Immigration and Mental Health: Stress, Psychiatric Disorders and Suicidal Behavior Among Immigrants and Refugees (Psychiartry - Theory, Applications and Treatments)

PSYCHIATRY – THEORY, APPLICATIONS AND TREATMENTS

IMMIGRATION AND MENTAL HEALTH: STRESS, PSYCHIATRIC DISORDERS AND SUICIDAL BEHAVIOR AMONG IMMIGRANTS AND REFUGEES

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PSYCHIATRY – THEORY, APPLICATIONS AND TREATMENTS

IMMIGRATION AND MENTAL HEALTH: STRESS, PSYCHIATRIC DISORDERS AND SUICIDAL BEHAVIOR AMONG IMMIGRANTS AND REFUGEES

LEO SHER AND

ALEXANDER VILENS EDITORS

Nova Science Publishers, Inc. New York

Copyright © 2010 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers‘ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Immigration and mental health : stress, psychiatric disorders, and suicidal behavior among immigrants and refugees / editors, Leo Sher, Alexander Vilens. p. ; cm. Includes bibliographical references and index. ISBN 978-1-61324-748-8 (eBook) 1. Immigrants--Mental health. I. Sher, Leo. II. Vilens, Alexander. [DNLM: 1. Emigrants and Immigrants--psychology. 2. Mental Health. 3. Acculturation. 4. Mental Disorders. 5. Stress, Psychological. 6. Suicide. WA 305.1 I33 2010] RC451.4.E45I46 2010 362.196'890086912--dc22 2010015602

Published by Nova Science Publishers, Inc. † New York

CONTENTS Preface

ix

Part I Suicidal Behavior Chapter 1

A Model of Suicidal Behavior among Immigrants with Psychiatric Disorders Leo Sher

1

Chapter 2

Immigration and Suicide: An Overview Brian Greenfield, Londa Daniel and Bonnie Harnden

Chapter 3

Immigrants and Suicidal Behavior: The Role of Gender Diana van Bergen and Sawitri Saharso

21

Chapter 4

Suicidal Behavior among Hispanic Immigrants in the United States Guilherme Borges, Liliana Mondragón and Joshua Breslau

37

Chapter 5

Suicidality and Acculturation in Hispanic Adolescents Andres J. Pumariega, Eugenio M. Rothe, Jeffrey Swanson, Charles E. Holzer, Arthur O. Linskey and Ruben Quintero-Salinas

57

Chapter 6

Suicide amongst Britain‘s Immigrant Population: Data Sources, Analytical Approaches, and Main Findings Peter J. Aspinall

Chapter 7

The Effects of Immigration on the Mental Health of Adolescents: Depression, Post-Traumatic Stress Disorder, Substance Abuse, Delinquent and Suicidal Behavior among Immigrant Youth Dana Galler and Leo Sher

9

71

87

Part II Acculturation and Mental Health Chapter 8

Acculturation and Mental Disorders among Immigrants Michael G. Madianos

Chapter 9

Immigration, Psychosocial Factors and Psychological Distress, with Focus on Perceived Control and Social Integration Odd Steffen Dalgard

101

113

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Contents

Chapter 10

Depression among Latinos in the United States Patricia Gonzalez and Monica Rosales

Chapter 11

Acculturation, Acculturative Stress, and Depression among Haitians in the United States Guerda Nicolas, Darren Bernal and Seth T. Christman

Chapter 12

Changes in the Psychological Well-Being of Immigrants: A ThreeYear Longitudinal Study of Immigrant Adolescents Including the Pre-Migration Period Eugene Tartakovsky

Chapter 13

Mental Health Problems among Immigrants in Israel Alexander M. Ponizovsky

Chapter 14

Epidemiology of Mental Health Problems among Immigrants. Case of Korean Immigrants in Brazil Sam Chun-Kang, Denise Razouk, Jair J. de Mari, Itiro Shirakawa and Luiza Beth Alonso

Chapter 15

Successful Use of Mental Health Migration Models: The New Zealand Experience Regina Pernice

133

149

163 187

209

223

Part III: Substance Abuse Chapter 16

Substance Use Disorder among Immigrants in the United States Sun S. Kim, David Kalman, Gerardo Gonzalez and Douglas Ziedonis

Chapter 17

Alcohol Drinking and Treatment among Immigrants from the Former Soviet Union (FSU) in Israel: Review of Recent Publications January 2007-June 2009 Shoshana Weiss

243

267

Part IV: Miscellaneous Chapter 18

The Motives for Migration Michal Sabagh and Barbara S. Okun

283

Chapter 19

The Social and Cultural Context of Immigration and Stress Katie Vasey and Lenore Manderson

295

Chapter 20

Post-traumatic Stress Disorder: Integration of Biological and Psychosocial Aspects María Dolores Braquehais Conesa and Leo Sher

313

Contents

vii

Chapter 21

Impulsivity: A New Concept for an Old Idea María Dolores Braquehais Conesa

Chapter 22

Not Just Another Pretty Face: The Cross-Cultural Perception and Social Ramifications of Facial Attractiveness Dana Galler

327

About the Editors

333

Chapter 23 Index

321

335

PREFACE Immigrants' journeys to a new nation have been among the most exciting and dignified of human endeavors. Immigrants are going to a new country for the best of intensions: the wish to improve their lives; the desire to leave countries whose governments they could not tolerate; and the eagerness to work for another country where individuals can live in freedom and dignity. Immigrants are an integral part of many societies, contributing both to the economy and diversity of their new countries. Immigration is usually very nerve-racking. Upon arrival to a new country immigrants are confronted with various stresses and adjustment problems in the receiving society. The pain, pressure and stress associated with immigration can come from all facets of life: language barriers, feeling of loneliness and marginality, homesickness, social role changes and identity crises, cultural differences, economic adversities, social discrimination and family troubles. There is a high prevalence of psychological distress among immigrants. This can lead to severe and long-lasting psychological and behavioral problems, including depression, anxiety, posttraumatic stress disorder, substance abuse, and a high risk for suicide. It has been suggested that immigrants are more likely to need psychiatric treatment than natives. Generally, there are two opposite viewpoints of immigrants‘ psychological health. The first one predicts higher psychological distress among immigrants, and the other argues that immigrants have better psychological health than natives. Some studies indicate the existence of positive migratory selection factors, i.e., the self-selection and selection effect of immigration policies motivate the mentally healthy people who can be characterized as having strong, optimistic and confident personalities, to migrate to other countries. Immigrants often face significant obstacles to receiving quality mental health care including financial difficulties, lack of insurance, the lack of culturally- and linguisticallyappropriate services, and mistrust of mental health providers. For example, in the U.S., a disproportionate number of immigrants work in low-wage jobs, in small firms, and in labor, service, or trade occupations, which are less likely to offer health benefits. This book is devoted to research on immigration and mental health. The contributors to this book are the leading international experts in psychiatry, psychology and sociology. We would like to acknowledge and thank all the contributors. Our task as the editors was greatly facilitated by their swift and positive response to our initial inquiry, and thereafter by producing their manuscripts diligently.

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Leo Sher dedicates this book to the memory of his parents, Ivetta Sher and Alexander Sher. Alexander Vilens dedicates this book to his parents, Blyuma Vilenskaya and Naum Vilensky. We welcome comments from readers. Please, submit your comments via the website at www.internetandpsychiatry.com Leo Sher Alexander Vilens December 2009

PART I SUICIDAL BEHAVIOR

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 1

A MODEL OF SUICIDAL BEHAVIOR AMONG IMMIGRANTS WITH PSYCHIATRIC DISORDERS Leo Sher Columbia University and New York State Psychiatric Institute, New York, New York, USA

ABSTRACT The term "immigration" is usually used to denote international immigration. The United Nations considers a long term international migrant to be ―A person who moves to a country other than that of his or her usual residence for a period of at least a year (12 months), so that the country of destination effectively becomes his or her new country of usual residence.‖ Immigrants‘ voyages to a new land have been among the most exciting and noble of human endeavors [4]. It is the amazing courage to flee oppression, to leave behind everything that is familiar, and to chance the hostility of a completely alien culture in order to find freedom, opportunity, and a better life. Many and many immigrants and refugees, including Albert Einstein, Ernst B. Chain, Selman A. Waksman, Enrico Fermi, Sigmund Freud, Eric Fromm, Bertold Brecht, Jean Gabin, Charles de Gaulle, Thomas Mann, Jean-Jacques Rousseau, François-Marie Arouet (Voltaire), Victor Hugo, David Ben-Gurion and Henry A. Kissinger, have made a remarkable contribution to the welfare and happiness of mankind. The editors of this book, Leo Sher, M.D. and Alexander Vilens, M.S. are also immigrants. Immigration is difficult and stressful. Many immigrants suffer from psychiatric disorders and some immigrants attempt or commit suicide. In this chapter, I propose a model of suicidal behavior among immigrants with psychiatric disorders. All immigrants experience preimmigration, immigration and post-immigration stress. Immigrants are frequently depressed. Depression in immigrants is associated with anxiety, post-traumatic symptoms, alcohol and/or drug use/abuse/dependence, pessimism, and stress-related medical illnesses such as hypertension, metabolic syndrome, and diabetes. Psychiatric and medical problems, genetic make-up, childhood experiences, availability of a social support, cultural acceptability of suicide, the degree of pre-immigration, immigration, and post-immigration stress, and other factors determine the vulnerability for suicidal behavior among immigrants with psychiatric disorders. Suicidal acts can be attributed to

2

Leo Sher the coincidence of a trigger with a vulnerability for suicidal behavior. Triggers for suicidal behavior among immigrants include financial problems, relationship problems, mood instability (e.g., the onset of a major depressive episode), alcohol intoxication, abuse/assault, and acute medical illness. Suicide prevention among immigrants requires comprehensive, coordinated, and continuous health and mental health services for immigrant populations provided by culturally competent professionals.

INTRODUCTION The term "immigration" is usually used to denote international immigration. The United Nations considers a long term international migrant to be ―A person who moves to a country other than that of his or her usual residence for a period of at least a year (12 months), so that the country of destination effectively becomes his or her new country of usual residence. From the perspective ... of the country of arrival the person will be a long-term immigrant‖ [1]. The International Organization for Migration has reported that there are more than 200 million migrants around the world today [2]. Europe hosted the largest number of immigrants, with 70.6 million people in 2005, the latest year for which figures are available. North America, with over 45.1 million immigrants, is second, followed by Asia, which hosts nearly 25.3 million. Only Northern America and the former USSR have seen a sharp increase in their migrant stock between 1970 and 2000 (from 15.9 per cent to 23.3 per cent for Northern America and 3.8 per cent to 16.8 per cent for the Former USSR). In the latter case however, this increase has more to do with the redefinition of borders than with the actual movement of people. The United Nations found that, in 2005, there were nearly 191 million international migrants worldwide, 3 percent of the world population. Recent surveys by Gallup found roughly 700 million adults would like to migrate to another country permanently if they had the chance [3]. The United States is the top desired destination country. Nearly one-quarter (24%) of these respondents, which translates to more than 165 million adults worldwide, name the United States as their desired future residence. From the time of the nation's founding, immigration has been crucial to the United States' growth. James Madison (1751-1836), an American politician and political philosopher who served as the fourth President of the United States (1809–1817), and was one of the Founding Fathers of the United States, wrote, ―America was indebted to immigration for her settlement and prosperity. That part of America which had encouraged them most had advanced most rapidly in population, agriculture and the arts.‖ At the turn of the 21st century, the United States has experienced another great wave of immigration, the largest since the 1920s. Immigration has also been very important to the development of many other countries.

IMMIGRATION AS A HUMAN ENDEAVOR Every day, migrants leave their homelands behind for new lives in other countries. Immigrants‘ voyages to a new land have been among the most exciting and noble of human endeavors [4]. It is the amazing courage to flee oppression, to leave behind everything that is familiar, and to chance the hostility of a completely alien culture in order to find freedom,

A Model of Suicidal Behavior among Immigrants with Psychiatric Disorders

3

opportunity, and a better life. Every person, every family has a different story to tell about the reasons for and the circumstances surrounding their departure from their native country. Immigrants are moving to a new country for the best of motives: the desire to improve their lives; the urge to leave countries whose governments they could not abide; and the willingness to work for another country where individuals can live in freedom and dignity. Many and many immigrants and refugees, including Albert Einstein, Ernst B. Chain, Selman A. Waksman, Enrico Fermi, Sigmund Freud, Eric Fromm, Bertold Brecht, Jean Gabin, Charles de Gaulle, Thomas Mann, Jean-Jacques Rousseau, François-Marie Arouet (Voltaire), Victor Hugo, David Ben-Gurion and Henry A. Kissinger, have made a remarkable contribution to the welfare and happiness of mankind. The editors of this book, Leo Sher, M.D. and Alexander Vilens, M.S. are also immigrants.

Figure 1. A model of suicidal behavior among immigrants.

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A MODEL OF SUICIDAL BEHAVIOR Immigration is difficult and stressful [5-7]. An old Italian story posted in today's Ellis Island museum puts it this way: "I came to America because I heard the streets were paved with gold. When I got here, I found out three things: First, the streets were not paved with gold. Second, they weren't paved at all. Third, I was expected to pave them." The sociocultural and political characteristics of the country of origin and the immigration social policy of the host country play an important role in the acculturation process of immigrants. Many immigrants suffer from psychiatric disorders and some immigrants attempt or commit suicide [5-12]. In this chapter, I propose the following model of suicidal behavior among immigrants with psychiatric disorders (Figure 1): 1. The future immigrants consist of the two groups: a) individuals without psychiatric disorders; and b) individuals with psychiatric disorders. Possibly, many individuals who did not have psychiatric disorders in their countries of origin but develop psychiatric conditions and exhibit suicidal behavior in a new country had certain maladaptive personality traits and/or some degree of psychiatric pathology and/or suicidal tendencies before immigrating to the new country [10]. However, it is very possible that practically healthy persons may develop psychiatric conditions and exhibit suicidal behavior as a result of immigration-related chronic stress. 2. All future immigrants experience pre-immigration stress. Pre-immigration stress is frequently related to traumatic experiences, loss of home, livelihood, social position, family, friends, community, homeland, familiar language, feeling of an uncertain future and doubts whether the decision to emigrate/immigrate is correct. Preimmigration stress can have a direct effect on mental and physical health status immediately after arrival to a new country. 3. All immigrants experience immigration stress. The process of relocation is difficult for many people. Immediately upon arrival to a new country, immigrants frequently become targets for abuse, cruelty and corruption. For example, in 1900, on Ellis Island, the main U.S. immigration center at that time, immigration officials demanded bribes from immigrants who appeared to have money; if the bribe was questioned, or slow in coming, an immigrant was detained [13]. Other immigration officials would admit pretty young women on the condition that the women make sex with them. Railroad agents sold tickets at inflated prices. Immigrants were compelled to buy box lunches they didn't want for many times their value. Employees at the Money Exchange simply lied about the exchange rates and then pocketed the difference. Some American immigration inspectors were issuing fake certificates of citizenship for a fee and splitting the profits with ship officers. I think that in other countries and in other times the experience of immigrants was quite similar. 4. Post-immigration stress is frequenlty very severe. Immigrants often face difficulty adjusting to their new home in a new country for many reasons, including coping with trauma experienced in their native country, overcoming cultural and language barriers, and encountering discrimination [5-7,11,12]. The effects of immigration on psychological and social well-being are especially profound for certain populations,

A Model of Suicidal Behavior among Immigrants with Psychiatric Disorders

5

including children, women, individuals with disabilities, and those with limited financial resources. Many immigrants are often forced to take low-qualified jobs, even though they have the training and education for professional jobs. They cannot sustain their former economic and social status, which can lead to psychological distress. Language barriers often force otherwise intelligent immigrant children and adolescents to study at one to two grades lower than their peers [12], creating a situation which can be potentially demoralizing. A combination of pre- and post-immigration stressful situations can lead to severe and long-lasting psychological and behavioral problems, including depression, anxiety, posttraumatic stress disorder, alcohol and/or drug abuse, and a high risk for suicide. Immigrants who experienced more stressful life events presented progressive deterioration in psychological well-being [14]. Post-immigration experience is affected by health related social policy and political factors. For example, U.S. immigration policy programs in the 1960‘s and 1970‘s took a good care of the Cubans fleeing the Castro regime and Cubans were among the healthiest of all Latino groups in the U.S.A. [15]. 5. Immigrants are frequently depressed [5,7,16]. Depression in immigrants is associated with anxiety, post-traumatic symptoms, alcohol and/or drug use/abuse/dependence, pessimism, and stress-related medical illnesses such as hypertension, metabolic syndrome, and diabetes. For example, a higher prevalence of impaired lipid metabolism in immigrants in comparison with native population has been observed [16]. A recent study has shown that immigrants who experience downward social mobility are at elevated risk for major depression [17]. Depression in immigrants is related to discrimination. It‘s a vicious cycle: a) discrimination leads to or aggravates depression, and b) depressed immigrants are easier targets for discrimination. Depressive disorders are associated with a negative bias in information processing [18]. Depressed immigrants are more likely to remember negative than positive emotional information. This may negatively affect their ability to adjust to the new environment. Substance abuse may be more pronounced if the immigrants acculturate into a more permissive society, abandoning the more traditional or conservative values of their former culture [19]. Genetic factors and childhood experiences play an important role in the pathophysiology of psychiatric conditions in immigrants. 6. Psychiatric and medical problems, genetic make-up, childhood experiences, availability of a social support, cultural acceptability of suicide, the degree of preimmigration, immigration, and post-immigration stress, and other factors determine the vulnerability for suicidal behavior among immigrants with psychiatric disorders. The suicidal process may be different for individuals of immigrant background compared to people living in the host country. The theory of anomie (lack of social regulation) suggests that it is not poverty that causes suicide, but rather declines in socioeconomic status that produce anomie and result in suicide

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[20]. Thus, immigrant populations that are accustomed to low (or high) socioeconomic status may not be negatively affected by the continuance of this status in their new host country. 7. Triggers for suicidal behavior among immigrants include financial problems, relationship problems, mood instability (e.g., the onset of a major depressive episode), alcohol intoxication, abuse/assault, and acute medical illness. 8. Suicidal acts can be attributed to the coincidence of a trigger with a vulnerability for suicidal behavior [21,22]. Suicidal acts include suicide attempts and suicides. Many individuals with depression and/or other psychiatric disorders have suicidal thoughts but they never attempt suicide [22]. Immigrants typically evidence higher suicide rates than those found in their countries of origin and/or in the host country into which they have migrated [8,9]. For example, in Sweden, a significant overrepresentation of immigrants has been reported in the total cases of suicide [8]. It is of interest to note that ethnic immigrant groups subjected to more negative ethnophaulisms, or hate speech, were more likely to commit suicide [23].

IMMIGRANTS AND MENTAL HEALTH SERVICES Despite the critical need for mental health services, immigrants face significant obstacles to receiving quality mental health care including financial difficulties, the lack of culturallyand linguistically-appropriate services, and mistrust of mental health providers [2,3]. Suicide prevention among immigrants requires comprehensive, coordinated, and continuous health and mental health services for immigrant populations provided by culturally competent professionals. It is important to recognize psychiatric disorders in these populations. Social and legal help should also be provided. Suicide prevention hotlines where immigrants can speak their native language may be very important. Special attention should be given to immigrants and refugees who experienced traumatic circumstances including exposure to war and natural disasters, human trafficking, physical, sexual and emotional abuse. Suicide prevention in this high-risk population should include treatment of medical and neurological disorders.

CONCLUSION The recognition of the full professional equality of immigrants, their social acceptance and respect for their vocational and cultural aspirations may be the best protections against mental health problems among immigrants. It is critical to create a welcoming environment where immigrants can realize their potential and succeed.

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REFERENCES [1]

[2] [3]

[4]

[5] [6] [7] [8]

[9] [10]

[11] [12]

[13] [14]

[15] [16] [17]

United Nations. Recommendations on Statistics of International Migration New York, 1998, p. Box 1. http://unstats.un.org/unsd/publication/SeriesM/SeriesM_ 58rev1E.pdf Accessed November 19, 2009 International Organization for Migration. http://www.iom.int/jahia/Jahia/aboutmigration Accessed November 19, 2009 Esipova N, Ray J. 700 million worldwide desire to migrate permanently. November 2, 2009. http://www.gallup.com/poll/124028/700-Million-Worldwide-Desire-MigratePermanently.aspx Accessed November 19, 2009 Schoolland K. Courage, Fear, and Immigration: The Significance of Welcoming Newcomers in a Free Economy. Julian Simon Memorial Lecture. Liberty Institute, New Delhi, India. January 10, 2005. http://www.idfresearch.org/ semImmigration.pdf Accessed May 23, 2009 Al-Issa I, Tousignant M. Ethnicity, Immigration, and Psychopathology. New York: Springer, 2004. Portes A, Rumbaut A. Immigrant America: A Portrait. 3rd edn. Berkely, CA: University of California Press, 2006. American Psychological Association. The Mental Health Needs of Immigrants. http://www.apa.org/ppo/ethnic/immigranthealth.html Accessed May 23, 2009 Ferrada-Noli M, Åsberq M, Ormstad K, and Nordström P. Definite and undetermined forensic diagnoses of suicide among immigrants in Sweden. Acta Psychiatrica Scand. 2007; 91(2): 130-135. Burvill PW. Migrant suicide rates in Australia and in country of birth. Psychol. Med. 1998; 28: 201–8. Sher L. On the role of neurobiological and genetic factors in the etiology and pathogenesis of suicidal behavior among immigrants. Med. Hypotheses 1999; 53(2): 110-1. Bhugra D: Migration, distress and cultural identity. Brit. Med. Bull. 2004; 60: 129-141 Sun S, Fung, WW, Kwong K. A Study on Mental Health of New Arrival Children for Their First Two Years of Settlement in Hong Kong. Hong Kong: City University of Hong Kong and Christian Action, 2000. History of Ellis Island. http://www.ohranger.com/ellis-island/history-ellis-island Accessed November 19, 2009. Slonim-Nevo V, Mirsky J, Rubinstein L, Nauck B. The impact of familial and environmental factors on the adjustment of immigrants: A longitudinal study. Journal of Family Issues 2009; 30(1): 92-123. Vega W A, Amaro H. Latino outlook: good health, uncertain prognosis. Ann. Rev. Pub. Health 1994; 15: 39-67. Tselmin S, Korenblum W, Reimann M, Bornstein SR, Schwarz PE. The health status of Russian-speaking immigrants in Germany. Horm. Metab. Res. 2007; 39(12): 858-61. Nicklett EJ, Burgard SA. Downward social mobility and major depressive episodes among Latino and Asian-American immigrants to the United States. Am. J. Epidemiol. 2009;170(6):793-801.

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[18] Harmer CJ, O'Sullivan U, Favaron E, Massey-Chase R, Ayres R, Reinecke A, Goodwin GM, Cowen PJ. Effect of acute antidepressant administration on negative affective bias in depressed patients. Am. J. Psychiatry 2009;166(10): 1178-84. [19] De La Rosa M. Acculturation and Latino adolescents' substance use: a research agenda for the future. Subst. Use Misuse 2002;37(4):429-56. [20] Durkheim E. Suicide: a study in sociology. Transl. by Spalding JA, Simpson G. London, Routledge and K. Paul, 1952. [21] Sher L. A model of suicidal behavior in war veterans with posttraumatic mood disorder. Med. Hypotheses 2009;73(2):215-9. [22] Sher L, Oquendo MA, Mann JJ. Risk of suicide in mood disorders. Clin. Neurosci. Res. 2001; 1(5):337-344. [23] Mullen B, Smyth JM. Immigrant suicide Psychosom. Med. 2004;66(3):343-8.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503- 4 © 2010 Nova Science Publishers, Inc.

Chapter 2

IMMIGRATION AND SUICIDE: AN OVERVIEW Brian Greenfield,1 Londa Daniel2 and Bonnie Harnden2 1. McGill University Faculty of Medicine and Montreal Children‘s Hospital, Montreal, Quebec, Canada 2. Concordia University, Montreal, Quebec, Canada

ABSTRACT Introduction: The assessment of patients contemplating suicide requires a specific skill set. When immigrants are involved, the complexity increases. Method: This article presents an overview of cultural issues concerning suicide, examining cultural differences among several countries of origin and tracking the impact of those disparities as immigrants adapt to the host culture through the first and subsequent generations. Results: Although suicide may be universally considered a final common pathway of distress, its acceptability, manifestations and execution vary widely across cultures. When individuals from disparate cultures immigrate to a host country, their suicide rates and methods gradually assume a profile similar to those of the host culture, mediated by acculturative stress, the process of acculturation and by risk factors (eg never having been married, drug use and rejection by the host culture) and protective elements (eg maintenance of traditional family relationships, belonging to an ethnic community, living in a large city and being married). Consideration is given to the Canadian Inuit, faced with problematic integration into the mainstream culture and particularly high suicide rates, to provide perspective on similar challenges and therapeutic matters in relation to suicidal immigrants. A case example highlights some of these characteristics. Conclusion: Although commonalities can be found between cultures in their attitudes toward suicide and the stresses associated with immigration, assessment of immigrants who are suicidal must be considered on an individual basis and superimposed on a sound clinical interview.

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Brian Greenfield, Londa Daniel and Bonnie Harnden

INTRODUCTION This chapter is an overview of suicide in the North American immigrant population. Some components inform clinicians about cultural factors that are relevant during assessment and treatment, while others guide researchers to literature supporting differences in suicide among immigrant populations. The term ‗immigrant population‘ refers to a heterogeneous cohort of diverse cultural backgrounds who have relocated for a range of different reasons and have lived in the host country for varying amounts of time. An exhaustive review of each group is beyond the scope of this chapter, which provides a framework clinicians can apply in assessing and that treating this population. What follows is a description of suicide rates, acculturation and acculturative stress (processes that influence the mental health of immigrants), protective and risk factors, cultural attitudes towards suicide, methods of suicide, suicide within aboriginal populations and a discussion of the applicability of cultural factors to diagnosis and treatment.

DIFFERENCES IN IMMIGRANT SUICIDE RATES Most of our current knowledge of suicide – statistics, predictors and protective and risk factors – has been derived from research with resident populations in industrialized (mainly North American and European) nations, and thus we know very little about the applicability and relevance of this literature to North American immigrant populations. Research on these groups, however scarce, indicates that significant differences in suicide tendencies may exist in comparison to non-immigrant populations. Within Canada and the US, suicide rates differ among cultural groups. Aboriginal and Inuit people are most likely to commit suicide, followed by non-Hispanic Caucasions, Hispanics, non-Hispanic Blacks and, least of all, Asian and Pacific Islanders [1]. In general, first generation immigrants demonstrate particularly low rates, resembling rates typical of their country of origin [2], with later generations demonstrating increased frequencies more comparable to North American trends [3]. Differences also exist by gender and age, following trends typical of the country of origin [4]. In the North American population, the suicide gender ratio is four men to every woman, reversing to 2:7 in many immigrant populations where women are more likely to commit suicide. Furthermore, suicide risk peaks in adulthood for Canadian-born populations, whereas in other groups, such as Chinese-Canadians, the elderly are at highest risk [4].

ACCULTURATION AND THE GENERATION EFFECT Acculturation describes the process of change that occurs as a result of exposure to a different culture [5]. It is responsible for change at both the individual and group levels. Individually, psychological changes occur, reflecting host society attitudes and behaviours. Collectively, cultural customs, economics and politics grow more similar to those of the host country. Acculturative stress describes the psychological difficulties which arise during the acculturation process [6]. For many, this process includes financial problems, discrimination,

Immigration and Suicide: An Overview

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language difficulties, separation from family and alienation from traditional cultural beliefs. Elevated blood pressure, a stress response to this process noted in immigrant populations, remains higher than normal for as long as 15 years following immigration [7]. The cooccurring phenomena of acculturation and acculturative stress seem to play separate roles in affecting the likelihood of suicide.

Acculturative Stress Although acculturative stress is associated with economic and sociological hardships, some immigrants nonetheless have better mental health and lower suicide rates than even the host population, as has been documented in the Hispanic immigrant population [8] and in a variety of youth immigrant populations [9]. Although the process of immigration is unquestionably inherently stressful, some have questioned the utility of the term acculturative stress given that first-generation immigrants could have lower rates of mental illness and suicide than the host population [6]. When it does have negative consequences, acculturative stress seems to decrease with time spent in the host country. For instance, first-generation immigrant populations living in the US for over 20 years have a lower risk of committing suicide than the same cohort living in the US for only 10 years [10]. These findings imply that negative effects of acculturative stress may become less salient over time and suicide risk thus decreases. This effect has also been documented in immigrant populations in Britain, with suicide rates of long-term firstgeneration residents lower than those for recent immigrants [11]. Thus, despite the lower suicide rates of first-generation immigrants compared to the native population, acculturative stress may nevertheless have a role to play. It may be that the initial lower suicide rates are more reflective of suicide factors in the culture of origin than the absence of mental stress during the immigration process.

Acculturation The process of acculturation seems to play a different role in the psychological wellbeing of second- and later-generation immigrants as compared to first-generation immigrants. Concerns appear to shift from acculturative stressors, such as moving and adjusting to new cultural norms, to reconciling conflicts between heritage and host culture, while stressors such as prejudice and stereotyping persist. An example of this is the Latin-American population, which has higher rates of mental illness and suicide in second- and later-generation immigrants. These later generations may be less protected by the strong family and community bonds characteristic of Mexican culture, for example, rendering them more susceptible to mental illness and suicide [3]. Hence, although acculturation has certain advantages (eg overcoming language barriers, increased employment opportunities, acceptance within the host culture), it is disadvantaged by ‗dissimilation‘ (estrangement) from the heritage culture [12].

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PROTECTIVE AND RISK FACTORS Researchers have identified a number of factors that either protect against, or constitute risk for, suicide.

Protective Factors Protective factors which have been theorized to account for the observed low rates of mental illness in immigrant groups include maintenance of traditional family relationships, belonging to an ethnic community, living in a large city and being married. Mexican and other Latino immigrant populations are likely to have especially strong family ties, as seen in traditional Mexican culture [13], and these relationships may be responsible for low suicide rates within these groups [14]. It is possible that the lower suicide rates observed among nonHispanic Black, Asian and Pacific Islander immigrants as compared to the US Caucasian population [1] may be due to similarly protective family relationships. Trovato and Jarvis [15] found that immigrant cultures differ in the extent to which they experience ‗community completeness‘, which is described as belonging to, and feeling supported within, a community. This feeling may play an important role in suicide prevention in different cultures. Immigrant groups in Canada with low levels of community completeness, such as the Welsh, Scots, Germans and Americans, tend to have higher rates of suicide, and groups with high levels of community completeness, such as the Italians, Portuguese and Irish, have lower suicide rates [15]. Emile Durkheim‘s early work, Suicide [16], offers an anthropologic perspective to account for the importance of community and social networking as protective against suicide. He maintained that the observed differences in suicide rates between cultures inversely reflected the level of social integration, such that individuals manifesting strong social bonds pose a lower risk than those with less developed social networks. In keeping with Durkheim‘s work, immigrant populations are advised to build community and social bonds via assimilation into the host country‘s culture or maintenance of ties with other immigrants sharing the same culture. In support of this theory, researchers have noted that living in a large city is protective against suicide. Canada‘s three largest cities, Toronto, Montreal and Vancouver, where more than 60% of Canada‘s immigrant population lives, have the lowest immigrant suicide rates, supporting the notion that ethnic community plays a powerful role in preventing suicide in immigrant populations [4]. Being married [17] is also generally a predictor of lower suicide rates and is particularly protective in immigrant populations. Kposowa, McElvain and Breault [10] found that single immigrants were 4.4 times more likely, and divorced or separated immigrants were 3.7 times more likely, to kill themselves than married immigrants. This finding might relate to the value placed on family versus autonomy in other cultures and to a feeling of loneliness and alienation often accompanying the immigration process.

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Risk Factors Acculturation, lack of an ethnic community, never having been married (or being divorced) and drug use may pose particular risks for suicidal behaviour in certain immigrant populations. Conversely, low drug use among first-generation Mexican immigrants [18] may account for lower rates of suicide in immigrant groups as compared to the host population, a relationship that was also observed by Greenfield et al [19] in a variety of immigrant youth populations. In later immigrant generations, rates of drug use increase significantly, paralleling the rates of suicide, though they still remain lower than the rates of the host population and lower than those recorded in the general Mexican population [18]. Pena et al [3] similarly found that drug use among Mexican immigrants may mediate the relationship between generation status and suicide, such that drugs (cocaine, inhalants, LSD, PCP, ecstasy, mushrooms, speed, ice, heroin or non-prescription pills) were closely related to suicidal behaviour in later-generation immigrants. Knowledge of the relationship between drug use and suicidal behaviour can inform clinicians, who would thus be advised to inquire about drug-use patterns and initiate early intervention as a component of suicide prevention in at-risk immigrant populations. Suicide risk is dependent upon level of rejection of immigrant groups by the host population and can be measured by the level of hate speech, or ‗ethnophaulisms‘, directed toward immigrant populations. Mullen and Smyth [20] found that European immigrant groups in the US that were subject to higher rates of ethnophaulisms were more likely to commit suicide, further underlining the role that host culture plays in determining suicide rates within ethnic groups. Given the financial stressors inherent in the immigration process, one might intuitively anticipate that immigrant populations would have higher levels of mental illness, poor-quality health care and increased suicide rates. This would be consonant with Hollingshead and Redlich [21], who documented a higher prevalence of schizophrenia among lowsocioeconomic-level populations. However, it has been demonstrated that, despite socioeconomic stressors, Mexican immigrant populations do not experience greater rates of mental illness [13]. Durkheim‘s theory of anomie (lack of social regulation) [16], posits that it is not poverty that causes suicide, but rather declines in socioeconomic status that produce anomie and result in suicide. Thus, immigrant populations that are accustomed to low (or high) socioeconomic status may not be negatively affected by the continuance of this status in their new host country. The clinician might therefore be advised to inquire about status or income changes during assessment.

CULTURAL ACCEPTABILITY OF SUICIDE Cultural attitudes toward suicide may protect or pose risk and can be examined from both religious and non-religious perspectives. In highly religious communities, suicide rates may be affected by attitudes that condemn or reward suicide. For instance, the Hindu faith is characterized by understanding and acceptance of suicide and Asian-Hindu immigrants to the US have has a correspondingly high rate of suicide compared to Asian immigrants practising the Islamic faith [22]. Similarly, Mexican [23] and African [24] immigrant populations both

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demonstrate strong religious affiliation and low rates of suicide. But the relationship between religion and suicide is not always this simple and requires a further examination of the country, politics, religious practice and manner in which the population adheres to particular religious values. For example, even countries practicing the same religion may have different suicide rates, so that Catholic countries such as Austria and France have high rates of suicide while others such as Ireland, Spain and Italy have low rates [25]. Rates can even differ within the same country and religion; Irish rural areas have demonstrated a more substantial increase in suicide rates than urban areas during a recent decade [26]. Others have examined non-religious cultural attitudes towards suicide. In the Japanese culture, suicide is a respected, serious act, yet suicide rates are very low among the Japanese immigrant population [27], possibly resulting from other predominating protective factors. Reynolds, Kalish, and Farberow [28] observed differences in attitudes towards suicide in four different cultural groups within the US: Japanese-American, Mexican-American, CaucasianAmerican and African-American. In response to the question ‗What kind of individuals commit suicide?‘, Japanese-Americans were significantly more likely to choose ‗cowardly‘, whereas both African- and Mexican-Americans were more likely to opt for ‗crazy‘ and Caucasian-Americans favoured ‗emotionally upset‘, again highlighting cultural attitudes toward suicide. Such differences may reflect variation in cultural expression of suicide rather than differences in underlying affect. It is possible that individuals in all cultures are driven to suicide by the same emotional experience (distress, guilt, sadness), but that cultural acceptability acts as a lens through which the emotion is interpreted and managed. Differences in cultural acceptability may lead to the enlistment of different attitudes to defend against the same negative affect.

METHOD OF SUICIDE First-generation immigrant populations within North America tend to choose methods of suicide that are influenced by their cultural heritage. Method is determined by cultural traditions and attitudes, availability of resources [29], country of origin, location within a given country and gender. For instance, traditional customs in Japan led to the popularity of ritual disembowelment (cutting the abdomen from left to right), which emerged as a means to preserve honour and respect when warriors were about to be killed by an enemy. Due to changes in cultural norms and availability of resources, this custom was eventually superseded; hanging and taking pills are now the most common methods [27]. In Switzerland, firearms, which constitute a symbol of respect for the military, are eschewed as a method of suicide in favour of the most common practice, inhalation of toxic gas [30]. Within the Chinese population, methods differ according to location and availability of resources. In Hong Kong, jumping from a height was the most common method, whereas in Taiwan, poisoning was most frequent [31]. In the Indian subcontinent, both men and women commit suicide through poisoning with agrochemicals, a readily accessible resource [32]. In South Africa, choice of method is dependent upon ethnicity and gender rather than location or resources. African and Indian men have high rates of hanging and women commit suicide

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most commonly by fire. Among the Caucasian population, men commit suicide most often with firearms and women choose poisoning [33]. There are also differences among cultures within North America. The most common method of suicide for Caucasian North Americans is by staged motor-vehicle accident, followed by poisoning, firearms and jumping from a height [1]. African-Americans use more violent methods compared to Caucasian-Americans, who have relatively higher rates of taking pills or toxic gases [34]. It has been postulated that these differences are driven by increased exposure to violence, lower socioeconomic status and increased availability of firearms within the African-American community [34]. Understanding suicide profiles in the country of origin, how those trends become manifest after transition to the host country can be evaluated. Lester [31] observed that recent Asian immigrants were influenced by suicide trends from their heritage culture and were more likely to choose hanging than Caucasian-Americans or African-Americans, consistent with the popularity of hanging in Chinese culture. However, as immigrant groups assimilate into the host culture, they are more likely to use methods prevalent in their adopted country. Burvill, McCall, Woodings and Stenhouse [35] have also found that although recent immigrants (from England, Scotland and Ireland) to Australia used methods that were common in their heritage culture, they were more likely to adopt Australian methods as their residency lengthened. Similarly, Lester [32] noted that Indian immigrants in other nations tend to switch from using poisoning with pesticides (popular in India) to hanging, perhaps reflecting a lack of availability of pesticides in the host countries or indicating how immigrants are influenced by the norms of the host culture.

SUICIDE AND ACCULTURATION WITHIN THE INDIGENOUS POPULATION There may be commonalities in the acculturation process between the Inuit and immigrant populations and, given the high suicide rate among Canadian Inuit, an examination of the factors contributing to that rate might increase understanding of risk factors in immigrants. Indigenous populations generally have higher rates of suicide than both Caucasian and immigrant populations [36]. Ihe Inuit population in Canada, for instance, demonstrates elevated patterns of suicide, with rates five times as great as those of the general population. In northern Quebec, this difference is even greater, with suicide rates among Inuit youth 20 times as great as those across the rest of Quebec [37]. Poor health care, poverty and lack of community control are some of the proposed factors accounting for that elevated rate. Heightened rates of indigenous suicide may also be due to conflict between Inuit and the majority North American culture; pressure to acculturate produces stress and alienation from heritage culture and loss of protective cultural traditions [38]. Especially high rates of suicide occur in communities that have high levels of acculturation (pressure to adopt the Caucasian culture) and are poorly integrated into social networks [39-40]. Several other risk factors associated with the Inuit population resemble those of immigrant groups and are worthy of mention. Drug and alcohol abuse are highly correlated with suicide and are prevalent among aboriginal youth with a proclivity to the use of solvents [37]. Lack of help-seeking behaviour is a particular obstacle in treating this population, as the

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embarrassment and stigma of treatment can easily lead to its avoidance and the denial of a need for help [41]. Other risk factors include parental history of drug or alcohol abuse, suicidal behaviour in a close friend, presence of mental illness and alienation from community and family. Addressing these risk factors is paramount during interviews of suicidal patients from various cultures.

APPLICABILITY TO DIAGNOSIS AND TREATMENT Many factors contribute to the decision to commit suicide during the immigration process and they do not lend easily to an equation or diagnostic formula. Clinicians must first consider the general risk factors for suicide, gender, age, marital status, family history, previous attempts and substance abuse [42]. A thorough individual evaluation (and, in a paediatric setting, a family assessment as well) would then be required, searching for and attempting to repair weaknesses in interpersonal communication styles, which may render individuals vulnerable to distress. Superimposed upon this clinical template, clinicians may then consider cultural risk and protective factors for assessment and treatment. Such factors include norms of the heritage culture, attitudes towards suicide, the process of acculturation, the duration of stay in the host country and differentiation between the first and second generations. Also of relevance in this interview process is the manner in which symptoms are expressed in a given culture. For instance, Chinese immigrants are known to express depressive symptoms somatically rather than psychologically [43]. In such cultures, where somatic complaints are more socially acceptable than emotional problems, less distinction is made between organic functioning and emotion, such that physical ailments may serve as markers of mental illness such as depression and are thus also important in assessing suicidal risk. Furthermore, development of the therapeutic alliance, a factor that has consistently been one of the strongest predictors of treatment outcome [44], may be especially aided by knowledge of, and respect for, cultural differences. It is also important to consider who should be included in the assessment and treatment of a patient. When dealing with clients from Asian cultures, where high value is placed on family and interdependence, treatment may be facilitated by the inclusion of family members [45]. When other cultures view mental illness as unacceptable, thereby causing the patient to feel shame and guilt, inclusion of the family may actually hinder treatment. It is thus essential to consider individual circumstances when deciding which family members should be involved in the interview.

CASE EXAMPLE T is an 18-year-old girl from China who presented to an urban university hospital emergency room (ER), accompanied by her elder brother, with a complaint of stomach-aches. A psychiatric examination was requested by the paediatrician, as the patient frequently cried during examination, was guarded when questioned concerning possible suicidality and no organic aetiology was detected. Psychiatric assessment revealed that the patient had been

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depressed during the previous two years and had frequently considered suicide, without having made attempts. She lived with her natural parents and brother. Despite discouragement from the paternal grandparents, the father, a successful businessman, had married the mother, who suffered from a long-standing gambling addiction. The mother had been increasingly indulging her addiction during the previous two years, with her husband fully aware of the problem but relatively helpless to stop her, thus rendering her less emotionally and physically available to the family. The patient, whose depression had worsened during that time, had no active plans to kill herself, but stated that her preferred choice would be by poisoning or overdose of overthe-counter medication in her home‘s medicine cabinets. Several clinical concerns were addressed during six sessions of crisis intervention with the family. The first ER assessment was focused on reinforcing the father‘s supervision of the patient, securing cleaning products and medications under lock-and-key and ensuring supervision of the patient after school and during weekends. The patient and family were also helped to understand the patient‘s somatic symptoms as cries for help, which needed to be taken seriously. The parents indicated that they were aware of the patient‘s physical suffering during recent years, but had felt they could address that themselves through consultation with Chinese friends. They now appreciated understanding that the emotional distress was masquerading as somatic complaints. During subsequent sessions, the patient revealed the stresses created by parental pressure for academic success. The parents indicated their perspective that, through study and hard work, the patient was more likely to become ‗successful‘ and ‗somebody‘. Household discussions thus focused on school-related activities, and no mention was made of the financial stresses induced by the mother‘s addiction. When this theme was aired, the father finally revealed that his long working hours were partially driven by a need to reimburse substantial debt incurred by the mother‘s habit and his further concerns that fatigue resulting from his heavy schedule could harm his own health, which worried the patient. Therapeutic efforts were focused on empathizing with the patient‘s academic struggles and with the family‘s stresses induced by the mother‘s gambling, the father‘s work load and the immigration process, validating their respective problems, and facilitating the mother‘s enrolment in a gambling rehabilitation program. The patient‘s clinical status was monitored and the impact of cultural issues on symptomatic presentation and evolution evaluated. A key therapeutic asset was understanding how Chinese parents function in a ‗cultural hierarchy‘, tending to predominantly interact with the oldest ‗parentified‘ child, who is then empowered to provide surrogate parenting to the younger siblings, with an expectation that the patient‘s illness would be healed by a ‗cultural collectivity‘. The patient‘s mother, burdened by her gambling habit, was less available to provide an example to the patient‘s brother, who was accordingly compromised in his ability to provide care for the patient, who then increasingly turned toward the host culture for solace and support, further distancing her from her parents. In common with dysfunctional families in the host culture, relationship issues, notably the mother‘s gambling, had never been addressed, there was pressure for the children to succeed academically, emotional issues were not recognized and the therapist used empathy and validation to produce therapeutic results. Of greater specificity to the Chinese culture, this family felt there was no pathway for receiving outside help, trying through their network of friends to deal with the patient‘s complaints. The mother and father directed their parenting to the oldest child, indirectly entrusting him with parenting the patient.

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CONCLUSION Although literature on immigrant populations tends to homogenize these communities, it would appear on closer examination that there may be further stratification among these groupings, such that each assessment must be considered individually. Assessment of suicidal patients is a complex process comprising individual and social risk factors. The complexity of that process is compounded by the multiplicity of risk factors inherent in the immigration experience over the generations. An awareness of these issues is essential in conducting interviews of immigrant populations and enriches them for all involved.

REFERENCES [1]

[2] [3]

[4] [5] [6] [7]

[8]

[9] [10] [11] [12] [13]

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control: Web-based Injury Statistics Query and Reporting System. 2006. Retrieved from: http://www.cdc.gov/ncipc/wisqars. Sainsbury P, Barraclough B: Differences between suicide rates. Nature 1968; 220:1252. Pena JB, Wyman PA, Brown CH, Matthieu MM, Olivares TE, Hartel D, Zayas LH: Immigration generation status and its association with suicide attempts, substance use, and depressive symptoms among Latino adolescents in the USA. Prev. Sci. 2008; 9: 299-310. Malenfant EC: Suicide in Canada's immigrant population. Health Rep. 2004; 15:9-17. Berry JW, Phinney JS, Sam DL, Vedder P: Immigrant youth: acculturation, identity, and adaptation. Appl. Psychol. 2006; 55:303-332. Rudmin F: Constructs, measurements and models of acculturation and acculturative stress. Int. J. Intercult. Relat. 2009; 33:106-123. Steffen PR, Smith TB, Larson M, Butler L: Acculturation to western society as a risk factor for high blood pressure: a meta-analytic review. Psychosom. Med. 2006; 68:386397. Vega WA, Kolody B, Aguilar-Gaxiola S, Alderete E, Catalano R, Caraveo-Anduaga J: Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Arch Gen. Psychiatry 1998; 55:771-778. Harker K: Immigrant generation, assimilation, and adolescent psychological well-being. Soc. Forces 2001; 79:969-1004. Kposowa AJ, McElvain JP, Breault KD: Immigration and suicide: the role of marital status, duration of residence, and social integration. Arch Suicide Res. 2008; 12:82-92. Bhugra D, Baldwin DS, Desai M, Jacob KS: Attempted suicide in West London, II. Inter-group comparisons. Psychol. Med. 1999; 29:1131-1139. Yinger JM: Toward a theory of assimilation and dissimilation. Ethn. Racial. Stud. 1981; 4:249-264. Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Anderson K: Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic whites in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen. Psychiatry 2004; 61:1226-1233.

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[14] Locke TE, Newcomb MD: Psychosocial predictors and correlates of suicidality in teenage Latino males. Hisp. J. Behav. Sci. 2005; 27:319-336. [15] Trovato F, Jarvis GK: Immigrant suicide in Canada: 1971 and 1981. Soc. Forces 1986; 65:433-457. [16] Durkheim E: Suicide: a study in sociology. Translated by Spalding JA, Simpson G. London, Routledge and K. Paul, 1952. [17] Stack S: Suicide: a 15-year review of the sociological literature. Part II: modernization and social integration perspectives. Suicide Life Threat Behav. 2000; 30:163-176. [18] Swanson JW, Linskey AO, Quintero-Salinas R, Pumariega AJ, Holzer CE, 3rd: A binational school survey of depressive symptoms, drug use, and suicidal ideation. J. Am. Acad. Child Adolesc. Psychiatry 1992; 31:669-678. [19] Greenfield B, Rousseau C, Slatkoff J, Lewkowski M, Davis M, Dube S, Lashley ME, Morin I, Dray P, Harnden B: Profile of a metropolitan North American immigrant suicidal adolescent population. Can. J. Psychiatry 2006; 51:155-159. [20] Mullen B, Smyth JM: Immigrant suicide rates as a function of ethnophaulisms: hate speech predicts death. Psychosom. Med. 2004; 66:343-348. [21] Hollingshead AB, Redlich FC: Schizophrenia and social structure. Am. J. Psychiatry 1954; 110:695-701. [22] Ineichen B: The influence of religion on the suicide rate: Islam and Hinduism compared. Mental Health, Religion and Culture 1998; 1:31-36. [23] Hovey JD: Acculturative stress, depression, and suicidal ideation in Mexican immigrants. Cultur Divers Ethnic Minor Psychol. 2000; 6:134-151. [24] Walker RL: Acculturation and acculturative stress as indicators for suicide risk among African Americans. Am. J. Orthopsychiatry 2007; 77:386-391. [25] Dublin LI: Suicide: a sociological and statistical study. New York, Ronald Press, 1963. [26] Kelleher MJ, Keeley HS, Corcoran P: The service implications of regional differences in suicide rates in the Republic of Ireland. Ir.Med. J. 1997; 90:262-264. [27] Iga M, Tatai K: Characteristics of suicides and attitudes toward suicide in Japan, in Suicide in Different Cultures. Edited by Farberow NL. Baltimore, MD, University Park Press, 1975. [28] Reynolds DK, Kalish RA, Farberow NL: A cross-ethnic study of suicide attitudes and expectations in the United States, in Suicide in Different Cultures. Edited by Farberow NL. Baltimore, MD, University Park Press, 1975. [29] Marzuk PM, Leon AC, Tardiff K, Morgan EB, Stajic M, Mann JJ: The effect of access to lethal methods of injury on suicide rates. Arch Gen. Psychiatry 1992; 49:451-458. [30] DeCatanzaro D: Suicide and self-damaging behavior: a sociobiological perspective. New York, Academic Press, 1981. [31] Lester D: The epidemiology of suicide in Chinese populations in six regions of the world. Chinese Mental Health Journal 1994; 7:25-36. [32] Lester D: Suicide in emigrants from the Indian subcontinent. Transcult Psychiatry 2000; 37:243-254. [33] Meer F: Race and suicide in South Africa. London, Routledge and K. Paul, 1976. [34] Stack S, Wasserman I: Race and method of suicide: culture and opportunity. Arch Suicide Res. 2005; 9:57-68.

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[35] Burvill PW, McCall MG, Woodings T, Stenhouse NS: Comparison of suicide rates and methods in English, Scots and Irish migrants in Australia. Soc. Sci. Med. 1983; 17:705708. [36] Leenaars AA: Suicide among indigenous peoples: introduction and call to action. Arch Suicide Res. 2006; 10:103-115. [37] Kirmayer LJ, Boothroyd LJ, Hodgins S: Attempted suicide among Inuit youth: psychosocial correlates and implications for prevention. Can. J. Psychiatry 1998; 43:816-822. [38] Berry JW: Acculturation and adaptation: health consequences of culture contact among circumpolar peoples. Arctic Med. Res. 1990; 49:142-150. [39] Bagley C: Poverty and suicide among native Canadians: a replication. Psychol. Rep. 1991; 69:149-150. [40] Van Winkle NW, May PA: Native American suicide in New Mexico, 1957-1979: a comparative study. Hum. Organ. 1986; 45:296-309. [41] Freedenthal S, Stiffman AR: Suicidal behavior in urban American Indian adolescents: a comparison with reservation youth in a southwestern state. Suicide Life Threat Behav. 2004; 34:160-171. [42] Kaplan HI, Freedman AM, Sadock BJ, editors. Comprehensive textbook of psychiatry. 3rd ed. Baltimore, MD, Williams and Wilkins, 1980. [43] Tseng WS, Asai M, Liu JQ, Wibulswasdi P, Suryani LK, Wen JK, Brennan J, Heiby E: Multi-cultural study of minor psychiatric disorders in Asia: symptom manifestations. Int. J. Soc. Psychiatry 1990; 36:252-264. [44] Horvath AO, Symonds BD: Relation between working alliance and outcome in psychotherapy: a meta-analysis. J. Couns. Psychol. 1991; 38:139-149. [45] Lin KM, Inui TS, Kleinman AM, Womack WM: Sociocultural determinants of the help-seeking behavior of patients with mental illness. J. Nerv. Ment. Dis. 1982; 170:7885.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 3

IMMIGRANTS AND SUICIDAL BEHAVIOR: THE ROLE OF GENDER Diana van Bergen1 and Sawitri Saharso2 1

2

The Netherlands Institute for Social Research, The Hague; VU University Amsterdam and University Twente, The Netherlands

ABSTRACT Ethnicity plays a major role in the rates and risk factors of suicidal behavior. While ethnocultural factors increasingly receive attention of suicidologists, the relevance of the intersections of ethnicity and gender are yet to be recognized. In this chapter, we review findings on the role that gender has for suicidal behavior of immigrants. We focus in particular on suicidal behavior of immigrant women and discuss gender specific risk factors. In addition, we summarize the indicators that exist cross culturally for the relevance of Durkheim‘s fatalistic suicide to understanding women‘s suicidal behavior.

INTRODUCTION Over the past decades, numerous empirical studies in suicidology have contributed to the knowledge of the epidemiology and risk factors of suicidal behavior. These studies have revealed remarkably consistent patterns of suicidal behavior according to gender. Females worldwide show higher rates of suicidal ideation and non-fatal suicidal behavior compared to males. A gender paradox emerges: across the globe, females are more suicidal, since they are more likely to report suicidal ideation and suicide attempts; however males are more likely to die by suicide [1, 2]. Hence, gender has a substantial predictive impact on suicidal behavior. Although suicide attracts most of the attention, it is statistically an infrequent phenomenon. Across cultures, non-fatal behavior is unequivocally found more often in females [3]. Since females worldwide outnumber men regarding this behavior, there is urgency in suicidology to focus on females. In spite of abundant evidence of the relevance of gender on suicide behavior, many studies fail to integrate gender as a crucial factor for detecting risk factors and origins of suicidal behavior [1]. Another shortcoming is that most studies conducted in the

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west fail to recognize that the suicidal process may be different for individuals of immigrant background. Furthermore, the intersection of ethnicity and gender and its impact to suicidology in particular are an area of neglect. For example, the major role that depression plays towards the suicidal process has gained univocal support in the west and is taken for granted. Depression is to be more prevalent in females compared to males in the west [2]. However, depression is sometimes suggested to be less relevant to suicide in females in non western cultures for instance in India and China [4, 5]. In addition, research that has addressed ethnicity as a focus of interest often fails to include gender. For instance, a large study on immigrant and suicidal behavior in Canada by Clarke et al [6] showed that Franco-Europeans and native Inuit population had high suicide risk compared to other ethnicities due to alcohol abuse. A study from the US [7] showed how anti social behavior was linked to suicide for whites more than for blacks. Gender was not mentioned in these studies, which obscures whether differential patterns exist for immigrant men compared to immigrant women. In order to make a contribution to the lacunae that exist on the role of gender, in this chapter we accumulated a number of findings of suicidal behavior in immigrants in relation to gender, with special attention to immigrant females. We first examine the role of the gender paradox in the epidemiology of immigrants‘ suicidal behavior. Next we discuss important risk factors that are influenced by gender. Lastly, we want to specifically address the role of Durkheim‘s archetype of fatalistic suicide [8], which has an important explanatory power for immigrant women of Asian background, who make up a substantial part of the immigrant population in western Europe as well as the United States.

THE GENDER PARADOX IN SUICIDAL BEHAVIOR The gender paradox in suicidal behavior has been validated cross culturally in the US and Europe, for many immigrant as well as non immigrant groups [9-13]. Females exceed on rates of non fatal suicidal behavior and males on suicide rates. The gender ratio generally observed in suicide in the US and Europe is about 3-4 to 1 for males compared to females. However, in many non western countries, for instance Hong Kong, Sri Lanka and India, the gender differences are much smaller, often less than 2:1. Moreover, in rural China and Batman province in Turkey, the suicide rates of young women exceed that of men [2, 14]. Patterns and rates of suicidal behavior of first generations of immigrants seem to be replicated in the host countries and sometimes increase in the second generation of immigrants [12, 15, 16]. Support for this thesis can be found in South Asian immigrant young women who have high rates of fatal and non fatal suicidal behavior worldwide [17] and similar high rates in their countries of origin [18-19]. For instance, In the province of Nickerie in Surinam (which has predominantly a South Asian immigrant population), hospital registration has shown a rate of attempted suicide of 4.0 per 1,000 for South Asian females [20], which is remarkably similar to the registered high rates of South Asian-Surinamese females in The Hague, The Netherlands (4.2 per 1,000) [11]. South Asian young females are overrepresented compared to majority females among those who attempt suicide as well as those who die from suicide in The UK, Singapore, Fiji and The Netherlands [11, 17, 21, 22]

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In the US, Latino, African American as well as Asian youth have been found to have increased rates of fatal as well as non fatal suicidal behavior compared to those of European descent. In adults, however, this appears not to be the case [23]. In all ethnic groups in the US, females‘ rates of non fatal suicidal behavior exceed that of males; the gender ratio being 3:1 on average. Regarding suicide statistics, an average ratio of 5:1 (males to females) has been reported for youth cross culturally in the US [9]. A worrisome finding of the past decade has been the increase of suicide among young men of African American descent. A similar increase could not be found in African American women [24]. However, although African American women have low rates of suicide, their rates of suicidal behavior are as high as of European –American women [25]. Research from Sweden indicated increased suicide rates in immigrant females but not males of non western origin (excluding the Middle East), when compared to Swedish native population. In addition, male and female immigrant youth of eastern European and western descent in Sweden had increased odds for suicide compared to Swedish majority youth [12]. Regarding non fatal suicidal behavior in Sweden, immigrants, both with a non western background as well as immigrants of other European descent, had increased rates of non fatal suicidal behavior compared to Swedish majority (with the exception of Southern European immigrants). Yet, the female immigrant rate of non fatal suicidal behavior was higher than the rate of immigrant males [13]. A study from The Netherlands showed heightened propensity for suicide in Turkish and Surinamese young men in the age band 30-45 in The Netherlands compared to white Dutch majority men [10]. Another study from the Netherlands showed that Turkish young immigrant women have high rates of non fatal suicidal behavior, four times higher compared to Dutch majority women, whereas South Asian–women in the UK as well as in the Netherlands have high rates of both fatal and non fatal suicidal behavior [11, 21, 22, 26]. In short, research of immigrants from Europe and the US confirm that females are more suicidal than males, yet men die more often by suicide. Examples of India, China and Turkey indicate that there are exceptions to this pattern, which is underscored by findings of South Asian immigrant women in the UK and The Netherlands who have high risk of suicide. One explanation for the gender paradox that has gathered much support, is that the choice of less lethal methods of females is likely to be responsible for the non fatality their acts. The female choice of self poisoning reflects culturally determined gender preferences that result in a higher likelihood of a non-fatal outcome. A study by Denning, Conwell, King and Cox [27] showed that men and women with equal intent to die choose methods of suicidal behavior that vary in lethality, with men turning to more lethal methods than women. In western countries, women predominantly use self poisoning (with-over the counter prescribed medicine with low lethality) [2]. Hence, this suggests that if women would turn to more lethal methods, they would quickly exceed the number of suicides by men. The likelihood of this scenario is underscored by examples can from rural China, Surinam and southern Indian states, where suicides by women are as frequent or higher compared to male suicides [4, 19, 20]. However, males are overrepresented in urban suicides in China. The methods used for suicidal behavior by women in the countryside in these countries are highly lethal (i.e. pesticides), notably more lethal than the methods commonly used by female suicide attempters in the west and in the urban areas of non-western countries. The choice of suicide method is often replicated via the cultural memory of immigrants and thereby exported to the host country. Evidence for this mechanism is found among South

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Asian immigrant women. Indian women in the UK sometimes choose burning as a method [28]. The choice of method reflects the acceptability of self-immolation as observed by women, but not by men, in India [29]. South Asian-Surinamese women in The Netherlands frequently use acid as a means to their suicidal behavior, which is comparable to the choice of method for suicide in their regions of origin in Surinam [20]. This shows how gender and culture influence the availability, familiarity and acceptability of a certain method [3].

GENDER AND LETHAL INTENT As a result of the gender ratio in suicide, suicide is often perceived as a male problem. Simultaneously, non fatal suicidal behavior has often been framed as attention seeking and inept [2]. Dahlen and Canetto [30] and Stillion [31] demonstrated that North American males evaluated suicidal behavior more negatively compared to suicide. Since women are overrepresented in suicide attempts, it is women in particular who are prone to these negative evaluations. Also, it is often assumed that women's suicidal behavior is non-medically serious and has a low suicidal intent. However, numerous studies have shown that a lethal intent is present as often in females as in males and that the acts of women are medically serious as often as that of male attempters [2, 32]. Regarding differences between immigrant and non immigrant females, little research is available. However, a study in the Netherlands that compared the lethal intent of immigrant women in three immigrant groups (South AsianSurinamese, Turkish and Moroccan women) to majority Dutch women showed that a lethal intent was in fact mentioned more often by immigrant females compared to majority Dutch women [33]. Regarding the communicative aspects of suicidal behavior, the motives of suicidal behavior with an external focus e.g. ―I wanted others to know how much pain I felt‖ are more often mentioned by females than by males in a WHO study of more than 10 European countries [34]. While this may seem paradoxical, the external focus does not occur at the expense of a lower lethal intent in women. It has already been established that individuals who demonstrate suicidal behavior employ different motives simultaneously and some of them may seem contradictory [35]. In sum, the research on gender, method and intent of suicidal behavior suggests that suicidal immigrant females have similar or stronger lethal intent compared to majority groups and compared to males, yet also their behavior may more often be a means of communication to their environment in comparison to males. However, further research is needed into gender aspects of communication in attempted suicide in immigrant groups. Their choice of methods in general, protects women from dying by suicide, but specifically immigrant women from regions of origin where highly lethal methods are used are prone to replicate this choice of method and die more often also in the western countries they have migrated to.

GENDER AND DEPRESSION Research into the contribution of psychiatric disorders acknowledged depression to be the most common risk factor for suicidal behavior. An estimated two thirds of all suicide

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attempters of white western background have a depressive illness [36]. However, it is also documented in the literature that up to one third will not qualify for a psychiatric diagnosis [37]. This indicates that depression is not a sufficient or necessary condition for suicidal behavior. Research on western populations indicated that depression is more often seen in women than in men. While depression is the most common risk factor for suicidal behavior in both men and women, it happens twice as often in women than men. Theories on differential socialization suggest that males and females may learn to use different methods of coping with life and respond differently to stress [38, 39]. Their upbringing directs girls toward internalization rather than externalization of psychological disturbance [38]. Socialization permits female adolescents fewer outlets for the release of aggression than males [40]. One empirical foundation for this is the fact that adolescent girls are more often depressed than boys [38], whereas boys score much higher on externalizing disorders e.g. conduct disorders. The higher prevalence of depression in women is correlated to an earlier age of first onset (rather than to persistence or recurrence of the disorder), with the gender difference first emerging in puberty, occurring simultaneously with a likewise gender difference in the emergence of suicidal ideation and suicide attempt [41, 42]. The propensity to internalize as passed on in socialization seems indicative of suicidal behavior as more of an appropriate way for a female to respond to severe stress or difficulties, in comparison to males [10]. It was validated [43] that the gender skewness in depression as observed in whites, is present in all immigrant groups they studied in the US (blacks, Puerto Rican, Mexicans and Cubans) and varied from 3.4 to 1.8 : 1 (females to males). Epidemiology of depression that focused on ethnicity showed that many immigrant groups in the US do not have elevated risk for depressive disorder compared to whites in the US. For example, most Hispanic groups and Asians report lower rates of depression than whites, and blacks report a similar rate as whites. Only Puerto Ricans report a higher rate of depression compared to whites [43]. Remarkably, Puerto Ricans and Mexican Americans of both genders, and Cuban American females as well as black females have lower suicide rate than expected on the basis of their depression rate. From this study, it can be derived that the relationship between depression and suicidal behavior cross culturally is not straightforward. Moreover, it is known that the elevated incidence rate of suicide attempts by adolescent girls is not maintained into young adulthood, whereas depression maintains to be gender skewed throughout the life course [44]. Depression is therefore unlikely to be the crucial or sole mediating factor to account for gender differences in suicidal behavior. This is supported by research that showed how the gender differences in self-reported rates of suicidal behavior among adolescents was not eliminated even when depression was controlled for [39]. This preposition has also been validated across ethnicities. Liu, Chen. Cheung and Yip [45] conducted a cross cultural comparison between suicide in Hong Kong and Victoria, Australia. Hong Kong has very small gender differences in the suicide ratio, whereas Victoria has a ratio of 1:3. (females to males). The gender differences in the prevalence of psychiatric disorders i.e. depression could not explain the gender differential in the suicide rates. It was observed that the most skewed gender ratio was observed in the groups of suicide attempters without a history of psychiatric illness. In addition, research in immigrant groups in western Europe showed that depression may be less relevant as a risk factor in immigrant women compared to the majority group. In a study by Bhugra, Desai and Baldwin [26], depression was less often mentioned by Asian

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women in the UK in samples of suicide attempters compared to white British women. In similar vein, when three groups of immigrant females of South Asian-Surinamese, Turkish and Moroccan background in The Netherlands were compared to Dutch majority women with a history of suicidal behavior, rates of depression were found to be to be lower in immigrant women [33]. At the same time, Turkish immigrants of both genders in all age bands in the Netherlands have higher rates of depression [46]. While it may seem plausible that this vulnerability is reflected in the rates of Turkish young men who have increased suicide risk in the Netherlands, this has not been empirically tested yet [10]. One possible suggestion is underreporting of depression in immigrants who have a history of suicidal behavior. However, it is also plausible that cultural meanings are involved in the understanding and experience of depression across different ethnic groups. Some findings support this preposition. A study by Fenton and Sadiq [47] in the United Kingdom indicated how symptoms such as a loss of meaning in life and loss of sense of personal worth, frequently associated with depression, were not easily found in the accounts of South Asian women of the first generation. This could be explained as a result of a difference in selfconception, which does not match a similar emphasis placed on the individual as commonly seen in white western individuals. This study suggests that vigilance is needed when applying western understandings of depression cross culturally. Hence, the explanatory power of psychiatric risk factors such as depression for the gender difference in suicidal behavior seems ambiguous. Social and cultural stressors are expected to contribute to the suicidal behavior of women in this group. Therefore we shift our attention to social and cultural causes of suicidal behavior from a gender perspective.

RISKS IN THE SOCIAL ENVIRONMENT: MARRIAGE AND ABUSE Research has consistently shown that social support is a crucial protective factor against suicide and suicidal behavior. Marriage is often mentioned as an institution that provides social support and as such expected to be a buffer against suicide. A large scale study [48] demonstrated that across Europe, suicide attempters were disproportionately divorced or single according to WHO registration in the 1990s and early twenty-first century. However, gender complicates these findings. Models that account for gender have found that divorce increases the suicide risk predominantly in men. In women divorce does not have a similar substantial influence in suicide [49, 50]. Moreover, in some non western countries evidence found that suicide seem to be more common in married young women. In Pakistan, Khan and Reza [51] found that suicides are more common in married women less than 30 years of age. In addition, in rural China and rural Turkey, researchers report on very high suicide rates in young married women who live with their in-laws [52, 53]. Further evidence for the role of marriage as a risk factor comes from studies in rural India [54] and Iran [55] Domestic stressors, imprisonment at home, physical abuse, and denigration by the in-laws or husband have been reported to characterize the lives of young women who attempt suicide [51, 53, 56]. For females in particular, the quality of the marital bond appears more important than the marital status.

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Over the past decades suicidologists have examined how adversities that take place in a marriage and family context constitute a risk for suicidal behavior of females and their propensity to suicidal behavior. Research into the role of sexual and physical abuse unanimously shows that these experiences play a crucial role as risk factors for suicidal behavior, while sexual abuse is known to happen more often to females than to males [57]. Between 20 to 50 per cent of women reported to have been sexually abused within a population sample of suicide attempters [58, 59]. Physical abuse is also found to constitute a risk to suicidal behavior [60], yet appears to have less impact than sexual abuse in relation to suicidal behavior [61]. Although women may also be involved as perpetrators of domestic violence, women are more likely to be victims of domestic violence incidents that involve serious injury and death. They are also more likely have suicidal ideation when they are in those circumstances [62]. Abuse often goes together with family conflict, low care by parents or parent psychopathologies which are established risk factors for suicidal behavior. It could be hypothesized that those individuals who have a history of abuse are perhaps suicidal because of these co-founding factors. However, there is strong support for a relationship between abuse and suicidal behavior, even when variables such as the above mentioned that are likely to co-occur in families with abusive parents are controlled for [63] as well as when psychopathology of the individual is taken into account [64]. The vulnerability to suicidal behavior after abuse has been validated cross culturally and validated for immigrant populations [33, 59, 65]. Salander Renberg, Lindgren and Osterberg [59] established the association of sexual abuse to suicidal behavior in ten European countries, whereas Anderson, Tiro Price, Bender and Kaslow [65] validated the impact of sexual and physical abuse on suicidal behavior of African American women. Further evidence regarding the role of sexual and physical abuse in Turkish, Moroccan and SouthAsian Surinamese immigrant women in The Netherlands was found by van Bergen, van Balkom, Smit and Saharso [33]. Several studies demonstrated the impact of abuse for Asian women in the UK who attempted suicide [66, 67, 68]. The risk of both suicidal ideation and suicide attempt progresses according to the extent of the abuse, whether be it sexual or physical. [57]. This finding has also been validated cross culturally. African American women who suffered multiple forms of abuse had 2-4 times more vulnerability to suicide attempts compared to those women who reported a single form of abuse [65]. Immigrant status may be an aggrandizing factor in the abuse that takes place. In particular when an individual has migrated to the west for marriage purposes, there may be no family support system available in the host country. Moreover, the immigrant will be unfamiliar with the health care system as well as the language spoken in the host country. In addition, in particular immigrant women may find themselves in a position where they are financially dependent on the husband and in-laws [66]. These are factors that may have prolonged effect on the abuse since immigrant women to whom this happens are unlikely to seek or find assistance [69]. Immigration policies are yet another complicating factor. When a spouse is dependent on the partner residing in the host country before marriage, a divorce may mean loss of residence permit [70]. Some countries (for instance the Netherlands) are more lenient and are willing to grant the abused partner a residence permit even though the criteria for an independent residence permit are not met. An additional risk is that in some immigrant communities the possibility of marriages between family members exists (e.g. a marriage between cousins). For instance, this occurs

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among immigrants who come from Pakistan, India, Kurdistan, Afghanistan and Turkey. These marriages render women in particular vulnerable to suicidal behavior when their relationship is characterized by domestic violence and abuse. Women who would disclose the abuse to their families or to the in-laws are sometimes not believed or simply expected to bear the abuse and the consequences. A woman‘s own family may ask of her to bear the abuse since they are the direct kin of the husband‘s parents and want to maintain close family relations. This was for instance found in a study of Turkish and Moroccan female suicide attempters [33]. In addition, if sexual abuse also means a loss of virginity, and when physical abuse is undertaken by relatives or the husband, disclosure will result in squandering of family honor in many Asian and North African cultures. This precipitates pressure on women to remain silent about the abuse that has taken place. Yet, it has been established that abused women who receive no treatment tend to experience greater maladjustment in adult life, which renders them more vulnerable to suicidal behavior in the future [71].

DURKHEIM’S FATALISTIC SUICIDE AND IMMIGRANT WOMEN The findings of the risk factors of domestic violence, physical abuse and sexual abuse warrant that oppressive conditions have a profound impact on suicidal behavior. Since these aspects have a strong gender component, and the risks they carry of suicidal behavior in immigrant women are significant, we will theorize their relevance further. Durkheimian theories of suicide, which provide a deeper understanding of suicidal behavior beyond risk factors, are beneficial to this. Durkheim argued that a seemingly individual act as suicide is constraint to a greater or lesser extent by the moral forces of social life [8]. According to Durkheim, the variation in the suicide rate could be explained by the extent of social integration and regulation in a social group in society. Social integration refers to the degree, to which people are attached, bonded or connected to each other. By regulation, Durkheim meant the extent to which society has control and guidance over the motivations and values of its individual members. In short, when extreme positions on either of these aspects developed, this would lead, he expected, to suicide. While lack of social integration seems better qualified to explain the suicidal behavior of (majority) men, overregulation seems to be more appropriate to explain the suicidal behavior of minority women. When individuals experience extremely high levels of regulation in their social world, Durkheim theorized this could result in being excessively controlled by social-cultural prescriptions and lead to a fatalistic suicide. Fatalistic suicide occurs as a result of an oppressive context where harsh moral demands prevail, and are upheld through force [72-,73]. Individuals who are faced with a severe lack of agency, develop a sense of powerlessness. When norms are considered external, demanding and obtrusive and fail to be internalized by the individual, a sense of alienation and dehumanization is created. The individual does not experience having meaningful relations and lacks a sense of connectedness and may thus subsequently enter a suicidal process. The patterns of suicidal behavior of women in many (immigrant) cultures around the world, we would like to suggest, can best be explained as (near) instances of fatalistic suicide. Davies and Neal [53] investigated the suicides of young women in rural China and described these as a case of fatalistic suicide, mostly because of the restricted sex roles for women.

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Central to these restrictions is the practice of marrying off daughters by all-powerful families. These daughters subsequently lived in unhappy marriages under the tyranny of their motherin-law, who expected total compliance and denigrated their daughter-in-law. Suicide rates for Chinese young women are much lower in the cities, which underscores that the risk for suicidal behavior is associated with the rural family system, as well as demonstrating the pivotal role of the method commonly employed in rural China, i.e. pesticide poisoning. Additional evidence for cases of fatalistic suicide of women comes from Iran. Pridemore and Aliverdinia [74] examined and validated the association between female suicide rates and multiple measures of social control of women through studying several provinces in Iran. High rates of suicide were found in areas with greater social regulation of the lives of women and stronger traditional tribal cultures. They concluded therefore that hyper regulation is correlated with higher suicide rates for females in Iran. Fatalistic suicide also described the circumstances of many South Asian, Turkish and Moroccan immigrant women with a history of suicidal behavior in the Netherlands [33]. The ability and right to act autonomously with regard to strategic life choices [75] was more limited for Turkish and Moroccan women and to some extent South Asian women. Strategic life choices refer to spouse choice, sexuality, freedom of movement, education and participation in the labor market. Cultural images of females were found that valued subordination to the family and husband, female self-sacrifice and honor protection, While their young women sometimes took pride in it that they were able to live up to the image of the ‗enduring wife‘, these cultural images also hampered women‘s change toward more autonomy, and were in the end detrimental to their self image. Yet simultaneously, the internalization of these cultural images of ‗enduring wife‘ and avoiding the image of ‗the girl gone astray‘ was the key to understanding why many minority women endured their hardship. Honor of women and their family were at stake here. Migration seemed to worsen the scope for autonomy, in the sense that disruption of the extended family system, marital stress and acculturative stress of parents increased control and the demand on the young immigrant women of these ethnic groups to take up caretaking roles. Although the fatalistic suicide seems relevant especially in non western countries, it also has been found to apply to young women in a few European cases. Beratis [76] reports of Greek female suicide attempters, whose behavior is described as ‗a quest for autonomy‘ (76, pp.165). Girls‘ behavior in the study was restricted in the sense that they were not allowed to go outside the house alone, instructed not to talk to anyone the parents did not know, and were only allowed to have a very minimal social life of their own. In sum, fatalistic suicide seems to be a highly relevant theoretical concept for understanding the suicidal behavior of females. Women most notably from some regions in Asia confronted with an absence or struggle over crafting one's own life course that is characteristic for fatalistic suicide. These circumstances have been observed also after migration. The pressure by the family members, the husband and parents (in law) to ensure a woman abided by cultural norms lead to distress and vulnerability to suicidal behavior. The relevance of fatalistic suicide for women also undermines the idea that strong community bonds or an ethnically dense populated neighborhood are always protective against suicidal behavior, as Trovato [77] and Neeleman and Wessely argued [78]. Travato [77] showed that immigrant groups in Canada with strong degrees of community cohesiveness share reduced odds in their incidence of suicide. Neeleman and Wessely in the UK [78] found that, although belonging to an ethnic minority group at national level heightens the propensity to suicidal

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behavior, when a specific ethnicity minority group hold up a majority position within a neighborhood in London this is protective of their suicide rate. However, neither of these studies reported on the rates of (non fatal) suicidal behavior of young women. Gender could have thrown a different light on the results. When a majority group has a dominant position in an area and is close knitted (cohesive) while simultaneously its culture values chastity behavior and honor of women, as is the case in many Asian cultures, social control, lack of freedom of movement and scrutiny of women‘s behavior will increase. Social integration and cohesion is hence is not necessarily always protective for women, because of the over guidance and strict control over women by community members this encompasses.

CONCLUSION Despite the overwhelming impact and predictive power of gender in suicidal behavior, knowledge of suicidal behavior of immigrants in relation to gender is scarce. The intersecting and predicting role of gender and ethnicity in suicidal behavior needs to receive more attention in suicidology. Since women are predominantly more at risk compared to men, there is urgency for more research of suicidal behavior in immigrant women. In this chapter, we have addressed some of the gender issues that are important areas of future research. We highlighted risk factors of physical and sexual abuse in the contexts of family (in-law) and marriage. These findings indicate the relevance of Durkheimian thought that marriage is protective only when it is not over or under regulating and only when it provides social integration rather than alienation [8]. In many cases for women this is not necessarily so, and the family and marriage may precipitate a risk rather than protection against suicidal behavior. Those immigrant women in particular for whom physical and sexual abuse are contextualized amidst honor traditions and cultural values of female chastity, are vulnerable to suicidal behavior. On the basis of previous empirical work [33], we observed that immigrant women of Turkish, Moroccan and South Asian-Surinamese background were fortunately not frozen in unrewarding and oppressive lives forever; shifts toward more autonomy and rejection of harmful notions of gender and honor did eventually happen. This has important implications for health care and prevention programs. Women would benefit from empowering techniques for dealing with harmful practices of silencing their selves and denial of their autonomy. Clearly, this is not analogue to the assumption that immigrant women should necessarily exit their family and cultural environment once they ask for equal rights. Many immigrant women are not in favor of such an exit strategy; rather they wish to improve their situation within their cultural milieu [79]. Beyond doubt, in the domain of sexual and reproductive life that is central in many cultures, women‘s role is often pivotal [80]. The sphere of sexuality and reproduction is a crucial theme in cultural practices since it enables the continuity of the ethnic group. As a result, it is women in particular who are considered to be ‗the guardians of the collectivity‘s identity and honor and who demarcate with their behavior the moral boundaries of their group‘ (80, pp 25). In addition, cultural traditions and sometimes the re-invention of traditions are often used as ways of legitimizing the control and oppression of women in situations in which individual men as well as the collectivity feel threatened by others.

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Discrimination and poverty in immigrant groups in the host society may increase a sense of moral advantage compared to the majority group regarding immigrant women‘s honor and chastity, and hence increase protection of women. Thus, improving the social economic position of immigrants may be beneficial to the decrease of control exercised over women. It is important that cultural images of women of ‗enduring wife‘ and ‗the girl gone astray‘, that contribute to the tolerance of living unrewarding lives, are counteracted. If our societies want to engage successfully in the prevention of suicidal behavior of young minority women, critique should be expressed of these cultural images of women and reflections upon how these images can be questioned at community level as well as in immigrant families. If this would be pursued, the personal, social and economic costs associated with suicidal behavior in immigrant communities and society at large could hopefully be decreased in the future.

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[34] Hjelmeland H, Knizek B, Nordvik H: The communicative aspect of nonfatal suicidal behavior - Are there gender differences? Crisis, the Journal of Crisis Intervention and Suicide Prevention 2002; 23(4): 144-155 [35] Leo D, Burgis S, Bertolote JM, Bille Brahe U, Kerkhof AJFM: Definitions of suicidal behavior: lessons learned from the WHo/EURO multicentre Study. Crisis, The Journal of Crisis Intervention and Suicide Prevention 2006; 27(1): 4-15. [36] Van Heeringen, K. The neurobiology of suicide and suicidality, A review, Canadian Journal of Psychiatry 2003; 48(5); 292-300. [37] Murphy GE: Why women are less likely than men to commit suicide. Comprehensive Psychiatry 1998; 39: 165-75. [38] Nolen-Hoeksema S: Sex Differences in Depression. 1990; Stanford, USA: Stanford University Press. [39] Wichstrom R: Explaining the Gender Difference in Self-Reported Suicide Attempts: A Nationally Representative Study of Norwegian Adolescents. Suicide and LifeThreatening Behavior 2002: 32: 101-116. [40] Vanatta, R.: Adolescent gender differences in suicide related behaviors. Journal of Youth and Adolescence 1997; 26 [41] Fergusson DM, Woodward LJ, Horwood LJ: Risk factors and life processes associated with the onset of suicidal behaviour during adolescence Psychological Medicine 2000: 30(1):23-39. [42] Kessler RC. Berglund P, Borges, G, Nock M. Wang PS: Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003. Journal of the American Medical Association 2005; 293: 2487-2495 [43] Oquendo MA, Ellis SP, Greenwald S, Malone KM, Weissman MM, Mann JJ. Ethnic and sex American Journal Psychiatry 2001; 158(10):1652-8. [44] Lewinsohn PMR, Seeley J: Psychosocial Risk Factors for Future Adolescent Suicide Attempts. Journal of Consulting and Clinical Psychology 1994; 62: 297-305. [45] Liu KY, Chen EY, Cheung AS, Yip PS: Psychiatric history modifies the gender ratio of suicide: an East and West comparison. Social Psychiatry Psychiatric Epidemiology 2009;44(2):130-4. [46] Van Oort, FA, Joung IMA, Van der Ende J, Mackenbach JP, Verhulst, FCA, Crijnen AM: Development of ethnic disparities in internalizing and externalizing problems from adolescence into young adulthood. Ethnicity and Health 2007; 48(2): 176-184. [47] Fenton, S, Sadiq-Sangster F: Culture, relativism and the expression of mental distress: South Asian women in Britain. Sociology of Health and Illness 1996; 18(1): 66-85 [48] Schmidtke, A, Lohr C: Socio-demographic variables of suicide attempters. Edited by De Leo D, Bille Brahe U, Kerkhof AJFM, Schmidtke: Suicidal Behavior. Theories and Research Findings 2004; Gottingen, Germany: Hogrefe and Hubers Publishers, pp.8193. [49] Kposowa AJ, McElvain JP, Breault KD: Immigration and suicide Archives of Suicide Research 2008; 12(1):82-92. [50] Pescosolido BA, Wright ER: Suicide and the role of the family over the life course. Family Perspective 1990; 24-58 [51] Khan MM, Reza H: Gender differences in nonfatal suicidal behavior in Pakistan: Significance of sociocultural factors. Suicide and Life Treatening Behavior 1998; 28(1):62-68.

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[52] Davies C, Neal M: Durkheimian Altruistic and Fatalistic Suicide. Edited by Pickering W.F.S and Walford Geoffrey 2000 Durkheim’s Suicide, a Century of Research and Debate; pp. 36-53 [53] Bağlı M, Sev'er A: Suicide, suicide theories, suicide rates, female suicides, Turkish women, gender and suicide, patriarchy and women's health, poverty and suicide. Women's Health and Urban Life: An International and Interdisciplinary Journal 2003; 2(1): 60-84. [54] Kumar V: Burnt wives. A study of suicides. Burns 2003; 29:31-25. [55] Rastegar, A, Joghataei MT, Adli YR, Zadeh YA, Alaghehbandan R: Epidemiology of suicide by burns in the province of Isfahan, Iran. Journal of Burn Care and Research 2007; 28: 307-311. [56] Pearson V, Liu M: Ling's death Suicide and Life Threatening Behavior 2002: 32(4):347-58 [57] Fergusson DM, Mullen PE: Childhood Sexual Abuse: An evidence-based perspective. 1999; Thousand Oaks, USA: Sage Publishers. [58] Coll, X, Law F, Tobias A, Hawton K, Tomas J: Abuse and deliberate self-poisoning in women: a matched case-control study. Child Abuse and Neglect 2001; 25(10): 12911302a. [59] Salander-Renberg E, Lindgren S, Osterberg I: Sexual abuse and suicidal behavior. Edited by De Leo D, Bille Brahe U, Kerkhof AJFM, Schmidtke A: Suicidal Behavior. Theories and Research Findings 2004; Gottingen, Germany: Hogrefe and Hubers Publishers, pp. 185-197 [60] Enns MW, Cox BJ, Afifi, TO, De Graaf R, Ten Have M, Sareen J: Childhood adversities and risk for suicidal ideation and attempts: a longitudinal population-based study. Psychological Medicine 2006; 36(12): 1769-1778. [61] Brodly BS, Stanley B: Adverse childhood experiences and suicidal behavior. Clinical Psychiatry North America 2008; 31(2): 223-235. [62] Fergusson DM, Horwood LJ, Ridder E: Partner violence and mental health outcomes in a New Zealand birth cohort. Journal of Marriage and Family 2005; 67: 1103-1119 [63] Brown J, Cohen P, Johnson JG, Smailes EM: Childhood abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality. Journal of the American academy of child and adolescent psychiatry 2005; 38(12), 1490-1496. [64] Molnar BE, Berman LF, Buka SL: Psychopathology, childhood sexual abuse and other childhood adversities: relative links to subsequent suicidal behaviour in the US. [Review]. Psychological Medicine 2001;31(6): 965-977. [65] Anderson PL, Tiro JA, Price AW, Bender MA, Kaslow NJ: Additive impact of childhood. Suicide and Life Threatening Behavior 2002;32(2): 131-138. [66] Chantler K, Burman E, Batsleer J, Bashir C: Attempted Suicide and Selfharm. South Asian Women. Project Report. Commisioned by Manchester, Salford and Trafford Health Action Zone; 2001. [67] Chew-Graham C, Bashir C, Chantler K, Burman E, Batsleer J: South Asian Women, Psychological Distress and Self Harm: Lessons for Primary Care Trusts. Health and Social Care in the Community 2002; 10 (5): 339-347. [68] Bhardwaj A: Growing up Young, Asian and Female in Britain: A Report on Self Harm and Suicide. Feminist Review 2001; 68: 52-67.

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[69] Raj A, Silverman JG: Immigrant South Asian women at greater risk for injury from intimate partner violence. American Journal of Public Health 2003; 93(3):435-7. [70] Van Walsum S, Spijkerboer T: Women and immigration law: New variations on classical feminist themes. 2006; London: Routledge-Cavendish. [71] Leitenberg H, Greenwald E, Cado S: A retrospective study of long-term methods of coping with having been sexually abused during childhood. Child Abuse and Neglect 1992; 16(3):399-407. [72] Bearman S: The Social Structure of Suicide. Sociological Forum 1991; 6 (3): 501-24. [73] Pearce F: The Radical Durkheim. 1998; London: Unwin Hyman Ltd. [74] Aliverdinia A, Pridemore WA: Women's fatalistic suicide in Iran: a partial test of Durkheim in an Islamic Republic. Violence Against Women 2009: 15(3):307-20. [75] Kabeer N: Resources, agency, achievements: reflections on the measurement of women's empowerment. Sidastudies, Discussing Women's Empowerment - Theory and Practice 2001; 3: 17-57. [76] Beratis S. Factors associated with adolescent suicidal attempts in Greece Psychopathology 1990; 23(3):161-168. [77] Trovato, F: Suicide and ethnic factors in Canada. International Journal of Social Psychiatry 1986; 32: 55-64. [78] Neeleman J, Wilson-Jones C, Wessely S. Ethnic density Journal of Epidemiology Community Health 2001; 55(2):85-90. [79] Van Bergen DD. Suicidal behavior of young migrant women in The Netherlands. A comparative study of minority and majority women. 2009; VU university Amsterdam [PhD ]thesis, [80] Yuval Davis N: Gender and Nation. 1997; London: Sage Publications.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 4

SUICIDAL BEHAVIOR AMONG HISPANIC IMMIGRANTS IN THE UNITED STATES Guilherme Borges1,3, Liliana Mondragón1 and Joshua Breslau2 1. National Institute of Psychiatry, México City, México 2. UC Davis School of Medicine, Sacramento, California, USA 3.Universidad Autonoma Metropolitana, México City, México

ABSTRACT At the end of 2002 it was estimated that there were about 33 million Hispanics in the US, 14.5 million being non natives (about 60 % from Mexico) and 75% Hispanics being either immigrants or children of immigrants. This review covers the research published within the last 20 years on the experience of people of Hispanic background regarding suicide ideation and attempt when they first come to the US (first generation) looking for improvements in their standard of living through better jobs and more social opportunities, and as immigrants get settle and have US-Born children (second generation) and grand-children (third generation and so on). We also introduce new research regarding suicide ideation and attempt among return migrants and the families that the immigrants leave behind in their homeland. The current research in this area is limited in number and scope of interest, with most studies focusing on the simple ethnicity comparison. The research is basically cross-sectional and has produced results that are inconsistent in several key points. Currently, we do not know if Hispanics have rates of suicide ideation and attempts that are higher (or lower) when compared to Whites in the US. Evidence is more consistent on four other points. First, there is evidence that immigrants of Mexican origin who immigrated while youths (12 years or less) have rates of suicide ideation and attempt that are higher than similar persons who remained in their home country (i.e. Mexican non-migrants). Second, immigrants have crude lower prevalence of suicide ideation and attempt (both lifetime and 12-month) when compared to US-Born Hispanics of the same ethnicity, especially if they immigrated at older ages. Third, there is some evidence that Hispanics with more US-Born parents to have higher crude prevalence of suicide attempt when compared to US-Born Hispanics with no USBorn parents, but this was not always supported in multivariate analyses. Fourth, all studies showed that the preference in the use of English was positively associated with

38

Guilherme Borges, Liliana Mondragón and Joshua Breslau ideation, and suicide attempt, but associations between language use and attempts did not reach statistical significance. Research efforts that combine populations and information from sending and receiving countries and expand the number of groups under comparison to cover as many specific migratory experiences as possible are needed. This effort will require much more complex research designs that will call for true international collaboration.

