year mental health problems among Mexican immigrants were present across virtually all types of disorders compared with US-born individuals. The authors offer three different explanations: selection effects or the so-called healthy migrant model; degree of social assimilation; and management of stress levels, partly revealing yet another paradox—that greater social assimilation increases psychiatric morbidity. A protective effect of foreign-born nativity against risks of psychiatric disorders was present for all Hispanic subgroups, but Puerto Ricans (44%) and Cuban Americans (28%) had a lower prevalence of psychiatric disorders than non-Hispanic white people (51%). The figures were similar among island-born Puerto Ricans 864

(39%), foreign-born Cuban Americans (22%), and foreign-born non-Hispanic white individuals (32%), and also among the three US-born subpopulations. Other researchers object to the generalisability of the Hispanic immigrant paradox. Alegría and colleagues,51 using data from the National Latino and Asian American Study (NLAAS) and the National Comorbidity Survey Replication, reported that although overall the risk of most psychiatric disorders was lower for Hispanic than for non-Hispanic white participants, risk varied when data were stratified by place of nativity and disorder, and adjusted for demographic and socioeconomic differences across groups. Puerto Rican immigrants had a higher lifetime prevalence (38%) than Mexican (28%) and Cuban (22%) immigrants; and a higher past-year prevalence (22% vs 14% in Mexicans and 16% in Cubans). Although the prevalence among Hispanics was consistently lower than in non-Hispanic white people, the authors caution that aggregating Hispanic people into a single group masks a substantial variability in the lifetime risk of psychiatric disorders, which seems to be a persuasive argument. Grant and colleagues52 analysed another nationwide US survey of 43 093 adults, and found that foreign-born Mexican-Americans (28%) and foreign-born non-Hispanic white people (47%) were at a significantly lower risk for any DSM-IV disorder than US-born Mexican-Americans (32%) and US-born non-Hispanics (52%), and also for a variety of specific diagnoses (alcohol and drug use, mood and panic disorders, social and specific phobias, and generalised anxiety). Odds ratio figures showed, in some cases, three times lower risk of a mental disorder among foreign-born Mexican-Americans and non-Hispanic white people than their US-born counterparts. The authors reflect on both the potentially protective effects of a retained culture (including a lower set of expectations about what constitutes success in the USA), and the deleterious effects of acculturation (including higher expectations for status attainment) on psychiatric morbidity. These data seem to indicate that the Hispanic paradox might be an immigrant paradox, not restricted to Hispanics. By contrast, using data from the NLAAS, Cook and colleagues53 identified pathways by which a longer time living in the USA could be associated with increased rates of psychiatric disorders in Hispanic immigrants, supporting the view that greater exposure to life in the USA and its acculturative implications tend to increase risk of mental illness among Hispanic immigrants, despite increases in socioeconomic status and other supposedly protective factors. The authors postulate that biculturalism, gender roles, aspirations of social integration, expectations of fair treatment, and availability of ethnic enclaves mediate the risk for mental illness after extended time in the USA. Moreover, supported by another analysis by Alegría and colleagues,54 they maintain that it is not nativity per se that accounts for www.thelancet.com/psychiatry Vol 3 September 2016

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these phenomena, but rather stressors associated with cultural transmutation and differences in contextual and interpersonal circumstances such as higher levels of discrimination, family conflict, or erosion of family bonding among US-born Hispanic people. Indeed, this most comprehensive perspective substantiates effectively the diverse modalities of health responses among acculturated Hispanic immigrants: although the decision to migrate entails mostly healthy convictions and characterological features, the circumstances of life in the host country are basically unpredictable and might lead to negative health outcomes.38,55