INTRODUCTION Over the past 20 years, studies of suicidality have found differences between Hispanics and other ethnic groups in the US and differences among foreign-born and US-born Hispanics in the prevalence of suicidal ideation and suicide attempts [1;2]. These patterns have significant implications for reducing the impact of suicide attempts and preventing suicide. Hispanics are the largest ethnic minority group in the US, comprising about 14% of the 2005 US population. They are also the fastest growing group, projected to comprise 29% of the US population in 2050 (http://pewhispanic.org/files/reports/85.pdf, accessed August 14, 2009). More than two-thirds are either foreign-born (40%) or have at least one foreign-born parent (28%)[3]. More recently, research has begun to examine the relationship between migration and suicidality in greater detail, recognizing diversity within migrant groups and complex transnational effects of migration in sending as well as receiving countries. The goal of this review is to examine existing research on the epidemiology of migration between Latin America and the United States and suicidality, characterized by suicidal ideation and suicide attempts, in order to identify patterns with implications for prevention as well as gaps in existing knowledge. The category of ‗Hispanic‘ in the US lumps together people with origins in any of the 45 countries of Latin America and the Caribbean, each of which has its own internal ethnic divisions. People of Mexican origin make up over 60% of US Hispanics, but no other single country contributes as much as 10%. Because of this diversity, studies in the US that use national samples of Hispanics or of immigrants are likely to reflect patterns among Hispanics of Mexican origin. Regional studies, on the other hand, reflect the diversity of regional Hispanic populations, with much higher numbers of people of Mexican origin in the West and Southwest and higher numbers of Caribbean and South American origin in the South and Northeast. Sociological studies have shown that migration is not simply a collection of individual moves, but an institutionalized transnational multi-generational network linking communities in both countries across the border. Epidemiological research has begun to take the potential transnational impacts of migration into account through studies of the impact of migration on health in the countries of origin of immigrants. Migrant networks, through which transnational connections are established and maintained over time are not merely pathways for the movement of people, but also for the movement of goods, money, and social behaviors. For example, the Mexican-born population of the US accounts for nearly 10% of the total Mexican-born population (in Mexico or the US). About one-third of the population living in Mexico have a family-member who is living in the US. Migration may have many impacts on health. Some health problems, such as malaria [4], may arise from exposures directly tied to the actual process of migration.

Table 1. Studies on suicidality and Hispanics immigrants, 1988-2009

First author Sorenson Sorenson Moscicki Petronis

Year 1988 1988 1988 1990

REF#text [9] [10] [11] [12]

Study name LA-ECA ECA ECA ECA

Swanson YRBSS

1992 1993

[13] [14]

YHBS

Vega Roberts

1993 1995

[15] [16]

Ungemack Hovey Crosby Kessler Blum

1998 1998 1999 1999 2000

[17] [18] [19] [20] [21]

Olvera Tortolero King Borowsky Powell Pirkis

2001 2001 2001 2001 2001 2003

[22] [23] [24] [25] [26] [27]

NHSDA Oquendo Guiao O'Donnell

2003 2004 2004 2004

[28] [29] [30] [31]

Kessler Borges Brook Waldrop Roberts

2005 2006 2006 2007 2007

[32] [33] [34] [35] [36]

HHANES ICARIS NCS NLSAH

MECA NLSAH NLSAH NHSDA HHANES NLSAH NCS, NCSR NCS-R HCC TH2K

Study Population USB-MEX, MIG-MEX WHI-HIS-ALL WHI-HIS- MEX WHI-HIS-ALL USB-MEX, MEX in MEXICO WHI-HIS-ALL WHI-CUB,NIC,HISOTH WHI-HIS- MEX USB-HIS-ALL, MIGHIS-ALL HIS-ALL NON HIS-HIS-ALL WHI-HIS-ALL WHI-HIS-ALL WHI-HIS, USB-HIS MIG-HIS WHI-HIS-MEX WHI-HIS-PRI WHI-HIS-ALL WHI-HIS-ALL WHI-HIS-ALL WHI-HIS- MEX, USBMIG-HIS CUB, MEX, PRI WHI-HIS-ALL BLK-HIS WHI-HIS-ALL WHI-HIS-ALL NON HIS-HIS-ALL WHI-HIS WHI-HIS- MEX

Ideation (Y/N) Y Y N N

Plan (Y/N) N N N N

Attempt (Y/N) Y Y Y Y

Age group (ADOL/ADU) ADU ADU ADU ADU

Comparison ACC ETH ETH ETH

TIME LIFETIME LIFETIME LIFETIME LIFETIME

Y Y

N Y

N Y

ADOL ADOL

MG-NMIG ETH

LAST WEEK 12 MONTHS

Y Y

N N

Y N

ADOL ADOL

ETH ETH, ACC

LIFETIME 12 MONTHS

Y Y Y Y Y

N N Y N N

Y N N Y Y

ADU ADOL ADU ADU ADOL

NAT, ACC AMI ETH ETH ETH

LIFETIME LIFETIME 12 MONTHS LIFETIME LIFETIME

Y Y Y N N N

N N N N N N

N N Y Y Y Y

ADOL ADOL ADOL ADOL ADU ADOL

ETH, NAT ETH ETH ETH ETH ETH

LIFETIME 2 WEEKS 6 MONTHS 12 MONTHS 12 MONTHS 12 MONTHS

Y N Y Y

N N N Y

Y Y N Y

ADOL ADU ADOL ADOL

ETH, NAT ETH ETH ETH

12 MONTHS LIFETIME 12 MONTHS 12 MONTHS

Y Y Y Y N

Y N N N N

Y N N Y Y

ADU ADU ADU ADOL ADOL

ETH ETH ETH ETH ETH

12 MONTHS 12 MONTHS 12 MONTHS 2 WEEKS LIFETIME

Table 1. Studies on suicidality and Hispanics immigrants, 1988-2009 (Continued)

First author Fortuna Freedenthal YRBSS Peña Borges

Year 2007 2007 2007 2008 2008

REF#text [37] [38] [39] [40] [41]

Study name NLAAS NHSDA YHBS NLSAH NCS-NCS-2

Study Population HIS-USB, HIS-FB WHI-HIS-ALL WHI-HIS-ALL USB-HIS, MIG-HIS WHI-HIS-MEX

Ideation (Y/N) Y Y Y N Y

Plan (Y/N) N N Y N N

Attempt (Y/N) Y Y Y Y N

Age group (ADOL/ADU) ADU ADOL ADOL ADOL ADU

Borges

2009

[42]

MNCSCPES

USB-MEX, MIG-MEX REL

Y

Y

Y

ADU

Comparison GEN, ACC, AMI ETH ETH NAT , GEN ETH NAT, TSP, AMI, RMI,FMI,MGNMIG

TIME LIFETIME 12 MONTHS 12 MONTHS 12 MONTHS 10 YEARS

LIFETIME

Study Populations: Whites (WHI), Cubans (CUB), Mexicans (MEX), Puerto Ricans (PRI), Nicaraguans (NIC),Hispanics other ethnicity besides Cuban, Puerto Ricans or Mexicans (HIS-OTH). Hispanics without any ethnicity distinction (HIS-ALL), US-Born (USB), Foreign-Born (FB), Migrants (MIG), Relatives of migrants (REL), Adolescents (ADOL), Adults (ADU). Non-Hispanics (NON HIS), Blacks (BLK). Comparisons are: Ethnicity (ETH), Nativity (NAT), Age at immigration (AMI), Acculturation (ACC). Generation (GEN), Return migrants (RMI), Family of Migrants (FMI), Migrants-Non-migrants (MG-NMIG). The Epidemiologic Catchment Area study. Los Angeles (LA-ECA); Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. The National Comorbidity Study (NCS); Hispanic Health and Examination Survey (HHANES). The National Comorbidity Study Replica (NCS-R); The Epidemiologic Catchment Area study. (ECA) The National Comorbidity Study 2 (NCS-2); The National Longitudinal Study of Adolescent Health (NLSAH) The National Latino and Asian American Population Survey (NLAAS); The Injury Control and Risk Survey (ICARIS) The Mexican National Comorbidity Survey (M-NCS); National Household Survey on Drug Abuse (NHSDA) The Teen Health 2000 (THK2); Healthcare for Communities (HCC) Collaborative Psychiatric Epidemiology Surveys (CPES); The National Youth Risk Behavior Survey (YRBS)

Suicidal Behavior among Hispanic Immigrants in the United States

41

Others, such as cancer [5] or multiple sclerosis [6], may arise from specific environmental exposures that are rare in one environment and common in another. Suicidality is yet more complex because it involves changes in social context which determine the availability of means and norms regarding suicidality as well as broader changes in employment, close social ties and support groups. This review examines evidence from large general population surveys that report specific rates of suicide ideation and attempts among Hispanics in the US as assessed using standardized epidemiological instruments [7;8], the first of which were conducted almost 20 years ago. Evidence from these studies is organized by the specific comparisons that are informative with respect to the different segments of the migration process among the different affected populations. Organizing the evidence in this way provides a basis for assessing the strength of current knowledge about the impact of migration on suicidality and identifying gaps in our knowledge that should be addressed in future research.

WHAT DO WE KNOW ABOUT HISPANIC IMMIGRATION AND SUICIDALITY? We searched for peer-reviewed population based research publications within the last 20 years that reported prevalence rates or odds ratio estimates for suicide ideation and/or suicide attempts among Hispanics. Clinical samples were not included. The resulting publications are listed in Table 1. The table lists all publications so that studies with multiple publications are listed with multiple entries. The publications are classified by the study population, the outcomes that were reported, the age group, the specific comparison of interest in the study, and the time-frame in which the outcomes were assessed. Study population describes the ethnic, national origin, or nativity of the sample using the following categories: (Whites (WHI), Cubans (CUB), Mexicans (MEX), Puerto Ricans (PRI), Nicaraguans (NIC),Hispanics other ethnicity besides Cuban, Puerto Ricans or Mexicans (HIS-OTH), Hispanics without any ethnic sub-division (HIS-ALL), US-Born (USB), Foreign-Born (FB), Migrants (MIG), Relatives of migrants (REL), Non-Hispanics (NON HIS), Blacks (BLK)). Age groups included in the sample are classified as Adolescents (ADOL) or Adults (ADU). The comparisons of interest, which are explained in detail below, are classified as: Ethnicity (ETH) (Whites Vs Hispanics), Nativity (NAT) (US-Born Vs Foreign-Born Hispanic), Age at first immigration (AMI) among the Foreign-Born, Acculturation (ACC) among the US-Born and the Foreign-Born, Generation (GEN) among the US-Born, Return migrants (RMI), Family of Migrants (FMI) and Non-migrants (NMIG) among Hispanics.

(#1) Ethnicity: Overwhelmingly, the most common focus of the papers listed in Table 1 is ethnic comparison, i.e a comparison of suicide ideation and/or attempts between Whites and some group of Hispanics. 27 of the 34 report such an ethnic comparison and 24 report only ethnic comparisons. Graphs 1-2 present the results of lifetime and 12-month prevalence of suicide ideation (Graph1) and suicide attempt (Graph 2) by ethnicity.

42

Guilherme Borges, Liliana Mondragón and Joshua Breslau

The goal of these graphs are to review results in groups of pairs (or more) ethnicities by each research dataset (for example, Whites Vs Hispanics in the YRBS [14], Whites Vs

Suicidal Behavior among Hispanic Immigrants in the United States

43

Mexican-Americans in the ECA [11], etc.) and not to compare the results across different datasets as some studies used different definitions of suicidality, time frame, or age groups (adolescents and adults). No research reported results for both adults and adolescents but some do provide results for both ideation and attempts. The simple prevalences of Graph 1 show inconsistent results for lifetime and 12-month suicide ideation. There is only one report of adult lifetime suicide ideation from the ECA [10] with higher prevalence of ideation among Whites. For lifetime ideation among adolescents, Vega [15] and Blum [21] reported higher prevalence among Whites from grades 9-12, but lower prevalence among Whites grades 7-8, and Olvera [22] reported a much higher lifetime prevalence of ideation among Hispanics adolescents relative to Whites. For 12-month prevalence of ideation, the two studies among adults show both a higher prevalence among Whites [19] and a lower prevalence [34]. More research is available among adolescents for 12-month ideation, and the results also show higher prevalence among Whites [19;24;28;36] and lower prevalence among Whites [14;16;23;31;34;39]. A similar picture of both higher [10] and lower [11] prevalence of lifetime suicide attempt in White adults and among White adolescents ([36] higher prevalence among Whites and [15] lower prevalence among Whites) emerged. In contrast, a consistent higher 12-month prevalence of suicide attempt among Hispanics was apparent in Graph 2, even when compared to Blacks [31]. Table 2. Estimates of risk of suicide ideation and attempt according to ethnicity status in the United States. Odds ratios (OR) and confidence interval are for Hispanics. Reference group is Whites.

Ref# [33] [32]

12 month Odds Ratio and 95% Confidence Interval 0.9 (0-5-1.6) 0.8 (0.5-1.4)

3.1 (1.09-8.81)

[31] [35] [16] [23] New Mexico [23] Texas

1.37 (0.89-2.11) 0.97 (0.71-1.33) 2.10 (1.6-2.6) 1.79 (1.40-2.28) 1.83 (1.39-2.41)

[12] [11]

0.33 (0.05-2.0) 0.56 (0.26-1.20)

[26] [32]

2.41 (1.47-3.94) 1.20 (0.5-2.8)

Adolescents [36]

0.70 (0.41-1.20)

[16] [27] [36] [35]

3.10 (1.09-8.81) 0.73 (0.45-1.16) 1.11 (0.46-4.76) 0.75 (0.34-1.64)

Ideation Adults

Ref# [20] [41]

Adolescents [22]

Attempt Adults

Lifetime Odds Ratio and 95% Confidence Interval 0.9 (0.6-1.4) 1.0 (0.7-1.15)

See Table 1 for description of studies. #26 is a matched case-cross over for suicide attempt hospitalization. #41 is on a 10 years follow-up. #31 ideation and attempts are lumped. #23 and #35 are on 2 weeks period. Reference group is Whites.

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Guilherme Borges, Liliana Mondragón and Joshua Breslau

Odds ratios (OR) and 95% Confidence Intervals (CI) (OR, lower CI-upper CI) are reported in a number of papers. We summarized these results in Table 2. As apparent from this table, the vast majority of results for both adults and adolescents, tend to suggest null results; there is no statistically significant difference in the age and sex adjusted risk of suicide ideation and suicide attempt between Hispanics and Whites. In some groups, such as studies on 12-month ideation among adolescents, two studies found higher risk among Hispanics [16;23], but two suggested null results [31;35]. For lifetime attempts, two studies in adults [11;12] and one in adolescents (36) suggest lower risk among Hispanics that does not reach statistical significance. In summary, research has not found a consistent pattern of differences in risk for suicidal ideation or suicide attempts between Hispanics and Whites in the US, whether these comparisons are made with respect to overall prevalence or age and sex adjusted odds ratios.

(#2) Non-Migrant Natives in Home Country Vs Current Migrants The overall contribution of migration related factors to ethnic differences in suicidality are likely to result from multiple distinct processes. The first of these to consider is the effect of migration on suicidality among migrants themselves. This has been a surprisingly difficult issue to study. As Stillman et al [43] put it ―to truly understand the effect of migration on mental health one must compare the mental health of migrants to what their mental health would have been had they stayed in their home country‖. However, the best comparison group for this purpose is the population from which migrants emigrated. Very few studies have been able to make such a comparison, in large part due to the difficulty of sampling sufficient numbers in both the sending and receiving countries and assessing suicidality using the same methodology with both groups. To the best of our knowledge, there are only two studies that have made such a comparison, both comparing Mexicans in Mexico with Mexicans in the US, one among adolescents [13] and one among adults [42]. Swanson [13] compared a group of Hispanic students (overwhelmingly of Mexican origin) in schools of Texas, with Mexicans students living in the State of Tamaulipas, Mexico, with respect to suicidal ideation. The one-week prevalence of suicide ideation was about twice as high in the US sample (23.43%) than in the Mexican sample (11.57%) (p=0.001). The report from Borges et al [42] compared the lifetime prevalence of suicide ideation and attempts in Mexicans with no migration background living in Mexico (ideation=6.7%; attempt=2.3%) with Mexican immigrants currently living in the US (ideation=7.8%; attempt=2.9%). The authors found a higher risk for ideation for the migrants among those that migrated before the age of 12 years (OR=1.84, 1.09-3.09) and a higher but non-significant OR (1.88, 0.92-3.83) for attempt in the same group of early aged migrants, while those that immigrated at age 13 or older had no increase in ideation or attempt.

(#3) Nativity A larger number of studies have compared foreign-born and US-born Hispanics, using data from studies conducted in the US. Since this comparison is based on the respondents

Suicidal Behavior among Hispanic Immigrants in the United States

45

place of birth we refer to it as a ‗nativity comparison‘. Graph 3 presents for the four studies that reported nativity comparison of lifetime prevalence among adults and two studies that reported a nativity comparison of 12-month prevalence among adolescents. In this graph the main comparison of interest is between the USB-FB pair from a similar ethnic group from the same study (for example, US-Born Mexicans Vs the Mexican Foreign-Born in the ECA).

46

Guilherme Borges, Liliana Mondragón and Joshua Breslau

The findings across studies are very consistent: The foreign-born of an ethnic group have lower prevalence of suicide ideation and suicide attempt when compared to the US-born of the same ethnic group, both in adults and adolescents. The difference between the lifetime prevalence of ideation for the USB-FB comparison was significant in Ungemack [17] and Fortuna [37], and for attempt in Fortuna [37] and Peña [40]. In summary, all surveys have showed lower prevalence of suicide ideation and attempt among FB-Hispanics when compared to a US-Born Hispanics. Fewer reported hypothesis tests (p values) or ORs. Among those, it seems that it is not just being Foreign-Born what is associated with lower prevalences, but also the age of entry (older ages have lower risk) into the US (see also below on ―age at migration‖).

(#4) Generation The nativity comparison can be broken down in several different ways in order to further describe differences in suicidality associated with migration. Researchers have been interested in comparisons among Hispanics with respect to their distance from their country of origin, as indicated by the number of generations separating them from migration or behavioral indicators of the extent to which they have adopted the culture of their host society. A goal of these studies has been to understand the environmental factors which occur after arrival in the US that contribute to suicidality. In demography first generation usually refers to Foreign-Born persons and second generation to US-Born persons. These comparisons were presented in the section just above under Nativity (#3). By generation analyses in the Latino suicidality-migration studies, we refer to possible differences in the second and the following generations (parents and grandparents nativity). Only two studies exist so far that reported such associations, one in adolescents [40] and one in adults [37] (Graph 4, right hand). In both, there was a tendency for Hispanics with more US-Born parents to have a higher crude prevalence of suicide attempt when compared to US-Born Hispanics with no US-Born parents. Nevertheless, multivariate analyses by Peña (40) found that the OR was only slightly higher among those of third and higher generation (1.25, 0.59-2.64), and Fortuna [37] found that those with no USBorn parents were at higher risk compared with those with at least 1 US-Born parent (OR=2.2, 95% CI 0.9-5.5 ,authors own calculations) . Disaggregated analyses from Fortuna [37] found that compared to those that were FB-Hispanics and arrived at ages 7 or older, only those US-Born with at least one US-Born parent had higher OR of suicide ideation (OR=1.7, 1.1-2.8). The Nativity (#3) and Generation (#4) analyzes above have been able to further specify two exposure variables: age at migration and acculturation. Age at first migration is used as there is a hypothesis that some exposures (usually conceptualized as the socialization process) happens mainly (or only) at an early age, in the context of primary schooling. So, only immigrants that arrived before schooling are truly exposed to this segment of the American environment. The concept of acculturation has multiple meanings and scales. By far, the most common operationalization of this concept is though some measure of English language skills or preference. There is, certainly, some overlap between these concepts. Duration of residence in the US has also been used in other areas of psychiatric epidemiology, but up to this moment it has not been reported in suicidality and migration studies among Hispanics.

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Age at Migration Graph 4 shows the studies that reported crude prevalence of suicide ideation and attempts by age of first immigration into the US. Two studies of suicide ideation among adults reported that the lifetime prevalence of ideation was lower among Hispanic migrants [37] and Mexicans migrants [42] that arrived at later ages in the US, and higher among those that immigrated at earlier ages. A similar trend was found for suicide attempt. The only study among adolescents reported median values on a scale of suicide ideation and reported the same trend: lower values among those that immigrated at older ages , but without statistical significance [18]. According to Fortuna, when lifetime ideation and attempts were compared between those that arrived within 0-6 years of age and those that arrived at 7 or more years, the ORs were 1.7 (0.8-3.6) for ideation and 1.4 (0.5-3.6) for attempts. Borges et al [42] reported that those that arrived at early ages, less that 12 years old, had significant higher ideation (p=0.007) but not higher prevalence of attempt (p=0.243) when compared to those that arrived at 13 and more years. Borges et al [42] also provided ORs: compared to those US-Born Mexicans, Foreign-Born Mexicans that arrived at 12 years or less had an OR of 1.18 (0.74-1.86) for suicide ideation and OR=0.96 (0.40-2.25) for suicide attempt; the ORs for those Foreign-Born Mexicans that arrived at age 13 and older were, in the same order, 0.52 (0.28-0.93) and 0.49 (0.15-1.59). The reference groups vary widely among the studies, with little theoretical justification for selecting the specific age cut-points. In summary, even when most studies found a relationship in the expected direction, with those that arrived in the US at early ages showing higher lifetime prevalence of ideation and attempt, multivariate analyses of these authors failed to find increased risks in all groups and outcomes.

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Acculturation Some studies attempt to directly assess distance from culture of origin at an individual level using acculturation scales. These scales assess behaviors, preferences and attitudes that are more or less like those presumed to characterize the culture of origin, such as language use, friendships with people of the same culture, food choices, and attitudes towards marrying people of other ethnicities. Often a single measure, such as language use, is used to assess acculturation in lieu of a full acculturation scales. Measures of acculturation have the advantage of being more direct, but they are also limited in that they do not help locate specific exposures that might lead to the differences they help identify. Only one study reported associations between a true scale of acculturation and suicidality [9], while three studies reported on the use of English language as a surrogate of acculturation [16;17;37]. The only study with adolescents [16] did not report prevalence rates, but in multivariate analyses those that used English at home were more likely to report suicidal ideation when compared to those adolescents that did not us English at home (OR = 1.4, 95% CI 1.0-1.9). Graph 5 shows prevalence as reported by three studies. Two studies [17;37] showed higher prevalence of ideation and attempt among those more fluent in English, while in Sorenson [9] the US-Born low in acculturation was the group with higher rates of ideation and attempt. Two studies provided more detailed analyses. Fortuna [37] showed that those who spoke more English as a child had higher risk of ideation (OR=1.7, 1.1-2.8) and Ungemack [17] found the difference of suicide ideation between those that had the interview in English compared to the interview in Spanish to be of statistical significance (p<0.03); both studies failed to find significant differences for suicide attempt (OR=1.5, 0.6-3.3 for Fortuna [37] and p=0.22 for Ungemack [17]). In summary, all studies showed that use of English was associated with increased ideation, and increased (but non-significant) suicide attempt. The only study to use a true measure of acculturation found the group of US-Born Hispanics that scored low in the acculturation scale to have higher levels of ideation and attempt, but did not provide measures of association.

(#5) Return Migrants and Families of Migrants There are two groups of particular interest within immigrant sending countries that might be affected by migration. First, return migrants are those immigrants who return to their home country after a period of immigration for work or education. Return migration is particularly common in areas where migration is driven by work in seasonal industries or where strong transnational networks are maintained over time. The tendency of migrants to return home due to illness is not well understood, but has clear implications for suicidality. If migrants who become depressed are more likely to return home, for instance, than return migrants might be a high risk group deserving public health attention within migrant sending countries. Second, family members of migrants who remain in the country of origin are also affected. Migration disrupts family life, which may leave some family members more vulnerable to mental health problems.

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Table 3. Lifetime suicide ideation and attempt among adults Mexican return migrants and families of migrants Return migrants Non-Migrants

Return Migrants

Family of migrants Return Migrants

ideation attempt

Prevalence (%) 6.7 2.3

OR and 95% CI REF REF

ideation attempt

6.9 1.0

1.34 (0.64-2.80) 0.67 (0.32-1.44)

ideation attempt

10.0 3.5

1.50 (1.06-2.11) 1.68 (1.13-2.52)

Study reported by Borges et al. (#42).

Only one study has examined these potential effects of migration in a migrant sending population. Borges et al compared suicidal ideation and suicide attempts among return migrants, family members of migrants and people with no migrant in their family in a survey of the Mexican general population. Results from that study are summarized in Table 3. Among return migrants, a slighter higher prevalence of suicide ideation was reported, but lower levels of attempts. Among families of migrants, both higher prevalence of ideation (OR=1.50, 1.06-2.11) and attempt (OR=1.68, 1.13-2.52) was reported. This study is very recent and as no prior study or even anecdotal report is available to contrast these results, they should be taken with reserve for the moment.

MAIN LIMITATIONS OF CURRENT RESEARCH This review shows that some areas of research remain under-developed for this population. Several reports are already available for the simple ethnicity comparison. But given the number of first generation Hispanics in the current US population, descriptive studies on suicidality that break down ethnic comparisons by nativity (at least) are sorely needed. Other than Mexicans, there are just few examples of research in specific groups of Hispanics in the US, including Puerto Ricans and Cubans-Americans. Research on specific groups is particularly important since the association between migration and risk for mood and anxiety disorders differs across these groups [44] . We found no research that described and tested whether immigrants that spent more time living in the US would be at increasing risk for suicidality. Two important issues on the current modern migration process characterized by a greater mobility between populations, the return of migrants and families of migrants, needs to be replicated and extended. There is no unified approach to segmenting the migration process into distinct processes that might contribute to changes in risk for suicidality. This makes it very difficult to reconcile evidence from various studies. For instance, associations of suicidality with immigrant generation may be due to differences in acculturation, or vice versa. There have not been attempts to integrate the evidence across these approaches into a consistent overall framework. Such a framework would be very useful for bringing epidemiological studies of

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migration to bear on the relationship between environmental and genetic factors associated with disease and health status. There is also a notable lack of longitudinal studies in this area. Cross-sectional surveys are not just the main type of study design used to study migration and suicidality among Hispanics in the US. In fact, all the studies conducted so far in this topic are cross-sectional surveys. These studies suffer from temporal ambiguity: it is difficult to know if migration preceded suicide ideation or attempt in lifetime and in 12-month comparisons. If the interest is to test whether migration is associated with an increase (or decrease) in suicidality among immigrants, the only time period of relevance is that following the migration episode among immigrants and the appropriate comparison group should be the population of the home country that did not migrate [43] . Only two studies in this review [13;42] used data on a population in home country of immigrants to perform such comparison, and only one, Borges et al [42], also separated pre and post migration person years. More studies that combine populations from both the sending and the receiving countries that provide appropriate comparison groups are needed. Comparisons of populations in both sending and receiving countries are also needed to evaluate two important issues that might contribute to associations between migration and suicidality that have only begun to be addressed. First, it is possible that immigrants differ from those in their population of origin prior to migrating. The ‗healthy migrant hypothesis‘, for instance, suggests that good health is a prerequisite for migration. Some of the apparent advantage enjoyed by immigrants relative to the US-born may be due to this selection process rather than to other environmental factors. Second, there is also concern that sick immigrants are more likely to return to their home countries for treatment, social support or death thereby decreasing the numerators of the rates of suicidality among immigrants sampled from the US population. This potential bias has been called ‗salmon bias‘.[45]. Future studies should be more specific when trying to disentangle whether these processes are operating for suicidality. For example, a study of the Mexican migration and mood and anxiety disorders found that Mexicans with anxiety but not mood disorders were more likely to immigrate [46] but a study of suicidality and migration among Mexicans [42] found no evidence of both biases regarding suicidal behavior [42]. Testing either of these hypotheses directly requires data on representative samples of migrants on both sides of the border, and information on the timing of suicidality relative to migration. Until very recently [47;48] there were no comparable data on the baseline rates (prevalence) of mental disorders including suicide ideation and attempts across a large set of countries. Therefore it was difficult to judge if, for example, the rates of suicide ideation found in US samples of Mexican-Americans were similar or not to the rates found among Mexicans in Mexico. Available data now suggest that, across a large array of countries, both developed and underdeveloped, the US lifetime prevalence of suicide ideation and attempt are among the highest, well above the rates from comparable studies in some Latin American countries [48;49] Should we then expect anything different than Latin American immigrants to the US to show lower prevalence of suicidality than the Whites in the US? If suicide has a genetic component [50] should it be any surprise that rates of suicide ideation and attempt among Mexican immigrants to be more similar to the rates found in their home country than to the rates of the populations from another country. As has been suggested for the epidemiology of cancer and migration, the important fact is not the convergence of rates from the migrant country to the host country, but the speed of this conversion [51]. Slower rates of conversion, from generation to generation of migrants, would point to genetics and

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admixtures of genetic background. Quicker conversion rates, even within the lifetime of a single generation of immigrants, would point to large environmental changes from home to host countries. Identifying these conversion rates and the relevant factors that drivers the speed of conversion are among the main topics for future research in suicide and immigration among Hispanics. Another limitation in the interpretation of the current results comes from the age of onset and risk period for suicidality and the age at migration. Immigrants that arrive in the US after the age of 35 years have passed most of the risk period for developing a first episode of ideation and attempt and other psychiatric disorders [48;52;53]. They are the ones that take the most advantage for spending their childhood in a country where the baselines rates for these disorders are comparatively low [54], including suicide rates. But even when several studies included in this review focused on the adolescent population, few of these included a wider interest on migration issues (nativity, age of entry, etc) while studies among adults tend to have a broader interest and included more scales relevant for this area.

SUMMARY: COMPARISON GROUPS OF RELEVANCE AND BINATIONAL EFFORTS The current research in this area is limited in number and scope of interest, with most studies focusing on the simple ethnicity comparison. The research is basically cross-sectional and has produced results that are inconsistent in several key points. Other attempts to summarize these researches have also noted the inconsistent and sometimes contradictory results, especially those related to the simple ethnicity comparison that tries to answer the basic question on whether there is a difference in the prevalence of suicidality between Whites and Hispanics in the US [36;55-57]. This summary tries to take this uncertainty into consideration. Currently, we do not know if Hispanics have rates of suicide ideation and attempts that are higher (or lower) when compared to Whites in the US. Evidence is more consistent on four other points. However, it is also important to keep in mind that the number of studies in each of these other areas is also smaller, so that there has been less opportunity for conflicting results to emerge. First, there is evidence that immigrants of Mexican origin who immigrated while youths (12 years or less) have rates of suicide ideation and attempt that are higher than similar persons who remained in their home country (i.e. Mexican non-migrants). Second, immigrants have crude lower prevalence of suicide ideation and attempt (both lifetime and 12-month) when compared to US-Born Hispanics of the same ethnicity, especially if they immigrated at older ages. Third, there is some evidence that Hispanics with more US-Born parents to have higher crude prevalence of suicide attempt when compared to US-Born Hispanics with no US-Born parents, but this was not always supported in multivariate analyses. Fourth, all studies showed that the preference in the use of English was positively associated with ideation, and suicide attempt, but associations between language use and attempts did not reach statistical significance. When and where exactly the shift (increase) in prevalence among generations of Hispanics emerges is not known. Limited evidence suggest that when compared to nonimmigrants Mexicans, immigrants that return to their home country after a period in the US do not show increased rates of suicidality, but the families of immigrants currently living in

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the US do report higher rates of suicide ideation and attempt. Research efforts that combine populations and information from sending and receiving countries and expand the number of groups under comparison to cover as many specific migratory experiences as possible are needed. This effort will require much more complex research designs that will call for true international collaboration.

ACKNOWLEDGMENTS This work was supported by grants from the National Institute of Mental Health (R01 MH-082023) and Health Initiative of the Americas (HIA) of the School of Public Health, University of California at Berkeley, through the Programa de Investigacion en Migracion y Salud (PIMSA/MARHC).

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In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 5

SUICIDALITY AND ACCULTURATION IN HISPANIC ADOLESCENTS Andres J. Pumariega1, Eugenio M. Rothe2, Jeffrey Swanson3, Charles E. Holzer4, Arthur O. Linskey,5 and Ruben Quintero-Salinas6 1. Temple University, Philadelphia, Pennsylvania, USA and The Reading Hospital, Reading, Pennsylvania, USA 2. Florida International University, Miami, Florida, USA 3. Duke University Medical Center, Durham, North Carolina, USA 4. University of Texas Medical Branch, Galveston, Texas, USA 5. University of Texas-Pan American, Edinburg, Texas, USA; 6. Universidad Autonoma de Tamaulipas, Matamoros, Mexico

ABSTRACT Recent literature has suggested a significant acceleration in the rate of suicide amongst Latino youth, now approaching the higher rates traditionally seen amongst white youth. Acculturation into mainstream culture has been suggested as a significant factor in this increase. This study reports on the association of suicidality and cultural status in two closely related Hispanic populations of youth, Mexicans and Mexican-Americans on either side of the lower Rio Grande Valley. We surveyed a total of 4,157 students, 11 to 19 years of age. In Mexico, we surveyed 2,382 students in "secundaria" (8th/ 9th grade equivalent) and "preparatoria" (high school) students. In the U.S., 1,777 students in grades 7 to 12 were surveyed. A self-administered questionnaire was developed which included demographic and socioeconomic variables, suicidality (one week and lifetime

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Andres J. Pumariega, Eugenio M. Rothe, Jeffrey Swanson et al. suicidal ideation and lifetime attempts), substance abuse, depressive symptoms, and time utilization by the student on various activities. Suicidal ideation in the past week (Chi square = 29.5, p < .001) and suicidal ideation ever (Chi Square = 202.4, p < .001) were both significantly correlated to a combination of parental origin and place of residence (U.S. vs. Mexico). Some of the culturally-mediated activity variables, generational status, and clinical variables were correlated to past week and lifetime suicidal ideation, though clinical variables predominated in their correlation to lifetime attempts. Results suggest that acculturation may increase the risk of suicidal ideation in Hispanic adolescents, while suicide attempts require clinical symptomatology.

INTRODUCTION The concept of cultural competence in children's mental health has begun to gain acceptance in the United States, and has brought with it an increasing focus on the understanding of the role of culture in the development of psychiatric and emotional disturbances in culturally diverse youth [1], [2]. One important indicator and outcome of mental health amongst youth is that of suicidality. A decade ago, research in this area showed that Hispanics appeared to be protected against suicide when compared to White, non-Hispanics and African-Americans, but most of these studies had been done on adults [3]. For example, rates of suicide in the Southwestern U.S. were found to be lower in Hispanic males and females locally and in relation to national averages, yet 25% of those Hispanics that committed suicide were less than 25 years old. [4]. However, recent studies have suggested a significant acceleration in the rate of suicide amongst adolescents of color, now approaching the higher rates traditionally seen amongst white youth [5], [6], [7]. In spite of these findings, there is a paucity of data on the causes of suicidal behavior on minority youth and more specifically of Hispanic adolescents [8]. Suicide is the third leading cause of death in Hispanics 10-24 years old and the 7th cause of death in this ethnic group before 75 years of age. The majority of suicides in Hispanics occur among males by means of firearms [9]. These are concerning statistics given the already higher rates of homicide and institutionalization amongst youth of color, suggesting that they now suffer from the "worst of both worlds" in terms of mental health. Risk factors that affect the rates of sucidality among Hispanics often yield contradictory results. In Texas, Hispanic women had the lowest suicide rates compared to White-nonHispanics and African-Americans [10]. Yet, another study found that suicide risk was higher among Hispanic females [11]. Family dysfunction and lower socioeconomic status have also been associated with increased risk for suicide among Hispanics [5], [6], [11], [12], [13], [14], as well as being a victim of physical and sexual abuse [13], [14]. The use of alcohol and drugs has also been found to increase the risk of suicide among Hispanics [15], [16], and substance abuse that is co-morbid with depression [11] and being a Hispanic homosexual male also increases the risk [17]. Protective factors against suicide among certain Hispanic subgroups appear to be related, 1) having a fatalistic view of the world, 2) a passive coping style and 3) moral and religious objections to suicide [18]. However, these findings seem to be more characteristic of individuals of low SES, and may not be representative of the totality of the Hispanic population in the U.S. [8].

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One of the major challenges of cross-cultural research is to disentangle the effects of culture from those of demographic factors such as socioeconomic status, ethnicity and family structure. Culture and SES can interact in ways that either exaggerates, or mask group differences [8], but race and ethnicity, income and family structure when taken together, ―only partially‖ explain suicide risk behavior in adolescents, including Hispanic adolescents [19].

ACCULTURATION AS A POSSIBLE ETIOLOGIC FACTOR Culture serves as the web that structures human thought, emotion, and interaction, and provides resources for dealing with major life changes and challenges, including illnesses [20]. Culture is also continually being changed by social processes such as migration and acculturation and is a product of group values, norms, and experiences, and of individual innovations and life histories [8]. Studies conducted on adult populations support the idea that, for many second generation Hispanics, the acculturative process may be deleterious to their mental health. One of these studies [20] found that recent Mexican immigrants in Fresno County, California had considerably lower prevalence rates of psychiatric disorders than their U.S. born counterparts and similar rates to comparable Mexicans living in Mexico City. Adult members of certain Hispanic sub-groups also appear to be more vulnerable to the stress of acculturation. In the Hispanic HANES study, these investigators [22] found that Puerto Ricans residing in the U.S. had a higher one-year prevalence of depression than Mexicans, Cubans and African-Americans, and more suicidal ideation in relation to chronic abdominal pain. Another study [23] reported a vulnerability to depression and low self esteem in Hispanic adolescents who complained of perceived discrimination. A study comparing Hispanic, African-American and Non-Hispanic, White adolescents [15] found higher levels of suicide attempts among drug using Hispanic adolescents who experienced more acculturative stress, which included perceived discrimination, perceived poor life chances, language and acculturation conflicts. A study focusing on suicidal ideation on immigrant adolescents [7] found that 25% of immigrant Hispanic adolescent high school students in their sample had positive symptoms of suicidal ideation and depression, and that these were significantly related to acculturative stress. These adolescents also experienced more family dysfunction and non-positive expectations for the future. Research that helps elucidate the causes of such an increase in risk for suicidality can help in the development of preventive programs for Hispanic youth. This paper reports on the association of suicidality and cultural status in two closely related Hispanic populations of youth, Mexicans and Mexican-Americans on either side of the lower Rio Grande Valley.

METHODS Participants: We surveyed a total of 4,157 students, 11 to 19 years of age. In Mexico, 2,285 students in the second and third years of "secundaria" (eighth and ninth grade equivalent) were surveyed. Another 97 "preparatoria" (high school) students, 15 to 19 years of age, were added later. In the U.S., 1,777 students in grades 7 to 12, 12 to 18 years of age,

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were surveyed. Table 1 summarizes the composition of the sample surveyed by gender, age group, and country. The survey region spans a broad range of living conditions on both sides of the border, from rural poor to suburban affluent. The population of the region on the U.S. side is approximately 90 % Mexican-American. Classrooms were used as the base sampling unit for this study. Classrooms were selected from all public junior and high schools in the three Texas communities and from most of the "secundaria" schools in the twin Mexican communities in the state of Tamaulipas. School administrators helped to chose classrooms in order to generate a sample with approximately equal numbers at each grade level. However, the pooled Texas sample was weighted to match enrollment by school, grade, and academic track (advanced, regular, remedial, and English-as-a-second-language.) Other than those variables included in the weighting stratification, there were no factors suspected to have biased classroom selection. Measures: A self-administered questionnaire, the "Pan American Youth Inventory/ Encuesta Panamericana a la Juventud," was developed for this study. The instrument included demographic and socioeconomic variables, family variables, substance abuse, depressive symptomatology, school performance, and time utilization by the student on various activities. The Spanish and English versions of this document were conformed by forward and back translation and adjudication by a bilingual panel of native speakers with clinical experience. The substance abuse sections of the Inventory are based on an adaptation of a World Health Organization questionnaire by one of the authors (A.O.L.), with modifications to match data collected in the annual NIDA surveys of drug abuse amongst high school seniors [24]. The instrument assesses lifetime and 30-day use of tobacco, alcohol, marijuana, inhalants, cocaine, amphetamines, barbiturates, tranquilizers, and other drugs. It also ascertains age at first use, problems at home and school caused by drug use, expectations of future use, and perception of use by a "best friend." In this paper, we will only use the 30-day drug use data. Analyses of the substance abuse data has been published in previous publications [25], [26]. The Center for Epidemiological Studies' Depression Scale (CES-D); [27] was used to measure symptoms of psychological distress. This is a widely used 20-item screening instrument, which asks the frequency with which the respondent has experienced vegetative, mood, self concept, and social withdrawal symptoms. Though other investigators [28] have suggested different adolescent norms for the CES-D, we used the traditional cut-off of 16 and above. This cut-off has been used in previous studies that have demonstrated a relationship between substance abuse and depression in adolescents and adults, and allow for comparability of our data with previous studies. Items from the Diagnostic Interview Schedule (DIS); [29] on past week and lifetime suicidal thoughts and suicidal attempts were used to determine history of suicidality. Time utilization was ascertained through a series of questions asking about "time spent outside of school." The activities covered (and corresponding labels used) were: little or no time spent on homework (NOHMWK); any time spent on work outside the home (JOB); time spent on sports (JOCK) (as an example of structured peer activity); unstructured time with friends (HANGOUT); watching TV or listening to music (TV/RADIO); little or no time spent with family other than watching TV (NOFAM); and involvement in religious activities (NORELIG). The respondents were asked to rate most of these items using a five-point Likert response with the following choices: little or no time, between a few minutes and 1 hour,

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between 1 and 2 hours, between 2 and 4 hours, and more than 4 hours. Religious activity was rated using a different 5 point Likert response: rarely or never, a few times a year, once a month, once a week, and more than once a week. The extreme responses were used in the analyses involving the different variables except for the "work outside the home" (WORK) variable, which was treated as a bimodal variable with any work experience reported being counted as positive. In examining the impact of socioeconomic status, it was decided to inquire about the adolescents' perceptions of their economic conditions given the many confounds involved in asking parental occupation and income level. Therefore, we asked youth simply to evaluate their family‘s income in comparison to their daily needs along a continuum: not enough, almost enough, enough, a little more than enough, and much more than enough. We analyzed responses from both extremes, labeling them POVERTY and AFFLUENT. However, it is important to note that this measure differs from a true measure of socioeconomic status. In fact, the Valley region is quite impoverished on both sides of the border, with almost 30 percent of families living below the poverty line on the U.S. side and more on the Mexican side. Table 3 summarizes the activity variables and other study variables, and Tables 2 and 4 summarize the cumulative frequencies for the drug use and time utilization variables for the total study population. Procedure: Questionnaires were completed anonymously and voluntarily in classroom groups during a regular class period. School counseling staff members were assisted by our research team in introducing the questionnaire, administering them, and collecting them at the end of the class period. The cooperation and item completion rate were quite high (over 95 percent) on both sides of the border. Margin notations made by the students expanding on their personal experiences with positive items, and high levels of attentiveness uniformly observed at the administration sessions were highly suggestive of good face validity of response. Analysis: Frequency analyses were conducted to determine the prevalence and demographic distribution of 30 day illicit drug use, depressive symptomatology, last week suicidality, and time utilization. Multivariate categorical models were developed to examine the interaction between current suicidal thoughts, depression and illicit drug use, as well as the interaction between past week and lifetime suicidal ideation, country residence, and parental place of birth (born in Mexico of the U.S.). Logistic regression was used to analyze correlation of last week and lifetime suicidal ideation and lifetime suicide attempts (dependent variables) to activity variables alone, and activity variables in combination with other demographic and clinical variables (independent variables).

RESULTS Rates of current (last week) suicidal thoughts were higher amongst U.S. youth in spite of equivalent levels of depression on both sides of the border (Table 1), and in parallel to rates of current (30 day) illicit drug use (Table 1). This was even true when controlling for co-existing depression, substance use, and combined depression and substance abuse (Table 2).

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Table 1. Current Depression, Suicidality, and Drug Use in US-Mexico Border Youth

United States 12-14 years Girls Boys 15-17 years Girls Boys Mexico 12-14 years Girls Boys 15-17 years Girls Boys

CES-D 16+ N %

Suicidal %

Drug Use %

303 243

49.05 37.66

25.04 20.77

1.22 27.28

632 577

56.44 42.84

26.22` 20.61

17.00 28.28

734 666

44.38 26.19

15.77 8.71

4.63 4.20

394 506

54.41 33.45

12.98 7.48

3.81 7.51

Table 2. Percent of Border Youth Reporting Current Suicidal Thoughts, Controlling for Depression and Drug Use

Not Depressed Drugs Only Depressed Only Depressed + Drugs

Mexico N 840 25 516 50

Suicidal Thoughts United States % N % 2.02 693 2.73 8.00 96 7.98 25.39 518 34.25 38.00 224 63.46

Table 3. Definition of Variables in Regression Analyses NOFAM NOREL FRIENDS MTV JOCK NOHWK WRK AGE MALE MOMGONE DADGONE POVERTY MOMED US1GEN US2GEN LONELY NOWDRUG

Little or no time spent with family Little or no time spent in religious activities 4+ hours/day spent with friends, unstructured 4+ hours/day spent on TV/ radio 4+ hours/day spent in athletic activities Little to no time spent in homework 4+ hours/day working outside home Age of youth in years Gender, male Mother absent from home Father absent from home Do not have enough economic means, youth rates Mother's education, in total years First generation in the US Second generation in the US Scores above cut-off in loneliness scale Current drug use

Suicidality and Acculturation in Hispanic Adolescents

Figure 1.

Figure 2.

63

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Andres J. Pumariega, Eugenio M. Rothe, Jeffrey Swanson et al. Table 4. Frequencies of Activity Variables Across National Groups Activity Variables NOFAM NORELI FRIENDS MTV JOCK NOHWK WRK

Mexico (%) 6.32 26.19 12.90 24.37 8.29 31.69 40.62

United States(%) 26.40 29.17 19.72 40.52 8.67 29.75 50.68

ChiSq. 300.2 a 4.3 c 42.5 a 93.0 a 0.1 c 1.7 c 34.2 a

a = p < .0001; c = N.S.

Table 5. Regression: Suicidal Ideation Past Week A. Activity Variables Only Multiple R .232 R Square .054 Adj R Sq .050 Std Error .354 Analysis of Variance DF Sum Sq Regress 7 11.291 Resid 1576 197.192 F = 12.891 Sig F = .0000 VARIABLES T NOFAM 4.316 NO REL .991 FRIEND 2.395 MTV 4.639 JOCK -.633 NOHWK 2.126 WORK .281 AGE MALE MOMGONE DADGONE POVERTY MOMED US1GEN US2GEN CES-D-16 LONELY NOWDRUG CONSTANT 4.173

B. All Variables Multiple R R Square Adj R Sq Std Error Mean Sq 1.613 .125 F = 8.626 Sig F = .0000 Sig T .0000 .3219 .0167 .0000 .5266 .0336 .7790

.0000

.258 .069 .059 .352 DF 13 1570

T 2.719 .704 1.317 2.723 .122 .875 .852 -3.248 -2.104 .549 -.280 .647 .284 1.193 1.680 13.408 3.152 6.543 2.514

Sum Sq 13.899 194.585

Mean Sq 1.069 .124

SigT .0066 .4817 .1882 .0065 .9028 .3817 .3944 .0012 .0356 .5829 .7795 .5180 .7765 .2329 .0932 .0000 .0017 .0000 .0120

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Suicidal ideation in the past week (Chi square = 29.5, p < .001) and suicidal ideation ever (Chi Square = 202.4, p < .001) were both significantly correlated to a combination of parental country of birth and nation of residence (U.S. vs. Mexico; Figures 1 and 2). The most striking continuum was found in suicidal ideation in the past week, found in 11.3 % of Mexican youth with both Mexican parents, 15.8 % of Mexican youth with one U.S. born parent, 22.5 % of U.S. born Hispanic youth with one Mexican parent, and 24.8 % of U.S. born Hispanic youth with two U.S. born parents (Figure 2). Table 3 lists the activity variables evaluated, many of which are hypothesized to be influenced by cultural orientation and values. The activity variables that demonstrated significant differences between youth living in Mexico and the United States were: little or no time spent with the family per week (NOFAM), more than 4 hours spent unsupervised with peers (FRIENDS), 4 or more hours listening to TV or radio (MTV), and 4 or more hours working outside the home (WRK; Table 4). Table 6. Regression: Lifetime Suicidal Ideation A. Activity Variables Only Multiple R .239 R Square .057 Adj R Sq .053 Std Error .441 Analysis of Variance DF Sum Sq Regress 7 18.782 Residual 1589 309.565 F = 13.772 Sig F = .0000 VARIABLES T NOFAM 6.065 NO REL .677 FRIEND 1.136 MTV 4.947 JOCK -1.185 NOHWK 1.445 WORK .113 AGE MALE MOMGONE DADGONE POVERTY MOMED US1GEN US2GEN CES-D-16 LONELY NOWDRUG CONSTANT 8.440

B. All Variables Multiple R R Square Adj R Sq Std Error Mean Sq DF 2.683 13 .195 1583 F = 11.588 Sig F = .0000 Sig T .0000 .4984 .2560 .0000 .2364 .1487 .9102

.0000

T 3.324 .289 -.370 2.645 .094 .563 .066 .218 -3.328 .188 1.565 -.575 2.319 3.435 4.331 12.837 3.110 5.053 -.392

.295 .087 .079 .435 Sum Sq 28.531 299.815

Mean Sq 2.195 .189

SigT .0009 .7729 .7116 .0082 .9251 .5736 .9475 .8277 .0009 .8507 .1177 .5655 .0205 .0006 .0000 .0000 .0019 .0000 .6954

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Andres J. Pumariega, Eugenio M. Rothe, Jeffrey Swanson et al. Table 7. Regression Analysis for Lifetime Suicide Attempts

A. Activity Variables Only Multiple R .203 R Square .041 Adj R Sq. .037 Std Error .319 Analysis of Variance DF Sum Sq Regress 7 6.942 Residual 1589 161.214 F = 9.776 Sig F = .0000 VARIABLES T NOFAM 5.348 NO REL -.633 FRIEND .703 MTV 2.541 JOCK 1.065 NOHWK 2.792 WORK -1.349 AGE MALE MOMGONE DADGONE POVERTY MOMED US1GEN US2GEN CES-D-16 LONELY NOWDRUG CONSTANT 5.240

B. All Variables Multiple R R Square Adj R Sq Std Error Mean Sq DF .992 18 .101 1578 F = 11.014 Sig F = .0000 Sig T .0000 .5265 .4821 .0111 .2870 .0053 .1777

.0000

T 4.117 -1.040 -.192 1.042 1.918 2.001 -.918 -1.806 -2.895 -.114 2.244 .495 .261 .585 1.250 6.520 1.816 5.511 2.045

.334 .112 .101 .308 Sum Sq 18.768 149.388

Mean Sq 1.043 .095

SigT .0000 .2987 .8481 .2975 .0553 .0456 .3586 .0711 .0038 .9091 .0249 .6208 .7944 .5586 .2215 .0000 .0696 .0000 .0410

Logistic regression analyses examined factors correlated to past week suicidal ideation (Table 5), lifetime suicidal ideation (Table 6), and self-reported lifetime suicide attempts (Table 7). The regression equation for activity variables alone showed that no time with family (p < .0000), unsupervised time with friends (p = .0167), media exposure (p < .0000), and no homework (p = .0336) were correlated with past week suicidal ideation. In the combination regression equation, past week suicidal ideation was significantly associated with no time with family (p = .0066), time on TV/ radio (p = .0065), younger age (p = .0012), female gender (p = .0356), depressive symptoms (CES-D over 16, p < .0000), loneliness (p = .0017), and current drug use (p < .0000; Table 5) Similar variables correlated in the combination regression equation with lifetime suicidal ideation (Table 6). In the activity variable regression analysis, lifetime suicidal ideation was correlated to: no time with family (p < .0000) and media exposure (p < .0000). In the

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combination regression equation, past week suicidal ideation was significantly associated with no time with family (p = .0009), media exposure (p = .0082), female gender (p = .0009), mother‘s education (p = .0205), U.S. first generation (p = .0006), U.S. second generation (p < .0000), depressive symptoms (CES-D over 16, p < .0000), loneliness (p = .0019), and current drug use (p < .0000; Table 6). The pattern of correlations was somewhat different for lifetime suicidal attempts. In the activity variable regression analysis, lifetime suicidal ideation was correlated to: no time with family (p < .0000) and media exposure (p = .0111). However, on the combination regression equation, lifetime history of suicidal attempts was correlated to no time with family (p < .0000) as the only activity variable, and also to female gender (p = .0038), father absence (p = .0249), depressive symptoms (CES-D over 16, p < .0000), and current drug use (p < .0000; Table 7).

DISCUSSION AND CONCLUSION The overall data on suicidal ideation across national residence and parental national origin suggests that there are major differences in the risk of suicidality across a relatively narrow border region. Such a wide gradient across such a narrow geographic area suggests the powerful influence of cultural values and beliefs that mitigate against suicidal ideation in Mexican youth, and the impact of acculturation on increasing the risk for such ideation in Mexican-American youth living in the United States. The logistic regression results further support these overall findings, indicating that some cultural variables associated with more mainstream American culture, particularly more independence from the family and greater exposure to the popular media, are associated with higher levels of suicidal ideation, and possibly with increased risk for suicide. These variables maintained their significance in the face of depression, loneliness, and substance use, all known to be significant variables. The pattern appears to be somewhat different for a history of actual suicide attempts, with more traditional demographic and clinical variables (such as depression, substance abuse, and father absence) seeming to predominate, with only independence from family remaining as an influential variable. It may be that cultural variables may increase risk of suicidal ideation, while clinical factors may then precipitate actual suicide attempts in at-risk individuals. This study had a number of limitations, including a lack of more systematic sampling (especially in the Mexican side), some asymmetry of sampling by age (which may underreport suicidality among Mexican youth as a result of their younger age), and lack of more methodology that obtains more in-depth assessment of cultural value orientation (this was sacrificed for more focus on substance abuse data and a greater sample size). However, its large sample size and its bi-national scope help to place the issue of suicidality among Mexican-American youth within a more appropriate bi-cultural context. This study supports the hypothesis that, as Hispanic youth transition from more to less protective activities and less traditional cultural values, their risk of suicidality may increase. This pattern is being borne out in the increasing rates of suicide among Hispanic youth in the United States, particularly Hispanic female adolescents [30], [31], [32], [33]. This study also suggests that such increases in suicidality are being compounded by a parallel increase in risk for substance abuse in Hispanic youth. Both of these trends are occurring in the context of

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decreasing family cohesion and increasing media exposure, as suggested in our study results [6], [7]. It is important to note that American youth have undergone similar changes in cultural values historically over the past five decades, and such may have also contributed to increases in the risk for suicide. The suicide rate is leveling out in the mainstream population as the impact of these cultural factors may be also leveling out, and being mitigated by greater antisuicide prevention efforts. However, suicide prevention efforts in underserved ethnic minority and immigrant populations are in their infancy [34]. Youth suicide prevention efforts in the U.S. could be informed by studying cultural values and their relationship to suicidality in youth from other cultures. As previously mentioned, there appear to also be additional cultural factors in traditional Mexican culture and other Hispanic cultures that may be protective to the contemplation of suicidality. One could hypothesize that a world view which is less future and achievement-oriented and more accepting of "fate" may be protective against suicidality in the face of other stressors. These were not accessible to evaluate in our survey given the complexity of such concepts and should be evaluated in future studies. Research into such culturally-mediated cognitive variables should be incorporated into preventive programs for suicidality for Hispanic youth as well as mainstream American youth. Studies with smaller but more representative samples of youth (including clinical and non-clinical samples) from different cultural and ethnic origins, using more in-depth measures evaluating such cultural value orientations are important as part of youth suicide prevention efforts [35].

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[24] Johnson L, O'Malley P, Bachman J: Drug use among American high school students, college students and other young adults: National trends through 1985, 1986; Rockville, MD: National Institute of Drug Abuse. [25] Pumariega A, Swanson J, Holzer C, Linskey A, Quintero-Salinas R: Cultural context and substance abuse in Hispanic adolescents. Journal of Child and Family Studies, 1992; 1, 75-92. [26] Swanson J, Linskey A, Quintero-Salinas R, Pumariega A, Holzer C: Depressive symptoms, drug use and suicidal ideation among youth in the Rio Grande Valley: A binational school survey. Journal of the American Academy of Child and Adolescent Psychiatry, 1992; 31, 669-678. [27] Radloff L: The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1977; 1, pp. 385-401. [28] Garrison C, Addy C, Jackson K, McKeown R, Waller J: The CES-D as a screen for depression and other psychiatric disorders in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 1991; 30, 636-641. [29] Robbins L, Helzer J, Croughan J, and Ratliff K: National Institute of Mental Health Diagnostic Interview Schedule: Its history, characteristics, and validity. Archives of General Psychiatry, 1981; 38, 381-389. [30] Malone S: Injuries among Hispanics in the United States: Implications for research. Journal of Transcultural Nursing, 2003; 14, 217-226. [31] Guiao I, Thompson E: Ethnicity and problem behaviors among adolescent females in the United States. Health Care Center International for Women, 2004; 25, 296-310. [32] Zayas L, Lester R, Cabassa L, Fortuna L: Why do so many Latina teens attempt suicide? A conceptual model for research. American Journal of Orthopsychiatry, 2005; 75: 275-287. [33] Oquendo M, Ellis S, Greenwald S, Malone K, Weissman M, Mann J: Ethnic and sex differences in suicide rates relative to major depression in the United States. Journal of the American Psychiatric Association, 2001; 158, 1652-1658. [34] Kataoka S, Stein B, Lieberman R, Wong M: Suicide prevention in the schools: Are we reaching minority youths?. Psychiatric Services, 2003; 54, 1444. [35] Gutiérrez P, Rodríguez P, García P: Suicide risk factors for young adults: testing a model across ethnicities. Death Studies, 2001; 25, 319-340.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 6

SUICIDE AMONGST BRITAIN’S IMMIGRANT POPULATION: DATA SOURCES, ANALYTICAL APPROACHES, AND MAIN FINDINGS Peter J. Aspinall University of Kent, Canterbury, Kent, UK

ABSTRACT This study attempts to examine variations in suicide rates between immigrant populations and ethnic groups in Britain. Lack of recording of ethnic group at death registration has precluded investigation of suicide mortality in minority ethnic groups. Most studies have investigated suicide rates by country of birth but this is now a poor proxy for ethnic group as around half the minority ethnic group population were born in Britain. Also, some country of birth data - such as that for Indian subcontinent countries contains White persons. Studies that have used this data show consistent findings: men and women born in Ireland and Scotland are at higher risk; men born in South Asia, West Africa, and the Caribbean Commonwealth have low rates of suicide but rates are elevated amongst young South Asian women. A study using name recognition software as a method of ascertaining South Asian ethnicity reported elevated suicide rates in young South Asian women in 1993-1998 data but rates no different from England and Wales in 1999-2003 data. In 1999-2003, however, older South Asian women were a group at risk. There is also no systematically collected information on risk factors for suicide in black and minority ethnic groups, except those who were in contact with mental health services in the year before death. A recent systematic review concluded that ‗we know surprisingly little about the rates of or risk factors for suicide in BME groups in England and Wales‘ and recommended that ethnicity rather than place of birth is recorded on death certificates and official records dealing with suicide. Consequently, this chapter accords importance to data sources and their shortcomings and the analytical strategies that can be used to investigate suicide mortality in migrant and minority ethnic groups.

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INTRODUCTION The evidence base on suicide rates amongst immigrant populations and minority ethnic groups in Western societies might be described as representing a dearth of knowledge. A number of factors may have contributed to this situation, including lack of data of quality on suicide cases coded by country of birth or ethnic group (which may necessitate imprecise methods of imputation), small numbers of suicide cases in some immigrant populations based on the relative rarity of suicide mortality (and thus subject to large random variations), difficulties in determining the denominator for calculating suicide rates (including, for example, census undercoverage and lack of data on residents in institutions), and the rapidly growing and changing ethnic composition of the population in some countries. In addition, inter-country comparisons are also complicated by differences in coverage (including the use of different definitions of foreign-born or immigrant status), differences in suicide recording methods, and in the denominator population. Similar problems may arise in comparing immigrant suicide rates to rates in their countries of origin. However, although ascertainment procedures may differ, analysts agree that suicide data is sufficiently robust to permit crossnational comparative studies [1,2]. Where suicide mortality is reported for the immigrant population in particular countries, rates frequently vary across country of birth groups compared with the native-born population and by gender, as shown in findings for European countries. Age-adjusted suicide rates amongst Turks residing in (West) Germany were reported to be lower than amongst Germans (relative risk 0.3), although for Turkish young women under 18 years the relative risk compared to Germans was 1.8 (95% confidence interval 1.4 to 2.3) [3]. In Denmark, however, suicide risk was generally higher among persons with ‗foreign background‘, and highest among Nordic-born persons, compared with the majority population, but significantly lower among Asian-born persons. As in Germany, there were gender differences in suicide risk across minority groups [4]. In the Netherlands, the migrant population (combined) did not have a significantly different relative risk for suicide compared with the native Dutch population, but risk varied across country of birth groups (significantly lower in Turkish and Moroccan migrant groups, and significantly higher amongst Surinamese migrants, in both men and women) [5]. In Sweden, a significant overrepresentation of immigrants has been reported in the total cases of undetermined and definite suicide, including a significant overrepresentation of the largest immigrant group (Finnish-born) [6]. In another study [7] second-generation immigrants tended to have higher odds for suicide death than the firstgeneration immigrants compared to the majority population in all the minority groups studied. The Finnish minority had the highest and the Middle Easterners the lowest odds for suicide death in both generations of immigrants. Further, the intercountry adoptees had very high odds for suicide death (adjusted OR: 5.0; 95 % CI 3.5–7.0). Outside Europe, an equally complex picture emerges. In Canada, age-standardised suicide rates (per 100,000) for immigrants were statistically significantly different: almost half those for the Canadian born population in 1990-92 (8.3 vs. 13.0) and 1995-97 (7.9 vs. 13.3), although the differential was substantially smaller amongst females [8]. Moreover, agestandardized suicide rates varied considerably by birthplace of immigrants being highest for Europe (10.9), and substantially lower for the Americas and Caribbean (6.0) and Asia (5.3). Moreover, among immigrants the pattern of suicide was more like that in their countries of

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origin than that of the Canadian-born population. In the United States, suicide rates vary across ethnic groups. There have been persistently lower rates of suicide amongst AfricanAmericans and consistently higher rates in the Native American population (including those in Alaska) and the antipodes [9]. This study attempts to examine variations in suicide rates between immigrant populations and ethnic groups in Britain. A major drawback to identifying and interpreting these differences across black and minority ethnic groups is a lack of ethnically coded data on suicide cases. There is no collection of ethnic group data at death registration and country of birth is now a poor proxy. Consequently, most of our knowledge relates to suicide in immigrants and there is little contemporary information on the full minority ethnic group population. Similarly, there is no systematically collected information on risk factors for suicide in black and minority ethnic groups, except those who were in contact with mental health services in the year before death. Consequently, this chapter accords importance to data sources and their shortcomings and the analytical strategies that can be used to investigate suicide mortality in migrant and minority ethnic groups. Finally, findings are reported from studies that have investigated suicide mortality by country of birth and in selected ethnic group populations. The lack of information on risk factors for suicide in the different migrant and minority ethnic groups, needed to inform suicide prevention strategies, is also highlighted.

DATA SOURCES In common with many western countries, the data available in Britain on suicide amongst its diverse immigrant and ethnic communities is limited. Suicide was one of the three specific service areas of particular concern (together with pathways to care and acute in-patient facilities) looked at in detail by the Department of Health (2003)‘s Delivering Race Equality: A Framework for Action (DRE) [10], a document setting out what those planning, delivering, and monitoring mental health services in England should do to improve services for those experiencing mental illness from Black and minority ethnic communities. The significantly raised risk of suicide and attempted suicide among young women born in India or of Indian origin born in East Africa and men born in Ireland was highlighted, the need to address this being identified as essential to meet the key national target of a 20 per cent reduction in the suicide rate by 2010. Despite this focus, DRE was silent on the lack of comprehensive ethnic data on suicides. In Britain, there is currently no collection of information on ethnic group when a death is registered. Country of birth of the decedent is collected but this is now becoming an increasingly unsatisfactory proxy for the size of different ethnic communities: the 2001 national population census showed that half of those belonging to minority ethnic groups were born in Britain. Nevertheless, extensive use has been made of official mortality statistics to investigate patterns of suicide by country of birth [11,12,13]. The omission of ethnic group from civil registration procedures has undoubtedly substantially limited our ability to investigate those differences revealed by studies of migrant suicide rates [14], including investigations by immigration generation status.

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A recent systematic review of suicide prevention for black and minority ethnic groups (15) similarly concluded: ‗We know surprisingly little about the rates of or risk factors for suicide in BME groups in England and Wales. This is mainly because of a lack of good quality data‘. They note: ‗The fact that place of birth not ethnicity is recorded on death certificates is a major obstacle to improving the evidence and understanding changes in trends. We recommend that ethnicity not place of birth is recorded on death certificates and official records dealing with suicide‘. With respect to the granularity of ethnicity classification, they argue that ‗specific investigation of cultural sub-groups should also include White sub-groups such as the Irish‘ and that ‗ultimately, suicide statistics should include more detailed ethnic codes‘. Alternative sources are limited. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness [16] reported information on suicides of people from minority ethnic groups within 12 months of contact with mental health services, including methods and the patients‘ social and clinical characteristics [17]. Its second five-year report was published in 2006, including tables recording the ethnic origin of Inquiry suicide cases and their clinical characteristics [18]. Several studies have utilised this source, including one focusing on ethnic group [19]. The Office for National Statistics (ONS) Longitudinal Study [20] is a potential source of information in the longer term, given that ethnically coded data from the 1991 and 2001 national population censuses have been added to the cohort, although there is a significant delay in linking death registrations to the Longitudinal Study [21]. Information in the Hospital Episode Statistics (HES) database [22] is of limited value as it relates only to deaths in hospital (hospital case fatalities), which account for a negligible proportion of suicides, even amongst those in contact with mental health services in the year before death. Moreover, the incompleteness of ethnic coding, although now substantially improved, is a further limitation. Apart from these, there are only one or two ethnically-coded specialised datasets relating to small population subgroups, such as that for maternal deaths by suicide [23]. Over the last few years two developments have offered the possibility to improve the information base. An opportunity to seek inclusion of ethnic group at birth and death registration was provided in the UK Government‘s consultation on its White Paper Civil Registration: Vital Change [24]. A robust case for such inclusion was made by the London Health Observatory and London Health Commission [14] and was also strongly supported in the General Register Office‘s Civil Registration Review of 2003. Further, the proposals, contained in a Draft Regulatory Reform Order that was intended to amend current legislation on civil registration, were propitious, indicating the likely piloting of the collection of ethnic group at birth and death registration [25]. However, the enabling legislation was rejected by Parliament on the grounds that it was too complex for the Regulatory Reform process, bringing this process to an end as there was no other legislative route available. The Equalities Review [21] has made the recommendation that ‗In England, Wales and Scotland (as appropriate) specific action should be taken to urgently introduce ethnicity coding as part of civil registration of birth and death that will enable the variations in infant mortality and life expectancy to be routinely monitored by ethnicity‘. However, there are currently no developments underway. The latest call that ‗recording of ethnicity on death certificates be reconsidered, despite concerns about accuracy‘ (the issue of non-self reporting) has come from the team developing the Equality Measurement Framework (which discharges the Equality and Human Rights Commission‘s legal duty under the Equality Act (2006) to

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monitor and evaluate progress towards equality and human rights, taking account of the seven statutory equality strands, including ethnicity [26]. The indicators include the suicide rate. A second major development was the Department‘s working towards the collection of information on ethnicity by coroners [10]. The National Institute for Mental Health in England (NIMHE) and others argued that suicide prevention strategies would be better supported and more effective if information on current or latest occupation and ethnic status were available as aggregate data, and have requested that coroners provide this information when reporting cases to the Registration Service [27]. The Government‘s ‗fundamental review‘ of death certification and investigation [28] supported this ‗good case in an important area‘ and recommended that ‗…from the earliest feasible date, coroners should wherever they can return information on ethnicity and latest occupation status when reporting self-inflicted deaths to the Registrar‘. However, this information would not be publicly accessible in the individual case. In its rationale, the report highlighted the fact that while there were grounds for thinking that suicide rates amongst young Asian women may be abnormally high, ‗…without good ethnicity data well founded preventive action is hard to design‘. In its response to the report by Her Majesty‘s Inspector of Anatomy on the use of adult organs and tissue (the Isaacs Report), the Department also refers to the new model consent forms for post mortem examination that ask on a voluntary basis for information about the religion of the deceased [29]. It also notes that ‗Home Office experience in piloting the routine capture of data relating to the ethnic origin or faith of persons whose death has been reported to the coroner has engendered a degree of concern and suspicion in some areas‘, necessitating additional work on the acceptable capture of this information. To date this development has also come to nothing: in response to a written question asking what progress had been made on the recording of ethnicity data by coroners [30], the Secretary of State for Justice stated: ‗At present coroners do not collect data on the ethnicity of the deceased in deaths which are referred to them. As part of our work to implement the coroner reforms included in the Coroner and Justice Bill we will be reviewing the statistical data currently collected by coroners and considering whether any changes are required‘. This was confirmed in a survey sent out by the London Development Centre to London coroners to find out about the level of ethnicity data they recorded in suicide cases [31]. The survey found that ‗record of ethnicity in suicide cases, in the majority of coroner‘s inquests, was not collected either through coroner‘s report or through information provided by the police. Protocols or strategies for recording ethnicity data did not exist and there are no plans to develop these‘. This leaves options such as data linkage, the utility of this approach having recently been demonstrated by ONS to compile infant mortality for England and Wales by ethnic group [32] and by an important initiative in Scotland that has linked individual census records with health and population data [33]. The NHS Information Centre‘s Mental Health Information Review [34], conducted in 2008, has recommended ‗as a high DH priority‘ that linkage should be established between the Mental Health Minimum Data Set (MHMDS) records of those who have been receiving specialist mental health care and ONS mortality records: as the MHMDS is ethnically coded, this should provide mortality data by ethnic group for a large population group. Most recently, Alkire et al. [26] have recommended that the Equality and Human Rights Commission and Government Equalities Office take forward discussions with the Department of Health and ONS about possible ways of producing mortality rates by ethnicity through data linkage.

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ANALYTICAL APPROACHES In the absence of recording of ethnic group at death registration, most studies of suicide in Britain have focused on the immigrant population using country of birth recorded on death certificates. Clearly, the use of country of birth as a proxy for ethnicity, precludes investigation of second-generation immigrant populations. Studies of suicide in the immigrant population have tended to focus on the years around the decennial census, the source of denominator data on country of birth. Use of country of birth has presented a number of analytical challenges. Firstly, country of birth includes foreign-born people of European origin and their effect on suicide mortality of groups other than White is difficult to assess but probably limited [35,36,13]. Secondly, country of birth groupings used by Harding and Maxwell [13] in their investigation of suicide amongst male migrants comprised ‗the Caribbean Commonwealth‘, ‗East African Commonwealth‘ (the majority of East Africans are of Indian origin, in contradistinction to those from West/South Africa who are of ‗Black African‘ ethnic origin), ‗Indian sub-continent‘ (India, Pakistan, Bangladesh, Sri Lanka), ‗Scotland‘, and ‗Ireland (all parts: both Northern Ireland and Republic of Ireland)‘. These aggregates were used as both Marmot et al. [35], on immigrant mortality in the 1970s, and Harding and Maxwell [13], using special tabulations from the ONS Longitudinal Study, found that country of birth was recorded differently on census forms compared to death certificates for those born in India, Pakistan, and Bangladesh and also for those born in Northern Ireland and Republic of Ireland. Moreover, the numbers of suicide cases in some of the countries of birth are too small to yield reliable findings: for example, for England and Wales for the years 1999-2003, there were only 16 deaths from suicide and undetermined injury amongst persons born in Bangladesh, compared with 70 in the Pakistan and 215 in the India country of birth groups. Recently, name information has been used to circumvent the limitations of country of birth data and to ascertain the ethnic origin of suicide cases. A recent study of suicide rates in people of South Asian origin in England and Wales [37] used the South Asian Group Recognition Algorithm (SANGRA) computer programme. However, such methods are feasible with only a few ethnic groups (notably, South Asians and Chinese) and more information is needed - acquired through processes of systematic review and national testing and accreditation - on how well SANGRA and others like Nam Pehchan ascertain individuals of South Asian origin. Further, inaccuracies are likely to arise through numerator/ denominator compatibility: while the numerator uses an operational definition of ethnicity derived from name information, the denominator is usually based on self-assignment by individuals to census categories [38]. Yet the utilisation of this technology by McKenzie et al. [37] yields findings for the whole of the UK South Asian population (and not just first generation migrants) and constitutes the currently best available evidence. Moreover, it is difficult to see how suicide rates in this population could be ascertained or findings replicated by other means in the absence of ethnically-coded death registration data.

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MAIN FINDINGS Suicides by Country of Birth Groupings UK studies have reported significant variation in suicide rates by country of birth, some groups in the migrant population appearing to be at greater risk. Amongst men aged 20-64 Harding and Maxwell [13] reported statistically significantly lower standardised mortality ratios for the Caribbean (SMR 59), East Africa (75), and Indian sub-continent (73) country of birth groups and statistically significantly higher rates for the Scotland (149) and Ireland (135) country of birth groups, based on an analysis of deaths in England and Wales, 1991-93. Adjusting for social classes I-V made little or no difference to the SMR in the Caribbean (57), East Africa (75), Indian sub-continent (76), and Ireland groups (134) groups, but increased the SMR in the Scotland group to 160. The social class gradient (non-manual vs. manual) was highest in the Scotland (85 vs. 208) and Ireland (83 vs. 164) groups, substantially lower in the ‗all countries‘ (67 vs. 111), Caribbean (41 vs. 65), and East African groups (49 vs. 79), and reversed in the Indian sub-continent group (83 vs. 63). These findings have been corroborated in subsequent studies of suicide in the immigrant population. The most recent data - for suicide and undetermined deaths in England and Wales for the years 1999-2003 - shows a persistence of these differentials for most groups [39]. The SMR for Irish-born males was 139 (95% confidence interval [CI] 126 to 154) and for Irishborn females 140 (95% CI 118 to 164). The rates for the born in Scotland group - higher than the Irish in the 1991-93 data - were now lower but still elevated: an SMR of 127 (95% CI 116 to 140) for males and 114 (95% CI 95 to 136) for females. By contrast the Indian subcontinent groups were all lower than for the England and Wales country of birth group amongst men (India, SMR 76, 95% CI 64 to 89; Pakistan, 29, 95% CI 21 to 39; Sri Lanka 75, 95% CI 49 to 110; and East Africa, 68, 95% CI 54 to 84); for women, rates were similar to or below that for England and Wales (India, SMR 104, 95% CI 81 to 132; Pakistan, 74, 95% CI 49 to 106; and East Africa, 104, 95% CI 73 to 144). SMRs for West Africa (men 70, 95 % CI 54 to 89 and all persons 63, 95% CI 50 to 79) and Caribbean Commonwealth (men, 67, 95% CI 51 to 86 and women, 55, 95% CI 33 to 84) country of birth groups remain low. However, two groups (not included in the 1991-93 analysis) emerge with elevated rates. The ‗Eastern Europe‘ country of birth group had SMRs higher than any other group for both males (147, 95% CI 124 to 174) and females (205, 95% CI 158 to 263); the ‗Other Western Europe‘ group (excluding England and Wales, Ireland, and Scotland) had significantly higher rates among females (154, 95% CI 131 to 179). Thus, certain consistent findings emerge from the investigation of country of birth data. Standardised mortality ratios for suicide have been consistently high among Scottish and Irish born men and women. In data for England and Wales for the period 1979-83, Irish-born men and women showed an excess in SMRs of 126 and 130 respectively, similar to the Scotlandborn (128 and 127, respectively). SMRs for suicide were especially elevated amongst young Irish migrants aged 20-29 years: a significant 74% excess in the case of young Irish males and an almost threefold excess for young Irish women (SMR 267) [11]. In 1988-92 national data for England and Wales all Irish-born people showed a 53% excess mortality from suicide [40]. Analyses of suicide mortality for the years 1991-93 showed an excess for Irish-born men of 35% [13] and for Irish born women of 44% [41]. The most recent data (1999-2003)

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continue to show excesses in SMRs for men and women born in Ireland (39% and 40%, respectively) and Scotland (27% and 14%, respectively). Data for 1999-2003 also show high rates for men and women born in Eastern Europe and women born in ‗Other Western Europe‘ (excluding England and Wales, Ireland, and Scotland). Again, these ratios reflect differentials found in the 1979-83 data, Polish-born men and women aged 20-69 years having SMRs of 172 and 238, respectively, and the USSR born, 240 and 242, respectively [11]. In this earlier period, SMRs were also high for German-born (167 and 151) and French-born (209 and 243) men and women. High suicide rates have also consistently been reported for young Asian women. Reports on suicide rates among immigrants in England and Wales during the periods 1970-1978 [42] and 1979-83 [11, 43] note these excess risks. Suicide data for England and Wales for 19881992 showed significantly raised suicide ratios in Indian and east African women (143 and 154, respectively), with a 2-3 fold excess at ages 15-34 years [44]. Ratios in Pakistani and Bangladeshi women were also elevated at 15-24 years. By contrast, low standardised mortality ratios have been consistently reported in studies for men born in the Indian subcontinent, West Africa, and the Caribbean Commonwealth and women born in the Caribbean Commonwealth. In the period 1979-83, SMRs for Indian Subcontinent-born men (71) and Caribbean Commonwealth-born men and women (80 and 59) were amongst the lowest. However, Raleigh [44] has reported raised ratios for Caribbeanborn men and women at aged 25-34 in suicide data for England and Wales for 1988-92.

Suicides by Ethnic Group The routine analysis of suicide rates by ethnic group has been precluded by lack of ethnic coding on death certificates. However, one source - the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI) - has enabled a particular segment of the population to be examined by ethnic group: those who committed suicide within 12 months of contact with mental health services. Further, new analyses have been undertaken for the Indian subcontinent population using distinctive names but these are only a proxy measure of ethnic group and not a direct measure. Findings from both sources are presented. The NCI was established at Manchester in 1996 and complete national data collection started the following year. The NCI has published two five-year reports: the first [45] presented findings on 4,859 cases presented to the Inquiry from April 1996 until March 2000, of whom 282 (6%, 95% CI: 5-7%) were in minority ethnic groups. The second report [18] covered the years April 2000 to December 2004 and provided information on 6,204 cases, of whom 423 (7%, 95% CI 6-8%) were in minority ethnic groups. In addition, Bhui and McKenzie [19] have undertaken a much more comprehensive analysis of NCI cases for the 5year period 1996 to 2001, which provides information on a total of 331 suicides in four minority ethnic groups (68 Black African, 97 Black Caribbean, 166 South Asian, and 7,698 White; the number of suicides in other ethnic groups than these was small (n=14)). The major benefit of the NCI source is that - while limited to suicides within 12 months of contact of mental health services and excluding some important ethnic groups such as the Irish and the aggregation of others (those comprising the white and Asian categories), the data is for ethnic groups and not just immigrants. The lead clinician responsible for completing the NCI form is asked to report the patient‘s ethnicity using selected ONS ethnic categories: South Asian

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(encompassing Indian, Pakistani, and Bangladeshi), black Caribbean, black African, white, Chinese, mixed, or other. Compared with standardised mortality ratios for the white group (men, n=5,441; women, n=2,257), low SMRs were found for South-Asian men (SMR=.5, 95% CI =.4-.6) and women (SMR=.7, CI=.5-.9). However, high SMRs were found for young women aged 25-39 of South Asian origin (SMR=2.8, CI=1.9-3.9) but very low rates for those aged 13-24 (SMR=.13, CI=.04-.34). High SMRs were found for men aged 13-24 of black Caribbean (SMR=2.9, CI=1.4-5.3) and black African (SMR=2.5, CI=1.1-4.8) origin. High SMRs were also found for young women aged 25-39 of black Caribbean (SMR=2.7, CI=1.3-4.8) and black African (SMR=3.2, CI=1.6-5.7) origin. These findings are broadly in accord with studies that have focused on suicide amongst young women born in the Indian subcontinent and East Africa [12, 42, 43, 44], increasing suicide rates among young Caribbean born men [11], and a higher risk of suicide among younger (as opposed to older) black Caribbean men with psychosis [46]. These investigators have undertaken further analyses of suicide in the England and Wales population originating in the Indian sub-continent for the period 1993-2003 using distinctive names (the South Asian Name and Group Recognition Algorithm) as a proxy for ethnicity [37]. They found that the age-standardised suicide rate for men of South Asian origin was lower than other men in England and Wales, and the rate for women of South Asian origin was marginally raised. However, a notable finding was that, in aggregated data for 19992003, the age-specific suicide rate in young women of South Asian origin was lower than that for women in England and Wales, while the suicide rate in women aged over 65 years was double that of England and Wales. The identification of older South Asian women as an atrisk group is an important new finding, as is the emergence in the data for 1999-2003 of young Asian women as a group no longer at risk. There are no other data with which to compare these findings, given that ethnicity is not recorded at death registration. The benefit of this approach is that it captures suicide in the whole population of South Asian origins and not just immigrants - over 50% of the South Asian population being born in the UK - and, indeed, it utilises the best evidence currently available. However, as the investigators admit [37, 47], there may be potential problems associated with the study‘s methodology, including the numerator (how well the SANGRA name recognition algorithm ascertains individuals of South Asian origin in more recent samples) and denominator (the validity of a linear interpolation of numbers over the study period). Given the finding on young South Asian women in the period 1999-2003, which runs counter to a substantial body of previous evidence, further cautions are required. The numerator in this study uses an operational definition of ethnicity but the denominator is based on self-assignment by individuals to census categories. The inclusion in the latter of the ‗Mixed: White and Asian‘ category but exclusion of ‗Other Asian‘ may require further consideration with respect to findings from the Longitudinal Study (LS) on the composition of these categories [38]. Further, the creators of SANGRA [48] admitted that further studies were needed to confirm whether the algorithm was able to produce valid results across Britain. Raleigh [49] has also called for national agencies to undertake a systematic review of the available namerecognition software programmes, to establish their robustness for epidemiological analyses. The only other data on suicide by ethnic group is that for limited samples. A three-year (1991-1993) survey was undertaken in Inner London [50] of all unnatural deaths of residents, coroners‘ records being used to determine ethnic group. ‗True likely‘ and ‗official‘ age-

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adjusted suicide rates were compared by ethnicity and, for the White group, birthplace. The investigators found that relatively few ethnic minority and White immigrant suicides had received a suicide verdict. An almost doubling in the risk of suicide was reported in women of South Asian origin under 45 years of age compared with a White comparison group. However, Afro-Caribbeans had relatively low rates. Rates of Scottish- and Irish-born residents were 2.1 to 2.9 times higher than the local base rate. Young White males‘ rates were higher than those of the elderly. While this important study found high rates of suicide in young South Asian women and showed that in this deprived area classification of suicide was biased with respect to ethnicity and national origin, there are significant differences in South Asian suicide rates by geographical location [47] which limit generalisabilty of findings. Also, use has been made of the Longitudinal Study (LS) to investigate mortality by suicide in the Irish ethnic group (which, as Britain‘s largest ethnic group, yields adequate numbers in this dataset). An analysis of the Irish second generation [51] showed SMRs of 145 for second generation Irish men and 125 for second generation Irish women during the period 1971-89 amongst those aged 15 –64 years.

RISK FACTORS FOR SUICIDE Relatively little is known about the risk factors for suicide or behaviours that might increase the likelihood of suicide amongst immigrants in Britain or the wider minority ethnic population, information that is needed to design specific preventive strategies. In their systematic review Bhui and McKenzie [52] concluded: ‗There is no contemporary information on comparative rates and risk factors for suicide in Black and Minority Ethnic groups in England and Wales. It is not clear whether different ethnic minority groups share the same risk profiles as the white British population‘. Many general risk factors have been identified across a life-course, including socioeconomic disadvantage (poverty, unemployment, and low levels of education), stresses around migration, and socio-cultural factors such as those associated with acculturation and discord between traditional South Asian cultures and the host culture. However, McKenzie et al. [37] have cautioned that these vary by immigrant and ethnic group and that ‗we need to be careful in assuming that standard risk factors for suicide act in the same way in different cultural groups‘. For example, Raleigh et al. [42] found that the association of suicide and social class was different in the South Asian origin population: 13.8% of suicides in women of South Asian origin occurred in social class 1, compared with 4.9% in the general population. There may also be protective factors that vary across ethnic groups. For example, the Islamic prohibition on suicide - as opposed to the tolerance of self-sacrifice in Hindu cultures - may contribute to the variation in rates across the South Asian groups [44]. Bhui and McKenzie [19] explore suicide risk indicators using the relatively rich information available on cases through the NCI process. They found that some widely accepted suicide clinical risk indicators were less common in the ethnic minority groups than in the white group. Suicidal ideas, emotional distress, and hostility were less common among black Africans, black Caribbeans, and South Asians. Hopelessness and depression were more common among South Asians. There were more symptoms of active psychosis for people

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from ethnic minority groups who later committed suicide. Perceived preventability was highest among black Caribbean people. Where attempts have been made to identify risk factors in particular ethnic groups, such as the Irish, they have been problematic. For example, Leavey [53] focuses on possible explanations for elevated suicide mortality amongst Irish migrants in Britain. He offers a hypothetical model that incorporates the lack of social cohesion and integration meshed with the inability to establish an authentic identity, adding that these factors are ‗likely to be the encompassing explanation‘, with lower social class, high levels of deprivation, and anti-Irish racism likely to be contributory factors. He also implicates Irish cultural attitudes to health and the use of alcohol as an accepted method of coping with stress. The approach relies heavily on macro-level economic associations with respect to a range of putative risk factors, problems of ecological effect modification and the lack of specificity of most sociodemographic predictors setting limits to the utility of such an approach [54]. More promising results have been obtained through individual level analysis. For Irish migrant men, Harding and Maxwell [13] showed that adjusting standardised mortality ratios for social class explained virtually none of the excess suicide rate. In a further study investigating patterns of immigrant suicide mortality by marital status, Maxwell and Harding [41] showed that, for Irish and Scots men and women, only those who were not married showed excess mortality from suicide. This finding of higher risks for unmarried persons has been reported in studies at the individual level in other countries [55, 56].

CONCLUSION The lack of recording of ethnic group at death registration has precluded investigation of suicide mortality in minority ethnic groups. Most studies have investigated suicide rates by country of birth but this is now a poor proxy for ethnic group as around half this population were born in Britain. Also, some country of birth data - such as that for Indian subcontinent countries - contains White persons. Studies that have used this data show consistent findings: men and women born in Ireland and Scotland are at higher risk; men born in South Asia, West Africa, and the Caribbean Commonwealth have low rates of suicide but rates are elevated amongst young South Asian women. A study using name recognition software as a method of ascertaining South Asian ethnicity reported elevated suicide rates in young South Asian women in 1993-1998 data but rates no different from England and Wales in 1999-2003 data. In 1999-2003, however, older South Asian women were a group at risk. Clearly, a current major impediment to more comprehensive studies of suicide mortality in ethnic groups is the lack of good quality data. A recent systematic review concluded that ‗we know surprisingly little about the rates of or risk factors for suicide in BME groups in England and Wales‘ and recommended that ethnicity rather than place of birth is recorded on death certificates and official records dealing with suicide.

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Sainsbury P: Validity and reliability of trends in suicide statistics. World Health Stat Q 1983; 36(3-4):339-348. Barraclough B: Differences between national suicide rates. Br. J. Psychiatry 1973; 122: 95-6. Razum O, Zeeb H: Suicide mortality among Turks in Germany. Nervenarzt 2004; 75 (11): 1092-8. Sundaram V, Qin P, Zollner L: Suicide risk among persons with foreign background in Denmark. Suicide Life Threat Behav. 2006; 36(4):481-489. Stirbu I, Kunst AE, Bos V, and Mackenbach JP: Differences in avoidable mortality between migrants and the native Dutch in the Netherlands. BMC Public Health 2006; 6:78. Ferrada-Noli M, Åsberq M, Ormstad K, and Nordström P: Definite and undetermined forensic diagnoses of suicide among immigrants in Sweden. Acta Psychiatr Scand. 1995; 91(2):130-135. Hjern A and Allebeck P: Suicide in first- and second-generation immigrants in Sweden. A comparative study. Social Psychiatry Psychiatr Epidemiol. 2002; 37(9):423-29. Malenfant EC: Suicide in Canada‘s immigrant population. Health Rep. 2004; 15(2):917. McKenzie K, Serfaty M, Crawford M: Suicide in ethnic minority groups. Br J Psychiatry 2003; 183:100-101. Department of Health: Delivering Race Equality: A Framework for Action. London, Department of Health, 2003. Raleigh VS, Balarajan R: Suicide and self-burning among Indians and West Indians in England and Wales. Br. J. Psychiatry 1992; 161:365-368. Raleigh VS: Suicide Patterns and Trends in People of Indian Subcontinent and Caribbean Origin in England and Wales. Ethn. Health 1996; 1(1):55-63. Harding S. and Maxwell R: Differences in mortality of migrants, in Health inequalities: Decennial supplement. Series DS No. 15. Edited by Drever F, Whitehead M). London, The Stationery Office, 1997, pp 108-121. Aspinall PJ, Jacobson B, Polato GM: Missing Record: The Case for Recording Ethnicity at Birth and Death Registration. London, London Health Observatory, 2003. McKenzie K, Bhui K: Suicide Prevention for BME groups in England. Report from the BME Suicide Prevention Project. Executive Summary (Revised). London, Centre for Health Improvement and Minority Ethnic Services, 2007 (February). The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. http://www.medicine.manchester.ac.uk/psychiatry/research/suicide/ prevention /nci/ Hunt IM, Robinson J, Bickley H, Meehan J, Parsons R, McCann K, Flynn S, Burns J, Shaw J, Kapur N, and Appleby L: Suicides in ethnic minorities within 12 months of contact with mental health services. National clinical survey. Br. J. Psychiatry 2003; 183:155-160.

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[18] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness: Avoidable Deaths. Five-Year Report. Manchester, NCI, 2006 (December). [19] Bhui KS and McKenzie K: Rates and risk factors by ethnic group for suicides within a year of contact with mental health services in England and Wales. Psychiatr Serv. 2008; 59(4):414-420. [20] Office for National Statistics (ONS) Longitudinal Study. http://www.statistics [21] Equalities Review: Fairness and Freedom: The Final Report of the Equalities Review. London, The Equalities Review, 2007 (February). [22] Hospital Episode Statistics (HES) database. http://www.hesonline.nhs.uk/Ease/servlet/ ContentServer?siteID=1937andcategoryID=537 [23] Confidential Enquiries into Maternal Deaths in the United Kingdom: Why Mothers Die 2000-2002: The Sixth Report of Confidential Enquiries into Maternal Deaths in the United Kingdom. London, RCOG Bookshop at the Royal College of Obstetricians and Gynaecologists, 2004. [24] Office for National Statistics: Civil Registration: Vital Change. Birth, Marriage and Death Registration in the 21st Century. London, TSO (The Stationery Office), 2002. [25] Cabinet Office: The Draft Regulatory Reform (Registration of Births and Deaths) (England and Wales) Order explanatory document. London, TSO (The Stationery Office), 2004. http://www.cabinetoffice.gov.uk/regulation [26] Alkire S, Bastagli F, Burchardt T, Clark D, Holder H, Ibrahim S, Munoz M, Terrazas P, Tsang T, and Vizard P. Developing the Equality Measurement Framework: selecting the indicators. Research report 31. Manchester, Equality and Human Rights Commission, 2009. [27] Department of Health: National Suicide Prevention Strategy for England. London, Department of Health, 2002 (September). [28] Secretary of State for the Home Department: Death Certification and Investigation in England, Wales and Northern Ireland. The Report of a Fundamental Review 2003 (Cm 5831). London, TSO (The Stationery Office), 2003. [29] Department of Health: Isaacs Report Response. Response to the Report by Her Majesty‘s Inspector of Anatomy. London, Department of Health, 2003. [30] House of Commons: Hansard Written Answers for 22 Jan 2009 (pt 0006). [31] London Development Centre: Coroners data recording survey. See: http://www. londondevelopmentcentre.org/mental-health/well-being-inclusion-and-psychologicaltherapies/well-being.aspx [32] Office for National Statistics: Infant Mortality by Ethnic Group, England and Wales, 2005. London, ONS, 2008. See also: http://www.statistics [33] Bhopal R, Fischbacher CM, Steiner M, Chalmers J, Povey C, Jamieson J, Knowles D: Ethnicity and health in Scotland: can we fill the information gap? Edinburgh, Public Health Sciences, University of Edinburgh, 2005. [34] NHS Information Centre: Mental Health Information Review. Leeds, The Information Centre, 2009 (January). [35] Marmot M, Adelstein A, Bulusu L: Immigrant mortality in England and Wales 197078. London, HMSO, 1984.

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[36] Balarajan R, Bulusu L: Mortality among immigrants in England and Wales, 1979-83, in Mortality and Geography – a review in the mid-1980s England and Wales. Edited by Britton M. London, HMSO, 1990. [37] McKenzie K, Bhui K, Nanchahal K, Blizard B: Suicide rates in people of South Asian origin in England and Wales: 1993-2003. Br. J. Psychiatry 2008; 193:406-409. [38] Aspinall PJ: Suicide rates in people of South Asian origin in England and Wales. Br. J. Psychiatry 2009; 194(6):566-7. [39] De Ponte P: Deaths from suicide and undetermined injury in London. London, London Development Centre for Mental Health and London Health Observatory, 2005 (August). [40] Balarajan R: Ethnicity and variations in the nation's health. Health Trends 1995-96; 27(4):114-119. [41] Maxwell R and Harding S: Mortality of migrants from outside England and Wales by marital status. Popul. Trends 1998; 91:15-22. [42] Raleigh VS, Bulusu L, Balarajan R: Suicides among immigrants from the Indian subcontinent. Br. J. Psychiatry 1990; 156:46-50. [43] Raleigh SV and Balarajan R: Suicide levels and trends among immigrants in England and Wales. Health Trends 1992; 24:91-94. [44] Raleigh VS: Suicide patterns and trends in people of Indian Subcontinent and Caribbean origin in England and Wales. Ethn. Health 1996; 1:55-63. [45] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness: Safety First. Five-Year Report. Manchester, NCI, 2001 (March). [46] McKenzie K, van Os J, Samele C, Van Horn E, Tattan T, and Murray R: Suicide and attempted suicide among people of Caribbean origin with psychosis living in the UK. Br. J. Psychiatry 2003; 183:40-44. [47] McKenzie K, Bhui K: Suicide rates in people of South Asian origin in England and Wales: Authors‘ reply. Br. J. Psychiatry 2009; 194:567-568. [48] Nanchahal K, Mangtani P, Alston M, dos Santos Silva I: Development and validation of a computerised South Asian Names and Recognition Algorithm (SANGRA) for use in British health-related studies. J. Public Health Med. 2001; 23: 278-85. [49] Raleigh VS: Suicide rates in people of South Asian origin in England and Wales. Br. J. Psychiatry 2009; 194:567. [50] Neeleman J, Mak V, Wessely S: Suicide by age, ethnic group, coroners‘ verdicts and country of birth. A three-year survey in inner London. Br. J. Psychiatry 1997; 171:463467. [51] Harding S and Balarajan R: Patterns of mortality in second generation Irish living in England and Wales: longitudinal study. BMJ 1996; 312:1389-1392. [52] Bhui K and McKenzie K: Final Report. Suicide Prevention for BME groups in England. Final Report from the BME Suicide Prevention Project. London, Centre for Health Improvement and Minority Ethnic Services, 2006 (June). [53] Leavey G: Suicide and Irish migrants in Britain: identity and integration. International Review of Psychiatry 1999; 11:168-172.

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[54] Aspinall PJ: Suicide amongst Irish migrants in Britain: A review of the identity and integration hypothesis. Int. J. Soc. Psychiatry 2002; 48(4):290-304. [55] Johansson LM, Sundquist J, Johansson S, Bergman B, Qvist J, and Traskman-Bendz L: Suicide among foreign-born minorities and native Swedes: an epidemiological followup study of a defined population. Soc. Sci. and Med. 1997; 44(2):181-187. [56] Trovato F: Nativity, marital status and mortality in Canada. Canadian Review of Sociology and Anthropology 1998; 35(1):65-91.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 7

THE EFFECTS OF IMMIGRATION ON THE MENTAL HEALTH OF ADOLESCENTS: DEPRESSION, POST-TRAUMATIC STRESS DISORDER, SUBSTANCE ABUSE, DELINQUENT AND SUICIDAL BEHAVIOR AMONG IMMIGRANT YOUTH Dana Galler1,2 and Leo Sher1 1. Columbia University and New York State Psychiatric Institute, New York, New York, USA 2. Yeshiva University, Stern College for Women, New York, New York, USA

ABSTRACT Immigration populations have generally been associated with elevated rates of mental illness and psychological disorders. And, while a taxing transition to a new country, culture, and environment can be extremely stressful for any immigrant, such stressors become even more dangerous for adolescents, who simultaneously face many physical, cognitive, and socio-emotional changes, including development of autonomy and identity. Studies of immigrant youth have consistently shown that the interaction of these stressors contribute to deteriorations of mental health, excessive amounts of anxiety, experiences of depression, and substance abuse in immigrant youth, putting them at elevated risks for engaging in suicidal behavior. Certain protective factors, however, have been found to boost the psychological resilience of immigrant adolescents, enabling these teens to successfully cope in response to significant risk exposure. Suggestions for successful intervention involve facilitating protective factors such as strong family bonds, peer support systems, and acquisition of the new language in adolescent immigrants.

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INTRODUCTION While accounts of migration as a socio-political phenomenon trace back to the earliest records of civilization, the psycho-social ramifications of such movement on the mental health of immigrants is of particular importance and deserving of extra examination and consideration. In March 2003, the civilian population in the United States included 33.5 million foreign born, representing 11.7 percent of the U.S. population [1]. Today, immigrants make up 1 in 9 U.S. residents, and 1 in 2 new workers. 1 in 5 children in the U.S. is an immigrant or has immigrant parents, and the proportion of students in U.S. schools who are children of immigrants has doubled from 1980-1997, from 10% to 20% [2]. Analyses of migration usually focus on the motivations behind these relocations: the ―push‖ and ―pull‖ pressures whose momentum encourages immigrants to leave their homelands [3]. However, such socio-political analyses of migrations rarely pay adequate attention to the psycho-social after-effects present in these immigrant populations. Successful adjustment to migration is a complex process, affected by the strength of family units [4] and social support networks [5], familiarity with the new language [6-7], and length of residence in the new country [8]. While studies rarely examine change over time in the same cohort [9], theoretical models of migration usually depict acculturation as a chronological, gradual process, with different psychological reactions at different stages [10-12]

IMMIGRATION AS A STRESSFUL EVENT FOR ADULTS AND ADOLESCENTS Immigrant populations have generally been associated with elevated rates of mental illness and psychological disorders [7, 13, 14]. The National Center for Health Statistics has indicated that women who confront the impact of immigration and acculturation report higher levels of depression than women who do not confront such issues and Asian American women over the age of 65 have the highest female suicide rate among all ethnic and racial groups. Studies have also shown that while immigrant women are more at risk for depression, pregnant immigrant women may be at particularly high risk [15]. In addition, Asian American adolescent girls have the highest rates of depressive symptoms of all racial groups and have the highest suicide rate among all women between 15 and 24 years of age [16]. Further, researchers in one recent longitudinal study found that, compared with the general Mexican population, English-speaking Mexican immigrants in the United States are at higher risk for first onset of an anxiety or mood disorder [17]. These findings are consistent with the acculturative stress hypothesis, and indicate that stressors associated with being an immigrant increase risk for psychopathology [18,19], and are also consistent with studies in the US [20] Europe [21], and Australia [22] that have found increased risk for psychotic disorders among immigrants. Indeed, because migrants must often discard many family connections, support systems, and the comforts of the familiar to face new languages, customs, and a loss of social status they are forced to undergo a profound life adjustment [23]. These experiences have the ability to produce anxiety, depression, obsessive behaviors, hostility, and other stress-related reactions in new immigrant populations [24]. A recent study documenting the mental health problems related to migration to Spain found that six of every 10 immigrants receiving health

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care services at the Department of Immigrant Health Services of Cataluna presented depressive symptoms, while 6.5% were diagnosed as having a mental health condition related to grieving for the loss of their country of origin and the stress related to their undocumented status or unemployment [25]. Further, when individuals sense that they are rejected and unwanted by others as a result of immigrant discrimination they tend to experience negative emotions and thoughts: sadness, insecurity, anxiety, self-devaluation, and hostility. These emotions can dilute the emotional strength that is needed to fulfill the tasks related to immigration. [26] Because a vast body of literature has attested to the fact that stressful life events affect the psychological and physical well-being of various populations [27-30], it is not surprising that, in another recent study, adult immigrants who experienced more stressful life events presented progressive deterioration in psychological well-being [26]. While a taxing transition to a new country, culture, and environment can be extremely stressful for any immigrant, such stressors can become even more dangerous to adolescent immigrants, who simultaneously face many physical, cognitive, and socio-emotional changes, including development of autonomy and identity [31-32]. Adolescent immigrants face adaptation to a new culture during a developmental period already characterized by ―rapid changes and redefinitions‖ [32-35]; in addition to meeting these developmental challenges, these adolescents must negotiate the stresses that are inherent in the immigration process. Therefore, psychological distress among immigrant adolescents is particularly acute [7], and is often attributed to immigration-related losses of support and empathy that complicate this process of identity formation [32, 35]. Moreover, the presence of stressors, or environmental events that objectively threaten the physical and/or psychological health or well-being of individuals at a particular age in a particular society [36], can adversely impact this delicate developmental process. These stressors often involve some sort of change in the environment (e.g., family, school, community), usually requiring individuals to adapt. Morevoer, parents may be stressed out and this may also affect their children. Some stressors can exhaust an individual's resources, resulting in maladaptation, such as depression or delinquency. For example, Caribbean youth who migrate to the United States, often alone, without immediate family members, face tremendous stressors during their transition; these stressors significantly impact their identity development and as a result, are detrimental to their mental health [37].

Depression among Adolescent Immigrants These stressors, common to immigrants, become risk factors by increasing the likelihood that a person will experience more serious adverse health outcomes such as depression [37]. It is the interaction of various risk factors which may exist at both the individual level (e.g. genetics, biology, cognition, and behavior) and broader contextual levels (e.g., family, peers, school, and community), which together work to influence the mental health of the individual [38]. Very stressful life events, such as migration, can be conceptualized as risk factors because exposure to these stressors potentially increases the likelihood of a person experiencing poor mental health outcomes [39-40]. Specifically, Immigrant adolescents potentially face three particularly important losses upon moving:

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These stressors can interact to present particularly potent risk factors, a situation which is greatly exacerbated if adolescents and parents do not share similar patterns of acculturation to the new society [46], if the language is difficult to acquire [5, 47], if the immigrant family simultaneously faces financial difficulties [48-49], or if issues of prejudice and discrimination are also present [50, 51, 52, 53-54]. Studies on immigrant youth have continuously shown that the interaction of these risk factors contribute to deterioration of mental health, excessive amounts of stress and experiences of depression in immigrant youth [55].

Co-Morbidity with Depression and other Psychiatric Problems A large body of research in the past decade has indicated that, as a response to life stressors, such as changes in residence and, on a larger scale, immigration, adolescents may not only develop internalizing symptoms such as depression, post-traumatic stress disorder, and anxiety, but may also develop externalizing symptoms such as substance abuse, aggression, and delinquency [55-56, 56-57]. Similarly, heightened levels of stress, resulting from cross-cultural transitions may precipitate a vast array of physical and emotional difficulties such as grief reaction, lowered mental health status, feelings of marginality and alienation, heightened psychosomatic symptom levels, and identity confusion [11, 58-59]. Acculturation, or the process by which the attitudes and/or behaviors of immigrants are modified as a result of contact with their new culture [60], may also have an effect on adolescent delinquency. However, studies examining acculturation as a moderator between immigration and delinquency have yielded inconsistent results [61]; while some studies found that adolescents who were less acculturated were more likely to engage in delinquent behaviors [53], others found that adolescent immigrants who were less acculturated and adhered more to their native values were less likely to be delinquent [54]. The recent sociological literature has questioned whether classical theories of immigrant adaptation, which assumed assimilation to be an integral part of the process of upward mobility for immigrants, are still applicable to today‘s immigrant youth. One theory that has emerged from this debate is segmented assimilation theory. This theory makes two main contentions: It argues that the effects of assimilation depend on the local context, and also that immigrants can choose whether to fully assimilate. However, the theory does not explicitly link these two contentions. International literature on immigration has shown that among immigrants, substance abuse may increase when it is used as a coping response to the stress associated with adaptation to the new society [62-63], and that this substance abuse may also be more pronounced if the immigrants acculturate into a more permissive society, abandoning the more traditional or conservative values of their former culture [62, 64-65]. Among adolescent immigrants, these two pathways may collide as youths may adopt pro-drug attitudes and

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behaviors as both a way of dealing with stress and as a result of their exposure and acculturation to a new society. [66-67]. At the same time, immigrants do seem to enjoy various inherent protections against substance abuse not shared by their native counterparts [68], as a result of greater social isolation, less developed peer groups and a lack of familiarity with local drug networks. For example, the so called ―Immigrant Paradox,‖ illustrated in several studies of United States Hispanics have shown that foreign-born Hispanics actually display better mental health and lower rates of cigarette, alcohol and drug use than their second or third generation United States-born Hispanic counterparts [69-70]. This is true despite the fact that foreign-born Hispanics, having faced immigration stresses and life disruptions, would seem to be more likely to report such substance abuse. Researchers explain this ―Immigrant Paradox‖ by pointing to both the deterioration of cultural and Hispanic family values, attitudes and behaviors [71], and the more prevalent exposure to illicit substances in the United States than in the immigrant host country [72].

Suicidal Behavior in Adolescent Immigrants This immigration-related depression coupled with substance abuse can often, unfortunately, result in elevated levels of suicide in an adolescent population.Prior research has associated substance use with an increased risk of suicide among youths [75]. According to the National Household Survey on Drug Abuse (NHSDA), youths who reported alcohol or illicit drug use during the past year were more likely than those who did not use these substances to be at risk for suicide during this same time period. For instance, youths who reported past year use of any illicit drug other than marijuana (29 percent) were almost three times more likely than youths who did not (10 percent) to be at risk for suicide during this time period [76] Further, adolescents who suffer from depression are at much greater risk of committing suicide than are children without depression [77]. Because suicide is the third leading cause of death for adolescents between the ages of 15 and 19 in the United States, a determined effort to reduce the number of suicide attempts among adolescents has become a national priority [76]. Because in the United States, first, second and third generation immigrant Latino adolescents, especially females, report higher rates of suicide attempts than their white or African-American counterparts [76], this population would seem to be an especially fertile target for psychological intervention. The association between immigrant generation status, suicide, and suicidal behavior has been replicated in representative samples of Latinos, and studies have found that more acculturated Latinos had higher rates of successful suicide than their less acculturated counterparts [78]. This association seems logical, considering that depression, problematic alcohol use, and illicit drug use, problems endemic to adolescent immigrants, are also three of the most important indicators in suicidal behavior [26]. Indeed, the strong association between these three immigration factors and suicide attempts among adolescents, has been replicated across multiple studies [78], suggesting that depressive symptoms, problematic alcohol use, and illicit drug use, resulting from increasing acculturation in subsequent generations of immigrant Latinos, may partially account for the elevated rates of suicidal behavior among United States-born descendants of Latino immigrants [26].

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RECOMMENDATIONS FOR ADOLESCENT IMMIGRANT INTERVENTIONS Despite some of the research cited above, not all adolescents exposed to stressors, such as immigration, experience behavioral problems. Certain protective factors have been found to boost the psychological resilience of immigrant adolescents [79], enabling these teens to successfully cope in response to significant risk exposure [80]. Therefore, it becomes necessary to examine not only the risk factors, but also the protective factors which have the potential to enhance a person‘s capacity to face adversities and transcend life difficulties [79]. Protective factors, such as strong family and peer social support systems and greater knowledge of and familiarity with the host language, may produce stronger levels of selfesteem, self-efficacy and moderate the potentially dangerous effects of correlated stressors [80]. Studies have suggested that achievements in schools, bonding with teachers, caring and supportive relationship from parents, supportive peer relationship, good problem-solving skills, positive sense of self-efficacy and positive outlooks are some of the major protective factors influencing the mental health of youths [27]. Such social support consistently appears to be an important protective factor, which can enhance the mental health of immigrant adolescent populations [5]. Social support from family, peers, school, or community has been proven effective in attenuating the impact of stressful life events on behavior [81-83]. ). In fact, researchers have indicated that it is the lack of social support associated with immigration that is related to higher levels of reported stress [90]. For example, in a Canadian study, parental attitudes toward new experiences affect the ability of their immigrant children to adapt to school [91]. An Israeli study showed that in immigrant families from the former Soviet Union (FSU), adolescents‘ perception of their family functioning predicted their functioning [92]. Moreover, studies have shown that adolescents do not have a peer support system to buffer their stresses isolated from a peer group are more susceptible to developing poor mental health [93]. Carefully identifying these various sources of social support is crucial in designing effective methods for strengthening those support systems [7].

Family Support Family interaction as a key factor that effects the adjustment of immigrants [4, 6-7].This logical association is consistent with many studies that have demonstrated that individuals in well-functioning families tend to present good psychosocial adjustment [89-92]. Moreover, among adolescents in particularly stressful situations, family cohesion can protect boys from developing behavioral problems [83] and can be a protective mental health factor for children who experience chronic illness [81]. Consistent with the notion that healthy family support systems are vital in securing the mental health of immigrant adolescents, parental conflicts are considered a major risk factor [7, 44], of psychological distress among these youths [7]. By minimizing the negative impact of stressors on adjustment, these family relations provide a buffering effect on the potentially deleterious effects of stress experience during development and therefore become an effective predictor of successful adjustment for adolescent immigrants [26]. The nuclear family is an essential element in society, traditional education and parental involvement in that education

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are important; a strong family unit creates a safe, positive and supportive place for all members to thrive. They are able to utilize resources and to live together in a fairly healthy manner. Parents should talk to their children about the importance of honesty, integrity, forgiveness, generosity, caring, conservation, respect for the earth and other forms of life, etc. A recent study has demonstrated that changes in adolescent self-esteem between the first year of immigration and two to four years later were significantly related to family relations: the better the relations, the greater the improvement in self-esteem, suggesting that family relationships have a significant impact on the long-term adjustment of immigrants, particularly on these adolescents‘ feelings of self-esteem [26]. It is imperative, therefore, for intervention programs to focus on fostering and encouraging strong family bonds by fully involving parents in the process of their child‘s adjustment. This can be accomplished via joint meetings, family group meetings, and workshops for parents [26]. It would be clearly beneficial for social workers and community organizers to plan programs for parents, such as local conferences and workshops, which address coping skills and solutions, marital interaction, parent–child communication, as well as skills for increasing family support and solidarity in the face of adversity and difficult circumstances [26].

Peer Support Aside from family members, the most important sources of support in the immigrant youth population are peers [26]. Peer support is an important element in determining the mental health of recent adolescent immigrants [93], and might be even more influential than parental support [7]. Further, success in both initiating and maintaining interpersonal relationships has the additional potential to evoke supportive responses from others and increase one‘s sense of self-efficacy [94]. Regretfully, immigrant adolescents who do not develop these good interpersonal relationships and therefore lack a strong peer support system to buffer their stresses, become more susceptible to developing poor mental health [95]. First generation adolescents are less likely to enter romantic relationships than adolescents in native-born families, but those who do participate engage in similar sex-related activities as native-born youth (King and Harris, 2007). Similarly, research has suggested that supportive peer relationships, good problem-solving skills, positive outlooks, and a positive sense of self-efficacy are some of the major protective factors influencing the mental health of youths [7]. Concerted efforts should therefore be made to ensure that special peer support groups are initiated to help these immigrants cope with stressful life events associated with adjustment and to bond and form a peer network support system with other adolescents facing the same issues. Similarly, immigrant adolescents should be carefully followed by social practitioners and educators since their mental health is at greater risk of deteriorating over the years [26].

Language Immersion Acquisition of language fluency is a vital potential protective factor in immigrant youth [7, 26]. While some adolescents may know the language of the country to which they immigrate: a) they studied this language in their home country, or b) their language is the

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same as the language in the new country (e.g., South American immigrants in Spain or Australian immigrants in the U.S.), many immigrant school age adolescents around the world face language barriers [50, 96-], a risk factor which can produce stress, generate feelings of lowered self-esteem, and make it harder to develop the peer network desperately needed. Indeed, these language barriers often force otherwise intelligent immigrant adolescents to study at one to two grades lower than their peers [97], creating a situation which can be potentially demoralizing [98]. A recent study examining the impact of individual, familial, and environmental factors on the adjustment of adult and adolescent immigrants found that the initial conditions of the immigrants with regard to varying aspects of language proficiency was highly significant in predicting the process of healthy adjustment over time [26]. In order to assuage this potentially potent risk factor, language immersion programs and curriculums must be developed to enable immigrant adolescents to adapt to and acquire language proficiency as quickly and smoothly as possible [26].

CONCLUSION While immigration populations have generally been associated with elevated rates of mental illness and psychological disorders [7, 13,14], recent research has indicated that stressors associated with such immigration become even more dangerous for adolescents, who simultaneously face many physical, cognitive, and socio-emotional changes, including development of autonomy and identity [31-32]. These problems may be further exacerbated and underscored when there is comorbidity with excessive amounts of anxiety, experiences of depression, and substance abuse in immigrant youth [55] and can even place them at elevated risks for engaging in suicidal behavior [26, 78]. However, not all adolescents exposed to stressors, such as immigration, experience behavioral problems. Certain protective factors have been found to boost the psychological resilience of immigrant adolescents [79], enabling these teens to successfully cope in response to significant risk exposure [80]. Social support, especially from family, peers, school, or community [77-79] has consistently appeared to be an important protective factor, which can enhance the mental health of immigrant adolescent populations [5]. Carefully identifying these various sources of social support, evaluating their importance, and creating effective intervention and protective programs to foster such relationships is therefore imperative in order to reduce the risks faced by immigrant adolescent populations.

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US Census Bureau. The Foreign-Born Population in the United States: March 2003. (2003). http://www.census.gov/prod/2004pubs/p20-551.pdf. Morse, A. (2004, June 17). A Quick Look at U.S. Immigrants: Demographics, Workforce, and Asset-Building. http://www.ncsl.org/Default.aspx?TabId=13146 Briggs Jr., V. M. (1994). The Administration of U.S. Immigration Policy: Time For Another Change. The Social Contract, 2, 192-193.

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Jasinskaja-Lahti, I., and Liebkind, K. (2001). Perceived discrimination and psychological adjustment among Russian-speaking immigrant adolescents in Finland. International Journal of Psychology, 36, 174-185. Meadows, S. O., Brown, J.S. and Elder, G.H. (2006) ‗Depressive symptoms, stress, and support: Gendered trajectories from adolescence to young adulthood‘, Journal ofYouth and Adolescence, online publication at www.springerlink.com Slonim-Nevo, V., Mirsky, J., Rubinstein, L., and Nauck, B. (2009, January). The impact of familial and environmental factors on the adjustment of immigrants: A longitudinal study. Journal of Family Issues, 30(1), 92-123. Wong, D. (2008, February). Differential impacts of stressful life events and social support on the mental health of mainland Chinese immigrant and local youth in Hong Kong: A resilience perspective. British Journal of Social Work, 38(2), 236-252. Slutzki, C. (1979). Migration and family conflict. Family Process, 18, 379-390. Hener, T., Weller, A., and Shor, R. (1997). Stages of acculturation as reflected by depression reduction in immigrant nursing students. International Journal of Social Psychiatry, 43, 247-256. Akhtar, S. (1999). Immigration and identity. Northvale, NJ: Jason Aronson. Berry, J. W. (1992). Adaptation and acculturation in a new society. International Migration, 30, 69-86. Grinberg, L., and Grinberg, R. (1999). Psychoanalytic perspectives on migration. In D. Bel (Ed.), Psychoanalysis and culture (pp. 154-169). 13. Marsiglia, F.F., et al., 2004. Ethnicity and ethnic identity as predictors of drug norms and drug use among preadolescents in the Southwest. Substance Use and Misuse, 39 (7), 1061_1094. Pernice, R., and Brook, J. (1994) ‗Relationship of migrant status (refugee or immigrant) to mental health‘, The International Journal of Social Psychiatry, 40, pp. 177–188. New York: Rutledge. Franks, R., and Faux, S. A. (1990). Depression, stress, mastery, and social resources in four ethnocultural women‘s groups. Research in Nursing and Health, 13,283–292. National Center for Health Statistics, Centers for Disease Control and Prevention. (1994). Health, United States 1995. Hyattsville, MD: U.S. Public Health Service. J. Breslau, S. Aguilar-Gaxiola, G. Borges, R.C. Castilla-Puentes, K.S. Kendler, M.E Medina-Mora, M. Su, and R.C. Kessler, Mental disorders among English-speaking Mexican immigrants to the US compared to a national sample of Mexicans, Psychiatry Research 151 (2007) pp. 115-122. Rogler et al., 1991 L.H. Rogler, D.E. Cortes and R.G. Malgady, Acculturation and mental status among Hispanics: convergence and new directions for research, American Psychologist 46 (1991), pp. 585–597. B.F. Grant, F.S. Stinson, D.S. Hasin, D.A. Dawson, S.P. Chou and K. Anderson, Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic whites in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions, Archives of General Psychiatry 61 (2004), pp. 1226–1233.

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[19] Malzberg and E.S. Lee, Migration and Mental Disease: A Study of First Admissions to Hospitals for Mental Disease, New York, Social Science Research Council, New York (1956), pp. 1939–1941. [20] E. Cantor-Graae and J.P. Selten, Schizophrenia and migration: a meta-analysis and review, American Journal of Psychiatry 162 (2005), pp. 12–24. [21] J. Krupinski and A. Stoller, Incidence of mental disorders in Victoria, Australia, according to country of birth, Medical Journal of Australia 2 (1965), pp. 265–269. [22] Marsiglia, F.F., et al., 2004. Ethnicity and ethnic identity as predictors of drug norms and drug use among pre-adolescents in the Southwest. Substance Use and Misuse, 39 (7), 1061_1094. [23] Escobar, J., Hoyo-Neri, C., and Gara, M.A., 2000. Immigration and mental health: Mexican Americans in the United States. Harvard Review of Psychiatry, 8 (2), 64_72. [24] Jansa , J.M. and Borrell, C., 2002. Inmigracio´n, desigualdades y atencio´n primaria: situacio´nactualy prioridades [editorial]. Aten Primaria, 29, 466_468. [25] Slonim-Nevo, V., Mirsky, J., Rubinstein, L., and Nauck, B. (2009, January). The impact of familial and environmental factors on the adjustment of immigrants: A longitudinal study. Journal of Family Issues, 30(1), 92-123. \ [26] Hammen, C. (2005). Stress and depression. Annual Review of Clinical Psychology, 1, 293-319. [27] Lantz, P. M., House, J. S., Mero, R. P, and Williams, D. R. (2005). Stress, life events, and socioeconomic disparities in health: Results from the Americans‘ Changing Lives Study. Journal of Health and Social Behavior, 3, 274-288. [28] Monroe, S. M., and Harkness, K. L. (2005). Life stress, the ―kindling‖ hypothesis, and the recurrence of depression: Considerations from a life stress perspective. Psychological Review, 112, 417-445. [29] Monroe, S. M., Torres, L. D., Guillaumot, J., Harkness, K. L., Roberts, J. E., Frank, E., et al. (2006). Life stress and the long-term treatment course of recurrent depression: III. Nonsevere life events predict recurrence for medicated patients over 3 years. Journal of Consulting and Clinical Psychology, 74, 112-120. [30] Bibb, A., and Casimir, G. (1996). Haitian families. In M.McGoldrick, J.Giodano, and J. K.Pearce (Eds.), Ethnicity and family therapy (pp. 97–111). New York: Guilford. [31] Papalia, D. E., and Olds, S. W. (1995) Human Development, New York, McGraw-Hill. [32] Erikson, E. H. (1968). Identity: Youth and crisis. New York: Norton. [33] Rosenberg, M., Schooler, C., and Schoenbach, C. (1989). Self-esteem and adolescent problems: Modeling reciprocal effects. American Sociological Review, 54, 1004-1018. [34] Gottesfeld, J., and Mirsky, J. (1991). To stay or return: Rapprochement manifestations in the migration of adolescents and young adults. Journal of Contemporary Psychotherapy, 21, 273-284. [35] Grant KE, Compas BE, Stuhlmacher AF, Thurn AE, McMahon SD, Halpert JA: Stressors and child and adolescent psychopathology: moving from markers to mechanism of risk. Psychology Bull 2003; 129:447–466. [36] Bibb, A., and Casimir, G. (1996). Haitian families. In M.McGoldrick, J.Giodano, and J. K.Pearce (Eds.), Ethnicity and family therapy (pp. 97–111). New Y27. Smith, E. J. (2006) ‗ The strength-based counseling model‘, The Counseling Psychologist,34 (1), pp. 13–79.

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[37] Shortt, A. L. and Spence, S. H. (2006) ‗Risk and protective factors for depression in youth‘, Behaviour Change, 23 (1), pp. 1–30. [38] Luthar, S. S. (2000) ‗The construct of resilience: A critical evaluation and guidelines for future work‘, Child Development, 71 (3), pp. 600–616. [39] Stuart, H. (2006) ‗Psychosocial risk clustering in high school students‘, Social Psychiatry and Psychiatric Epidemiology, 41, pp. 498–507. New York: Guilford. [40] Goodenow, C., and Espin, O. (1993). Identity choices in immigrant adolescent females. Adolescence, 28, 183-184. [41] International Social Service Hong Kong Branch (1997) A study on The Chinese New Immigrants in Hong Kong, Hong Kong, International Social Service Hong Kong Branch. [42] Beiser, M., Dion, R., Gotowiec, A., Hyman, I., and Vu, N. (1995). Immigrant and refugee children in Canada. Canadian Journal of Psychiatry, 40, 67-72. [43] Hepperlin, C. (1991). Immigrant adolescents in crisis: A model for care. In B. Ferguson and E. Browne (Eds.), Healthcare and immigrants (pp. 122-145). Sydney, Australia: McLeannon and Petty. [44] Rosenthal, D. (1984). Intergenerational conflicts and culture: A study of immigrant and nonimmigrant adolescents and their parents. Genetic Psychology Monographs, 109, 5375. [45] Kim, E., Cain, K., and McCubbin, M. (2006). Maternal and paternal parenting, acculturation, and young adolescents‘ psychological adjustment in Korean American families. Journal of Child and Adolescent Psychiatric Nursing, 19, 112-129. 41. [46] International Social Service Hong Kong Branch (1997) A study on The Chinese New Immigrants in Hong Kong, Hong Kong, International Social Service Hong Kong Branch. [47] Hankin, B. L. (2005) ‗Adolescent depression: Description, causes and interventions‘, Epilepsy and Behavior, 8 (1), pp. 102–114. [48] The Hong Kong Federation of Youth Groups (1995) The Population Poser: How Do Young New Arrivals from Mainland China Adapt? Hong Kong, The Hong Kong Federation of Youth Groups. [49] Yeh, C. J., Arora, A. K., Inose, M., Okubo, Y., Li, R. H. and Greene, P. (2003) ‗The cultural adjustment and mental health of Japanese immigrant youth‘, Adolescence, 38 (151), pp. 481–500. [50] Chan, D. (1998) ‗Stressful life events, cognitive appraisals, and psychological symptoms among Chinese adolescents in Hong Kong‘, Journal of Youth and Adolescence, 27 (4), pp. 457–473. [51] Hyekhung, C. (2005). Stress process of adjustment problems among adolescents in immigrant families: Generational differences. Dissertation Abstracts International: A. 49. [52] Lim KV, Levenson M, Go CG: Acculturation and delinquency among Cambodian male adolescents in California. Netherlands: Swets and Zeitlinger Publishers; 1999. p. 231– 244.

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[53] Bankston CL III, Zhou M: Valedictorians and delinquents: the bifurcation of Vietnamese American youth. Deviant Behav. 1997; 18:343–364. [54] Chan, J. (1999) A Survey Study on The Psychological Adaptation of Newly Arrived Students from Mainland China, Hong Kong, Aberdeen Kai-Fong Welfare Association Social Service Centre. [55] West SG, Sandler I, Pillow DR, Baca L, Gersten JC: The use of structural equation modeling in generative research: toward the design of a preventive intervention for bereaved children. American Journal of Community Psychology 1991; 19:459–480 [56] Youngstrom E, Weist MD, Albus KE: Exploring violence exposure, stress, protective factors and behavioral problems among inner-city youth. American Journal of Community Psychology 2003; 32:115–129

PART II ACCULTURATION AND MENTAL HEALTH

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 8

ACCULTURATION AND MENTAL DISORDERS AMONG IMMIGRANTS Michael G. Madianos University of Athens Department of Mental Health and Behavioral Sciences School of Health Sciences Athens, Greece

ABSTRACT Acculturation an anthropological term introduced by Redfield, Linton and Herskovitch ―comprehends those phenomena which result when groups of individuals having different cultures come into continuous, first hand, contact with subsequent changes in the original culture of either or both groups‖. Acculturation has been considered to be a cause of stress related psychopathological symptoms, as a result of immigrants continuous but unsuccessful efforts for social integration, acceptance and marginalization, in their host country. In this chapter the literature for the past thirty years related to research on acculturation and the prevalence of mental disorders will be reviewed in the light of the theoretical framework on immigration and psychopathology.

1. INTRODUCTION The continuous growth of international migration has been accompanied by the expansion of sociopsychiatric research, since social mobility has long been linked to a variety of psychosocial problems and increase of psychiatric morbidity [1-18]. One of the emergent issues in the studies on immigrant and mental health, is the role of culture either as a health risk or a protective factor, and particularly the phenomenon of acculturation [7, 16, 19-34]. Acculturation an anthropological term introduced by Redfield, Linton and Herskovitch [35] ―comprehends those phenomena which result when groups of individuals having

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different cultures come into continuous, first hand, contact with subsequent changes in the original culture of either or both groups‖. In the forties and fifties several social anthropologists explored the process of acculturation among tribes of Amerindians and Eskimos. Since the sixties in a parallel way, a number of social and behavioural scientists have conducted studies on acculturation and mental health among immigrant groups, mainly in USA and later in Western Europe (UK, Germany, Scandinavian countries). In the literature there are predominant two explanatory models of the process of acculturation, the unidimensional and the bidimensional model, both connected with the formation of acculturation stress.

2. THE UNIDIMENSIONAL MODEL This is the socioanthropological approach of the phenomenon of acculturation, dominating the relevant research in post war era. However social scientists in the early 1900s offered various theories related to immigrants adaptation. The most notable model was developed from the ecological school of thought [36]. The sociologist Park [14] proposed first a linear and directional model leading to marginalization of the immigrant. The unidimensional model may include three domains first the adaptation to technical culture of the lost country and secondly the acculturation process in the local social organization, including mastery of host country‘s language use, social contacts (at work, communication with homeland, participation in local societies, friends among the ethnic group or not, shopping from ethnic stores, ethnic density of neighborhood) social preferences in everyday cuisine, in music, in family or religious celebrations, in choosing a health professional, in news reading and finally in cultural values (beliefs in stereotypes and ethnic identity). Strong ethnic orientation expression of these homebound values indicate cultural ethnic orientation (e.g. ethnocentrism and lack of acculturation).

3. THE BIDIMENSIONAL MODEL The acculturation bidimensional model constructed by Berry [28] gives more room to psychological adaptation and refers to the group and the individual level. The factors in the group level are the country of origin e.g. individualistic or collectivistic societies and the receiving country‘s culture both influencing the group in terms of acculturation. At the individual level there are two kind of moderators (variables) those before and the ones during acculturation. Those variables along with those of the group level factors, have an effect on the psychological acculturation and the consequent behaviour changes, the acculturative stress, related psychopathology and marginalization. The psychological acculturation leads to psychological, sociocultural and economic adaptation. In the latter the moderator variables (at the individual level) have supposingly also an effect. At the group level factors, the sociocultural and political characteristics of the country of origin and the immigration social policy of the host country, play an important role in the acculturation process of the immigrant group. At the individual level the moderator variables before acculturation could include ethnicity, gender, age, education, motivation for

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immigration, voluntary or forced (traumatic) immigration. The moderators during immigration are the length of stay, the residence area with or without their ethnic group, the use of host or mother language, the development of relations with their own ethnic group only or with the natives. Conclusively Berry [37] suggests that the process of acculturation is analogous to psychological models of moving towards or against and away from a stimulus.

4. ACCULTURATION AS A CAUSE OF STRESS RELATED MENTAL DISORDERS Acculturation as a phenomenon that results when individuals having different cultures, come into continuous contact and experience subsequent changes in their original cultures with corresponding cognitive styles and behavioural patterns [16, 38]. These changes have been identified either as ―risk factors‖ or protective mechanisms [7, 21, 24, 26, 27, 29-34]. The majority of these studies have suggested that when foreign immigrants become acculturated to their host society culture, increases the risk of a mental disorder or unhealthy behaviour. Acculturation stress is a chronic strain and a result of immigrants‘ continuous and unsuccessful efforts for social integration and acceptance by the host population, leading to identity crises, feelings of frustration and subsequent aggression directed toward themselves or others [38, 39]. The domains of acculturation (language, entertainment, food and shopping habits, festivities and cognitive styles) are closely linked with cultural identity and selfesteem. Therefore, acculturation efforts are likely to be related to greater exposure to stressors linked to loss of cultural identity, alienation and demoralization. The latter is a condition that is likely to be experienced by socially marginal groups such as migrants [40, 41]. The individual suffers from feelings of anxiety, discouragement, hopelessness, helplessness and depression. These symptoms of distress do not constitute a specific nosological entity but among these individuals who are exhibiting these psychopathological symptoms these cases of clear cut psychopathology, mainly suffering from mood disorders (major depressive episode), anxiety disorders (generalized anxiety disorder) and drugs or alcohol abuse and addiction. Rejection and deculturation (loss of identity, alienation and acculturation stress) are the possible outcome of the exposure between two cultures. The inversion of the relationship between high acculturation and psychological impairment, reported by many investigators, has been questioned by several others [21, 29, 32, 34, 42-45]. All these studies suggested that the adoption of an integrative mode of acculturation is linked with better psychological adjustment and mental health of the immigrant. It becomes evident that acculturation of the immigrant to the host country‘s cultural values and social organization is a rather complex phenomenon, which includes factors such as motives for immigration, preacculturation, the translocation stress, the type of the native society (individualistic versus collectivistic), the density of the immigrant group, and the support system in the host country, which may play a crucial role in the process of acculturation ant the corresponding distress.

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Table 1. The relationship between acculturation and mental disorders in immigrant population in selected publications >1980 Author (s)

Year of Publication (1981)

Age range >20

Ethnic group Mexican Americans in USA M+F Greeks in USA M+F

Instrument

Results

Acculturation Rating Scale for Mexican Americans Greek Immigrant Acculturation Scale

Mexican Americans in USA M+F US Hispanics M+F

Acculturation Rating Scale for Mexican Americans Acculturation Scale

Greek Cypriots in England M+F Mexican Americans in USA M+F Greek Cypriots in England M+F Third world immigrants in Norway M+F

Greek Immigrant Acculturation Scale (modified) Acculturation Scale

No relation between severity of psychopathology and acculturation The more acculturated manifested higher degree of psychological impairment Acculturation was associated with increased rate of psychiatric disorders Acculturation was associated with higher frequency of drinking Highly acculturated males were found to be mentally impaired Acculturated younger Mexican-Americans were found to be more distressed The less acculturated manifested a higher level of psychological distress Acculturation stress was found to exist among children although having to migrate or being born in Norway was not related to mental health status Low acculturation among Hawaiians did not correlate with any measure of psychosocial pathology Most newly arrived Amerasians experience acculturative stress Women who were the heaviest alcohol drinkers were also the least acculturated Respondent highly acculturated during their stay in the host country were found to be mentally impaired during their repatriation in their native country

1.

Cuellar et.al [24]

2.

Madianos [7]

(1984)

20-59

3.

Burham et al. [25]

(1987)

>18

4.

Caetano R. [26]

(1987)

18-65

5.

Mavreas and Bebbington [42] Kaplan and Marks [27]

(1990)

18-64

(1990)

30-74

7.

Adamopoulou [43]

(1990)

16-65

8.

Sam and Berry [44]

(1995)

10-17

9.

Streltzer et al. [58]

(1995)

19-65

Hawaiians and not Hawaiians M+F

Na Med Hawai‘i Scale

10.

Nwadiora and Mc Adoo [46]

(1996)

30-55

Amerasians M+F

11.

Hines et al. [29]

(1998)

18-29

12.

Madianos et al. [47]

(1998)

39-75

African American women M+F Greeks former immigrants repatriated in rural area of Greece M+F

Refugee Acculturation Stress Inventory Acculturation Adaptation to US mainstream Society Scale Greek Immigrant Acculturation Scale

13.

Ortega et al. [30]

(2000)

15-54

6.

Hispanics in USA from Nat.

Greek Immigrant Acculturation Scale (modified) Acculturation Questionnaire

Acculturation rating Scale

The more acculturated were more likely to

Acculturation and Mental Disorders among Immigrants Comorbidity study M+F AsianAmerican adolescents M+F

14.

Hahm et al. [31]

(2003)

12-17

15.

Mc Lachlan et al.[45]

(2004)

19-65

Irish in Dublin M+F

Acculturation and Social Change Questionnaire

16.

Oppedal et al. [46]

(2004)

14-17

Acculturation and Ethnic Identity Crisis Scale

17.

Lau et al.[32]

(2005)

Immigrant adolescents in Oslo, Norway M+F American families Mexican

18.

Virta et al. [59]

(2004)

Structured Questionnaire

19

Kim et al. [33]

(2006)

Turkish adolescents in Norway and Sweden M+F Korean American families

20.

Campos et al. [60]

(2008)

25-55

Females Hispanics in California

Structured Questionnaire

21.

Madianos et al. [34]

(2008)

20-60

Immigrant Acculturation Scale

22.

Karriker-Jaffe and Zemore [49]

(2009)

>18

Foreign immigrants in Athens, Greece M+F Mexicans in USA M+F

23.

Gul and Kolb [50]

(2009)

21-24

Turkish patients in Germany M+F

Acculturation Questionnaire

14-16

Acculturation Questionnaire

Structured Interview

Structured Questionnaire

Structured Questionnaire

105

exhibit higher prevalence of mental disorders and substance use The odds of alcohol use were 11 times greater in the highly acculturated group The more acculturated were getting better in terms of their mental health Ethnic identity crisis was positively correlated with all psychiatric problem categories More conduct problems occurred in families in which the adolescent member was more aligned with traditional culture than the paren Poorer adaptation and mental health of Turks in Norway was related to lower degree of Turkish identity Maternal acculturation moderated the relation between mother‘s reports of maternal acceptancerejection and young adolescents report of their psychological adjustment Low acculturation was not a significant predictor of mental health but had a protective effect with regard to substance abuse High acculturation level was correlated with low number of depressive symptoms Men at high levels of acculturation were more likely to be drinkers but only if they had above average income Depression was related with high level of acculturation when other family members had conflicts of adaptation

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Michael G. Madianos

5. A REVIEW OF SELECTED STUDIES ON ACCULTURATION AND MENTAL HEALTH In table 1 several studies on the relationship between acculturation and mental health in immigrant groups in USA and Europe are presented. These studies have been published since 1980 and these were carried out in representative immigrant groups of all ages with the use of standarardized instruments. Out of 23 studies only one reported no relation between severity of psychopathology detected in the sample and the level of acculturation. In more than half (60%) of the publications listed in table 1, high levels of acculturation of their samples were found to be related to the increased prevalence of psychopathological symptoms or specific psychiatric problems or disorders mainly depression and alcohol abuse. Only five studies reported that low levels of acculturation were found to be linked with high prevalence of mental disorders. For the rest of the studies, the investigators of three studies reported that high levels of acculturation were related with well-being and in one study low level of acculturation was found to be related with better mental health.

DISCUSSION Several investigators confirmed the hypothesis that the process of acculturation is causing stress related mental disorders [7, 25-27, 30, 42, 46-50]. The acculturation stress induced psychopathological mechanism has already been described. However the inverse relationship between acculturation level and demoralization (anxiety and depressive symptoms) has been reported by several others. Adamopoulou et al. [43] reported that the less acculturated Greek Cypriots living in London, England, manifested a higher level of psychopathological disturbance. Sam and Berry [44] examined the relationship between acculturation and emotional disorders among young immigrants in Norway and found out that a stressful acculturative experience alone could account for only 1% of the self-reported depressive symptoms. Another study explored the role of acculturation on alcohol consumption and risky sexual behavior among African American women [29]. The results indicated that women who were the heaviest drinkers were also the least acculturated. However, risky sexual behaviour was related to high acculturation levels. Two other studies reported that higher levels of acculturation are linked to better mental health status. McLachlan et al. [45] found a significant relationship between temporal higher acculturation and better mental health of Irish general population individuals. Lau et al. [32] tested the acculturation gap-distress hypothesis by examining whether parent-adolescent acculturation gaps were associated with greater risk of problems among Mexican American families. Greater discrepancies in children‘s acculturation compared to their parents‘ acculturation were not found to be related to increased conduct problems. More frequent conduct disorders were prevalent in families in which the youth was less acculturated than the parent.

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In a recent study with foreign immigrants living in a greater Athens area the main finding was that the higher the degree of acculturation of the immigrant individuals, the lower the number of CES-Dscale depressive symptoms were suffering [34, 51]. It seems that better mental health of immigrants is linked to the adoption of an ―integration‖ mode of acculturation, rather than the rejection of the host culture [21, 52, 53]. Nevertheless the phenomenon of acculturation is a multidimensional and a complex one. It may affect health behaviors and well being as a consequence of continuous striving efforts of the immigrant, coping with the immigration traumatic experiences, like discrimination, racism and poverty, change or loss of identity as well as lack of social support, exposure to different beliefs, cultural values and norms, concerning also particular patterns of health behaviours (drinking, smoking, taking illicit drugs). The question is to what extend the various components of the acculturation process could be beneficial and protective for the immigrant individual and his/her family members? According to the bidimensional model of the acculturation process of Berry [28], several variables at both group and individual levels, could be considered as protective from the acculturation stress. At immigrant group level, the sociocultural structure of country of origin may play important role in the group process of acculturation. For example if the country of origin is of that of collectivist society where people from birth onwards are cohesively integrated living in a protective environment from aggression from outsiders, building a collective ethnic identity, group inter-dependence and solidarity, sharing stable family ties and friendships and the host country is of that of individualist one, supporting autonomy, selfsufficiency and respecting the rights of others, in a spirit of liberarism, the immigrant coming from traditionalism to individualism and liberarism, probably will face several difficulties to be adapted first and then acculturated. The ideal case is that both native and host countries to be of the same sociocultural structure and congruent. At individual level, the moderator/ protective variables before acculturation could be considered sociodemographic factors, younger age, higher education, voluntary immigration, pre-migration political status e.g. non traumatic exposure, knowledge of the host language, motivation for immigration being preacculturated e.g. preacceptance of the way of life of the host country. The moderator/protective variables during the acculturation process could include length of stay in the host country the financial security, bilingualism, family solidarity and support, living in high ethnic-density neighborhood (avoiding alienation), biculturarism (feeling comfortable from both cultures) and therefore being part of both cultures, preventing marginalization which leads to symptoms of distress. There is little doubt that there are cultural variables with a beneficial effect on health and mental health of the immigrant exposed to a different dominant culture. However some of them are uncontrolled. There are variables unavoidable in terms of their effect like the one of the sociostructural dissonance of the native and host societies. We don‘t choose the place to be born and raised. Another case is of that of the pre-migration trauma. Furthermore several ―protective‖ variables during the acculturation process are to be questioned. To live in ethnicdensity-neighborhoods is not always linked with better wellbeing. Ethnic enclaves are often transformed into slums or ghettos where poverty, unemployment, poor housing conditions and high crime are prevalent. On the other hand there are studies showing that the incidence rate of schizophrenia for immigrants was significantly increased in low ethnic density neighborhoods [54, 55].

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The issue of family solidarity and support is unquestionable. However it is not surprisingly that there are very traditional families demanding unbearable sacrifices from their members, raising reaction from non fanatics or the local community e.g. forced marriage in young ages. Moreover, the prevention of acculturation stress is affected by the complexities of culture and health related social policy and political factors. The Cubans in the 60‘s and 70‘s fleeing the Castro regime, in USA were well taken care by the US immigration policy programs and Cubans were among the most healthy of all Latino groups in USA [56]. It is basic to understand the context in which ongoing cultural and socioeconomic changes take place and the dynamics that reproduce according to the complexities of the dominant culture settings in which immigrants find themselves. Nevertheless cultural identity is one of the key determinants of mental health status of immigrant individuals. The question is how protective is the adoption of both cultural identities, of that of native and the host culture. Biculturism as cultural orientation could be, to a certain degree, beneficial to immigrants coping process with the strain. Biculturism is a common phenomenon exceeding the personal attitude of the immigrant and covers greater parts of both cultures mainly in the areas of language (both languages often spoken) folklore (ethnic food and music are fashionable) and traditional rituals (spiritual healing, psychic activities are accepted). Biculturism progressively leads to segmented assimilation. The segmented assimilation theory [57] refers to diverse patterns of adaptation, whereby the immigrant adopts the attitudes and cognitive style (values, beliefs) and consequently behaviours of divergent cultural group. For example second generation minority group follow a standard pattern of acculturation-assimilation to middle class majority group. The question is if this kind of acculturation process has a non deleterious effect on health and immigrant.

CONCLUSION In sum acculturation process is linked with the mental health status of the exposed immigrants in the host culture. Several studies confirmed that acculturation process is related to stress related mental disorders under certain psychological, social, political and ecological (the immigrant group density) conditions as well as the social support system and policy. However this view is not unidimensional. Other investigators provided the view that acculturation could be beneficial for the well being of the immigrant. More and better research is obviously required to explore the role of acculturation on mental health of immigrants and how the various components of culture interrelate with historical, political, social, economic factors in the formation of acculturation stress and the incidence of depression or anxiety disorders on any psychopathological pattern of behaviour. Additionally the research findings are needed to provide a reliable evidence for the organization of social policy programs to prevent socioculturally driven phenomena e.g. isolation, marginalization or racism and how deliver culturally responsive mental health care for immigrant populations.

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[20] Koranyi E K, Kerrenyi A B, Sarwer-Foner G I: Adaptive difficulties of some Hungarian immigrants: The process of adaptation and acculturation. Compr. Psychiatry 1963; 4: 47-57. [21] Fabrega H: Social psychiatry aspects of acculturation and migration: a general statement. Compr. Psychiatry 1969; 10: 314-326. [22] Nachson I, Druguns J G, Broverman I K, Philips L: The reflection of acculturation in psychiatric symptomatology: a study of an Israeli guidance clinic population. Soc. Psychiatry 1972; 75: 109-118. [23] Padilla A M: Acculturation: Theory, Models and some findings. Westview, Press Boulder Co, 1980. [24] Cuellar I, Lorwen C H, Naron N: (1981) Evaluation of a bilingual bicultural treatment program for Mexican American psychiatric inpatients. In Explorations in Chicago psychology. Edited by Baron A, New York, Praeger, 1981, pp 165-186. [25] Burnam A, Hough P L, Karno M, Escobar J L, Telles C: Acculturation and lifetime prevalence of psychiatric disorders among Mexican Americans in Los Angeles. J. Health and Soc. Beh. 1987; 28: 89-102. [26] Caetano R: Acculturation and drinking patterns among US Hispanics. Brit. J. Addiction 1987; 82: 789-799. [27] Kaplan M, Marks G: Adverse effects of acculturation: Psychological distress among Mexican American young adults. Soc. Sci. Med, 1990; 31:1313-1319. [28] Berry J W: Immigration, acculturation and adaptation. Applied Psychology: An International Review 1997; 46: 5-18. [29] Hines A M, Snowden L R, Graves K L: Acculturation, alcohol consumption and AIDS related risky sexual behaviour among African American women. Women’s Health 1998; 27: 17-35. [30] Ortega A N, Rosenheck R, Alegria M, Desai, R A: Acculturation and the lifetime risk of psychiatric and substance use disorders among Hispanics. J. Nerv. Ment. Dis. 2000; 188: 736-740. [31] Hahm H C, Lahiff M, Guterman N B: Acculturation and parental attachment in AsianAmerican adolescents‘ alcohol use. J. Adol. Health 2003; 33: 119-129. [32] Lau A S, Mccabe K M, Yeh M, Garland A F, Wood P A, Hough R L: The acculturation gap-distress hypothesis among high risk Mexican-American families. J. Fam. Psycho.l 2005; 12: 361-375. [33] Kim E, Cain K, Mccubbin M: Maternal and parental parenting, acculturation, and young adolescents. Psychological adjustment in Korean American families. J. Child Adol. Psychiat. Nurs 2006; 19:112-129. [34] Madianos M, Gonidakis F, Ploubidis D, Papadopoulou E, Rogakou E: Measuring acculturation and symptoms of depression of foreign immigrants in the Athens area. Int. J. Soc. Psychiat. 2008; 54: 338-349. [35] Redfield R, Linton R, Herskovits M: Memorandum on the study of acculturation. Amer. Anthropologist 1936; 38: 149-152. [36] Park R E: Human migration and the marginal man. Am. J. Sociol. 1928; 33: 881-893. [37] Berry, J W: Acculturation as varieties of adaptation. In Acculturation: Theory, models and some findings. Edited by Padilla A, Colorado, Westview Press, 2000. [38] Berry, J M: Phinney L S , Sam D L, Vedder P: Immigrant youth: acculturation, identity and adaptation. Applied Psychol: Intl. Rev. 2006; 55: 302-332.

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[39] Ruesch J A, Jacobson A, Loeb M B: Acculturation and illness. Psychological Monographs. Washington DC, American Psychological Association, 1948. [40] Figuerido J: The law of sociocultural demoralization. Soc. Psychiatry 1983; 18: 73-78. [41] Link B, Dohrenwend B P: Formulation of hypotheses about the true prevalence of demoralization in United States. In Mental Illness in the United States. Edited by Dohrenwend B P, Dohrenwend B S, Schwartz M, Gould M, Link B. New York, Praeger, 1980, pp 114-130. [42] Mavreas V, Bebbington P: Acculturation and psychiatric disorder: a study of Greek Cypriot immigrant. Psychol. Med. 1990; 20: 941-951. [43] Adamopoulou A, Garyfalos G, Bouras N, Kouloumas G C: Mental health and primary care in ethnic groups Greek Cypriots in London: a preliminary investigation. Int. J. Soc. 1990; 36: 244-251. [44] Sam D L, Berry I W: Acculturative stress among immigrants in Norway. Scand J Psychol 1995; 36: 10-24. [45] McLachlan M, Smyth C, Breen F, Madden T: Temporal acculturation and mental health in modern Ireland. Intl. J. Soc. Psychiatry 2004; 50: 345-350. [46] Nwadiora E, McAdoo M: Acculturative stress among Amerasian refugees: gender and racial differences. Adolescence 1996; 31: 477-487. [47] Madianos M, Bilanakis N, Liakos A: Acculturation, demoralization and psychiatric disorders among repatriated Greek migrants in a rural area. Eur. J. Psychiatry 1998; 12: 95-108. [48] Oppedal B, Roysamb E, Heyerdahl S: Ethnic group, acculturation and psychiatric problems in young immigrants. J. Child Psychol. Psychiatry 2005; 46: 646-660. [49] Karriker –Jaffe K J, Zemore S E: Associations between acculturation and alcohol consumption of Latino men in the United States. J. Stud. Alcohol. Drugs 2009; 70:2731. [50] Gul V, Kolb S: Acculturation, bicultural identity and psychiatric morbidity in young Turkish patients in Germany. Turk. Psykiyatri Derg. 2009; 20: 138-143. [51] Radloff LS: The CES-D scale: a self report depression scale for research in the general population. Appl. Psychol. Measur. 1977; 1: 385-401. [52] Szapoeznik J, Kurtiness W: Acculturation biculturation and adjustment among Cuban Americans. In Acculturation: theory models and some new findings. Edited by Padilla A, Boulder, Co, Westview Press, 1980, pp 80-89. [53] Gaviria F M, Richman J, Flaherty J: Migration and mental health in Peruvian society. Towards a psychological model. Soc. Psychiatry 1986; 21: 193-199. [54] Boydell J van Os J, Mc Kenzie K, Allardyce J, Goel R, Mc Greadie R G, Murray, R M: Incidence of Schizophrenia in ethnic minorities in London: ecological study into interactions with environment. BMJ 2001; 323: 1336-1338. [55] Veling V, Sysser E, Van Os J, Mackenbach J, Selten J P, Hock H W: Ethnic density of neighbourhoods and incidence of psychotic disorders among immigrants. Am. J. Psychiat. 2007; 65: 66-73. [56] Vega W A, Amaro H: Latino outlook: good health, uncertain prognosis. An. Rev. Pub. Health 1994; 15: 39-67. [57] Zhou, M. Segmental assimilation: Issues, controversies and recent research on the new second generation. Int. Migration Rev. 1997; 31: 975-1008.

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[58] Streltzer J, Rezentes W C, Araki M: Does acculturation influence psychosocial adaptation and well-being in Native Hawaiians? Int. J. Soc. Psychiat. 1996; 42: 28-37. [59] Virta E, Sam D L, Westin C: Adolescents with Turkish background in Norway and Sweden: a comparative study of their psychological adaptation. Scand. J. Psychol. 2004; 45: 15-25. [60] Campos M D, Podus D, Anglin M D, Warda U: Mental health need and substance abuse problem risk: acculturation among Latinas as a protective factor among Calworks applicants and recipients. J. Ethn. Subst. Abuse 2008; 7: 268-291.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 9

IMMIGRATION, PSYCHOSOCIAL FACTORS AND PSYCHOLOGICAL DISTRESS, WITH FOCUS ON PERCEIVED CONTROL AND SOCIAL INTEGRATION Odd Steffen Dalgard Norwegian Institute of Public Health, Oslo, Norway

ABSTRACT Background: Studies have shown that immigration may be associated with good as well as poor mental health, depending on the social context, and that various social and psychosocial variables may act as explanatory factors. Aims of the study: To investigate the relationship between psychosocial variables and psychological distress in immigrants in Oslo, Norway, with special focus on perceived control and social integration. Methods: The study was based on data from a community survey in Oslo, and encompassed 13992 Norwegian born, 1118 Western immigrants and 1619 Non-western immigrants. Psychological distress was measured by a 10 items version of Hopkins Symptom Check List (HSCL-10), perceived control by scales of generalized self-efficacy and powerlessness, and social integration by an index based on four items: Knowledge of the Norwegian language, reading Norwegian newspapers, visits by Norwegians and receiving help from Norwegians. Information on paid work, household income, marital status, social support and conflicts in intimate relationships was also included in the study. Results: Compared to the Norwegian born and the Western immigrants, the Nonwestern immigrants had a higher prevalence of psychological distress, and they were more often without paid work, had lower household income, weaker social support and more negative life events, perceived less control, and were less socially integrated. When adjusting for these factors, the increased prevalence of psychological distress in the Nonwestern immigrants compared to the Norwegian born was substantially reduced, perceived control having an independent effect. Social integration was associated with good mental health in Non-western men but not in Non-western women.

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Odd Steffen Dalgard Conclusion: Lack of perceived control over own life situation, and in men, lack of social integration, contributes to increased prevalence of psychological distress in Nonwestern immigrants, and should be addressed in preventive work. In Non-western women the role of social integration is more complex, and one should be more cautious in expecting rapid social integration in these women.

INTRODUCTION Migration and its impact on mental health has been subject for studies for several decades, and the first classical studies were carried out before the second world war [1, 2]. Whereas the first studies were based on hospital statistics, the later studies have been based on surveys, with or without the use of clinical interviews. Anxiety, depression and post traumatic stress disorder (PTSD have been the indicators of mental health in most of the recent studies. The term ―psychological distress‖ is often used, in the sense of anxiety/depression which may be on the clinical or subclinical level. In recent years there has been a growing interest in the study of international migration and its impact on mental health, parallel with the trend of increasing migration between countries, especially from low-income to high-income countries [3]. The global problem of refugees has also been an important subject for recent psychiatric research. Most of the studies of international migration have reported higher rates of psychological distress among immigrants compared to the native population [4, 5, 6], but there are exceptions [7, 8]. Obviously, migration by itself does not represent a threat to mental health; it depends on the social context, and the conditions under which the migration takes place. Different mechanisms have been put forward to explain associations between migration and mental health. Stress, in the sense of an unbalance between challenges and the normal coping mechanisms, is a central concept in most of these explanations. To the extent migration leads to increased stress, either by increase in stress-leading events (stressors) and/or by weakening of coping resources, the risk of mental health problems increases. Premigration stressors are not so often studied as post-migration stressors, and if studied, this is mainly by retrospection. Especially in refugees, traumatic events in the country of origin, like imprisonment and torture, are shown to increase the rate of mental health problems [9]. But also post-migration stressors, like somatic illness, family conflicts, economic problems and unemployment, especially in migrants from low-income to high-income countries, contribute to mental health problems in immigrants [3, 10, 11]. Social isolation and lack of social support are other risk factors [12], increasing stress by reducing the coping abilities of the immigrants. In the present study, a special focus will be on two factors that may affect the mental health of immigrants, perceived control over own life situation and social integration, factors that in different ways may be connected with stress. To the knowledge of the author, perceived control has not been the explicit subject for prior research in this field, whereas the research on social integration has given somewhat inconsistent results.

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Perceived Control It is known for long time that perceived lack of control increases psychological distress [13], and it is suggested that lack of control is an important mediator between low socioeconomic status and mental health problems [14]. Consequently, it is not unlikely that lack of perceived control could contribute to mental health problems also in other socially marginalized groups, like immigrants, in particular those coming from countries with a different culture. Perceived lack of control may be defined and measured in somewhat different ways, for instance as sense of powerlessness or low self-efficacy. A sense of powerlessness develops when coping is not successful, and the individual feels that nothing can be done to relieve a stressful life situation. The feeling of powerlessness or helplessness, which is often associated with low self esteem, is by different authors described as a burden on health, mental as well as somatic [15, 16, 17, 18, 19, 20]. With the growing interest in the relationship between social inequality and health, the concept of powerlessness has taken on greater importance [21]. Self- efficacy, as defined by Bandura in 1977, is the subjective assessment of what one ―can do‖, and hence affects how people feel and think about the future. A low sense of selfefficacy is associated with helplessness and pessimistic thoughts about one‘s own development and accomplishments [22] , whereas a strong sense of self-efficacy motivates the individual to perform more challenging tasks, investing more effort, and for greater persistence in attempting to obtain desired goals [23].

Social Integration By social integration is usually meant the adaptation of the norms and values of the ―main stream‖ majority culture by the minority group, especially with respect to language, daily costumes and social behavior In some studies social integration is associated with good mental health, in others with mental health problems. In this literature ―social integration‖ and ―acculturation‖ have often been used interchangeably, even if there may be differences in the content of these concepts [24]. Different measures of degree of social integration or acculturation have been used, the most widely used probably being the learning of the language of the host country. Other indicators have been share of cultural values with the host population and use of host media. Several community studies in U.S. have indicated that social integration is associated with increased health problems, rather than the opposite. In one study immigrants of Hispanic ethnic origin had a lower prevalence of psychiatric disorder than the host population, and the prevalence was increasing by increasing integration in terms of learning the English language [8]. In a community study in United Kingdom, immigrants from India, Pakistan, Bangladesh and China had lower prevalence of anxiety and depression than the host population, whereas the Irish had higher rates [25]. Among the Pakistani and Bangladeshi groups who spoke fluently English, the prevalence of anxiety was doubled, whereas there was almost no difference for the Indians. Likewise, in a study of Greek immigrants in New York, those who were most ―Americanized‖, in terms of sharing American values and customs, had the highest score on psychological distress [26]. Other studies indicate that social integration is positive for mental health. As an example, a study from a recently established neighborhood in Oslo,

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where the same method of measuring integration as in the study from New York was applied, showed that the best integrated immigrants had the best mental health [27]. Likewise, in a study of Pakistani immigrants in U.K. [28], depression was associated with lack of fluency in English, and the same was the case in a study of immigrants in Australia [29]. In Canada Vietnamese refugees, and students from other Asian countries, had better mental health the more contacts with Canadians and Canadian culture [30]. As a conclusion then, social integration may be associated with good as well as poor mental health, depending on the social context. There are different contextual factors that might influence the association between social integration and mental health. One important factor seems to be the size of the immigrant community [31]. If the immigrant group is small compared to the host community, it is likely that the pressure towards integration will be strong, and consequently that lack of integration generates stress and mental health problems. If, on the other side, the immigrant group is relatively big, there will be less need for integration, since the group may develop it‘s own ethnic subculture. Another factor likely to affect mental health and social integration among immigrants is the attitudes of the host population towards the new-comers. Do they represent a pluralistic or multicultural ideology, with attendant tolerance for cultural diversity, or is there an ideology in favor of assimilation, with pressures to conform to a single cultural standard [30]? If there is an ideology in favor of assimilation, it is of importance how fast the new-comers are expected to assimilate, and there is some evidence that a pressure towards fast assimilation increases the risk of mental disorder, and that a pluralistic community is best for the mental health of immigrants [31]. A third factor playing an important role for social integration, is the cultural distance between the immigrants and the host population. If the cultural gap is wide, eventually with conflicting values, integration may be difficult. Especially in relation to immigration to Western countries from Asia or Africa, the conflict between individualistic and collectivist cultures is of relevance [32]. Individualistic society, then, is one where the ties between individuals are relatively loose, and everyone is expected to look after himself /herself and his/her immediate family, whereas collectivism refers to a type of society to which people from birth onwards are integrated into strong cohesive in-groups, especially family and kinship, which throughout their lifetime continues to protect them an demand unquestionable loyalty [33]. Not all individuals being alike, this means than an individualistic person from a collectivist culture may adjust easily to an individualistic society, and vice versa. The possibility of gender differences in the process of social integration is barely mentioned in the literature referred to above, as if men and women of the same ethnic origin have more or less the same problems in relating to the new cultural environment. This is not necessarily so, and in a qualitative study of elderly Indian women in Canada, there are examples of cultural conflicts which seem to hit women stronger than men [34]. The traditionally strong position of the elderly women in the family, not least in the function of mother-in-law is eroded, and their inability to transmit their culture and traditions to next generation, is felt as a loss and a source of sadness. Limited facility with the English language and household responsibility make it difficult for them to take part in the social life, and social isolation is likely to be a bigger problem for them than for men. Conflict with social norms, threats to the self and/or loss of identity could also be sources of distress, relatively stronger in the non- western immigrant women than men.

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To which extent the contrasting associations between social integration and mental health may be explained by the factors mentioned above, is not certain. However, it seems important in future research to take them all into consideration when investigating the relationship between social integration and mental health.

Aims of the Present Study The aims of the present study is to investigate the distribution of social and psychosocial risk factors in different immigrant groups compared to the Norwegian- born in Oslo, and to explore to which extent these factors explain the differences in psychological distress between the immigrants and the Norwegian- born. Special emphasize will be put on the role of perceived control and social integration. Some of the results are presented in prior publications [35, 36].

METHODS The Scene According to Statistics Norway, more than 7 % of the population of Norway consists of immigrants, and this constitutes almost 20% of the population of Oslo. Of the immigrants 52% comes from Africa or Asia (12% and 40%), the rest from Eastern Europe (16%), the Nordic counties (15%) the rest of Western Europe (10%) and America/Oceania (7%).

Sample The University of Oslo, National Health Screening Service of Norway (now the National Institute of Public Health), and Oslo Municipality jointly organized a general health survey known as the Oslo Health Study in 2000-2001. The study subjects were all the inhabitants of Oslo born in 1970, 1960, 1955, 1940/41 and 1924/25. The details on the methodology are described elsewhere [37]. Of the 40,888 in the sample, only 18,770 (45.9%) participated in the study. However, the weighted prevalence estimates of self-rated health and other analysed variables differed only slightly between attendees and the target population, and the association measures were found to be less influenced by the self-selection [37]. Among the responders 13992 were born in Norway, 1025 in Western Europe, North America and Australia (Western countries) and 1928 from Eastern Europe, South America and countries in Africa and Asia (Eastern countries). Data about country of birth was missing for 1825. Among the immigrants from ―Eastern countries‖ 259 came for Eastern Europe, 605 from the Indian subcontinent, 340 from South East Asia, 293 from Africa, 318 from the Middle East, and the rest (113) from other countries. In the analysis refugees (217) were not included, which gives a total analyzed sample of 15 723, split in three major groups according to place of birth: Norway (13992), Western countries (1118) and Non-Western countries (1619).

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Instruments The Oslo Health Study questionnaire was translated into the following 11 languages other than Norwegian: Albanian, Arabic, English, Farsi, Serbo-Croatian, Somalian, Spanish, Tamil, Turkish, Urdu and Vietnamese. The variables used in the present study are the following:

Mental Health A 10-items version of Hopkins Symptom Check List [38] was used as a measure of psychological distress. Each item was rated on a scale of 1 (not at all) to 4 (extremely) during the past week. In contrast to the 25 items Hopkins Symptom Check List (HSCL-25), where symptoms can be subdivided into depression and anxiety categories [39], the HSCL-10 provides a measure of global psychological distress. The internal consistency of the scale was high in the sample (Cronbach‘s alpha=0.89), and there were no difference with respect to this between the Norwegian born and the immigrant groups. In most of the analyses the distress score was dichotomized with cut off point 1.85 , which has been shown to correspond to the conventional cut-off point of 1.75 in HSCL-25 (38). Non-responders to HSCL-25 were unevenly distributed across the migratory groups, 4,3% of the Norwegian born, 6,2% of the immigrants from Western Europe/America and 20,5% of the immigrants from ―other countries‖ being non-responders. This means that especially the last group of immigrants is substantially reduced when comes to analyses including this variable. Social Support Social support was measured by two questions from the Oslo social support scale [40], one about number of close confidants, and the other about perceived positive interest and concern from other people. These questions have high face validity, and high predictive validity with respect to psychological distress. Negative Life Events To measure negative life events, a 12 items inventory of threatening experiences, developed by Brugha et al. [41] was used in the screening questionnaire. This inventory is developed by rating negative life events by two different methods in the same sample, i.e. an inventory developed by Tennants and Andrews [42], and a semi structured interview developed by Brown and Harris [17]. The inventory categories including most of the negative events in the interview representing marked or moderate threat, were identified. Very rare events were excluded. In an independent study the 12 items inventory, recording negative life events during the last 6 months, was associated with a significant increase in the risk of developing depression. The inventory is especially recommended for use in connection with depression, when the more costly use of semi-structured interview cannot be afforded. Perceived Control Control was measured by two instruments, generalized self-efficacy, developed by Jerusalem et al. [43], and the power-powerlessness factor in the Empowerment scale developed by Rogers et al. [44]. The two scales differ considerably in their content. Whereas

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the generalized self efficacy scale measures the confidence in being able to control challenging environmental demands by means of taking adaptive actions, the powerlessness scale measures the sense of power in a community context. Whereas generalized self efficacy is known to be relatively stable over time, and related to personality traits, like extraversion and optimism, less is known about powerlessness in the Empowerment scale. However, it is reason to believe that the powerlessness scale is more sensitive to the actual life situation, and hence measures a state rather than a trait. Examples of questions from the self-efficacy scale are:   

I always manage to solve difficult problems if I try hard enough I am confident that I could deal efficiently with unexpected events Thanks to my resourcefulness, I know how to handle unforeseen situations

Examples of questions from the powerlessness scale are:   

You cannot fight city hall When I am unsure about something, I usually go along with the group Experts are in the best position to decide what people should do and learn

The scales of generalized self efficacy and powerlessness both showed high internal consistency in the sample, Cronbach‘s alpha being respectively 0.90 and 0.67. The rationale for expecting the control variables to explain differences in psychological distress between Norwegian born and immigrants, is that lack of control, as measured in the study, has a negative effect on mental health in both groups. This is not necessarily so. As put forward by Rothbaum et al. [45], one may distinguish between primary and secondary control. Whereas primary control is to bring environment into line with one‘s wishes, secondary control is to bring oneself into line with the environmental forces. Both types of control may be adaptive, dependent on the circumstances. In the present study, the two indicators of control obviously measure primary control. It might be, then, that for the Norwegian born, lack of primary control is associated with a sense of failure and psychological distress, whereas for immigrants, because of their more difficult life situation, lack of primary control is not that bad, and rather an expression of a realistic assessment of the situation. If this is so, one should expect a higher correlation between the measures of control and psychological distress in the Norwegian born than in the immigrants. However, this was not so. The Pearson correlations between Powerlessness and psychological distress in respectively Norwegian born, Western immigrants and Non-western immigrants, were .30, .31 and .39. For generalized self-efficacy the correlations were –.31, -.35 and – .25. So it seemed that primary control was equally important for mental health in Norwegian born as in immigrants, and that it was meaningful to explore to which extent this type of control explains the differences in psychological distress.

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Social Integration Four items were used as indicators of integration into the Norwegian community:    

Knowledge of the Norwegian language Reading Norwegian newspapers last year Visit by Norwegians last year Help/support from Norwegians last year

The first item had 5 response alternatives from ―very good‖ to ―bad‖, and the other items had 4 response alternatives from ―daily‖ to ―never‖. An index was established by summarizing the scores of each item (Cronbach‘s alpha: 0.57), high score meaning high acculturation.

Socio-Demographic Data The analyses also included data about gender, age, marital status, household income and paid work. Information on family income was gathered from register data. Information about employment was based on the question: Are you in paid work?

The response alternatives were dichotomized into to two groups: ―In full-time or parttime paid work‖, ―not in paid work‖. Marital status was dichotomized in married/cohabitant and the rest.

Statistical analyses Testing of significance: The differences in distribution of categorical variables were tested by Chi-square (table 1 and figure 1), and of continuous variables by ANOVA (table 2). Correlations between variables were tested by Pearson correlations, two-tailed (table 3). Logistic linear regression analyses were used to estimate the associations between psychological distress (HSCL-10) and place of birth, when adjusting for various predictors, presenting Odds ratios and 95% confidence intervals (tables 4 and 5). Steps of analyses: The distribution of socio-demographic and psychosocial variables and the correlations between variables are presented for the total sample. The analyses of associations between place of birth and psychological distress, when adjusting for sociodemographic and psychosocial variables, with the exception of social integration, are based on the Norwegian born and the Non-western immigrants. When social integration is included, the analyses are based on the Western and Non-western immigrants.

RESULTS Distribution of socio-demographic and psycho-social variables The distribution of socio-demographics variables is shown in table 1.

Immigration, Psychosocial Factors and Psychological Distress… Table 1. Socio-demographic variables Age < 45 years

Married

Household income <200.000 NOK Not paid work

Place of birth Norway Western countries Non-western countries Norway Western countries Non-western countries Norway Western countries Non-western countries Norway Western countries Non-western countries

Men 40.1 (2497) 47.3 (214) 59.7 (465) 51.2 (3189) 49.3 (223) 73.4 (572) 7.3 (300) 10.7 (31) 29.2 (100) 10.2 (519) 12.4 (50) 24.5 (167)

Women 40.5 (3144) 47.6 (317) 63.0 (529) 43.5 (3378) 47.3 (315) 72.7 (611) 9.2 (460) 10.1 (47) 37.0 (120) 16.3 (1004) 17.4 (99) 44.3 (330)

Distribution of socio-demographic variables. Percentages, absolute numbers in brackets.

Table 2. Psycho-social variables Confidants

Social support

Negative life events

Powerlessness

Generalized self-efficacy

Social integration

Psychological distress

Distribution of psychosocial variables. Means, standard deviation in brackets.

Place of birth Norway Western countries Non-western countries Norway Western countries Non-western countries Norway Western countries Non-western countries Norway Western countries Non-western countries Norway Western countries Non-western countries Norway Western countries Non-western countries Norway Western countries Non-western countries

Men 8.6 (7.3) 7.8 (8.1) 6.1 (7.3) 3.9 (1.0) 3.9 (1.1) 3.6 (1.1) 0.7 (1.1) 0.9 (1.4) 1. 4 (1.8) 2.1 ( .5) 2.1 ( .5) 2.4 ( .6) 3.1. ( .4) 3.1. ( .5) 3.1 ( .5)

Women 8.7 (6.1) 8.7 (7.1) 5.0 (4.9) 4.0 (1.0) 4.0 (1.0) 3.8 (1.0) 0.8 (1.2) 0.8 (1.1) 1.4 (1.7) 2.2 ( .5) 2.2 ( .4) 2.4 ( .6) 3.0 ( .4) 3.0 ( .4) 3.0 ( .5)

15.6 (2.2) 13.4 (2.4) 1.2 ( .4) 1.3 ( .4) 1.5 ( .6)

16.0 (2.1) 13.8 (2.6) 1.4 ( .5) 1.4 ( .4) 1.6 ( .6)

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Table 3. Correlations between variables

Psychological distress Household income Not paid work Married

Psychol. distress 1 -.25

Household income 1

.29

-.30

Not paid work 1

Married

-.08

.35

.03

1

Close confidants Social support Negative life events Powerlessness

-.16

.09

-.08

.04

Close confidants 1

-.19

.08

-.09

-.03

.24

Social support 1

.28

-.21

.16

-.09

-.03

-.04

Negative life vents 1

.31.

.31

.13

-.05

-.14

-.25

.11

Powerlessness 1

Generalized self-efficacy

-.30

-.30

-.09

-.00

.14

.24

-.03

-.21

Generalized self-efficacy 1

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123

There were significant differences between the Norwegian born and the Non-western immigrants with respect to all variables, whereas the differences between the Norwegian born and the Western immigrants were relatively small. The Non-western immigrants were younger, were more often married, had lower household income and were more often without paid work (table 1). Also with respect to psycho-social variables, there were significant differences between Norwegian born and Non-western immigrants, whereas Western immigrants differed very little from Norwegian born (table 2). The Non-western immigrants reported significantly fewer close confidants, less social support, more negative life events and more powerlessness than both the Norwegian born and the Western immigrants. With respect to generalized self-efficacy there were no differences between the three groups. The level of social integration was significantly lower in the Nonwestern immigrants compared to the Western immigrants, and the level of psychological distress significantly higher.

Correlations between Variables The correlations between variables are shown in table 3. As expected, the level of psychological distress showed a high negative correlation with household income, married, close confidants, social support and generalized self-efficacy, and positive correlation with not paid work, negative life events and powerlessness. Also between the other variables there were high correlations. Low household income, and not paid work, were associated with few close confidants, little social support, many negative life events, low generalized self-efficacy and high sense of powerlessness. Low generalized self-efficacy and high sense of powerlessness were associated with few close confidants and low social support. Tabel 4. Logistic regression analyses

Predictors Place of birth Gender Age Income Not paid work Married Confidants Social support Negative life ev. Powerlessness Nagelkerke R Square

Model 1 OR 95%CI 1.76 (1.63-1.89) 1.88 (1.68-2.10) 1.01 (1.00-1.01)

.04

Model 2 OR 95%CI 1.50 (1.33-1.39) 1.62 (1.39-1.88) 1.01 (1.00-1.02) .74 ( .70- .79) 2.71 (2.25-3.23) .76 ( .64 - .90)

.13

Model 3 OR 95%CI 1.35 (1.18-1.56) 1.84 (1.56-2.38) 1.01 (1.00-1.02) .80 ( .76- .86) 2.31 (1.90-2.81) .80 ( .66- .97) .94 ( .92- .96) .71 ( .66- .77) 1.38 (1.31-1.46)

.21

Model 4 OR 95%CI 1.17 (1.01-1.36) 1.85 (1.56-2.19) 1.01 (1.00-1.02) .84 (.79- .90) 2.32 (1.90-2.84) .82 (.68- .99) .95 (.93- .96) .79 (.73- .85) 1.35 (1.27-1.42) 3.48 (2.89-4.21 .29

Associations between place of birth (Non-western countries versus Norway) and psychological distress (HSCL>1.85), with adjustment for various predictors.

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Associations between Immigration (Non-Western Immigrants Versus Norwegian Born) and Psychological Distress, with Adjustment for Socio-Demographic and PsychoSocial Variables The associations between place of birth and psychological distress, with adjustment for various combinations of variables, are shown in table 4. The results are based on four logistic regression analyses (model 1- 4). The results for men and women are put together, as the results were similar in both genders. When adjusting for gender and age (model 1), Non-western immigrants had a significantly increased level of psychological distress (Odds ratio 1.76, 95 % confidence interval 1.63-1.89) compared to the Norwegian born. When also adjusting for household income, paid work and marital status (model 2), the association between place of birth and psychological distress was reduced (Odds ratio 1.50, 95 % confidence interval 1.33-1.39). 25

23.5 21.4

20

15 12.5

Western countries 10

Non-western countries

10 7.2

6.3 5

0 Low integration

Medium integration

High integration

30 26.8

26.6 24

25 20.8 20 15.4

Western countries

15

Non-western countries 9.6

10

5

0 Low integration

Medium integration

High integration

Figure 1. Social integration and psychological distress (HSCL-10>1.85). Percent

Adjusting for confidants, social support and negative life events (model 3), reduced the association further (Odds ratio 1.35, 95 % confidence interval 1.18-1.56). When finally

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adjusting also for powerlessness (model 4), the association between place of birth and psychological distress was even further reduced, but was still statistically significant (Odds ratio 1.17, 95 % confidence interval 1.01- 1.36). In the final model, all variables were independently associated with psychological distress, not being in paid work and feeling of powerlessness emerging as the strongest risk factors.

Associations between Immigration (Non-Western Versus Western Immigrants) and Psychological Distress, with Special Focus on Social Integration The relationship between social integration and psychological distress in immigrants from Non-western and Western countries is shown in figure 1. In Western immigrants, men and women, the prevalence of psychological distress was lowest in the group with highest integration, and the same was true for male immigrants from Non-western countries. In the well integrated male immigrants the prevalence of psychological distress was not much higher than among the Norwegian born men (6.6 %), whereas the well integrated female immigrants from Western countries in fact had somewhat lower prevalence than the Norwegian born women (12.5 %) . For women from Non-western countries, however, there was no difference in prevalence of psychological distress across social integration. Irrespective of integration these women had a high prevalence of psychological distress. The lacking effect of social integration on psychological distress in women from Non-western countries was repeated in logistic regression analysis (data not shown). Whereas there were significant associations between social integration and psychological distress in women from Western countries (p=, 04), and men from Nonwestern countries (p= .06), when adjusting for age, there was no such association in women from Non-western countries (p= .49). The multiplicative interaction between gender and psychological stress with respect to psychological distress in Non-western immigrants was close to significance (p= .06). When adjusting for social integration, the association between place of birth and psychological distress in men from Non-western countries was substantially reduced (OR from 2.67 to 2.28), whereas the reduction in Non-western women was small (OR from 2.53 to 2.43). Association between Social Integration and Psychological Distress in Non- Western Immigrants The association between social integration and psychological distress (HSCL-10>1.85) in Non-western immigrants, when adjusting for various predictors, is shown in Table 5. When only adjusting for age (model 1), there is, as we already know, a significant association between social integration and psychological distress in men, but not in women. When adjusting for household income and not paid work (model 2), the association between social integration and psychological distress in men is reduced below the level of significance, and further reduced when also adjusting for powerlessness (model 3). In women the pattern is different. When adjusting for household income and not paid work, there is positive association between social integration and psychological distress, and when also adjusting for powerlessness there is a significant positive association, i.e. psychological distress increases by increasing social integration.

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Odd Steffen Dalgard Table 5. Logistic regression analyses Predictors

Men

Women

Integration Income Not paid work Powerlessness Nagelkerke Square Integration Income Not paid work Powerlessness Nagelkerke Square

Model 1

Model 2

Model 3

OR 95% CI

OR 95% CI

OR 95% CI

.88 ( .77-1.00)

.96 ( .83-1.11) .61 ( .44- .85) 1.55 ( .60-3.95)

.029

.116

.99 ( .85-1.16) .65 ( .46- .92) 1.22 ( .43-3.42) 3.35 (1.61-6.99) .198

1.03 ( .94-1.15)

1.13 ( .99-1.30) .85 ( .67-1.07) 1.64 ( .78-3.45)

.025

.060

1.19 (1.02-1.37) .88 ( .69-1.14) 1.54 ( .69-3.45) 3.33 (1.71-6.49) .146

DISCUSSION Immigrants from Non-western countries had a higher score on psychological distress than the Norwegian born and the immigrants from Western countries. The immigrants from Nonwestern countries reported less close confidants, less social support and more negative life events than the Norwegian born, and they had lower household income and were less often in paid work. Between the Western immigrants and the Norwegian born the differences were small. When adjusting for the socio-economic and psychosocial factors, the difference in psychological distress between the Non-western immigrants and the Norwegian born was substantially reduced, indicating that these factors to a considerable extent explained the increased level of psychological distress in the Non-western immigrants.

Perceived Control With respect to the indicators of perceived control, a sense of powerlessness was more prevalent in the Non-western immigrants than in the other groups, whereas this was not the case for generalized self-efficacy. When adjusting for sense of powerlessness, in addition to socio-demographic and other psychosocial variables, the associations between place of birth and psychological distress was further reduced, indicating that sense of powerlessness in itself contributed to the difference in psychological distress between the Non-western immigrants and the Norwegian born. It is in agreement with our hypothesis that perceived lack of control, in the sense of a feeling of powerlessness, emerged as an explanatory factor for the increased level of psychological distress in Non-western immigrants. But it is not clear if the perceived lack of control in Non-western immigrants reflected their actual life situation, or was rather an expression of their habitual attitude towards life, probably linked to personality traits. However, it seems less likely that the last was true, since these immigrants were coming from

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countries far away, and had showed initiative and courage by leaving their country of birth. This certainly does not indicate that they felt without control, at least not the men, when they decided to emigrate; it rather indicates that the reported lack of control was a consequence of a difficult and a stressful life situation in their new home country . The finding that the reported lack of control was closer to a state than a trait, was also to some extent supported by the finding that generalized self- efficacy, which is probably closer to a trait than sense of powerlessness [46], was not associated with immigration..