Psychopathology among Hispanic immigrants The first large-scale, community-based data of lifetime prevalence for DSM-III disorders among MexicanAmericans,56 compared with non-Hispanic white people, were collected in Los Angeles (CA, USA), one of five sites in the Epidemiologic Catchment Area (ECA) project. It included 1243 Mexican-Americans and 1309 non-Hispanic white people. Drug abuse or dependence and major depression were strongly present among young (aged 18–25 years) non-Hispanic white people (25% for drug abuse and 9% for drug dependence), but less common among Mexican-American women of any age (15% and 6%, respectively) and people older than 40 years of either ethnic group (6% and 4%, respectively), and only moderately prevalent among young Mexican-American men (4% for both conditions).57 By contrast, alcohol abuse or dependence showed very high prevalence among both Mexican-American (17·3%) and non-Hispanic white (14·8%) men of any age, whereas Mexican-American women were less afflicted by those conditions (4·6% vs 8·4% among non-Hispanic white women). Antisocial personality disorder was more prevalent among young Mexican-American men (aged 18–34 years) than older Mexican-American men (8% vs 2%, respectively), although whether these are clinically cogent estimates or a reflection of selective non-reporting by older participants is unknown. Among migrant farm workers from Mexico and Guatemala labouring in California, lifetime prevalence of any psychiatric disorder in the indigenous subpopulation (Zapotec, Mixtec, and Maya) was lower for women (14·6%) than for men (30·4%), whereas for the total study population, the proportions were 16·8% for women and 26·7% for men.58 Prevalence of alcohol dependence was more than seven times higher among men than among women (12·9% vs 1·7%) and prevalence of drug dependence in the same total sample of migrant workers was 4·9% among men but 0·0% among women. In the same indigenous population, men had higher rates of anxiety disorders (16·1%) than women had of mood disorders (8·4%). Among the non-indigenous sample in the same study population, 7·5% of women had agoraphobia, and 15·4% of men had any substance dependence.58 Lifetime www.thelancet.com/psychiatry Vol 3 September 2016

alcohol abuse or dependence was more likely to occur (as calculated by OR and 95% CI) among individuals aged 26 years and older than among younger migrant workers. Along the same lines, respondents with more than six years of education had higher risks of alcohol and drug abuse or dependence than those who were less educated. However, respondents who were primarily residents of Mexico (so-called temporary residents) had less than half of such risks. Acculturation increased the likelihood of mood disorders but, more importantly, in comparison with local, national, and international samples, the lifetime prevalence of mental disorders among Mexican and Guatemalan immigrants in Fresno County (CA, USA) was similar to that of those more recently arriving in the USA and to rates found in people residing in Mexico City (20–23%). The prevalence of mood disorders of immigrants in Fresno County was less than half the rate for US-born Mexican-Americans (49%) or for the USA Hispanic population as a whole (51%).58

Depression The prevalence of depression among Hispanic immigrants is similar to prevalence in the overall US and worldwide populations.59,60 Cuellar and Roberts61 compared risk and symptoms of depression on the basis of acculturation categories, bicultural orientations, and self-rated ethnic identity categories in 1271 Hispanic first-year college students (89% self-identified MexicanAmericans, 11% Mexican nationals). 41 students (3·2%) met criteria for having experienced a major depressive episode during the previous 2 weeks. Confirming previous studies among Hispanic people,62,63 Borges and colleagues64 found that the initial low-to-mild risk of suicidality reported by Asian and Hispanic immigrants to the USA increased through the 3–6-year acculturation period, to a risk similar to that among the non-Hispanic white population. The debates about the influence of ethnicity and acculturation versus socioeconomic status or gender on depression scores persist. Using the Fabrega Migration Adaptation Model,65 Vega and colleagues66 found that in a community-based, low-income Mexican-American immigrant female sample in California, depression was associated with four factors: family disruption, circumstances surrounding the decision to migrate, re-establishment of social roles in the receiving environment, and satisfaction levels with the conditions encountered. 41% of the sample met caseness criteria for depression, a figure much higher than the 16–18% in the general US population. Moreover, depressive symptoms were inversely related to: income, education, and years in the USA; voluntary migration; assimilation, fairness of opportunity, satisfaction with the decision to migrate; and perception of cultural compatibility. The intensity or severity of the symptoms was lower among married women, and highest among those who had never married. Feeling too far away from the place of 865