Social Integration Non-western immigrants were less socially integrated into the Norwegian community than the Western immigrants, and they reported a higher level of psychological distress. However, only in men this explained some of the increased level of psychological distress in the Non-western immigrants. The reason for this seemed to be that social integration in Nonwestern men was positive for mental health, whereas this was not the case in women. The positive effect in men seemed to be mediated by household income and paid work, since the effect of social integration was reduced substantially when adjusting for these variables. In women, social integration was negatively associated with mental health when adjusting for household income and paid work, indicating that the negative effect had been covered up by these other associated variables. There may be several reasons for the different effects of social integration in men and women from non-Western countries. One possibility is that women, with their central role in the family, to a greater extent than men are challenged by cultural values different from their own. It is not unlikely that the conflicts between the collectivistic values in most of the nonWestern countries and the individualistic values in the Western countries [32] are more strongly felt by immigrant women. Another explanation may be that social integration in women in some instances is met by negative sanctions from men of their own ethnic group. It is well known, that for instance Muslim women are not always stimulated by their families to adopt the Norwegian language and Norwegian costumes, rather to the contrary, and are expected to stay apart from the Norwegian community. All together, the attempt of these women to integrate into the Norwegian community may easily lead to conflicts with social norms, threats to the self and/or loss of identity, which could be a burden on mental health, at least temporary. One reason for the seemingly positive effect on mental health of social integration among Non-western men in the present study, may be the relative small size of the immigrant groups in Oslo. The size is too small to provide the immigrants with a subculture, where they can spend most of their time, even getting paid work, without much contact with the host community. Different from the big groups of Mexican immigrants in California [7] and of Greeks in New York [26], where social integration was associated with poor mental health, the Non-western immigrants in Oslo will have great problems in getting paid work without good knowledge of the Norwegian language of the host country, which in itself is an important indicator of social integration. For the Non-western women the situation is somewhat different, with less pressure towards paid work, and probably stronger ties to their own ethnic group.

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Another possible explanation of the positive effect of social integration on the mental health of the Non-western men in Oslo, is that Norway up to recently has been a culturally homogenous country, with strong pressure towards assimilation. In Norway there has been a strong pressure on immigrants to adopt Norwegian language and Norwegian customs, in spite of the public policy being ―integration‖ rather than ―assimilation‖. Even if the immigrants may keep important elements of their own culture, they are expected to adjust rather quickly to the Norwegian society. So integration is the best way to avoid conflicts with the Norwegian culture, which may be good for mental health, but the price may be conflicts within their own culture, which is probably most strongly felt by the Non- western women. The study has weaknesses which makes it difficult to draw firm conclusions. First, it is problematic that the response rate in the survey was low (45.9%). However, as mentioned earlier, in a study of the sample, where socio-demographic register data, also for the nonparticipants, were taken into consideration, the prevalence rates of self-rated health, including mental health, was not much changed by self-selection (Søgaard et al., 2004). Even so, one may question the representativeness of the sample, especially when comes to psychological distress, because of the relatively low response rate for this variable in the immigrants. This implies that one should be cautious drawing conclusions about prevalence rates of psychological distress in the sample, whereas one may feel more confident with respect to the findings related to associations between variables. Even if the questions in the questionnaire were translated into the native languages of the immigrants, one may doubt if the questions about stress and psychosocial conditions have the same validity in different cultures. Further research into this problem is of great importance for cross-cultural comparisons in this field. Another weakness of the study is the cross-sectional design, which makes it difficult to draw conclusion about causality. In principle, the increased prevalence of psychological distress among the immigrants could simply reflect that they had poorer mental health before entering Norway. That pre-migration stressors, like imprisonment, war experiences and torture, contribute to the excess morbidity of refugees, is documented by another study of the same sample (Thapa et al., 2005). Even here, however, post-migration factors seemed to be more important than pre-migration factors for mental health. Also with respect to non-refugee immigrants, whom the present study is dealing with, it is likely that pre-migration factors play a certain role.

CONCLUSION Together with low household income, unemployment, weak social support and negative life events, perceived lack of control contributes to the increased prevalence of psychological distress in Non-western immigrants. In accordance with this, empowerment should be an important part of preventive work in these immigrants. Lack of social integration is an important risk factor for mental health in men from Non-western countries living in Oslo, whereas this is not so for women from these countries. This indicates that from a mental health point view one should be cautious in expecting a rapid social integration of these women.

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ACKNOWLEDGMENTS The author is grateful to the Oslo Health Study 2000-2001 who have provided the data and made them ready for statistical analysis.

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[15] Seligman, MEP. Helplessness: On depression, development and death. San Francisco: Freeman, 1995 [16] Brown GW and Harris T The social origins of depression. London: Tavistock Publications, 1978. [17] Seeman, M. and Lewis, S. Powerlessness, health and mortality. A longitudinal study of older men and mature women. Soc. Sci. Med. 1995; 41: 517-525 [18] Syme, S.L. Rethinking disease: where do we go from here? Ann. Epidemiol. 1996; 6: 463-468 [19] Marmot MG, Bosma H, Heminway H, Brunner, Stansfeld S. Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet 1997; 349: 235-239 [20] McCubbin, M (editor.). Pathways to health, illness and well being: From the perspective of power and powerlessness. J. Community Appl. Soc. Psychol. 2001; 11 (2) [21] Kawachi, I. and Kennedy, BP. Income inequality and health. Pathways and mechanisms. Health Services Research 1999; 34: 215-227 [22] Schwarzer R. and Fuchs R. Self efficacy and health behaviour, in Predicting health behaviour. Edited by Rutter M and Norman P. Buckingham: Open University Press, 1966, pp 163-196 [23] Locke EA. and Latham GP. A theory of goal setting and task performance. Englewood Cliffs N J: Prentice Hall, 1990 [24] Hunt LM, Schneider S, Comer B. Should ―acculturation‖ be a variable in health research? A critical review of research on US Hispanics. Soc. Sci. and Med. 2004; 59: 973-986 [25] Nazroo J. Etnicity and mental health. London: P.S.I., 1997 [26] Madianos M. Acculturation and mental health of Greek immigrants in USA, in. Social Psychiatry. Edited by Hudolin. NY, USA: Plenum Publishing Company, 1984, pp 549557 [27] Dalgard OS, Sandanger I, Sørensen T. Mental health among immigrants in Oslo, Norway, in Social psychiatry in a global perspective. Edited by Varma VK, Masserman CM, Malhorta A and Malik SC. New Dehli: Macmillan India Limited, 1998, pp.107112 [28] Husain N, Creed F, Tamenson B. Adverse social circumstances and depression in people of Pakistani origin in the U.K. Br. J. Psych. 1977; 171: 434--438 [29] Minas H. Migration and mental health. Melbourne: Transcult Psych Unit Report, 1999 [30] 30 . Berry JW and Kim U. Acculturation and mental health, in Health and cross-cultural psychology, towards applications. Edited by Dasen P, Berry JW, Sartorius N. London: Sage publications 1988, pp. 207-238 [31] Murphy HBM. Migration, culture and mental health. Psychol. Med. 1977; 7: 677-684 [32] Bhugra D. Migration and mental health. Acta Psychiatr. Scand. 2004; 109: 243-258 [33] Hofstede G. Cultures consequences. Beverly Hills, CA: Sage, 1980 [34] Choudhry UK. Uprooting and resettlement experiences of South Asian immigrant women. Western J. Nurs Research 2001; 23: 376-393 [35] Dalgard, OS, Thapa, SB, Hauff, E, McCubbin, M and Syed, HR. Immigration, lack of control and psychological distress: Findings from the Oslo Health Study. Scand. J. Psychol. 2006; 47: 551-558

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[36] Dalgard, OS, Thapa, SB. Immigration, social integration and mental health in Norway, with focus on gender differences. Clin. Pract. Epidemiol. Ment. Health 2007, 3: 24. [37] Søgaard AJ, Selmer R, Bjertness E, Thelle D. The Oslo Health Study: The impact of self-selection in a large, population based survey. Int. J. Equity Health 2004, 3: 3 [38] Strand BH, Dalgard OS, Tambs K, Rognerud M. Measuring mental health of the Norwegian population: a comparison of the instruments SCL-25, SCL-10, SCL-5 and MHI-5 (SF-36). Nord. J. Psychiatry 2003; 57: 113-118 [39] Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L. The Hopkins Symprom Checklist (HSCL): a self-report symptom inventory. Behav. Sci. 1974; 19: 1-15 [40] Dalgard, OS, Dowrick, C, Lehtinen, V, Vasquez-Barquero JL, Casey P, Wilkinson, G, Ayuso-Mateos, JL, Page, H, Dunn, G. Negative life events, social support and gender difference in depression. A multinational community survey with data from the ODIN study. Soc. Psychiatry Psychiatr Epidemiol. 2006; 41: 444 - 451 [41] Brugha T, Bebbington PE, Tennant C, Hurry J. The list of threatening experiences: a subset of 12 life event categories with considerable long-term contextual threat. Psychol. Med. 1985; 15: 189-194 [42] Tennant C, Andrews G. A scale to measure the cause of life events. Aust. N. Z. J. Psychiatry 1977; 11: 163-167. [43] Jerusalem, M., Scwarzer, R. (1992). Self-efficacy as a resource factor in stress appraisal process, in Self-efficacy: Thought control of action. Edited by Schwarzer, R. Washington, DC: Hemisphere, 1992, pp. 195-213 [44] Rogers, ES, Chamberlin, J, Ellison, ML, Crean, BA. A consumer-constructed scale to measure empowerment among users of mental health services. Psychiatr. Serv. 1997; 48: 1042-1047. [45] Rothbaum, F, Weisz, JR, Snyder, SS. Changing the world and changing the self: A twoprocess model for perceived control. J. Pers. Soc. Psychol. 1982; 42: 5-37. [46] Eriksen, HR., Ursin, H. Social inequalities in health: Biological, cognitive and learning theory perspectives. Norw. J. Epidemiol. 2002; 1: 33-38

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 10

DEPRESSION AMONG LATINOS IN THE UNITED STATES Patricia Gonzalez1 and Monica Rosales2 1

2

San Diego State University, San Diego, California, USA City of Hope National Medical Center, Duarte, California, USA

ABSTRACT Depression is a major public health concern that places significant burden on the lives of Latino individuals, their families, and society. Latinos comprise a growing and diverse population making up the largest ethnic minority group in the U.S. This chapter provides an overview of the impact of demographic, immigration, acculturation, and social factors on depression among U.S. and non U.S. born Latinos. The review of the literature illustrates the complex nature of the relationships among these factors across Latino groups. Given the distinct immigration patterns and cultural backgrounds of Latinos, we recommend that research examine differences between Latino groups to determine how these differences shape depression outcomes. The main findings described in this chapter provide pertinent information about the correlates of depression and can guide interventions aimed at reducing depression risk among Latinos.

INTRODUCTION Depression is a major public health concern in the United States (U.S.) that places significant burden on the lives of individuals, families, and society. More specifically, major depression is the most common psychiatric disorder in the U.S. with an estimated 17% lifetime prevalence in the general population [1, 2]. In any given year, major depression afflicts approximately 6.7% of the U.S. population 18 years of age and older [2]. Findings from NHANES data (2005-2006) indicate that in any 2 week period, 5.4% of Americans 12 years of age and older, experienced depression [3]. In 2000 Latinos comprised 13.3% of the U.S. population [4]), becoming the largest ethnic minority group in the U.S. [5]. In 2002, of the total U.S. Latino population, the largest group

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was of Mexican origin (66.9%) followed by Central and South American (14.3%), Puerto Rican (8.6%), Cuban (3.7%) and other Latinos (6.5%) [4]. Given that two in five U.S. Latinos are immigrants, greater understanding of Latino immigrants‘ mental health status is increasingly important [6]. Despite the fact that Latino immigrants represent a growing U.S. population they continue to remain ignored in the literature [7]. This chapter describes depression among Latino immigrants and U.S. born Latinos by presenting; (1) a synthesis of existing evidence concerning the relationship between demographic variables and depression (2) the impact of immigration on depression; (3) the impact of acculturation and social stressors associated with depression; and (4) the limitations of current literature and recommendations for future research.

Prevalence of Depression Although a few national (e.g., HHANES, NIMH Epidemiologic Catchment Area Program, Mexican American Prevalence and Services Study), community, and primary care studies have included Latino samples (mainly Mexican Americans), the rate and risk factors of major depression have been primarily studied among non-Latino Whites. Existing data indicates that in 2006, Latino adults 50 years of age and older reported higher rates of mental distress (13.2%) compared to non Latino Whites (8.3%) and non Latino Blacks (11.1%) [8]. Further, Latino adults were more likely to report current depression (11.4%) compared to non Latino Whites (6.8%) and non Latino Blacks (9%) [8]. NHANES data indicate that in 20052006, 6.3% of Mexican Americans 12 years of age and older reported current depression compared to 4.8% among non Latino Whites [3]. Table 1 presents a summary of the studies reviewed, some of which are discussed in this chapter. As mentioned earlier research on Latino immigrants is limited and empirical findings on depression among Latinos to date have been inconsistent [9, 10]. For example, some studies have reported: 1) higher depression levels among Latinos compared with non-Latino Whites [11]; 2) higher depression among Latino immigrants compared to U.S. born Latinos [12]; and 3) some studies have reported lower depression levels among Latino immigrants [5, 13] compared to their U.S. born counterparts.

Factors Associated with Depression Several factors have been linked to depression among Latino immigrants. In particular, the variability in depression rates is influenced by socio-demographic factors (e.g., education, income, and sex), nativity (U.S.-born, non-U.S. born), acculturation, perceived social support, and feelings of deprivation. Moreover these factors tend to be linked to ethnicity [14]. Together these factors would suggest that Latinos may be at an elevated risk for depression compared to Whites.

Table 1. Depression Studies Reviewed Authors

Study Purpose

Sample/location

Examined the effects of psychosocial risk and protective factors on depressive symptoms among agricultural workers from Mexico working in California Examined depression prevalence among U.S. Latinos across ethnicity, nativity, generational status, Englishlanguage proficiency, length of residence in the U.S. and age at migration

1,001 Participants Sex: 500 Males, 501 Females Ages 18-59 Rural California 2554 Participants Sex: 1127 Males, 1427 Females Nationally representative U.S. sample

Breslau, AguilarGaxiola, Borges, Castilla-Puentes, Kendler, MedinaMora, Su, and Kessler (2007)

Examined whether migrants have higher risk for onset and persistence of mental disorders after they migrate to the U.S., the period during which environmental stressors could have an impact

Crockett, Iturbide, Torres Stone, McGinley, Raffaelli, and Carlo (2007) Cuellar, Bastida, and Braccio (2004)

Examined acculturative stress, psychological functioning, social support, and coping style in Mexican American college students

Alderete, Vega, Kolody, AguilarGaxiola (1999)

Alegria, Mulvaney-Day, Torres, Polo, Cao, and Canino (2007)

Compared mental well-being between Mexican immigrants and U.S. born Mexican Americans

Country of Birth/Immigration status Mexican Immigrants (n=1001)

Depression measure

Findings

CES-D

Time in US did not increase risk of depressive symptoms. Acculturation was a significant mental health risk factor.

Immigrants (n=1630) U.S. born (n=924) Latino groups: Mexican (n=868) Puerto Rican (n=495) Cuban (n=577) Other (n=614)

World Mental health Survey Initiative version of the WMH-CIDI

Subsample of the US National Comorbidity Survey Replication (NCSR), and Mexicans, the Mexican National Comorbidity Survey

Mexican Immigrants (n=75) Mexican residents (n= 2326)

Compositie International Diagnostic Instrument ( v3)

148 Participants Sex: 49 Males, 99 Females Age: 18-30 Texas and California 353 Participants Sex: Males (25.8%), Females (74.2%) Age: 45-88; M=63; Texas

Mexican Immigrants (17%) Mexican Americans (83%)

CES-D

Mexican Immigrants (n=148) Mexican Americans (n=205)

Depressive Symptom Scale

Puerto Ricans had the highest overall psychiatric prevalence rate among Latino groups. Mexican origin Latinos were less likely to have a history of depression. Latino immigrants less likely than U.S.-born Latinos to have a history of overall psychiatric disorders. Immigrants had significantly higher lifetime and 12 month prevalence of mood disorders than the Mexican sample, with a lifetime prevalence of any mood disorder twice as high among immigrants as Mexican residents, and a 12-month prevalence close to three times as high among immigrants as Mexican residents. Acculturative stress was associated with higher anxiety and depression. Parental support buffered acculturative stress effects on anxiety and depressive symptoms. No differences in depression scores between Mexican Americans and Mexican immigrants were observed.

Table 1. Depression Studies Reviewed (Continued) Authors

Study Purpose

Finch, Kolody and Vega (2000)

MAPSS Investigated the direct and moderating connections between perceived discrimination, acculturative stress, and mental health Assessed differences between U.S. born Mexican Americans and Mexico-born immigrants in depression using community data

3,012 Participants Age: 18-59 Fresno, California

1244 Participants U.S. born: Male (46%) Female (54%) Age: Mean=38 Los Angeles, California

Mexican Immigrants (n=706) Mexican Americans (n=538)

CES-D

Gonzalez, Haan, and Hinton (2001)

Examined the association between acculturation, immigration, and depression among older Mexican Americans.

1663 Participants Sex: 695 Males, 968 Females Ages: Mean=70.6; 60100 Northern California

CES-D

Gonzalez and Gonzalez (2007)

Examined the association among acculturation and native status in the prevalence of depression

Beck Depression Inventory-II

Women and low acculturated individuals were more likely to report depressive symptoms.

Hovey (2000)

Examined the relationship among acculturative stress, depression, and suicidal ideation as well as predictors of depression and suicidal ideation among Mexican immigrants

153 Participants Sex: 61 Males, 91 Females Age: Mean = 25; 18-56 Southern California 114 Participants Sex: 38 Males, 76 Females Ages: Mean=34; 17-77 Los Angeles, California

U.S. born (n=831) Immigrant ( n=832) Mexican Immigrants (89%) Other country Immigrants (11%): Central America (67%) South America (20%) Caribbean (13%) Mexican American (n= 57) Mexican Immigrants (n=96) Mexican Immigrants (n=114)

CES-D

Mexican immigrants who experienced more acculturative stress, family dysfunction, and ineffective social support had higher levels of depression.

Golding and Burnam (1990)

Sample/location

Country of Birth/Immigration status Mexican Americans (n=1,124) Mexican Immigrants (n=1,888)

Depression measure CES-D

Findings Discrimination was directly related to depression, but this effect was moderated by country of birth, English-language acculturation, sex, and country of education variables. Higher depressive symptoms were observed among Mexican Americans compared to Mexican immigrants. Not being married, lack of marital support (for married), and less relatives were associated with depressive scores. Immigrants and less acculturated Latinos had higher prevalence of depression compared to U.S. born Latinos and more acculturated Latinos.

Authors

Study Purpose

Hovey (2000a)

Examined the relationship among acculturative stress, depression, and suicidal ideation among Central American immigrants

Kessler, McGonagle, Zhao, Nelson, Hughes, Eshlemann, Wittchen, Kendler (1994)

Presents lifetime and 12 month prevalence of 14 DSM-III-R psychiatric disorders from the National Comorbidity Survey

Miranda and Umhoefer (1998)

Examined differences in depression among low acculturated, bicultural, and high acculturated Latinos

Salgado de Snyder, Cervantes, and Padilla (1990)

Examined the relationship between gender, ethnicity, psychological stress and generalized distress among immigrant Latinos and US born Mexican Americans

Vega, Kolody, Aguilar-Gaxiola, Alderete, Catalano and CaraveoAnuduaga (1998)

Compared psychiatric morbidity for immigrant and native-born adults of Mexican origin with rates for the U.S. national population from the NCS and from Mexico City, Mexico

Sample/location 78 Participants Sex: 14 Males, 64 Females Age: Mean=38.5; 17-75 Los Angeles, California Sex: 49.1% Males, 50.9% Females Age: 15-54 75% White 11.9% Black 8.6% Hispanic 4.5% Other 282 Participants Sex: 138 Males, 175 Females Ages: Mean=31 Georgia

593 Participants Sex: 293 Males, 300 Females Age: Immigrant Mean=24; U.S. born Mean=22 Los Angeles, California 3012 Participants Sex: 1496 Males, 1516 Females Age: 18-59 Fresno, California

Country of Birth/Immigration status Immigrants (n=78): El Salvador (71.1%), Guatemala (17.1), Honduras (9.2%), Nicaragua (2.6%) County of birth not reported

Depression measure CES-D

Central American immigrants with greater acculturative stress, family dysfunction, and lower social support were at greater risk for depression.

Composite International Diagnostic Interview (CIDI)

Over 17% of participants had a history of major depressive episode (MDE) in their lifetime, and more than 10% had an episode in the past 12 months. Latinos had higher prevalence of current affective disorders and compared to Whites. Less acculturated Latinos had slightly higher depression scores than high acculturated and bicultural Latinos. Bicultural Latinos had significantly higher social interest and lower depression scores.

U.S. born (n=81%) Immigrant (n=19%)= Mexico, Cuba, El Salvador, Chile, Puerto Rico, Panama, Argentina, Peru, Bolivia, Ecuador, Uruguay, Venezuela, Honduras, Guatemala, Paraguay Mexican American (n=329) Mexican Immigrants (n=138), Central American Immigrants (n=126),

BDI

Mexican American (n= 1202) Mexican Immigrant (n=1810)

Composite International Diagnostic Interview (CIDI) modified version

Note. Mexican American refers to individuals of Mexican origin born in the U.S. Mexican Immigrant refers to individuals of Mexican origin born in Mexico.

Findings

CES-D

Depression scores higher among Central American than Mexican immigrants and Mexican immigrants had higher scores than Mexican Americans. Among, immigrants, family conflict was associated with higher depressive symptoms. Mexican immigrants had lifetime rates similar to Mexican citizens. Mexican Americans (14.8%) had higher lifetime prevalence of a major depressive episode compared to Immigrants (5.2%). As Mexican immigrants acculturated their mental health worsened.

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Socio-economic Status Factors Education. The impact of education on depression has been examined primarily among White samples, while minimal research has examined the impact of education on depression among Latinos. The few studies that have included Latino samples have found lower education levels to be significantly associated with prevalence of major depressive disorder for Mexican American individuals [15, 16]. Education may provide immigrants with the resources to cope better in a new society. However, greater research attention is needed to clearly understand the impact of education on Latinos. Income. Higher rates of depression among Latinos compared to Whites may be due, in part, to Latinos‘ lower socioeconomic status (SES) [14]. Latinos in the U.S. regardless of citizenship status, tend to have lower SES than Whites [4]. Furthermore, there is a wide range of income levels among Latinos [17]. Studies have found that low SES increases Latinos‘ risk for depression [2, 18, 19]. More specifically, the SES - depression relationship may be mediated by stress, given that lack of financial resources may be perceived as stressful and depression may develop in the context of psychosocial stress. For example, lower SES levels may lead to problems meeting basic needs, which may place individuals at risk for depression. Thus, to the extent that Latinos face financial hardships, they may be at increased risk for depression [9]. Sex. Depressive symptoms tend to be higher for women than men [9, 20-23].Overall, women have been found to be twice as likely to develop depression compared to men. Further, sex has been found to be a risk factor among Mexican and Puerto Ricans [23, 24]. Several explanations may shed light on these findings. First, poverty, a risk factor for depression, is more prevalent among women than men [18]. Second, cultural differences in gender socialization may impact the magnitude of depression-sex differences [9]. For example, traditional Latino values that emphasize strength for males and submissiveness for females may increase the likelihood that Latinas express psychological distress through internalizing pathways such as depressive symptoms [9]. Yet another explanation for these sex differences may be attributed to differences in explanatory style. According to NolenHoeksema [25] when depressed, men tend to engage in extracurricular activities (i.e., sports). Women, on the other hand, tend to be less active and ruminate about the potential causes of their depression. Furthermore, individuals who engage in activities to distract themselves from their depressive mood appear to recover faster from depressive episodes than individuals who remain inactive and ruminate about the causes of their emotional state [25]. Immigration Factors As a group, Latinos face particularly stressful life situations [26]. Many are immigrants who enter the U.S. to work [26] and the vast majority do not speak English [27]. Overall, Latino immigrants endure numerous stressors that impact their mental health. For example, immigrants may experience the breaking of ties to family and friends in their country of origin, thus resulting in feelings of loss and a reduction in coping resources. Immigrants also experience stressful factors specific to their new environment including discrimination, language difficulty, lack of social and financial resources, and feelings of not belonging in the host society [28]. Despite the numerous stressors that Latino immigrants encounter, several studies report more favorable mental health outcomes [17, 23]. More precisely, the risk of major depression seems to be greater for U.S. born Latinos than for Latino immigrants.

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Latino Groups Regional as well as national studies have begun to uncover differences in depression among Latino groups that may be accounted for by native status [29, 30]. A limitation of these studies is that the majority of them have involved depression estimates of a single Latino group, Mexican Americans in particular, in southwestern U.S. regions. Additionally, no major mental health studies to date have included other growing Latino groups (e.g., Dominican, Colombians, Ecuadorians) [31]. Emerging evidence suggests that depression patterns appear to vary by Latino group (e.g., Mexican, Puerto Rican, and Cuban). For example, Puerto Ricans have been found to have significantly higher lifetime rates of major depression episodes (9.24) than Mexican Americans (4.17) and Cubans (3.24) [32]. Puerto Ricans have also reported a greater number of psychiatric disorders than Mexican or Cuban Americans [29, 30]. Puerto Ricans experience the lowest SES of the major Latino groups [31, 33] which in part may explain their higher depression rates. Acculturation Acculturation as a contributing factor to Latinos‘ mental health has been examined [3436]. Acculturation refers to the process by which individuals adjust to a nonnative culture [37, 38]. Two theories of acculturation have been proposed. One theory is that acculturation is unidimensional ranging from not acculturated to acculturated [37, 39]. The second theory is that acculturation is bidimensional and emphasizes integration or biculturalism [37, 39]. Modern theories are more likely to embrace the latter conceptualization of acculturation suggesting that multiple cultural attachments are possible [35]. Given that U.S. Latinos may be at greater risk of suffering from mental health problems [33, 40], examining the relationship between acculturation and depression is warranted. However, research examining this relationship has revealed mixed and contradictory findings [13, 40, 41]. Some studies have found no association between acculturation and depression. For example, Falcon and Tucker [33] found no association between acculturation level and depression among Latinos (i.e., Puerto Rican, Dominican and other Latinos) residing in Massachusetts. In addition, Canabal and Quiles [42] found no association between depression and acculturation among Puerto Ricans. Several studies examining Mexican Americans and Mexican immigrants also report no association between acculturation level and depression [10, 13, 43]. Yet, other studies report that mental health deteriorates as acculturation level increases [44-46]. More specifically, associations between acculturation and depression have been highlighted in the literature. However, the results are unclear in that some studies report an association between higher acculturation levels and depression while others report lower acculturation levels to be associated with depression. Some studies with large population samples (e.g., NESARC, ECA, H-HANES) report an association between depression and length of time among Mexican immigrants, indicating that the longer they live in the U.S. the more likely they are to experience depression [47-49]. Similar results have been found for older Dominican immigrants [33]. The depression and acculturation link has also been examined among U.S. born and immigrant Latinos. A review that examined studies focusing on U.S. born and Latino immigrants (i.e., Mexican, Central American, Puerto Rican, Cuban) reported higher rates of depression among U.S. born Latinos compared to immigrants [50]. Similarly, higher

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depressive symptoms have been found among U.S. born Mexican Americans compared to Mexican immigrants [11, 48, 51]. Despite research suggesting that depression increases with time in the U.S., there are other studies that have reported the opposite. For example, higher depression rates have been reported among immigrants (Mexican, Central and South American) and less acculturated Latinos compared to U.S. born Latinos and more acculturated Latinos [10, 12].Similarly, island born Puerto Ricans have reported higher levels of depression than U.S. born Puerto Ricans [51].

Acculturative Stress A related yet distinct construct resulting from the acculturation process is acculturative stress [52, 53]. As immigrants adapt or acculturate to a new society, they may experience several changes and stressors [38, 52] that impact acculturative stress. These changes and stressors include factors such as language familiarity and use, cultural heritage, ethnic pride and identity, discrimination [38, 52], pre-immigration experiences, post migration acculturation experiences (e.g., immigration stress, feelings of not belonging in the host society) [52], degree of acculturation [38, 54] generational status, age [55], and familial factors such as severing ties with family and friends in the country of origin [38, 52, 56]. Acculturative stress has been linked to depression [36, 38, 44, 57]. For example, higher levels of acculturative stress have been found to be significantly associated to depression among Mexican origin Latinos residing in the U.S. [44, 58]. Studies examining the association between acculturative stressors and depression found that Mexican immigrants who experienced greater acculturative stressors (e.g., discrimination, immigration stress, family structure changes, separation from family, and feeling excluded because of ethnic background) also had higher depression levels [21, 46, 54, 57]. Similar findings have also been reported for Central American immigrants [21, 52]. Social and Emotional Support Past studies suggest a positive relationship between social support and mental health, including depression [23, 59-62]. The support received and required by different groups may come from different sources. For example, among Latinos, families may provide social and emotional support, which serves as a stress buffer [32, 44]. In the Latino culture, familismostrong feelings of attachment, shared identity, family loyalty- is emphasized [63]. Further, strong familial bonds fostered through family cohesion are expected to promote family support [22]. Thus, it is not surprising that the social and emotional support received from immediate and extended family has been linked to lower depressive symptoms [34, 44, 55, 64, 65]. Familial factors such as marital status, marital support, and number of relatives residing in the U.S. have been associated with lower levels of depression [11]. Among Mexican and Central American immigrants, family conflict has been associated with higher depressive symptoms [21]. Hiott et al. [46] found that among Mexican immigrant women, separation from family, which contributes to loss of social support, was associated with greater depressive symptoms. Moreover, among Mexican immigrants [57] and Central American immigrants [52], family dysfunction and ineffective social support have been found to be associated with higher levels of depression. Aranda, Castaneda, Lee, and Sobel [64] found that among Mexican immigrant and Mexican American men low social support from relatives predicted higher levels of depressive symptoms and among women lower partner

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social support predicted depressive symptoms. Similarly, family cohesion has been found to be associated with lower levels of psychological distress (e.g., depression) among Mexican, Puerto Rican, Cuban and other Latino immigrants residing in the U.S. [22].

Latino Health Paradox In spite of all the factors mentioned above, overall, Latinos appear to have better health outcomes compared to Whites [66], a phenomenon often described as the Latino health paradox. Several hypotheses have been offered to explain the paradoxical association between immigration status and depression, including selective migration, relative deprivation [10], and stress coping skills. The selective migration explanation predicts that individuals with good mental health are more likely to immigrate than those with poor mental health [5, 11]. In terms of stress coping skills, Latinos may employ healthier stress coping styles than Whites [26]. For example, one study found that Mexican immigrants tended to process stress in more adaptive ways than Whites [26]. Moreover, Mexican immigrants may retain culturally protective factors that may provide powerful sources of emotional resilience [9]. For example, the Latino cultural value of familismo, which places a strong emphasis on family relationships, may foster positive social support that protects individuals from depression [9]. This resilience may decrease as individuals become fluent in English or spend more time in the U.S. [9]. Although widely reported among Latino populations, inconsistent evidence exists regarding the generalizability of the Latino health paradox [29]. The relationship between nativity and depression risk, best established among Mexican Americans, may also extend to other Latino groups [17]. That being said, when examining depression, caution should be exercised in generalizing the Latino health paradox to all Latino groups [29]. Relative Deprivation. Another explanation for Latino immigrants‘ positive mental health may be attributed to immigrants‘ better psychological resources and lower expectations for income and employment status, which may account for lower depression rates relative to their U.S. born counterparts [11]. For example, Latino immigrants may experience economic hardships and inequality in their country of origin and in turn, these experiences may then decrease the likelihood of demoralization among Latino immigrants in their new environment and increase resignation to negative outcomes, resulting in lower depression risk. Expectations of the new country both in terms of personal and social gains must be matched by achievement in order for the individual to function well [67]. U.S. born Latinos, having higher expectations for status attainment, may be more distressed and experience a greater sense of deprivation and greater risk of psychiatric morbidity when they fail to meet their own expectations than their foreign born counterparts [5]. However, immigrants may have a differing viewpoint and set of expectations about what constitutes ―success‖ in America [23]. For example, since Puerto Ricans are U.S. citizens they may experience a greater sense of failed expectations if they are not economically successful (Alegria et al. 2007).

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CONCLUSION A synthesis and review of major findings was provided concerning depression among U.S. Latino immigrant groups as well as a brief table depicting some of the studies reviewed. The research to date is plagued with several limitations. First, researchers who investigate the determinants of depression in Latino immigrants tend to focus on social processes occurring after migration [68]. An examination of psychological influences operating prior to migration may help elucidate observed individual differences in the adaptation process [34]. Therefore, our understanding of the relationship between immigration and depression can be enhanced by comparing Latino immigrants to Latinos in their home countries. Second, grouping Latinos together and generalizing findings to all Latino groups will not suffice [32]. Several studies aggregate study results under the umbrella of Latino and do not stratify key variables (e.g., immigration status) by Latino group. However, Latinos are a heterogeneous group in several aspects such as by birth place, acculturation, and reasons for migrating [31, 36]. It is important to acknowledge this heterogeneity because these factors can contribute to Latinos‘ immigration and acculturation experiences in the U.S., which in turn influence their mental health. Guarnacia (2000) argues that using a general label to represent Latinos is inappropriate because factors as those just mentioned differ between Latino groups. For example, Hovey [52] suggests that greater levels of depression among Central American immigrants compared to Mexican immigrants may in part be due to preimmigration factors such as trauma experienced as a result of socio-political circumstances. Third, studies have been conducted primarily in states such as California and Texas and have focused on Latinos of Mexican origin [33, 35] and on those aged 20 to 64 years [33]. Delgado et al. [47] highlight the under-representation of Central and South Americans in the literature and the need for research with these populations to gain an understanding of their mental health. Thus, it is important to examine depression and its risk factors among Latino groups other than Mexican immigrants and Mexican Americans. Fourth, the existent studies have used assessment instruments that have been normed on White samples (CES-D and BDI-II). More research on the use, validity and reliability of depression scales is needed. What are the reliability and validity of currently available scales among Latino subgroups? Furthermore, acculturation is a unique construct that has not been operationalized or measured consistently across time and studies. It has been pointed out that proxy variables (e.g., use of the English language, ethnic identity, birthplace, and length of time in the U.S.) have been used to measure acculturation [69, 70]. Lara et al. [35] noted that their review of the literature revealed inconsistencies in the measurement of acculturation and stated the importance of this inconsistency in the interpretation of findings. These methodological differences (i.e., operationalization; domains measured) reflect the inconsistent and contradictory findings in acculturation research [40]. Further, whether acculturation has a positive or negative effect on Latinos‘ mental health depends in part on the way acculturation is measured [35]. Thus, while measuring acculturation is no easy task, its role as a contributing factor to depression among Latinos merits further examination. Given the substantial increase of Latinos from different countries in the U.S., the unfavorable effects of depression on overall well-being should continue to be examined. With the continued entry of Latino immigrants, and changes in public opinion about immigration, predicting how the U.S. will change with Latino culture is no easy task [53]. Thus, the

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relationship between depression and Latinos is a complex one influenced by multiple factors. A greater understanding of the correlates of depression among Latinos is essential for managing and facilitating depression treatment appropriately. The questions that remain are: what factors place U.S. born and immigrant Latinos at greater risk for depression? Which factors serve as protective factors against mental health problems? By broadening our understanding of the key risk factors across Latino groups we will be better able to address depression disparities.

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Patricia Gonzalez and Monica Rosales the literature and recommendations for policy research: FOCUS: The Journal of Lifelong Learning in Psychiatry 2006; 4: 38-47. Alderete E, Vega WA, Kolody B Aguilar-Gaxiola S. Depressive symptomatology: Prevalence and psychosocial risk factors among Mexican migrant farmworkers in California: Journal of Community Psychology 1999; 27: Vega WA, Kolody B, Aguilar-Gaxiola S, Alderete E, Catalano RCaraveo-Anduaga J. Lifetime Prevalence of DSM-III-R Psychiatric disorders among urban and rural Mexican Americans in California: Archives of General Psychiatry 1998; 55: 771-778. Escobar JI, Hoyos Nervi CGara MA. Immigration and mental health: Mexican Americans in the United States: Harvard Review of Psychiatry 2000; 8: 64-72. Torres-Stone R, Rivera FI Berdahl T. Predictors of depression among non-Hispanic Whites, Mexicans and Puerto Ricans: A look at race/ethnicity as a reflection of social relations: Race and Society 2004; 7: 79-94. Hovey JD. Acculturative stress, depression, and suicidal ideation among Central American immigrants: Suicide and Life-Threatening Behavior 2000a; 30: 125-140. Caplan S. Latinos, acculturation, and acculturative stress: A dimensional concept analysis: Policy, Politics, and Nursing Practice 2007; 8: 93-106. Finch B Vega W. Acculturation stress, social support, and self-rated health among Latinos in California: Journal of Immigrant Health 2003; 5: 109-117. Hovey JDKing CA. Acculturative stress, depression, and suicidal ideation among immigrant and second generation Latino adolescents.: Journal of the American Academy of Child and Adolescent Psychiatry 1996; 35: 1183-1192. Miranda AO, Estrada DFirpo-Jimenez M. Differences in family cohesion, adaptability, and environment among Latino families in dissimilar stages of acculturation: The Family Journal 2000; 8: 341-350. Hovey JD. Acculturative stress, depression, and suicidal ideation in Mexican Immigrants: Cultural Diversity and Ethnic Minority Psychology 2000; 6: 134-151. Shattell MM, Smith KM, Quinlan-Colwell A Villalba JA. Factors contributing to depression in Latinas of Mexican origin residing in the United States: Implications for nurses: Journal of the American Psychiatric Nurses Association 2008; 14: 193-204. Berkman LF. The role of social relations in health promotion: Psychosomatic Medicine 1995; 57: 245-254. Kawachi I Berkman LF. Social ties and mental health: Journal of Urban Health 2001; 78: 458-467. House JS, Landis KR Umberson D. Social relationships and health: Science 1988; 241: 540-545. Seeman TE. Social ties and health: Annals of Epidemiology 1996; 6: 442-451. Marin GMarin BV Research with Hispanic populations, ed. S. Publications. 1991, Newbury Park, CA. Aranda MP, Castaneda I, Lee P Sobel E. Stress, social support, and coping as predictors of depressive symptoms: Gender differences among Mexican Americans: Social Work Research 2001; 25: 37-48. Alderete E, Vega WA, Kolody B Aguilar-Gaxiola S. Lifetime prevalence of and risk factors for psychiatric disorders among Mexican migrant farmworkers in California: American Journal of Public Health 2000; 90: 608-614.

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[66] Morales LS, Kington RS, Valdez RO Escarce JJ. Socioeconomic, cultural, and behavioral factors affecting Hispanic health outcomes: Journal of Health Care for the Poor and Underserved 2002; 13: 477-503. [67] Bhugra D Ayonrinde D. Depression in migrants and ethnic minorities: Advances in Psychiatric Treatment 2004; 10: 13-17. [68] Grzywacz JG, Quandt SA, Early J, Tapia J, Graham CN Arcury TA. Leaving family for work: ambivalence and mental health among Mexican migrant farmworker men: Journal of Immigrant and Minority Health 2006; 8: 85-97. [69] Hunt LM, Schneider S Comer B. Should ―acculturation‖ be a variable in health research? A critical review of research on U.S. Hispanics: Social Science and Medicine 2004; 59: 973-986. [70] Heilemann M, Lee K Kury F. Strengths and vulnerabilities of women of Mexican descent in relation to depressive symptoms: Nursing Research 2002; 51: 175-182.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 11

ACCULTURATION, ACCULTURATIVE STRESS, AND DEPRESSION AMONG HAITIANS IN THE UNITED STATES Guerda Nicolas, Darren Bernal and Seth T. Christman University of Miami, Miami, Florida, USA

ABSTRACT Acculturation and Acculturative Stress have been shown to be important factors in understanding the mental health of immigrants and ethnically diverse groups. This study is the first examination of the role of acculturation, acculturative stress, and depression in the Haitian population residing in the United States. Results from the study revealed that age, gender, and acculturative stress accounted for significant variance in depression levels. Implications for practice and research are discussed.

INTRODUCTION The Surgeon General‘s Report on Mental Health and its Supplement report [1] highlighted the disparities that exist for ethnic and racial minority groups in need of mental health services. The report concluded that racial and ethnic minorities had less access to mental health services than Whites, were less likely to receive needed care, and when care was received, it was more likely to be of poor quality [1]. A number of barriers are reported to explain the underutilization of mental health services among ethnic minorities. Some of the most commonly identified barriers are: (1) socioeconomic status, (2) lack of knowledge about mental health services, (3) mistrust and fear of treatment, (4) different cultural ideas about illness and health, (5) lack of insurance, (6) immigration status, (7) stigma, (8) language, and (9) discrimination [2, 3, 4, 5]. Acculturation, defined as the extent to which a person identifies with his or her group of origin and its culture or with the mainstream dominant culture [6], has been studied among various ethnic groups in the U.S. For ethnic minorities, this means acculturating to the

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dominant, White culture. Few studies have focused on the specific acculturation experiences of Blacks, and there is no known study focusing on the acculturation process of Haitians in the United States. Indeed, several studies have shown that acculturation and acculturative stress differ across different ethnic/cultural groups [7, 8] in a number of ways. In this chapter, we review the literature on acculturation and acculturative stress among ethnic minority immigrants in the U.S. and summarize the results of a project from a community sample of Haitian immigrants in the United States with respect to their acculturation and acculturative stress.

ACCULTURATION AND MENTAL HEALTH Acculturation is considered an interactive process between an individual and the dominant host culture [8, 9]. An individual‘s acculturation will depend on the degree of changes in attitudes, behaviors, cognitions, identity, and values resulting from contact with the dominant host culture [8]. More acculturated individuals will retain less of their native culture (i.e. language, values, beliefs, traditions) and experience more changes in thinking and behavior. For example, acculturation can be particularly difficult for Latinos because they maintain closer ties to their native country by preserving their language and cultural characteristics [10]. However, integrating their cultural beliefs with those of the dominant culture can be challenging, often becoming a significant stressor that places Latinos at risk for developing mental health problems [11]. Although some studies have argued that higher levels of acculturation are associated with higher levels of psychological distress and mental health problems, [12], this does not appear to be the case for Colombian immigrants [10]. With respect to this finding, it is important to recognize that many of the participants came to the Unites States at an older age. Therefore, unlike immigrants in the Balls et al. study [12], the participants may not have acculturated to the point of losing traditional cultural norms or the supportive family networks which are believed to guard against distress. Overall, these results support those of previous findings, mainly that there is a significant impact of acculturation and acculturative stress on mental health for Latinos, the effects of which have been found to be similar across different ethnic Latino groups. The relationship between acculturation and mental health status is complex. Numerous studies have shown a relationship between low levels of acculturation and mental health problems [13]. Low levels of acculturation and mental health problems may be explained in part by recent immigrants leaving their support systems and entering a new society, resulting in higher levels of psychological distress. Conversely, highly acculturated individuals may experience psychological stressors, such as the challenges of adjusting to the cultural values of the dominant society [14]. Latinos reporting high levels of acculturation also report greater levels of depressive symptoms [15], more psychopathological symptoms [16], and higher levels of chemical dependency [17].

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Acculturative Stress and Mental Health The term ―acculturative stress‖ refers to the stress that an individual experiences as they move away from their country of origins to another [18]). Some studies suggest that high levels of acculturative stress may place individuals at risk for developing psychological problems [19, 20]. Studies on acculturative stress show that it can lead to a number of healthrisks, including depression, anxiety, psychosomatic symptoms, suicidal ideation, and identity confusion [19, 20]. For Latinos, acculturative stress has been reported to negatively influence occupational functioning, decision making abilities, and physical health. Lacks of social support, English language competency, and socioeconomic status have all been found to increase acculturative stress in Latinos [21, 20]. It is evident from the cited studies that acculturative stress can have a negative impact on mental health in Latinos. Understanding the impact of acculturative stress among other ethnically diverse groups will assist in advancing the mental health field.

HAITIAN POPULATION IN THE UNITED STATES Although research has increasingly focused on racial minority families, very little attention has been paid to the rapidly increasing Black Caribbean communities in the United States. Data from the 1990 U.S. Census show that almost one million persons were of English-speaking, West Indian heritage, and that 6% of the Black population was foreignborn. With regard to specific Caribbean groups, data from the 2000 Census indicate that there were 419,317 foreign-born Haitians in the United States. It is estimated that 544,000 to 637,000 second-generation Haitians resided in the United States in 2001, with anywhere from 163,000 to 191,000 of those living in New York City [22]. After Jamaica, Haiti is the second largest source of Black immigrants to the United States [23], and Haitians comprise at least 8% of the population that researchers commonly classify as African Americans [23]. Despite the large number of Haitian immigrants in the United States, there is a dearth of information about the mental health of this group [24]. Considering the rapidly increasing number of Haitians immigrating to the United States and the paucity of research concerning them, it becomes important to investigate factors that influence the mental health of this group in order to ensure that efficacious mental health treatment and prevention methods are developed specifically for this population in the United States.

The Focus of the Chapter Acculturation and acculturative stress research to date has examined both the characteristics and the impact of these factors in the lives of many immigrant groups [19, 13]. Unfortunately, however, research has not yet examined these issues for Haitian immigrants, nor has it provided descriptive information on the characteristics and impact of acculturation and acculturative stress in the lives of Haitian immigrants. Therefore, the purpose of this study is to (a) report descriptive information about acculturation and acculturative stress of Haitian immigrants; (b) explore relationships between acculturation, acculturative stress and

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depression among Haitian immigrants; and (c) determine whether acculturation and acculturative stress predict depression for Haitian immigrants. This in-depth examination will provide mental health clinicians and researchers with data on the characteristics and impact of acculturation and acculturative stress for Haitian immigrants. Such results can elucidate strategies for treatment and research delivery for this population. Table 1. Demographics Characteristics and Percentage of Sample n

%

Female

90

60.4

Male

59

39.6

Less than high school

16

12

High school completion

65

43.3

Completed college or trade school

44

27.3

Graduate degree

19

12.7

Never married

42

28

Engaged

2

1.3

Cohabitating/common law marriage

2

1.3

Married

71

47.3

Separated

3

2

Divorced

23

15.3

Widow/widower

7

4.7

Work full-time

76

50.7

Work part-time

24

16

Homemaker

4

2.7

Disabled

3

2

Student (full and part-time)

4

2.7

Retired

3

2

Unemployed/seeking employment

33

22

No

133

89.3

Yes

16

10.7

Gender

Education

Marital status

Employment status

Born in the US

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METHODS Participants The participants of the study consisted of a convenience sample of 149 Haitians residing in the United States. Table 1 summarizes the characteristics of the participants. Participants‘ ages ranged from 22 to 82 years, with a mean of 40.74 (SD = 12.66). The average age of arrival to the United States was 26.00 years (SD =11.98), with a range of 2 to 66 years. A majority of the sample (n = 106) resided in the United states for more than six years, as opposed to the smaller portion (n = 33) who arrived less than six years ago. The mean income of the participants was $21,750 (n = 117, SD = 16,062), with a range of $1,000 to $42,000. Just over half the sample (n = 82) spoke a combination of languages (English, Creole, French, and Spanish) at home, with the remaining participants (n = 67) speaking primarily Creole, English or French at home. The primary language used at home is not reflective of the language abilities of the participants, almost all of which were multilingual.

Measures Acculturative Stress. The Social, Attitudinal, Familial, and Environmental Acculturative Stress Scale (SAFE) is a 24-item scale used to measure acculturative stress in social, attitudinal, familial and environmental contexts, and includes perceived discrimination [21]. Responses on the SAFE scale are based on a 5-point Likert scale with options ranging from ―not stressful‖ to ―extremely stressful.‖ The range of total scale scores is from 0 to 120. Mena, Padilla, and Maldonao [26] reported an internal consistency reliability coefficient of .89 for the scale. Additionally, the reliability characteristics for the total scale have been shown in a variety of multiethnic populations, including a heterogeneous group of Latinos (α = .89; 27), African Americans (α = .87, 28), and Asian Americans (α = .89; 26). A Cronbach alpha of .92 was found for the sample of this study. Depression. The Center for Epidemiologic Studies Depression Scale (CES-D) is a 20item screening self-report of depressive symptoms present within the past week [29; 27]. The CES-D was designed to measure current levels of depressive symptomatology, especially depressive affect. The 20 items were selected by Radloff [29] from five previously used depression scales to represent every major component of depressive symptomatology. The components include: depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, loss of appetite, sleep disturbance, and psychomotor retardation. The scale can differentiate between clinical groups and general community groups. Though it is generally scored continuously, there are several cut-off scores for clinical depression with rational links between cutoff scores and a clinical diagnosis. The CES-D is recognized as a measure for assessing the number, type, and duration of depressive symptoms across gender, as well as race and age categories [30, 29, 31]. Responses are rated on a 4point scale, ranging from 1 (―rarely or none of the time‖) to 4 (―most or all of the time‖) and are summed to yield a total score. Total scores may range from 0 to 60 with higher scores signifying higher levels of depressive symptoms. A score of 16 or higher is used as a cut-off point for depressive symptoms [29]. High internal consistency has been reported, with

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Cronbach‘s alpha coefficients ranging from .85 to .90 across studies with ethnic minorities [32, 29]. A Cronbach alpha of .88 was obtained for the present sample, which is similar to those obtained by Radloff [29] and Bernal [33] for immigrant populations.

Procedure Three Haitian community centers in the New England area were contacted as possible sites for recruitment of participants for the present study. The first author and her colleague met with the directors of the centers that provide services to Haitians. The three directors introduced the researchers to the staff members of their respective centers who had direct contact with Haitians in the community. In addition to the centers, community members were solicited by means of fliers, churches, beauty salons, referrals from previous participants, and radio announcements. In each case, interested participants contacted the researchers and scheduled a meeting for an interview. Once consent was obtained, research assistants conducted a semi-structured interview with the participant for approximately 90 minutes. During the interview, the previously described measures were administered. All of the meetings were conducted by trained research assistants either at the community centers, churches, or participants‘ homes. All of the interviews and documents were in English because funding was not available for translation into Haitian-Kreyol. At the end of the study, participants were compensated $25.00 for their involvement. The were provided with a letter specifically describing the purpose of the project, contact information for the researchers if any questions or concerns were to arise after the interview process, and a form to request results of the study upon completion of the study.

RESULTS Descriptive Statistics for Acculturation Our sample consisted of 149 Haitians of which 89.3% (n = 133) were born in Haiti and 10.6% (n = 16) were born in the United States. Of this population, a majority 92.6% (n = 138) reported that their parents were born in Haiti, leaving only 7.4% (n = 11) with at least one male parent born in the U.S. One-hundred percent (n = 149) of the respondents‘ mothers were born in Haiti and 98.6% (n = 147) of respondents‘ fathers were born in Haiti and 1.3% (n = 2) of fathers born in Cuba. The strong Haitian lineage was also demonstrated in grandmothers and grandfathers of the respondents, 98.7% (n = 147) and 97.3% (n = 145) respectively. The remaining grandparents in the sample were either both Jamaican and Haitian (n = 2) or both Cuban and Haitian (n = 2). Participants reported residing in the United States an average of 16.3 years with a range of 1 to 52 years. All but one of the male participants stated they spoke at least one other language in addition to English (See table 1 for more details information).

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Descriptive Statistics for Acculturation Stress On average the participants obtained an average score of 55.44 on the SAFE scale. The range of the middle 25th to 75th percentile was 41.00 to 69.50 on the SAFE scale, with a low score of 3 and a high of 115. However, an item analysis of scale indicates that the participants were stressed by some areas. Overall, respondents stated that 54.6% of the time they were either extremely or very stressed that people they knew used drugs, opposed to 38% who stated this drug usage was somewhat, little, or not stressful at all. Respondents were not stressed about not having close friends around, with 54% stating it was a little stressful or not stressful in comparison to the 22% who stated it was at least somewhat stressful. Similarly, almost half of the participants (48%) stated they did not feel stressed by pressure to assimilate, opposed to 33.9% who found the pressure to assimilate at least somewhat stressful. In line with this response, half of the participants stated they were not bothered by having an accent or felt little stress about their accent, while 38.9% stated it was at least somewhat stressful to have an accent.

Gender Differences Independent sample t-tests examined the potential difference in the levels of reported acculturation stress and depression between Haitian men and women. The range for acculturation stress was 3 to 115. On average, female participants reported less acculturation stress (M = 60.91, SE = 2.87) than male participants (M=51.43, SE=2.29), t(148), p = .01, with a medium sized effect (r =.21). Female respondents reported higher levels of depression (M=18.21, SE=1.22) compared to males (M=13.06, SE=1.13), t(148), p < .01. This difference in depression had a medium sized effect (r = .25).

Relationship between Acculturation and Depression The scores on the depression measure ranged from 0 to 50. No significant difference was found between levels of acculturation stress and depression when comparing the 133 native born participants to the 16 who were born in the United States. Both men and women who lived in the United States for less than six years reported higher levels (M = 67.64, SE = 3.71) of acculturation stress than the group who resides in the U.S. more than 6 years (M = 51.82, SE = 2.10), t(138), p < 01. There was also a difference in depression between participants with less than 6 years spent in the U.S. (M = 18.09, SE = 1.47) and those who had resided in the U.S. for longer (M = 15.85, SE = 1.13), though this difference was not statistically significant ( p =.31). A medium-sized effect (r =.30) was found, however. Linear regression revealed the amount of time spent in the United States R2 = .289, F(1, 138) = 12.59, p < .001 accounted for 7.7% of the variance in acculturation stress. Regression analysis however did not reveal a significant effect of time spent in the US and depression levels R2 = .131, F(1, 128) = 2.23, p =.138. Similarly t-tests did not find a significant difference in acculturation stress and depression levels in native born versus first generation Haitians in the United States.

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Relationships between Acculturative Stress and Depression Pearson correlations (two tailed) revealed a significant relationship between acculturation stress and depression r= .33, p<.01. In our sample acculturation stress was negatively related to the amount of time spent in the US r=-.29, p<.01. There was also a negative relationship between depression and age r=-.25, p<.01. No similar significant relationship was found between the acculturation stress and age. The 140 participants who disclosed the amount of time that they spent in the United States and their depression level was regressed upon acculturation stress, the omnibus test was statistically significant, R2 = .408, F (2, 137) =13.70, p < .001. The two explanatory variables combined to account for 15.4% of the variance in acculturation stress. Regression of acculturation stress and age of participants on depression also produced a significant omnibus test R2 = .399, F (2, 147) =13.89, p < .001. Together these two variables accounted for 14.8% of the variance levels of depression. Thus acculturation stress and age was statistically predictive of some of the levels of depression found in our sample.

DISCUSSION Overall, the results obtained in the current study suggest that, for Haitians residing in the United States, both acculturative stress and age are significant predictors of depression. Acculturative stress and depression are positively correlated, yet men and women experienced this relationship differently, with women reporting higher levels of depression and men reporting higher acculturative stress. Conversely, as the age of participants increased, depression scores decreased. With this, high levels of acculturative stress, occurring at a younger age, are more likely to be related to negative mental health outcomes for Haitians. Indicators such as the participant‘s place of birth, family place of birth, length of time in the U.S., primary languages usage, and languages spoken at home indicate that Haitians maintain many aspects of their culture, while transitioning and establishing themselves in the U.S. for substantial durations. In addition, the results of the current project indicate that most of the population was born in Haiti, and has Haitian parents and grandparents. Similar to acculturation studies with other ethnically diverse groups [12], almost all participants speak a language besides English at home, indicating that Haitians retain language, and are surrounded by others of similar backgrounds. Thus, length of stay in the United States does not appear to eradicate the use of their native language. This is different from results of some studies with different cultural groups, which show that native language can be impacted upon immigration to the United States [36]. While the overall SAFE scores were normally distributed, looking closely at the individual items revealed interesting patterns. Over half of the participants reported low stress levels related to not having friends around, indicating that Haitian are not experiencing isolation and lack of social support. This may be due to the fact that most Haitian immigrants tend to live relatively close to their family [34] and neighbors. This is important, as previous research has shown that both peer and family support mitigate negative mental health outcomes [35]. Almost as many respondents indicated that they did not feel pressure to assimilate. This indicates that, while they are still exposed to the same environment and

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stressors as other immigrants, many Haitian immigrants possess strengths which cause them to experience less assimilation stress. Haitian immigrants may feel less pressure to assimilate because they are around other Haitians, or seek communities and social support structures, such as churches or community centers, that promote Haitian culture and values and limit the pressure to assimilate. Participants also reported feeling little or no stress about their accent, which is contrary to research on general immigrant populations [37] showing that language proficiency is a key component of acculturative stress. While this study did not measure language proficiency, low stress around one‘s accent may stem from the fact that the majority of the participants are multilingual and speak multiple languages at home.

Relationships between Acculturation, Acculturative Stress, and Depression The results of this study add to previous research [19, 20, 35] that link acculturative stress to mental health outcomes in immigrant groups, showing that acculturative stress was found to be related to depression among Haitians. However, there were notable differences within the sample that lend to further introspection into the unique acculturation experiences of Haitians, and the related mental health implications. An example of such an intra-group difference was the influence of gender on acculturative stress and depression. Acculturative stress scores were significantly higher for men and lower for women, while depression scores were higher for women than for men. So, while depression and acculturative stress were significantly and positively correlated for both groups, the meaning of the relationship is different based on gender. While women across ethno-cultural groups suffer nearly twice the rate of major depression than men [38, 39] found that women of color are more likely to experience risk factors for depression. Acculturation is one such stressor, yet Haitian women report low stress in this area. Conversely, men report high stress and few depressive symptoms. Further investigation is warranted to explain the impacts of gender roles, cultural expectations, and social support as they pertain to the experiences of Haitian men and women. Interestingly, age was found to be negatively correlated to depression among Haitians. This is of particular interest among this normally distributed sample whose age range was from 22 years to 82 years. This proves contrary to a growing trend in psychology focusing on geriatric depression. Nguyen and Zonderman [40] found significant increases in depressive symptoms after age 70, even when threats to physical health were controlled for. According to the present studies data, this does not appear to be true for Haitians. While there are certainly multiple variables that influence the onset of depression across the lifespan, this warrants further investigation, and implies that perhaps cultural variables mediate the relationship between age and depression. An individual‘s immigration history is also important to consider when evaluating the influences of acculturation on mental health. For those born in Haiti and immigrating within the past six years, both acculturation stress and depression were higher. Time in the U.S. seemed to lessen acculturation stress and decrease depression, as both scores decreased beyond 6 years in the U.S. This brings an important focus to newly-immigrated Haitians, and the need to provide culturally appropriate mental health services early in the immigration process, perhaps even embracing a preventative, preimmigration approach when possible. Haitians who have been in the U.S. for a longer period

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of time should not be forgotten, however, as depression and acculturative stress still exists in this population.

Limitations While acknowledging the relationship between acculturation stress and depression is a valuable practical approach, the fact that acculturation stress and depression lessened over time spent in the U.S. poses, perhaps, more questions than it solves. While lower acculturative stress and depression is a promising outcome, the present study did not measure other possible confounding variables such as cultural or racial identity, or other mental health variables such as self esteem or anxiety. Therefore, the study was unable to determine whether these decreases were due to improved coping styles, or to increased assimilation and detachment from one‘s cultural roots. Also, while our population was age-diverse, the study was not longitudinal and was therefore unable to measure the long-term mental health effects of acculturation. The fact that study participants were all from the same geographical area posed threats to the external validity of the results. This area is diverse and urban, and many of the participants may have shared similar immigration patterns and current cultural environments. Participants may have been members of the same families, or shared social circles. Results, then, may not be easily generalized to Haitians across different geographic regions, experiencing acculturative stress in different contexts. Furthermore, participants were recruited through social support structures, such as churches and community centers, resulting in a sample that has some level of community involvement and social participation. The study was unable to reach those who may not have made those cultural and community connections, and thus, could have missed a part of the population that may have elevated acculturative stress because of this lack of connectivity. The language of the measurement may also have skewed the results. Both the CES-D and the SAFE scale were given in English to ensure their validity and reliability. However, almost all of the participants were multilingual and the study did not include a measure of English proficiency. Subtle nuances in language and cultural variations in the meanings and expression of emotions and stress may have confounded the measurement of these variables.

Implications and Recommendations Despite the limitations outlined above, this study indicates that it is important to consider the impact of acculturation stress in the lives of Haitian immigrants. It is clear that the experience of immigration is associated with unique stressors and that these stressors affect the mental health of those who experience them. In working with immigrants, it is important to examine the overall level of acculturation stress, as well as the individual stressors that make up the acculturative experiences of an individual. Only by conceptualizing the relevant acculturative stressors, connecting the relevant mental health symptoms, and identifying the strengths and preventative factors of these individuals can mental health professionals work toward capitalizing on these strength to reduce acculturative stress and decrease negative mental health outcomes.

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A problematic approach commonly used in research on acculturation is the tendency to make generalizations about cultural or ethnic groups without attending to within-group differences. Indeed, the results of this study point to the need to consider many different variables, such as gender, age, nativity, language, and time in country, in reaching a more complete understanding of the acculturation experience for Haitians. Future studies should continue to analyze intra-group differences, explore other mental health outcomes, strengths and preventative factors associated with acculturative stress, and explore the complex qualitative experience of acculturation stress over time. Understanding Haitian acculturative stress must also be examined in the context of the experiences of other immigrant groups. In doing so, future researchers can come to a fuller understanding of the immigrant experience, as well as the unique experiences of Haitian immigrants.

CONCLUSION This study reveals that as acculturative stress increases for Haitian immigrants, symptoms of depression also increase. In addition to acculturation stress, age also predicts depression and is negatively correlated. Haitian men report higher levels of acculturation stress than Haitian women, and women report higher levels of depression than men. These results provide evidence that levels of acculturation and the experiences of acculturative stress are culturally specific, and thus, unique for Haitians. This calls for culturally appropriate assessment, conceptualization, and treatment that attends to the role of acculturation and acculturative stress in Haitian mental health and provides an important area for future research.

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Guerda Nicolas, Darren Bernal and Seth Christman Alegria, M., Canino, G., Rios, R., Vera, M., Calderon, J., Rusch, D., et al. (2002). Inequalities in use of specialty mental health services among Latino, African Americans, and Non-Latino Whites. Psychiatric Services, 53, 1547-1555. Berry, J. W. (1997). Immigration, acculturation, and adaptation. Applied Psychology: An InternationalReview, 46, 5–68. Alvidrez, J., Azocar, F., Miranda, J. (1996). Demystifying the Concept of Ethnicity for Psychotherapy Researchers. Journal of Consulting and Clinical Psychology, 64 (5), 903-908. Sandoval, M. C., and De La Roza, M. (1986). Cultural perspectives for serving the Hispanic client. In H. P. Lefley and P. B. Pedersen (Eds.), Cross-cultural training for mental health professionals (pp. 151–160). Springfield, IL: Charles C Thomas. Cervantes, R. C., Salgado de Snyder, V. N., and Padilla, A. M. (1989). Posttraumatic stress in immigrants from Central America and Mexico. Hospital and Community Psychiatry, 40,615–619. Balls P., Organista, K. C., and Kurasaki, K. (2003). The relationship between acculturation and ethnic minority mental health. In K. Chun, P. Balls Organista, and G. Marı´n (Eds.), Acculturation: Advances in theory, measurement, and applied research (pp. 139–161). Washington, DC: American Psychological Association. Salgado de Snyder, V. N. (1987). Factors associated with acculturative stress and depressive symptomatology among married Mexican immigrant women. Psychology of Women Quarterly,11, 475-488. Dressler, W.W. (1990). Lifestyle, stress, and blood pressure in a southern Black community. Psychosomatic Medicine, 52, 182-198. Neff, J.A., and Hoppe, S.K. Race/ethnicity, acculturation, and psychological distress: Fatalism and religiosity as cultural resources. Journal of Community Psychology, 21(l):3-20, 1993. Miranda J., Siddique J., Belin T.R., and Kohn. L.P. (2005). Depression prevalence in disadvantaged young black women: African and Caribbean immigrants compared to US-born African Americans. Soc. Psychiatry Epidemiol; 40: 253–58. Bernal, G., and Enchautegui-de-Jesus, N. (1994). Latinos and Latinas in community psychology: A review of the literature. American Journal of Community Psychology, 22, 531–557. Chung, I. (2002). The prevalence of mental health problems among Asian American adolescents and children: Symptoms and treatment issues. Retrieved on September 6, 2005, from www.fcmsdocs.org/Conference/11th/The%20Prevalence%20of%20Mental %20Health%20Problems%20Among.pdf Hovey, J. D., and King, C. A. (1996). Accuhurative stress, depression, and suicidal ideation among immigrant and second-generation Latino adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 35,1183-1192. Williams, C. L., and Berry, J. W. (1991). Primary prevention of accuiturative stress among refugees: Application of psychological theory and practice. American Psychologist, 46, 632-641. Padilla, A. M. "The Role of Cultural Awareness and Ethnic Loyalty in Acculturation." In Acculturation Theory, Models, and Some New Findings. Edited by A. M. Padilla. Boulder, CO: Westview Press, 1980, 47-84.

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[22] Zephir, F. (2001). Trends in ethnic identification among second-generation Haitian immigrants in New York City. Westport, CT: Bergin and Garvey. [23] Zéphir, F. (1996). Haitian immigrants in Black America. Westport, CT: Bergin and Garvey. [24] Migration Policy Institute. The foreign born of Haiti in the United States. Retrieved October 25, 2004, from http://www.migrationinformation.org/USFocus/ whosresults.cfm. [25] Jean-Louis, E., Walker, J., Apollon, G., Piton, J., Antoine, B., Mombeleur, A., et al. (1997). Drug and alcohol use among Boston's Haitian community: A hidden problem unveiled by CCHER's enhanced innovated case management program. Drugs and Society, 16(112), 107-122. [26] Mena, F. J., Padilla, A. M., and Maldonado, M. (1987). Acculturative stress and specific coping strategies among immigrant and later generation college students. Hispanic Journal of Behavioral Sciences, 9(2), 207-225. [27] Fuertes, J.N., and Westbrook, F.D. (1996). Using the social, attitudinal, familial, and environmental (S.A.F.E.) acculturation stress scale to assess the adjustment needs of Hispanic college students. Measurement and Evaluation in Counseling and Development, 29, 67-76. [28] Perez, M., Voelz, Z. R., Pettit, J. W. and Joiner, T. E. (2002). The role of acculturative stress and body dissatisfaction in predicting bulimic symptomology across ethnic groups. The International Journal of Eating Disorders, 31, 442-454. [29] Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401. [30] Knight, R. G., Williams, S., McGee, R., and Olaman, S. (1997). Psychometric properties of the Center for Epidemiologic Studies Depression Scale (CES-D) in a sample of women in middle life. Behavior Research and Therapy, 35(4), 373-380. [31] Neilson, D., and Boot, D. (1988). A prospective study of severe mental disorders in Afro-Caribbean patients. Psychological Medicine, 18, 643-657. [32] Bernal, G., and Scharron-Del-Rio, M. R. (2001). Are empirically supported treatments valid for ethnic minorities? Toward an alternative approach for treatment research. Cultural Diversity and Ethnic Minority Psychology, 7, 328-342. [33] Bernal, G., Trimble, J. E., Burlew, K. A., and Leong, F. (2003). Handbook of racial and ethnic minority psychology. Thousand Oaks, CA: Sage Publications. [34] Nicolas, G., DeSilva, A. M., Grey, K. S., and Gonzalez-Eastep, D. (2006). Using a multicultural lens to understand illnesses among Haitians living in America. Journal of Professional Psychology: Research and Practice, 37(6), 702-707. [35] Crockett, L.J., Iturbide, M.I., Torres Stone, R.A., McGinley, M., Raffaelli, M., and Gustavo, C. (2007). Acculturative stress, social support, and coping: Relations to psychological adjustment among Mexican American college students. Cultural Diversity and Ethnic Minority Psychology, 13(4), 347-355. [36] Schrauf, R.W. (1999). Mother tongue maintenance among North American ethnic groups. Cross Cultural Research, 33, 175-192. [37] Yeh, C.J. and Inose, M. (2003). International students' reported English fluency, social support satisfaction, and social connectedness as predictors of acculturative stress. Counselling Psychology Quarterly, 16(1), 15-28.

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[38] Burt V.K., and Stein K. (2002). Epidemiology of depression throughout the female life cycle. Journal of Clinical Psychiatry, 63(7), 9-15. [39] McGrath, E., Keita, G. P., Stickland, B. R., and Russo, N. F. (1990). Women and depression: Risk factors and treatment issues. Washington, DC: American Psychological Association. [40] Nguyen, H. and Zonderman, A. (2006). Relationship between age and aspects of depression: consistency and reliability across two longitudinal studies. Psychology and Aging, 21(1), 119-126.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 12

CHANGES IN THE PSYCHOLOGICAL WELL-BEING OF IMMIGRANTS: A THREE-YEAR LONGITUDINAL STUDY OF IMMIGRANT ADOLESCENTS INCLUDING THE PRE-MIGRATION PERIOD Eugene Tartakovsky The Bob Shapell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel

ABSTRACT This article analyses well-being of adolescents immigrating from the Former Soviet Union (FSU) to Israel without their parents. Immigrant adolescents were compared with the matched sample of non-emigrating adolescents living in the FSU. Several aspects of well being were measured: the number of emotional and behavioral problems, loneliness, general self-esteem, body image, and social and school competence. Immigrant adolescents completed the questionnaires four times: about six months before emigration, and then in the first, second, and third years after their arrival to Israel. Adolescents living in the former Soviet Union completed questionnaires once. At the pre-migration stage, the immigrants‘ well-being was higher than that of their non-emigrating peers. After the immigration, the immigrants‘ psychological well-being declined, but remained higher than well-being of adolescents living in the FSU. At the post-migration stage, each dimension of well-being strongly correlated with the corresponding pre-migration measurement. The perceived discrimination had a strong negative effect and the social support received from peers and adults in Israel had a positive effect on the immigrants‘ psychological well-being. Based on the obtained results, an integrative approach to the understanding of psychological processes of immigration is suggested.

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INTRODUCTION Numerous studies focus on the immigrants‘ psychological well-being. However, most often the post-migration factors affecting the psychological well-being are investigated, while the factors related to the pre-migration period remain obscure. The presented study applies a longitudinal design and follows the immigrants from the pre-migration period (about a half year before the immigration) and during three years after their immigration. In addition, the psychological well-being of immigrants is compared with their non-emigrating peers in the country of origin. This design permits to study the effect of the pre-migration well-being and the perceived social conditions in the host country on the post-migration well-being. In addition, it permits to investigate the effect of immigration on the psychological well-being of immigrants.

THE PSYCHOLOGICAL WELL-BEING OF IMMIGRANTS Studies of the psychological well-being of immigrants are usually based on a stresscoping model. The use of such a model assumes that interaction with a new culture is a stressful event that causes culture shock or acculturative stress, i.e., disorientation, identity problems, and a decline in psychological well-being [1, 2, 3]. Two hazards of immigration are most frequently mentioned: a massive loss of habitual environment (including mother tongue, social networks, geographic and architectural environment, and food), and cognitiveemotional difficulties of adjustment to the host country (e.g., difficulty in learning a new language and mastering new patterns of behavior accompanied by feelings of helplessness and low self-esteem). Some researchers argue that immediately after immigration, the immigrants‘ psychological well-being may be unusually high, i.e. the immigrants are euphoric. The euphoric stage may appear either because immigrants are excited to meet the new culture [4], or because they are so busy with the task of survival in the host country that they deny difficulties and are detached from their psychological problems [5, 6]. Researchers who claim the existence of a euphoric stage do not deny culture shock; they simply assume that it follows the initial euphoric stage. The stress-coping paradigm assumes that with time in the host country, immigrants learn to cope with immigration stress, and their psychological well-being improves accordingly. Therefore, the immigrants‘ psychological well-being follows a U-curve: it declines after immigration and improves after some time in the host country [3, 7]. Some researchers argue that with time immigrants fully recover to the pre-migration level of well-being due to homeostatic mechanisms that restore their psychological equilibrium after an initial disturbance caused by the change in social environment [1, 3, 8]. However, many researchers, explicitly or implicitly, adhere to the immigration morbidity hypothesis. They believe that immigration permanently damages the psychological well-being of immigrants, and their psychological well-being remains worse than the well-being of the non-immigrant population [9]. Only a few researchers believe that immigration may be beneficial for immigrants [10, 11, 12].

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Many researchers consider immigration especially dangerous for adolescents [13, 14, 15]. Adolescents may suffer from the same hazards of immigration as adults do, but these researchers deem that the psyche of adolescents is more vulnerable than that of adults and, therefore, they are more in need of a stable environment for normal development [16]. In addition, immigration may interfere with the delicate process of identity formation of adolescents [5]. Several factors may further aggravate the conditions of unaccompanied minors in the process of immigration. Researchers mention the loss of parental authority, frustration and anger at not being a part of the immigration decision-making process, and loss of stability in the family system, all of which require adjustment efforts on the part of adolescents and parents in the separation and unification stages [15, 16]. In most studies, the psychological well-being of immigrants in the first year following immigration was either worse or did not differ significantly compared with subsequent years [7, 16, 18]. Therefore, the existence of post-migration euphoria was not confirmed. In most studies, the psychological well-being of immigrants positively correlated with the duration of their stay in the host country, therefore corroborating the stress-coping model [7, 18, 19, 20]. However, in some studies the psychological distress of immigrant adolescents did not ameliorate with time [17]. In order to test the hypotheses of acculturative stress and immigration morbidity, immigrants were compared with their non-emigrating peers in their homeland. The results of the comparisons were inconsistent. In some studies, immigrant adolescents demonstrated higher psychological well-being than their non-emigrating compatriots [21]. In other studies, no differences in psychological well-being were found [22]. And in some studies, the psychological well-being of immigrants was worse than that of their non-emigrating peers in their homeland [9, 23, 24]. Studies comparing immigrants with the local population in the host country also yielded inconsistent results [25]. Most often immigrants had lower psychological well-being than host-nation adolescents [9, 18, 21, 24, 26, 27]. However, in some studies, the immigrants did not differ from the local population [11, 19, 28] or even reported higher psychological wellbeing [29]. Differences between immigrants and host-nation adolescents often ceased to exist when results were controlled for the socio-economic status of the parents [30]. Therefore, comparisons with non-immigrant populations have not confirmed that immigration is inevitably damaging to the psychological well-being of immigrants. The psychological and social resources of immigrants were consistently associated with their psychological well-being [3]. Social conditions in the host country also affected the immigrants' psychological well-being: social support had a positive effect, while discrimination had a strong detrimental effect on the psychological well-being of immigrants [19, 31, 32, 33]. Immigrant adolescents from single-parent families had lower psychological well-being than their peers from two-parent families [31, 34, 35], and immigrant adolescents from conflicting families had lower psychological well-being compared with their peers from families with a low level of conflict [35, 36]. In summary, empirical studies have partly corroborated the stress-coping model of immigration. The hypothesis of post-migration euphoria was not empirically supported, while the hypothesis of acculturative stress and coping received stronger support. Neither the morbidity hypothesis, nor the beneficial effect of immigration was uniformly confirmed, and a great variability in the psychological well-being of immigrants was found across countries.

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It is possible that methodological limitations hindered the corroboration of the stresscoping model. Most previous studies investigated changes in the immigrants‘ psychological well-being using a cohort design. However, the immigrants‘ cohorts differ not only in their time in the host country, but also in their experience, in the homeland as well as in the host country. In addition, very few studies investigated immigrants in the pre-migration period, and only the pre-post comparison enables the particular effect of immigration on the psychological well-being of immigrants to be singled out. However, the problem may not be merely methodological. The inconsistent results of these empirical studies may indicate the need to modify the stress-coping model of immigration. In this study, we broaden the stress-coping model with the ecological systems theory. This theory assumes that the interplay between the inborn characteristics of an individual and the surrounding ecosystem determines the individuals‘ development and well-being [37]. The ecosystem includes several interactive levels: family, community, country, and the global world. Ecological theory stresses the importance of social systems larger than the family, mainly the community and society, in the development of individuals (Garbarino, 1999). According to ecological theory, the psychological resources of immigrants formed in the homeland, together with social conditions in the host country, should affect their postmigration psychological well-being. In this study, ecological theory was applied to the investigation of the psychological wellbeing of adolescents immigrating from Russia and Ukraine to Israel. The study used a longitudinal design that overcomes methodological limitations of previous cross-sectional studies. The psychological well-being of immigrants was measured in the pre-migration period, as well as over the first three years following immigration. In addition, the psychological well-being of immigrants was compared with that of their non-emigrating peers in their homeland. The following hypotheses were formulated: 1. Pre-migration expectations for a better life in the host country may cause immigrants to feel euphoric. Thus, their pre-migration psychological well-being will be higher than that in the post-migration period, and it will be higher than the well-being of the non-emigrating adolescents in their homeland. 2. Psychological well-being during the process of immigration will follow a U-curve: it will decrease in the first year after immigration, due to acculturative stress, and return to the pre-migration level in the third year after immigration, due to adjustment. The social conditions of adjustment to the host country are benign for the studied population; hence, they may ensure a non-morbid character of immigration. Therefore, post-migration psychological well-being of immigrants will be similar to the pre-migration level, and it will remain higher than that among the non-emigrating adolescents in the immigrants' homeland. 3. The pre-migration psychological well-being of immigrants will predict their postmigration psychological well-being. 4. Benign perceived social conditions in the host country (high social support and low discrimination) will be associated with high psychological well-being of immigrants in the post-migration period. 5. Family characteristics that ensure greater psychological and social resources for immigrant adolescents (the availability of both parents, higher education of the

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parents, their professional or managerial occupation, and a good financial situation) will be associated with higher psychological well-being of immigrant adolescents.

METHOD Target Population The present study focused on Jewish high-school adolescents from Russia and Ukraine who participated in an Israeli immigration program called Na'ale. Na‘ale is a Hebrew acronym for ―adolescents immigrating without their parents.‖ Fifteen-year-old adolescents living all over the world, who are eligible for immigration to Israel according to the Law of Return (i.e., having at least one Jewish grandparent), may participate in this program [38]. These adolescents undergo testing to the program about half a year before their prospective emigration; therefore, they are available for study in the pre-migration period. Adolescents accepted to the program live in boarding schools and kibbutzim and study in Israeli high schools for three years. The Israeli government covers the basic needs of the adolescent immigrants, including housing, food, school fees, and health insurance. During the summer vacations, the adolescents usually fly home to their parents. Upon graduation from high school, most Na‘ale graduates join Israeli youth in the army, work places, colleges, and universities; however, some return to their homeland or emigrate to other countries [39]. Table 1. Socio-demographic characteristics of the samples Socio-demographic characteristics Live in large cities (one million citizens or more) Proportion of females in the sample Single-parent families Number of children in the family, mean and SD Families where one or both parents died Families with three generations living together Fathers with a higher education * Mothers with a higher education * Fathers occupied in a managerial or professional position * Mothers occupied in a managerial or professional position Fathers unemployed Mothers unemployed Number of people in the family apartment, mean and SD Number of rooms in the family apartment, mean and SD School GPA, on a 5-point scale, mean and SD * Differences between the samples are significant at p<.05.

Immigrants 46%

Non-immigrants 52%

59% 26% 1.92 (.80) 8% 20% 73% 71% 67%

60% 24% 1.84 (.76) 7% 17% 58% 59% 59%

52%

51%

10% 24% 3.60 (1.01)

9% 19% 3.74 (.90)

2.70 (.79)

2.82 (1.11)

4.24 (.47)

4.21 (.54)

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Sampling Two hundred eleven immigrant adolescents participated in this three-year longitudinal study. The comparison sample of non-emigrating adolescents included 489 adolescents living in Russia and Ukraine and studying in public high schools. In order to check for comparability of the two populations, i.e. immigrants and non-immigrants living in Russia and Ukraine, the main socio-demographic characteristics of the samples drawn from those populations were compared (Table 1). Among the 15 measured parameters, only three differed between immigrants and local adolescents in Russia and Ukraine: more parents of immigrant adolescents had tertiary education (fathers: 73% vs. 58%, χ2=10.79, p<.05; mothers: 71% vs. 59%, χ2=8.03, p<.05), and more of the immigrant adolescents‘ fathers occupied managerial and professional positions (67% vs. 59%, χ2= 4.27, p<.05). The differences obtained probably reflect the traditional Jewish value of education and a higher proportion of Jews occupying managerial and professional positions in the Soviet Union [40].

Procedure At the time of testing for the Na‘ale program in the FSU in the spring of 1999, 646 program candidates completed the research questionnaires. These adolescents were questioned at eight geographic locations throughout Russia and Ukraine, which were randomly chosen from 18 locations where testing was conducted that year. They came from nearly 40 cities and towns scattered all over Russia and Ukraine, and they constituted about 30% of all program candidates tested that year. This procedure ensured a random sample of Na‘ale students immigrating from Russia and Ukraine. From those candidates to the program who completed the questionnaires at the time of testing in the FSU, 211 adolescents accepted to the program were approached in Israel in the Spring of 2000 for the purpose of this study. These adolescents filled out the questionnaires at the end of each school year during their three-year participation in the Na‘ale program. Signed informed consent was obtained from the adolescents participating in the study and from their parents. Twenty-four participants discontinued their participation in the second year, and 32 in the third year of the study (28% dropout rate). Statistical analyses showed that the adolescents who dropped out did not differ significantly from those who participated to the end in any variable in the study. Nonemigrating adolescents participating in this study lived in twelve cities and towns in Russia and in four cities in Ukraine. These were the same cities where testing for Na'ale was conducted. Russian and Ukrainian school psychologists working with the Na'ale program questioned the non-immigrating adolescents in their classes during school hours. The classes were randomly chosen in each school.

Measures of Psychological Well-Being This study applied six indexes of psychological well-being. Four scales measured positive psychological well-being: general self-esteem, body image, social competence, and school competence. Two scales measured negative psychological well-being (distress): emotional and behavioral problems and loneliness. The six indexes of psychological well-

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being moderately or highly correlated with each other (correlations varied from .29 to .65), which supported the assumption that these measures assessed a common construct. All questionnaires used 5-point self-report Likert scales, except the Youth Self-Report that used a 3-point scale, and the Crown-Marlow Social Desirability Questionnaire that used a 2-point scale. Self-esteem was measured by the Self-liking/Self-worth scale [41]. This scale consists of 20 positively and negatively formulated items reflecting feelings of social worth and personal efficacy. Item examples: "Owing to my capabilities, I have much potential"; "It is often unpleasant for me to think about myself". The scale demonstrated medium-high internal consistency (Cronbach α=.79) and high test-retest reliability (.89). 1 Body image was measured by the body image scale of the Offer Self-Image Questionnaire [42]. This scale consists of 14 items measuring the perception of one's physical appearance and physical abilities. Item examples: "I feel strong and healthy"; "I feel unhappy with my body". The scale demonstrated high internal consistency (Cronbach α=.82) and medium-high test-retest reliability (.78). Social competence was measured by the short form B of the Texas Social Behavior Inventory (TSBI) (43). This 16-item scale measures feelings of perceived competence and comfort in social situations. Item examples: "I enjoy being around other people and seek out social encounters frequently"; "I would describe myself as socially unskilled". The scale demonstrated medium internal consistency (Cronbach α=.73) and high test-retest reliability (.82). School competence was measured using items from the multifaceted academic selfconcept scale [44]. This scale consists of 10 positively and negatively formulated items related to the subjective perception of one‘s abilities in performing various school tasks. Item examples: "I am a good pupil"; "Compared with my classmates, I must study more than they do to get the same grades". The scale demonstrated medium internal consistency (Cronbach α=.73) and high test-retest reliability (.90). Behavioral and emotional problems were measured by the Youth Self-Report questionnaire (YSR) [45]. The YSR includes 112 items grouped into nine syndromes (sample items are provided in parentheses): withdrawn ("I would rather be alone than with others"); somatic complaints ("I feel dizzy"); anxious/depressed ("I feel lonely"); social problems ("I act too young for my age"); thought problems ("I can‘t get my mind off certain thoughts"); attention problems ("I have trouble concentrating or paying attention"); delinquent behavior ("I don‘t feel guilty after doing something I shouldn‘t"); aggressive behavior ("I argue a lot"); self-destructive/identity problems ("I act like the opposite sex"). The total problem score is computed by summing all the symptom scores obtained. For reasons of brevity, only the total problem score was used in this study. The internal consistency of the scale was high (Cronbach α=.93), as was its test-retest reliability (.85). Loneliness was measured by a Short-Form Measure of Loneliness [46]. This scale measures distress associated with inadequate social contacts. It consists of eight items, positively and negatively formulated, from the revised UCLA Loneliness Scale. Item

1

Internal consistencies of the scales are provided only for the first measurement; however, in all stages of the study they were similar to those presented here. Time consistency was measured in a sub-sample of immigrants (n=49) in the first year after immigration using a one-month test-retest procedure.

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examples: "I lack companionship"; "I am an outgoing person". The scale demonstrated high internal consistency (Cronbach α=.83) and test-retest reliability (.81).

Measures of Perceived Social Conditions in Israel The participants' perception of social conditions in Israel was assessed in two areas: social support and discrimination. Perceived social support was measured by a Multidimensional Scale of Perceived Social Support [47]. This questionnaire consists of 12 items, which are divided into three subscales relating to social support received from parents, peers, and teachers. Item examples: "There is a teacher who is around when I am in need"; "My family really tries to help me"; "I have friends with whom I can share my joys and sorrows". Each of the three subscales demonstrated high internal consistency, as measured by Cronbach α: .79, .84, .87. Due to a technical error, the scale was not applied in the first year after immigration and, therefore, its time consistency was not measured. Perceived discrimination was measured by the Discrimination Questionnaire [48]. The questionnaire consists of 10 items measuring immigrants‘ suffering due to negative attitudes of the host-country population. Item examples: "Israeli students in my school are hostile towards me because I am from Russia/Ukraine", "I feel that I am not wanted in Israeli society because I am from Russia/Ukraine". The scale had high internal consistency (.87) and medium-high test-retest reliability (.80).

Socio-Demographic Characteristics of the Adolescents and Characteristics of Their Family Included in the Analyses      

2

Country of origin: 1 – Russia; 2 – Ukraine. Gender: 1 – male; 2 – female. Family composition: 1 – single-parent family; 2 – two-parent family. 2 Mother’s education: 1 – secondary, 2 – tertiary. Mother’s occupation: 0 – unemployed, 1 – manual or clerical occupation, 2 – professional or managerial occupation.3 Number of rooms in the family‘s apartment was used as an indicator of the family's financial situation. It was chosen because the adolescents had no information about their parents‘ income.

The category of two-parent families included families where both biological parents lived together with the adolescent and families where a biological parent and a stepparent lived with the adolescent. 3 Father's education and occupation was not included in the analysis, because a quarter of the adolescents came from single-parent families.

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Social Desirability Bias The first measurement in this study was conducted when the adolescents were tested for the immigration program. Such a testing situation most often stimulates participants to engage in image management and thus report an inaccurately high psychological well-being. Researchers use social desirability scales in order to measure bias caused by image management and to control it statistically when analyzing the results [49, 50, 51, 52]. In this research, the Crowne-Marlowe Social Desirability Scale measured social desirability bias [53]. The scale includes 33 items, describing behaviors that are socially desirable but are highly unlikely to occur, and participants are asked to report whether they engage in these behaviors. Item examples: "I never hesitate to go out of my way to help someone in trouble", "I like to gossip at times". In this research, the scale demonstrated moderate internal consistency (Cronbach α=.75) and moderate test-retest reliability (.72). Throughout the entire immigration period, social desirability bias was significantly higher in the immigrants' population than amongst the non-emigrating adolescents. In the immigrant population, social desirability bias was higher in the pre-migration compared with the post-migration period (Table 2).

RESULTS A Comparison between Immigrant and Non-Emigrating Adolescents Means and standard deviations of all measures of psychological well-being are presented in Table 2. ANCOVAs tested the statistical significance of the differences between the premigration measures of the six indexes of psychological well-being in the immigrants' population with the corresponding measures among the non-emigrating adolescents. To control for different social desirability bias in the two populations, this variable was included in the analysis as a covariate. Statistically significant differences were found for five out of six indexes of psychological well-being: self-esteem, social competence, school competence, emotional and behavioral problems, and loneliness. For body image, the difference was in the hypothesized direction, but not significant. ANCOVAs tested the statistical significance of the differences between each of the six indexes of psychological well-being amongst immigrants in the second year after immigration, when all indexes of psychological well-being were at their lowest, and the corresponding measures amongst the non-emigrating adolescents. Social desirability bias was included as a covariance in the analyses. The differences were statistically significant for four out of six indexes: self-esteem, social competence, school competence, and emotional and behavioral problems. The differences were not significant for body image and loneliness; however, for all six indexes, the psychological well-being of immigrants was higher than that amongst the non-emigrating adolescents in Russia and Ukraine.

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Table 2. Means and standard deviations of the variables Variables

Immigrants

Self-esteem

Time0 4.02 (0.45)a

Body image

3.82 (0.56)a

Social competence

3.91 (0.50)a

School competence

3.91 (0.46)a

Emotional and behavioral problems Loneliness

37.4 (18.3)a

Social desirability bias Perceived discrimination

22.2 (4.9)a not measured not measured not measured not measured

Perceived social support from parents Perceived social support from peers Perceived social support from teachers

1.62 (0.61)a

Nonimmigrants Time1 3.94 (0.48)b 3.68 (0.62)b 3.75 (0.53)b 3.78 (0.58)b 48.7 (20.4)b 1.87 (0.71)b 18.4 (5.3)b 2.08 (0.64)a not measured not measured not measured

Time2 3.97 (0.47)b

3.89 (.88)a

Time3 4.09 (0.47)c 3.88 (0.63)c 3.85 (0.57)c 3.80 (0.57)d 49.3 (24.5)b 1.86 (0.78)d 18.6 (5.8)b 1.95 (0.66)b 3.82 (.94)a

4.04 (.77)a

4.19 (.85)b

not measured

3.47 (1.06)a

3.73 (1.10)b

not measured

3.72 (0.64)b 3.77 (0.49)b 3.72 (0.62)c 49.3 (22.1)b 1.97 (0.70)c 18.3 (5.5)b 2.03 (0.65)a

3.77 (.51) e f 3.62 (.60) 3.62 (.55) e f 3.42 (.67) e f 61.5 (23.0) e f 2.07 (.81) e 17.3 (5.3) e f not measured not measured

Time0 – half a year before immigration; Time1 – half a year after immigration; Time2 – one and a half years after immigration; Time3 – two and a half years after immigration. Means with different subscripts are significantly different at p<.05. Means with the superscript "e" in the non-immigrants' column are significantly different from the corresponding pre-migration measures in the immigrants' population. Means with the superscript "f" in the non-immigrants' column are significantly different from the corresponding measures in the immigrants' population in the second year after immigration.

Table 3. Hierarchical Linear Model: The effects of time and time2 on the six indexes of psychological well-being Indexes of psychological wellbeing Self-esteem Body image Social competence School competence Emotional and behavioral problems Loneliness

Intercept

Time2

Time

Social desirability

Coefficient 3.541*** 3.200*** 3.519*** 3.668*** 68.38***

SE .110 .145 .119 .129 4.77

Coefficient -.083 -.124 -.204** -.183* 8.55**

SE .063 .083 .067 .073 2.76

Coefficient .028* .038* .044** .034* -1.42**

SE .012 .016 .013 .014 .541

Coefficient .025*** .031*** .026*** .018*** -1.71***

SE .003 .004 .003 .004 .137

2.288***

.161

.324**

.095

-.060**

.019

-.043***

.005

* p<.05; ** p<.01; *** p<.001. SE=standard error.

Changes in the Psychological Well-Being of Immigrants

173

Table 4. Zero-level correlations between the variables Variables Self-esteem, Time1 Self-esteem, Time2 Self-esteem, Time3 Body image, Time1 Body image, Time2 Body image, Time3 Social competence, Time1 Social competence, Time2 Social competence, Time3 School competence, Time1 School competence, Time2 School competence, Time3 Emotional and behavioral problems, Time1 Emotional and behavioral problems, Time2 Emotional and behavioral problems, Time3 Loneliness, Time1

PMWB .63*

PD -.35*

PSSPa nm

PSST nm

PSSPe nm

.44*

-.16*

.09

.21*

.32*

.23*

-.38*

.20*

.23*

.38*

.51*

-.30*

nm

nm

nm

C .02 .01 .05 .03

G .06

FC .26*

ME -.08

MO -.12

NR .17*

.04

.16*

.04

-.09

.08

.01 .01 .01

.12

-.01

.03

.01

.21*

.04 .05

.07 .06

.08

-.16

.17* .18* -.10

.08

.13

.22* -.09

.42*

-.24*

.03

.22*

.15

.03

.32*

-.45*

.21*

.28*

.35*

.62*

-.19*

nm

nm

nm

.22*

-.09

-.08

.09

.50*

-.17*

.14

.22*

.27*

.00

.08

.15*

-.04

-.07

.09

.34*

-.37*

.21*

.24*

.45*

.05

.06

.04

-.07

.06

.07

.60*

-.23*

nm

nm

nm

.08

.01

.14*

.16*

-.04

.19*

.48*

-.06

.02

.13

.21*

.03

.02

.13

.19*

.05

.24*

.41*

-.18*

.09

.10

.19*

.13

.09

.07

.10

.06

.07

.56*

.39*

nm

nm

nm

.09

.08

-.01

.04

.07

-.10

.46*

.32*

-.13

-.19*

-.24*

.04

.01

-.05

.06

-.03

.15*

.38*

.39*

-.14

-.12

-.25*

.08

.07

-.05

.01

-.06

-.10

.50*

.36*

nm

nm

nm

-.06

.41*

-.22*

-.37*

-.41*

.02

.14

-.07

Loneliness, Time3

.32*

.46*

-.27*

-.31*

-.53*

.15* .15* -.12

.10

.48*

.08 .04 .11

.10

Loneliness, Time2

.08 .09 .02

.11

-.03

-.08

.01 -.05

PMWB = a pre-migration index of psychological well-being, corresponding to each post-migration index. PD = perceived discrimination. PSSPa = perceived social support from parents. PSST = perceived social support from teachers. PSSPe = perceived social support from peers. C = country of origin. G = gender. FC = family composition. ME = mother's education. MO = mother's occupation. NR = number of rooms in the family apartment. nm=not measured. * p<.05.

174

Eugene Tartakovsky

Changes in Psychological Well-Being during Immigration The hypothesis that changes in psychological well-being during the process of immigration would follow a U-curve was tested using the Hierarchical Linear Model. Tests of fixed effects included three factors: time, time2, and social desirability bias; and their effects were calculated separately for each of the six indexes of psychological well-being (Table 3). The effect of time was significant for four out of six indexes of psychological well-being: social competence, school competence, emotional and behavioral problems, and loneliness; it was not significant for self-esteem and body image. The effect of time2 was significant for all six indexes of psychological well-being. Planned comparisons tested the statistical significance of the differences between the adjacent levels in each of the six indexes of psychological well-being. All six indexes of psychological well-being measured in the first year after immigration were statistically lower than the corresponding indexes in the pre-migration period. Comparing the first and second years after immigration, two indexes indicated a further decrease in psychological well-being: school competence and loneliness. Comparing the second and third years after immigration, changes in five measures of psychological well-being indicated a significant improvement in the psychological well-being of immigrants in the third year: self-esteem, body image, social competence, school competence, and loneliness. Comparing the third year after immigration with the pre-migration period, three indexes of psychological well-being differed significantly: self-esteem showed improvement, while emotional and behavioral problems and loneliness indicated decrease in psychological well-being in the post-migration period.

Predictors of Post-Migration Psychological Well-Being To test for a separate effect of the predicting variables, their correlations with the indexes of psychological well-being at each time point in the post-migration period were calculated. The predicting variables included the following: a pre-migration index of psychological wellbeing, four variables reflecting perceived social conditions in the host country (discrimination, social support received from parents, teachers, and peers), and six sociodemographic characteristics of the immigrants (country of origin, gender, family composition, mother's education, mother's occupation, and number of rooms in the family apartment). The predicted variables included the six indexes of psychological well-being measured at the three consecutive years after immigration (Table 4). Thus, each line in the table presents correlations between an index of psychological well-being measured in a particular year after immigration and the following variables: the same index of psychological well-being measured in the pre-migration period, perceived discrimination and social support measured in the particular post-migration year, and socio-demographic characteristics of the immigrants. Each pre-migration index of psychological well-being was positively correlated with the corresponding post-migration index. Perceived discrimination was correlated with all indexes of post-migration psychological well-being, except school competence at Time2. Perceived social support from parents was correlated only with some indexes of post-migration psychological well-being at some time points: self-esteem at Time3, body image at Time3, social competence at Time3, and loneliness at Time2 and Time3. Perceived social support

Changes in the Psychological Well-Being of Immigrants

175

from teachers was correlated with most but not all indexes of post-migration psychological well-being: self-esteem at Time2 and Time3, body image at Time2 and Time3, social competence at Time2 and Time3, emotional and behavioral problems at Time2, and loneliness at Time2 and Time3. Perceived social support from peers was correlated with all indexes of post-migration psychological well-being, except body image at Time2. Country of origin and gender were not correlated with any index of psychological wellbeing. Characteristics of the immigrants' family were related to some but not all indexes of psychological well-being. Two-parent family was associated with the following indexes of post-migration psychological well-being: self-esteem at Time1 and Time2, body image at Time1, social competence at Time1 and Time2, school competence at Time1, and loneliness at Time1 and Time2. Mother's tertiary education was associated with higher school competence at Time1 and Time2; however, contrary to the hypothesis, it was associated with lower body image at Time1. Also contrary to the hypothesis, mother's occupation in managerial or professional positions was associated with lower body image at Time1 and Time2. The family economic situation, as measured by the number of rooms in the family apartment, was associated with self-esteem at Time1, school competence at Time1 and Time2, and fewer emotional and behavioral problems at Time2. Hierarchical Linear Models (HLM) tested the effects of the predicting variables on the post-migration indexes of psychological well-being when all the predicting variables were considered simultaneously. In addition, the HLM tested how the effect of the predicting variables changed with time in the host country. The following predicting variables were included in the model: pre-migration psychological well-being, post-migration perceived discrimination, post-migration social support received from peers, teachers, and parents, country of origin, gender, family composition, mother‘s education, mother‘s occupation, and number of rooms in the family apartment. Since perceived social support was not measured at Time1 due to a technical error, only the measurements conducted at Time2 and Time3 were included in the model. A two-wave model did not have enough degrees of freedom to test linear or higher effects of time; therefore, time was included in the model as a discreet variable. Interactions of each predicting variable with time were included in the model in order to test how the effects of the predicting variables changed with time. Hierarchical Linear Models were calculated separately for each of the six indexes of psychological wellbeing (Table 5). For each of the six indexes of psychological well-being, Table 5 presents coefficients of the polynomial functions, in which each index of post-migration psychological well-being is conceived of the corresponding index of pre-migration psychological well-being, postmigration perceived discrimination, and post-migration social support received from parents, teachers, and peers. The coefficients' increments for Time2 demonstrate how each coefficient at Time2 differs from the corresponding coefficient at Time3. No effect of socio-demographic or family characteristics was significant; therefore, these variables are not presented in the table. All variables included in the model were transformed in order to bring them closer to a normal distribution. The four variables measuring positive psychological well-being were transformed as measuring psychological distress, subtracting their values from 6; after that, all variables were square rooted. Thus, positive coefficients in Table 5 indicate a positive association between the predicting variables and post-migration psychological distress.

Table 5. Hierarchical Linear Model: coefficients of the polynomial functions for the six indexes of post-migration psychological well-being

Predicting variables1 Intercept Pre-migration index of psychological well-being, coefficient for Time3 Pre-migration index of psychological well-being, the coefficient's increment for Time2 Perceived discrimination, coefficient for Time3 Perceived discrimination, the coefficient's increment for Time2 Perceived social support from parents, coefficient for Time3 Perceived social support from parents, the coefficient's increment for Time2 Perceived social support from teachers, coefficient for Time3 Perceived social support from teachers, the coefficient's increment for Time2 Perceived social support from peers, coefficient for Time3 Perceived social support from peers, the coefficient's increment for Time2

Predicted variables Self-esteem

Body image

Coefficient 1.422*** .236*

SE .241 .092

Coefficient 1.404*** .251**

.245*

.097

.062*

Social competence

School competence

Loneliness

SE .257 .091

Emotional and behavioral problems Coefficient SE 3.418* 1.487 .347*** .086

SE .279 .094

Coefficient 1.289*** .379***

SE .242 .087

Coefficient .708** .482***

Coefficient 2.733*** .294***

SE .583 .083

.138

.101

.105

.093

.047

.082

.084

.080

.172*

.085

.031

.096*

.038

.056

.032

.072*

.032

.598**

.194

.188*

.077

-.016

.038

-.005

.046

.019

.038

-.062

.036

-.023

.218

.053

.091

-.003

.021

-.032

.024

-.007

.021

-.001

.021

-.044

.122

-.054

.051

.019

.026

.036

.031

.006

.026

.015

.025

-.058

.150

.010

.063

-.037*

.017

-.069**

.021

-.041*

.018

-.019

.018

-.002

.106

-.119**

.043

.014

.022

-.001

.027

.008

.022

-.019

.021

-.091

.125

.071

.054

-.077**

.025

-.055

.030

-.079**

.025

-.035

.025

-.084

.147

-.312***

.060

.016

.032

.065

.038

.049

.032

.007

.030

-.217

.178

.066

.075

SE = standard error. * p<.05; ** p<.01; *** p<.001.

1

The coefficient's increment for Time2 demonstrates how the coefficient at Time2 differs from that at Time3.

Changes in the Psychological Well-Being of Immigrants

177

The results of the HLM analyses demonstrate that each pre-migration index of psychological well-being predicted the corresponding post-migration index. The effect of perceived discrimination was significant for all indexes of psychological well-being in the post-migration period, except social competence. Perceived social support from parents had no significant effect on any index of psychological well-being. The effect of perceived social support from teachers was significant on post-migration self-esteem, body image, social competence, and loneliness; its effect on school competence and emotional and behavioral problems was not significant. The effect of perceived social support from peers was significant for self-esteem, social competence, and loneliness; its effect on body image, school competence, and emotional and behavioral problems was not significant. The interaction of only two variables with time yielded significant: pre-migration self-esteem and pre-migration loneliness. These pre-migration indexes of psychological well-being had a stronger effect on the corresponding post-migration indexes in the second year compared to the third year after immigration.

DISCUSSION This longitudinal study investigated the psychological well-being of adolescents immigrating from Russia and Ukraine to Israel without parents. Measurements were conducted four times: half a year before emigration and in each of the three consecutive years after immigration to Israel. In addition, the psychological well-being of the immigrants was compared with that of non-emigrating adolescents in Russia and Ukraine. In the pre-migration period, adolescents who planned emigration reported higher psychological well-being compared with their Russian and Ukrainian peers who did not plan to emigrate. Since the socio-demographic characteristics of the two samples were similar, the higher psychological well-being of the emigrating adolescents may have been due to the planned emigration. Specifically, expectations of a better life in a new country might increase immigrants' self-esteem and self-competence, as well as reduce their anxiety and thus partly ameliorate their emotional and behavioral problems. In addition, contacts with other immigrants-to-be might reduce the immigrants' loneliness in the pre-migration period. Two previous qualitative studies found that adolescents immigrating from the Former Soviet Union to Israel without parents had high expectations and felt elated during the pre-migration period [54, 55]. The results of the present quantitative study corroborate the hypothesis that euphoria appears in the pre-migration period and not after the immigrants' arrival to the host country, as researchers of immigration previously thought [4, 5, 6]. For those immigrants who experience pre-migration euphoria, immigration does not begin with acculturative stress, as the stress-coping model suggests, but rather with high expectations and elation. In this aspect, voluntary immigration may be similar to some other major life-transition events, which are characterized by eustress rather than distress, such as moving to a college, obtaining a desirable job, getting married, or expecting a baby. Premigration euphoria may play an important role in the immigration process, helping immigrants mobilize their psychological resources during separation from their homeland and in the initial period of adjustment to the host country [54, 55, 56, 57]. Pre-migration euphoria may be widespread among voluntary immigrants; however, other categories of immigrants,

178

Eugene Tartakovsky

such as accompanying persons, refugees, and exiled persons, may feel entirely different in the pre-migration period. In the investigated three-year period, five indexes of immigrants' psychological wellbeing followed a U-curve: self-esteem, body image, social competence, school competence, and loneliness. These measures indicated a decline in psychological well-being in the first year after immigration and an improvement in the third year after immigration. Emotional and behavioral problems of the adolescent immigrants followed a unique pattern: they increased in the first year after immigration and remained consistently high throughout the postmigration period. The reduction in psychological well-being in the first year after immigration compared with the pre-migration period supported the hypothesis that the period after arrival in the host country is stressful for immigrants [1, 3]. However, given the exceptionally high measures of pre-migration psychological well-being found in the studied population, the post-migration reduction in psychological well-being may be indicative of post-migration disillusionment rather than trauma from immigration. In the second year, compared with the first year after immigration, loneliness further increased and school competence decreased. This finding indicates that in the later stages of adjustment to the host country, immigrants may encounter social challenges that negatively affect their psychological well-being. Considering the specific circumstances of the adolescents participating in this study, we may assume that their transition from the immigrants' to the regular school classes in the second year after immigration might have caused an increase in their loneliness and a decrease in school competence. The necessity to communicate with host-country adolescents in class and to study subjects that demand a good command of the new language might tax the immigrants‘ resources and cause a decline in their psychological well-being. The results of this study indicate that immigration is neither unequivocally morbid nor beneficial for the immigrants. In the third year after immigration, the two indexes of psychological distress (emotional and behavioral problems and loneliness) remained worse than they were in the pre-migration period. Among the four indexes of positive psychological well-being, self-esteem exceeded the pre-migration level, and the remaining three indexes (body image, social competence, and school competence) returned to the pre-migration level after an initial decline. However, beyond this inconsistency, throughout the entire postmigration period, the psychological well-being of immigrant adolescents remained higher than that of their non-emigrating peers in the homeland. This finding confirms that immigration may be non-traumatic [58]. At the same time, adolescents from Russia and Ukraine participating in this study, both immigrants and non-immigrants, had higher levels of emotional and behavioral problems compared with adolescents in developed countries, including Israel [59, 60]. Previous studies consistently found that the psychological well-being of adolescents in the Former Soviet Union was lower than that of their Western peers [61, 62, 63, 64]. The low psychological well-being of adolescents in the FSU may be due to a low level of economic development, higher crime rate, and high level of corruption [65]. Therefore, some adolescent immigrants from the FSU may need professional help not because of the harmful effect of immigration, but because they have formed nonadaptive emotional and behavioral patterns even before their emigration. Pre-migration psychological well-being of the immigrants was the most sustainable predictor of their post-migration psychological well-being. The strongest prediction was for

Changes in the Psychological Well-Being of Immigrants

179

the first year after immigration, when the pre-migration measures explained up to 40% of the variance in the corresponding post-migration measures. Although the predictive power of the pre-migration psychological well-being decreased with time in the host country for two out of six indexes, for all indexes it remained significant throughout the entire immigration period. This finding indicates that the adjustment of immigrants in the host country strongly depends on the psychological resources accumulated in the pre-migration period: those who are well adjusted before immigration tend to adjust well in the host country. This finding also indicates that immigration does not shatter the developmental process (as would be in a case of trauma). The immigrants' personality remains basically stable despite the drastic social changes. Perceived social conditions in the host country predicted the immigrants‘ psychological well-being beyond their pre-migration adjustment. Perceived discrimination had a strong detrimental effect on the psychological well-being of immigrants. This finding corroborates the results of previous studies on the effect of discrimination [19, 31, 32]. Perceived social support from peers and teachers had a positive effect on some but not on all indexes of the immigrants' psychological well-being. Social support provided by peers and teachers positively affected the self-esteem and social competence of immigrants, and reduced their feelings of loneliness. In addition, perceived social support from teachers positively affected body image of immigrant adolescents. However, perceived social support from peers and teachers affected neither school competence, nor emotional and behavioral problems of immigrant adolescents. The reason for this is not clear and requires further research. Perceived social support from parents was not associated with any index of psychological well-being. One reason for this may be the specific circumstances of the unaccompanied minors participating in the present study: social support provided by parents who live far away from their children might have little effect on the adolescents' psychological well-being. Another possible explanation is more general: according to the ecological system theory, beginning from early adolescence, the social environment has a stronger effect on the psychological well-being of individuals than the family does [37, 66]. It is important to note that perceived social support received from teachers and peers was higher, and perceived discrimination was lower in the third year after immigration compared with the second year. This indicates that ensuring social support and feeling accepted in the host country takes time, and these processes parallel changes in the immigrants' psychological well-being. The effect of family characteristics on the adolescents' post-migration psychological well-being was significant only when measured separately from psychological variables. A better financial situation in the family was associated with higher self-esteem, increased school competence, and fewer emotional and behavioral problems among immigrant adolescents. This finding corresponds with previous studies on psychological well-being, which found that an individuals' financial situation is a strong predictor of their psychological well-being [67]. Immigrant adolescents coming from two-parent families reported higher selfesteem, more positive body image, higher social competence, higher school competence, and less loneliness. It is probable that, in average, two-parent families can provide their children with greater tangible resources and emotional support than single-parent families can. Higher mother's education was associated with higher school competence among the adolescents; however, contrary to the hypothesis, mothers' higher education and professional or managerial occupation were associated with lower body image among the adolescents. A possible explanation may be that highly educated professional mothers demand more from

180

Eugene Tartakovsky

their children, which has both positive and negative consequences. However, there was no effect of family characteristics on the psychological well-being of immigrant adolescents when it was calculated together with pre-migration psychological well-being and perceived social conditions in the host country. It is possible that family characteristics affected the premigration psychological well-being and, when this variable was taken into consideration, the effect of socio-demographic characteristics was masked. Apparently, this issue requires further research. Overall, the obtained results confirmed that the pre-migration psychological well-being of immigrants together with the perceived social conditions in the host country determine post-migration psychological well-being. Therefore, the ecological systems theory was corroborated in its application to the situation of immigration. However, not all results of this study can be generalized onto other immigrant populations. The adolescents participating in this study had high motivation for immigration and ample psychological resources. In addition, they enjoyed relatively high social support and low discrimination in the receiving country. Probably for these reasons, immigration was not traumatic for these adolescents. However, for other immigrant populations the situation may be different. For instance, immigrant adolescents who are sent abroad against their will may suffer from distress in the pre-migration period, a decline in their psychological well-being may be more profound, and their psychological well-being may remain low in the post-migration period. Immigrants who encounter unfavorable social conditions in the host country may also experience a greater decline in their psychological well-being, and it may remain at a low level for a long time. This study has methodological limitations: the pre-migration measurement was conducted during the time of testing for participation in the Na'ale program, and self-report measures of psychological well-being that are susceptible to social desirability bias were used. Further longitudinal studies should include implicit measures of pre-migration psychological well-being and embrace a wide range of immigrant populations.

CONCLUSION The results obtained corroborate the hypothesis that euphoria appears in the premigration period and not after the immigrants' arrival to the host country, as researchers of immigration previously thought. Expectations of a better life in a new country might increase immigrants' self-esteem and self-competence, as well as reduce their anxiety and thus partly ameliorate their emotional and behavioral problems in the pre-migration period. In addition, contacts with other immigrants-to-be might reduce the immigrants' loneliness in the premigration period. The reduction in psychological well-being in the first year after immigration compared with the pre-migration period supported the hypothesis that the period after arrival in the host country is stressful for immigrants. However, given the exceptionally high measures of pre-migration psychological well-being found in the studied population, the post-migration reduction in psychological well-being may be indicative of post-migration disillusionment rather than trauma from immigration. Pre-migration psychological well-being of the immigrants was the most sustainable predictor of their post-migration psychological well-being. This finding indicates that the adjustment of immigrants in the host country strongly depends on the psychological resources

Changes in the Psychological Well-Being of Immigrants

181

accumulated in the pre-migration period: those who are well adjusted before immigration tend to adjust well in the host country. Perceived discrimination had a strong detrimental effect on the psychological well-being of immigrants. Perceived social support from peers and teachers had a positive effect on some but not on all indexes of the immigrants' psychological wellbeing. Perceived social support from parents was not associated with any index of psychological well-being. It is probable that social support provided by parents who live far away from their children has little effect on the adolescents' psychological well-being. The obtained results confirmed that the pre-migration psychological well-being of immigrants together with the perceived social conditions in the host country determine post-migration psychological well-being. These findings corroborate the ecological systems theory in its application to the situation of immigration.

ACKNOWLEDGMENTS This study was partly supported by a grant from the Chief Scientist's Office at the Israeli Education Ministry. The author thanks the psychologists, social workers, and counselors working in the Na'ale program in Israel, the psychologists cooperating with the Na'ale program in Russia and Ukraine, and the Na'ale Administration for their help in conducting the study. The author is grateful to the adolescents who participated in this study. An earlier version of this article was published in Journal of Research on Adolescence, 2009, 19(2), 177-204.

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[26] Fazel, M., and Stein, A. (2003). Mental health of refugee children: comparative study. British Medical Journal, 327, 134. [27] Reijneveld, S. A., Harland, P., Brugman, E., Verhulst, F. C., Verloove-Vanhorick, S. P. (2005). Psychosocial problems among immigrant and non-immigrant children: ethnicity plays a role in their occurrence and identification. European Child and Adolescent Psychiatry, 14, 145-152. [28] Vollebergh, W. A. M., ten Have, M., Dekovic, M., Oosterwegel, A., Pels, T., Veenstra, R., de Winter, A., Ormel, H., Verhulst, F. (2005). Mental health in immigrant children in the Netherlands. Social Psychiatry and Psychiatric Epidemiology, 40, 489-496. [29] Fuligni, A. J. (2004). The adaptation and acculturation of children from immigrant families. In U. Gielen and J. Roopnarine (Eds.), Childhood and adolescence: crosscultural perspectives and applications. pp. 297-318. [30] Nesdale, D., and Mak, A. S. (2003). Ethnic identification, self-esteem, and immigrant psychological health. International Journal of Intercultural Relations, 27, 23-40. [31] Leung, C. (2001). The sociocultural and psychological adaptation of Chinese migrant adolescents in Australia and Canada. International Journal of Psychology, 36(1), 8-19. [32] Liebkind, K., and Jasinskaja-Lahti, I. (2000). The influence of experiences of discrimination on psychological stress: a comparison of seven immigrant groups. Journal of Community and Applied Social Psychology, 10, 1-16. [33] Liebkind, K., Jasinskaja-Lahti, I., and Solheim, E. (2004). Cultural identity, perceived discrimination, and parental support as determinants of immigrants‘ school adjustment: Vietnamese youth in Finland. Journal of Adolescent Research, 19(6), 635-656. [34] Murad, S. D., Joung, I. M. A., Verhulst, F. C., Mackenbach, J. P., Crijnen, A. A. M. (2004). Determinants of self-reported emotional and behavioral problems in Turkish immigrant adolescents aged 11-18. Social Psychiatry and Psychiatric Epidemiology, 39, 196-207. [35] Sowa, H., Crijnen, A. A. M., Bengi-Arslan, L., Verhulst, F. C. (2000). Factors associated with problem behaviors in Turkish immigrant children in the Netherlands. Social Psychiatry and Psychiatric Epidemiology, 35, 177-184. [36] Florsheim, P. (1997). Chinese adolescent immigrants: factors related to psychosocial adjustment. Journal of Youth and Adolescence, 26(2), 143-163. [37] Bronfennbrenner, U. (1989). Ecological systems theory. In R. Vasta (Ed.), Six theories of child development, vol. 6, pp. 187-250. Greenwich, CT: JAI Press. [38] Na‘ale Program (2006). www.Naale.org.il. [39] Bendas-Jacob, O., and Fridman, Y. (2000). Naale: Adolescents emigrating without their parents. Henrietta Sold Research Institute of Social Science, Jerusalem. (In Hebrew). [40] Brym, R. J., and Rivkina, R. (1994). The Jews of Moscow, Kiev, and Minsk. New York: New York University Press. [41] Tafarodi, R. W., and Swann, W. B. (1995). Self-liking and self-competence as dimensions of global self-esteem: initial validation of a measure. Journal of Personality Assessment, 65(2), 322-342. [42] Offer, D., Ostrov, E., and Howard, K. I. (1982). The Offer Self-Image Questionnaire for Adolescents: a manual. Third edition. Michael Reese Hospital and Medical Center, Chicago.

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[43] Helmreich R., and Stapp, J. (1974). Short forms of the Texas Social Behavior Inventory (TSBI), an objective measure of self-esteem. Bulletin of the Psychonomic Society, 4(5A), 473-475. [44] Marsh, H. W., Byrne, B. M., and Shavelson, R. J. (1988). A multifaceted academic selfconcept: Its hierarchical structure and its relation to academic achievement. Journal of Educational Psychology 80(3), 366–380. [45] Achenbach, T. M. (1991). Manual for the Youth Self-Report and profile. Burlington, VT: Department of Psychiatry, University of Vermont. [46] Hays, R. D., and DiMatteo, M. R. (1987). A short-form measure of loneliness. Journal of Personality Assessment, 51, 69-81. [47] Zimet, G. D., Dahlem, N. W., Zimet, S. G., and Farley, G. K. (1988). The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 52(1), 30-41. [48] Phinney, J. S., Madden, T., and Santos, L. J. (1998). Psychological variables as predictors of perceived ethnic discrimination among minority and immigrant adolescents. Journal of Applied Social Psychology, 28(11), 937-953. [49] Corey, E. M. (2001). What conclusions can be drawn from social desirability measure research? Panel Discussion, 21st Annual Conference of the Society for Industrial and Organizational Psychology, Dallas, Texas. [50] Heine, S. J., and Lehman, D. R. (1995). Social desirability among Canadian and Japanese students. Journal of Social Psychology, 135, 777-779. [51] Johnson, T. P., and Fendrich, M. (2002). A validation of the Crowne-Marlowe social desirability scale. Paper presented at the annual meeting of the American Association for Public Opinion Research, St. Petersburg, FL. http://www.srl.uic.edu/publist/ Conference/crownemarlowe.pdf [52] Silverthorn, N. A., and Gekoski, W. L. (1995). Social desirability effects on measures of adjustment to university, independence from parents, and self-efficacy. Journal of Clinical Psychology, 51(2), 244-251. [53] Crowne, D., and Marlowe, D. (1960). A new scale of social desirability independent of psychopathology. Journal of Consulting Psychology, 24, 349-354. [54] Bertok, N., and Masterov, B. (2006). The "sent away" children: a psychological analysis of adaptation of adolescents participating in educational programs in Israel. In E. Tartakovsky and V. Sobkin (Eds.), Community psychology: national experience in the global perspective, pp. 53-62. Moscow: GraFix. (In Russian). [55] Markowitz, F. (1996). Shopping for the future: culture change, border crossing, and identity options of Jewish teenagers from the CIS. Ethos, 24(2), 350-373. [56] Barnett, D. (December 2004). No child left behind: new rules for unaccompanied minor illegal aliens. Center for Immigration Studies. http://www.mnforsustain.org/ cis_no_child_left_behind_barnett.htm [57] Littlefield, L. (11 August 2005). Unaccompanied immigrants and refugee minors. National Conference of State Legislatures. http://www.ncsl.org/programs/immig/ Unaccompaniedminorsfactsheet.htm [58] Tartakovsky, E. (2007). A longitudinal study of acculturative stress and homesickness: high-school adolescents immigrating from Russia and Ukraine to Israel without parents. Social Psychiatry and Psychiatric Epidemiology, 42(6), 485-494.

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[59] Verhulst, F. C., Achenbach, T. M., van der Ende, J., Erol, N., Lambert, M. C., Leung, P. W. L., Silva, M. A., Zilber, N., Zubrick, S. R. (2003). Comparisons of problems reported by youths from seven countries. American Journal of Psychiatry, 160, 14791485. [60] Zilber, N. (1999). Preliminary results of YSR in the Israeli sample. Unpublished research report. Jerusalem: JDC – Falk Institute. [61] Amir, M., Ayalon, L., Varshavsky, S., and Bulygina, N. (1999). Motherland or home country: a comparative study of Quality of Life among Jews from the former Soviet Union who immigrated to Israel, Jews in Russia, and Israeli non-immigrants. Journal of Cross-Cultural Psychology, 30(6), 712-721. [62] Balatsky, G., and Diener, E. (1993). Subjective well-being among Russian students. Social Indicators Research, 28, 225-243. [63] Jose, P. E., D‘Anna, C. A., Cafasso, L. L., Bryant, F. B., Chiker, V., Gein, N., and Zhezmer, N. (1998). Stress and coping among Russian and American early adolescents. Developmental Psychology, 34(4), 757-769. [64] Scheer, S. D., and Unger, D. G. (1998). Russian adolescents in the era of emergent democracy: the role of family environment in substance use and depression. Family Relations, 47(3), 297-303. [65] Tartakovsky, E. (2009). Children of perestroika: the changing socioeconomic conditions in Russia and Ukraine and their effect on the psychological well-being of high-school adolescents. Social Psychiatry and Psychiatric Epidemiology. [66] Garbarino, J. (1999). Lost boys: Why our sons turn violent and how we can save them. Anchor books: New York. [67] Diener, E., Diener, M., and Diener C. (1995). Factors predicting the subjective wellbeing of nations. Journal of Personality and Social Psychology, 69(5), 851-864.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 13

MENTAL HEALTH PROBLEMS AMONG IMMIGRANTS IN ISRAEL Alexander M. Ponizovsky Mental Health Services, Ministry of Health, Jerusalem, Israel

ABSTRACT This chapter describes findings of the Israel National Health Survey (INHS), conducted in 2003-2004 in conjunction with the World Mental Health (WMH) survey initiative. The INHS was designed to estimate the prevalence rates of psychological distress and common mental disorders, and the use of health care services and psychotropic medication in the adult Israeli population. Personal interviews were held with 3,906 veteran Israelis and 952 immigrants from the former Soviet Union (FSU) and other countries, who had immigrated to Israel after 1989. In addition, we also review here preliminary findings from the Israeli Survey of Mental Health among Adolescents (ISMEHA), conducted in 2004-2005 by the Mental Health Services at the Israeli Ministry of Health on a representative nationwide sample of 957 adolescents aged 14-17 (131 immigrants and 826 Israel-born peers). Psychological distress was measured by the General Health Questionnaire-12 (GHQ-12). Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) disorders were assessed using a revised version of the Composite International Diagnostic Interview (CIDI), and the Development and Well-Being Assessment Inventory (DAWBA) was used for diagnosis assessment in adolescents. Respondents were asked to report any health service and psychotropic drug use during the previous 12 months. Adult immigrants were almost twice as likely to report both mild and severe psychological distress compared with veteran Israelis. Both populations were equally likely to have a common mental disorder and to have used health care services during the past 12 months. This was the case for adolescent immigrants as well. Among adult respondents who did not meet the DSM-IV criteria for a specific mental disorder, the immigrants reported markedly more use of psychotropic drugs than veteran Israelis, in particular more anxiolytics, mood stabilizers, and hypnotics. The results suggest that the common mental disorders and the use of mental health services are no higher among the immigrants than among their veteran counterparts. The higher use of psychotropic drugs by adult immigrants may be an indirect indicator of a higher level of psychological distress symptoms, such as anxiety,

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INTRODUCTION The international migration has a long history, but it has become increasingly prevalent phenomenon during the past four decades [1]. To give only few examples, Canada has welcomed, on average, 220,778 immigrants and refugees a year for the past 10 years; the Australian immigration program for 2003-2004 offered 100,000-110,000 places for migrants, plus a parent contingency reserve of 6,500 places for a full year [2]; and the last wave of Jewish emigration from the former Soviet Union (FSU) brought 962,458 immigrants to Israel between 1989 and 2004 [3]. Immigration has been considered a major stressful life-event producing elated emotional distress and mental disorders in vulnerable individuals, and causing maladjustment [4-6]. Psychological reactions to significant life events are expressed in a variety of psychological symptoms, mainly in a mixture of anxiety and depression symptoms [7]. These nonspecific responses to stressful events vary in intensity, constituting proxy measures of mild to severe psychopathology. If the extent to which these symptoms are expressed is insufficient to diagnose specific mental disorder according to ICD or DSM criteria, they have been diagnosed as psychological distress or, sometimes, as demoralization syndrome. The acculturation stress hypothesis has been proposed [8,9] as an explanation of the effects of immigration on mental health. This hypothesis proposes that the stresses of living in a foreign culture precipitate mental disorder in vulnerable individuals [10-15]. It also assumes that the higher emotional distress accompanying migration is, among other reasons, a result of the disruption to family, friendship and other social support networks [16,17], and of the migrant‘s exposure to an unfamiliar culturo-physical environment [18], to prejudice and discrimination [4,19], and to decreased socioeconomic status [20]. Tests of this hypothesis, however, have given conflicting results: some studies find levels of psychological distress in immigrants higher than in the indigenous general population [21-25], but others report lower levels [26-30]. Of course, the discrepancies between studies may be explained by marked methodological differences in sampling procedures, age grouping, screening instruments, and time frame, but may be attributed to differences in national immigration policies as well. Obviously, immigrant mental health has important implications for health provision in their host countries [31,32]. While a large influx of healthy newcomers can improve the mental health profile of the general population [33,34], distressed and mentally ill immigrants are likely to increase the burden on health care and social welfare services [35,36]. There is accumulating evidence, however, which challenges the common belief that mental illness is more frequent among immigrants than indigenous populations [37-39]. Schizophrenia, affective disorders, substance dependence and abuse, and post-traumatic stress disorder among immigrants have been areas of increased research interest [16,40]. However, stressrelated anxiety disorders―which account for most psychiatric cases in the community―and

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the association between immigrant status and affective and anxiety disorders have both been studied far less [41]. Israel is a culturally polyphonic country, built by Jewish immigrants from all over the world and has always been open to them as one of the founding principles of the state. Over the sixty years of its history many waves of immigrants have reached its shores. Many veteran Israelis identify with the newcomers as a result of their own experience as immigrants and provide them with emotional support [42]. The state employs several sorts of instrumental social support for new immigrants, the most important of which is supported housing for an extended period. New immigrants can be initially settled either in the absorption centers, where they could live for several years paying minimal rent ("centralized absorption" model) or they can receive financial support from the state to rent housing on the free market ("direct absorption" model). Another sort of instrumental support received by immigrants in Israel is learning Hebrew on free language instruction courses for a six-month period [43]. Although Jewish newcomers from different countries to Israel differ from one other (sometimes tremendously), there are some features they held in common. First, usually immigrants emigrate en masse and not as individuals that provides individual immigrants with a meaningful familial network and a frame of reference. Second, as a rule, immigrants enjoy the advantage of meeting in Israel former immigrants from their country of origin who act as cultural facilitators to help to bridge the gap. Therefore, the integration process begins on a familiar and personal basis, using informal routes of acculturation, with help and support provided by families and friends [42]. The majority of the Jewish Israeli population is first- or second-generation immigrants from Europe, North Africa or Asia. For instance, 1,180,870 immigrants arriving between 1989 and 2004 were mainly Jews from the FSU and Ethiopia [3]. Undoubtedly, such a mass migration offers a unique opportunity to test the acculturation-stress hypothesis, as well as to study a variety of risk and protective factors. Previous studies have shown higher levels of psychological distress among FSU immigrants compared to the veteran Israeli population [44-51]. However, most of these studies suffered from methodological shortcomings and were carried out on groups of limited size or populations in treatment. Only one study has compared psychological distress among Jewish newcomers from different countries [42]. That study found that FSU immigrants were more distressed than their counterparts from Ethiopia, though the former displayed more symptoms of anxiety and associated hostility, while the latter – paranoid ideation. This chapter reviews and interprets findings from the Israel National Health Survey (INHS), the first national study of mental health in Israel [52], which was conducted in 20032004 in conjunction with the World Mental Health (WMH) survey initiative [53]. The INHS made it possible to estimate and compare the need for mental health services and treatment in the immigrant and veteran Israeli populations [54,55] and its findings have better informed health providers and policymakers at national, regional, and local levels, as well as guiding their decisions on service development and interventions for both immigrants and veteran Israelis. INHS data also substantially supplement the international epidemiological picture for mental disorders and health service and psychotropic drug use among immigrants. The INHS provides a unique opportunity to compare recent immigrants and the veteran Israeli population on their prevalence rates for ―

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psychological distress; mood and anxiety disorders; health care service use; and, psychotropic drug use.

One limitation of the INHS was that it referred to adults only. The epidemiological picture for mental health problems and service use among adult immigrants would be very usefully supplemented if we had data on the adolescent immigrant population and these data have indeed recently become available and will be presented below, see Adolescent Immigrants. As a component of the 27-country World Mental Health Survey, the INHS followed established uniform methodology and procedures [56], which have been reported in detail elsewhere [52]. Briefly, the INHS sample was extracted from the National Population Register and comprised non-institutionalized de jure residents aged 21 and older. The sample was designed to represent the distribution of selected gender-age population groups in the general population (Arabs and Jews; the Israel-born; immigrants from the FSU or other countries after 1989). The sample was weighted back to the total population to compensate for unequal selection probabilities resulting from disproportionate stratification, clustering effects and non-response. The weights were adjusted to make weighted sample totals conform to population totals already known from reliable Israel Central Bureau of Statistics (CBS) sources. Between May, 2003, and April, 2004, personal interviews were conducted with the respondents' households in Arabic, Hebrew or Russian. The survey was conducted by means of laptop-computer-assisted personal interviews, by interviewers trained and supervised by the CBS. Informed consent was received from all participants to the study, as required by the Israel Ministry of Health‘s Experimentation on Human Subjects Committee. The overall response rate was 73%. A total of 4,859 completed interviews were collected, comprising 3,906 interviews with veteran Israelis (2,758 native-born Israelis and 1,148 immigrants who had immigrated to Israel from different countries prior to 1989), and 952 interviews with immigrants from the FSU and from other countries who immigrated after 1989 and had average length of time since immigration 9 years. Data were analyzed with the SAS 9.1 software package (SAS Institute Inc., Cary, N.C.), which is designed to analyze complex sample surveys and weighted data. Prevalence estimates for psychological distress and common mental disorders were computed and reported as both absolute numbers and percentages, with 95% confidence intervals. We computed the proportion of respondents in the general population who reported using psychotropic drugs and health services in the 12 months preceding the interview. Crosstabulations were used to calculate bivariate odds ratios and 95% confidence intervals to assess the intensity of reported drug and service use, and gender differences. We performed univariate logistic regression analysis to analyze the association of clinical-diagnostic characteristics with psychotropic drug and service use.

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Psychological Distress Psychological distress was measured by the General Health Questionnaire (GHQ-12) [57] ― a valid and reliable measure of nonspecific psychological distress which has been used extensively worldwide [58]. The questionnaire asked whether the respondent had experienced a particular symptom or behavior during the month preceding the survey and responses were rated on a 4-point frequency scale, ranging from ―Much less than usual‖ (score 0) to ―Much more than usual‖ (score 3). GHQ total scores range from 0 to 36 and vary by study population, with total scores of about 11-12 that are typical, and a score higher than 15 suggesting mild distress and a score higher than 20 suggesting severe psychological distress [59,60]. Using these cut-off points, we found that immigrants were nearly twice as likely to report mild psychological distress as veteran Israeli respondents (21% vs. 12%) and almost twice as likely to be rated as suffering from severe psychological distress (9% vs. 5%). Psychological distress was associated with being female, aged over 50, divorced, secular, having higher education and ―not in workforce‖ employment status. In every sociodemographic subgroup immigrants reported twice as much psychological distress as veteran Israelis. These findings support the acculturation-stress hypothesis as an explanation for immigrants‘ psychological distress. Acculturation is conceptualized as a complex socioculturo-psychological process of adaptation to new living conditions [8,9], and length of time since immigration is one of its key indicators [45,51]. However, recent literature on acculturation and adaptation has emphasized a distinction between two types of adaptive outcome, the psychological and the sociocultural [61,62]. The former refers to good mental health, psychological wellbeing and the achievement of personal satisfaction in the new cultural milieu, while the latter refers to the acquisition of the social skills and behavioral codes needed for successful everyday functioning. Our findings clearly support this distinction. Socioculturally, the immigrants can be considered well adapted, given that they have lived in Israel more than nine years on average and do not differ from the host population on employment status. Yet their high levels of psychological distress show that they still remain psychologically maladjusted. Recall here that in addition to the demands of acculturation every immigrant is encountered with everywhere, immigrants to Israel are subject to the acute and chronic stressors of terrorist activity, which is permanent and in times increasing. Of course, all sectors of Israeli society are affected by terrorism [63-65], but immigrants‘ acculturation problems may exacerbate their exposure. For example, their lower socioeconomic status (SES) means that they frequent more the public places and facilities preferred for terrorist attack (buses, markets, malls, etc.) so that permanent awareness of their vulnerability may cause an anticipatory anxiety that in turn contributes to psychological distress. Regarding the immigrants‘ lower SES than veteran Israelis, one should keep in mind that this rating depends on the variables used to assess SES (education, income, employment status, etc.). Although the immigrants in our study were as likely to be employed as veteran Israelis and more likely to be highly educated, their SES is still relatively low because of ‗underemployment‘, namely, people being forced to work at a job inconsistent with their specialist training [66]. It seems that this very common occurrence among immigrants with higher education could explain our finding that employed immigrants were more distressed

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than their employed hosts. Furthermore, we found that respondents from the ‗Not in workforce‘ category (students, homemakers, the retired, the disabled) were more distressed than both employed and unemployed respondents and that ‗Not in workforce‘ immigrants were more distressed than ‗Not in workforce‘ veterans. A possible explanation is that this variable is confounded by gender, age and education because female, older and highereducated respondents are overrepresented in the immigrant population. The higher psychological distress associated with immigrant status has been reported in many previous studies [16,24,25,67-70]. Research also suggests that the association between time since immigration and psychological distress might be non-linear [21,45], with two possible peak risk periods ― just after immigration and several years later [69,70]. The first peak reflects distress at the immediate drastic life changes caused by immigration, whereas the second peak reflects the later emergence or cumulative exacerbation of family difficulties. Revealing of the elevated psychological distress among immigrants with mean time since immigration 9 years suggests that emotional distress may recur in the later stages of adjustment to migration [45] and that, in certain cases, the distress may persist for many years [51]. In order to see what demographic factors explained elevated psychological distress, we compared the GHQ scores across socio-demographic subgroups. This analysis indicated that certain groups were more vulnerable to high psychological distress― women, older people, the divorced/widowed, the secular, those who had less than college education, the unemployed and particularly those in the ‗Not in workforce‘ category. In all these groups, the scores for psychological distress were higher for immigrants than for their veteran counterparts. In the main, these results are consistent with the literature on immigrant mental health, which has reported psychological distress to be associated with female gender [71-76], older age at migration [77-82], marital status [69,70], employment [21,69], and religious observance [83]. However, our findings differ from previous studies in three respects. Firstly, as expected, there was a clear increase in GHQ mean scores with age. However, the patterns of this change were different for immigrants and veteran Israelis: among the former, psychological distress increased gradually across the life span, whereas in the latter, higher levels of distress appeared after fifty years of age. We suggest that for immigrants this difference can be attributed to age-specific adjustment difficulties, but that for the older host population it is to be attributed only to health-related distress. This assumption relies on findings from our previous study which showed that age differences in the stress process of recent immigrants to Israel were generally associated with age-specific perceived adjustment difficulties [78]. Contrary to the age-related increase in distress noted in this study, the INHS found no age-related increase in the 12-month prevalence of mood and anxiety disorders [84]. These seemingly contradictory results could be explained by methodology, namely by the differences between the GHQ screening of distress symptoms and diagnosing specific mental disorders according to DSM-IV criteria using the Composite International Diagnostic Interview [56]. Second, respondents who were divorced and widowed (the ‗Married before‘ category) had higher levels of psychological distress than their married and single counterparts. However, even among married respondents, married immigrants were more distressed than married veterans. A possible explanation for this difference is the emergence or exacerbation of family difficulties at later stages of acculturation [21,45].

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Third, among both secular and religious respondents, the levels of distress were higher for immigrants than for veteran Israelis. It is well-known that spirituality and religion, and the practices and circumstances that go together with them, can strengthen the sense of a meaning in life, bolster emotional well-being and serve as a buffer to life‘s stresses. Hence, our finding could mean that the supportive resources afforded by spirituality and religion are insufficient to compensate immigrants for disrupted family, friendship and other social support networks [16,17].

Mood and Anxiety Disorders Diagnosis assessments were made by the CIDI [56], a structured diagnostic interview for assessing the lifetime and 12-month prevalence of selected psychiatric disorders on both the International Classification of Diseases, 10th revision, and the DSM-IV classification systems. The following disorders were assessed: anxiety disorders (panic disorder, generalized anxiety disorder, agoraphobia without panic disorder, post-traumatic stress disorder) and mood disorders (major depressive disorder, dysthymia, bipolar disorder I and II). Prevalence estimates for mental disorders were determined from the respondents‘ self-reporting of current symptoms which met the 12-month diagnostic criteria for DSM-IV disorder. Every tenth respondent (10%) reported signs and symptoms during the past 12 months which met the DSM-IV criteria for a mood or anxiety disorder. There were no significant differences between immigrants and veteran Israelis with respect to the estimates for any mental disorder (11% vs. 9%; OR=0.9; 95% CI 0.7 to 1.1), for any mood disorder (7% vs. 6%; OR=0.9; 95% CI 0.6 to 1.2) or for any anxiety disorder (3% vs. 3%; OR=1.2; 95% CI 0.8 to 1.9). There were also no significant differences in pure major depression (7% vs. 6%; OR=0.8; 95% CI 0.6 to 1.1), pure mood disorder (0.2% vs. 0.6%; OR=3.7; 95% CI 0.9 to 16.2) and pure anxiety disorder (1% vs. 2%; OR=1.3; 95% CI 0.7 to 2.4). Only in the immigrant group women reported any anxiety disorder more frequently than men (OR=4.6; 95% CI 1.7 to 12.4). The INHS found that roughly each tenth respondent had been diagnosed with a common mental disorder during the past year [84] ― very similar to the rate reported in Europe. However, the frequencies for anxiety disorders and mood disorders were, respectively, somewhat higher and somewhat lower than in Europe [85]. We found no significant differences in the rates of mental problems among immigrants as compared with veteran Israelis. This finding is inconsistent with community health survey results in other countries with a relatively large immigrant component [86-93]: these latter reported that immigrants suffered from mental health problems either more or less than the host population. Our results can be explained by the convergence hypothesis, which posits that, compared with the host population, immigrants may have a lower or higher mental health risk before or immediately after their arrival, but that their risk level converges with the general population level the longer the immigrants live in their new country [91]. Alternatively, the results may be explainable by the characteristics of Israel‘s immigrant population, which could give rise to diagnostic bias, namely, the systematic under-diagnosis of mental disorders. However, the differences between the sociodemographic profiles of the immigrants and the veterans, namely that the immigrants have a higher proportion of women and unmarried people, are older and more educated and less religious than the general Israeli population [94], make such

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an explanation unlikely, since the above characteristics have been consistently shown to be associated with higher rates of psychological distress and morbidity [44, 95-97].

Health Care Services Use The use of health care services for emotional or mental health problems during the 12 months preceding the survey was assessed by the CIDI section on general services [98]. These services included (a) consulting any mental health professional (psychiatrist, psychologist, social worker, or other specialist mental health provider) in a public, private, workplace, or welfare setting; (b) consulting non-psychiatrist medical professionals (general practitioners, other medical doctors or health professionals), and (c) consulting informal health care providers, such as social workers, religious leaders, counselors, or traditional healers. Questions probing service utilization were included in several sections of the CIDI ― in the section on general services and in each diagnostic section dealing with a specific psychiatric category. Due to the data reported here were taken from the general section only, service use may be slightly underestimated. As for the mental disorder prevalence estimates, we found no significant differences between immigrant and veteran Israelis who were diagnosed with any mental disorder in the previous 12-months in their use of either professional or informal health services (28% vs. 36% respectively; OR=1.4; 95% CI 0.9 to 2.3). In both immigrants and veterans, significantly more frequent service use was found in women, both in the overall sample and in respondents with no recognizable disorder. Service use by veteran Israeli women diagnosed with pure mood disorder was particularly frequent (OR=6.4; 95% CI 1.5 to 26.7). About 1 in 10 respondents had consulted either formal or informal health care services during the 12 months prior to the survey (the same rate as those diagnosed with a common mental disorder). Of respondents diagnosed with a mental disorder, 34% had consulted health services in the same period (98). These figures are higher than data reported in the European Study of Epidemiology of Mental Disorders, perhaps because that study reported on formal service use only [99-101]. Many studies have demonstrated a substantial gap between levels of immigrants‘ mental health needs and their use of mental health services [102-109]. The explanations for this gap have included: age at migration and length of time since immigration [108], low education level [99], cultural and linguistic barriers to accessing care [86,90,109,110] unfamiliarity with local mental health services [106], poor state of health [111], high number of somatic symptoms [112], the dismissive attitudes of doctors and the doctors‘ reliance on pharmaceutical interventions in contrast to the immigrants‘ faith in the curative powers of non-medical interventions, such as divine will and traditional folk medicine [111]. Our findings, by contrast, do not indicate an under-use of mental health services among immigrants as compared with veteran Israelis. A possible explanation for this parity may be either the similar rates for common mental disorders, indicating the same level of health care need in both populations, or the absence of barriers to access for Israel‘s immigrants. There are several reasons why Israel‘s immigrants may find mental health care more accessible than immigrants elsewhere. First, all immigrants in Israel receive special social and financial support from the government, including full medical insurance coverage, which removes the financial barrier to service use. Second, FSU immigrants, comprising the most of respondents

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in the subsample, have less negative and stigmatizing attitudes to, and a higher level of trust in, Israeli psychiatric services, as these measure up very well against Soviet psychiatry, often misused and manipulated by the regime for political reasons [113]. Finally, the language barrier is almost insignificant as many immigrant mental health care providers have entered the health services in Israel and it is usually not difficult to find Russian-speaking mental health personnel.

Psychotropic Drug Use The assessment of psychotropic drug use during the 12 months preceding the survey was performed by a 191-item section of the survey instrument which inquired specifically and in detail into drug use, the identity of the prescribing clinician(s), the duration and frequency of use, reasons for discontinuation, and related issues. The analyses presented here refer to all episodes of use in the 12 months prior to the interview and do not distinguish between occasional use (a single episode over the year) and regular or systematic use. In order to overcome the recall bias that often hampers drug use studies (especially with respect to shortterm use), a standard booklet was provided which listed the psychotropic drugs commonly used in Israel to treat mental health problems and psychiatric disorders. Psychotropic drugs were recorded in the interviews by their national brand names and then converted to a drug coding system based on the Anatomical Therapeutic Chemical classification system [114]. The data presented here are confined to 5 main drug categories: 1) antidepressants (including tricyclics and new generation antidepressants); 2) anxiolytics (including benzodiazepines and non-benzodiazepine anxiolytic agents, such as buspirone); 3) hypnotics of any pharmacological class; 4) drugs used for the treatment of psychotic disorders, including antipsychotics (conventional and atypical antipsychotic agents, such as clozapine, olanzapine, quetiapine, ziprasidone, and risperidone), and antipsychotic depot injections; and 5) mood stabilizers (including lithium, carbamazepine, valproate, gabapentin, topiramate, and lamotrigine). We expected that our estimate of mood stabilizer use can be somewhat exaggerated as some of the drugs included are commonly used for other indications, for example, chronic pain treatment.

Figure 1. Twelve-month psychotropic drugs use by immigrants and veteran Israelis.

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25

Percent

20

15 Immigrants Veteran Israelis

10

5

0 No disorder

Mild distress

Severe Distress

Figure 2. Prevalence rates of mild and severe psychological distress and twelve-month psychotropic drug use by immigrants and veteran Israelis without diagnosed mental disorder (left charts).

In the year preceding the study, veteran Israelis took psychotropic drugs (any class) half as often as immigrants did (OR=0.5; 95% CI 0.4 to 0.7). This was the case both for overall use and for the specific use of anxiolytics (OR=0.5; 95% CI 0.4 to 0.7), mood stabilizers (OR=0.4; 95% CI 0.3 to 0.6), and hypnotics (OR=0.5; 95% CI 0.3 to 0.7) (Figure 1). Among both veterans and immigrants, female respondents were significantly more likely than males to have used psychotropic medication (any class) and anxiolytics, the gender differences being particularly pronounced in the immigrant group. In both immigrant and veteran Israeli populations, nearly twice as many women as men with no formal diagnosis took some psychotropic drug in the 12 months prior to the survey (OR=2.3; 95% CI 1.4 to 3.7 and OR=1.6; 95% CI 1.1 to 2.1, respectively). There were no significant gender differences in medication use among respondents diagnosed with a mental disorder. Also, there were no significant differences in psychotropic drug use between veteran Israelis and immigrants who had been diagnosed with a specific mental disorder. In contrast, veteran Israelis with no formal diagnosis were half as likely to take a psychotropic drug as their immigrant counterparts (OR=0.5; 95% CI 0.4 to 0.6) (Figure 2). In most countries the proportion of psychiatric medications in the gross domestic health product is rapidly increasing [115]. Despite this fact, epidemiological studies have indicated that patients with common mental disorders are frequently mistreated (that is, treated with inappropriate drugs) or undertreated (treated with appropriate drugs in insufficient doses) [116-118]. For example, the Canadian Community Health Survey: Mental Health and WellBeing indicated that 66% of respondents diagnosed with bipolar disorder did not take a mood

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stabilizer or antidepressant medication, and 22% took antidepressants without a mood stabilizer [105]. The INHS found a 7% rate of psychotropic drug use in the general population and a 20% rate in respondents with any 12-month mental disorder [119]. Analyzing INHS data we found that, compared with their veteran counterparts, immigrants have a higher 12-month prevalence rate for the use of any class of psychotropic drug. This finding reflects a higher use of anxiolytic, mood stabilizer, and hypnotic drugs, but not of antidepressants and antipsychotics. The most interesting is that this pattern of medication use was found only among respondents who failed to meet the DSM-IV criteria for a specific mental disorder. In other words, the discrepancies in drug use between immigrants and veteran Israelis cannot be attributed to differences in the prevalence rates for common mental disorders and health services utilization. Undoubtedly, the higher use of psychotropic drugs by immigrants may be an indirect indicator of a higher level of psychological distress symptoms, such as anxiety, depression and sleep disorders. It is also possible, however, that it is this very drug use that does not allow the distressing symptoms progress to reach the threshold required for the diagnosis of a specific mental disorder on DSM-IV criteria. Alternative explanation for this finding could be diagnostic bias, as a result of the tendency of some immigrants to under-report distressing symptoms [120]. This explanation, however, seems most unlikely in the light of our finding showing that the immigrants are twice as likely as veteran Israelis to report both mild and severe psychological distress. Hence, we suggest that treating distressing symptoms with psychotropic medication may be a factor deterring psychiatric morbidity in the immigrant population at the levels similar to those revealed in the host population. Our findings show that the 12-month use of psychotropic drugs was twice as high for women as for men, in accord with what previous studies have consistently reported―that women have higher rates of psychological distress than men [44,95,96]. The gender differences in psychotropic medication use found in our study lend further, if indirect, support to the argument that the increased drug use by immigrants may be caused by higher levels of experienced emotional distress. Studies suggest that there are particular risk periods for the psychological distress associated with immigration and for psychiatric morbidity among immigrants. For instance, a study of recent immigrants from the FSU to Israel demonstrated a 2-phase temporal pattern in the development of psychological distress. Distress levels gradually rose to a peak in the 27th month after arrival and then fell to normal levels by the 44th month [45]. Our analysis ― of respondents who had been in the country for an average of 9 years ― suggests that this emotional distress may return in the later stages of adjustment to immigration. The findings also imply that the temporal pattern of immigration distress may be subject to variation and that in particular cases distress may persist for a long time [51].

Adolescent Immigrants The Israeli Survey of Mental Health among Adolescents (ISMEHA), conducted in 20042005 by the Mental Health Services of the Ministry of Health in collaboration with the Ministry of Education, the Sieff Hospital, Tzfat, and the Schneider Children's Medical Center, Petakh Tikva, enables us to substantially extend the epidemiological picture of mental health

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problems among adult immigrants by data on immigrant adolescents [121,122]. The ISMEHA was carried out on a representative nationwide sample of 957 adolescents aged 1417 and their mothers, and employed a standardized diagnostic tool, the Development and Well-Being Assessment Inventory (DAWBA), designed to make ICD-10 and DSM-IV psychiatric diagnoses for children aged 5 to 17 [123]. The diagnoses made included separation anxiety, specific phobias, social phobia, panic attacks and agoraphobia, posttraumatic stress, compulsions and obsessions, generalized anxiety, and depression disorder. Comparing 131 adolescents who had immigrated to Israel with 826 Israel-born adolescents, we found that both groups were equally likely to have a mental disorder (11% and 12%, respectively; OR=0.93; 95% CI 0.45 to 1.92) and to use both professional and informal health care services (12% and 11%, respectively; OR=0.90; 95% CI 0.52 to 1.56). Of all variables studied, the maternal single or divorced status was the only factor for service underuse among immigrant adolescents (OR=0.24; 95% CI 0.07 to 0.88). Although we were not able to obtain data on the prevalence of psychological distress and the use of psychotropic drugs among immigrant adolescents, these results suggest that in general the mental health of adolescent immigrants is no worse than their Israel-born peers, but the immigrant adolescents with single or divorced mothers underuse mental health services (Ponizovsky AM, Mansbach-Kleinfeld I. Prevalence of mental disorders and use of services in an immigrant adolescent population: Findings from the Israel Survey of Mental Health among Adolescents (ISMEHA), unpublished report). Because of lack of statistical power due to small numbers of the specific mental disorders in the immigrant adolescents, only any mental disorder could be compared between the two populations. We explained the absence of an association between immigrant status and mental health problems by the acculturation hypothesis, specifically, that the immigrant adolescents surveyed had come to Israel so young (54% before age 5 and a further 32% between age 6-10) that by the time of the survey (i.e., on average 9 years later) they were effectively acculturated. A high rate of acculturation among migrant children and adolescents was pointed out in previous studies in Israel and worldwide [82,124]. For instance, we reported lower levels of internalizing and externalizing problems in Jewish native adolescents in Russia compared to Israeli native and immigrant adolescents from Russia in Israel, whereas the immigrants and Israelis showed similar problem scores [82]. These findings were highly suggestive of that the immigrant adolescents apparently adopted the Israeli cultural attitudes of how people should feel and act in different situations. The two distinct sets of independent findings, for adult and adolescent immigrants, are very similar and, consequently, enable policymakers to plan services and prevention programs for both immigrants and veteran Israelis of all ages.

Strengths and Limitations Before this chapter will be finished, strengths and limitations of our studies should be addressed. The methodological strengths include: 1) a reliably representative sample of the country‘s population) owing to rigorous sampling procedures; 2) a relatively high response rate (73% for adults and 68% for adolescents); 3) the interviews conducted in the respondents‘ mother tongue (Hebrew, Arabic, or Russian) and, thus increasing the likelihood of the respondents' understanding the questions; 4) the interviews conducted with the assistance of computer programs, which increased data quality by drastically reducing

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between-interviewer variation; and 5) the use of standard uniform instruments, which provides an opportunity for cross-country comparisons. The main limitation of our studies is that the veteran Israeli sample was not separated into locally-born and pre-1989 immigrant subsamples, and that all post-1989 immigrants were combined into a single category, wherever they came from. This was done to provide sufficient statistical power of our analyses. The heterogeneity of the Israeli population, made up of the native-born plus immigrants from 70 countries, could be exploited to check the direction of the association between immigration and health indicators across different ethnic groups. For instance, a recent study, using data linkage between the Israeli Draft Board and the National Psychiatric Hospitalization Registry, showed that risk for schizophrenia was increased among both first- and second-generation Ethiopian immigrants in Israel compared with other immigrant groups and with native-born Israelis [125]. Further research is needed to examine the ethnic factors which may be affecting the variables we studied. For now, extrapolating our findings to immigrant populations in other countries should be done with caution. A limitation is also that we did not analyze data on the non-medication treatment of psychiatric disorders. Most of our respondents (75% to 80%) who had been diagnosed with a common mental disorder reported not receiving psychotropic treatment, and this fact suggests that some of them may have been treated with psychotherapy or alternative and complementary therapies. Given that cognitive-behavioral therapy for mood and anxiety disorders is as popular among patients and doctors as pharmacotherapy [126,127], it is possible that the extent of under-treatment is actually lower than we report. A further drawback is that we did not measure the duration of psychotropic drug treatment, which means that we cannot evaluate the appropriateness of the treatment received for each psychiatric disorder. Filling of these gaps requires further analyses. Apart from the limitations noted here, there is a major methodological problem shared by the whole field of research on immigrant mental health: most research employs crosssectional comparisons of migrants with native populations [124]. We more than agree with Stevens and Vollebergh's review conclusion that the longitudinal design, in which particular migrant groups are followed prior to and after migration, including the exploration of all relevant background factors enabled to separate the effects of mere process of migration from an effect of culture, of selection or of belonging to the ethnic minority population on mental health problems of immigrants. The progress in mental health research will be contingent upon implementing this methodology.

CONCLUSION Overall, the results of our studies show that adult immigrants in Israel demonstrate higher levels of psychological distress than veteran Israelis. Despite this discrepancy, both populations are equally likely to suffer from mood and anxiety disorders and to use health care services. This is the case also for our immigrant adolescents. On the other hand, compared to their veteran counterparts, adult immigrants who do not meet the DSM-IV criteria for mental disorders are twice more likely to use psychotropic drugs, in particular anxiolytics, mood stabilizers and hypnotics. These findings substantially supplement the

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epidemiological picture of mental disorders, health service utilization and psychotropic drug use among immigrants in European countries and across the world [31-35,86-93]. Our findings have important implications for mental health services. They show that, although the mental health care needs of immigrants, as measured by the prevalence rates of common mental disorders and health service utilization, may be no higher than those of veteran Israelis, the immigrants experience more psychological distress and make more use of psychotropic drugs. Under such circumstances, the role of family doctors as first gatekeeper assumes increased importance. These practitioners, if properly trained in culturally sensitive care provision, may be able to detect and treat immigrants‘ psychological symptoms with appropriate psychotropic drugs at an early stage, thus preventing the development of fullblown psychiatric disorders.

FUNDING AND SUPPORT The Israel National Health Survey (INHS) was funded by the Ministry of Health with additional support from the Israel National Institute for Health Policy and Health Services Research and Israel‘s National Insurance Institute. The views and opinions expressed in this chapter are those of the author and should not be construed to represent the views of any of the sponsoring organizations, or of the Israeli government. The INHS was carried out in conjunction with the World Health Organization/World Mental Health (WMH) Survey Initiative. We thank the staff of the WMH Data Collection and Data Analysis Coordination Centers for assistance with instrumentation and fieldwork, and for consultation on data analysis. These activities were supported by the National Institute of Mental Health (R01 MH070884), the John D and Catherine T MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, Eli Lilly and Co, Ortho-McNeil Pharmaceutical Inc, GlaxoSmithKline, and Bristol-Myers Squibb. The Israel Survey of Mental Health among Adolescents (ISMEHA) was supported by the Israel National Institute for Health Policy and Health Services Research, Israel, the Association for Planning and Development of Services for Children and Youth at Risk and their Families (ASHALIM), the Englander Center for Children and Youth of the Brookdale Institute and the Rotter Foundation of the Maccabi Health Services, Israel.

ACKNOWLEDGMENTS We wish to thank Dr. Alexander Grinshpoon for encouragement, Mrs. Ira Radomislensky for statistical assistance and Mr. Nahum Steigman for editing. Dr. Ponizovsky was supported in part by the Ministry of Immigrant Absorption.

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[116] Olfson M, Fireman B, Weissman MM, Leon AC, Sheehan DV, Kathol RG, Hoven C, Farber L: Mental disorders and disability among patients in a primary care group practice. Am. J. Psychiatry 1997;154:1734–1740. [117] Bhugra D, Mastrogianni A: Globalization and mental disorders. Overview with relation to depression. Br. J. Psychiatry 2004;184:10–20. [118] Colman I, Wadsworth ME, Croudace TJ, Jones PB: Three decades of antidepressant, anxiolytic and hypnotic use in a national population birth cohort. Br. J. Psychiatry 2006;189:156–60. [119] Grinshpoon A, Marom E, Weizman A, Ponizovsky AM: Psychotropic drug use in Israel: Results from the National Health Survey. Prim. Care Companion J. Clin. Psychiatry 2007;9:356–363. [120] Williams R, Eley S, Hunt K, Bhatt S: Has psychological distress among UK South Asians been under-estimated? A comparison of three measures in the west of Scotland population. Ethn. Health 1997;2:21–29. [121] Farbstein I, Mansbach-Kleinfeld I, Levinson D, Goodman R, Levav I, Vograft I, Kanaaneh R, Ponizovsky AM, Brent DA, Apter A: Prevalence and correlates of mentaldisorders in Israeli adolescents: results from a national mental health survey. J. Child Psychol. Psychiatry 2010;51:630-639. [122] Mansbach-Kleinfeld I, Farbstein I, Levinson D, Apter A, Erhard R, Palti H, Geraisy N, Brent DA, Ponizovsky AM, Levav I: Service use for mental disorders and unmet need: results from the Israel Survey on Mental Health Among Adolescents. Psychiatr. Serv 2010;61:241-249. [123] Goodman R, Ford T, Richards H, Gatward R, Meltzer H: The Development and WellBeing Assessment: description and initial validation of an integrated assessment of child and adolescent psychopathology. J. Child Psychol. Psychiatry 2000;41:645-655. [124] Stevens GW, Vollebergh WA: Mental health in migrant children. J. Child Psychol. Psychiatry 2008;49:276-294. [125] Weiser M, Werbeloff N, Vishna T, Yoffe R, Lubin G, Shmushkevitch M, DavidsonM: Elaboration on immigration and risk for schizophrenia. Psychol. Med. 2008;38:11131119. [126] Olfson M, Marcus SC, Druss B, Pincus HA: National trends in the outpatient treatment of depression. JAMA 2002;287:203–209. [127] Bebbington P, Brugha T, Meltzer H, Jenkins R, Ceresa C, Farrell M, Lewis G: Neurotic disorders and the receipt of psychiatric treatment. Int. Rev. Psychiatry 2003;15:108– 114.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 14

EPIDEMIOLOGY OF MENTAL HEALTH PROBLEMS AMONG IMMIGRANTS. CASE OF KOREAN IMMIGRANTS IN BRAZIL Sam Chun-Kang1, Denise Razouk1, Jair J. de Mari1, Itiro Shirakawa1 and Luiza Beth Alonso2 1. Federal University of Sao Paulo, Sao Paulo, Brazil 2. Catholic University of Brasilia,Brasilia, Brazil

ABSTRACT Objectives: This study investigated the frequency of lifetime mental disorders among Korean immigrants in the city of São Paulo, Brazil. Methods: Snowball sampling with multiple focuses was used to recruit Korean immigrants older than 18 years and living in Sao Paulo. A total of 324 Korean immigrants were selected and their mental status was evaluated using a structured interview, the Portuguese or the Korean version of the Composite International Diagnostic Interview 2.1. The diagnoses of mental disorders were made according to the ICD-10. Results: The frequency of any lifetime psychiatric disorder was 41.9%. The frequencies of main disorders were: anxiety disorder, 13.0% (PTSD, 9.6%); mood disorder, 8.6%; somatoform disorders, 7.4%; dissociative disorder, 4.9%; psychotic disorder, 4.3%; eating disorder, 0.6%; any substance (tobacco, alcohol, drugs) use disorder, 23.1%. The frequency of any psychiatric disorder except alcohol and tobacco use disorders was 26.2%. The social and cultural correlates of any psychiatric disorder but substance use or dependence were gender, the perception of prejudice for being immigrants and evaluation of socioeconomic status as low in relation to Korean immigrants in Brazil. Conclusion: The frequency of lifetime psychiatric disorders among Korean immigrants in São Paulo was between the prevalence rates for Koreans in Korea (32.6%) and for the Brazilian population (45.9%). Therefore, Korean immigrants have more psychiatric disorders than the Korean population in Korea, specially PTSD, and almost the same rate as the Brazilian population. Mental health authorities should promote a healthier integration and the development of culturally sensitive mental health programs for Korean immigrants.

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INTRODUCTION Population studies have shown that immigrants are more vulnerable to mental health disorders than the individuals in their countries of origin who have not immigrated. When immigrants leave their country of origin and get in contact with a new reality, they face several changes: environmental (place and type of residence, population characteristics); biologic (food, local diseases); cultural (political, economic, religious, linguistic differences); and psychological (identity, values, internal references). These changes can be experienced as stressors, which may increase vulnerability to mental disease [1, 2]. Among Mexican immigrants in the United States, 33.8% had some lifetime psychiatric disorder, whereas the prevalence rate among Mexicans in Mexico was 24.7%. This research applied a modified version of WHO-CIDI (Composite International Diagnostic Interview) to 3012 participants of Mexican origin in California and showed that higher acculturation level was associated with higher risk of lifetime mental health problem. The prevalence among those who were interviewed in English was higher than the rate among those who were interviewed in Spanish for affective (OR=1.55), anxiety (OR=1.63), alcohol abuse or dependence (OR=2.20) and drug abuse or dependence disorders (OR=5.70). And the prevalence among those with more than 13 years in United States was higher than the rate among recent immigrants. The effect of time was more pronounced among Indians when the group was divided according to heterogeneous ethnicity. It showed that mental health status may vary depending on the particularity of each group of immigrants, even being origin of same country. Since these immigrants show very low education and income levels, one of the explanations for the effect time among them is related to cultural variance rather than socioeconomic status, which was investigated and showed by other surveys. Investigations about risk factors of American culture and protective components of Mexican culture may be helpful for understanding mental health problems [3, 4, 5]. A survey on Sardinian immigrants in Paris also showed unfavorable mental health status of immigrants compared either to the population in the country of their origin or to the local population. The study applied CIDIS (Shortened version of WHO-CIDI) to 153 immigrants, 1040 Sardinian residents and 2260 Parisians. The immigrants showed higher rate of anxiety disorder than the general population in Paris (13.1% vs. 6.2%), as did Sardinian resident population (11.15%), and higher frequency of depressive disorders than Sardinians in their country (17.6% vs. 13.6%), as did Parisians (19.2%). The rate of dysthymia among immigrants (7.1%) was higher than both of populations (1.9% among Parisians and 4.0% among Sardinian residents) The immigrants showed higher rate of mental health problems in all disorder groups – panic, bulimia, social phobia, somatoform, substance-related disorder either than the local population or than the residents in their origin [6]. Another study showing strong association between mental health and immigration was realized comparing two Japanese-Brazilian communities, one in Japan (n=158) and another in Brazil (n=213). The estimated rate of minor psychiatric disorders was 17.8% for the immigrants, much higher the rate among those living in Brazil (OR=7.01). Sociodemographic factors associated with bad mental health status were gender (female, OR=2.98), smokers (OR=2.76) and having been student when living in Brazil (OR=9.57). The survey applied SRQ-20 (Self Reporting Questionnaire-20) [7].

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Although population cross-sectional studies cannot show whether immigrants already had more mental problems before immigration than individuals who stayed in their country of origin, longitudinal studies may compare mental disorder rates before and after immigration. Jewish people who immigrated from the Former Soviet Union to Israel were followed up for five years, and results showed that they had more depressive and anxiety disorders after immigration: major depression – from 1.9% to 3.2%; dysthymia – from 2.0% to 3.5%; anxiety disorders – from 3.9% to 5.2%. Higher prevalence and incidence rates were found among the elderly than in younger adults, different from other epidemiological studies. From a random sample of immigrants who arrived in Israel in 1990, 116 were interviewed with an abbreviated version of CIDI [8]. Studies with patients in psychiatric hospitals identified that different psychiatric disorders were associated with immigration. Studies conducted in American hospitals found a greater rate of immigrants among patients with bipolar disorder (20.6%) [9] and unipolar depressive disorders (19%) [10]. A greater risk of schizophrenia was found among Afro-Caribbeans in England than in the local population (OR, from 5 to 18) [10,12]. A study based on clinical interviews with 111 Iranian patients showed greater rates of adjustment disorder with depressed or anxious mood (60%), post-traumatic stress disorder (10%) and schizophrenia (9%). Among them, only 14% had a history of psychiatric illness prior to emigration and the rest of them started having mental health problems after immigration [13]. In this text, a study of frequency of psychiatric disorders among Korean immigrants in Brazil will be focused, offering one more data for the discussion of a complex issue: immigration and mental health. No surveys have been conducted about mental health of this population that emigrated from a country with a lower prevalence of mental disorders (32.6%) than the country of resettlement (45.9%). Each group of immigrants should be investigated with their particularities in mind, such as the country of origin, the country of residence, the time and reasons of immigration. The frequency of psychiatric disorders among Korean immigrants in São Paulo will be compared with rates found in Korea. This is a particularly adequate time to study the mental health of first-generation Korean immigrants in Brazil because there is no great immigration movement lately. Brazil is a country that is largely made up of immigrants and their descendents. According to the latest Brazilian census [14], there are 685 thousand immigrants in Brazil, and 87% of them come from 15 countries. Korean immigration to Brazil started in 1963 with the arrival of a small group of individuals (N=92). The Korean immigrant community grew in the following decades with the arrival of groups organized by the Korean government and of illegal immigrants that entered the country through the borders of neighboring countries, such as Paraguay, Bolivia and Argentina. Illegal Korean immigrants were granted amnesty by the Brazilian government at four different times (1969, 1981, 1989 and 1998).There are about 50 thousand Koreans in Brazil, and they are 20% of the total number of immigrants that have been in Brazil for less than 10 years.

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METHOD Sample Population São Paulo was selected because it has the largest Korean immigrant community in Brazil (98%). As no list of Korean immigrants in Brazil was available, a previous selection of the subjects was not possible. The sample of Korean immigrants was recruited from the community according to the following inclusion criteria: to be a Korean immigrant older than 18 years and living in São Paulo. The minimum sample size (N=257) was based on an estimate of the proportion of respondents who were likely to have experienced a lifetime mental disorder: 40% (SE=3%) [15]. Participants were recruited at immigrant community churches. Two Protestant and one Catholic churches were selected from 44 immigrant churches located in a city area with a high concentration of immigrants. Another method was the selection at Korean immigrant commercial businesses. In the area of Korean immigrant concentration, commercial streets were selected; from each street, one block was chosen and all the Korean commercial businesses (N=58) were visited by a field coordinator. The last method was snowball sampling with three focuses: subjects contacted through religious institutions, commercial businesses, and the group of interviewers [16, 17].

Instruments A standardized psychiatric interview, the Portuguese version of the Composite International Diagnostic Interview (CIDI 2.1) [18,19] and the equivalent Korean version, [20] were applied to the immigrants together with a questionnaire about immigration-related issues specifically designed for this study. The CIDI is a structured interview schedule developed by World Health Organization (WHO) and based on the National Institute of Mental Health Diagnostic Interview Schedule (DIS). It was designed to estimate the prevalence of mental disorders across countries or geographic regions. The interview can be used by trained lay interviewers [21,22]. The questionnaire had sociodemographic and immigration related questions: age, gender, marital status, education level, occupation, religion, family income, age at emigration; time in the country; language knowledge; self-rated acculturation level; self-rated socioeconomic status according to two references - immigrant community and general society; perception of prejudice for being an immigrant; participation in immigrant associations. It was also asked self-rated mental health status, use of medical assistance including mental health agents.

Procedure Eleven bilingual interviewers, fluent in Portuguese and Korean, were recruited for this study. All of them were college students with various majors, and were trained at the CIDI Training Center in Brazil in Universidade Federal de São Paulo.

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At the first Protestant church visited, 100 subjects were selected from the list of 350 members and were contacted by telephone. This procedure proved to be complicated and to yield a very high refusal rate. Therefore, participants were recruited by means of pamphlets that invited volunteers and were distributed after Sunday Service. This method was used in all three religious institutions. Subjects were asked to introduce one nonreligious friend to be a control for sample bias associated with religiosity. They had great difficulty in indicating nonreligious friend(s), so friends with a religious background were accepted. Respondents were also recruited at commercial businesses run by Korean immigrants. All subjects and the group of interviewers themselves were asked to indicate friends and relatives. Before the application of the interview, written informed consent was obtained after full description of the study to respondents. Interviews were conducted in Portuguese or Korean according to respondent‘s preference. Average length of interview was 75 minutes. Data collection began in July 2004 and finished in June 2005.

Statistical Analysis The CIDI (ICD10_lt.sco) software, which generates psychiatric disorders according to ICD-10 criteria [23], was used to establish diagnoses. The CIDI provides lifetime, 12-month and 1-month psychiatric diagnoses. In this survey, only lifetime disorders according to ICD10 were reported. The 66 diagnoses provided by the program of CIDI were grouped in diagnostic categories. Logistic regression models tested effects on psychiatric diagnostic categories of sociodemographic and immigration related correlates. Statistical significance was based on a probability level of 0.05.

RESULTS From the total of about 4000 immigrants contacted, only 324 (8%) accepted to take part in the study. Through the religious institutions, about 3700 immigrants were contacted and only 124 (3.4%) accepted to be interviewed. They indicated 36 friends/relatives and 11 (31%) accepted to answer the questionnaires. Refusal rate was 80% when subjects were contacted by telephone and 96.6%, when the contact was made through fliers. From the 58 commercial businesses visited by a field coordinator, 23 subjects (40%) participated in the survey. They indicated 12 friends/relatives, and 11 (92%) accepted to participate. The group of interviewers indicated 121 friends/relatives, and 116 (96%) accepted to participate. These subjects further indicated 55 friends/relatives, and 39 (71%) accepted to participate. Each snowball-sampling effort ended up in the second stage due to difficulties or refusals to indicate friends.

Sociodemographic Characteristics The sample comprised 162 men and 162 women. Mean age was 35 years (SD=13.1) and 53.1% were married. The most common occupations were self-employed professionals

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(55.7%), students (23.6%) and employees (10.8%). Most had a high family income (88.3%; >U$ 12000.00 per year) and high educational level (61.7%; >12 years of schooling) for the Brazilian context. Almost all participants (96.6%) were religious.

Immigration Related Characteristics Most participants (65.1%) had emigrated young, at an age of up to 20 years, and almost half (47.5%) had been living in Brazil for up to 15 years. Majority (74.4%) understood and spoke Korean very well while fewer subjects (39.8%) did it in Portuguese. Almost all respondents (95.4%) were participating at some Korean immigrants association, especially religious ones (93.8%). Self-rated socioeconomic class was lower when compared to Koreans than to Brazilians: 15.7% rated themselves as high class compared to Brazilians while only 8% said the same compared to Koreans; low class, 4.3% compared to Brazilians and 9% compared to Koreans. About the resident country, almost all participants (98.5%) liked it even though 63.6% had perception of prejudice for being Korean. Related to inter-ethnic marriage, 70.4% were favorable for or indifferent and 29.6% was against it.

Frequency of Psychiatric Disorders The lifetime frequency of psychiatric disorders according to ICD-10 for the total sample is shown in Table 1. Nearly 42% of the sample had at least one lifetime mental disorder. The most prevalent disorder was substance (alcohol, tobacco, drug) use disorder (23.1%). The second most frequent was anxiety disorder (13%), followed by mood (8.6%), somatoform (7.4%), dissociative (4.9%), psychotic (4.3%) and eating (0.6%) disorders. Of all subjects, 9.6% had post-traumatic stress disorder. Excluding alcohol and tobacco use disorder, 26.2% had at least one lifetime psychiatric disorder. Of all respondents, 18.2% had at least one lifetime anxiety disorder or mood disorder. The number of subjects that sought any kind of medical assistance in the previous year was investigated. Of all participants, 22.5% obtained general medical service; 3.4% sought emergency services; and 1.9% used service of mental health professionals (psychiatrist, psychologist or social worker).

Variables Associated with Psychiatric Disorders The association of correlates with psychiatric disorders was studied after dividing the mental health problems into two groups: one, any lifetime psychiatric disorder but substance use disorder and another one, only substance use disorders. Gender was associated with both groups of disorders. Women were 1.8 times more likely than men to have any lifetime psychiatric disorder except substance use or dependence, and men were 5.8 times more likely to have substance use disorder. The gender was the only variable associated with substance use disorder.

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Table 1. Frequency of ICD-10 psychiatric disorders among Korean immigrants in Brazil

ICD diagnosis

N (324)

%

Korea* (%)

Brazil† (%)

Any disorder

135

41.7

32.6

45.9

Any disorder but tobacco dependence

113

34.9

27.0

33.1

Any disorder but alcohol/tobacco use

85

26.2

13.2

Substance use disorder

75

23.1

Alcohol use disorder

42

13.0

16.8

Alcohol abuse

34

10.5

7.1

Alcohol dependence

19

5.9

9.8

Tobacco use disorder

51

15.7

11.1

Tobacco abuse

22

6.8

2.9

Tobacco dependence

29

9

10.2

Drug use disorder

4

1.2

0.25

Drug abuse

4

1.2

0.2

Drug dependence

2

0.6

0.05

Any anxiety/mood disorders

59

18.2

Any anxiety disorder

42

13.0

9.1

12.5

Generalized Anxiety disorder

15

4.6

2.3

4.2

Panic disorder

1

0.3

0.4

1.6

Any phobia

4

1.2

Agoraphobia

2

0.6

0.3

2.1

Specific phobia

1

0.3

5.2

4.8

Social phobia

1

0.3

0.2

3.5

Obsessive-compulsive disorder

-

-

0.8

0.3

Post-traumatic stress disorder

31

9.6

1,7

Any mood disorder

28

8.6

4.7

18.4

Depressive episode

20

6.2

4.1

16.8

Dysthymia

8

2.5

0.5

4.3

Depressive disorder (DE/dysthymia)

27

8.3

Bipolar disorder

1

0.3

0.2

1.0

Somatoform disorder

24

7.4

0.6

6.0

Dissociative disorder

16

4.9

27.3

5.5

25.0

1.1 24.0

8.4

18.1

2.2

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Sam Chun-Kang, Denise Razouk, Jair J. de Mari et al. Table 1 (Continued)

ICD diagnosis

N (324)

%

Korea* (%)

Brazil† (%)

Psychotic disorder

14

4.3

1.2

1.9

Schizophrenia

5

1.5

0.2

Eating disorder

2

0.6

0.2

Bulimia nervosa

2

0.6

0.03

Anorexia nervosa

1

0.3

0.2

1.5

* Data from Ministry of Health and Welfare of Korea (24), N=6275, DSM-IV criteria. † Data from Andrade et al. (25), N=1464, ICD-10 criteria.

Among self-rated variables, those who had perception of prejudice for being Korean immigrants in Brazil and those who considered themselves as low socioeconomic class in relation to Korean community had more psychiatric problems: 2.8 and 2.7 times more likely than those who didn‘t rate themselves the same way. Other correlates such as age, marital status, occupation, family income, age at immigration, length of time in Brazil and knowledge of languages were not associated with mental health problems.

CONCLUSION This is the first study about the mental health of immigrants in Brazil using the WHOCIDI. Results show that Korean immigrants in Brazil have a rate of lifetime mental disorders (41.9%) that is between the prevalence in Korea (32.6%) and in Brazil (45.9%) (24, 25). The prevalence surveys in Korea and in Brazil used the same diagnostic instrument as this study (CIDI), but different diagnostic criteria: DSM-IV in Korea and ICD-10 in Brazil. A cautious comparison of results is recommended since ICD-10 criteria identify more cases of depression and fewer cases of anxiety disorders than the DSM criteria [26]. The population in this survey had higher rates in all categories of psychiatric diagnoses than Koreans in Korea. The rate of any lifetime disorder except alcohol and tobacco use disorder among immigrants was almost twice the rate for Koreans in their native country (26.2% vs 13.2%). This result is in agreement with other studies that demonstrated that the pattern of mental health among immigrants was unfavorable when compared to the population in their country of origin: Mexicans in the United States [3-5], Italians in Paris [6] and Japanese-Brazilians in Japan compared with those in Brazil [7]. The patterns of psychiatric disorders were not homogenous in the different diagnostic categories when compared to those in the Brazilian population: Korean immigrants have more psychotic (4.3% vs. 1.9%), dissociative (4.9% vs. 2.2%) and somatoform disorders (7.4% vs. 6.0%), fewer mood disorders (8.6% vs. 18.4%) and substance use disorders (23.1% vs. 27.3%), and a similar rate of anxiety disorders (13.0% vs. 12.5%). Studies about Afro-Caribbeans in Britain suggest that social and environmental adversities, such as unemployment, early separation from parents, inadequate housing, and experiences of racism, are risk factors for immigrants to develop a severe mental disorder

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[11,12,27]. However, in the case of Korean immigrants in Brazil, social adversities may not be associated with the high rate of psychotic disorders, since 88.3% of the subjects have an annual income greater than U$12,000.00, which can be regarded as middle or high economic class in Brazil. A survey on 130 Japanese-Brazilian patients that went to Japan to work but had to come back to Brazil due to mental problems showed that 76.1% had a psychotic disorder. That study pointed out that experiencing a cultural change might be a stressful factor, which could explain the onset of the psychotic crises [28]. In the case of the participants in this survey, the experience of immigration might have increased their vulnerability, since immigration may precipitate the predominance of psychotic mechanisms by rupture of the balance between psychological conflicts and defenses [1]. The western definition of psychiatric disorders, with its emphasis on biological factors, may increase the rate of somatoform disorders in communities with culturally different symptoms [29-31], particularly among Asians, who show more physical complaints than psychological symptoms [32-34]. However, a higher frequency of somatoform disorders among immigrant Koreans than among nonimmigrant Koreans (7.4% vs. 0.6%) raises questions about the role of immigration on the onset of this psychiatric disorder. Substance use disorder was the most prevalent group of disorders in this study. Drug dependence rate was between the prevalence rate for Koreans in Korea and that for the Brazilian population. However, both tobacco (9%) and alcohol dependence rates (5.9%) were similar to the lower prevalence in the two populations: tobacco dependence, similar to that for Koreans in Korea (10.2% vs. 25% for Brazilians); and alcohol dependence, similar to that for Brazilians (5.5% vs. 9.8% for Koreans in Korea). These results differ from those found in a survey with elderly Koreans in Los Angeles, which showed similar rates of alcohol use disorder for immigrants (19.0%) and for the population of their native country (21.7%) (29,35). The results of our survey may have been affected by the religiosity of the subjects: most were Protestants (68.5%), whose religion has rules against substance use. The rate of mood disorders for immigrant Koreans (8.6%) is double the rate for nonimmigrant Koreans (4.7%) and less than half of that among Brazilians (18.4%). Comparing the findings of this study with those of other surveys, which used the same diagnostic instrument, our study subjects had a lower rate of mood disorders than MexicanAmericans (12.1%) (3) and Sardinians in Paris (17.6%; depressive episode) [6]. The comparison with Chinese-Americans revealed a similar rate of depressive episodes (6.2% vs. 6.9%), but a lower rate of dysthymia (2.5% vs. 5.2%) [36]. Surveys show that Asians have lower rates of mood disorders than Western people because they rarely report psychological complaints [33, 36, 37]. However, even considering this culturally different psychopathological pattern among Asians, Korean immigrants have more depressive disorders (8.3%, depressive episode/dysthymia) than other Asian communities in Brazil: Japanese-Brazilians (3.2%, using SRQ-20) [5] and Chinese-Brazilians (4.8%, using the Beck Depression Inventory) [34]. Although rates obtained by using different instruments are not easily compared, higher rates of mood disorders among this study subjects than in the population of their native country and in other Asian communities in Brazil may indicate higher vulnerability of this community to mood disorders. A higher rate of anxiety disorders among Korean immigrants than among Koreans in Korea (13% vs 9.1%) may be explained by the strikingly higher rate of PTSD among immigrants in this study (9.6% vs. 1.7%). The analysis of the CIDI section that corresponds to PSTD (section K) revealed that 35% of the subjects had suffered physical attack or assault;

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23% were involved in accidents with life risk; 20% had seen somebody being severely injured or killed; and 16% had been threatened with fire guns, kidnapped or secluded. Some studies report that immigrants are vulnerable to develop PTSD due to their feelings of helplessness [1, 31, 38]. Severe urban violence in São Paulo in addition to the stressful and traumatic experiences associated with migration may promote the onset of PTSD in immigrants. Comparative studies about urban violence and PTSD in both immigrant and nonimmigrant populations should investigate whether immigrants are suffering more violence and whether violent experiences lead to more PTSD among immigrants than among the general population. The percentage of study participants that sought mental health services (1.9% in the previous year) was lower than that found for Brazilians (7.7% in the previous month) [25] and much lower than the potential estimate of 25% according to the frequency of mental health problems found in this study [39]. The explanation for such low percentage may be cultural because mental problems are seen as ―mental weakness‖ or ―reason to be ashamed‖ [40]. This may also be assigned to difficulties in communication, because there are no public services available for culturally diverse populations. Strategies should be developed to bring adequate treatment to this population. This survey shows higher participation when the participants are contacted personally. The lowest refusal rate (4%) is found among those indicated by the interviewers and the highest refusal rate (96.6%), among those contacted at community churches through fliers. It indicates the importance of sampling method based on personal contact to promote higher participation among Asian immigrants. Some of the limitations of this survey are high refusal rate, low rate of participation of nonreligious population and difficulties/refusals to indicate friends, which made snowball design difficult. It may limit the generalization of results to the whole community of Korean immigrants in Brazil. Although this study worked with the best available number at the moment of the survey, further studies are required to control possible sample bias and to find more accurate rate of mental disorders for the immigrant community. Our results show that the prevalence of psychiatric disorders for Korean immigrants is greater than for Koreans in Korea and almost the same as for the Brazilian population. Furthermore, considering high religiosity of the subjects and protecting function of religion, the rate of mental disorders among the immigrants might be higher than that found in this study. The results of this survey, which revealed a more unfavorable pattern of mental health among immigrants than among the population in their native country, cannot be generalized to all immigrants in Brazil or to all Korean immigrants in other countries. However, attention from mental health authorities is required for a healthier integration of new immigrants, and the development of culturally sensitive mental health services for this population.