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origin, feeling closer to friends back home than those in the USA, and the difficulties of visiting their country, family, and friends were also associated with more depressive symptoms. Thus, maintaining strong social and emotional ties to those left behind as well as with new friends in the host country might counteract the frustration surrounding unfulfilled expectations of economic improvement. The sociocultural components of the stress–coping– outcome equation delineated in the preceding paragraph are an important yet often neglected aspect in the assessment of depression. Aranda and colleagues67 studied a sample of 171 Mexican-American men and women, finding no differences in depressive symptoms between sexes. However, their findings distinguished men and women in their sources of stress and social support—women reported higher stress levels about the fate of their marital relationships and the impact of cultural conflicts than did men. Women also reported higher levels of social support from the marital partner and relatives, and from culturally constructed values such as marianismo (strength of patience and resignation inspired by the life of the Virgin Mary), familismo, and hembrismo (persevering femaleness).68,69 Men reported higher stress levels and greater subsequent depression related to occupational-economic factors and less social support from relatives than did women, perhaps related to their own and others’ expectations about their roles as the head of the family and main provider, and the bearer of machismo. Of note, avoidance as a coping strategy was related to higher levels of psychiatric symptoms in both genders.49,67 Socioeconomic variables such as poverty and unemployment had a much stronger impact on depressive symptoms than did acculturation, in a study of 1519 Puerto Rican immigrants, aged 20 years or older, by Canabal and Quiles.70 Using data from the Hispanic Health and Nutrition Examination Survey (HHANES), these authors found that the lower the poverty index, the higher the depression score. Using multiple regression techniques, women were found to be more likely than men to have depression; however, women were found to be less susceptible than men when married and cohabitating with their spouses. Once again, acculturation was not the main direct determinant of social behaviour adjustment among Puerto Rican immigrants. This fact might be related to their American citizenship status, greater accessibility to the mainland, and English language proficiency, so depression as a clinical occurrence in them might be connected more to dissatisfaction and frustrations related to social inequality than to mild acculturative stress.

Other mood and anxiety disorders The HHANES study70 showed that for any mood (major depression, dysthymia, mania, hypomania) or anxiety (panic, generalised anxiety, social and specific phobia) 866

disorder, prevalence in island-born Puerto Rican immigrants was higher than in any foreign-born groups. However, political strife in many Central and South American countries has evolved into political violence, often leading to post-traumatic stress disorder.71,72 In an NLAAS-surveyed sample of 1630 individuals, 11% of Hispanic immigrants reported exposure to political violence and 76% described additional lifetime trauma. Fortuna and colleagues73 assessed depression, anxiety, and alcohol and drug abuse or dependence, and found numerically higher rates among Hispanic immigrants exposed to political violence than those who were not exposed (28% vs 24%). Immigrants exposed to political violence were more likely to perceive the need for mental health services (18% vs 11%) and to have a chronic medical illness (asthma, diabetes, cancer, cardiovascular disease; 33% vs 25%) than those not exposed. Notwithstanding the fact that post-traumatic stress disorder, generalised anxiety disorder, panic disorder, phobias, chronic pain, and other psychiatric and medical diagnoses constitute a complex set of political violencerelated clinical problems,74,75 the prevalence of these disorders (and of depression) found in different studies was surprisingly lower than expected. The roles of different protective factors, from family unity to individual resilience, have been invoked.46,76

Substance and alcohol use disorders Alegría and colleagues,77 using data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, n=43 093), reported that the prevalence of any alcohol use disorder among island-born Puerto Rican immigrants and foreign-born non-Hispanic white people was similar (15% and 16%, respectively), but notably lower among foreign-born Cuban Americans (5%), whereas the US-born respondents had consistently higher prevalence of both alcohol abuse (20·8%) and drug use (8·9%) disorders. Further analysis indicated that the odds of alcohol abuse were greater among US-born non-Hispanic white people compared with US-born Puerto Ricans.78 Among Mexican immigrants, those whose family members had migrated to the USA previously and had returned to Mexico, were more likely to develop a substance use disorder than those who had not experienced such separations.79 Thus, although foreign nativity could be considered a protective factor for substance abuse and other disorders among different Hispanic groups,45,50 acculturation still seems to increase risks of multiple psychiatric comorbidities.41,47,80 Its pathogenic reach (including sexually transmitted diseases81) might even affect women and people younger than 21 years, and actual or eventual immigrants. Merikangas and colleagues82 expand this perspective in their comparative study of Puerto Rican families living in Hartford (CT, USA) and San Juan (Puerto Rico). Although total rates for alcohol use were www.thelancet.com/psychiatry Vol 3 September 2016

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greater among the children living in Puerto Rico than among their migrant counterparts, a strong association was observed between parental and child substance use at both sites—ie, regardless of location, the offspring of parents with drug use disorders were at greatest risk for substance use and related disorders.

Psychotic disorders, symptoms, or syndromes For Hispanic immigrants, the distinction between genuine and putative psychotic symptoms (thought insertion, thought broadcasting, and thought control most notably, independent from delusions or hallucinations) becomes extremely important as, because of cultural factors, they report these symptoms more often than Europeans, Asians, or African-Americans. The clinician’s task involves a careful differential to establish whether such symptoms are truly part of a psychotic condition, of another disorder such as anxiety, depression, or substance misuse, or cultural idioms of distress.83 Vega and colleagues84 describe the prevalence of putative psychotic symptoms independent of or co-occurring with any psychiatric disorder in a Mexican-American sample (n=3012). Total lifetime prevalence for one or more putative psychotic symptoms was 18%, with 12% among immigrants and 26·9% among US-born Mexican-Americans. Four symptoms (being followed, visual, tactile, or auditory hallucinations) occurred at frequencies of 5% or more for the total study population, and more in men than in women, despite men not meeting criteria for any diagnosis. By contrast, Schneiderian first-rank symptoms (hallucinations, thought withdrawal, thought insertion, thought broadcasting, delusions, and actions influenced by external agents) were twice as high in probands of both sexes, and in those with an established disorder.

Discussion Psychiatric disorders among Hispanic immigrants in the USA vary widely and have wide implications for policy making, clinical care, and public health. Mental health problems or lack thereof might be the result of a variety of stressful agents and protective processes. Compared with non-Hispanic immigrants, Hispanic immigrants still confront occupational disadvantages, are less likely to hold managerial and professional jobs, are more likely to have lower incomes, poorer English language fluidity, and ambiguous receptivity from the host society, and they confront numerous health-related problems as a result of a variety of factors (eg, younger age distribution and lower average educational level). Acculturation, perhaps the most powerful force in the migration experience, is affected by at least two expectations in the immigrant’s psyche: striving for the maintenance of cultural legacies, and desiring to assimilate within the host country. Berry32 and colleagues85 outline four descriptive, self-explanatory www.thelancet.com/psychiatry Vol 3 September 2016

outcomes for this process: marginalisation, separation or segregation, assimilation, and integration. The strength of each of these outcomes will have a predictable effect on the mental and physical health of communities of, and individual, immigrants. The Hispanic contingent shows some inconsistency in these areas, depending on the interplay of protective and risk factors that generate variable levels of vulnerability to the stresses of migration.55,81 Acculturative stress can cause physical changes and alter physiological processes, increase maladaptive behaviours and lifestyle choices, and induce variations in subjective perceptions of physical symptoms.46,53,86–88 To confirm or discard vulnerabilities determined by pre-existing psychopathologies, true longitudinal epigenetic studies would be the only valid approach to assess mental and emotional conditions existing before emigration.43,48,77,89 Furthermore, diverse clinical manifestations related to problems in adjusting to a new culture constitute acculturation difficulty, defined by the code V62.4 (Z60.3) in DSM-5, which is described as “a condition that may be the focus of clinical attention”.90 Gender and generational differences, and the issues of selective migration and selective acculturation, constitute additional research topics that require investigation.91,92 These topics include conceptual delineations about, for instance, the role of cultural features such as marianismo: although described as passivity and self-denial,68 it arguably also entails patience, acceptance, and resignation as well as moral strength, spiritual consistency, and interpersonal strategies,69,93,94 all of which could strengthen a persistent survival effort or even a pattern of resilience.76