ACKNOWLEDGMENTS Special thanks to Caderno de Saúde Pública for the authorization of the use of the following article in this text: Kang S, Razzouk D, Mari JJ, Shirakawa I. The mental health of Korean immigrants in São Paulo, Brazil. Cad. Saúde Pública, 2009, vol. 25, n. 4, p. 819-826. ISSN 0102-311X.

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[19] Quintana MIS. Validity of Composite International Diagnostic Interview (CIDI/WHO) Version 2.1 in mental health services in Brazil. São Paulo: Universidade Federal de São Paulo, 2005. [20] Cho MJ, Hahm BJ, Suh DW, Hong JP, Bae JN, Kim JK, et al. Development of a Korean version of the Composite International Diagnostic Interview (K-CIDI). J. Korean Neuropsychiatr. Assoc, 2002; 41:123-137. [21] Robins LN, Wing J, Wittchen HU, Helzer JE, Babor TF, Burke J, et al. The Composite International Diagnostic Interview: an epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch Gen. Psychiatry, 1988; 45:1069-1077. [22] Wittchen HU, Robins LN, Cottler LB, Sartorius N, Burke JD, Regier D. Cross-cultural feasibility, reliability and sources of variance of the Composite International Diagnostic Interview (CIDI). Br. J. Psychiatry, 1991; 159:645-653. [23] World Health Organization. International statistical classification of diseases and related health problems. 10th revision. Geneva: WHO, 1992. [24] Ministry of Health and Welfare of Korea. Prevalence of DSM-IV psychiatric disorders in Korea. 2001. Available at: http://www.mohw.go.kr/databank. Accessed March 20, 2003. [25] Andrade L, Walter EE, Gentil V, Laurenti R. Prevalence of ICD-10 mental disorders in a catchment area in the city of São Paulo, Brazil. Soc. Psychiatr. Epidemiol, 2002; 37:316-325. [26] Wacker HR, Müllejans R, Klein KH, Battegay R. Identification of crises of anxiety disorders and affective disorders in the community according to ICD-10 and DSM-III-R by using the Composite International Diagnostic Interview (CIDI). Int. J. Methods Psychiatr. Res, 1992; 2:91-100. [27] Mallet R, Leff J, Bhugra D, Pang D, Zhao JH. Social environment, ethnicity and schizophrenia: a case-control study. Soc. Psychiatry Psychiatr. Epidemiol, 2002; 37:329-335. [28] Shirakawa I, Nakagawa D, Miyasaka LS. Emigration and mental disorders of Brazilians in Japan. J. Bras Psiquiatr, 2003; 52:73-78. [29] Lee CK, Kwak YS, Yamamoto J, Rhee H, Kim YS, Han JH, et al. Psychiatric epidemiology in Korea. Part I: Gender and age differences in Seoul. J Nerv Ment Dis, 1990; 178:242-252. [30] Villaseñor Y, Waitzkin H. Limitations of a structured psychiatric diagnostic instrument in assessing somatization among Latino patients in primary care. Med. Care, 1999; 377:637-646. [31] Mangado EO, Muelas NV, Suarez ML. Síndromes depresivos en la población inmigrante. Rev. Clin. Esp, 2005; 205:116-118. [32] Hsu LKG, Folstein MF. Somatoform disorders in Caucasian and Chinese Americans. J. Nerv. Ment. Dis, 1997; 185:382-387. [33] Chen JP, Chen H, Chung H. Depressive disorders in Asian American adults. West J. Med, 2002; 176:239-244. [34] Wang YP, Andrade LH, Gorenstein C. Validation of the Back Depression Inventory for a Portuguese-speaking Chinese community in Brazil. Braz. J. Med. Biol. Res, 2005; 38:1-10.

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[35] Yamamoto J, Rhee S, Chang DS. Psychiatric disorders among elderly Koreans in the Unites States. Commun. Mental Health J, 1994; 30-1:17-27. [36] Takeuchi DT, Chung RC, Lin KM, Shen H, Kurasaki K, Chun CA, et al. Lifetime and twelve-month prevalence rates of major depressive episodes and dysthymia among Chinese-Americans in Los Angeles. Am. J. Psyquiatry, 1998; 155:1407-1414. [37] Wang PY, Gorenstein C, Andrade LH. Patterns of psychopathological manifestations among ethnic Chinese living in Brazil. Eur. Arch Psychiatry Clin. Neurosci, 2004; 254:36-42. [38] Bhugra D. Migration and mental health: review article. Acta Psychiatr Scand, 2004; 109:243-258. [39] Almeida-Filho N, Mari JJ, Coutinho E, França JF, Fernandes JG, Andreoli SB, et al. Brazilian multicentric study of psychiatric morbidity: methodological features and prevalence estimates. Br. J. Psychiatry, 1997; 171:524-529. [40] Kramer EJ, Kwong K, Lee E, Chung H. Cultural factors influencing the mental health of Asian Americans. West J. Med, 2002; 176:227-231.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 15

SUCCESSFUL USE OF MENTAL HEALTH MIGRATION MODELS: THE NEW ZEALAND EXPERIENCE Regina Pernice Massey University, New Zealand

ABSTRACT This chapter outlines the development of theories and models which explain migrants‘ mental health and their successful application in New Zealand. The Social Selection Theory was the first theory proposed in the 1940s, but it soon proved to be unsatisfactory in explaining the relationship between immigration and mental health as it attributed the occurrence of mental health problems in the immigrant population to a predisposition of the individual to mental disorder. The alternative theory, the Social Causation Theory, was equally limited, in that it attributed mental illness to external stress alone. It became apparent in the 1960‘s that the two theories were not separable as a predisposition and the experience of stress both contribute to an increase of mental health problems. Therefore it became necessary to examine the multiple factors that comprise the process of immigration and the Multivariate Model of the Immigrant Adaptation Process was proposed in the 1970s. It took into consideration pre-migration conditions, post-migration factors in the society of settlement, the length of residence, and characteristics of individuals, and offered testable explanations of the relationship between immigration and mental health. Subsequent research using the Multivariate Model led to proposals with distinctly different patterns of the Length of Residence factor and also added new aspects to the model, e.g. the Circumstances of Migration (either forced or voluntary). This Multivariate Model had become very influential, provided the evidence needed to improve health and social services particularly for refugees. The most recent model, the bi-dimensional Acculturation Process Model explored the individual‘s attitude to acculturation (expressed by four adaptation styles) with two successful styles of adaptation to the host society and two styles detrimental to mental health. New Zealand‘s research, being focused for many years on the physical health effects of migration had neglected mental health research. The settlement of large numbers of Indochinese refugees prompted some exploration of mental health concerns using aspects of the Multivariate Model of the Adaptation Process. Despite a relatively large migration

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Regina Pernice research focus in New Zealand, there have not been many specifically mental health studies. Those that were carried out, however, applied the theoretical framework of the migration models and generated findings that were successfully applied to migrant service provision in New Zealand.

INTRODUCTION The earliest awareness of an excess of mental disorder among immigrants seems to have been by the superintendents of American asylums in the 1840‘s. Some blamed this phenomenon on the hard conditions the immigrants had to endure while others thought that immigration only attracted the destitute and unstable. In the subsequent hundred years data were collected to support each rival argument. The early literature dealt primarily with populations of institutions and compared the proportions of the foreign and native populations in mental hospitals. The authors estimated the numbers of the mentally ill among the foreign born, speculated about precipitating circumstances, examined claims that the mentally ill had been induced to emigrate from some particular countries and suggested procedures for more adequate screening at ports of entry into the United States. The early publications were relatively uncontroversial and apolitical. Later literature reflected the developing political pressures against the entrance of new immigrants, particularly against the influx of Eastern Europeans. Only a few articles contributed fundamentally to knowledge and formulated testable inferences. Their methodology has been criticised and, as Malzberg and Lee [1] pointed out, many authors committed an important statistical error since they did not take into account the different age distribution of the native born versus the foreign born population groups. Without correction, this factor would influence the ratio of mental illness making it spuriously high for the foreign born. Improvements were made in the quality of the data which was collected, but no suggestion of a viable theory occurred until Odegaard‘s work in the 1930‘s.

SOCIAL SELECTION THEORY Odegaard linked clinical observation to sound epidemiology. He came to the conclusion that, mainly in respect to schizophrenia, immigrants were liable to have an excessive incidence rate, because, in part, this disorder interferes with its victim‘s attachments to his native community and makes him disproportionately liable to emigrate [2]. Odegaard suggested that constitutional vulnerability to mental illness predisposes the person to migrate. The studies of Odegaard [2,3] were based on admission rates to mental institutions in Minnesota for Norwegian born immigrants compared with native Americans; and for the general population in Norway compared with returned migrants to Norway. The analysis took into account both the selection process operating in immigration (by comparing immigrants with the parent population), and the differentials emerging in the process of assimilation (by comparing immigrants with the indigenous population in the area of settlement). Odegaard found that the Norwegian born immigrants to the United States had a 30-50% higher admission rate than the American born. There was a higher admission rate for

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Norwegians born in Minnesota, than for the population of Norway. Returned migrants to Norway had twice as high an admission rate to mental institutions as the Norwegian general population. Odegaard concluded that he had found strong evidence that the high incidence of mental disorder in the immigrant population was due to the prevalence of certain psychopathic tendencies in the constitution of those who migrate. Social selection seemed the only possible explanation for this phenomenon. Odegaard‘s social selection theory was supported by Clark [4], Malzberg and Lee [1] and Mezey [5]. Clark standardised his data for social class, Malzberg and Lee looked at internal migration within the United States, while Mezey investigated personal characteristics of Hungarian refugees. All studies found a higher incidence of psychoses in the migrant population. The social selection theory, also called the premorbid personality theory [6], or the self selection theory [7], was soon considered too deterministic. Moreover, it ignored disorders other than the psychoses as well as the obvious hardships of immigrant life at that time.

SOCIAL CAUSATION THEORY Later researchers suggested an alternative theory, sometimes referred to in the literature as the external stress theory [6], the stress hypothesis, or the general hazard theory [7], all emphasising social causation. This theory implicated the severe stressors associated with migration as the precipitating factors of the immigrants‘ high incidences of mental disorder. These stressors included cultural changes and economic and social difficulties. It was supported by Ruesch et al. [8] and by the Manhattan study [9], both studies dealing with non-psychotic disorders in the community. Soon the social causation theory appeared equally simplistic and pessimistic and brought about a change in the nature of the question being asked. Instead of asking why migrants have a higher rate of mental disorder, it became necessary to ask under what conditions do they have these higher rates and researchers found it necessary to examine the multiple elements that comprise the process of migration.

MULTIVARIATE MODEL OF THE IMMIGRANT ADAPTATION PROCESS Goldlust and Richmond [10] after studying the native and foreign born population in Toronto, proposed a Multivariate Model of the Immigrant Adaptation Process. This model considered pre-migration conditions and characteristics, the situational determinants in the receiving society, and the length of residence in the society of settlement (see Figure 1).

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From Goldlust and Richmond, 1974. Figure 1. Multivariate Model of the Immigrant Adaptation Process.

Goldlust and Richmond emphasised the importance of individual characteristics of the immigrant by defining three elements within the immigrant‘s subjective state: (i) identification, involving modification of the sense of personal identity and the transference of loyalty (ii) internalisation, referring to the changes of attitudes and values that were part of the socialisation process, and (iii) level of satisfaction with various aspects of the immigrant‘s life relative to his or her pre-migration situation as compared with specific reference groups against which the immigrant measured himself/herself. Most researchers favoured the multivariate model of the immigrant adaptation process as it took into account pre-migratory and post-migratory factors, individual characteristics and the length of residence in the society of settlement. Several mental health workers such as Tyhurst [11], Cohon [12] and Sluzki [13], who worked with refugees and immigrants, had observed that refugees and immigrants go through different stages or phases during their resettlement and some of these phases were characterised by a higher level of mental health risk than others. Therefore they suggested that the length of residence in the receiving society significantly influences mental health levels and they suggested different time patterns of adaptation.

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LENGTH OF RESIDENCE IN THE SOCIETY OF SETTLEMENT Tyhurst [11] proposed a pattern of refugee adjustment dynamics which he called the Social Displacement Syndrome. He reviewed 27 years of clinical experience and field work with refugees in Canada and aimed at an all-inclusive picture of the psychological reactions of refugees. Four groups of refugees to Canada were studied: the displaced people, who arrived in the late forties and early fifties, the Hungarian refugees admitted in 1956, the Czechoslovakians who came in 1968, and the Asians expelled from Uganda in 1972. Tyhurst formulated three inter-related stages in the clinical phenomena that emerged among refugees, and considered that the general structure of these stages has been consistent for all refugee groups. The first stage or the initial period lasts about two to three months after arrival and consists of an ‗incubation period‘ that is symptom free and during which the refugee‘s outlook is often positive, even euphoric. This is followed after three months by the onset of a general disequilibrium in the refugee which reaches its peak six months after entry. This second stage is characterised by a cluster of symptomatology presented by (i) a range of paranoid behaviours from suspiciousness to acute paranoid psychotic episodes (ii) generalised hypochondriasis with pain as the central complaint and fatigue often being the earliest subjective symptom, and (iii) a mix of anxiety and depression with somatic complaints predominating. Tyhurst stated that the paranoia observed during this stage is mild and benign except in cases of refugees with concentration camp experience. The third stage of the Social Displacement Syndrome consists of a series of phenomena that are situation specific and affect the individual‘s sense of continuity of self, his orientation to place and time, with accompanying fluidity of mood, and at times vivid hallucinations related to the previous experience of flight. Another characteristic of this third stage is impairment of interpersonal and social skills manifested by contradictory tendencies of social withdrawal or hostility. Tyhurst did not suggest whether symptoms gradually ameliorated after reaching the peak after six months of residence in the society of settlement or when this might occur. Cohon [12] suggested a similar pattern of refugee adjustment but with different time intervals. In his analysis of data collected on 54 Indochinese refugee-clients treated in the San Francisco area, he noted that during the first year of residence in the United States the most frequent difficulties were related to socialisation as, for example, issues related to housing or other practical matters. From a mental health point of view, however, the first year of residence was symptom free. Beginning with the thirteenth month and slowly increasing in frequency, depression was the mental health problem diagnosed most often. For refugees who lived in the United States longer than two and a half years, severe depression was the problem of most concern, and was diagnosed in 92% of the cases. Therefore, the peak of presenting mental health problems occurred after two and a half years. Sluzki [13] proposed the Stage Model of the migratory process that applies to all migrants and not only to the displaced people or refugees. The model is ‗culture free‘, regardless of how culture-specific the styles of coping may be. In his investigation of

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immigrant families, Sluzki suggested that a period of overcompensation and euphoria, lasting some six months is followed by a period of major crisis, one in which the long-range responses to migration take place. This period of crisis can last for several years and might reach its peak from one to six years after arrival. Although Cohon [12] and Sluzki [13] generally support Tyhurst‘s [11] Social Displacement Model, there are some slight differences in the timing of these events. All three researchers confirm an initial symptom free period, for three months [11], six months [13] or one year [12]. In Tyhurst‘s Social Displacement Model the onset of crisis occurs after 3 months, reaching its peak at about 6 months, whilst Cohon found that problems increased after one year and that after two and a half years symptoms of depression were most severe. Sluzki stated that with immigrants and refugees the peak of the crisis could be found between one year and six years. None of the authors explicitly stated a drop of symptom levels after the crisis or the peak has been reached, although it appears that this is implied (see Figure 2).

Tyhurst, 1977; Cohon, 1979; Sluzki, 1986. Figure 2. Diagramatic representation of three different time patterns of adaptation.

Sluzki‘s description of the migrant‘s (refugee and immigrant) adaptation process was supported by Grinberg and Grinberg [14] in their work with immigrants to the United States. Other researchers however, such as Beiser [15] working with refugees and Flaherty et al. [16], investigating immigrant‘s mental health, suggested that migrants pass through prolonged periods of demoralization, which increase over time and reach a peak by the fourth or seventh year of residence in the country of settlement. A third response pattern of immigrants (not refugees) proposed a gradual improvement in mental health over time [17, 18]. Other aspects of the migration process which could explain the mental health consequences, were suggested by Murphy [19]. He agreed with Goldlust and Richmond‘s [10] multivariate model in general outline, but formulated it with slight differences in detail. He suggested additional factors of importance to migrants‘ mental health. He proposed that the mental health of a migrant group is determined not only by factors inherent in the,

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(i) society of origin (including personal characteristics), and by elements operating in the (ii) society of settlement, including the length of residence, but as well by (iii) circumstances of migration According to Murphy, all three sets of factors need to be considered if understanding and reduction of the level of mental disorder in any immigrant group is to be achieved.

(i) The Society of Origin The society of origin plays a crucial role in shaping the attitude of the individual and how emigration is perceived. In Europe, for example the Netherlands have, overall, encouraged emigration during the last 100 years, seeing it as an admirable act, requiring courage and the willingness to work hard. Under these circumstances a positive selection (that is, a selection of people likely to have no prior mental health problems) is likely to take place, whereas if emigration is looked upon as a desertion or a betrayal to the community, then negative selection is likely to occur. This view is based on personal observation by Murphy [19] who found that Dutch immigrants to Canada had lower rates of mental hospitalisation than immigrants from France. He speculated that France, with a lower birth rate and a greater need for soldiers, has been traditionally critical of emigration. Thus, negative selection could be a contributing factor for higher rates of mental disorders. The information provided to emigrants regarding conditions in the country of settlement is similarly relevant. Weinberg [20] and David [21] found a general consensus in the literature, namely, that emigrants who were prepared and well-briefed on their new sociocultural environment tended to adapt more readily than those who were ill-informed. The transition into the new society was better accomplished and, as a consequence, the incidence of mental disorder was lower. Consideration must be given, too, to the fact that certain societies seem to have a high predisposition for, and therefore a high incidence of, certain disorders, such as schizophrenia in the case of the Irish [22]. On these grounds it would be expected that the Irish immigrant population would show a higher rate of this condition than other immigrant groups. Similarly, a high incidence rate of peptic ulcers in the Japanese immigrant cannot be solely attributed to immigrant stress since Japan has the highest rate of this disorder in the world [23]. Furthermore, Nguyen [24] in accordance with Goldlust and Richmond [10] suggested that the immigrant‘s characteristics, his or her age, sex, educational level, social class and personality and the language and culture of the society of origin have to be considered, if one seeks to understand the mental health problems of any immigrant group.

(ii) The Society of Resettlement In the society of resettlement the factor most likely to affect mental health is the relative size of the immigrant‘s own minority group [7]. In Singapore, for example, where the Chinese population is divided by marked language differences, it was found that there was a

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strong inverse correlation between the size of the language group and the incidence of mental disorders [19]. Governments have tried to discourage the establishment of immigrant communities or ghettos. The ‗melting pot‘, a romantic American idea, was considered to be the ideal. It was hoped that both the native and the immigrant or refugee would be changed and merged into a new, supposedly stronger, alloy [25]. It was slowly recognised, however, that small resettlement communities had poorer mental health than larger ones [19]. Murphy‘s findings were consistent with the idea that ethnic enclaves are important for recently arrived refugees and immigrants, serving a mediating function between the newcomer and the host culture [26]. Thus, the model of assimilation considered then appropriate became cultural pluralism, and governments have encouraged it. It was hoped that the immigrants or refugees would adapt to the dominant cultural patterns, particularly in politics, play, education and work, while at the same time preserving their communal life and most of their culture. This meant, from the point of view of mental health, that migrants who were linguistically and culturally very different from the society of resettlement, should be encouraged to settle in large groups of the same origin. The greatest protection against mental health problems is not only the existence of large clusters of people of the same origin but, as well, the recognition of the full professional equality of migrants, their social acceptance and respect for their vocational and cultural aspirations [21]. Krupinski et al. [27] have shown that in Australia, central European professionals had quite abnormally high rates of mental breakdown which appeared to be linked to the fact that recognition of their professional qualifications was denied for many years. Vignes and Hall‘s [28] Louisiana study confirmed the findings of Krupinski et al., and called attention to the risk factors for psychopathology if there was status dislocation, loss of professional identity and the loss of employment status among heads of households. Another issue in the society of settlement is the experience of xenophobic hostility, directed by the population of the host country towards a particular immigrant group. Prejudice in the society of resettlement is felt strongly by some ethnic groups, especially when great distances in religious, ideological, and other cultural traits exist, or when there are obvious physical and anthropological differences [29]. The resulting discrimination, social isolation, and the sense of not belonging, can influence negatively the mental health status of refugees and immigrants. In the society of resettlement, factors such as remaining in one residence, closeness or distance from people of the same ethnic group, English language ability, the presence of relatives and support groups, an adequate social network, and satisfactory employment seem to affect the mental health of the immigrants. Westermeyer et al. [30] compared patient status with pre-migration and post-migration factors in a group of Hmong refugees to Minnesota. The findings suggested that remaining in one residence and greater distance from other Hmong, were significantly correlated with fewer emotional problems. However, the relative drop in occupation or social class, insufficient English language acquisition, and lack of relatives and support groups, were associated with higher symptom levels and patient status. Formal English instruction, however, was found to have only limited effects. Another universal risk factor for mental health problems mentioned in the literature is the lack of an adequate social network [31].

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(iii) The Circumstances of Migration The conditions of migration appear to influence the future psychological functioning of the immigrant. Of these conditions the most important is whether the migration has been forced or free. If it has been forced, as in the case of refugees, by real threat of persecution, famine or war, the trauma created by these experiences, and the fact that the migration has been undertaken without adequate preparation, can be the cause of considerable mental health problems. Researchers from all over the world have confirmed that refugees are more psychologically at risk than voluntary immigrants and usually experience significant levels of depression, anxiety and/or traumatic stress disorder [27, 32].

THE ACCULTURATIVE STRESS MODEL The most recent model to explain why there is an overrepresentation of migrants among those who experience mental health problems is the widely accepted bi-dimensional model of the acculturation process by Berry et al. [33]. The term acculturation refers to cultural change that results from prolonged and direct contact between two distinct cultural groups. In essence, acculturation occurs when a non-dominant ethnic group adapts to a dominant society [34]. Psychologically, adjusting to a new culture results in changes to the immigrant‘s values, behaviours, and beliefs toward the host country. The degree of acculturation stress experienced typically depends on the amount of behaviour change required during the adaptation process [35]. Berry divided the adjustment patterns of immigrants into four categories, based on two questions: ‗Is it considered to be of value to maintain my cultural identity and characteristics?‘ and ‗Is it considered to be of value to adapt to cultural identity and characteristics of the host country?‘ the answer to each question broadly defines the category each immigrant falls into: assimilation, integration, separation or marginalisation. Assimilation occurs when the immigrant abandons or rejects his/her traditional cultural conventions or identity and is absorbed into the dominant culture. Integration is when the immigrant maintains some of his/her cultural integrity, as well as adjusting their behaviour to become an integral part of the dominant societal framework. Separation is defined as the situation when the immigrant has no interest in building a tangible relationship with the dominant culture and holds onto his/her traditional culture. Finally, Marginalisation usually results from severe acculturation stress where, no longer acknowledging his/her cultural group and unable to adjust to the larger society, the immigrant in the adjustment process rejects both the old and the new culture. Conceptually, each acculturation style has far reaching consequences for the immigrant‘s psychological wellbeing. According to Berry [36] separation and marginalisation tend to be ineffective strategies in adjusting to a new culture as the societal issues the immigrant is confronted with remain unresolved, which may result in declining mental health. Berry argues that integration and assimilation result in the least stress on immigrants as they selectively adopt the mainstream culture. Integration is often seen in the bicultural individual who derives benefits from both population groups. For example, research by Niles [37] in Australia found that immigrant groups who preserved their values, traditions and culture (and

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thus maintained a strong ethnic identity) while partially adopting Australian culture in terms of language, education and societal norms, had a high sense of psychological well-being (see Figure 3).

Berry et al., 1989. Figure 3. Berry‘s four Acculturation Styles.

There are several factors that contribute to and determine acculturation style, with social and economic contexts (including host country attitudes towards the immigrant) playing a major role [34]. Without adequate social or cultural support, immigrants can face numerous mental health problems, often related to unemployment, poverty, substandard housing, prejudice, discrimination and lack of health care services and education. Moreover, acculturative experiences can often exacerbate the effect of daily stressors. These additional stressors are especially potent for immigrants who experience a great distance between the cultural norms of their former country and the society of settlement [35]. When the difference is significant, and the immigrant is unable to cope with the cultural changes and acquisition of language skills, the experiences can often lead to severe acculturation stress during the resettlement period [34]. Age also has an impact on the acculturation process, with older immigrants clinging to their traditional past and resisting the cultural norms of the host country [38]. The extent of acculturative stress and coping strategies differ between individuals, and thus determines the long-term outcomes of each immigrant. More recent research adopting a bidimensional approach did not make the a priori assumption of a typology [39, 40, 41]. In these studies, each acculturation dimension was first used to predict psychological adjustment separately. Findings from these immigrant studies suggested that in general, acculturation towards the host culture held adaptive implications and more positive mental health outcomes whilst acculturation towards the heritage culture held maladaptive implications. However, Cheung-Blunden and Juang‘s [42] study with young girls and their parents from Hong Kong found that acculturation towards Chinese (majority) culture was related to adaptive implications, whereas acculturation towards western (minority) culture was related to poorer adaptation and mental health problems. They

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suggested that the bicultural composition (e.g., status, prestige, strength of cultural networks of each culture) should be incorporated into acculturation theory to better understand adjustment implications across a wide range of contexts. The mental health migration theories and models, developed and extensively tested in predominantly immigrant nations of North America, have stimulated and guided researchers in other nations to raise awareness of migrant mental health issues and to initiate improvements in health and social services.

THE NEW ZEALAND EXPERIENCE New Zealand is a small nation of migrants. Its distance from major land masses resulted in it being one of the last countries to be inhabited. Ancestors of the Maori settled some 800 years ago from the Pacific. European colonisation did not commence until midway through the 19th Century but since then active immigration policies have been pursued to encourage further immigration. These policies were highly selective, favouring Europeans, especially migrants from the United Kingdom [43]. However, the 1987 changes in immigration policy and in particular the introduction of the 1992 point system provided highly skilled migrants from all parts of the world the opportunity to settle in New Zealand. The objectives of policies in the late 20th and early 21st century have always fallen into two main categories: those serving specific national interests, such as needed highly skilled staff resources for economic development and those of a humanistic nature, such as family reunification and acceptance of refugees. This resulted in a multicultural population with large ethnic minority groups. According to the latest 2006 census New Zealand has 4 million inhabitants and of these 14% identify as Maori, 9.2% as Asian, 6.6% are from the Pacific nations, 67.6% are of European descent, close to 1% identify as from the Middle East, Latin America and Africa and about 1.6% chose the ‗other‘ category [44]. Migrant research in New Zealand had focused on physical health with several researchers investigating the general health of the immigrant population. For example, such conditions as coronary and hypertensive heart disease, high blood pressure and ulcers have been clearly associated with immigration [45]. An early study by Eastcott [46] revealed a high rate of lung cancer among British immigrants and both Jackson et al. [47] and Sutherland et. al. [48] reported high rates of diabetes and asthma among the Polynesian population. Prior [45] reported that the health problems of the Vietnamese, Cambodians and Lao refugees to New Zealand, such as tuberculosis and worm infestations, were assessed, starting in 1978 and treated prior to settlement. However, ―…the exploration and examination of immigrant mental health had been grossly neglected in New Zealand‖ p. 94 [45]. The resettlement of large numbers of Indochinese refugees (nearly 10,000) during the late 1970s and 1980s provided the stimulus for the first systematic mental health research in the country [49]. Researchers looked for tested theories and models, overseas findings and experience with mental health measures [such as: 50, 51, 52] guided and inspired research designs leading to results that would inform the implementation of specific services for refugee and immigrant resettlement in New Zealand. The first study on mental health of migrants in the country by Pernice [53], Pernice and Brook [54, 55, 56] explored aspects of the Multivariate Model of the Immigrant Adaptation

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Process, in particular the relationship between mental health levels of Indo-Chinese refugees, immigrants from the Pacific Nations and British migrants and their pre-migration (demographic) characteristics, their length of residence, the circumstances of migration, and their post-migration experiences in New Zealand society. The findings indicated that the demographic characteristics such as age, gender, marital status and educational level had little influence on emotional distress, whereas discrimination in their daily life in New Zealand, experienced by both the Indochinese refugees and the immigrants from the Pacific nations was the crucial post-immigration factor associated with high symptom levels. Also the test of Sluzki‘s [13] length of residence did not support the influence of such stages on mental health, as no euphoric period or a time-linked mental health crisis were evident. The most definite aspect of the findings was the rejection of the concept of a euphoric period among the whole population of migrants. The hypothesis that the circumstances of migration (being a refugee or immigrant) would affect mental health and that refugees would experience more emotional distress than migrants was only supported when refugees were compared with British immigrants. Both Indochinese refugees and the immigrants from the Pacific nations had poor mental health. However, the incidence of clinical depression and clinical total emotional distress was higher among refugees which supported findings from international research [32]. Cheung [57], a psychiatrist in the South Island of New Zealand, investigated Cambodian refugees who presented with depression and post-traumatic stress disorder (PTSD). He discussed why traumatised Cambodians somatise their mental health problems and the difficulties involving them in Western style psychotherapy. A study of 223 Cambodians by Cheung and Spears [58] explored the psychiatric and physical health status, the pattern of health care service use and problems encountered with local health services. Their findings indicated that 15.7% had severe mental health problems but less than 3% of the refugees had ever attended any mental health services. Most participants had used traditional services in their home country but very few had used them in New Zealand. Over half of the refugees reported problems with use of health services. As these studies indicated, New Zealand‘s mental health research in the late 1980s and early 1990s focused on mental health of refugees and immigrants (as comparison groups) and predominantly investigated experiences in the society of settlement, including the length of residence, as opposed to pre-migration characteristics. Consideration of these findings encouraged a revision of service provision in New Zealand which resulted in an extension of refugee support agencies in all major cities of the country, where programmes used volunteer sponsors for each refugee family. In 1997 additional specialist clinics were established in Wellington and Auckland. These Refugees as Survivors (RAS) centres‘ main mission is to provide those who experienced torture and trauma with access to free and appropriate mental health services. Therefore these are examples of the practical successes that have been achieved by the awareness of refugees‘ special needs. This awareness by policy makers and health providers was in turn informed by migrant mental health research. Later mental health studies shifted their attention to voluntary immigrants and focused on aspects important to adjustment to life in New Zealand [59, 60, 61, 62]. Abbott et al.‘s [59, 60] community survey of 271 Chinese migrants (the majority from Hong Kong and Taiwan), used the Acculturative Stress Model (which identifies four adaptation styles) to assess their preferred adjustment strategies and mental health levels. The findings indicated that the bicultural or integration style provided the optimal path to adaptation with most respondents having neither major adjustment nor mental health problems supporting overseas research

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[33, 36]. The authors concluded that the prevalence rates of mental disorder were similar to those found in 1994 in surveys of the general population. However, major predictors of psychiatric morbidity included unemployment, low English proficiency, shorter residency in the country and younger age. Migrants‘ employment status also appeared to be a major mental health issue for the highly skilled Asian migrants who had been attracted via New Zealand‘s point system immigration policy in 1992 and 1995. Therefore Pernice et al. [61, 62] collected mental health data from Chinese (from the People‘s Republic of China), Indian and South African skilled immigrants and their employment status over five years, spanning Sluzki‘s length of residence stages. The research, built on the post-migration aspects of the Multivariate Model of the Immigrant Adaptation Process, found that mental health levels during the participants first year and a half in the country were no better for the employed than for the unemployed. Migrants in both employment categories experienced poor mental health similar to those in a previous study of the general long-term unemployed population in New Zealand [63]. For those migrants who were employed, this could be due to underemployment, occupational stress or dissatisfaction or to a combination of these factors. Poor mental health was equally evident among migrants from all three national origins. This situation persisted particularly over the first two data collection periods with slightly improved mental health levels during the following three years [62]. While most South Africans were successful in finding employment from the beginning, compared to the Indians and Chinese, this did not prevent them from having poor mental health. This may in part have been a result of the South Africans having different motivational factors driving their migration (e.g. feeling more ‗pushed‘ out of their country of origin rather than being ‗pulled‘ by the attraction of settling in New Zealand) . No positive relationship could be established between mental health and duration of residence. However, the generally poor mental health of the three groups of participants (particularly during the first year and a half in New Zealand) supports neither the concept of a euphoric/optimistic initial period nor a subsequent crisis period as proposed by Sluzki‘s [13] Stage Model. Instead, a different trend was observed with poor mental health in the first year and a half and slightly improved but still poor mental health thereafter [62]. While there are not many, specifically mental health studies, among the large number on various aspects of immigration to New Zealand, they have provided the knowledge base for some successful advances in support services to migrants, in particular for refugees. The more recent research on skilled migrants highlighted that post-migration factors such as employment status are not a clear determinant of mental health. Pre-migration aspects also need to be considered as the original Multivariate Model of the Immigrant Adaptation Process, developed in North America over 30 years ago, would have predicted.

CONCLUSION This chapter outlines theories and models of migration and its relationship to mental health and puts these into the context of the New Zealand experience. It describes the shift away from the Social Selection and Social Causation theories to a Multivariate Model of the

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Immigrant Adaptation Process. This model proposed in the 1970s became the most influential and tested model in North America and it inspired mental health research with refugees and migrants in many Western countries, including New Zealand. It took into consideration the characteristics of the individual, pre-migration conditions and postmigration factors in the society of settlement including the migrant‘s length of residence. Subsequent research tested various aspects of this model and the relationship of each aspect to migrant mental health. Some researchers suggested new factors to be of significance to the adaptation process. Others focused predominantly on settlement issues in the host society, with the latest model proposing individual characteristics such as his/her choice of adaptation style to the country of settlement. New Zealand‘s mental health researchers also explored and tested aspects of the Multivariate Model of the Adaptation Process starting in the late 1980s. The main focus has been post-migration settlement issues in New Zealand society, with both refugees and immigrants. Their research significantly contributed to an understanding of migrant mental health and to the successful implementation of improved service provision. Therefore the New Zealand experience has affirmed the experience elsewhere by determining that the use of theoretical frameworks from the mental health migration models has been a productive research avenue leading to better migrant service provision in New Zealand.

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[12] Cohon JD: A Preliminary Analysis of Indochinese Refugee Mental Health Clients. San Francisco, International Institute of San Francisco. Indochinese Mental Health Project 1979. [13] Sluzki CE: Migration and family conflict, in Coping with Life Crises. Edited by Moos RH. New York, Plenum, 1986, pp 277-288. [14] Grinberg L, Grinberg R: Psychoanalytic Perspectives of Migration and Exile. New Haven, Yale University Press, 1989. [15] Beiser M: Influences of time, ethnicity and attachment on depression in Southeast Asian refugees. American Journal of Psychiatry 1988; 145: 46-51. [16] Flaherty JA, Kohn R, Levav I, Birz S: Demoralization in Soviet-Jewish immigrants to the United States and Israel. Comprehensive Psychiatry 1988; 29: 588-597. [17] Scott WA, Scott R: Adaptation of Immigrants: Individual Differences and Determinants. Oxford, Pergamon Press, 1989. [18] Tran TV, Manalo V, Nguyen VTD: Nonlinear relationship between length of residence and depression in a community-based sample of Vietnamese Americans. International Journal of Social Psychiatry 2007; 53(1): 85-94. [19] Murphy HBM: Migration, culture and mental health. Psychological Medicine 1977; 7: 677-684. [20] Weinberg A: Mental health aspects of voluntary migration. Mental Hygiene 1954; 39(3): 450-566. [21] David HP: Involuntary international migration: adaptation of refugees, in Behavior in New Environments. Adaptation of Migrant Populations. Edited by Brody EB. Beverly Hills, Sage, 1969, pp 73-95. [22] Murphy HBM: Alcoholism and schizophrenia in the Irish: A review. Transcultural Psychiatric Research Review 1975; 12: 116-139. [23] Stocks P: Indications of a possible association between peptic ulcer and vascular lesions of the central nervous system. British Journal of Preventive and Social Medicine 1968; 22: 206-211. [24] Nguyen SD: Mental health services for refugees and immigrants. The Psychiatric Journal of the University of Ottawa 1984; 9(2): 85-91. [25] Stein BN: The refugee experience: Defining the parameters of a field study. International Migration Review 1981; 15(1): 320-330. [26] Brody EB: Introduction, in Behavior in New Environments. Adaptation of Migrant Populations. Edited by Brody EB. Beverly Hills, Sage, 1969, pp 13-21. [27] Krupinsky J, Stoller A, Wallace L: Psychiatric disorders in East European refugees now in Australia. Social Science and Medicine 1973; 7: 31-49. [28] Vignes AJ, Hall RCW: Adjustment of a group of Vietnamese people to the United States. American Journal of Psychiatry 1979; 136: 424-444. [29] Lazarus J, Locke BZ, Thomas DS: Migration differentials in mental disease. Milbank Memorial Fund Quarterly 1963; 41: 25-39. [30] Westermeyer J, Vang TF, Neider J: Migration and mental health among Hmong refugees. Association of pre- and post-migration factors with self-rating scales. The Journal of Nervous and Mental Disease 1983; 171(2): 92-96. [31] Yamamoto J, Satele A: Samoans in California. Psychiatric Journal of the University of Ottawa 1979; 4: 349-352.

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[32] Williams CL, Berry JW. Primary prevention of acculturative stress among refugees. American Psychologist 1991; 46: 632-641. [33] Berry JW, Kim U, Power S, Young M, Bujaki M: Acculturation attitudes in plural societies. Applied Psychology: An International Review 1989; 38: 185-206. [34] Ekbald S, Kohn R, Jansson B: Psychological and clinical aspects of immigration and mental health, in Clinical Methods in Transcultural Psychiatry. Edited by Okpaku S. Washington, DC, American Psychiatric Press, 1998, pp 42-66. [35] Schmitz PG: Psychological aspects of immigration, in Cross-cultural Topics in Psychology. Edited by Alder LL, Gielen UP. Westport, CT, Praeger, 2001, pp 229-243. [36] Berry JW: Acculturation and adaptation: a general framework, in Mental Health of Immigrants and Refugees. Edited by Holtzman WH, Bornemann TH. Austin, Texas, Hogg Foundation for Mental Health, 1990, pp 90-102. [37] Niles FS: Stress, coping and mental health among immigrants to Australia, in Merging Past, Present and Future in Cross-cultural Psychology. Edited by Lonner W, Dinnel D, Forgays D, Hayes S. Lisse, The Netherlands, Swets and Zeitlinger, 1999, pp 293-307. [38] Ghaffarian S: The acculturation of Iranian immigrants in the United States and the implications for mental health. Journal of Social Psychology 1998; 138: 645-675. [39] Costigan CL, Su TF: Orthogonal versus linear models of acculturation among immigrant Chinese Canadians: a comparison of mothers, fathers and children. International Journal of Behavioral Development 2004; 28(6): 518-527. [40] Nguyen HH, Messe LA, Stollak GE: Toward a more complex understanding of acculturation and adjustment. Journal of Cross-cultural Psychology 1999; 30(1): 5-31. [41] Ryder AG, Alden LE, Paulhus DL: Is acculturation unidimensional or bidimensional? A head-to-head comparison in the prediction of personality, self-identity, and adjustment. Journal of Personality and Social Psychology 2000; 79: 49-65. [42] Cheung-Blunden VL, Juang LP: Expanding acculturation theory: are acculturation models and the adaptiveness of acculturation strategies generalizable in a colonial context? International Journal of Behavioral Development 2008; 32(1): 21-33. [43] King M: The Penguin History of New Zealand. Auckland, NZ, Penguin Books (NZ), 2003. [44] Statistics New Zealand: QuickStats about New Zealand‘s Population and Dwellings: 2006 Census. Wellington, Department of Statistics, 2007. [45] Prior I: Immigrants and health: a selective review and suggestions for future research, in New Zealand and International Migration. A Digest and Bibliography No1. Edited by Trlin AD, Spoonley, P. Palmerston North, NZ, Massey University, Department of Sociology, 1986, pp 81-96. [46] Eastcott DF: The epidemiology of lung cancer in New Zealand. Lancet 1956; 1: 37-39. [47] Jackson RT, Beaglehole R, Rea HH, Sutherland DC: Mortality from asthma: a new epidemic in New Zealand. British Medical Journal 1982; 285: 771-774. [48] Sutherland DC, Beaglehole R, Fenwick J, Jackson RT, Mullins P, Rea HH: Death from asthma in Auckland: circumstances and validation of causes. New Zealand Medical Journal 1984; 97(769): 845-848. [49] Abbott M: Introduction, in Refugee Resettlement and Wellbeing (based on the first National Conference on Refugee Mental Health in New Zealand). Edited by Abbott M. Auckland, Mental Health Foundation, 1989, pp 3-11.

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[50] Mollica RF, Lavelle JP: The Trauma of Mass Violence and Torture: An Overview of the Psychiatric Care of the Southeast Asian Refugee (Report). Boston, Indochinese Psychiatry Clinic, St. Elizabeth‘s Hospital, 1986. [51] Mollica RF, Wyshak G, Marneffe D, Tu B, Yang T, Khuon F, Coelho R, Lavelle J: Hopkins Symptom Checklist-25. Manual. Cambodian, Laotian and Vietnamese Versions. Boston, Indochinese Psychiatry Clinic, St. Elizabeth‘s Hospital, 1986. [52] Mollica RF, Wyshak G, Marneffe D, Khuon F, Lavelle J: Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. American Journal of Psychiatry 1987; 144(4): 497-500. [53] Pernice R: Chapter 12. Refugees and mental health, in Refugee Resettlement and Wellbeing (based on the first National Conference on Refugee Mental Health in New Zealand). Edited by Abbott M. Auckland, Mental Health Foundation, 1989, pp 155160. [54] Pernice R, Brook J: Relationship of migrant status (refugee or immigrant) to mental health. International Journal of Social Psychiatry 1994; 40(3): 177-188. [55] Pernice R, Brook J: The mental health pattern of migrants: is there a euphoric period followed by a mental health crisis? International Journal of Social Psychiatry 1996; 42(1): 18-27. [56] Pernice R, Brook J: Refugees‘ and immigrants‘ mental health: Association of demographic and post-migration factors. Journal of Social Psychology 1996; 136(4): 511-519. [57] Cheung P: Somatisation as a presentation in depression and post-traumatic stress disorder among Cambodian refugees. Australian and New Zealand Journal of Psychiatry 1993, 27: 422-428. [58] Cheung P, Spears G: Illness aetiology constructs, health status and use of health services among Cambodians in New Zealand. Australian and New Zealand Journal of Psychiatry 1995; 29: 257-265. [59] Abbott MW, Wong S, Williams M, Au M, Young W: Chinese migrants‘ mental health and adjustment to life in New Zealand. Australian and New Zealand Journal of Psychiatry 1999; 33: 13-21. [60] Abbott MW, Wong S, Williams M, Au M, Young W: Recent Chinese migrants‘ health, adjustment to life in New Zealand and primary health care utilization. Disability and Rehabilitation 2000; 22(1/2): 43-56. [61] Pernice R, Trlin AD, Henderson AM, North N: Employment and mental health of three groups of immigrants to New Zealand. New Zealand Journal of Psychology 2000; 29(1): 24-29. [62] Pernice R, Trlin AD, Henderson AM, North N, Skinner M: Employment status, duration of residence and mental health among skilled migrants to New Zealand: results of a longitudinal study. International Journal of Social Psychiatry 2009; 55(3): 272287. [63] Pernice R, Long N: Long-term unemployment, employment attitudes and mental health. Australian Journal of Social Issues 1996; 31(3): 311-326.

PART III: SUBSTANCE ABUSE

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 16

SUBSTANCE USE DISORDER AMONG IMMIGRANTS IN THE UNITED STATES Sun S. Kim1, David Kalman1,2, Gerardo Gonzalez1 and Douglas Ziedonis1 1. University of Massachusetts School of Medicine, Worcester, Massachusetts, USA 2. Edith Nourse Memorial Veterans Administration Medical Center, Bedford, Massachusetts, USA

ABSTRACT The purpose of this chapter is to describe substance use disorders among immigrants based on a review of literature conducted in the United States. This chapter consists of three parts: the first part covers the definition of substance use disorders and a brief description of biological and psychosocial aspects of addiction; the second part is a review of empirical literature; and the third part is conclusion of the chapter. Thirty two studies of U.S. immigrants are reviewed. About 65.0% (13/20) of the studies with adults and 50.0% (6/12) of the studies with adolescents were conducted exclusively with Hispanics; studies with other immigrants are scarce. Findings are consistent across subgroups of Hispanics, with the exception of Puerto Ricans, that immigrants are less likely to have substance use disorders than U.S. natives. Due to lack of studies with African and Asian immigrant groups, findings are inconclusive about these groups. The majority of studies with African, Asian, and European Americans report findings in aggregated data of all groups without ethnic-specific information on subgroups. Acculturation is the variable that has been most frequently studied in relation to substance use disorders among immigrants. Importantly, the level of acculturation is strongly associated with sociodemographic factors (e.g., gender and age), and socioeconomic factors (e.g., education and family income). More studies are needed to determine how to modify maladaptive processes contained in some trajectories of acculturation into American culture that may increase substance use, especially among female immigrants and their female offspring. In addition, future research should focus on developing interventions that are designed to foster the retaining of protective cultural norms against substance use prevalent of an ethnic group within the immigrant community.

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INTRODUCTION Substance use disorders are chronic, often relapsing, diseases that are characterized by compulsive drug-seeking and drug-taking behaviors, despite negative consequences. It is a leading suicide risk factor [1-3] and has been a serious public health problem across nations. With health care costs attributable to alcohol, tobacco and other illicit drug use estimated annually at more than 100 billion dollars, substance use disorder is a leading health problem in the United States (US) [4]. According to the National Epidemiologic Survey on Alcohol and Related Conditions conducted in 2001-2002, the 12-month prevalence of any substance use disorders (excluding nicotine) was 9.35% (19.4 million); the prevalence rates of alcohol and drug use disorders were 8.46% (17.6 million) and 2.00% (4.2 million adult Americans), respectively [5]. More recently, the National Survey on Drug Use and Health in 2008 reports that about 22.2 million Americans aged 12 years or older, or 8.9% of the population, can be considered to have a substance use disorder (including alcohol and illicit drugs) [6]. Between 2002 and 2008, there was almost no change in number of persons with substance abuse or dependence (22.0 million in 2002 and 22.2 million in 2008). Studies on substance use disorders among immigrants are scarce and findings have been inconsistent due to heavy reliance on convenience samples. Most studies report findings in an aggregated format by race or language use such as Spanish-speaking without ethnic-specific information. Although substance use among immigrants tend to be less common than among U.S. natives, estimates of substance use disorders and types of substances abused most frequently may vary by race and ethnicity. The purpose of this chapter is to describe substance use disorders among immigrants in the US based on a review of empirical literature that report rates of substance use disorders. The chapter consists of three parts:   

Part I. Definition and Etiologies of Substance Use Disorders Part II. Review of Studies on Substance Use Disorders among U.S. Immigrants Part III. Conclusion

In this chapter, we first define substance use disorders, using the current classification of the Diagnostic and Statistical Manual fourth edition text revised (DSM-IV TR) [7] and then provide an overview of substance use disorders, describing pertinent biological and psychosocial etiological factors. We then describe how ethnic and racial differences in biological systems that contribute to, or protect from, problematic substance use. We then present a review of the extant literature in substance use disorders among immigrants in the US. Finally, we conclude the review with some recommendations for future studies.

PART I. DEFINITION AND ETIOLOGIES OF SUBSTANCE USE DISORDERS Substance use disorders include abuse and dependence. According to the American Psychiatric Association [7], substance abuse is defined as a maladaptive pattern of substance use during 12 months leading to clinically significant impairment or distress as manifested by recurrent substance use despite its negative consequences in the user‘s life. Abuse is

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considered the less severe version of substance use disorders with fewer symptoms of the overall syndrome of dependence. Substance dependence is the more severe version of substance use disorders and includes other symptoms of tolerance, withdrawal, and compulsive drug seeking behavior. The dependent user has an intensive desire for the substance ("craving") and needs more of the substance to achieve the effect that a lesser amount induced in the past (―tolerance‖). When use is interrupted, the dependent user experiences withdrawal symptoms that include negative emotions and physiological changes, which often leads to relapse to use. In this chapter, the term ―drug addiction‖ is used interchangeably with ―substance dependence‖ as they are in the DSM-IV TR [7].

Biological Explanation of Addiction Biological theories of addiction explicate that individuals initially consume substances for the ability of the agents to produce a pleasurable effect (that is, reward) and that dependence develops as a function of the time and recurrent drive for reward [8]. This idea of positive reinforcement by drugs with abuse liability has been widely seen as a primary factor behind substance abuse and dependence. Drugs of abuse are generally classified into different categories, including cannabinoids, depressants (i.e., ethanol), stimulants (i.e., nicotine, amphetamines and cocaine), hallucinogens (for example, lysergic acid diethylamide [LSD] and ecstasy) and inhalants (i.e., toluene and nitrous oxide) [9]. Although these drugs often produce differential behavioral effects and have diverse pharmacological profiles and withdrawal symptoms, they all act on one common feature the mesocorticolimbic dopamine (DA) activity in the brain [10, 11]. The mesocorticolimbic dopamine activity. The mesocorticolimbic system, which is implicated in the rewarding properties of both natural stimuli (for example, food, drink and sex) and addictive drugs, consists of DA projections from cell bodies in the ventral tegmental area to limbic structures of the mesolimbic pathway that include nucleus accumbens (NAcc), the amygdala, ventral striatum, and hippocampus, and cortical areas of the mesocortical pathway including the prefrontal cortex, the orbitofrontal cortex and the anterior cingulate. The mesolimbic pathway is involved in the acute reinforcing effects of drugs and various conditioned responses related to craving and relapse, whereas changes in the mesocortical pathway mediate the conscious drug experience, drug craving and a loss of behavioral inhibition that results in compulsive drug-seeking and drug-taking behaviors [9]. The enhancement of DA secretion in the NAcc is a common effect of different pharmacological classes of drugs of abuse: opiates, cocaine, amphetamine, ethanol, nicotine and cannabinoids. This effect can result from direct action on dopaminergic neurons as is the case with nicotine, cocaine, and amphetamine or an indirect effect as is the case with ethanol and opioids. Noradrenergic and serotonergic neurons. Findings from animal studies suggest that DA is not the only neurotransmitter involved in addiction. Noradrenergic (norepinephrine containing) receptors and serotonergic (serotonin containing) systems are also involved [12]. For example, in genetic studies, dopaminergic transporter (DAT)-knockout mice continue to experience DA release in the reward circuit in response to stimulants and consequently still self-administer cocaine [13, 14]. In contrast, α1b-adrenergic receptor-knockout mice do not show behavioral sensitization to d-amphetamine [15], nor increased DA release in the NAcc [16]. This suggests that norepinephrine contributes to stimulant effects independently of the

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DAT. The serotonergic system appears to be involved in the regulation of impulse-control mechanisms related to craving and relapse rates [17].

Racial and Ethnic Differences in Biological Factors Not everyone who experiments with drugs that have abuse ability will become dependent on them and this individual difference in addiction vulnerability has been explicated in large by gene-environment interplay. Attempts to identify genes conferring susceptibility to addictive diseases have been undertaken via a range of research designs including adoption and twin studies [18-26]. Adoption studies consistently find greater similarities between substance abuse phenotypes with biological relatives than with adopted family members. Genetic studies have found moderate to high genetic influences on addiction that account for 30 to 70% of the total variance [20]. It has also been suggested that genetic vulnerability is influenced by gender, age and ethnicity [24]. Very limited studies exist that examine genetic differences in substance use by racial and ethnic groups and most have focused on alcohol and nicotine dependence. For example, the importance of genetic factors in the development of alcohol dependence has been well established [27]. A protective relationship has been found between alcohol dehydrogenase (ADH2*2) and alcoholism in Asians [28] and Jews [29]. A liver enzyme, Cytochrome P450 2A6 (CYP2A6), with alleles associated with slow nicotine metabolism, has been reported more frequently with Asian populations (15-20%) than European and Middle East populations (less than 1%) [30, 31]. Others also found that Japanese smokers have lower active genotypes of the CYP2A6 enzyme than white counterparts [32]. However, significant genetic differences exist within the Asian population: Japanese and Koreans living in Japan presented significant differences (p < 0.005) in the activity of CYP2A6 enzyme [33]. More recently, genome-wide association (GWA) studies with substance dependent individuals have been conducted within and across racial and ethnic groups. For example, there was a significant association of polymorphisms in the melanocortin receptor type 2 (MC2R or ACTH receptor) gene with heroin addiction in 272 subjects including Caucasians, Hispanics, and African Americans [34]. The researchers found a significant association (p = 0.0004) of the allele – 184A with a protective effect from heroin addiction in Hispanics.

Psychosocial Explanations of Substance Use among Immigrants Psychosocial stress model explains drug addiction and relapse in light of the interaction between biological and psychosocial factors [35-37]. Stress is generally defined as any disruption of homeostasis from internal and external challenges [38]. To return to homeostasis, people respond by the activation of two adaptive systems: first, stress activates the hypothalamic–pituitary–adrenal axis through the release of corticotrophin-releasing factor (CRF) and second, stress activates the sympathetic nervous system resulting in the release of epinephrine. The release of CRF results in release of adrenocorticotropin hormone [ACTH] into general circulation. ACTH then acts on the adrenal cortex resulting in release of glucocorticoids into blood. While the high concentration of glucocorticoids act in a negative feedback fashion to terminate the release of CRF, it also stimulates the release of epinephrine

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from the adrenal medulla by regulating the level of the enzyme, phenylethanolamine-Nmethyltransferase, which controls the synthesis of epinephrine from norepinephrine [39]. Acculturative stress model versus Assimilation model. Immigrants are confronted with a variety of problems upon arrival in a new society. Language difficulties, cultural differences, ethnic discrimination, family separations, and loss of social networks, valued social roles, identities, and occupational positions are but a few of the challenges that are often faced by immigrants [40]. The acculturative stress model suggests that the stress caused by cultural conflict at point of destination and lack of social and economic resources for coping may result in substance use and substance use disorders [41-43]. Studies of immigrants from Latin America to the US indeed have found an association of acculturative stressors with psychological distress and substance use disorders [44-46]. In contrast, the assimilation model suggests that as immigrants adopt the customs and practices of the host society, their patterns of substance use will also begin to parallel those of their new environment [47, 48].

Conceptual Definitions of Acculturation and Other Related Terms ―Assimilation‖, ―enculturation‖, and ―socialization‖ are some other terms that have been used interchangeably with ―acculturation‖, which creates confusion. Instead of ―acculturation‖, the term ―assimilation‖ had been used for a while to depict the process or an outcome of adaptation of a group of racial/ethnic minority groups to the dominant group [4951]. Scholars then believed that immigrants were destined to lose completely the traits of their original cultures and to be absorbed into the dominant culture. This belief was based on an idea that the host society consists of the basic homogeneity of Anglo-Saxon culture and that immigrants could conform to social and cultural norms within a national framework [52]. Hence, the end product of assimilation was frequently conceived as a situation of complete conformity to the majority society at all cultural, social, and economic levels. Many scholars who are themselves descents of immigrants, however, argue that the assimilation theory is incongruent with so called ―salad bowl‖ reality in which ethnicity seems to be persistent across generations [52]. In line with this, Berry and colleagues [53] proposed a multidimensional model of acculturation that has been widely accepted in studies of immigrants across disciplines. They suggested that immigrants living in a multicultural society face two fundamental issues: (1) the value of retaining one's own cultural identity and customs and (2) the value of adopting the culture and custom of the host society. Depending upon answers to the two questions, people can select one of four modes: (1) assimilation mode whereby one relinquishes one's cultural identity by moving into the host culture, (2) integration mode, which entails maintaining relationships with both the culture of origin and the host culture, (3) separation mode whereby one maintains relationships only with one‘s culture of origin, and (4) marginalization mode in which relationships are lost with both the culture of origin and the host culture [54-56]. Integration mode is considered the ideal option, whereas marginalization mode in which the greatest acculturative stress is to be found is the most maladaptive one. Acculturation has also been viewed as synonymous with enculturation. Cavalli-Sforza and Feldman [57] proposed that enculturation and acculturation are identical phenomena with one exception: the behavior to be learned belongs to one's own cultures in the former case, while in the latter case it belongs to another culture. Socialization also has been viewed as

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synonymous with acculturation. For example, Spiro [58] argued that the values and beliefs one holds are constructed to a greater degree by social experience and social heritage than an individual's private experience. Thus, he placed emphasis on social interaction that involves acquiring knowledge and internalizing values. Berry et al. [53], however, disagreed with Spiro‘s view by arguing that enculturation and acculturation are the processes whereby a person gradually learns culture and then incorporates into one‘s core values and beliefs; whereas, socialization refers to the process by which institutions deliberately shape one‘s values and beliefs.

PART II. REVIEW OF STUDIES ON SUBSTANCE USE DISORDERS AMONG U.S. IMMIGRANTS Table 1 summarizes findings of 32 studies on substance use disorders among U.S. immigrants [41, 48, 59-88]. These studies were identified with key words such as ―immigrants AND substance use―, ―immigrants AND substance use disorders‖, and ―immigrants AND alcohol use disorders‖ from a computer search on databases of healthrelated literature such as PubMed, Social Sciences Citation Index, and Cumulative Index to Nursing and Allied Health Literature. A total of 93 research articles published through June 30, 2009 were retrieved from a combination of computer search of the databases and manual search from the list of references in selected articles. We found 32 articles (34.4%) that met our inclusion criteria. To be included, the study had to be conducted with a representative sample or a large number of subjects (N ≥ 1000) and must provide information on subject characteristics, particularly, nativity (U.S. born vs. foreign born) and/or generation status (immigration, first, and second generation). A total of 25 studies that simply reported prevalence rates of alcohol and/or tobacco use were not included; yet, studies (n = 13) with immigrants on any illicit drug use were all included due to paucity of such studies.

Prevalence of Substance Use Disorders among Immigrants in the US Among the 32 studies listed in Table 1, all but three [41, 65, 72] reported findings with aggregated data without racial or ethnic classifications. Of the three with disaggregated data, one was conducted with adults and two were with adolescents. Most studies reported that immigrants had lower lifetime prevalence of substance use disorders than U.S.-born natives of the same national origin. This finding had been consistent across studies with adolescents as well as across studies with adults of all racial and ethnic groups except for Puerto Ricans [48, 64]. Immigrants had a later age of onset for substance use and also had a lower propensity for progression from substance use to disorders. However, further analysis presented a different picture when substance use was compared among immigrants by their length of residency in the US. There was a trend toward equality in risk for substance use disorders between immigrant adults and U.S. natives after 15 years of residence [41, 48] and between immigrant adolescents and U.S. natives after 5 to 10 years of residence [65, 68]. The trend was often understood as a result of the maladaptive process of acculturation or assimilation to the American norm of substance use.

Table 1. Studies on Substance Use among Immigrants in the United States by Race and Ethnicity Age Group

Citation

Study Location

Group Origin

Major Findings

Adults

Alegria et al., 2006 [62]

Nationwide

Puerto Rican Cuban

U.S.-born non-Hispanic Whites and Cuban Americans reported higher alcohol and drug use disorders as compared with their foreign-born counterparts. For Puerto Ricans, there was no difference in alcohol use

Alegria et al., 2007 [63]

Nationwide

Hispanic

Self-perceived high social standing in the U.S. community was associated with decreased likelihood of reporting any substance use disorders in the past 12 months (ORa = 0.3, p < 0.05). Coming to the US after age 25 did offset the elevated risk of substance use from exposure to neighborhood disadvantage.

Alegria et al., 2008 [64]

Nationwide

Hispanic

U.S.-born Latinos except Puerto Ricans reported higher rates for substance use disorders than Latino Immigrants. No differences were found between foreign-born and U.S.-born Puerto Ricans.

Amaro et al., 1990 [79]

Nationwide

Mexican, Puerto Rican Cuban

Use of marijuana and cocaine was higher among U.S.-born Hispanics of all groups than among those who were born outside the US. Regardless of ethnicity, drug use was highest among English-speaking Hispanics than among those who were bilingual Hispanics, whose drug use in turn was higher than among those who were primarily Spanish- speaking.

Borges et al., 2006 [61]

Nationwide

Mexican

Borges et

Tijuana,

Mexican

The prevalence of alcohol dependence was 4.8% for the Mexicans, 4.2% for the Mexico-born immigrants, and 6.6% for U.S.-born Mexican immigrants. High acculturation was associated with higher risks of alcohol use disorders for women; however, unexpectedly, high acculturation was associated with lower risks for men. Migrants who had worked in the US and returned to Mexico were more

al., 2009

Ciudad Juarez,

likely to have used alcohol, marijuana or cocaine in their life-time and in the

[66]

and Monterrey,

past 12 months, and were more likely to develop a substance use disorder

disorders but there were differences in any drug use disorders.

Mexico Breslau et al., 2007 [87]

Nationwide

compared with others in the general population of Mexico. Black, Hispanic,

Immigrants had lower lifetime risk of substance use disorders than natives.

White

Risk was equally large for natives who were children of immigrants as for natives of subsequent generations.

Table 1. Studies on Substance Use among Immigrants in the United States by Race and Ethnicity (Continued) Age Group

Citation

Study Location

Group Origin

Major Findings

Burnam et

Los Angeles,

Mexican

Lifetime prevalence rates of alcohol and drug use disorders were higher for

al., 1987

CA

high acculturated or native Mexican Americans than for low acculturated or

[78] Caetano et al., 2008

Mexican immigrants. Texas

Mexican

Acculturation was related to lower rates of alcohol use disorders among men and a higher frequency of heavy episodic drinking among women. those who are ‗‗very Mexican,‘‘ ‗‗bicultural Mexican,‘‘ or ‗‗bicultural Anglo‘‘

[85]

are more at higher risk for alcohol abuse and ⁄ or dependence compared with ‗‗very Anglo ⁄ Anglicized‘‘ men. For women, acculturation level did not predict alcohol use disorders. Chae et al.,

Nationwide

2008 [80]

Chinese,

U.S.-born Asian Americans were more likely to report lifetime history of

Filipino, Vietnamese, Other Asian alone Biracial/Mixed

alcohol abuse/dependence than foreign-born Asian Americans. Controlling for sociodemographic characteristics, Asian Americans who reported experiencing unfair treatment had higher odds of lifetime history of alcohol abuse/dependence disorders (OR = 5.26, CI = 0.23 to 0.90).

Finch et al., 2003 [81]

California

Mexican

Employment frustration resulting from labor market exclusion and discrimination were significantly related to past-year alcohol abuse and dependence.

Grant et al, 2004 [69]

Nationwide

Mexican White

Harrison and Sidebottom, 2009 [82]

Minnesota

Black American Indian Asian, Hispanic White Biracial/Multiracial

Foreign-born Mexicans and Whites were at lower risk (p < 0.05) of DSM-IV substance use disorders compared with their U.S.-born counterparts. The rate of any drug use disorders for U.S.-born Mexican Americans was 8.3 times greater than for foreign-born, while for Whites the ratio was about 2.4:1.0 between U.S.-born and foreign-born. Pre-pregnancy alcohol and drug use was much higher among U.S.-born women than immigrant women regardless of race/ethnicity. American Indians had the highest rates of the use among all racial/ethnic groups. U.S.-born African Americans had the higher use rates than U.S.-born Asian Americans or Hispanics.

Age Group

Citation

Study Location

Group Origin

Major Findings

Johnson et al., 2002

Nationwide

not disaggregated

Immigrants were less likely to report past-year and lifetime use of alcohol and drugs than those born in the US. Lifetime prevalence generally

[41] Ojeda et al.,

increased with longer length of residence in the US. Nationwide

2008

Hispanic,

The odds of lifetime substance use by Hispanic and White immigrants were

White

lower than for U.S.-born Whites. Hispanic Immigrants' odds of lifetime

[71]

substance use were lower than for U.S.-born Latinos. Hispanic immigrants reported lower use of cigarettes, marijuana, and LSD than did White immigrants.

Ortega et al,

Mexican,

Mexican Americans were less likely than Whites to have any substance use

2000

Nationwide

Puerto Rican,

disorders. No significant findings were found for Puerto Ricans or other

[48]

Other Hispanic,

Hispanics compared with Whites. Acculturation predicted greater risk of

White

having a substance use disorder for all Hispanic groups. Cumulative exposure to traumatic events was a strong predictor of drug dependence. The exposure was lower among immigrants than natives. This difference appeared to contribute importantly toward accounting for observed nativity differences in drug dependence among Hispanic women. Binge drinking and alcohol dependence were higher in rural areas than in urban areas. However, drug use and drug-related problems were similar in both areas. Rural residents were more likely than urban residents to be recent immigrants and to have lower incomes and educational attainment. Co-occurring lifetime rates of substance use disorders with non-substance

Turner et al., 2006 [86]

South Florida

Cuban Other Hispanic

Spence et al., 2007 [83]

Texas

Hispanics, mostly Mexican

Vega et al.,

California

Mexican

2003 [73] Vega et al.,

Youth

use psychiatric disorders were 12.3% for the U.S.-born Mexican Americans Nationwide

Hispanic

and were 3.5% for Mexican immigrants. Compared to US-born Hispanics, foreign-born Hispanic were less likely to

2009

have dual diagnoses (OR = 0.234, p ≤ 0.0001) or any substance disorder

[76]

(OR = 0.261, p ≤ 0.0001), if they reported any lifetime substance use.

Blake et al., 2001 [65]

Massachusetts

Not disaggregated

Compared with U.S.-born youths, immigrant youths (particularly those living in the US for 6 years or less) reported lower lifetime and recent alcohol and marijuana use (p < 0.001). There was no difference in use of other illegal drugs between the two groups.

Table 1. Studies on Substance Use among Immigrants in the United States by Race and Ethnicity (Continued) Age Group

Citation

Study Location

Group Origin

Major Findings

Brindis et al. 1995

California

Hispanic White

Hispanic students engaged in a greater number of risk-taking behaviors than native Whites. Greater proportions of native-born Hispanic students,

[84]

as compared to Hispanic immigrants, reported use of alcohol and marijuana, whereas Hispanic immigrants were more at risk for unintended pregnancy and self-violence.

Dierker et, al. 2006 [88]

San Juan, Puerto Rico New Haven, CT

Puerto Rican

DSM-IV nicotine dependence was strongly associated with attentiondeficit-hyperactivity-disorder (ADHD) (OR = 20.1, CI = 2.39–169.12), alcohol abuse/dependence (OR = 19.5, CI = 1.98–190.86) and drug abuse/ dependence (OR = 57.3, CI = 8.86–370.5). Yet, the association between ADHD and nicotine dependence was significant only for the San Juan site

Frank et al., 2007 [67]

California

Asian, Black, Hispanic, White

Hispanic adolescents were less likely to engage in substance use than White adolescents. Yet, third-generation Hispanics were not different from Whites. Asians demonstrated lower risk of substance use compared to Whites. There was no difference in substance use between Black and White adolescents

Gfroerer and Tan, 2003 [68]

Nationwide

not disaggregated

Prevalence rates of substance use were lower among foreign-born youths than among U.S.-born youths (p < 0.05), especially for youths aged 16 to 17 years. Foreign-born youths who had been in the US for less than 5 years had lower prevalence than did U.S.- born youths. The rates of use for foreign-born youths in the US for 10 or more years were not different from the rates for U.S.-born youths.

Khoury et

Florida

Black, Cuban

Compared to Black and foreign-born Hispanics, White and U.S.-born

Other Hispanic, White

Hispanics had the highest lifetime and past-year prevalence rates of substance use. Cuban American girls had higher lifetime prevalence rates for alcohol use than girls in the other ethnic groups. Cuban American boys had the largest percentages of alcohol heavy use, whereas White boys had the largest percentages of heavy cigarette smoking and other illicit drug use.

Not disaggregated

Individuals who spoke English at home were more likely to use drugs during the preceding 3 months (OR = 1.28, p = 0.000) compared to those who spoke a language other than English at home.

al., 1996 [70]

Saint-Jean et al., 2008 [72]

Florida

Age Group

Citation

Study Location

Group Origin

Major Findings

Tonin et al., 2008 [59]

A southwestern state

Hispanic

Acculturation and gender interacted with attitudes towards drugs to predict current alcohol, inhalant, and marijuana use. The effects of attitudes on alcohol and inhalant use were stronger for girls compared to boys.

Vega and Gil, 2005] [74

Florida

Hispanic

Ethnic differences existed in rates and progression of tobacco use to other drug use or dependence, with African Americans and foreign-born Latinos having larger proportions of non-smokers and lower rates of persistent use compared to White Americans. The odds of progression to marijuana use or dependence by later adolescence were highest (OR = 4.9) among persistent smokers but not significant for foreign-born Latinos.

Vega et al.,

Nationwide

Hispanic

African Americans and Hispanic immigrants had lower risk of smoking

2007 [75]

a

OR: odd ratio.

initiation and tobacco dependence. However, adolescents who initiated smoking shared increased risk for substance use disorders and other psychiatric disorders regardless of race and ethnicity.

Warren et al., 2008 [77]

Arizona

Mexican

There was no difference in lifetime substance use prevalence between U.S.-born and foreign-born Mexican pre-adolescents. Mexican preadolescents who were reared in single, blended, nuclear, and extended families reported a similar prevalence of lifetime substance use.

Willgerodt and Thompson, 2006 [60]

Nationwide

Chinese, Filipino, White

Ethnicity did not predict substance use; however, generational status did among Chinese and Filipino adolescents. Substance use by generational status among Euro American adolescents was not compared due to the small number of first- and second-generations within the group.

Sun S. Kim, David Kalman, Gerardo Gonzalez et al.

254

Table 2. Group Differences in Substance Use Disorders by Nativity and/or Acculturation Ethnic Origin Mexican

Substance Use Disorders Alcohol

Any drugs

Cuban

Puerto Rican

Any substances Alcohol Any drugs Any substances Alcohol

Nicotine Any drugs Any substances Other Hispanics Hispanics

Asian

Any substances Alcohol Nicotine Marijuana and other drugs Any substances Alcohol

Black White

Any substances Alcohol

Any drugs

Any substances a

Author and Year Alegria et al., 2008 [63] Borges et al., 2006 [61] Burnam et al., 1987 [78] Caetano et al., 2008 [85] Grant et al., 2004 [69] Vega et al., 2003 [73] Alegria et al. 2008 [64] Borges et al., 2009 [66] Burnam et al., 1987 [78] Grant et al., 2004 [69] Vega et al. 2003 [73] Alegria et al. 2007 [63] Ortega et al., 2000 [48] Alegria et al. 2006 [62] Alegria et al. 2006 [62] Alegria et al. 2007 [63]

Differed by U.S. Nativity? Yes Yes Yes Yes Yes Yes Yes -a Yes Yes Yes -a No Yes Yes -a

Differed by Acculturation? -a Yesb Yesc Yesc only for men -a -a -a Yesd Yesc -a -a Noe Nof -a -a Noe

Alegria et al. 2006 [62] Alegria et al. 2008 [64] Dierker et al., 2006 [88] Dierker et al., 2006 [88] Alegria et al. 2008 [64] Dierker et al., 2006 [88] Alegria et al. 2007 [63] Ortega et al., 2000 [48] Alegria et al. 2007 [63] Ortega et al., 2000 [48] Vega and Gil, 2005 [74] Vega et al, 2007 [75] Vega and Gil, 2005 [74]

No No No No No No -a No -a Yes No Yes Yes

-a -a -a -a -a -a Noe Yesf Noe Yesf -a -a -a

Breslau et al., 2007 [87] Vega et al, 2009 [76] Chae et al. 2008 [80]

Yes Yes Yes

Yesb -a -a

Breslau et al., 2007 [87] Alegria et al. 2006 [62] Alegria et al. 2008 [64] Grant et al., 2004 [69] Alegria et al. 2006 [62] Alegria et al. 2008 [64] Grant et al., 2004 [69] Breslau et al., 2007 [87]

Yes Yes Yes Yes Yes Yes Yes Yes

Yesb -a -a -a -a -a -a Yesb

no reports were available for differences; b acculturation was measured by age at immigration and length of residency in the US; cacculturation was assessed on a composite measure of multi-items; d acculturation was measured by migration work experiences in the US; eacculturation was measured with age at immigration; facculturation was assessed with use of English vs. Spanish language;

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Differences in Substance Use Disorders by Nativity and/or Acculturation Table 2 summarizes findings for racial or ethnic groups whose members demonstrated differences in substance use disorders by nativity status (natives vs. immigrants) and/or acculturation level (high vs. low). Although acculturation was often used to examine differences in substance use disorders within a racial/ethnic group, except for two studies [78, 85], the variable was usually assessed on a proxy measure such as language use [79] and age at immigration [63, 87]. The two studies used a composite measure of acculturation covering language used, media preference, food preference, ethnic identity, and other aspects of daily life. The findings for each racial/ethnic group are summarized below. Hispanic Americans. Hispanic Americans represent a diverse population with many ethnic groups, including Mexicans, Cubans, Puerto Ricans, different South and Central American Countries, and Spain. Mexican Americans had been studied most frequently (n = 11) and findings were consistent across studies: Mexico-born adults were less likely to have alcohol and drug disorders than U.S.-born Hispanic adults in general and U.S.-born Mexican adults in particular. However, Mexican immigrant youths did not differ in rates of substance use and substance use disorders from U.S.-born Mexican youths if they had been in the US for 10 or more years [68]. Mexican pre-adolescents also had similar lifetime prevalence of substance use regardless of their birth place [77]. Similar to findings for Mexicans, Cuban immigrant adults had lower prevalence rates of substance use disorders than their U.S.-born counterparts [62, 79]. Cuban American girls, particularly those born in the US, reported higher lifetime prevalence rates of alcohol use than girls in any other Hispanic groups [70]. Similarly Cuban American boys were more likely to report heavy alcohol use than boys in any other Hispanic groups. Spanish-speaking Mexican and Cuban American adults were less likely to use marijuana and cocaine than their English-speaking counterparts [79]. Unlike other groups of Hispanic origin, Puerto Ricans [48, 64] did not present any differences in substance use and/or its related disorders by their nativity status and/or acculturation level. Amaro and others [79], however, reported significant differences in marijuana and cocaine use between Spanish-speaking and English-speaking Puerto Rican adults although this latter study was conducted about a decade earlier than the two studies reporting no difference. Differences in acculturation measurement might have contributed to the inconsistency of findings across studies and more studies are needed before any conclusion can be drawn about Puerto Ricans. Of note, Alegria and others [63] reported that coming to the US after age 25 years seemed to offset the increased risk of substance use among Hispanic immigrants regardless of ethnic origin even after they had been exposed to neighborhood drug use. European Americans. European Americans had been studied second most frequently (n = 9) and findings were consistent across studies that European immigrants had lower rates of substance use disorders than their U.S.-born counterparts. However, no single study could be identified that had ethnic-specific information about any groups of the population. All the studies grouped all immigrants from Europe into a single racial category ―White‖ and the majority of the studies compared prevalence rates of substance use and/or substance use disorders for the group with those for Hispanic and/or other racial groups. The study by Breslau and colleagues was the only one reporting significant differences in substance use disorders among European immigrants by acculturation level [87].

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African Americans. Four studies had specific information on substance use among African immigrants in the US [67, 70, 82, 87]. Most studies compared prevalence rates for the group with those for other racial/ethnic groups. Breslau et al. [87] found significant differences in this group by nativity status and acculturation level. Similar to findings for Hispanics and Europeans, African immigrants had lower rates of substance use disorders compared to U.S.-born African Americans. Findings were, however, inconclusive with regard to whether U.S.-born African Americans had lower rates of substance use and/or substance use disorders than U.S.-born European Americans or U.S.-born Hispanic Americans. Asian Americans. The study by Chae and others was the only one that presented specific information about Asian American adults [80]. In this study, Asian Americans who had a history of alcohol use disorders were disproportionately more often single, U.S.-born, male, and uninsured. Two studies had been conducted with Asian American adolescents: Asian immigrant youths were less likely to use any substances than U.S.-born Asian youths who in turn were less likely to drink alcohol or to smoke cigarettes than U.S.-born White youths [60, 67].

Gender Difference in Substance Use Disorders within the Immigrant Population For immigrants, substance use disorders are more common among males and, therefore, studies of substance use had been conducted primarily with male subjects. In the US – there are also gender differences in substance use disorders; however, percentages for alcohol, tobacco, and other drugs are much closer between males and females. Recent studies of women have brought attention to gender differences in biology related to substance abuse, epidemiology of the disorders, etiologic and treatment considerations, and psychiatric comorbidity [89]. In one study, it was found that women were more likely than men to (1) attribute the causes of alcohol and drug abuse to genetic disposition, family history or environmental stress, (2) perceive drugs as more powerful, (3) perceive a higher prevalence of substance abuse, and (4) believe prevention and treatment are more effective [90]. On the other hand, there was no significant difference in individual factors: men and women equally attributed lack of moral character and willpower as causes of substance abuse. There are many factors for the lower rate of substance use among females. Although many factors differentiate women from men, one factor of major importance is the societal response to women with substance use disorders. Women experience more social disapproval of substance use and are more stigmatized for the use than men [89]. The striking gender differences in substance use disorders that are often found in Asia and Latin America may be in part related to this societal factor. However, when female immigrants from these regions acculturate into American culture that has less strict gender-role proscription against female substance use; they and their female children are more likely to initiate substance use. This premise is supported in studies of substance use among immigrants. Vega and colleagues [91] found that the combined effect of U.S. nativity and acculturation on drug use, was greater among women (adjusted OR = 29.3) than among men (adjusted OR = 7.4). Similar findings are also reported in studies with Asian immigrants. Acculturated women are about five times more likely to smoke cigarettes compared to Asian culture-oriented women [92]. Regardless of racial and ethnic origin, there is a trend among boys and girls aged 12 to 17 years toward

Substance Use Disorder among Immigrants in the United States

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comparable rates of initiation and use of alcohol, cocaine, heroin, and tobacco [93]. If this trend continues, over time there may be a narrowing of the male-to-female prevalence ratios of substance use in the older age groups.

Studies on Substance Use Disorders in Relation to Suicide among Immigrants An additional computer search was conducted to identify studies on substance use disorders in relation to suicide among immigrants. However, most of the studies were conducted with immigrants in European countries [94-96]. Studies with immigrants in the US were very limited. Most European studies reported higher suicide rates among immigrants, which was attributed, in part, to their higher rates of substance use. In contrast, studies with U.S. immigrants generally examined suicide in relation to acculturative stress or depression [97-101]. Only one study examined suicide in relation to substance use [3]. The study reported that among Latino adolescents, immigration generation status predicted the risk of suicide attempts, problematic alcohol use, repeated marijuana use, and repeated other drug use. However, the direct effects of generation status on suicide attempts became nonsignificant (0.11 and 0.15) for later-generations (second and third) when substance use variables were included in the model. The authors suggested that substance use mediate the effects of generation status on suicide attempts [3].

PART III. CONCLUSION More than half of the studies (19/32, 59.4%) were conducted exclusively with Hispanic group. The remaining studies also largely compared prevalence rates of substance use disorders between Hispanic and European Americans. Hispanic immigrants, except for Puerto Ricans, were less likely to have substance use disorders than U.S.-born Hispanics. Studies on African, Asian, and European immigrants in the US were extremely rare and hence, no conclusion can be drawn about them. It is crucial to examine whether African, Asian, and European immigrants follow the same trend toward increased risk of substance use disorders as that has been observed among immigrants of Hispanic origin in general. It would also be informative to better understand how gender moderates the process as discussed with smoking among Asian Americans [102]. There is a need to better understand rates of substance use, abuse, and dependence, and progression among immigrants in general and immigrants of African, Asian, and European ethnic subgroups. Except for Mexican, Cuban, and Puerto Rican, Hispanics from other ethnic origins were often grouped together as Hispanic others or other Hispanics without country of origin or racial specific information [48, 68]. Similar to Hispanics, immigrants from Africa, Asia, and Europe comprise complex and heterogeneous groups and information on correlates and comorbidities of substance use disorders within and across ethnic groups of the populations may help guide prevention and treatment interventions for respective ethnic groups. The arbitrary racial categorization of these groups may not have any biological or cultural implications in understanding of substance use and its related disorders.

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Similar to studies with immigrants in other health areas, acculturation is the most predominant psychosocial and cultural variable in studies of substance use disorders among immigrants. Despite the continuous accumulation of health research on acculturation, the concept remains ambiguous and complicated. Researchers continue to debate whether acculturation is appropriate as an explicatory construct to account for differences in substance use disorders among immigrants. Many suggest a cautious interpretation in the effect of acculturation on substance use disorders because the variable has a strong interaction effect with other sociodemographic and socioeconomic factors. For example, Amaro and others [79] found significant interaction effects of language use that was used as a proxy measure of acculturation with education, sex, marital status, and place of birth. Instead of the ambiguous term acculturation, marginalization or downward social mobility may be the true underlying process whereby immigrants learn the dysfunctional behaviors of social outcasts in the host country. The relatively lower prevalence of substance use disorders among immigrants during first 15 years after migration to the US may be related to time needed for immigrants to be naturalized as a U.S. citizen. The threat of deportation may serve as powerful deterrents to experimentation with illicit substances and/or becoming dependent on substances [41]. It will be interesting to compare prevalence of substance use disorders among immigrants by U.S. citizenship and how much the citizenship alone can explain the difference when other confounding factors such as education and acculturation variables are adjusted for. It will be worthy to examine whether immigrants with U.S. citizenship are more likely to progress from substance use to abuse, and then to dependence compared with immigrants who don‘t have the citizenship. The latter group may be more likely to maintain the use within the socially acceptable limit or may be less likely to report use of any illicit substances. Future research in the following areas may help produce information necessary and crucial for the prevention and reduction of substance-related morbidity and mortality in immigrants and their offspring. First, there is a need for surveys with large representative samples of diverse subgroups of immigrant populations that yield ethnic- and gender-specific data for each group and compare findings by immigration generation status and acculturation level. It is also crucial to validate self-reported data with biochemical testing if possible because there is tendency to underreport substance use and its related disorders among immigrants because of the potential threat of greater legal sanctions among non-citizens as described above. In 2002, Johnson and colleagues indicated that validation studies of the quality of drug and alcohol self-reports among immigrant populations in the US and other countries have not been conducted [41]. We also failed to identify any studies that reported self-reports in conjunction with biochemical validation. Researchers should consider undertaking such validation with obtaining a Certificate of Confidentiality that guarantees exemption from any subpoenas of collected data. Second, researchers in future studies that examine substance use disorders in relation to acculturation must provide a conceptual definition of the term and utilize a standardized measure in order to enhance the credibility of findings and comparability across studies. Based on a review of 69 research articles between 1996 and 2002, Hunt and colleagues [103] expressed concerns that acculturation in health research seems to be based more on ethnic stereotyping than on objective representation of cultural differences. According to Olmedo, there are two key problems encountered in the definition of acculturation: (1) it rests on an a priori definition of culture, and (2) its contextual scope differs across disciplines [104].

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Future studies on substance use disorders in relation to acculturation should assess the concept on a standardized measure that was based on a clear conceptual framework. The measure should also have sound psychometric properties with the ethnic group under investigation. Finally, more cross-cultural studies are urgently needed that explore cultural norms of certain ethnic groups that serve as protective factors against substance use. This information can be used to develop interventions designed to foster the retaining of these protective norms within the immigrant community. It will also be interesting to conduct studies with a cohort of immigrants who are followed over time since their arrival in the US with the purpose of investigating how their perceptions of substance use change over time, what factors are associated with such changes, and how these factors are associated with their actual use of substances.

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In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 17

ALCOHOL DRINKING AND TREATMENT AMONG IMMIGRANTS FROM THE FORMER SOVIET UNION (FSU) IN ISRAEL: REVIEW OF RECENT PUBLICATIONS JANUARY 2007-JUNE 2009 Shoshana Weiss Alcohol Research Unit, Nahariya, Israel

ABSTRACT This chapter attempts to cover the current state of alcohol use among immigrants from the Former Soviet Union (FSU) in Israel, as a continuation of a previous publication which reviewed studies published in the professional literature (mainly in Hebrew) and referred to an earlier period from the beginning of the 1990s until 2006. This chapter reviews studies published (also mainly in Hebrew) from January 2007 through June 2009 and describes alcohol use patterns and treatment among FSU immigrants. As in the previous review, the present review confirms the findings that alcohol use among FSU immigrants continues to be more prevalent than among the general Jewish-Israel society and that FSU immigrants continue to be over-represented in treatment programs. Recommendations for future research activities include the need for a special research focus on specific groups of FSU immigrants not covered in current Israeli research.

INTRODUCTION Israel is a country of immigrants. It was founded in 1948 as a Jewish state with about 650,000 Jewish citizens (35% Israeli-born). The Israeli Law of Return, passed by the Knesset (Israel parliament) in 1950, enables any person who has at least one Jewish grandparent to be eligible for automatic citizenship. In April 2009 the number of Jewish citizens in Israel was 5,593,000, and additional 320,000 were non-Arab non-Jewish citizens from the Former

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Soviet Union (FSU) that are not ―halachically‖ Jewish (according to Jewish religious law) and not registered as Jews [1]. Since the end of communism and the dissolution of the USSR, about one million Soviet Jews and halachically non-Jewish members of Jewish households from the European and Asian republics of the FSU took advantage of liberalized emigration policies, and immigrated to Israel. The wave of immigration from this region began in 1989 [2, 3], as seen in Table 1. The total number of FSU immigrants who came to Israel in the immigration wave since 1989 is 991,347 and non-Jewish immigrants make up about 30% of this total. As the number of citizens in Israel was about 7,400,000 (including Arab / Druze residents) in 2008, the FSU immigrants who arrived since 1989 constituted about 14% of the total Israeli population. Most of these immigrants arrived from the European republics of the FSU, mainly Russia and the Ukraine. This wave also brought groups from Bukhara and the Caucasus. This large number of newcomers for such a small country like Israel would be equivalent to about 40 million immigrants which the USA would have absorbed. It is worth noting that FSU immigration occurred at the same time as a smaller wave of Ethiopian immigrants who exhibited totally different socio-cultural profile and needs, and constitute only 1.4% of the entire population [4]. Immigration has been described as an earthquake that causes major disruptions in a person's life, and an uprooting that may lead to huge problems. Immigration is an experience that involves many losses and changes: loss of employment, social status, relationships, financial security, familiar physical environment, familiar language and more. Many books, articles and newspaper reports have been published about the characteristics of the FSU immigration to Israel and the life of the newcomers in the absorbing society [e.g. 5-11]. Table 1. Immigration to Israel from the FSU Year 1948-70 1971-88 1989 1990 1991 1992 1993 1994 1995 1996 1997

Number of FSU immigrants 20,872 164,579 12,932 185,277 147,839 65,093 66,145 68,079 64,848 59,048 54,621

Year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Number of FSU immigrants 46,032 66,848 50,817 33,601 18,508 12,383 10,130 9,431 7,469 6,643 5,603

Sources: Data are taken from references 2, 3.