Panel 4: Key challenges for research on the mental health of Hispanic immigrants in the USA • Delineation and measurements of mental health risk and protective factors in the different Hispanic immigrant groups • Interactions and correlations between protective and risk factors and prevalence of specific clinical disorders • The influence of the acculturation experience, the immigration context, and coping modalities (including resilience) • Interactions of patients and their families with the health-care system and multidisciplinary health and mental health teams • Cross-ethnic, racial, and socioeconomic factors influencing help-seeking patterns, explanatory models of disease and illness, and cultural concepts of distress • Cross-generational transmission of mental disorders, prevalence of medical conditions, comorbidities, and mutual impact of disorders before and after migration • Quality and adequacy of mental health care, including qualitative and narrative medicine methods

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Search strategy and selection criteria We did a computer-aided search of MEDLINE and PsycINFO databases. Additional studies were identified in the bibliographies of included studies. We screened abstracts for eligibility and obtained the full-text article if the study was deemed eligible or if the abstract was unclear. Key search terms used were “latino”, “hispanic”, “psychiatry”, “psychopathology”, “immigration”, and “mental health”. Studies published 1980–2015 were included. We did not restrict search results by language. We excluded case studies, reviews, and commentaries.

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Conclusions The trajectory of a Hispanic immigrant in the USA entails courageous decision making, stressful circumstances before, during, and after the transition, enormous adaptation efforts, and even uncertain outcomes. Neurobiological and sociocultural factors play powerful roles in this acculturation process, and the pathogenic nature of the process requires further multidisciplinary research efforts (panel 4) and cogent initiatives by government health agencies and political leaders. Finally, a truly humanistic, non-discriminatory approach to these complex phenomena would convey genuine features of respect and dignity into well-conceived immigrant mental health-care programmes.95 Declaration of interests We declare no competing interests. References 1 Desjarlais R, Eisenberg L, Good B, Kleinman A. World mental health: problems and priorities in low-income countries. Oxford, UK: Oxford University Press, 1995. 2 Ennis SR, Ríos-Vargas M, Albert NG. The Hispanic population: 2010. Washington, DC: US Census Bureau, Department of Commerce, 2011. 3 Larsen LJ. The foreign-born population in the United States: 2003. Population characteristics. Washington, DC: US Census Bureau, Department of Commerce, 2004. 4 Acosta YD, De la Cruz GP. The foreign-born from Latin America and the Caribbean: 2010. Washington, DC: US Census Bureau, Department of Commerce, 2011. 5 Grieco EM, Acosta YD, De La Cruz GP, et al. The foreign-born population in the United States: 2010. Washington, DC: US Census Bureau, Department of Commerce, 2012. 6 US Census Bureau News. Facts for features. Hispanic heritage month 2014: Sept. 15–Oct. 15. Washington, DC: US Census Bureau, Department of Commerce, 2014. 7 US Census Bureau. Public use microdata areas. Washington, DC: US Census Bureau, Department of Commerce, 2015. 8 Camarota SA, Zeigler K. Immigrant population hits record 42·1 million in second quarter of 2015. Washington, DC: Center for Immigration Studies, August, 2015. 9 Colby SL, Ortman JM. The baby boom cohort in the U.S. 2012 to 2060: population estimates and projections. Washington, DC: US Census Bureau, Department of Commerce, 2014. 10 Durand J, Massey DS, Zenteno RM. Mexican immigration to the United States: continuities and changes. Latin Am Res Rev 2001; 36: 107–15. 11 Livingston IL, Neita M, Riviere L, Livingston SL. Gender, acculturative stress and Caribbean migrants’ health in the United States. of America: an exploratory study. West Indian Med J 2007; 56: 213–22.

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