Overall, the immigration from the FSU is rich in human resources, although a relatively large portion of immigrants are employed in blue-collar jobs, particularly those with higher education, because the small Israeli labor market became oversaturated with a large number of professionals. These immigrants share a rich cultural heritage expressed in the importance of their children learning Russian language and literature, and as well as maintaining exclusive social relations among the immigrants. However, poverty and low socio-economic

Alcohol Drinking and Treatment among Immigrants from the Former Soviet Union… 269 status, life in densely populated apartments (three generations together), violence and delinquency among young immigrants and high rates of school dropouts are all evident. The immigrants from the FSU differ from the Israeli-born population in having smaller family sizes, more single-parent families, and especially in a heavy alcohol drinking culture. FSU immigrants left a country with well-known very high rates of alcohol consumption and alcohol-related health and social problems [e.g. 12-17]. Immigrants to Israel arrived at a country with a lower alcohol consumption rate. The claim that "Jews do not drink" was widespread in the FSU. However, alcohol use can be affected by the "immigration experience": the separation from familiar social networks, changing of environmental conditions, concerns about family members left behind, language barriers, loss of valued social and occupational roles, lack of sufficient economic resources, cultural dissonance, difficulties in adjustment to the Israeli reality and bureaucracy, and the need to cope with stresses. In the case of FSU immigrants, studies conducted from the beginning of 1990s until 2006 [18], showed that they did not adopt the drinking customs of the host country (Israel) and their patterns of alcohol use did not reflect those of their new location. Given the magnitude of the changes in the immigrants‘ lives one could expect immigrants from the FSU to have increases in social, health and psychological problems that contribute to alcohol abuse and related alcohol problems [18, 19]. The previous review published in 2008 [18] summarized studies (mainly in Hebrew) by Israeli researchers as well as reports and theses from the early 1990s through 2006. It provided information in English about alcohol drinking patterns and problems in the FSU immigrant community in Israel. The review noted that alcohol drinking among FSU immigrants was more prevalent than among the general Jewish-Israeli society. FSU immigrants also were over-represented as patients in alcoholism treatment. This current chapter attempts to review studies and reports published in Hebrew and English from January 2007 through June 2009 in Israel or by Israeli researchers. This review continues to provide data that updates the current state of alcohol use and treatment among the FSU immigrants in Israel. Books and journals in academic and institutional libraries, treatment centers reports and the Knesset's Information Center protocols and reports were reviewed. Information available on the Internet was also reviewed in order to check whether there are any significant differences in the current period (January 2007-June 2009) compared to the earlier period of the 1990s to 2006. The assumption has been that earlier trends identified up until 2006 [e.g.20] continue, with higher rates of alcohol consumption among FSU immigrants as compared to Israeli adolescents and adults.

EPIDEMIOLOGICAL ASPECTS Eight epidemiological studies in 12 publications published in 2007-June 2009 dealing with alcohol consumption were identified, most written in Hebrew. It should be noted that in all Israeli studies, respondents were instructed to disregard ceremonial use of alcoholic beverages. Table 2 illustrates these studies among immigrants from the FSU. Five publications published in this period referred to studies carried out in previous years and their results are in accordance with the findings and trends identified in the previous

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review: FSU immigrants have higher rates of alcohol use and related problems in comparison to native-Israelis [18]. One study [21] conducted in 2003 and published in 2007 reviewed 12 to-18-year old (245 Israeli-born and 120 FSU-born) at-risk (detached) youth in alternative education and training programs, street "drop-in" centers and organized evening street activities in the southern region and northern Haifa. It noted that FSU youth reported a significantly higher level of liquor use in the previous month, as well as binge drinking in the last month (Table 3). ―Detached youth‖ is defined as a population of adolescents with varying degrees of social detachment, including those who neither work nor study, those who work and study in special educational settings or those who are formally listed as students, but rarely attend school. Table 2. Domain, year of publication, reference and language of publication of the reviewed studies among FSU immigrants published in 2007-June 2009 Domain

Year of publication

Reference

Local study in the southern region and northern Haifa among at-risk youth National epidemiology study for the Ministry of Health among adults Local study in the city of Haifa among youth in relation to terrorism Local study in the city of Beer-Sheba among youth

2007

21

Language of publication English

2007

22

English

2008

23

Hebrew

2007 2009

24 25

Hebrew English

Local study in the city of Beer-Sheba among older people Local study in the city of Reshon Lezion among youth National epidemiology study for the Anti-Drug Authority (IADA) among youth and detached youth National epidemiology study for IADA among youth in relation to negative life events

2009

26

English

2007

27

Hebrew

2007 2008 2008 2008

28 29 30 32

Hebrew Hebrew Hebrew Hebrew

Table 3. Percentage of alcohol use and binge drinking in previous 30 days among at-risk Israeli-born youth and FSU-born youth Alcohol used at least once Beer Wine Hard Liquor Binge drinking at least once *p=<0.05. Source: Data are taken from reference 21.

FSU-born 65.8% 47.5% 51.7%* 39.2%*

Israeli-born 56.7% 46.9% 38.0% 28.2%

Alcohol Drinking and Treatment among Immigrants from the Former Soviet Union… 271 An article published in 2007 [22] summarized drinking patterns from the 2004 national health survey among 4,859 participants (including 844 FSU immigrants). Fifty two percent of the 4,859 adult participants reported any alcohol consumption in the prior year. About 3.6% drank 3 or more drinks on a single occasion at least once per week. Significantly higher rates of consumption of occasions of 3 or more drinks were found among FSU immigrants (6.4%) in comparison to native-Israelis (4%), those from American-European origin (4%), those from Asian origin (2.7%) and among those from African origin (2.6%). This higher consumption was more common among 21-44 year old males (7.9%) than women (1.3%). However, 10.1% of 21-44 years old FSU immigrant males reported drinking three drinks or more on a single occasion at least once per week. As far as alcohol disorders are concerned, the likelihood of an alcohol disorder was higher among FSU immigrants compared with their native-Jewish Israeli counterparts. DSM-IV criteria for alcohol abuse or dependence were met by 215 participants, of which 52 were FSU immigrants. Doctoral research [23] conducted in 2004 and published in 2008 investigated the consequences of acts of terrorism on drug and alcohol use among adolescents. About 960 10th and 11th grade students from Haifa participated in the study that included 211 FSU immigrants (23.1%). They answered separate questions about their consumption of beer, wine and distilled spirits within the last 12 months on a 7-point scale (1=never to 7=30 or more times). A composite scale was created, combining maximum consumption of the three types of alcoholic drinks. FSU immigrants had higher drinking levels than Israeli-born adolescents (drinking scale means = 4.21 vs. 3.05 respectively). To measure binge drinking, the respondents answered how often they had 5 or more drinks within a few hours in the last month on a 5-point scale (from 1= never to 5 =6 or more times). Among drinkers, binge drinking was more prevalent among FSU immigrants than among native Israelis (binge drinking scale means = 1.65 vs. 1.33 respectively). Drunkenness in the last year was measured using a 5-point scale (1=never to 5=6 or more times), and these rates were also higher among FSU immigrants than among the native-Israelis (drunkenness scale means = 1.67 vs. 0.93 respectively). All these findings were significant (p<.001). Another study conducted in 2005-2006 and published in 2007 [24, 25] of 155 high school FSU immigrant adolescents and 326 Israel-born adolescents in the city of Beer-Sheba reported that the two groups had low levels of positive attitudes towards alcohol drinking. However, the immigrants had more permissive attitudes. A study of 197 older FSU immigrants (74 men, 123 women) median age 73, conducted in Beer-Sheba in 2005 and published in 2009 [26] revealed that men more than women used alcohol (35.1% vs. 2.4%, p<.01), believed they need to reduce their alcohol consumption and were more likely to be criticized and felt guilty about their drinking behavior. However, additional research is needed to understand the extent of excessive alcohol use among elderly FSU immigrants, so that special services can be developed to address quality of life needs. These findings, as well as the findings of the four other studies, support the conclusions of the previous review [18] that there continue to be higher rates of alcohol use among FSU immigrants in comparison to the Jewish-Israeli-absorbing society. A 2007 survey [27] of 615 Israeli-born and 246 FSU students from middle and high schools in Reshon Lezion noted that 40% of FSU immigrants reported consuming alcoholic beverages during the last year compared to 25% of the Israeli-born students. Again, this also supports a continued higher alcohol use rates among FSU immigrants.

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A comprehensive study of drug and alcohol use among FSU adolescents was conducted in 2007 [28-30] in six cities: Haifa and Karmiel in the north, Petach-Tikva and Hulon in the center and Beer-Sheba and Kiriat-Gat in the south. The numbers were adjusted to reflect the ratio of FSU immigrants in these cities and the ratio of immigrants from each FSU homeland (formerly Russian, Caucasian and Bukharin). Nearly 750 youth ages 12-18 participated in the study, of which 60% were students and 40% were detached adolescents. Half of the participants were boys and half were girls. Most of respondents were born in the FSU (89%), and half of them immigrated after 1996. Nearly 10% were born in Israel to parents immigrated from the FSU. Table 4 presents some drinking variables. It should be noted that the Table does not provide a comparison to the findings in the last published epidemiological national study in 2005 [31] among native-Israeli students, detached adolescents and FSU detached youth. Although the current study did report similar variables, there is a gap of two years between the two studies and there are major differences in sample sizes and in the situations of the detached youth. Detached youth in the 2005 study were in alternative learning and working situations while in 2007 most of them neither worked nor studied. Table 4. Percentage of drinking and drunkenness in the last year (2007) and in the last month by type of FSU youth

Any alcoholic drink Wine Beer Distilled spirit Drunkenness once Drunkenness 2-3 times Drunkenness 4-5 times Drunkenness 6+ times

The sample last year N~740*

Students last year N~450*

Detached youth last year N~290*

The sample last month N~740*

84%

80% 22% 43% 48% 12% 16% 11% 14%

90% 23% 40% 55% 12% 20% 17% 22%

60% 10% 28% 31% 14% 12% 3% 2%

22% 42% 51% 12% 18% 13% 17%

Source: Data are taken from reference 28. *The exact numbers of the sample and the youth groups were not presented in the study report [28]. The numbers presented here are calculated on the basis of various tables in the original Hebrew report.

More FSU adolescents drink distilled spirits (perhaps Vodka) than beer or wine (Table 4). This strengthens the conclusions that drinking alcohol and choosing this type of alcoholic beverage (distilled spirit) are both related to their culture of origin. It is evident (p<.001) that the percentages of drunkenness are higher among detached youth in comparison to students. Although alcohol use is a cultural norm of FSU immigrants and most of them have their first drink mainly in a familial framework (at home, at a family event), those who drink are significantly more likely to be boys (90% of boys drank in the last year compared to 82% of girls), aged 16-18 (64% of those aged 12-13 drank in the last year compared to 83% of 14-15 years old and 94% of 16-18 years old), detached after dropping out of school at grades 10-12, secular, living in single-parent families, having most of their friends from the FSU and wanting to stay separate from native-Israelis youth whom they feel rejected by. Therefore,

Alcohol Drinking and Treatment among Immigrants from the Former Soviet Union… 273 drunkenness may result from some of these factors. Binge drinking (consumption of 5 drinks or more on a single drinking occasion) once in the last month was reported by 14% of respondents, 2-3 times by 10%, 4-5 times by 3% and 6 or more times by 3%. Therefore, while most of FSU immigrants drink moderately, there is a significant group that drinks heavily and gets drunk 4 or more times (5%) and drinks five drinks or more on a drinking occasion (6%) [28-30]. Another important study conducted among Israeli-born and FSU immigrant youth referred to consequences of negative life events in addition to alcohol and other substance use [32]. A national sample of about 2,730 Jewish 10th and 11th grade high school students included 260 immigrants born in the FSU. It included 18 students (6.9%) who immigrated during the five prior years, 77 students (29.6%) who immigrated 6-10 years prior and 165 students (63.5%) who had immigrated more than 10 years prior to the study. About half of the respondents were boys and half were girls. The study reported that FSU immigrants drank more in the last year compared to native Israelis (p<.001). In Table 5, 51.4% of FSU immigrants drank beer at least once a month in the last year, 34% drank wine and 48.7% drank distilled spirits compared to 30.7%, 19.9% and 35.3% respectively of native-Israelis. Additionally, FSU immigrants tended to consume more drinks on their last drinking occasion (p<.001), as Table 6 illustrates: Only 14.3% of Israeli-born adolescents reported drinking 6 drinks or more compared to 24.5% of FSU immigrants. Table 5. Percentage of drinking in the last year among FSU immigrants and veteran Israelis

Drinking

Beer Wine Distilled Spirits

FSU N=259 Every day At least once a week 4% 26.6% 2.8% 15.1% 4.4% 21.4%

At least once a month 20.8% 16.2% 22.9%

Native Israelis N=2,446 Every day At least once a week 4.3% 12.2% 3.4% 8.8% 3.7% 12.9%

At least once a month 14.2% 7.7% 18.7%

Source: Data are taken from reference 32.

Table 6. Amounts of drinks consumed on a last drinking occasion among FSU immigrants and veteran Israelis in % Amounts Native Israelis N=2,471 FSU immigrants N=260

1 drink 22.8%

2-3 drinks 20.2%

4-5 drinks 12.2%

6-7 drinks 6.7%

8+ drinks 7.6%

19.7%

24.3%

14.3%

11.4%

13.1%

Source: Data are taken from reference 32.

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Table 7. Number of days of binge drinking (5+ drinks on a drinking occasion) in the last month in % No. of days Israeli-born N=1,862 FSU immigrants N=224

1 day 17.8%

2 days 5.9%

3-5 days 7.8%

6-9 days 3.0%

10+ days 2.4%

20+ days 3.2%

22.5%

9.2%

12.3%

3.9%

2.4%

5.0%

Source: Data are taken from reference 32.

To determine binge drinking, participants were asked how many days in the last month they had consumed 5 or more drinks on a single occasion. The results are presented in Table 7. FSU immigrants reported more days (p<.01) of binge drinking: 23.6% of FSU immigrants drank 3 days or more in the last month compared to 16.4% of Israeli-born. Furthermore, FSU immigrants reported more episodes of drunkenness in the previous year than native-Israelis (p<.001). Forty-four percent of FSU immigrants reported drunkenness at least 2 times in the last year compared to 31.2% of native Israelis. Driving under the influence of alcohol at least once in the last month occurred more frequently among FSU immigrants than among Israeli-born students. About 14.1% of Israeli-born students and 13.9% of FSU immigrants had a driving license. FSU immigrants drove more under the influence of alcohol (44% versus 22%) (p <.01), and reported traveling more in a car with a drunk driver at least once in the last month (34.5% versus 19.4%) [32]. Higher percentages of drinking and drinking related problems among FSU immigrants might reflect cultural differences [18] and also psychological distress, which has been found to be higher among adult and young FSU immigrants than among veteran Israelis and immigrants from elsewhere, and explained by the acculturation stress hypothesis [33, 34]. Psychological distress might be expressed in a cultural accepted domain (alcohol use) [28, 34], as students from FSU reported more stressful conditions such as poverty, victimization by violence, parental divorce and being removed from home than their Israeli counterparts [32, 34]. Again, the higher alcohol use patterns identified in the previous review continue after 2007. Table 8. Numbers of FSU immigrants in treatment and their representation in the total patient group, 2000-2008 Year 2000 2001 2002 2003 2004

Number of FSU immigrants 496 506 533 528 589

% of total patients 35.5% 35.4% 38.6% 32.6% 36.0%

Year 2005 2006 2007 2008

Number of FSU immigrants 544 534 442 400

% of total patients 30.7% 35.2% 25.1% 23.6%

Sources: Data are taken for years 2000-2005 from reference 18 and for years 2006-2008 from reference 36.

Alcohol Drinking and Treatment among Immigrants from the Former Soviet Union… 275

TREATMENT The public ambulatory centers for alcohol treatment began absorbing immigrants from the FSU in 1991 [18], and these immigrants continue to represent a significant portion of patients in treatment [35]. Table 8 presents the numbers of immigrants from the FSU in the alcoholism treatment program in the public outpatient treatment centers throughout Israel. As seen in Table 8, immigrants from the FSU continue to be over-represented in outpatient treatment in the last decade, although a trend started to emerge in 2007-2008 of somewhat reduced numbers and percentages. This can also be a result of recording (since 2007) FSU immigrants in some outpatient centers as those immigrated to Israel up to 5 years prior to treatment. However, these figures may still under-represent the actual situation because among the FSU immigrant community there is still resistance to entering treatment for alcoholism because treatment was equated with punishment in their homeland. In addition, there are still other barriers and obstacles encountered by FSU immigrants that restrict access to treatment services. These include fear of stigma ("All immigrants from the FSU are alcoholics", a sentiment that still prevails among native Israelis), lack of information about treatment options, reluctance to cooperate with Israeli Western-oriented group therapy treatment approaches, difficulty being emotionally exposed, the belief that their alcohol problem is not as serious as that seen in the FSU, and the belief that a person can manage his own problems by himself [18]. The representation of non-Jewish FSU immigrants in alcohol treatment in the public outpatient centers was recorded only up until 2003. No detailed demographic or socioeconomic variables specific to FSU immigrants are available in the annual reports of the public outpatient centers since 2004, and from 2009 no data specific to FSU immigrants in those centers are being collected. Up until 2003 their representation remained higher than their percentages in the immigration wave (42.4% in treatment in 2003) [18]. It is reasonable to assume that this finding continues in more recent years, consistent with data about drug addicts in treatment in 2006 [37-39]. From January 2002 to January 2006 572 lifetime heroin users (272 native Israeli and 300 FSU immigrants) were interviewed in three drug treatment centers located in the southern region in Israel. Almost all native Israelis identified themselves as Jewish, whereas only 66% of the FSU group did so. Thus, the wave of immigration from the FSU brought to Israel a significant number of non-Jewish persons who had in 2006 slightly higher rates of admission to drug treatment centers than their percentage in the immigration wave. Immigrants from the FSU with alcoholism create a particular challenge for the Israeli treatment system. In various outpatient centers, particularly in cities that absorbed large numbers of immigrants, special group therapy programs in Russian have been implemented. Although this had been a primary recommendation from a qualitative study of 25 alcoholics and homeless alcoholics in a special treatment program in a rehabilitation hostel [40], there is still no documented evidence that special programs in Russian for FSU immigrants have better treatment outcomes than the normal programs. Moreover, special heterogeneous groups of veteran Israelis and FSU immigrants treated alternately in both Hebrew and Russian are operating in Jaffa (part of Tel Aviv) as a unique practice in the Israeli treatment system [41]. In some treatment centers special alternative treatment methods more common to the FSU are provided. In the city of Hadera, where in 2008 about 47% of patients in the public treatment

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center were FSU immigrants, yoga and meditation were included into the recovery process targeted specifically at these immigrants [42].

CONCLUSION This chapter summarized findings related to alcohol use, alcoholism and alcohol treatment among Former Soviet Union (FSU) immigrants in Israel, relying largely on materials published in Hebrew, and not previously available to English readers. The review of articles and reports published from January 2007 through June 2009 began with epidemiological studies, and extended to data related to treatment issues, including identification of barriers to treatment for FSU immigrants. Considering that these immigrants came from the FSU where per capita consumption is the highest in the world [43], and a place with high mortality rates and reduced life expectancy that are connected to alcohol problems [44], it is not surprising that the two major findings, which emerge from this review, match the findings of the previous 15 years [18]: Alcohol use is more prevalent among FSU immigrants than among the Jewish-Israeliabsorbing society and therefore FSU immigrants continue to be over- represented in treatment programs. This persists even more than a decade after immigration. These findings may be the effect of cultural patterns of heavy drinking in their country of origin, and despite patterns of lower use in Israel. It may also be influenced by the impact of their "immigration experience". The chapter has practical applications for social workers and educators, who may incorporate this information into their practices. Indeed, some special education and prevention programs targeted to FSU immigrants and parents were implemented in 2008 [e.g. 45, 46]. But this is still not enough and it is essential to develop, implement and evaluate more prevention and treatment programs that meet the FSU immigrants' special needs. In addition, it is important to reverse the 2009 policy decision to not identify information about FSU immigrants in the annual reports of the public outpatient centers. This decision will not allow researchers to investigate the special characteristics and treatment needs of FSU immigrant alcoholics in any detail. Finally, Israel needs studies of children of FSU alcoholics, FSU prisoners, homeless persons, hospital admissions for alcohol-related trauma, alcoholrelated violence and crime, drinking and driving and other special social and cultural factors that impact on FSU immigrants alcohol use in Israel. Data concerning these problem areas are still absent in Israeli research.

ACKNOWLEDGMENT The author would like to thank Steven Schwartz, Ph.D. (Cand.), formerly New York State Office of Alcoholism and Substance Abuse, for his comments on drafts of this chapter.

Alcohol Drinking and Treatment among Immigrants from the Former Soviet Union… 277

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PART IV: MISCELLANEOUS

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 18

THE MOTIVES FOR MIGRATION Michal Sabagh and Barbara S. Okun Department of Sociology and Anthropology, Demographic Studies, The Hebrew University of Jerusalem, Israel

ABSTRACT This chapter addresses the question: "What are the Motives for International Migration?" By dividing the major theories in international migration to four levels of analysis, the authors put forth four interrelated answers to that question. The first suggests that international migration is the accumulated result of individuals' choices to improve their lives. The second argues that the motives for migration lie in differential wage and labor force opportunities between countries. The third emphasizes the importance of social networks as links between the first micro- and second macro-level explanations. Finally, the fourth answer stresses global structural differences between world regions. This theoretical review includes world wide examples and is preceded by a short description of major periods of migration in the modern world.

INTRODUCTION According to United Nations estimates to the year 2010, there will be a stock of 214 million international migrants [1]. For most people, immigration means severance from their home-land, community and family and arrival to another culture, language and a different set of values. In all cases, the immigration experience is a significant event that influences every aspect of the individual's life. What can explain this action? What are the motives to international migration? Is it a rational decision made by individuals in order to improve their quality of life, their income and their future? Or are international migration flows the result of global processes, which were associated with colonialism, global economic forces and international agreements? Perhaps there are important links between individual will and macro forces: is immigration embedded in social networks and motivated by family connections?

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In this chapter we will review four levels of analysis of the migration phenomenon. The micro-level model is a classic economic framework of analysis of international migration. According to this model, individual rational actors migrate as a result of cost-benefit calculations – they migrate if they expect a positive net return in terms of future income. This rational decision is made in a macro-context of wage gaps between developed and developing countries. The social-networks links micro and macro levels of migration theory. This level suggests a structural explanation that examines the motives to migration through the family and community units. According to social networks scholars, the decision to migrate is made by household units in order to maximize economic benefits. At the global level, we will introduce another structural argument that divides the world into three dependent components. The global point of view argues that the penetration of capitalist economic relations into non-capitalist or pre-capitalist societies creates potential emigrant populations.

MIGRATION IN THE MODERN WORLD The phenomenon of migration is almost as old as Human Sapiens. In recent years, research has documented what can be understood as the first migration in the history. Paleoanthropologists and genetic researchers have found genetic and fossil evidence suggesting that the origins of the modern human is in Africa, and that he migrated from there to Europe and Asia [2; 3]. In what can be considered more recent narratives, we find evidence of early migration in the Lord's commandment to Abraham 'Get thee out of thy country, and from thy kindred, and from thy father's house, unto the land that I will show thee' [4], Abraham is only one of many Biblical heroes who left their homeland in order to find food and prosperity in other countries. The history of international migration in the modern world was divided by Massey [5] into four periods. The first is the Mercantile Period, between 1500 and 1800. This period was characterized by European out-migration, which accompanied colonization and economic growth under mercantilist capitalism. European emigrants settled in North and South America, Africa, Asia and Oceania. An important component of this period was labor migration from East Asia to the Americas, in addition to the ten million slaves who were forced to migrate from Africa. During the second period, known as the Industrial Period, between 1800 and 1925, approximately 50 million people emigrated from industrialized Europe (mostly from Britain, Italy, Norway, Portugal and Spain) to the New World colonies (USA, Argentina, Australia, Canada and New Zealand). European population growth, industrialization and urbanization accelerated emigration from the Old World to the New World. A rise in real wages in Europe made the emigration process more affordable, as more potential emigrants could finance transportation and resettlement in the New World [6]. The third period of modern migration, between the mid 1920's and the early 1960's, was referred to by Massey as the period of Limited Migration. Beginning with the end of the second period, and the onset of World War I, there was a reduction in the size of immigration flows. Following this, the third period was characterized by restrictive migration laws that were passed in important receiving countries such as the USA. In addition, the outbreak of the Great Depression brought world population movement to a nearly complete halt. Following

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the Second World War, there were flows of refuges, but not in the volumes characterized in previous period. The period of post-industrial migration began in the 1960's has broadened the international migration to other sending countries outside Europe. Since 1960, there has been a movement of people from countries in early stages of industrialization to post-industrial countries. The new emigrants were coming from Africa, Asia and South America. The set of receiving countries was also widening to Western Europe, especially to Germany, France, Belgium, Switzerland and the Netherlands. Several million emigrants from North African countries such as Morocco, Tunis and Algeria continue to leave the Maghreb mostly to Western Europe countries such as France [7]. After the oil crisis of the 1970's, the Persian Gulf region was also open to receiving migration flows. By the 1980's industrialized countries such as Singapore, Hong Kong and Korea also joined the circle of migration receiving countries. At about the same time, growing numbers of asylum seekers and refugees migrated from East to West Europe [8]. This phase was followed by flows of refugees from Croatia, Bosnia-Herzegovina and Kosovo to Western Europe since the 1990's. Between 1960 and 2010 the stock of international migrants will almost triple itself, from 75 million in 1960 to up to 2141 million in 2010 [1]. The number of countries receiving more than 500,000 migrants has increased from 30 in 1960 to 64 in 2005 [9]. The United States has the largest fraction of immigration stock, followed by the Russian Republic, Germany, Ukraine, France and Saudi Arabia. Women comprised 50% of the international migration stock in 2005; this finding is differential in the regional level. As a result of ongoing wars, refugees have become an important component of the international migration stock, particularly in Africa and Asia. For example, there are about 1.5 million Iraqi refugees in Jordan, Syria and Egypt [10] since the war in 2003.

MICRO-LEVEL MODELS: INDIVIDUALS CHOOSE TO MIGRATE The roots of classical micro-level models of migration can be found in rational choice theories of economics [11]. The basic underlying notion of this theory is that the source of social change can be found in cost-benefits calculations made by individuals. "The elementary unit of social life is individual human action. To explain social institutions and social change is to show how they arise in as the result of the action and interaction of individuals" [12]. According to micro-level models, migrants are viewed as individual, rational actors, who decide to move based on cost-benefit calculations. Thus, microeconomic models suggest that "individuals migrate because it is in their benefit to do so" [13]. Individual migration behavior is guided by the search for better economic opportunities; individuals choose to migrate after considering the financial and legal constraints. Individual migration is guided by a comparison of incomes between countries. Cohen and Haberfeld [14] compared Former Soviet Union emigrants to the United States and Israel. Their research shows that the more educated FSU emigrants chose the United States as their destination, rather than Israel, because in the United States they had faster rates of earning increases. But it is not all about the money: According to Borjas [13] 1 This number includes the former USSR migrants after its disintegration in 1991. Before 1991, movement inside the USSR was considered as internal migration.

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there are also other aspects that are considered in the micro-level migration decision, such as weather in the receiving country, its culture and its crime rates. The development of the microeconomic model of individual choice focuses on immigrant characteristics (selfselection) and interactions with the host country and its natives (assimilation). Self selection theories [15; 16] address the question: who migrates? According to these theories, migrants are not randomly selected from the population; rather, migrants are those who expect to benefit the most from transition. People will migrate to countries where returns to skills are compatible with their skill endowments. Those skills can be summarized as human capital which includes education, job experience and skills acquired through formal on-the-job training. Some of this human capital may be transferable to many types of jobs [17]. Scholars have focused on the educational component of human capital and its contribution to the ability and the motivation of an individual to migrate. According to Chiswick "among those with little schooling, the most able and the most highly motivated migrate, while among those with high levels of schooling the immigrants are drawn more widely from the ability distribution" [18]. Portes and Rumbaut [19] highlight the educational component of the self-selection process by comparing the educational level of immigrants in United States to that of their homeland. Their analysis showed that on average, immigrants to the United States from countries with low overall levels of education, such as India and Egypt, had high educational levels compared to the population in the countries of origin. In addition, Gould and Moav show that the probability of emigrating from Israel is 2.5 times higher for educated individuals than for those with less education [20]. These studies suggest that self-selection of migrants is at least partially based on higher-than-average levels of education in the country of origin. In contrast to these studies, there is the argument for "negative selection" of immigrants from Mexico to United States. Durand et al. [21], in a study that examines the profile of Mexican migrants to the United States, have found that the educational level of migrants is decreasing over time. The educational level is still high only because of the increase on the average education level in Mexico. Another aspect of the microeconomics model of individual choice in migration is the interaction of the immigrants with the host country and its natives: assimilation. One early definition of assimilation is: "a process of interpenetration and fusion in which persons and groups acquire the memories, sentiments, and attitudes of other persons and groups and, by sharing their experience and history, are, incorporated with them in common cultural life." [22]. There are several interpretations to the assimilation concept [23], including those that emphasize the adaptation of the "cultural concepts" of the host society by the immigrants group, as well as those that emphasize generational replacement as the driving force behind ethnic change. One aspect that we would like to focus in, as a component of the decision of an individual to migrate is his or her human capital and the value of that specific capital in the destination country. When arriving to a new country, an immigrant may discover that the human capital he brought with him is not applicable in the receiving country. For example, one form of human capital is language skills [24; 25]. Finding a job and becoming integrated in the economic and social life will be easier for those who speak the local language. Kossoudji [26], who studied the benefits of knowing English among Latin American and Asian immigrants in the United States, shows that there is an economic cost to English language deficiency. The lack of English proficiency among Latin American immigrants kept them in

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lower status occupations and income levels. We conclude that destination language proficiency is a component of human capital that affects the possibilities for assimilation.

MACRO LEVEL MODELS It is difficult to distinguish between the micro-level, which focuses on the rational choice of individuals, and the macro-level, which highlights the differential circumstances across countries as motivators for individuals to migrate. We can imagine a continuum line: on one side there is the micro level, where individual chose to migrate after making cost-benefit calculations, while on the other side there are the geographical differences in wages and labor force opportunities which are factors important to those calculations. The macro-level relates to people as if they are transportable goods. The assumption is that there is an "immigration market" – people, like other goods, are traded across boundaries in the international migration market [13]. The origins of neoclassical macro-level economic theories of migration lie in the theory of rural-urban migration [27]. The decision to migrate from rural to urban areas is related to two principal variables. The first is the rural-urban differential in real income, and the second is the lower probability of obtaining rural employment. The same principal is applicable to international migration: Neoclassical macro-level economic theory explains migration by geographical differences in wages and in the demand and supply of labor. The movement of immigrants will be from low wage countries to high wage countries and from countries with labor surpluses to countries with labor shortages. An example of the wage gap between a poor sending country and her richer receiving country can be found in a comparison of Mexico and her neighbor the United States. A 1996 survey of 465 Mexicans illegal immigrants who where caught and removed from United States showed that the Mexican immigrants reported weekly wages in their last Mexican job as $31 on average, while the weekly wage in their United States job was $278 on average [28]. Moreover, migrant flows can be very sensitive to changes in wage gaps. A study of undocumented migrants from Mexico to California between 1980 and 1993 found that when California's economy grew dramatically during the mid 1980's, there was a dramatic increase in the number of undocumented migrants from Mexico. When California's economy suffered during the early 1990's, there was also a decrease in Mexican migration to California [28]. Rosenzweig [29] focuses on the flow of students from developing countries to the developed world. Students from low-wage countries seek schooling in high-wage countries in order to increase their chances of obtaining a high wage job in the developed countries. Rosenzweig's finding shows that the top five sending countries of foreign students to the United States are located in Asia. These are countries with high population growth rates and low returns-to-education such as India and China. Student migrants, according to Rosenzweig, are motivated not by the return to education in their home country, but by the gaps in wage levels between developed and developing countries. The other aspect of macro level models is differential demand and supply for labor in sending and receiving countries. We will illustrate this point with an example from the German-Turkish experience [30; 31]. The surplus of labor supply in Turkey was the result of population growth coupled with reduced employment in the agrarian sector and an inability to

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absorb enough workers in the industrial sector. This surplus labor increased pressure to emigrate. On the other side, German economic development and the demand for additional working hands led the German government to approve the recruitment of Turkish workers. Organized Turkish labor emigration began with an agreement between German and Turkey on 1961. The number of Turkish workers in Germany increased from about 22,000 in 1963 to over 600,000 by the middle of 1974. Thus, geographical differences in the demand and supply of labor between the two countries led to a movement of population (goods) from areas of surplus labor to areas of labor shortage. Another important macro-level motive to migration is outlined in "Dual Market Labor Theory" by Michael Piore [32]. In addition to the push factors in the sending country such as low wages and unemployment, Piore emphasizes the pull factors in the receiving country. Countries with developed economies require foreign employees for employment positions that the local labor force no longer wishes to fill (positions that historically were occupied by teenagers, women and the rural population). The discussion of the supply and demand of labor force leads us to another central concept in macro level models: the labor migrant. Programs of mobilization of labor migrants (Guestworker Programs) became popular in the 1950's in both Europe and North America2. These programs can be characterized by differential legal and political status between migrant workers, on the one hand, and the citizens of the destination country and from other migrants, on the other hand. This differential status is based on the principal of rotation and the transitory nature of labor migration [5; 33]. For example, migrant workers may be denied voting rights, regardless of their length of stay in the destination country; thus, they are unable to influence policies towards guest workers and other issues regarding migration.

SOCIAL NETWORKS The analysis of social networks is suggested as a tool for linking micro and macro levels of sociological theory. The analysis of processes in interpersonal networks was suggested by Granovetter [34] as the most fruitful micro-macro bridge. Through these networks, smallscale interaction is translated into large-scale patterns that feed back into small groups. Social networks were found to be highly relevant for studies of international migration. The subject of social networks is not new in international migration research. As Tilly [35] determined, "To put it simply: Networks Migrate". Tilly's statement means that the migration process is driven by networks. This approach to migration theory takes as its starting point the assumption that the effective units of migration are neither individuals nor households, but sets of people linked by acquaintance, kinship or work experience. This approach fits in with the emergence of a relatively new stream in migration research which critiques the micro-level neoclassical approach. According to social network theory, the decision to migrate is not made by the isolated individual but within larger social units: households or entire communities, in order to maximize the economic benefit from migration. Stark and Taylor [36] have demonstrated the economic decision that was made by the villagelevel social network in Mexico. Households wisely match their members with the labor

2

Additional reading on labor migration into the Middle East: Massey et al ,1998.

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markets in which the returns to their human capital are likely to be greatest. Immigrants are not viewed as individuals with personal qualifications and skills, but as members of groups and participants in broader social structures In addition to macro-structural forces that enable and constrain the action of individuals, there is also internal differentiation by gender, generation and social class that places an equally powerful delimitation on individual action. [37]. From the point of view of the destination country, there are at least three levels3 of reception to the immigrant group [38; 19]: The first reception level is the government's policy toward different immigrant groups. The second reception level involves civic society and public opinion. Whereas some immigrant groups were accepted with open arms, others were rejected or treated with fear. The third reception level highlights the importance of networks in the receiving society. At this level of reception, according to Portes and Rumbaut [19], the characteristics of the immigrants‘ own ethnic communities matter. The character of the immigrant's community in the destination country will influence the immigrant‘s ability to integrate in the new labor market. Labor market integration is easier for those immigrants whose co-nationals in the destination country have already succeeded in establishing an economic network and are therefore able to offer job opportunities to newcomers An important work of research which undertakes the understanding of the roots and significance of social networks in the migration process is Cecilia Menjívar's [37] analysis of El Salvador's emigrants in the United States. Networks of friends and family emerged as the most significant organizing factor behind the massive Salvadoran migration in recent years. Menjívar traces crucial aspects of the Salvadorian immigrant experience. According to her, social networks were a critical component in all aspects of the migration process, including reasons for leaving El Salvador, the relationships with the decision-makers regarding migration, and the chances of surviving the long journey through Mexico. Furthermore, after arriving in San Francisco, social networks were embedded in all aspects of life: finding work, housing, and daily necessities. The importance of social networks among immigrants cannot be replaced by government social support intervention programs. The intervention that in the native's case is made by the state is made in the case of immigrants by the migrant's network. That is, the primary source of help and support for immigrants is their own informal social network [39]. This point highlights the importance of social networks as a motive for migration. Social networks play a part in the economic decision made by the community, the help that is needed during the travel, the connections that are necessary for integration in the new labor market, and finally the social support that is helpful for living in a foreign country. Massey [5; 40] has expanded the effect of the migration networks further, with the concept of cumulative causation. Over time, international migration tends to sustain itself in ways that make additional migration more likely. Every new migrant reduces the costs and the risks of subsequent migration for a set of family and friends, thereby leading to further migration. This, in turn, further expands the set of people with ties abroad and reduces costs for new set of people.

3

Portes and Rumbaut were referring especially to the labor market.

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GLOBAL LEVEL MODELS What is the difference between the macro level and the global one? "There is a world of difference between change in specific domains and change sweeping entire social structures and systems"[41]. The latter changes are regarded as a natural outcome of economic development under the market economy. Massey [42] identifies three features of capitalist growth which affect migration streams. The first is that economic growth is never monotonic; it is characterized by short-term cycles of expansions and contractions that in the long run evolve into positive growth. The second feature is that there is an uneven geographic distribution of growth. The process of economic growth varies across countries/global regions with different natural resources, population characteristics, physical capital, human capital, and traditions. The third feature of economic growth that promotes migration is the declining real costs of transportation and communication. Development makes international movement cheaper and easier and reduces the concerns of living abroad. Massey's classification serves as background for a common explanation for migration at the global level: world system theory. What began as Wallerstein‘s [43] framework for analyzing the expansion of global capitalism was adopted later by migration scholars as a structural-historical explanation to migration flows [44; 45]. An extensive division of labor is at the base of Wallerstein‘s theory. The division is made along geographic lines, and includes three typological areas: core-state, peripheral, and semiperipheral areas. The core-state is characterized by strong state machinery coupled with a national culture. Peripheral areas are characterized by weak indigenous states with little or no autonomy. Semiperipheral areas have moved from the peripheral condition but are not yet core-state; they serve to stabilize the world system by mediating between the two other types of areas. According to world system theory, the penetration of capitalist firms into non-capitalist or pre-capitalist societies creates populations that have the potential to migrate. In order to maximize profits, managers of capitalist firms from the core capitalist nations seek land, employees, material and markets in the peripheral areas. The entry of these firms leads to the feminization of the work force by creating job opportunities for women without creating job opportunities for men. As a result, these non-capitalist or pre-capitalist societies become "prone" to migration [40]. The transportation and communication foundations which were established in order to transfer goods from the developing countries to the developed countries also serve to increase the mobility of people. We discuss briefly the case of the Dominican Republic as a peripheral society and its historical relationship with United States as a core-state. The occupation of Santo Domingo by U.S marines occurred in 1965. As a result, there was an increase in political and economic ties between the Dominican Republic and the United States. The United States invested in Dominican agriculture (sugar cane, coffee, cocoa and tobacco), manufacturing and exports. That investment caused tremendous gaps in standard of living between Dominican rural and urban populations. Those gaps, together with a reduction in employment rates and greater inequality in the distribution of income led to a population that was "prone" to migration. The number of immigrants from the Dominican Republic to the United States increased from 4,500 between 1955-1959 to 58,000 between 1965 and 1969. This case exemplifies an unequal system of exchange of commodities, capital and labor produced by a core state and periphery society [46; 45].

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Massey [5; 40] emphasizes the security and military components that contributed to the creation of societies prone to migration in the developing countries. Core capitalist nations have the economic interest and the military means to preserve the global trading regime. The contact of the local population with military troops created matrimonial relations, and increased knowledge of the English language and American culture. These factors consequently increased the motivation to migrate to the U.S. from countries that were occupied by American troops.

CONCLUSION In this chapter we presented four theories which answer the question "What are the motives for migration?" at four different levels of analysis. Some of the theories highlight economic considerations while others emphasize social circumstances. Some theories focus on social structure, while others have functionalist roots. In addition to the social and economic factors, differences in migration policy across countries can influence migration opportunities by giving preference to one group of migrants over another. Wars and political circumstances also result in refugees seeking political asylum.

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International Migrant Stock, United Nations, Population Division 2008; http://esa.un.org/migration/ [2] Stringer CB, Andrews P: Genetic and Fossil Evidence for the Origin of Modern Humans. Science, 1988; 239: 1263 – 1268. [3] Li JZ, Absher DM, Tang H, Southwick AM, Casto AM, Ramachandran S, Cann HM, Barsh GS, Feldman M, Cavalli-Sforza LL, Myers RM: Worldwide Human Relationships Inferred from Genome-Wide Patterns of Variation. Science, 2008; 1100 – 1104. [4] Genesis Chapter 12. [5] Massey DS, Arango J, Hugo G, Kouaouchi A, Pellegrino A, Taylor JE. Worlds in Motion: Understanding International Migration at the End of the Millennium. New York, Clarendon Press-Oxford, 1998. [6] Hatton TJ, Williamson JG Migration and the international labor market, 1850-1939. New York, Routledge, 1994, pp 55-71. [7] Baldwin-Edwards M. Between a Rock and a Hard Place: North Africa as a Region of Emigration, Immigration and Transit Migration. Review of African Political Economy, 2006; 33:311-324. [8] Zaiceva A, Zimmermann KF. Scale, Diversity and Determinants of Labor Migration in Europe. Oxford Review of Economic Policy, 2008; 24(3):427-451. [9] Trends in Total Migration Stock. The 2005 Revision. CD-Rom Documentation. Economic and Social Affairs. United Nation. 2005. [10] Refugees International, Iraq. 2009. http://www.refugeesinternational.org/where-wework/middle-east/iraq

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[11] Coleman JS. The Mathematics of Collective Action. Chicago, Aldine, 1973. [12] Elster J. Nuts and Bolts for the Social Sciences. Cambridge, Cambridge University Press, 1989. pp 13. [13] Borjas GJ. Economic Theory and International Migration. International Migration Review, 1989; 23: 457-485. [14] Cohen Y, Haberfeld Y. Patterns of Self-Selection and Earning Assimilation among Immigrants from the Former Soviet Union in Israel and the US. Demography, 2007; 44: 649-668. [15] Roy, AD. Some Thoughts on the Distribution of Earnings. Oxford Economics Papers, New Series, 1951; 3: 135-146. [16] Borjas GJ, SG Bronars, Trejo SJ. Self-selection and internal migration in the United States, Journal of Urban Economics, 1992; 32:159-185. [17] Sicherman N. "Overeducation" in the Labor Market. Journal of Labor Economics, 1991; 9: 101-122. [18] Chiswick BR. The Effect of Americanization on the Earnings of Foreign-Born Men. Journal of Political Economy, 1978; 897-921. [19] Portes A. Rumbaut RG. Immigrant America: a portrait. Los Angeles: University of California Press, 2006; pp 67-101. [20] Gould E, Moav O. Israel's Brain Drain. Israel Economic Review, 2007; 5: 1-22. [21] Durand J, Massey DS, Zenteno RM. Mexican Immigration to the United States: Continuities and Changes. Latin American Research Review, 2001; 107-127. [22] Park RE, Burgess EW. Introduction to the Science of Sociology. Chicago: University of Chicago Press.1969. pp 360. [23] Alba R, Nee V. Rethinking Assimilation Theory for a New Era of Immigration. In the Handbook of International Migration: The American Experience. Edited by Hirschman C, Kasinitz P, DeWind J. New York, Russell Sage Foundation, 1999, pp 137-160. [24] Chiswick BR, Miller PW: The International Transferability of Immigrant's Human Capita. Economics of Education Review 2009; 28: 162-169 [25] Chiswick BR, Miller PW. Language in the immigrant Labor Market. In Immigration, Language and Ethnicity: Canada and the United States. Washington, DC: American Enterprise Institute, 1992. [26] Kossoudji SA: English Language Ability and the Labor Market Opportunities of Hispanic and East Asian Immigrant Men. Journal of Labor Economics, 1988; 6: 205228 [27] Todaro MP. A Model of Labor Migration and Urban Unemployment in Less Developed Countries. The American Economics Review, 1969; 59: 138-148. [28] Stalker P. Workers without Frontiers-The Impact of Globalization on International Migration. Colorado, Lynne Rienner Publishers, 2000, 21-34. [29] Rosenzweig MR. Global Wage Differences and International Student Flows. Brookings Trade Forum, 2006; 57-86. [30] Penninx R. A Critical Review of Theory and Practice: The Case of Turkey. International Migration Review, 1982; 16: 781-818. [31] Escobar A, Hailbronner K, Martin Philip, Meza L. Migration and Development: Mexico and Turkey. The International Migration Review, 2006; 40:707-718. [32] Piore M. Birds of Passage: Migrant Labor in Industrial Societies. New York, Cambridge University Press, 1979.

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[33] Kemp A, Raijiman R. Migrants and Workers: The Political Economy of Labor Migration in Israel. Van Lir Institute and Hakibutz Hameuchad Publishing House, 2008; 37-40. (In Hebrew) [34] Granovetter SM. The Strength of Weak Ties. American Journal of Sociology, 1973; 78:1360-1380. [35] Tilly C. Transplanted Networks. In Immigration reconsidered: History, Sociology and Politics Edited by Virginia Yans-McLaughlin. New York. Oxford University Press.1990: 79-95. [36] Stark O, Taylor EJ. Migration Incentives, Migration Types: The Role of Relative Deprivation. The Economic Journal, 1991; 101: 1163-1178. [37] Menjívar, C. Fragmented Ties: Salvadoran Immigrant Networks in America. Los Angeles. University of California Press. 2000. [38] Portes A.The Economic Sociology of Immigration: Essays on Networks, Ethnicity and Entrepreneurship. New York. Russell Sage Faundation.1995:1-41. [39] Hernández-Plaza S, Alonso-Morillejo E,Pozo-Muñoz C. Social Support Interventions in Migrant Populations. British Journal of Social Work, 2006; 36:1151-1169. [40] Massey DS. Why Does Immigration Occur? A theoretical Synthetic. In the Handbook of International Migration: The American Experience. Edited by Hirschman C, Kasinitz P, DeWind J. New York, Russell Sage Foundation, 1999, pp 34-52. [41] Vertovec S. Transnationalism. Oxon: Routledge, 2009. pp 22. [42] Massey DS. Economic Development and International Migration in Comparative Perspective. Population and Development Review, 1988; 3: 383-413. [43] Wallerstein IM. The Modern World-System: Capitalist Agriculture and the Origins of the European World-Economy in the Sixteenth Century. New York: Academic Press, 1974. [44] Portes A, Walton J. Labor, Class and the International System. New York: Academic Press, 1981. [45] Sassen S. Globalization and its Discounts: Essays on the New Mobility of People and Money. New York, The New Press, 1998, pp 31-53. [46] Pessar PR. The Role of Households in International Migration and the Case of U.S.Bound Migration from the Dominican Republic. International Migration Review 1982; 16:342-364.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 19

THE SOCIAL AND CULTURAL CONTEXT OF IMMIGRATION AND STRESS Katie Vasey and Lenore Manderson School of Psychology and Psychiatry, Monash University, Victoria, Australia

ABSTRACT In this chapter, we highlight the social and cultural factors that shape the experiences, responses to and understandings of stress among immigrant populations. In developing our argument, we focus on migration from resource poor to middle income and especially highly industrialized settings, with attention to both the short and longer term stress experienced by people in contexts where there are marked linguistic, cultural, material and economic differences between migrant and host communities. While we use examples from diverse settings relevant to a North American readership, we draw also on our work in Australia and elsewhere. As we will argue, the simple categorizations that underpin migration research, policy and programs, differentiating between voluntary/forced, regular/irregular, and internal/international migration, fail to encompass the complex paths that lead people to relocate, or to attend to the intrinsic stresses involved. As a result, they fail to provide the necessary evidence to support the development and delivery of appropriate social support services.

INTRODUCTION International migration has increased dramatically in recent decades, with the number of international migrants (those resident in a foreign country for more than one year) climbing from an estimated 84 million in 1975, to between 175 million and 191 million in 2005 [1, 2]. By 2008, the figure had approached 200 million or approximately 3 per cent of the world‘s population of 6.5 billion people [3], with an estimated 10 million officially recognized refugees worldwide and some 12 million residing illegally in the USA alone [4]. However, good statistics are absent in much of the world, particularly for illegal migration, and even estimates are unreliable.

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Even so, the rising numbers of people involved in international migration continue to shape and reshape societies round the world. Multiple and inter-related movements of people over large distances from diverse origins - economic, social and cultural – occur for many reasons: work, family reunification, study, retirement, or the search for protection from environmental and climatic changes, violent conflict, political oppression and human rights violations. Many who move are ‗forced migrants,‘ fleeing their homes and seeking refuge in another place. Their reasons for doing so, often not formally recognized by the international protection regime [5], include displacement from environmental devastation, natural disasters, and large-scale development projects, as well as protracted civil conflict. By 2006, the number of internally displaced persons (IDPs) – forced migrants who remain in their country of origin and are unable to cross international borders to seek asylum – grew to about 26 million [4]. Growing inequalities in wealth between the north and the south also compel increasing numbers of people to migrate. Migration is not just a reaction to difficult circumstances in home countries; it is also motivated by the search for opportunities elsewhere; in some contexts, now and historically, because of the economic value of remittances, it is actively encouraged. Further, movements between rich countries are also increasing, and the old dichotomy between migrant-sending and migrant-receiving states is diminishing. It is now difficult to distinguish between countries of emigration, immigration and transit, as a growing number of countries experience all types of migration, often simultaneously. In an increasingly interconnected world, expanding mobility has enabled in many long-term settler migrants, and those have been born or brought up in receiving countries, to continue relationships with countries of family origin. As an expanding literature illustrates, information and communication technologies, and cheap air travel, enable many to maintain significant transnational social, economic and cultural ties with people in country of origin and with fellow migrants elsewhere [6-11]. These factors change the nature of stress experienced by migrants, and how this might be addressed by host countries and their services. Contributing authors in this volume have drawn attention to the particular stresses and distress experienced by humanitarian immigrants, including refugees and asylum seekers. These categories of migrants emerge from juridical and administrative boundaries, which position people within a dichotomy of either involuntary or volitional migration; this in turn affects their rights, access to services, and wellbeing. As already suggested, however, migration movements are complex. The simple categorizations that underpin migration research, policy and programs, which differentiate between voluntary/forced, regular/irregular, and internal/international migration, fail to encompass the complex paths that lead people to relocate; and fail to capture the complexity of individual mobility and people‘s vulnerability in moving and relocating. Undocumented migrants include people with provisional, temporary or work visas, students, and those who simply overstay or are itinerant; many fall outside of bureaucratic focus, policy and programs. Those legally recognized as migrants also have diverse experiences, which may have very different effects on their capacity to settle, access appropriate services, and find a place locally to make their home. And while migration policy typically favors accepting those in good health and of reproductive age, with the social and economic capital to contribute to their place of resettlement, legal migrants include people with mental and physical health problems that emerge following migration; people unable to gain the employment and occupational status

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they expected at the time of their decision to migrate; and any immigrant whose life is unsettled with changes in family composition and structure (through marriage, births and deaths). Further, regardless of volition, all migrants necessarily leave family members and friends behind, with the stress associated in doing so. Our aim in this chapter is to highlight the social and cultural issues that influence the experiences, responses to and understandings of stress experienced by immigrants, which derive from migration and resettlement. Using examples from settings relevant to a North American readership, and drawing on our work in Australia and elsewhere, we attend to both short and longer term stresses, especially where there are marked linguistic, cultural, material and economic differences between migrant and host communities. For pragmatic purposes, we have divided the topic in relation to the chronology of departure and resettlement. Yet this is arbitrary and so problematic, for it assumes that immigration is a singular, linear and sequential process, rather than sets of overlapping processes [12]. At every point in movement and migration, people may experience uncertainty and stress. The uncertainties are not culture specific, but relate to the importance of establishing legal status and to the different rights that a particular status bestows, including access to settlement, health, education and welfare services, and employment. Vulnerability in any area leads to greater vulnerability across domains, in ways that are cumulative and compounding [13, 14].

CULTURAL ASPECTS OF STRESS AND DEPRESSION Changes in mood or state of mind are hard to define and label where differences pertain in vocabulary, etiology, social acceptance and management. For this reason, identifying ‗depression,‘ ‗anxiety‘ or other ‗mood disorders‘ such as stress, among people from diverse language backgrounds, can be problematic. Lay and biomedical discourses, symptomatology and expressions of distress, anxiety and depression, vary [15]. Considerable work has been undertaken in this field by medical anthropologists and transcultural psychiatrists, in mapping local etiology, terminology and expression against biomedical categories of mental illness and distress. Arthur Kleinman‘s work on explanatory models (EM) of illness has been especially influential in linking culture, health and illness [16, 17]. Kleinman and other researchers, who have described apparently culture-bound syndromes and culturally concentrated categories of distress, such as latah and amok, susto and nervios, highlight how local perceptions of the etiology of illness shape its management, accommodation, healing practices and prognoses, and how states of the mind, social and behavioral aberrations, may be interpreted, often somatized, accommodated within a local nosology, and so managed in ways that restore health and maintain the social order [18-21]. This work draws attention to the differences in understanding and managing poor mental health in different settings, although this can overemphasize cultural factors and divert attention from the social, economic, practical and structural determinants of health. Mental health problems are embedded in and take meaning from the diverse social worlds and economic circumstances of individuals and their communities [18, 19, 22-24]. Ideas about stress influence how people understand the experience, and shape when and from whom they seek care for any mental health problem, if at all, outside of the immediate family.

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To illustrate this, in a study exploring the relationships of mood, mood disorder and diabetes among different migrant groups in Melbourne, Australia, all participants provided a ―model‖ of distress that drew attention to the social context of their lives [25, 26]. This incorporated what they presented as a negative feedback loop: everyday circumstances led to stress, worry or anxiety, which lead to and complicated preexisting diabetes, precipitating further stress and depression. Study participants from each of the study communities (Pacific Islanders, Greeks, Chinese and Indians) routinely received this explanation too from their doctors when they reported signs of depression or changes in their physical health status. Recent research with Spanish speaking immigrants in Los Angeles, also on diabetes and depression, corroborates this understanding of lay perceptions of the reciprocal pathways of diabetes and depression [27]. Other studies also illustrate the importance of social and economic context to people‘s understanding of depression and anxiety; vulnerability, poverty, homelessness and isolation provide a powerful explanation of and provide an idiom to describe feelings of sadness and loss [28, 29]. At the same time, people often use physical health problems as an idiom of distress, reflecting in part the stigma associated with mental health problems and mood disorders. Through somatization, people complain of physical symptoms – often vague aches, pains, headaches or stomach ache - which may be caused by emotional or mental difficulties, and may be seen as more acceptable reasons to present to a doctor.

THE PROCESSES OF MIGRATING The mixed motives for and diversity of pathways of migration highlight the problematic nature of institutional categories, such as visa classes. Under the Geneva Convention, refugees are defined in relation to perceived and/or demonstrated persecution for reasons of race, nationality, membership of a particular social group, or political opinion [30, 31]. This privileges personal wellbeing over other considerations, including the roles of migrants as providers and family members [32]. However, the immediate causes of involuntary migration shape and are complicated by varying options for departure, including timing, costs, secrecy and forewarning. These factors add to stresses associated with the usual practicalities and uncertainties of migration: what to take, who to take, when to go, how to go, whether and how to gain documentation, legal status on departure, en route and on arrival. To this complexity, there is the added stress of official status, particularly for people who are stateless and therefore largely invisible. The insecurity of such strategies, the growing commerce in and cost of migration assistance – including the escalating number of private migration agents and migration lawyers - and the surveillance of those applying for or granted temporary visas, adds to stress and insecurity at multiple levels. The personal, economic, political and environmental conditions precipitating migration, willing or not, with or without official sanction and support, are inevitably stressful. The decision to migrate is complicated by different traditions of migration, the perceived capacity to move successfully to an environment that offers more than at home, and by personal networks and practical opportunities [33]. Again, it is not always helpful to differentiate migrants on the basis of volition, and paradigms both of asylum-migration and migrationdevelopment stress the complexity of motives that influence the decision to migrate and make official categorizations problematic [34]. Population movement from Zimbabwe to South

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Africa illustrates this interplay of events. Rural areas of Zimbabwe for over two decades have had recurrent drought, water shortages, poor crop yields, and poor prices for produce. In urban areas, people have dealt with increasing problems of homelessness and unemployment. Nationwide, increasing political instability and violence, economic volatility and hyperinflation, the collapse of essential services, and the increased incidence of HIV/AIDS, early death and growing numbers of orphaned children, have all led to overwhelming daily stressors. Those who can do so migrate, often on a temporary basis, usually to South Africa; by moving, they gain greater economic security despite continued poor living conditions, sometimes exploitative working conditions, and exclusion from government services [35-38]. In an informal sense, these Zimbabwean immigrants are refugees. Those who leave their homeland as refugees or asylum seekers, and seek assistance through this status, are particularly vulnerable to violence and intimidation [39]. People may have to flee without documentation, or for the safety of those left behind, may bury evidence of family status, fake their ethnicity, occupation and other kinds of identification. Routinely, people seeking asylum enlist the support of and pay people to smuggle them across borders. Those with sufficient access to capital to leave their country of origin in the first place still often arrive in transit countries, and later destination countries, without money and in debt. Journeys are dangerous, both to travelers as a result of mode of transport, physical border crossings and hostilities from border patrols, and because of the risks to the safety of family members left behind. Although humanitarian status may help an intending immigrant gain entry to another country, asylum-seekers experience considerable economic, social and political vulnerability and stress [40]. On arrival many asylum-seekers have little choice but to live in sub-standard housing and to work illegally, in sweatshops and as sex workers, for instance. Illegal travel and entry can also lead to the isolation of asylum-seekers from potentially supportive ethnic networks, particularly where smugglers choose the final destination, which may or may not be a country where there are significant populations of co-ethnics. However, many people are influenced by powerful social drivers to migrate which outweigh risks of being apprehended, detained, repatriated, imprisoned, or killed. An example relates to US border enforcements since 1993, which have had remarkably little influence on the propensity of Mexicans migrating illegally to the USA [24]. Many undocumented immigrants pay high prices to ‗coyote guides,‘ creating sophisticated criminal organizations that leave people open to exploitation. By crossing the heavily enforced boundary, the risks of apprehension, incarceration, deportation and death, and indebtedness, are high. Between 1990 and 2002, there have been more than 3000 dead and missing unauthorized immigrants and 15,000,000 apprehensions and deportations along the MexicanU.S. border alone [41]. Each undocumented and illegal move adds further to the possibility of exploitation, disadvantage and poor access to services, compounding the stress inherent in such moves. But political restrictions on immigration are far outweighed by economic and family-related incentives to migrate. The social capital of immigrants – networks, trust, and interpersonal obligations – help potential migrants to access modes of entry that minimize risk, such as with the assistance of smugglers and nonprofessional helpers personally known to undocumented migrants.

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ON ARRIVAL While transit carries high risks, the life of unauthorized immigrants working on the border is also precarious. This includes fear of authorities and the risk of legal interventions from authorities, the impact of illegal actions promoted as protective, the exploitation of illegal residents in relation to their living and working conditions and salaries, rent, and their lack of access to health, welfare, police and other services because of their illegal or indeterminate civilian status [41-45]. These stressors are mediated by various other community factors: both positive factors that draw on and build new resilience factors, and negative factors such as the effects of continuing poverty, exploitation, insecurity and separation from family in country of origin [10, 46]. For undocumented Latino immigrants, for example, illegal status and preoccupation with disclosure and deportation can heighten the risk for emotional distress and impair their access to any health care, particular quality care for mental health conditions [47]. As the incidence of illegal immigration suggests, many men and women leave their home countries by choice, either semi-permanently or for shorter stays, often on several occasions as labor migrants, guest workers, or in other ways to earn remittance. Some have legal protection, as has been conventional for guest workers in Europe, although this does not protect them from exploitation, discrimination, marginalization or loneliness. Others, such as commercial sex workers, underage immigrants, and those who migrate as spouses in arranged or assisted marriages, sometimes negotiated only through internet or family-based marriage brokering, and those who overstay legitimate visas, live with the constant anxiety of risk of apprehension and with no access to services or protection [46, 48, 49]. Illegal labor migrants, people who are trafficked (e.g. from Africa to Europe, and across Europe), and children born to undocumented workers, are especially vulnerable [50]. In Australia, there has been a growing reported trend for legal temporary immigrants (students) and skilled migrants to use their status to gain permanent residency, and from there to gain visas for family members to join them [51-53]. Resettlement is stressful regardless of motivation to migrate, ability to plan the move, and networks in place at point of destination. All immigrants face complex tasks as they work to build their lives in a country whose structure and workings they may know very little about. Immigrants from poor resource settings are often under particular pressure to ‗hit the ground running‘ to earn enough to remit money to family left behind and to succeed in the new setting [6, 54-57]. But for most migrants, there is strong emphasis on financial success, and educational and occupational successes are also tied to household economics and the capacity to build capital and remit funds. All experience stress because of their uprooting, but for many this is compounded by poor command of language in the country of resettlement, the need to accept welfare support or lower positions in the employment sector, isolation from the mainstream society, the absence of local ethnic communities, and a diminished social circle of friends and family. Those who speak a common language with the majority in the host country – English speakers in the US, Francophone Africans in France, Angolans in Portugal, and so on – generally fair better than those whose backgrounds are culturally and linguistically distinctive, if only because of their ability to negotiate everyday needs [58-60]. Language skills are imperative to success, as language competence enables settlers more effectively to negotiate life in the host society, leading to employment possibilities, improved

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socioeconomic status and financial situation, and general way of life [59]. By comparison, linguistic deficiency may leave some migrants with limited options and virtually unreachable by government, social or ethnic organizations and groups. In extreme cases, immigrants are exploited; others are uninformed, ignored and silenced. Often immigrant groups occupy low socioeconomic status, which leads to an increase in health problems and comparatively high rates of chronic illness and disability, difficulties in accessing appropriate health care, and difficulties in communicating with doctors and other professionals [61, 62]. In combination, language dispossession, low socio-economic status and poor familiarity of the operation of health, welfare and other services (e.g. housing assistance) inhibit access, particularly but not only for recent immigrants [63-65]. Limited access to health and welfare services or, where they exist, from social support organizations operating within the migrant populations themselves, is then reflected in social disadvantage and a poorer standard of living [49], which severely limits immigrants access to social capital, in terms of social connections, trust and social bonds (family, co groups) and their influence on quality of life and social bridges (with other communities). Conventionally, high levels of social capital have been tied to enhanced mental health and wellbeing, while low levels of social capital have been associated with increased vulnerability and anxiety [66, 67]. Although undocumented immigrants living in the United States (and elsewhere) typically lack access to health care, education and other services, those who are documented may also be discouraged from presenting for care if they belong to a community or network with other undocumented family or other community members; their registration in an administrative system potentially draws to the attention of authorities others who are illegal. Legal status places many immigrants at risk, vulnerable to abuse by authorities and private citizens. While over time immigrants adapt to their new settings as they are incorporated into the social and cultural world of the host society, assimilation is not always possible nor is it any longer an explicit goal of host governments. Multicultural societies such as Australia and Canada, and ethnic communities worldwide, point to the partial nature of relocation as people retain some aspects of their previous identity and attempt to recreate them in a home away from home, a process understood as ―homing‖ [68]. Some immigrants may never fully complete the migrational rite of passage, and forever be regarded and identify as immigrants, belonging fully to neither place nor, for many, the interim places of settlement between source and final place of settlement. This sense of homelessness or lack of place is not surprisingly most marked for people in situations of intermediate, temporary or protracted temporary migration. The stresses, including of deprivation, isolation, lack of ways of being productive, violence and uncertainty associated with intermediate and temporary migration, have been well documented. This is especially so for people in refugee camps, but applies also to people in processing camps and others staying in one place as they apply for residence permission or are relocated [69-73]. In many cases this results in a near-permanent sense of liminality, involving nearly constant presence of fear, anxiety, and stress [74]. For example, in Australia, people have been placed until recently on temporary protection visas (TPV) often continued to experience posttraumatic stress disorder, chronic anxiety and depression, with pre-migration trauma compounded by their indeterminate status [75]. Johnston and colleagues [76] document how social policies can lead to the visible (formal) and invisible (informal) exclusion of refugees, with unintended consequences for support networks between refugees on different visa categories, and for social relationships between refugees and the broader Australian

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community, as well as impacting upon remittances and other forms of transnational support [55].

HEALTH STATUS AND STRESS In addition to stressors associated with spatial relocation and integration into environments that are often foreign institutionally, socially, culturally, and linguistically, with time migrants must also come to terms with changing bodies due to illness, ageing and associated ailments. Research on immigrants in North America, Australia and Europe has focused on the largest, newest, and culturally most distinctive populations in migrantrecipient countries, on matters of health assumed to be most subject to different cultural interpretations and on early and short term resettlement [77, 78]. Women make up a significant number in most types of migration, partly due to the special migration category of ―women at risk‖ for those who lack the protection of male family members [79]. The most extensive research on women migrants relates to pregnancy and childbirth. This emphasis can be explained for several reasons. Most people migrate at an age that coincides with early reproduction, and so the needs of new immigrants and new parents converge. Secondly, traditional practices around pregnancy, birth and infant feeding have the potential for conflict between health services and women, and highlight the need for culturally sensitive care [80-82]. An additional reason for this attention is the risk of antenatal and postnatal depression, the difficulties in diagnosing and managing this for people with whom communication is difficult, and the added stressors for new mothers whose own mother, or other supporters, are absent [29, 83-85]. Consequently, considerable attention has been given to the importance of flexibility of doctors and midwives in ensuring that clients can follow cultural prescriptions associated with pregnancy and childbirth. However, little attention has been given to the welfare of women and children after these early critical months. Most informal support to young mothers is organized within friendship groups, or, like breast-feeding support groups and counselling, has been accessed primarily by middle class women. In consequence, immigrant women from new communities especially tend to have little social support as they deal with everyday stresses with infants and small children, and postnatal depression is less likely to be identified than among women well connected and supported. The increasing feminization of migration also has implications for the emotional and psychological health of immigrant women. One such example is of women‘s migration from Oaxaca, Mexico. Women often arrive in the United States, having left their children and other family members behind; opportunities to reunite with their children may be rare. Adaptive values help women, and all family members, deal with the stress associated with such separation. This is illustrated for Filipino migrant mothers working in the domestic service sector in France, among who ideas of being a good mother are reinterpreted as women fulfill their maternal obligations via their new role as primary economic provider of the family. Their physical absence from home is compensated by the remittances they send to their families, intended to sustain the basic needs of those at home [42]. Simultaneously, women who are left behind also must deal with the suffering of separation and persistent

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undercurrents of sorrow because the increasingly dangerous and intransigent US-Mexico border that makes family reunifications so difficult [10]. Difficulties also arise as migrant women must combine paid work and household responsibilities, regardless of age of children or household structure. Immigrant women are also vulnerable within households, including to gender-related and sexual violence from husbands and familiar others, partly reflecting the stressors on these families and the particularly powerless of women to find external support and leave if need be [86, 87]. Older immigrant women, and younger women married to older men, including through transnational marriage arrangements, take on care giving roles of ageing partners and parents, in addition to other domestic, labour force and care giving responsibilities (including caring for grandchildren), often without taking advantage of government provisions for care-givers (where these exist) because of their understanding of gender roles and their notion of entitlements as immigrants. They are, in consequence, often profoundly isolated [88]. Women to a larger extent than men are also subject to social pressure to look after their relatives back home, particularly children and elderly. Research on migrants and refugees whose families are scattered across different parts of the world and who engage in caring ―at a distance,‖ suggests that the obligation on kin to provide care and support and the practical difficulties of doing so while living transnationally entails great emotional stress [89]. Young people and their parents also experience pressure. The children of immigrants, both those who have migrated when young and those born after their parents‘ migration, are typically expected to perform well in school and take advantage of the opportunities afforded them through migration, although those living in poverty may have relatively few resources to study, lacking a dedicated study space or a home computer, for instance. They may be under stress at school also, as a result of racism and school bullying, reflected in depression, violence, and the misuse of alcohol and drugs. Young people must also negotiate with their parents around personal freedom, values, dress and sex [90-93]. Conventionally, too, children provide parents without language skills with help in translation and interpretation, again placing all family members under stress. Stress and depression is also components of poor health, and with ageing, this is increasingly common. Recently arrived older immigrants are an especially vulnerable population who face many risks associated with their health and well being, related to social isolation, mental health vulnerability, the expectation of family care, cultural barriers to using aged care services lack of knowledge of services, fear of using services, and lack of ethnospecific services [94]. But cultural and social factors influence long-term settlers as well as recent migrants as they deal with ageing and declining health. Australian research illustrates that immigrant participants were familiar with ―depression‖ as an illness and with stress as a cause, symptom and consequence of other illness and other circumstances, because of their exposure to a range of health communication strategies concerning mental health [25, 26]. They were not necessarily aware of its diagnostic specifics, however. Consequently, some used the term depression when speaking of sadness, stress, distress, worry, and tiredness and lethargy, not only to physical disease but to wider life circumstances, and situated their emotional wellbeing in a broad social context. Distress and depression, as well as poor physical health, impacted on people‘s ability to carry out everyday living tasks and to contribute to family and social life. This contributed to their social isolation and unsettled self-identity, resulting in feelings of personal inadequacy, loss and further distress. Some were reluctant to speak of stress or depression because of the

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associated stigma, and focused instead on distress linked to concrete changes in life circumstances and sadness associated with tragic losses. These life adversities, traumas, disruption and multiple losses, not surprisingly, often occurred long after and were often unrelated to migration: unemployment, indebtedness, loss of a spouse, and so on. Again, in line with the propensity to somatize rather than to speak directly of mental health problems, as discussed earlier, participants were also more likely to speak of their physical rather than mental health status to doctors and family members, as an idiom of depression [95-97]. This is not unique to immigrants from cultural backgrounds especially distinct from that of the majority population. Stigma and shame are commonly and widely associated with mental health problems and their manifestations – the abuse of illegal drugs, alcohol and prescribed medicines, smoking, domestic violence, eating disorders, suicidality, and social pathologies, for example.

CULTURALLY APPROPRIATE RESPONESES All countries with major immigration programs have recognized the importance of providing services to people and communities of diverse racial, ethno-cultural and language backgrounds [77, 98]. As discussed above, immigrants from cultural and linguistic backgrounds distinct from the host society are generally underserved by local health care and other social services, experience unequal burdens of disease, confront cultural and language barriers to accessing appropriate health care, and receive a lower level and quality of care when they do access health care services compared to the average population [77, 98-100]. But there is often poor understanding of ―cultural‖ issues and poorly informed expectations of recent immigrants by health professionals and other service providers. In response, there have been various handbooks and guides aimed at ensuring ―cultural competence‖ so that appropriate quality health care is provided for immigrants. Much of this literature assumes that access to health services can be enhanced through cultural competence, with the assumption that some familiarity with different belief systems and experiences will resolve suspicion, poor understanding, economic barriers to accessing health care, and the insensitive of providers. The approach is helpful in highlighting the differences in understandings, knowledge systems, and experiences across cultural groups, although the risk is of exacerbating rather than removing stereotypes of immigrants, reinforcing expectations of particular belief systems, practices or values (e.g. avoiding ―cold‖ foods after delivery) and placing particular groups under surveillance because of perceived risk (e.g. the fear that daughters might be subject to Female Genital Mutilation). Although familiarity with cultural issues is important in ensuring access to health care, there is enormous diversity in populations of all cultures, important differences between rural and urban groups, and among different classes and genders. Even within these groupings, individuals vary to the extent that they believe in or adhere to particular cultural practices.

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CONCLUSION We have drawn attention to the complexity of migration movements. We have suggested that the differentiation between voluntary/forced, regular/irregular, and internal/international migration, fails to encompass the complex paths that lead people to relocate, and the intrinsic stress involved in mobility and resettlement. Stress is inherent in relocating, and individual capacity to respond to multiple stressors cannot be predicted on the basis of acculturation, cultural distance, language competence nor legal category. Although cultural ties with people in countries of origin and with fellow migrants elsewhere [6-11] may provide support to new immigrants, they can also be disruptive and unsettling. Various changes in the circumstances in the home country and country of resettlement, and changes in individual circumstance, all place stress on immigrants, who at times may require support from health and other social service providers. Often, such stress cannot be resolved by individual psychological or medical care, but rather, through practical assistance in employment, housing, education, and in enhancing social connections. As we have suggested, the backgrounds of immigrants, the reasons for migrating, and the capacity to resettle, vary for social, economic, cultural and personal reasons. Migration status is therefore one signpost of possible disadvantage and inequality, highlighting particular stressors and the possibility of others. But comprehensive policies to provide services that are sensitive to migration-related stress, and are able to respond to the needs of immigrants at different points throughout the life-cycle, require an evidence-base. There is concurrently a need for attention to individuals in the delivery of clinical services, and a need for further research on broad social interventions – within and beyond the health sector – to respond more comprehensively to immigrants in ways that reduce social inequality, and enhance social support, social networks and connectedness. Such interventions need to be situated in and among communities, addressing needs beyond those of individuals in especial distress. Many of these too need to take account of locality, and address the social and structural causes of health problems, both mental and physical. The complexity of immigration experiences, the stresses experienced by immigrants, and the vulnerability of immigrants, are largely independent of migrant pathway or status, age or gender. Consequently, comprehensive government and community-based strategies are needed to reduce social inequality in order to enhance capacity and reduce distress experienced by immigrants, for economic reasons as well as in relation to human rights and social justice. However in response to the pressures of globalization, shifts to post-industrial labor markets, changes in family patterns and ageing populations, welfare states are undergoing reforms. Throughout the world, governments are restructuring social and welfare provision to give a stronger emphasis to individuals to provide for themselves, grasp opportunities and succeed in competitive markets. Such reforms have been reasonably successful in delivering more efficient and responsive services to most people. However, they leave out poor and vulnerable groups and erode public trust in welfare services. The reforms risk undermining the public support needed to ensure social provision in the future [101]. Central to such an approach to bring about more inclusive social citizenship, including for immigrant communities, would be to provide opportunities for people to participate in the design and setting of objectives and priorities of social institutions.

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In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 20

POST-TRAUMATIC STRESS DISORDER: INTEGRATION OF BIOLOGICAL AND PSYCHOSOCIAL ASPECTS María Dolores Braquehais Conesa1 and Leo Sher2 1. Vall d‘Hebron University Hospital, Barcelona, Spain 2. Columbia University and New York State Psychiatric Institute, New York, New York, USA

ABSTRACT Trauma is a widespread experience, inherent to nature, and has been experienced and expressed by humans in many different ways in space and time. The post-traumatic stress disorder (PTSD) consists of a cluster of signs and symptoms developed in response to an extreme traumatic stressor. The general population prevalence of PTSD is estimated to range between 2-15%, whereas the prevalence in risk groups is reported to vary from 358%. These variations may be due to several factors: the prevalence of trauma exposure, the magnitude and quality of the stressor/s, differences in individual vulnerability, discordances in psychosocial narratives, and their consideration of resilience and distress, and the methodology that is being used in each study. The response to trauma depends on pre-trauma, peri-trauma, and post-trauma variables. Trauma may lead to a persistent failure of the inhibitory processes ruled mainly by the frontal cortex over a fearmotivated hyperresponsive limbic system. From an evolutionary perspective, the main psychobiological circuits involved in emotions related to fear and anger are primitive, and they have their basis in ancient sub-cortical regions, whereas well-developed cortical regions, such as the prefrontal cortex, play a modulatory role. Abnormalities in the balance between inhibitory and excitatory neurocircuits could also be involved in the pathophysiology of PTSD. However, a comprehensive multi-level approach to trauma should not only focus on the basic psychobiological mechanisms but also on the specific psychosocial context within which the response to trauma developes.

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INTRODUCTION The post-traumatic stress disorder (PTSD) is a cluster of signs and symptoms developed in response to an extreme traumatic stressor [1]. According to the 4th edition of the Diagnostic and Statistical Manual (DSM-IV) [2], the characteristic symptoms resulting from the exposure to an extreme trauma must be present for at least 1 month and include: persistent reexperiencing of the traumatic event, continual avoidance of stimuli associated with the trauma, numbing of general responsiveness, and relentless symptoms of increased arousal. The person reacts to this event with fear and helplessness, and tries to avoid being reminded of it. Traumatic events include military combat, violent personal assault, being kidnapped, being taken hostage, terrorist attack, torture, incarceration, natural or man-made disasters, automobile accidents, or being diagnosed with a life-threatening illness. Although some of their clinical symptoms were known since the Ancient Ages, the description of the specific syndrome started in the second part of the nineteenth century. Since then, different names were used: railway spine, shell shock, traumatic neurosis, war neurosis, concentration-camp syndrome, and rape-trauma syndrome [3] [4]. In the DSM-I, the precursor to PTSD was called "traumatic neurosis." In the DSM-II, it became "transient situational disturbances." The specific name PTSD first appeared in the Diagnosis and Statistical Manual of Psychiatric Disorders (DSM-III) in 1980, and it has been maintained, with some changes in the inclusion criteria, in its following editions. The DSM-V is currently in consultation and preparation, due for publication in May 2012. DSM editors are reconsidering a DSM-IV proposal to create a category called Stress-Induced and Fear Circuitry Disorders. Such a grouping might also include acute stress disorder, adjustment disorders, and "disorder of extreme stress not otherwise specified." This last group could include some patients exposed to extreme stress who do not meet criteria for any DSM categories. Another goal is to simplify the 19 criteria for the disorder. In the last International Classification of Diseases released by the WHO (ICD-10), the PTSD appears in the category ―Reaction to severe stress and adjustment disorders‖ (F43), sub-category ―non-specified disorders‖ (F43.1) [5]. Symptoms of PTSD have to develop after exposure to a terribly frightening, life-threatening or otherwise highly unsafe experience. The inaccuracy of the definitions used by the American Psychiatric Association (APA) and the WHO to categorize violence, disaster, trauma, barbarism and catastrophe makes difficult the generalization of research findings [6]. Some researchers have called into question the existence of the PTSD syndrome arguing that its diagnostic formulation remains invalid [7]. They state that the PTSD symptom profile frequently overlaps with other common medical conditions such as mood disorders, anxiety disorders, and substance abuse, and that several socio-economic interests may be playing a role in its legitimacy as a psychiatric diagnosis.

EPIDEMIOLOGY Trauma is a experience inherent to nature and has been experienced and expressed by humans in different ways in space and time [8]. Even though there may be culture-specific expressions of distress, many of the signs and symptoms included in the PTSD are said to

Post-traumatic Stress Disorder: Integration of Biological and Psychosocial Aspects 315 encompass a pattern of universal post-traumatic distress [9] [10] [11]. However, the prevalence of PTSD is estimated to range between 2-15%, whereas the prevalence in risk groups is reported to vary from 3-58% [12]. These variations may be due to several factors [8;11;13]: prevalence data of trauma exposure, magnitude and quality of the stressor/s, differences in individual vulnerability, discordances in psychosocial narratives and their consideration of resilience and distress, and differences in the methodology that is used to study the phenomenon. The European Study of the Epidemiology of Mental Disorders (ESEMED) project [14], using the WHO-Composite International Diagnostic Interview, found that 13.6% of reported subjects had any anxiety disorder and more than 6% reported any anxiety disorder in the last year. Women were twice as likely to suffer 12-month mood and anxiety disorders as men, while men were more likely to suffer alcohol abuse disorders. Prevalence of 12-month PTSD was 1.1%. When PTSD was present, the mean number of potential traumatic event (PTE) experienced was 3.2. In a multivariate analysis on PTEs and gender, six PTEs were found to be more traumatic, and to explain a large percentage of PTSD: rape, undisclosed private event, having a child with serious illness, beaten by partner, stalked, and/or beaten by a caregiver [15]. The National Comorbidity Survey Replication (NCS-R) [16], using the DSM-IV diagnostic instruments, estimated the prevalence of lifetime PTSD to be 6.8% in the United States population, with women (10.4%) twice as likely as men (5%) to have PTSD at some point of their lives. This represents a small proportion of those who have experienced at least one traumatic event. In fact, all distress should not be considered pathological [8] [7]. Actually, although exposure to trauma is rather common, PTSD is fairly uncommon [17] [18]. About 50-60% of Americans are exposed to significant traumatic events over the course of their lifetime, but only 8-20% develops PTSD [19]. The burden of PTSD in U.S. communities is said to be greater in women than in men, in part due to the greater effect of assault and/or sexual violence on women [20;21]. The majority of people in the NCS experienced two or more types of trauma [16]. The events most associated with PTSD in men were: rape, combat exposure, childhood physical abuse, and childhood neglect. Between 14% and 25% of individuals exposed to catastrophic trauma develop PTSD, and as many as one-half of them have at least one additional axis I diagnosis [22] [23]. However, if victims are exposed to a severe, chronic trauma, and if cruelty is involved, PTSD and/or its most common co-morbid disorders (depression and substance abuse) can affect as much as 80-90% of them [24]. Comorbidity of PTSD and other psychiatric disorders is high, compounding symptom severity and social dysfunction. Some 40% of PTSD subjects acutely, and up to 95% lifetime, are said to meet MDD criteria [25]; and up to 34% meet criteria for dysthymic disorder [26]. Persons with PTSD and comorbid MDD also have a high risk for suicidal behavior [23] [27] [28] [1] [29]. Comorbidity of PTSD and MDD is related to increased illness burden, poorer prognosis, and delayed response to depression treatment [30].

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BIOLOGICAL AND PSYCHOSOCIAL INTERACTIONS The response to trauma depends on multiple factors [31-33] [17;34;35]: a) pre-trauma variables (temperamental predisposition, gender, previous exposure to another traumatic event, family history of psychological problems, history of mental disorders, and current psychosocial narratives); b) peri-trauma variables (time, duration and type of stressor, sense of controllability, degree of personal impact, immediate reactions to the event, presence of dissociation at the time of the traumatic event, and persistence of life threatening events); and c) post-trauma variables (perceived social support, subsequent life stress, and ongoing threat to safety). Our genome contributes to the architecture of our brain but it is difficult to know the pathways that lead from our gene information to our brain constitution. It is also difficult to clarify which selective events are crucial to modulate the expression of some genes. Moreover, there is significant evidence [36] [37] [38] of the role of personal experiences in the activation of gene expression though we do not know yet the way through psychosocial conditions affect the brain response to trauma [8]. The brain-mind complex interprets experiences as threatening or non-threatening and is responsible for behavioral, physiological, and psychological reactions to each situation [39]. After an acute stressful event, there is a plethora of changes in the nervous, cardiovascular, endocrine, and immune systems [34]. From an evolutionary perspective, the main psychobiological circuits involved in emotions related to fear and anger are primitive [40], and they have their basis in ancient sub-cortical regions, whereas well-developed cortical regions, such as the prefrontal cortex, play a modulatory role [35;41]. Many neurobiological studies hold that chronic, repeated, or intense trauma exposure may lead to a persistent failure of the inhibitory processes ruled mainly by the frontal cortex over a fear-motivated hyperresponsive limbic system. Abnormalities in the balance between inhibitory and excitatory neurocircuits could also be involved in the pathophysiology of PTSD. Studies using positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) have demonstrated a hyperreactivity of the amygdala to trauma-related stimuli [42]. Exaggerated startle responses and flashbacks have been related to a failure of frontal regions to dampen the symptoms of arousal and distress that were mediated as reminders of the traumatic event [41]. Abnormalities in the orbitofrontal cortex and amygdala may affect decision-making systems and may increase the vulnerability to act more impulsively, including attempting suicide [43;44]. Intrusive re-experiencing PTSD symptoms can be related to a failure of inhibitory brain processes over a fear-motivated hyperresponsive limbic system [45;46]. The hippocampus also takes part in cognitive processes and may be vulnerable to stress, especially in learned fear, but not in innate fear [35]. Damage or atrophy of the hippocampus impairs the ―shut off‖ of ―emergency symptoms‖ by the brain and leads to a more prolonged hypothalamic-pituitary-adrenal (HPA) response to psychological stressor. Furthermore, stress may close this feed-back process because it also leads to lose of neurons in the hippocampus and to a decrease in synaptic connectivity [39;47]. Moreover, a new hypothesis suggesting that some or all individuals diagnosed with comorbid PTSD and MDD could have a separate psychobiological condition that can be termed "post-traumatic mood disorder" (PTMD), has recently been put forward [1]. This idea

Post-traumatic Stress Disorder: Integration of Biological and Psychosocial Aspects 317 is sustained by a significant number of clinical, translational, and other studies suggesting that patients suffering from comorbid PTSD and MDD are different clinically and biologically from individuals with PTSD alone or MDD alone. Patients with comorbid PTSD and MDD are characterized by greater impairment compared to individuals with PTSD alone or MDD alone. Neurobiological evidence supporting the concept of PTMD includes the findings related to dopaminergic, serotonergic, and hypothalamic-pituitary-adrenal axis function and other observations. Bracha has recently proposed the ―Neuroevolutionary Time-depth Principle‖ of innate fears [40], suggesting a new neuroevolution-based taxonomy of stress-triggered and fearcircuitry disorders. Based on current data of fears‘ prevalence, his hypothesis tries to explain the dissimilar stress-resilience levels after different types of menaces, including lifethreatening situations. Bracha [40] holds that the PTSD rate of males after combat exposure is as high as 39% [19], and it could be due to the fact that this fear-stress response appeared in response to intergroup male-to- male and intra-group killings (this could be applied to the large-scale interethnic battlefield warfare), after the rising of population densities, which lead to the emergence of tribalism and ethnic identity in the Neolithic (starting aproximately 12,000 years ago). This hypothesis could explain why PTSD rates following exposure to lethal intergroup violence (combat, war-zone exposure or intentionally caused disasters such as terrorism, and persistent trauma involving cruelty) are said to be 5–10 times higher than rates following large-scale natural disasters such as forest fires, floods, hurricanes, volcanic eruptions, and earthquakes [24;34]. However, particular and historical cultural narratives as well as previous personal experiences are also decisive in the expression, evolution, treatment, and prevention of the disorder (8), because they shape genotypical expression, and they should also be taken into account when trying to understand the nature of our response/s to trauma.

CONCLUSION A comprehensive approach to trauma should be based not only on the basic psychobiological mechanisms but also on the particular psychosocial context within which the response to trauma developed. If not, theoretical models would be far from our personal, clinical, day-to-day experience.

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María Dolores Braquehais Conesa and Leo Sher Organización Mundial de La Salud. CIE-10. Decima revisión de la clasificación internacional de la enfermedades. Trastornos mentales y del comportamiento. 1992. Braga LL, Filks JP, Mari JJ, Mello MF. The importance of the concepts of disaster, catastrophe, violence, trauma and barbarism in defining posttraumatic stress disorder in clinical practice. BMC 2008;8(68). Wilson D, Barglow P. PTSD has unreliable diagnostic criteria. Psychiatric Times 2009 Jul 9;26(7). Stein DJ, Seedat S, Iversen A, Wessely S. Post-traumatic stress disorder: medicine and politics. The Lancet 2007 Jan;369:139-44. Joop TV, De Jong J, Komproe IH, Van Ommeren M, El Masri M, Araya M, et al. Lifetime Events and Posttraumatic Stress Disorder in 4 Postconflict Settings. JAMA 2001;286:555-62. Pham PN, Weinstein HM, Longman T. Trauma and PTSD Symptoms in Rwanda. Implications for Attitudes Toward Justice and Reconciliation. JAMA 2004;292:602-12. Friedman MJ. Diagnosis and Assessment of PTSD: A Report to the Institute of Medicine. www.iom.edu/Object.File/Master/32/925/Presentation.PTSD.Friedman.pdf; 2006 Jun 16. Sadock BJ, Sadock VA. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 8th ed. Lippincott Williams and Wilkins.; 2005. Perkoning A, Kessler RC, Storz S, Wittchen HU. Traumatic events and post-traumatic stress disorder in the community: prevalence, risk factors and comorbidity. Acta Psych. Scand. 2000;101(1):46-59. Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS, Bryson H, et al. Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand. Suppl. 2004;(420):21-7. Darves-Bornoz JM, Alonso J, de GG, de GR, Haro JM, Kovess-Masfety V, et al. Main traumatic events in Europe: PTSD in the European study of the epidemiology of mental disorders survey. J. Trauma Stress 2008 Oct;21(5):455-62. Kessler RC, Chin WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen. Psychiatry 2005;62:617-27. Hoge EA, Austin ED, Pollack MH. Resilience: research evidence and conceptual considerations for posttraumatic stress disorder. Depress Anxiety 2007;24:139-52. Foa EB, Stein DJ, McFarlane AC. Symptomatology and psychopathology of mental health problems after disaster. J. Clin. Psychiatry 2006;67(Suppl 2):15-25. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen. Psychiatry 1995;52:1048-60. Breslau N. Gender differences in trauma and posttraumatic stress disorder. J. Gend. Specif. Med. 2002 Jan;5(1):34-40. Tolin DF, Foa EB. Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research. Psychol. Bull. 2006 Nov;132(6):959-92. Green BL, Krupnick JL, Chung J, Siddique J, Krause ED, Revicki D, et al. Impact of PTSD comorbidity on one-year outcomes in a depression trial. J. Clin. Psychol. 2006 Jul;62(7):815-35.

Post-traumatic Stress Disorder: Integration of Biological and Psychosocial Aspects 319 [23] Kramer TL, Lindy JD, Green BL, Grace MC, Leonard AC. The comorbidity of posttraumatic stress disorder and suicidality in Vietnam veterans. Suicide Life Threat Behav. 1994;24(1):58-67. [24] Kramer TL, Lindy JD, Green BL, Grace MC, Leonard AC. The comorbidity of posttraumatic stress disorder and suicidality in Vietnam veterans. Suicide Life Threat Behav. 1994;24:58-67. [25] Shaley AY, Freeman S, Peri T, et al. Prospective study of posttraumatic stress disorder and depression following trauma. Am. J. Psychiatry 1998;155:630-7. [26] Keane TM, Wolfe J. Comorbidity in post-traumatic stress disorder: an analysis of community and clinical studies. J. Applied Social Psychology 1990;20:1776-88. [27] Oquendo MA, Friend JM, Halberstan B, Brodsky BS, Burke AK, Grunebaum MF, et al. Association of comorbid posttraumatic stress disorder and major depression with greater risk for suicidal behavior. Am. J. Psychiatry 160[3], 580-582. 2003. [28] Oquendo M, Brent DA, Birmaher B, Greenhil L, Kolko D, Stanley B, et al. Posttraumatic stress disorder comorbid with major depression: factors mediating the association with suicidal behavior. Am. J. Psychiatry 2005 Mar;162(3):560-6. [29] Sher L. The concept of post-traumatic mood disorder and its implications for adolescent suicidal behavior. Minerva Pediatr 2008 Dec; 60(6): 1393-9. [30] Campbell DG, Felker BL, Chuan-Fen L, Yano E, Kirchner J, Chan D, et al. Prevalence of PTSD-Depression Comorbidity: Implications for Clinical Practice Guidelines and Primary Care interventions. J. Gen. Intern. Med. 2007;22:711-8. [31] Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of postraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin 2003;129:52-73. [32] Declerck F, Palmans V. Two subjective factors as moderators between critical incidents and the occurrence of post-traumatic stress disorder: "Adult attachment" and "perception of social support". Psychology and Psycotherapy: Theory, research and practice 2006;79:323-37. [33] Kotler M, Iancun I, Efroni R, Amir M. Anger, impulsivity, social support, and suicide risk in patients with posttraumatic stress disorder. J. Nerv. Ment. Dis. 2001 Mar;189(3): 162-7. [34] Schneiderman N, Ironson G, Siegel SD. Stress and Health: Psychological, Behavioral and Biological Determinants. Annu. Rev. Clin. Psychol. 2005;1:607-28. [35] Lara DG, Akiskal HS. Toward an integrative model of the spectrum of mood, behavioral and personality disorders based on fear and anger traits: II. Implications for neurobiology, genetics and psychopharmacological treatment. J. Affect Disord. 2006;94: 89-103. [36] Post RM, Weiss SR, Li H, Smith MA, Zhang LX, Xing G, et al. Neural plasticity and emotional memory. Dev. Psychopathol. 1998;10(4):829-55. [37] Bibancos T, Jardim DL, Aneas I, Chiavegatto S. Social isolation and expression of serotonergic neurotransmission-related genes in several brain areas of male mice. Genes Brain Behav 2007 Aug;6(6):529-39. [38] Anisman H, Merali Z, Stead JD. Experiential and genetic contributions to depressiveand anxiety-like disorders: clinical and experimental studies. Neurosci. Biobehav. Rev. 2008 Aug;32(6):1185-206. [39] McEwen BS. Physiology and Neurobiology of Stress and Adaptation: Central Role of the Brain. Physiol. Rev. 2007;87:873-904.

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[40] Bracha HS. Human brain evolution and the "Neuroevolutionary Time-depth Principle: "Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder. Prog. Neuropsychopharmacol. Biol. Psychiatry 2006;30:827-53. [41] Nutt DJ, Malizia AL. Structural and functional brain changes in posttraumatic stress disorder. J. Clin. Psychiatry 2004;65(Suppl 1):11-7. [42] Dickie EW, Brunet A, Akerib V, Armony JL. An fMRI investigation of memory encoding in PTSD: influence of symptom severity. Neuropsychologia 2008 Apr;46(5):1522-31. [43] Monkul ES, Hatch JP, Nicoletti MA, Spence S, Brambilla P, Lacerda AL, et al. Frontolimbic brain structures in suicidal and non-suicidal female patients with major depressive disorder. Mol. Psychiatry 2007 Apr;12(4):360-6. [44] Jollant F, Guillaume S, Jaussent I, Bellivier F, Leboyer M, Castelnau D, et al. Psychiatric diagnoses and personality traits associated with disadvantageous decisionmaking. Eur. Psychiatry 2007 Oct;22(7):455-61. [45] Francati V, Vermetten E, Bremmer JD. Functional neuroimaging studies in posttraumatic stress disorder: review of current methods and findings. Depress Anxiety 2007; 24(3):202-18. [46] Weiss SJ. Neurobiological Alterations Associated with Traumatic Stress. Perspectives in Psychiatry Care 2007;43(3):114-22. [47] Woon FL, Hedges DW. Hippocampal and amygdala volumes in children and adults with childhood maltreatment-related posttraumatic stress disorder: a meta-analysis. Hippocampus 2008;18(8):729-36.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 21

IMPULSIVITY: A NEW CONCEPT FOR AN OLD IDEA María Dolores Braquehais Conesa Vall d‘Hebron University Hospital, Barcelona, Spain

ABSTRACT The concern about the recent increase of behaviors related to a lack of self-control in industrialised and post-industrialised societies is linked to the old idea of achieving selfcontrol, a preoccupation of all ethical and moral doctrines throughout the history. The term impulsivity started to be widely used to describe the failure to manage our impulses since the nineteenth century, when impulsivity was mainly studied as a pathological state. At the turn of the century, the psychoanalytical approach began to consider impulses as psyche‘s drives. Since the mid twentieth century, due to the influence of statistics and behaviorism, impulsivity was studied as a personality trait. Nowadays, neurobiologists have tried to identify it with a failure of the brain ―decision-making‖ circuitries and with the hypofunction of inhibitory neurotransmitters systems, mainly the serotonergic system.

INTRODUCTION Although impulsivity has been related to many psychological factors and psychopathological conditions [1], it can also be said that recent changes in socio-cultural models in high-income countries may be playing a critical role in the increased prevalence of behaviors related to the lack of self-control. For instance, it is clear that in the last decades, the structure and dynamism of families has been reshaped in both industrialized and postindustrialized societies, in part due to huge and rapid economical and cultural changes. As a result of those adjustments, a new ―basic personality", called by the French psychoanalist Lazartigues [2] ―narcissitic-hedonistic‖, is said to be replacing the ―basic normal/neurotic‖ one, which dominated until the second half of the twentieth century. That ―narcissistichedonistic‖ subject is defined by Lazartigues [2] as an individual more dependent on external

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objects who finds delay in the achievement of instinctive aims hard to take, is allergic to frustration, and develops a ―sensation seeking‖ pattern of behavior. However, the concern about the importance of controlling our behavior is not original. All ethical and moral views throughout the history have tried to explain the causes of the failure achieving self-restraint. But it is only since the nineteenth century when the terms impulsivity and impulsive acts (especially in the Occidental realm and in the biomedical setting) have extensively described the lack of self-control. This relatively ―new concept‖ is currently used when referring to the ―old idea‖ of control of passions.

THE IMPORTANCE OF WILL First related to the concept of will, in Classical Times lack of self-control was identified with a failure to manage the power of passions. The lack of self-restraint had also a close relationship with the Greek concept of hybris and with the Roman concept of impotentia. For the Stoics, the will was considered a semantic blend of affect and cognition. This view changed in the Judeo-Christian tradition where the will became an autonomous mental function. The English noun ―will‖ comes from the Germanic term welljon, related to willan which meant ―to wish‖. The meaning ―written document expressing a person‘s wishes about disposition of property after death‖ was first recorded in 1380 [3]. The will has been one of the fundamental axes not only of the history of philosophy but also of psychology, especially among several eighteenth and nineteenth century psychopathologists, who held that insanity and diseases of the soul were caused by a failure of the will [4]. Since the Enlightenment, researchers brought forward the ―moral approach‖ for psychiatric disorders. They stressed the importance of the patient‘s regain of rational control over his/her behavior [5]. A hundred years ago, it was thought to be an important descriptive and explanatory concept, naming the human ―power, potency and faculty‖ to initiate action [6]. On the other hand, the term ―impulse‖ (implied in ―impulsion‖) first appeared in English in 1432, as ―an act of impelling, a thrust, push‖, coming from the Latin word impulsus (―a push against, pressure, shock‖ but also ―incitement, instigation‖) that was the participle of impellere. The meaning of ―stimulus in the mind arising from some state or feeling‖ was first recorded in 1647. ―Impulsive‖ appeared in 1604 and referred to medicines that reduce swelling or tumors; the sense or ―rash‖ was first recorded in 1847 [3].

THE EMERGENCE OF THE CONCEPT “IMPULSIVITY” The French word ―impulsion” (impulsivity as a state or act), frequently used by the nineteenth century French alienists, had been imported with this meaning from mechanics. By the 1860s, ―impulsion” was caught in two dichotomies: it was used both as a description and as an explanation, and it was considered at the same time as being both internally generated and a reaction to external events [6].

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The first classification of impulsive acts was developed in the seventeenth century by Theophile Bonet (1631-92), but it was not until the nineteenth century, especially by French psychopathologists, when impulsivity was thoroughly studied as a pathological state more than as a personality trait. This perspective was mainly due to the study of uncontrolled criminal behaviors and of suicidal acts from a medical and forensic perspective. Different psychological theories about personality were developed during the nineteenth century, thus influencing the nosology and nosography of impulsive behaviors. Nonetheless, the classifications of impulsive disorders developed in that century were mainly influenced by the tripartite division of the mind (cognition, affect, and behavior) propounded by the Faculty Psychology [7]. During the nineteenth century there was a further reaction against the view that the will could be reduced to other mental functions. For example, a strong ―voluntarist‖, Maine de Biran (1766-1824), proposed to replace Descartes‘ ―cogito ergo sum‖ by ―volo ergo sum‖ [6].

SINCE THE TWENTIETH CENTURY Berrios states [8] that around the beginning of the twentieth century, researchers slowly turned away from the study of the will and became more interested in the comprehension of affect and cognition. He argues that this change could have been due both to the influence of psychoanalysis and behaviorism, and to the anti-rationalism and pessimism that appear in the wake of the First World War, as well as to the acceptance of mechanistic and neurological explanations for the disorders of motility (e.g. tics, forced movements, stereotypes, etc.) seen after the epidemics of encephalitis lethargica. This change created a conceptual vacuum in the ―domain of the voluntary‖ which has since been unsatisfactorily filled by notions such as ―instinct‖, ―drive‖, ―motivation‖, ―decision making‖ and ―frontal lobe executive‖. In his opinion, the study of certain pathologies (aboulia, agoraphobia, impulsions and obsessions) as ―disorders of the will‖ was discontinued at the beginning of the twentieth century. However, the truth is that the importance given by psychoanalysts to the concept of ―drive‖ could be considered a renewed interest in the study of impulsive acts. And, though we should admit that since the mid twentieth century researchers started to show a renewed interest for the psychopathology of the will (8) (with a special focus on the study of impulsivity as a personality dimension), this fact was mainly due to the earlier contributions of behaviorism and to the importance given to statistics since the late nineteenth century.

CURRENT MODELS Nowadays, impulsive behaviors are said to comprise a wide spectrum of actions characterized by quick and non-planned reactions to external or internal stimuli, without taking into account the possible negative consequences for the individual or for others [9]. Two extreme types of impulsivity can been described [10]: a) functional impulsivity, associated with faster information processing, thus facilitating quicker responses to environmental challenges, and improving the individual‘s adaptation to the environment; and,

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b) dysfunctional impulsivity that would lead to harmful consequences for the individual or the others. As we have already seen, the term impulsivity has been used to describe [11] [12]:   

A behavior (impulsivity as a state or impulsion). A personality dimension (impulsivity as a trait). A lifestyle.

And, when studying the history of descriptions of impulsivity, it becomes difficult to achieve a clear distinction between the history of impulsivity as a state (impulsive behavior) and the history of impulsivity as a trait (impulsivity as a dimension of personality). In fact, the reflections on the nature of the impulsive act habitually concentrate as well on the stable characteristics of the subject. From the point of view of impulsivity as an act, the two main current classificatory systems, the official classification system of the American Psychiatric Association (APA), the Diagnostic and Statistic Manual of Mental Disorders (DSM), and the International Classification of Diseases (ICD) published by the World Health Organization (WHO) have included the category ―Impulse Control Disorders‖ in their latest editions [13] [14] [15]. Recent dimensional models (based on the factorial analysis of psychometric instruments) propound that impulsivity can be divided into several dimensions. These sub-dimensions could correspond with some specific neurobiological alterations. Nowadays, neurobiological explanations have identified impulsivity with a failure of the brain inhibitory processes ruled by the decision-making circuitry [16] [17] [18] [19] as well as with the hypofunction of inhibitory neurotransmitters systems, mainly the serotonergic system [20] [21] [22] [23]. According to Berrios [6], the current interest in a ―modular approach‖ to explain all psychological symptoms as well as the fashionable neuropsychological notion of ―frontal lobe executive‖ function are not free from the very same conceptual objection (regression ad infinitum) that once was considered fatal to the concept of will.

CONCLUSION The consideration of the historical construction of impulsivity proves that it is a description construct which changes in time, irrespectively of the changing nature of the object itself. Both comprehensive and explanatory methods are necessary to deeply understand the nature of impulsivity. Integration of conceptual definitions with recent findings in the neurobiology realm is one of the aims that should be taken into account in future psychiatric research.

REFERENCE LIST [1]

Soubrié P. Reconciling the role of central serotonin neurons in human and animal behavior. Behav. Brain Sci. 1986;9:319-64.

Impulsivity: A New Concept for an Old Idea [2]

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Lazartigues A, Planche P, Saint-André S, Morales H. New society, new families: a new basic personality? From the neurotic to the narcissistic-hedonistic personality. Encephale 2007;33(3 Pt 1):293-9. Online Etymology Dictionary. [computer program]. www.etymonline.com: 2001. Gili M, Roca M. Psicopatología de la acción y la voluntad. In: Luque R, Villagrán JM, editors. Psicopatología descriptiva: nuevas tendencias. 1 ed. Madrid: Editorial Trotta; 2000. p. 433-44. Pagán G, Ruiz MJ. La historia del pensamiento psiquiátrico. In: Cervera S, Conde V, Espino A, Giner J, Leal C, Torres F, editors. Manual del Residente de Psiquiatría I. 1 ed. Madrid: Litofinter, S.A.; 1997. p. 13-24. Berrios GE. The will and its disorders. The history of mental symptoms. Descriptive psychopathology since the nineteenth century.Cambridge (UK).: Cambridge University press.; 1996. p. 351-68. Luque R, Villagrán JM. Psicopatología descriptiva: Nuevas tendencias. Madrid: Editorial Trotta, S.A.; 2000. Berrios GE, Gili M. Will and its disorders: a conceptual history. History of Psychiatry 1995;6:87-104. Moeller FG, Barrat ES, Schmitz JM, Swann AC. Psychiatric aspects of impulsivity. Am-J-Psychiatry 2001;158:1783-93. Dickman SJ. Functional and Dysfuncitional impulsivity: personality and cognitive correlates. J. Personality Social Psychol. 1990;58:95-102. Frosch J, Wortis SB. A contribution to the nosology of the impulse disorders. Am. J. Psychiaty 1954;111:132-8. Szerman N. Nosología. Clínica de los trastornos por impulsividad. Psiquiatr. Biol. 2002;9 (Supl 2):1-9. American Psychiatric Association. DSM-IV breviario. Criterios diagnósticos. Barcelona: Masson; 1995. López-Ibor JJ, Valdés J, Miyar Md. DSM-IV-TR. Manual diagnóstico y estadístico de los trastornos mentales. Texto revisado. Barcelona: Masson; 2002. Vallejo Ruiloba J. Introducción a la psicopatología y a la psiquiatría. 6 ed. Barcelona: Elsevier Masson; 2007. Depue RA, Spoont MR. Conceptualizing a serotonin trait: A behavioral dimension of constraint. Ann. N. Y. Acad. Sci. 1986;487:47-62. Casey BJ, Durston S, Fosella JA. Evidence for a mechanistic model of cognitive control. Clinical Neuroscience Research 2001;1:267-88. Rahman S, Sahakian BJ, Cardinal RN, Rogers DD, Robbins TW. Decision making and neuropsychiatry. Trends in Cognitve Sciences 2001 Jun;5(6):271-7. García-Ribas G. Neuroanatomía de la impulsividad. In: Ros-Montalbán S, Peris-Díaz MD, Gracia-Marco R, editors. Impulsividad. 1 ed. Barcelona: Psiquiatría Editores, S.L.; 2004. p. 43-52. Mann JJ, Arango V, Marzuk PM, Theccanat S, Reis DJ. Evidence for the 5-HT hypothesis of suicide. A review of post-mortem studies. Br. J. Psychiatry Suppl. 1989 Dec;(8):7-14. Markowitz PI, Coccaro EF. Biological Studies of Impulsivity, Agression and Suicidal Behavior. In: Hollander E, Stein DJ, editors. Impulsivity and aggression.Chichester: John Willey and Sons Ltd.; 1995. p. 71-90.

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[22] Ros-Montalbán S, Arranz-Marti B, Arranz-Estévez F.J., Rodríguez-Martínez A, Casanova-Alba N. Terapéuticas farmacológicas de la impulsividad. In: Ros-Montalbán S, Peris-Díaz MD, Gracia-Marco R, editors. Impulsividad. 1 ed. Barcelona: Psiquiatría Editores, S.L.; 2004. p. 249-66. [23] Ramos-Atance JA. Neuroquímica de la impulsividad. In: Ros-Montalbán S, Peris-Díaz MD, Gracia-Marco R, editors. Impulsividad. 1 ed. Barcelona: Psiquiatría Editores, S.L.; 2004. p. 43-52.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 22

NOT JUST ANOTHER PRETTY FACE: THE CROSS-CULTURAL PERCEPTION AND SOCIAL RAMIFICATIONS OF FACIAL ATTRACTIVENESS Dana Galler Yeshiva University, Stern College for Women, New York, New York, USA

ABSTRACT Physical attractiveness is a significant predictor of important life outcomes, since attractive adults tend to receive more attention and help from others, achieve greater occupational success, have more positive social interactions including dating and sexual experiences, become more popular, and enjoy better physical and mental health than their less attractive counterparts. While a cross-cultural and universal criteria for the discernment of beauty does indeed exist and certain facial cues universally seem to be indicative of an individual‘s attractiveness, other factors, such as facial familiarity, parental influences and olfactory cues may also contribute to the perception of attractiveness. Recent social psychological research further indicates that society not only attributes more positive qualities to those viewed as more attractive, but also tends to treat these individuals more favorably.

INTRODUCTION While many collaborating factors often contribute to an individual‘s success in society, attractiveness is an asset whose profound significance is often overlooked. Research indicates that humans across many diverse cultures not only share similar criteria for defining facial beauty [1], but also tend to attribute more positive assets and qualities, beyond mere physicality, to those they deem beautiful [2; 3]. Indeed, physical attractiveness is a significant predictor of important life outcomes, since attractive adults tend to receive more attention and

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help from others, achieve greater occupational success, have more positive social interactions including dating and sexual experiences, become more popular, and enjoy better physical and mental health than their less attractive counterparts [1]. Similarly, media outlets consistently highlight what should be considered beautiful and teach youngsters to associate goodness with beauty [4]. With such a strong cultural emphasis on beauty, it is no wonder that citizens of industrialized countries such as the United States spend more each year on beauty products and services than they do on education [5].

CROSS-CULTURAL PERCEPTION OF FACIAL ATTRACTIVENESS However, even though the western media does play a large role in promulgating, disseminating and emphasizing facial beauty ideals, these standards are by no means exclusive or unique to western culture. Surprisingly, research consistently shows that across cultures, people tend to share similar perceptions of what is considered attractive [1]. Cunningham, in his study of beautiful features, attempted to mathematically assess and quantify physical beauty by asking participants to rate the attractiveness of photographs, and by then measuring the relative sizes of the different facial features in each photograph. Cunningham‘s findings suggest that large eyes, a small nose and chin, high cheekbones, and a large balanced smile are strong indicators of an attractive female face [6]. Male faces, on the other hand, are considered attractive when comprised of prominent cheekbones, large eyes, a large chin and a big smile [7]. Interestingly, large eyes, a ―baby-face‖ feature, may be considered attractive because they effectively elicit feelings of parental warmth and nurturance in perceivers [8]. Despite the fact that some racial and ethnic groups do have preferences for certain different facial features, researchers found that amongst a cross-cultural pool of subjects, inter-rater reliability was strong, and participants‘ ratings were highly correlated, indicating that members of different countries, ethnicities and racial groups share a similar sense of what is attractive [9]. Moreover, a meta-analysis of many similar studies illustrates that overall, raters within and across cultures agree about who is and who is not attractive, and that across cultures goodlooking children and adults bearing these attractive characteristics are treated more positively and display more positive behaviors and traits then those who are perceived as less attractive [1]. The possible existence of an innate universal attractiveness criterion is further underscored by a string of studies done with infants who were not yet exposed to cultural norms and media outlets. These 3-6 month olds, when shown pictures of adult-judged attractive and unattractive faces actually preferred the pictures of the adult-judged attractive faces [9]. In an inventive study, researchers attempted to define an innate human criterion for beauty using both an evolutionary and information-processing point of view, predicting that faces representing the average of the population would be consistently judged as more attractive. The researchers digitized samples of male and female faces, mathematically averaged them, and had adults judge the attractiveness of both the computer-generated and individual faces. Tellingly, both males and females consistently judged the composite faces to be more attractive than the individual faces from which they had been comprised. Further,

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they found that the composite faces became increasingly attractive as more individual faces were averaged in. These data, showing that averaged features are most attractive, are consistent with evolutionary pressures that favor characteristics close to the mean of the population and with cognitive processes that favor prototypical category members [9]. At the same time, other research indicates that perhaps familiarity is the key to interpersonal attraction, and that average faces are more attractive simply because they seem more familiar to viewers [10]. Several studies have shown that facial attractiveness is positively correlated with both familiarity and typicality [11]. Researchers in one recent wellcrafted study manipulated the familiarity of typical and distinctive faces to measure its effect on attractiveness. They collected ratings of attractiveness, distinctiveness, and familiarity for 84 images of female faces using three different groups of participants, and then continually exposed the participants to only some of the images. Researchers found that not only were attractiveness ratings positively correlated with original familiarity ratings, but also that increased exposure to faces increased their perceived attractiveness [12]. Other studies also find that when participants were repeatedly presented with faces of different individuals, participants rated faces they saw more frequently as more attractive [12; 13]. Interestingly, Little and Perrett found that people also seem to prefer faces that look like their own [14]. Penton-Voak used a special computer program to turn each subject‘s face into the face of someone of the opposite gender, and hid key characteristics like hairstyle, earrings and clothing. None of the subjects recognized any of the faces as their own, yet seemed to prefer these faces over others [15]. Perrett also found in later studies that parental influence may play a large role in what subjects perceive as attractive. Perrett's team presented male and female students with computer-generated images of average faces of the opposite sex, at different stages of life, and asked the students to rate each face in terms of attractiveness and then to answer questions about their parents — including their parents' ages. Perrett found that subjects born to parents older than 30 years of age overwhelmingly preferred older faces, while subjects born to younger parents judged younger faces as more attractive [16]. Another study examining hair and eye color also found that people generally prefer faces with the same eye and hair color as their parent of the opposite sex [17]. Other features, aside from just visual cues, also seem to contribute to interpersonal attractiveness. Studies have found that olfactory cues may be influential in evaluating attractiveness [18; 19]. In a recent study, subjects were presented with facial photographs and their owner‘s worn t-shirt odors. The study‘s results showed that visual cues in the facial photographs and olfactory cues in the worn t-shirts were both found to contribute to the overall attractiveness ratings of participants. However, visual cues did seem to be significantly greater predictors of attractiveness than olfactory cues [20].

SOCIAL RAMIFICATIONS OF FACIAL ATTRACTIVENESS Despite the fact that facial attractiveness is often superficially and rapidly evaluated, people tend to show a substantial personal preference for attractive over unattractive individuals. [21]. And, even though physical attractiveness is unrelated to any objective measure of internal qualities such as intelligence and personality, much research indicates,

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and repeated studies confirm, that attractiveness is perceived as being reflective of a host of other positive qualities. The ―What is beautiful is good stereotype‖ indicates that when people see an attractive person, they believe that there are additional desirable qualities beyond the physical beauty that they actually see; they tend to ascribe certain other pleasing internal qualities to the person, such as kindness and outgoingness [2; 3]. Interestingly, this stereotype is also demonstrated cross-culturally, as people in both individualistic and collectivistic cultures attribute to more attractive individuals more of the traits that are considered valued in their respective societies. For example, subjects from individualistic countries, such as the United States and Canada, attribute qualities such as ―strong,‖ ―assertive‖ and ―dominant‖ to the more attractive individuals, whereas subjects from a more collectivistic culture, Korea, attributed qualities such as ―sensitive,‖ ―honest,‖ ―empathetic,‖ ―trustworthy,‖ and ―generous‖ to these same physically attractive individuals [22]. In light of these automatic social inferences, it is not surprising that society tends to shower attractive people with preferential treatment. A recent disturbing news report shocked viewers with the statistic that attractive infants born prematurely in hospitals across the country had vastly higher rates of survival then less attractive premature newborns. This enigmatic statistic was explained by the fact that the nurses on call tended to favor and care for the attractive babies more than the less attractive ones [23]. Scientifically-based empirical studies substantiate and underscore this association. A study on popularity among adolescents found that physical attractiveness had an even stronger effect on popularity than perceived attitude similarity [24]. Researchers have also found an association between the rated attractiveness of yearbook photos and reproductive success in a contemporary industrial population [25]. Such preferential treatment may also have significant implications on a societal level, as one jury task simulation experiment illustrated that more attractive defendants were found to be evaluated more positively and with less certainty of guilt than less attractive defendants [26].

CONCLUSION Therefore, while a well known axiom may admonish that ―Beauty is in the eye of the beholder,‖ it is evident that a cross-cultural and universal criteria for the discernment of beauty does indeed exist. Further, while certain facial cues universally seem to be indicative of an individual‘s attractiveness, other factors, such as facial familiarity, parental influences and olfactory cues may also contribute to the perception of attractiveness. And, while other well known axioms may remind us ―Not to judge a book by its cover‖ and that ―Beauty is only skin deep,‖ research indicates that society not only attributes more positive qualities to those viewed as more attractive, but also tends to treat these individuals more favorably.

REFERENCES [1]

Langlois, J. H., Kalakanis, L., Rubenstein, A. J., Larson, A., Hallam, M., and Smoot, M. (2000). Maxims of myths of beauty? A meta-analytic and theoretical review. Psychological Bulletin, 126, 390-423.

Not Just Another Pretty Face [2] [3]

[4] [5] [6]

[7]

[8]

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Dion K., Berscheid E. and Walster E. What is beautiful is good. Journal of Social Psychology 24:285-90. 1972. Ashmore, R.D., and Longo, L.C. (1995). Accuracy of Social Stereotypes: What Research on Physical Attractiveness can tell us. In Y.T. Lee, L.T Jussim, and C.R. McCauley (eds.), Stereotype Accuracy: Towards Appreciating Group Differences. Washington, D.C: American Psychological Association, 63-86. Aronson, E., Wilson, T.D., and Akert R.M. (2007). Social Psychology. Upper Saddle River, NJ: Pearson Education. 313-314. Pots of Promise: The Beauty Business. (2003) The Economist, May 23, p.3. Cunningham , M.R. (1986). Measuring the Physical in Physical Attractiveness: Quasiexperiments on the sociobiology of female facial beauty. Journal of Personality and Social Psychology, 50, 925-935. Cunningham , M.R., Roberts, A.R., Barbee, A.P. and Pike, C.L. (1990). What do Women Want? Facialmetric assessment of multiple motives in the perception of male facial physical attractiveness. Journal of Personality and Social Psychology, 59, 61-72. Berry, D.S. (1995). Beyond beauty and after affect: An event perception approach to perceiving faces. In R.A . Eder (Ed.), Craniofacial anomalies: Psychological perspectives (pp. 14-29). New York: Springer-Verlag. Langlois, J.H., Roggman, L.A., and Rieser-Danner, L.A. (1990). Infants Differential social responses to attractive and unattractive faces. Developmental Psychology, 26, 153- 159. Bercheid E. and Reis, H.T. (1998). "Attraction and Close Relationships". In Daniel T. Gilbert, Susan T. Fiske, and Gardner Lindzey, editors, Handbook of Social Psychology, New York: McGrawHill, 193-281. Halberstadt, J.B. and Rhodes, G. (2000). The attractiveness of nonface averages: Implications for an evolutionary explanation of the attractiveness of average faces. Psychological Science, 11, 285-289. Peskin, M. and Newell, F. (2004). ―Familiarity breeds attraction: Effects of exposure on the attractiveness of typical and distinctive faces‖. Perception 33: 147-157. Rhodes, G., Halberstadt, J., Brajkovich, G. (2001). ―Generalization of mere exposure effects to averaged composite faces.‖ Social Cognition 19: 57-70. Little, A.C., and Perrett, D.I. (2002). Putting beauty back in the eye of the beholder. Psychologist, 15, 28-32. Penton-Voak, I., Perrett, D., and Peirce, J. (1999). Computer Graphic studies of the role of facial similarity in judgments of Attractiveness. Current Psychology, 18 (1), 104117. Perrett, D.I., Penton Voak, I.S, Little, A.C., Tiddleman, B.P., Burt M.D., Schmidt, N., Oxley R., Kinloch, N., and Barrett, L. (2002). Facial Attractiveness Judgments Reflect Learning of Parental Age Characteristics. Biological Sciences, 269 (1594), 873-880. Little A.C., Penton-Voak I.S, Burt D.M, Perrett D.I (2002). Investigating an imprintinglike Phenomenon in Humans. Partners and opposite-sex parents have similar hair and eye colour. Evol. Human Behavior, 24 (1) 43-51. Thornhill, R., and Gangestad, S. W. (1999). The scent of symmetry: A human pheromone that signals fitness? Evolution and Human Behavior, 20, 175-201.

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[19] Rikowski, A. and Grammer, K. (1999). Human body odour, symmetry and attractiveness. Proceedings of the Royal Society of London. Series B: Biological Sciences, 266(1422):869-874. [20] Foster, J. (2008). Beauty Is Mostly in the Eye of the Beholder: Olfactory Versus Visual Cues of Attractiveness The Journal of Social Psychology, 148 (6), 765-774. [21] Baumeister,R.F., and Bushman, B.J. (2008). Social psychology and human nature. Belmont, Ca:Thomson Higher Education. [22] Wheeler, L. and Kim, Y. (1997). What is beautiful is Culturally Good: The Physical Attractiveness Stereotype has Different content in Collectivistic Cultures. Personality and Social Psychology Bulletin, 23 (8), 795-800. [23] Morin, R. (2002). Bias and Babies. Washington Post, March 3, p.B5. [24] Cavior, N., and Dokecki,P. (1973). Physical attractiveness, perceived attitude similarity, and academic achievement as contributors to interpersonal attraction among adolescents. Developmental Psychology, 9 (1), 44-54. [25] Jokela, M. (2009). Physical attractiveness and reproductive success in humans: Evidence from the late 20th century United States. Evolution and Human Behavior, 30 (5), 342-350. [26] Efran, M.G. (1974). The effect of physical appearance on the judgement of guilt, interpersonal attraction, and severity of recommeneded punishment in a simulated Jury Task. Journal of Research in Personality, 8, 45-54.

In: Immigration and Mental Health Editors: Leo Sher and Alexander Vilens

ISBN 978-1-61668-503-4 © 2010 Nova Science Publishers, Inc.

Chapter 23

ABOUT THE EDITORS LEO SHER, M.D. Leo Sher, M.D., is an internationally recognized physician and scientist. Dr. Sher is a psychiatrist with a background in internal medicine. His areas of expertise include the diagnosis, treatment and neurobiology of posttraumatic stress disorder, depression, bipolar disorder, alcoholism, and suicidal behavior. Dr. Sher is involved in many scholarly activities. He has excellent leadership skills and frequently develop new ideas and initiatives. Dr. Sher's interests in the natural sciences date from his early teenage years. He was awarded the Gold Medal upon graduation from High School, and graduated Summa Cum Laude from the Ukrainian National Medical University in Kiev, Ukraine. Dr. Sher did his Residency in Psychiatry at the Albert Einstein College of Medicine Program at Long Island Jewish Medical Center in New York and the National Institute of Mental Health Program in Bethesda, Maryland. He completed a Research Fellowship at the National Institute of Mental Health in Bethesda, Maryland. Dr. Sher is a Diplomate of the American Board of Psychiatry and Neurology. Currently, Dr. Sher is an Associate Professor in the Department of Psychiatry at Columbia University and Research Psychiatrist at the New York State Psychiatric Institute in New York City. Dr. Sher has authored more than 450 scientific publications. He is the editor of 14 books. Dr. Sher is a reviewer for numerous medical journals. He gave talks at many research and teaching conferences. Dr. Sher is the recipient of several awards including the Charlotte Marker Zitrin, M.D. Award from the Long Island Jewish Medical Center for the Best Scientific Paper (1997) and the International Award for Excellence in Published Clinical Research in The Journal of Clinical Endocrinology and Metabolism (2004). He is also the recipient of two grants from the American Foundation for Suicide Prevention. Dr. Sher was the first researcher in North America who introduced the use of the combined dexamethasone suppression/corticotropin-releasing hormone stimulation test for psychiatric purposes. He has proposed the concept of posttraumatic mood disorder that was met with significant interest by experts in the field. Dr. Sher has also proposed a model of suicidal behavior in traumatized war veterans. Dr. Sher is listed in Who's Who in America, Who's Who in the World, Who's Who in Medicine and Healthcare, and Who's Who in Science and Engineering. In his leisure

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time, Dr. Sher has many interests. He enjoys traveling and is interested in politics, history, geography, and sociology.

ALEXANDER VILENS, M.S. Alexander Vilens, M.S., is an internationally known informational technology expert with a background in physics, mathematics, and business administration. Mr. Vilens received his M.S. degree in Physics from Odessa University in Odessa, Ukraine. He also has knowledge and experience in business management. Mr. Vilens lives and works in New Jersey. For more than 17 years, he has been a leading expert of "Relational Architects International." This well-known informational technology company is based in Hoboken, New Jersey, and has multiple affiliates around the world. Mr. Vilens is a recognized authority on checkpoint/restart for z/OS batch applications and DB2 thread management. He is an expert in development, marketing and support of the program products which enhance IBM's z/OS, DB2 and IMS environments with successful implementations in Fortune 1000 organizations worldwide. Mr. Vilens is the editor of 7 books: Internet and Suicide (2009), War and Suicide (2009), Terror and Suicide (2009), Suicide in the Military (2009) Suicidal Behavior in Alcohol and Drug Abuse and Dependence (in press), Neurobiology of PostTraumatic Stress Disorder (in press), and Immigration and Mental Health: Stress, Psychiatric Disorders and Suicidal Behavior Among Immigrants and Refugees (in press). Mr. Vilens has many interests. He likes classical music and psychological movies and is interested in psychiatry, history, and arts.

INDEX A acculturation level, 105, 106, 139, 210, 212, 250, 255, 256, 258 achievement, 68, 141, 184, 191, 322, 332 ACTH, 246, 261 acute stress, 314, 316 adaptation, 18, 20, 60, 89, 90, 102, 105, 108, 109, 110, 111, 115, 142, 160, 181, 182, 183, 184, 191, 201, 203, 223, 226, 228, 231, 232, 234, 236, 237, 238, 247, 262, 277, 286, 323 ADHD, 252 adjustment, ix, 7, 88, 92, 93, 94, 95, 96, 97, 103, 105, 110, 111, 123, 124, 145, 161, 164, 165, 166, 177, 178, 179, 180, 181, 182, 183, 184, 192, 197, 203, 204, 211, 227, 231, 232, 234, 238, 239, 269, 277, 278, 314 administrators, 60 adolescence, 33, 53, 68, 95, 179, 183, 253 adolescent female, 54, 70, 97 adulthood, 10, 25, 33, 95 affective disorder, 137, 188, 219, 220 Africa, 73, 77, 79, 116, 117, 233, 257, 284, 285, 299, 300, 308 African American women, 23, 27, 35, 104, 106, 110 African Americans, 19, 151, 153, 160, 246, 250, 253, 256 ageing, 302, 303, 305, 309 ageing population, 305 aggression, 25, 90, 103, 107, 325 aggressive behavior, 169 agriculture, 2, 290 AIDS, 110 Alaska, 73 alcohol dependence, 217, 246, 249, 251, 261 alcohol problems, 269, 276

alcohol use, 91, 105, 110, 161, 217, 248, 249, 250, 252, 255, 256, 262, 267, 269, 270, 271, 272, 274, 276, 278 alcoholics, 275, 276, 279 alcoholism, 246, 269, 275, 276, 278, 333 alcohols, 277 Algeria, 129, 263, 285 alienation, 11, 12, 15, 16, 28, 30, 90, 103, 107 American culture, 67, 210, 243, 256, 291 American Psychiatric Association, 70, 244, 259, 314, 317, 324, 325 American Psychological Association, 7, 110, 160, 162, 236, 331 amphetamines, 60, 245 amygdala, 245, 316, 320 anger, 165, 313, 316, 319 ANOVA, 120 anthropologists, 102, 297 antidepressant, 8, 196, 208 antidepressant medication, 196 anxiety disorder, 49, 50, 55, 103, 108, 188, 190, 192, 193, 199, 204, 205, 206, 209, 210, 211, 214, 215, 216, 217, 219, 220, 259, 314, 315 Argentina, 137, 211, 284 Asia, 2, 20, 29, 72, 116, 117, 189, 256, 257, 284, 285, 287 Asian Americans, 109, 153, 207, 221, 250, 256, 257, 264, 265 Asian countries, 116 assault, 2, 6, 217, 314, 315 assessment, 9, 10, 13, 16, 17, 18, 67, 69, 115, 119, 142, 159, 187, 195, 208, 311, 331 assets, 327 assignment, 76, 79, 207 assimilation, 12, 18, 90, 108, 111, 116, 128, 157, 158, 224, 230, 231, 247, 248, 286, 287, 301 asylum, 205, 285, 291, 296, 298, 299, 310 attachment, 110, 140, 237, 319

Index

336

attitudes, 9, 10, 13, 14, 16, 19, 32, 48, 81, 90, 108, 116, 150, 194, 198, 226, 232, 238, 239, 253, 262, 264, 265, 271, 278, 279, 286 attractiveness, 327, 328, 329, 330, 331, 332 atypical antipsychotic agents, 195 Australia, 7, 15, 20, 25, 88, 96, 97, 116, 117, 129, 183, 201, 204, 230, 231, 237, 238, 284, 295, 297, 298, 300, 301, 302, 306, 308, 309, 310, 311 authors, 44, 46, 47, 60, 115, 224, 228, 235, 257, 283, 296 autonomy, 12, 29, 30, 87, 89, 94, 107, 290 availability, 1, 5, 14, 15, 24, 41, 166 awareness, 18, 191, 224, 233, 234

B background, 5, 22, 23, 25, 26, 30, 37, 44, 51, 72, 82, 111, 199, 213, 290, 309, 333, 334 Bangladesh, 76, 115 barbiturates, 60 barriers, 5, 94, 149, 194, 275, 276, 303, 304, 309 base rate, 80 basic needs, 138, 144, 167, 302 beauty, 154, 327, 328, 330, 331 Beck Depression Inventory, 136, 217 beer, 271, 272, 273 behavior, iv, 1, 4, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 35, 53, 59, 69, 89, 91, 92, 150, 164, 191, 204, 205, 245, 247, 260, 264, 265, 271, 279, 285, 322, 323, 324 behavioral dimension, 325 behavioral problems, ix, 5, 92, 94, 98, 163, 168, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180, 182, 183 behaviorism, 321, 323 Belgium, 206, 285 belief systems, 304 beliefs, 67, 102, 107, 108, 150, 231, 248, 306 beneficial effect, 107, 165 beverages, 269, 271 bias, 5, 8, 50, 55, 171, 172, 174, 180, 193, 195, 197, 213, 218 binge drinking, 270, 271, 274 biological systems, 244 bipolar disorder, 193, 196, 207, 211, 333 birth, 7, 34, 45, 55, 61, 65, 71, 72, 73, 74, 76, 77, 81, 84, 96, 107, 116, 117, 120, 121, 123, 124, 125, 126, 127, 136, 137, 142, 156, 208, 229, 255, 258, 302, 310 blood pressure, 11, 160 body dissatisfaction, 161 body image, 163, 168, 169, 171, 174, 175, 177, 178, 179

Bolivia, 137, 211 bonds, 11, 12, 29, 87, 93, 140, 301 border crossing, 184, 299 Bosnia, 285 Bosnia-Herzegovina, 285 brain, 245, 259, 316, 319, 320, 321, 324 brain structure, 320 Brazil, vi, 129, 209, 210, 211, 212, 214, 215, 216, 217, 218, 219, 220, 221, 307 Britain, 11, 33, 35, 71, 73, 76, 79, 80, 81, 84, 216, 284, 309 buffer, 26, 92, 93, 140, 192 burning, 24, 32, 82 business management, 334

C Canada, 9, 10, 12, 15, 18, 19, 22, 29, 35, 72, 82, 85, 97, 116, 183, 188, 201, 203, 206, 219, 227, 229, 284, 292, 301, 330 cancer, 41, 50, 52, 55 Caribbean, 38, 71, 72, 76, 77, 78, 79, 81, 82, 84, 89, 136, 151, 160, 161, 207, 219 categorization, 257 category b, 79 Caucasian population, 12, 15 Caucasians, 246, 261 Caucasus, 268 causal attribution, 307 Census, 94, 151, 238 central nervous system, 237 certification, 75 child development, 183 childhood, 1, 5, 34, 35, 51, 315, 320 childhood sexual abuse, 34 children, 5, 17, 37, 58, 68, 69, 88, 89, 91, 92, 93, 97, 104, 106, 160, 167, 179, 181, 182, 183, 184, 198, 201, 202, 208, 238, 249, 256, 268, 276, 299, 300, 302, 303, 320, 328 Chile, 137 China, 16, 22, 23, 26, 28, 31, 115, 235, 287 chronic illness, 92, 301 citizenship, 4, 138, 258, 267, 305 City, 7, 37, 59, 69, 133, 137, 151, 161, 333 class period, 61 classes, 168, 178, 245, 298, 304 classification, 74, 80, 193, 195, 207, 220, 244, 290, 308, 323, 324 clients, 16, 227, 302 clinical depression, 153, 234 clinical diagnosis, 153 clinical symptoms, 314 clozapine, 195

Index cocaine, 13, 60, 69, 245, 249, 255, 257, 264 cognition, 89, 322, 323 cognitive process, 316, 329 cognitive style, 103, 108 cognitive variables, 68 cohesion, 30, 68, 81, 92, 140, 141, 144, 146 cohesiveness, 29 cohort, 10, 11, 32, 34, 74, 88, 129, 166, 208, 259, 263, 265 collaboration, 38, 52, 197 collectivism, 116 college students, 70, 135, 145, 161, 212 common law, 152 communication, 24, 93, 102, 218, 290, 296, 302, 303, 307 communication strategies, 303 communication technologies, 296 community psychology, 160 comorbidity, 94, 143, 256, 318, 319 compatibility, 76 competence, 58, 68, 163, 168, 169, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180, 183, 300, 304, 305, 307, 310 competitive markets, 305 complexity, 9, 18, 68, 296, 298, 305 components, 10, 107, 108, 153, 210, 284, 291, 303 composition, 60, 72, 79, 170, 173, 174, 175, 233, 297 comprehension, 323 concentration, 212, 227, 246, 314 conceptual model, 55, 70 conceptualization, 139, 159 conditioned response, 245 conduct disorder, 25, 106 confidence, 43, 72, 77, 119, 120, 124, 190 confidence interval, 43, 72, 77, 120, 124, 190 conflict, 15, 116, 165, 247, 296, 302, 310, 311 conformity, 247 confounding variables, 158 confusion, 90, 151, 247 consent, 75, 154, 190 consumption, 207, 269, 271, 273, 276 control, 15, 28, 29, 30, 34, 113, 114, 115, 119, 126, 130, 131, 171, 213, 218, 219, 220, 246, 260, 261, 265, 278, 308, 321, 322, 325 convergence, 50, 95, 193 conversion rate, 51 coping strategies, 161, 232 coronary heart disease, 130 correlation, 58, 61, 119, 123, 230 correlations, 67, 119, 120, 123, 169, 173, 174 corruption, 4, 178 cortex, 245, 246, 316

337

corticotropin, 333 costs, 31, 289, 290, 298 counseling, 53, 61, 96 country of origin, 4, 10, 14, 15, 46, 48, 89, 102, 107, 114, 138, 140, 141, 151, 164, 173, 174, 175, 189, 210, 211, 216, 235, 257, 276, 286, 296, 299, 300 covering, 255 craving, 245, 246, 260 Croatia, 285 cross-cultural comparison, 128 cross-sectional study, 203 Cuba, 137, 154 cues, 261, 327, 329, 330 cultural beliefs, 11, 150 cultural differences, ix, 9, 16, 138, 247, 258, 274 cultural heritage, 14, 140, 268 cultural identities, 108 cultural memory, 23 cultural norms, 11, 14, 29, 150, 232, 243, 247, 259, 328 cultural practices, 30, 304 cultural tradition, 14, 15, 30 cultural transition, 90, 181, 182, 204 cultural values, 30, 67, 68, 102, 103, 107, 115, 127, 150

D data analysis, 200 data collection, 78, 235 database, 55, 74, 83 death, 8, 19, 27, 34, 50, 58, 71, 72, 73, 74, 75, 76, 78, 79, 81, 91, 130, 299, 322 deaths, 74, 75, 76, 77, 79, 278, 297 decision making, 151, 323 decision-making process, 165 definition, 76, 79, 217, 243, 258, 286 delinquency, 89, 90, 97, 269, 278 delinquent behavior, 90, 169 delivery, 152, 295, 304, 305 demographic characteristics, 167, 168, 174, 177, 180, 234 demographic factors, 59, 134, 192 denial, 16, 30 Denmark, 72, 82 density, 35, 102, 103, 107, 108, 111 Department of Health and Human Services, 52, 159 depressive symptomatology, 60, 61, 153, 160 depressive symptoms, 16, 18, 19, 58, 66, 67, 69, 88, 91, 105, 106, 135, 136, 137, 138, 140, 143, 144, 145, 146, 147, 150, 153, 157, 259 deprivation, 81, 134, 141, 301 detachment, 158, 270

338

Index

detection, 207, 261 developed countries, 178, 287, 290 developing countries, 284, 287, 290, 291 developmental process, 89, 179 diabetes, 1, 5, 233, 298, 307 Diagnostic and Statistical Manual of Mental Disorders, 187, 259 diagnostic criteria, 193, 216, 318 differentiation, 16, 289, 305 direct action, 245 direct measure, 78 discrimination, ix, 4, 5, 10, 59, 69, 89, 90, 95, 107, 136, 138, 140, 149, 153, 163, 165, 166, 170, 172, 173, 174, 175, 176, 177, 179, 180, 181, 183, 184, 188, 202, 230, 232, 234, 247, 250, 264, 300 disequilibrium, 227 dislocation, 230 disorder, ix, 5, 25, 31, 52, 109, 111, 115, 129, 133, 135, 187, 188, 193, 194, 196, 197, 198, 199, 202, 209, 210, 211, 214, 215, 216, 217, 224, 225, 229, 231, 244, 249, 251, 252, 264, 271, 314, 315, 317, 318, 319, 320, 333 displaced persons, 261, 296 displacement, 296 disposition, 256, 322 dissonance, 107, 269 distribution, 61, 117, 120, 190, 224, 236, 279, 286, 290 distribution of income, 290 diversity, ix, 38, 116, 260, 298, 304, 307, 310 division, 41, 290, 323 division of labor, 290 divorce, 26, 27, 274 doctors, 188, 194, 199, 200, 298, 301, 302, 304 domestic violence, 27, 28, 304 Dominican Republic, 290, 293 dopamine, 245, 260 drinking pattern, 110, 269, 271, 278 drinking patterns, 110, 269, 271, 278 drought, 299 drug abuse, 5, 60, 210, 252, 256, 260 drug addict, 245, 246, 275 drug addiction, 245, 246 drug dependence, 251, 264 drug treatment, 199, 275 drug use, 1, 5, 9, 13, 19, 60, 61, 62, 66, 67, 69, 70, 91, 95, 96, 187, 189, 190, 195, 196, 197, 199, 208, 244, 248, 249, 250, 251, 252, 253, 255, 256, 257, 261, 263, 264, 278, 279 drugs, 13, 58, 60, 103, 107, 155, 187, 195, 196, 197, 200, 209, 244, 245, 246, 251, 252, 253, 254, 256, 259, 260, 263, 264, 303, 304

DSM, 18, 69, 95, 109, 129, 137, 143, 146, 187, 188, 192, 193, 197, 198, 199, 216, 219, 220, 244, 245, 250, 252, 263, 271, 314, 315, 317, 318, 320, 324, 325 DSM-II, 18, 69, 129, 137, 143, 146, 219, 220, 314 DSM-III, 18, 69, 129, 137, 143, 146, 219, 220, 314 DSM-IV, 18, 95, 109, 143, 187, 192, 193, 197, 198, 199, 216, 220, 244, 245, 250, 252, 263, 271, 314, 315, 317, 318, 325 duration, 16, 18, 34, 153, 165, 195, 199, 235, 239, 316 dysthymia, 193, 210, 211, 215, 217, 221 dysthymic disorder, 315

E East Asia, 117, 205, 284, 292 Eastern Europe, 77, 78, 117, 224 eating, 205, 209, 214, 304 eating disorders, 304 economic adaptation, 102 economic development, 178, 233, 288, 290 economic disadvantage, 80 economic growth, 284, 290 economic problem, 114 economic resources, 247, 269 economic status, 32, 115, 165, 210, 269, 301 economic theory, 287 economics, 10, 285, 300 editors, iv, ix, 1, 3, 20, 55, 314, 325, 326, 331 Education, 138, 152, 181, 292, 331, 332 educational attainment, 251 educational programs, 184 Egypt, 285, 286 El Salvador, 137, 289 elderly, 10, 80, 116, 206, 211, 217, 221, 271, 303 elders, 144, 145 emigration, 163, 167, 177, 178, 188, 211, 212, 229, 268, 284, 288, 296 emotion, 14, 16, 59 emotional disorder, 106 emotional distress, 17, 80, 188, 192, 197, 234, 262, 300, 307 emotional experience, 14 emotional information, 5 emotional state, 138 emotional well-being, 192, 308 emotions, 89, 158, 307, 313, 316 employees, 214, 288, 290 employment, 11, 41, 120, 141, 152, 191, 192, 230, 235, 239, 268, 277, 287, 288, 290, 296, 297, 300, 305 employment status, 141, 191, 230, 235

Index empowerment, 35, 128, 131 England, 15, 32, 71, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 104, 106, 109, 182, 211 environment, 5, 6, 24, 30, 41, 46, 87, 89, 107, 111, 116, 119, 138, 141, 146, 156, 164, 165, 220, 229, 246, 247, 298, 323 environmental change, 51, 306 environmental conditions, 269, 298 environmental factors, 7, 46, 50, 94, 95, 96 epidemic, 238 epidemiology, 19, 21, 22, 38, 46, 50, 52, 220, 224, 238, 256, 270, 318 epinephrine, 246, 261 equality, 6, 75, 230, 248 ethnic background, 140 ethnic groups, 13, 23, 26, 29, 31, 38, 54, 71, 72, 73, 74, 76, 78, 80, 81, 111, 145, 149, 159, 161, 199, 230, 246, 248, 250, 252, 255, 256, 257, 259, 328 ethnic minority, 29, 38, 68, 80, 82, 133, 150, 160, 161, 199, 233, 247 ethnicity, 14, 21, 22, 25, 30, 37, 40, 41, 43, 49, 51, 52, 53, 59, 68, 69, 71, 74, 75, 76, 78, 79, 80, 81, 102, 134, 135, 137, 144, 146, 159, 160, 183, 205, 210, 219, 220, 237, 244, 246, 247, 249, 250, 253, 262, 299, 306 ethnocentrism, 102 etiology, 7, 297 euphoria, 165, 177, 180, 228 Euro, 253 Europe, 2, 22, 23, 25, 26, 72, 88, 106, 117, 189, 193, 206, 229, 255, 257, 284, 285, 288, 291, 300, 302, 307, 309, 311, 318 European refugees, 237 European Union, 203 evolution, 17, 262, 317, 320 exchange rate, 4 exclusion, 79, 250, 299, 301 exposure, 6, 10, 15, 46, 66, 67, 68, 87, 89, 91, 92, 94, 98, 103, 107, 188, 191, 249, 251, 278, 303, 313, 314, 315, 316, 317, 329, 331 externalizing disorders, 25

F face validity, 61, 118 facilitators, 189 failure, 119, 313, 316, 321, 322, 324 family conflict, 27, 95, 114, 137, 140, 181, 237 family environment, 185 family functioning, 92 family history, 16, 256, 316 family income, 120, 212, 214, 216, 243 family life, 48

339

family members, 16, 27, 29, 48, 49, 89, 93, 105, 107, 246, 269, 297, 298, 299, 300, 302, 303, 304, 309 family relationships, 9, 12, 93, 141, 145 family support, 27, 92, 93, 140, 156 family system, 29, 165 family therapy, 96 family units, 88 fear, 149, 275, 289, 300, 301, 303, 304, 313, 314, 316, 317, 319, 320 feedback, 246, 298 feelings, 90, 93, 94, 103, 134, 138, 140, 153, 164, 169, 179, 218, 298, 303, 310, 328 females, 21, 22, 23, 24, 25, 26, 27, 29, 32, 54, 58, 72, 77, 91, 138, 167, 256, 328 Fiji, 22 Filipino, 250, 253, 262, 302, 308, 310 financial resources, 5, 138 financial support, 189, 194 Finland, 95, 183 firearms, 14, 15, 58 ffirst generation, 10, 22, 26, 37, 46, 49, 67, 76, 155 First World, 307, 323 focusing, 37, 51, 59, 74, 139, 150, 157 food, 48, 103, 108, 164, 167, 210, 245, 255, 284 forced migrants, 205, 296 forced migration, 306 France, 14, 229, 262, 285, 300, 302, 308 freedom, ix, 1, 2, 29, 30, 175, 303 friendship, 188, 193, 302 frontal cortex, 313, 316 frontal lobe, 323, 324 frustration, 103, 165, 250, 264, 322

G gender differences, 22, 25, 33, 72, 116, 131, 190, 196, 197, 205, 206, 256, 278 gender role, 157, 303 gene, 159, 246, 260, 261, 316 gene expression, 316 General Health Questionnaire, 187, 190, 204 general practitioner, 194 generalization, 218, 314 generalized anxiety disorder, 103, 193, 311 generation, 11, 13, 14, 18, 32, 37, 46, 49, 50, 62, 69, 72, 73, 76, 80, 82, 91, 93, 151, 160, 161, 189, 195, 199, 211, 248, 252, 257, 258, 259, 260, 289 generational status, 58, 135, 140, 253 genes, 246, 260, 261, 316, 319 genetic factors, 7, 50, 246 genetics, 50, 89, 260, 319 Geneva Convention, 298, 307 genome, 246, 260, 316

Index

340 geography, 308, 334 Georgia, 53, 54, 137 Germany, 7, 34, 72, 82, 102, 105, 109, 111, 201, 203, 279, 285, 288, 308 gestures, 33, 54 GHQ, 187, 190, 192, 204 girls, 25, 88, 232, 252, 253, 255, 256, 272, 273 globalization, 305 government, iv, ix, 3, 167, 194, 200, 211, 230, 288, 289, 299, 301, 303, 305 GPA, 167 grades, 5, 43, 57, 59, 94, 169, 272 grants, 52, 333 graph, 45 Great Britain, 202 Great Depression, 284 Greece, 35, 101, 104, 105 Greeks, 104, 127, 298 grounding, 309 group therapy, 275 grouping, 142, 188, 314 growth, 2, 101, 181, 290 Guatemala, 137 guidance, 28, 30, 110 guilt, 14, 16, 153, 330, 332 guilty, 169, 271

H Haiti, 151, 154, 156, 157, 161 hazards, 164, 165 health care, 6, 13, 15, 27, 30, 54, 89, 187, 188, 190, 194, 198, 199, 200, 203, 204, 206, 207, 232, 234, 239, 244, 300, 301, 304, 309, 311 health care costs, 244 health care system, 27 health effects, 158 health insurance, 167 health problems, 38, 114, 115, 116, 150, 198, 199, 210, 218, 220, 223, 227, 230, 233, 234, 263, 297, 301, 304, 305 health services, 6, 74, 149, 157, 189, 190, 194, 195, 197, 198, 218, 234, 237, 239, 302, 304, 310 health status, 7, 50, 109, 129, 202, 203, 205, 210, 239, 278, 304, 308 helplessness, 103, 115, 153, 164, 218, 314 heroin, 13, 246, 257, 261, 275, 279 heterogeneity, 142, 199 high blood pressure, 18, 233 high school, 57, 59, 60, 70, 97, 152, 167, 168, 271, 273 higher education, 107, 166, 167, 179, 191, 268 hippocampus, 245, 316

Hispanic population, 38, 57, 58, 59, 146 Hispanics, 10, 37, 38, 39, 40, 41, 42, 43, 44, 46, 48, 49, 50, 51, 52, 58, 59, 68, 69, 70, 91, 95, 104, 105, 110, 129, 130, 144, 145, 147, 243, 246, 249, 250, 251, 252, 254, 256, 257, 262, 264, 265, 307 HIV, 299 HIV/AIDS, 299 Hmong, 230, 237, 310 homelessness, 298, 299, 301 homeostasis, 246 homework, 60, 62, 66 Hong Kong, 7, 14, 22, 25, 95, 97, 232, 234, 285 hopelessness, 103, 153 hormone, 246, 333 hospitalization, 43, 201, 207 hospitals, 109, 211, 224, 330 host population, 11, 13, 103, 115, 116, 191, 192, 193, 197 host societies, 107 hostilities, 299, 308 hostility, 1, 2, 80, 88, 189, 227, 230 House, 83, 96, 146, 293 household income, 113, 120, 123, 124, 125, 126, 127, 128 households, 190, 230, 268, 288, 303 housing, 107, 167, 189, 203, 216, 227, 232, 289, 299, 301, 305 human capital, 286, 289, 290 human nature, 262, 332 human resources, 268 human rights, 75, 296, 305 humanitarian immigrants, 296 hurricanes, 317 husband, 17, 26, 27, 28, 29 hyperactivity, 252 hyperinflation, 299 hypertension, 1, 5 hypochondriasis, 227 hypothesis, 46, 50, 67, 84, 88, 96, 106, 110, 126, 164, 165, 174, 175, 177, 178, 179, 180, 188, 189, 191, 193, 198, 225, 234, 274, 316, 317, 325 hypothesis test, 46

I ICD, 188, 198, 209, 213, 214, 215, 216, 220, 314, 324 identification, 79, 161, 183, 226, 264, 276, 299 identity, ix, 7, 18, 30, 69, 81, 84, 87, 89, 90, 94, 95, 96, 102, 103, 105, 107, 108, 109, 110, 111, 116, 127, 140, 142, 150, 151, 158, 164, 165, 169, 182, 183, 184, 195, 205, 210, 230, 231, 232, 247, 255, 277, 301, 317

Index ideology, 116 illegal aliens, 184 illicit substances, 91, 258 IMA, 33 image, 29, 169, 171, 172, 173, 175, 176, 177, 179 images, 29, 31, 329 immune system, 316 implementation, 233, 236, 334 imprinting, 331 imprisonment, 26, 114, 128 impulsive, 322, 323, 324 impulsivity, 319, 321, 322, 323, 324, 325 incarceration, 299, 314 incidence, 25, 29, 33, 54, 107, 108, 111, 130, 211, 224, 225, 229, 230, 234, 236, 299, 300 inclusion, 16, 74, 79, 83, 212, 248, 314 income, 13, 35, 53, 59, 61, 69, 105, 114, 121, 122, 123, 125, 127, 129, 134, 138, 141, 145, 153, 170, 191, 205, 210, 217, 236, 283, 284, 287, 295, 321 independent variable, 61 India, 7, 15, 22, 23, 24, 26, 28, 32, 73, 76, 77, 115, 130, 286, 287, 309 Indians, 32, 82, 115, 210, 235, 250, 298 indicators, 19, 21, 46, 75, 80, 83, 91, 114, 115, 119, 126, 191, 199, 207, 259, 328 indigenous, 15, 20, 188, 224, 290 indigenous peoples, 20 indirect effect, 245 individual action, 289 individual character, 226, 236 individual characteristics, 226, 236 individual differences, 142, 205 individualism, 107 individualistic values, 127 industrialized countries, 285, 328 inequality, 115, 130, 141, 290, 305 infant mortality, 74, 75 infants, 302, 328, 330 inferences, 224, 330 infestations, 233 information processing, 5, 323 informed consent, 168, 213 inhibition, 245 initiation, 253, 257 injections, 195 injury, 19, 27, 35, 76, 84 insanity, 108, 201, 322 institutions, 72, 212, 213, 224, 248 instruction, 189, 230 instrumental support, 189 instruments, 41, 106, 118, 131, 142, 188, 198, 217, 315, 324 insurance, ix, 149, 194

341

integration, 9, 28, 30, 81, 84, 107, 113, 114, 115, 116, 117, 119, 120, 121, 124, 125, 127, 128, 139, 189, 203, 210, 218, 231, 234, 247, 262, 289, 302 interaction, 59, 61, 87, 89, 90, 92, 93, 125, 164, 177, 246, 248, 258, 285, 286, 288 interaction effect, 258 interaction effects, 258 interactions, 111, 286, 327, 328 internal consistency, 118, 119, 153, 169, 170, 171 internalization, 25, 29 internalizing, 33, 90, 138, 198, 248 International Classification of Diseases, 193, 314, 324 international migration, 101, 114, 188, 237, 283, 284, 285, 287, 288, 289, 295, 296, 305, 307 internet, 300 interpersonal communication, 16 interpersonal relations, 93 interpersonal relationships, 93 interrelations, 69 intervention, 13, 17, 87, 91, 93, 94, 97, 289 interview, 9, 16, 48, 118, 154, 190, 193, 195, 209, 212, 213 intoxication, 2, 6 Iran, 26, 29, 34, 35 Iraq, 291 Ireland, 14, 15, 19, 53, 71, 73, 76, 77, 78, 81, 111, 205 Islam, 19 isolation, 91, 108, 114, 116, 156, 230, 298, 299, 300, 301, 303, 319 Italy, 14, 109, 201, 203, 284

J Jamaica, 151 Japan, 14, 19, 129, 210, 216, 217, 219, 220, 229, 246 Jews, 168, 183, 185, 189, 190, 205, 219, 246, 268, 269, 277 jobs, ix, 5, 37, 268, 286 Jordan, 285

K Korea, 209, 211, 215, 216, 217, 218, 220, 285, 330 Kosovo, 285

L labeling, 61

342

Index

labor, ix, 29, 250, 264, 268, 283, 284, 287, 288, 289, 290, 291, 300, 305, 306, 310 labor force, 283, 287, 288 labor markets, 289, 305 labour, 303, 308 labour force, 303 labour market, 308 lack of control, 115, 119, 126, 128, 130, 202 land, 1, 2, 233, 283, 284, 290 language acquisition, 230 language barrier, ix, 4, 11, 94, 194, 269, 304 language proficiency, 94, 135, 157, 287 language skills, 46, 232, 286, 303 laptop, 190 later life, 202 Latin America, 38, 50, 233, 247, 256, 286, 292 Latinos, vi, 69, 91, 133, 134, 135, 136, 137, 138, 139, 140, 141, 142, 143, 145, 146, 150, 151, 153, 159, 160, 202, 207, 249, 251, 253, 263 laws, 26, 27, 28, 284 learning, 115, 131, 164, 189, 268, 272 legal protection, 300 leisure time, 334 Less Developed Countries, 292 lethargy, 303 life changes, 59, 192 life course, 25, 29, 34 life cycle, 162 life expectancy, 74, 276, 279 life satisfaction, 182 life span, 192 lifespan, 157 lifestyle, 324 lifetime, 18, 37, 41, 43, 44, 45, 46, 47, 50, 51, 53, 54, 57, 60, 61, 66, 67, 95, 109, 110, 116, 129, 133, 135, 137, 139, 143, 145, 193, 205, 209, 210, 212, 213, 214, 216, 248, 249, 250, 251, 252, 253, 255, 262, 263, 264, 275, 315 likelihood, 11, 23, 80, 89, 138, 141, 198, 249, 271 limbic system, 313, 316 limitation, 51, 74, 139, 190, 199 line, 119, 155, 174, 247, 287, 304 linear model, 238 linkage, 75, 199 links, 34, 153, 283, 284 lipid metabolism, 5 living conditions, 60, 191, 299 local community, 107 locomotor, 260 loneliness, ix, 12, 62, 66, 67, 163, 168, 171, 174, 175, 177, 178, 179, 180, 182, 184, 300 longitudinal study, 7, 84, 88, 95, 96, 130, 168, 177, 181, 184, 205, 239, 260, 279

loss of appetite, 153 Louisiana, 230 loyalty, 116, 140, 226 LSD, 13, 245, 251 lung cancer, 233, 238 lysergic acid diethylamide, 245

M machinery, 290 magnetic resonance, 316 magnetic resonance imaging, 316 Mainland China, 97 mainstream society, 300 maintenance, 9, 12, 161 major cities, 234 major depression, 5, 33, 54, 70, 133, 134, 138, 139, 145, 157, 193, 211, 319 major depressive disorder, 138, 193, 320 majority group, 24, 25, 30, 31, 108 malaria, 38 males, 19, 21, 22, 23, 24, 25, 27, 58, 77, 80, 104, 138, 155, 196, 256, 271, 317, 328 management, 144, 161, 171, 297, 334 manic-depressive illness, 219 manufacturing, 290 marginalization, 101, 102, 107, 108, 247, 258, 300 marijuana, 60, 91, 249, 251, 252, 253, 255, 257, 264 marital status, 16, 18, 26, 34, 81, 84, 85, 109, 113, 120, 124, 140, 192, 212, 216, 234, 258 market, 29, 189, 250, 268, 287, 289, 290, 291, 306 market economy, 290 markets, 191, 289, 290 marriage, 26, 27, 30, 107, 152, 214, 297, 300, 303, 308 mathematics, 334 meanings, 26, 46, 158 measurement, 35, 142, 158, 160, 163, 169, 171, 180, 255 measures, 29, 48, 68, 115, 117, 119, 154, 169, 171, 172, 174, 178, 179, 180, 184, 188, 208, 233 media, 66, 67, 68, 115, 255, 328 median, 47, 271 medical care, 305 medication, 17, 187, 196, 197, 199, 204 Mediterranean, 207 memory, x, 319, 320 men, 10, 14, 21, 22, 23, 24, 25, 26, 28, 30, 33, 71, 72, 73, 77, 78, 79, 80, 81, 111, 113, 114, 116, 124, 125, 127, 128, 130, 138, 140, 147, 155, 156, 157, 159, 193, 196, 197, 213, 214, 249, 250, 254, 256, 261, 271, 277, 290, 300, 303, 315

Index mental disorder, 50, 55, 96, 101, 103, 104, 106, 108, 109, 116, 135, 161, 187, 188, 189, 190, 192, 193, 194, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205, 208, 209, 211, 212, 214, 216, 218, 220, 223, 224, 225, 229, 230, 235, 316, 318 mental health professionals, 158, 160, 214 mental illness, 11, 12, 13, 16, 20, 52, 73, 87, 88, 94, 144, 188, 204, 223, 224, 236, 263, 297 mentally impaired, 104 meta-analysis, 20, 55, 96, 264, 319, 320, 328 metabolic syndrome, 1, 5 metabolism, 246, 261 Mexico, 20, 37, 38, 43, 44, 50, 57, 59, 61, 62, 64, 65, 135, 136, 137, 160, 210, 249, 255, 263, 264, 286, 287, 288, 289, 292, 302, 308 Miami, 57, 149 mice, 245, 260, 319 microeconomics, 286 middle class, 108, 302 Middle East, 23, 72, 117, 233, 246, 288 migrant population, 72, 77, 225, 301 migration movements, 296, 305 minorities, 82, 85, 111, 144, 147, 149, 154, 161 minority, 28, 29, 30, 31, 32, 35, 58, 70, 71, 72, 73, 74, 78, 80, 81, 108, 115, 149, 151, 184, 229, 232 minority groups, 72, 81, 149 minors, 165, 179, 184 mobility, 5, 7, 49, 101, 258, 290, 296, 305, 306 models, 18, 61, 88, 102, 103, 110, 111, 213, 223, 233, 235, 236, 238, 262, 285, 287, 288, 297, 307, 317, 321, 324 moderators, 102, 103, 319 money, 4, 38, 285, 299, 300, 306 mood, 2, 6, 8, 49, 50, 55, 60, 88, 103, 135, 138, 153, 187, 190, 192, 193, 194, 195, 196, 197, 199, 206, 207, 209, 214, 215, 216, 217, 227, 259, 297, 298, 314, 315, 316, 317, 319, 333 mood disorder, 8, 50, 88, 103, 135, 193, 194, 207, 209, 214, 215, 216, 217, 297, 298, 314, 316, 317, 319, 333 morbidity, 128, 164, 165, 193, 258 Morocco, 285 mortality, 55, 71, 72, 73, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 130, 258, 265, 276, 277, 278, 279 mortality rate, 75, 276 mother tongue, 164, 198 mothers, 154, 168, 179, 198, 238, 302, 307, 310 motivation, 102, 107, 180, 286, 291, 300, 323 motives, 3, 24, 103, 283, 284, 291, 298, 331 movement, 2, 29, 30, 38, 88, 211, 284, 285, 287, 288, 290, 297, 298 MRI, 316 multidimensional, 107, 247

343

multiple factors, 143, 223, 316 multiple sclerosis, 41, 52 music, 60, 102, 108, 334

N narratives, 277, 284, 313, 315, 316, 317 nation, ix, 2, 65, 84, 165, 233, 259 national culture, 290 national emergency, 55 national interests, 233 national origin, 41, 67, 80, 235, 248 native population, 5, 11, 23, 114, 199, 224 natural disasters, 6, 296, 317 natural resources, 290 natural sciences, 333 NCS, 39, 40, 54, 137, 259, 315 negative attitudes, 170 negative consequences, 11, 180, 244, 323 negative emotions, 89, 245 negative outcomes, 141 negative relation, 156 neglect, 22, 34, 315 Netherlands, 21, 22, 23, 24, 26, 27, 29, 32, 33, 35, 72, 82, 97, 129, 183, 202, 207, 229, 238, 285 network, 17, 38, 93, 94, 189, 230, 288, 289, 301 neurobiology, 33, 319, 324, 333 neuroimaging, 320 neurons, 245, 260, 316, 324 neuropsychiatry, 325 neurotransmission, 319 neurotransmitter, 245 New England, 154 New Zealand, vi, 34, 205, 223, 233, 234, 235, 236, 238, 239, 279, 284, 310 Nicaragua, 137 nicotine, 244, 245, 246, 252, 260, 261 nitrous oxide, 245 non-citizens, 258 non-institutionalized, 190 norepinephrine, 245, 247 normal development, 165 normal distribution, 175 North Africa, 28, 189, 285, 291 North America, 2, 10, 14, 15, 19, 24, 32, 34, 117, 161, 233, 235, 236, 264, 288, 295, 297, 302, 333 Northern Ireland, 76, 83 Norway, 104, 105, 106, 111, 113, 117, 121, 123, 128, 129, 130, 131, 205, 224, 236, 284

Index

344

O occupational prestige, 236 Oceania, 117, 284 OECD, 207 olanzapine, 195 older people, 192, 270 omission, 73 on-the-job training, 286 opiates, 245, 260 order, 1, 2, 22, 38, 46, 47, 60, 94, 141, 151, 165, 168, 171, 175, 192, 195, 258, 260, 269, 283, 284, 287, 288, 290, 305 orientation, 65, 67, 69, 102, 108, 227

P Pacific, 10, 12, 205, 233, 234, 298 Pacific Islanders, 10, 298 pain, ix, 24, 59, 69, 195, 227 Pakistan, 26, 28, 34, 76, 77, 115, 309 Panama, 137 Paraguay, 137, 211 parental attitudes, 92 parental authority, 165 parental influence, 327, 329, 330 parental involvement, 92 parental pressure, 17 parental support, 93, 183 parenting, 17, 97, 110 parents, x, 17, 27, 28, 29, 37, 46, 51, 65, 88, 89, 90, 92, 93, 97, 106, 154, 156, 163, 165, 166, 167, 168, 170, 172, 173, 174, 175, 176, 177, 179, 181, 183, 184, 216, 232, 272, 276, 302, 303, 329, 331 Parisians, 210, 219 Parliament, 74 pathogenesis, 7 pathology, 4, 104 pathophysiology, 5, 313, 316 pathways, 38, 73, 90, 138, 298, 316 patient care, 207 PCP, 13 PCR, 261 Pearson correlations, 119, 120, 156 peer group, 90, 91, 92 peer relationship, 92, 93 peer support, 87, 92, 93 peers, 5, 65, 89, 92, 93, 94, 163, 164, 165, 166, 170, 172, 173, 174, 175, 176, 177, 178, 179, 181, 187, 198 peptic ulcer, 229, 237 perceived attractiveness, 329

perceived control, 113, 114, 115, 117, 126, 131 perceptions, 61, 259, 265, 277, 297, 298, 328 Persian Gulf, 285 personal efficacy, 169 personal identity, 90, 226 personality, 4, 119, 126, 179, 225, 229, 238, 319, 320, 321, 323, 324, 325, 329 personality disorder, 319 personality traits, 4, 119, 126, 320 Peru, 137 PET, 316 pharmacotherapy, 199, 207 photographs, 328, 329 physical abuse, 26, 27, 28, 315 physical attractiveness, 327, 329, 330, 331 physical environment, 188, 268 physical health, 4, 151, 157, 223, 233, 234, 296, 298, 303 physical well-being, 89 policy makers, 234 political instability, 299 politics, 10, 14, 230, 310, 318, 334 polymorphism, 261 polymorphisms, 246, 261 polynomial functions, 175, 176 poor, 13, 59, 60, 71, 73, 81, 89, 92, 93, 107, 113, 116, 127, 141, 149, 194, 234, 235, 287, 295, 297, 299, 300, 301, 303, 304, 305 population group, 75, 190, 224, 231 Portugal, 182, 284, 300, 309 positive attitudes, 271 positive behaviors, 328 positive correlation, 123 positive mental health, 141, 232 positive reinforcement, 245 positive relation, 140, 235 positive relationship, 140, 235 positron emission tomography, 316 post traumatic stress disorder, 114 posttraumatic stress, ix, 5, 318, 319, 320, 333 post-traumatic stress disorder, 90, 188, 193, 211, 214, 234, 239, 301, 313, 314, 318, 319 poverty, 5, 13, 15, 31, 34, 61, 80, 107, 138, 232, 268, 274, 298, 300, 303 poverty line, 61 power, 22, 26, 30, 118, 130, 179, 198, 199, 322 prediction, 178, 238 predictive validity, 118 predictors, 10, 16, 19, 81, 95, 96, 120, 123, 125, 136, 145, 146, 156, 161, 184, 235, 264, 329 preference, 37, 46, 51, 213, 255, 291, 308, 329 preferential treatment, 330 prefrontal cortex, 245, 313, 316

Index pregnancy, 250, 252, 264, 302, 310 prejudice, 11, 90, 188, 209, 212, 214, 216, 232 pressure, ix, 15, 17, 28, 29, 116, 127, 128, 155, 156, 277, 288, 300, 303, 322 prestige, 233 prevention, 2, 6, 12, 13, 20, 30, 31, 38, 53, 54, 68, 70, 73, 74, 75, 82, 108, 151, 160, 198, 238, 256, 257, 258, 276, 317 preventive programs, 59, 68 PRI, 39, 40, 41 probability, 69, 213, 286, 287 problem behavior, 54, 70, 183, 278 problem behaviors, 54, 70, 183 problematic alcohol use, 91, 257 problem-solving, 92, 93 problem-solving skills, 92, 93 professional qualifications, 230 profits, 4, 290 prognosis, 7, 111, 315 program, 110, 161, 167, 168, 171, 180, 181, 188, 213, 275, 325, 329, 334 prosperity, 2, 284 protective factors, 14, 16, 80, 87, 92, 93, 94, 96, 98, 135, 141, 143, 189, 259, 261 protective mechanisms, 103 psychiatric diagnosis, 25, 314 psychiatric disorders, iv, 1, 4, 5, 6, 18, 20, 24, 25, 51, 59, 69, 70, 95, 104, 110, 111, 129, 135, 137, 139, 143, 145, 146, 188, 193, 195, 199, 200, 202, 209, 210, 211, 213, 214, 215, 216, 217, 218, 219, 220, 251, 253, 263, 264, 307, 315, 322 psychiatric hospitals, 211 psychiatric illness, 25, 211 psychiatric morbidity, 101, 111, 137, 141, 197, 221, 235 psychiatrist, 194, 214, 234, 333 psychoanalysis, 323 psychological health, ix, 89, 183, 302 psychological problems, 151, 164, 269, 316 psychological processes, 163 psychological resources, 141, 166, 177, 179, 180 psychological stress, 125, 137, 150, 183, 316 psychological stressors, 150 psychological variables, 179 psychological well-being, 5, 11, 18, 89, 163, 164, 165, 166, 167, 168, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180, 185, 232 psychologist, 194, 214 psychology, iv, ix, 110, 130, 157, 161, 181, 184, 262, 322, 332 psychometric properties, 259 psychopathology, 27, 88, 96, 101, 102, 103, 104, 106, 184, 188, 201, 208, 230, 262, 318, 323, 325

345

psychoses, 225 psychosis, 79, 80, 84, 219 psychosocial conditions, 128, 316 psychosocial factors, 126, 246 psychosocial functioning, 129 psychosocial stress, 138, 144, 261 psychosomatic, 90, 151 psychostimulants, 260 psychotherapy, 20, 199, 234, 307 psychotropic drugs, 187, 190, 195, 196, 197, 198, 199, 200 PTSD, 114, 209, 217, 234, 313, 314, 315, 316, 317, 318, 319, 320 puberty, 25 public health, 48, 133, 244 public opinion, 142, 289 public policy, 128 public service, 218 public support, 305 Puerto Rico, 137, 252 punishment, 275, 332

Q quality of life, 271, 283, 301

R race, 32, 52, 53, 59, 69, 144, 146, 153, 159, 244, 250, 253, 262, 298, 306 racial differences, 111, 244 racism, 81, 107, 108, 216, 303 radio, 62, 65, 66, 154 Rainbow Nation, 308 range, 10, 60, 81, 104, 138, 153, 154, 155, 157, 180, 191, 227, 228, 233, 246, 263, 303, 313, 315 rating scale, 237 ratings, 328, 329 readership, 295, 297 reading, 102, 113, 288 real income, 287 real wage, 284 reality, 210, 247, 265, 269 reason, 119, 127, 179, 218, 297, 302 receptors, 245, 260 recognition, 6, 71, 79, 81, 230 recurrence, 25, 96 reflection, 110, 144, 146 reforms, 75, 305 refugee camps, 301, 309, 310 refugee group, 227 refugee resettlement, 310

Index

346

refugees, iv, 1, 3, 6, 111, 114, 116, 117, 128, 129, 160, 178, 188, 201, 207, 223, 225, 226, 227, 228, 230, 231, 233, 234, 235, 236, 237, 238, 239, 285, 291, 295, 296, 298, 299, 301, 303, 307, 309, 310, 311 region, 60, 61, 67, 268, 270, 275, 285 regression, 61, 66, 67, 120, 123, 124, 125, 126, 155, 190, 213, 324 regression analysis, 66, 67, 125, 190 regression equation, 66, 67 regulation, 28, 29, 83, 207, 246 rejection, 9, 13, 30, 105, 107, 234 relationship, 2, 6, 13, 14, 17, 25, 27, 28, 31, 38, 47, 50, 60, 68, 69, 92, 103, 104, 106, 113, 115, 117, 125, 134, 136, 137, 138, 139, 141, 142, 143, 144, 150, 156, 157, 158, 160, 223, 231, 234, 235, 236, 237, 246, 260, 290, 322 relative size, 229, 328 relatives, 28, 136, 140, 213, 219, 230, 246, 303 relevance, 10, 16, 21, 28, 29, 30, 50, 116 reliability, 82, 142, 153, 158, 162, 220, 328 religion, 14, 19, 75, 192, 212, 217, 218 religiosity, 160, 213, 217, 218 remittances, 296, 302 representativeness, 128 reproduction, 30, 302 reproductive age, 296 resettlement, 129, 130, 211, 226, 229, 230, 232, 233, 284, 296, 297, 300, 302, 305 resilience, 87, 92, 94, 95, 96, 141, 300, 313, 315, 317, 320 resistance, 275 resources, 14, 59, 89, 93, 114, 138, 160, 178, 192, 233, 303 retirement, 296, 309 risk factors, 9, 10, 15, 16, 18, 21, 22, 26, 27, 28, 30, 53, 55, 70, 71, 73, 74, 80, 81, 83, 89, 90, 92, 103, 114, 117, 125, 130, 134, 142, 143, 146, 157, 202, 203, 205, 206, 210, 216, 219, 230, 259, 318 risk profile, 80 risk-taking, 252 romantic relationship, 93 Royal Society, 332 rural areas, 14, 251 Russia, 166, 167, 168, 170, 171, 177, 178, 181, 184, 185, 198, 268, 277, 278 Rwanda, 318

S sadness, 14, 89, 116, 298, 303 sample survey, 60, 190

sampling, 44, 60, 67, 188, 198, 209, 212, 213, 218, 219 Sartorius, 130, 204, 220 satisfaction, 161, 191, 207, 226 Saudi Arabia, 285 schizophrenia, 13, 107, 109, 199, 208, 211, 219, 220, 224, 229, 236, 237 school, 17, 19, 44, 53, 60, 70, 88, 89, 90, 92, 94, 102, 152, 163, 167, 168, 169, 170, 171, 174, 175, 177, 178, 179, 183, 184, 185, 262, 269, 270, 272, 303 schooling, 46, 214, 286, 287 scores, 120, 135, 136, 137, 153, 155, 156, 157, 169, 191, 192, 198 second generation, 16, 22, 37, 46, 59, 67, 80, 84, 108, 111, 146, 248 Second World, 285 secondary students, 204 security, 107, 268, 291, 299 self esteem, 59, 69, 115, 158 self-concept, 26, 169, 182, 184 self-control, 321, 322 self-efficacy, 92, 93, 113, 115, 118, 119, 121, 122, 123, 126, 184 self-esteem, 92, 93, 94, 103, 163, 164, 168, 171, 174, 175, 177, 178, 179, 180, 182, 183, 184, 262 self-identity, 238, 303 sensitization, 245 separation, 11, 140, 165, 177, 181, 198, 216, 231, 247, 269, 300, 302 serotonin, 245, 260, 324, 325 service provider, 304, 305 SES, 58, 59, 138, 139, 191 severe stress, 25, 225, 314 severity, 55, 104, 106, 143, 204, 279, 315, 318, 320, 332 sex, 4, 28, 33, 44, 70, 93, 134, 136, 138, 169, 229, 245, 258, 260, 299, 300, 303, 329, 331 sex differences, 33, 70, 138 sex role, 28 sexual abuse, 27, 28, 30, 35, 58 sexual behavior, 106, 263 sexual behaviour, 106, 110 sexual experiences, 327, 328 sexual health, 311 sexual violence, 303, 315 sexuality, 29, 30 shame, 16, 304 shape, 133, 248, 295, 296, 297, 298, 317 sharing, 12, 107, 115, 286 shock, 164, 181, 314, 322 signs, 193, 298, 313, 314 simulation, 330 Singapore, 22, 229, 285

Index skills, 93, 141, 286, 289, 300, 333 sleep disturbance, 153 smokers, 210, 246, 253 smoking, 107, 253, 257, 261, 264, 304 social acceptance, 6, 230, 297 social behavior, 22, 38, 115 social capital, 299, 301 social change, 179, 285 social circle, 158, 300 social class, 77, 80, 81, 109, 129, 225, 229, 230, 289 social competence, 168, 171, 174, 175, 177, 178, 179 social context, 41, 113, 114, 116, 298, 303 social control, 29, 30 social desirability, 171, 174, 180, 184 social environment, 164, 179 social group, 28, 298 social institutions, 285, 305 social integration, 12, 18, 19, 28, 30, 34, 101, 103, 113, 114, 115, 116, 117, 120, 123, 125, 127, 128, 131 social justice, 305 social life, 28, 29, 116, 285, 286, 303 social network, 12, 15, 164, 230, 247, 269, 283, 284, 288, 289, 305 social norms, 116, 127 social oppression, 69 social order, 297 social participation, 158 social phobia, 198, 210 social policy, 4, 5, 102, 108 social problems, 169, 269 social regulation, 5, 13, 29 social relations, 144, 146, 268, 301 social relationships, 301 social resources, 95, 165, 166 social roles, 247 social services, 223, 233, 304 social situations, 169 social skills, 191, 227 social standing, 249 social status, 5, 88, 268 social stress, 31, 134 social structure, 19, 289, 290, 291 social support network, 88, 188, 193 social units, 288 social welfare, 182, 188 social withdrawal, 60, 227 social workers, 93, 181, 194, 276 socialization, 25, 46, 138, 247, 248 socioeconomic status, 5, 13, 15, 58, 59, 61, 138, 144, 149, 151, 188, 191, 209, 212, 301 software, 71, 79, 81, 190, 213 solidarity, 93, 107

347

somatization, 205, 220, 298, 307 South Africa, 14, 19, 76, 235, 299, 308 South Asia, 22, 23, 24, 26, 29, 30, 33, 35, 71, 76, 78, 79, 80, 81, 84, 130, 208 Southeast Asia, 237, 239 Soviet Union, vi, 92, 163, 168, 177, 178, 182, 185, 187, 188, 203, 205, 211, 219, 267, 268, 276, 277, 278, 279, 285, 292 space, 303, 313, 314 Spain, 14, 88, 94, 255, 284, 313, 321 special education, 270, 276 spectrum, 319, 323 speech, 6, 8, 13, 19 Sri Lanka, 22, 76, 77 stability, 165 stabilizers, 187, 195, 196, 199 standard deviation, 121, 171, 172 standard error, 172, 176 standard of living, 37, 290, 301 standards, 328 statistics, 10, 23, 58, 73, 74, 82, 83, 114, 277, 295, 321, 323 status of refugees, 230 stereotypes, 102, 304, 323 stereotyping, 11, 258 stigma, 16, 149, 275, 298, 304 stigmatized, 256 stimulant, 245 stimulus, 103, 233, 322 stock, 2, 283, 285 strategies, 71, 73, 75, 80, 152, 231, 234, 238, 298, 305 stratification, 18, 60, 190 strength, 41, 88, 89, 96, 138, 158, 233, 279 stressful events, 188 stressful life events, 5, 89, 92, 93, 95 stressors, 11, 13, 26, 68, 87, 88, 89, 90, 92, 94, 103, 114, 128, 135, 138, 140, 157, 158, 191, 210, 225, 232, 247, 299, 300, 302, 303, 305 striatum, 245 strong interaction, 258 structural equation modeling, 97 students, 44, 57, 59, 61, 70, 88, 95, 97, 116, 161, 168, 170, 181, 184, 185, 191, 214, 252, 262, 270, 271, 272, 273, 274, 287, 296, 300, 329 subgroups, 54, 58, 74, 142, 145, 192, 243, 257, 258 subjective well-being, 145, 185 sub-Saharan Africa, 307 substance abuse, ix, 16, 58, 60, 61, 67, 70, 87, 90, 91, 94, 105, 112, 244, 245, 246, 256, 263, 314, 315 substance use, 8, 18, 61, 67, 91, 104, 110, 129, 185, 209, 214, 216, 217, 243, 244, 246, 247, 248, 249,

Index

348

250, 251, 252, 253, 255, 256, 257, 258, 259, 260, 261, 262, 263, 264, 273, 279 sugar, 290 suicidal behavior, 1, 3, 4, 5, 6, 7, 8, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 50, 53, 54, 55, 58, 68, 69, 87, 91, 94, 265, 315, 319, 333 suicidal ideation, 19, 21, 25, 27, 34, 38, 44, 48, 49, 53, 54, 55, 58, 59, 61, 65, 66, 67, 69, 70, 136, 137, 146, 151, 160, 259, 265 suicide attempters, 23, 25, 26, 27, 28, 29, 33 suicide attempts, 6, 18, 21, 24, 25, 27, 32, 35, 38, 41, 44, 49, 53, 54, 58, 59, 61, 66, 67, 69, 91, 182, 205, 257, 259 suicide rate, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 22, 23, 25, 26, 28, 29, 30, 33, 34, 51, 55, 58, 68, 70, 71, 72, 73, 75, 76, 77, 78, 79, 80, 81, 82, 88, 257 supply, 287, 288 support services, 235 surveillance, 298, 304 survival, 164, 330 Sweden, 6, 7, 23, 32, 72, 82, 105, 109, 111, 205 swelling, 322 Switzerland, 14, 182, 285, 307 symmetry, 331, 332 sympathetic nervous system, 246 symptom, 20, 90, 109, 131, 169, 191, 227, 228, 230, 234, 303, 314, 315, 320 symptomology, 161 symptoms, 1, 5, 16, 17, 26, 53, 59, 60, 70, 80, 89, 90, 95, 97, 101, 103, 106, 107, 110, 118, 129, 138, 140, 144, 150, 151, 153, 158, 159, 187, 188, 189, 192, 193, 194, 197, 200, 203, 204, 217, 227, 228, 245, 261, 298, 313, 314, 316, 319, 324, 325 syndrome, 188, 245, 314 synthesis, 134, 142, 247, 261 Syria, 285

T Taiwan, 14, 234, 308, 311 tangible resources, 179 target population, 117 task performance, 130 teachers, 92, 170, 172, 173, 174, 175, 176, 177, 179, 181 teaching, 333 teenagers, 184, 288 teens, 55, 70, 87, 92, 94 telephone, 213 temporary protection, 301 temporary protection visa, 301 terrorism, 191, 204, 270, 271, 278, 317

tertiary education, 168, 175 test-retest reliability, 169, 170, 171 therapy, 199 thinking, 75, 150 Third World, 308 thoughts, 6, 60, 61, 89, 115, 169 threat, 114, 118, 131, 231, 258, 316 threats, 116, 127, 157, 158 threshold, 188, 197 time frame, 43, 188 timing, 50, 228, 298 tobacco, 60, 209, 214, 215, 216, 217, 244, 248, 253, 256, 257, 263, 264, 290 toluene, 245 torture, 114, 128, 234, 314 toxic gases, 15 TPV, 301 traditional practices, 302 traditionalism, 107 traditions, 30, 116, 150, 231, 290, 298 training, 5, 159, 160, 191, 270 training programs, 270 traits, 230, 247, 319, 320, 328, 330 tranquilizers, 60 transference, 226 transformation, 306 transition, 15, 87, 89, 177, 178, 229, 260, 286 transitions, 55 translation, 60, 154, 303 translocation, 103 transmission, 260, 262 transnationalism, 307 transport, 299 transportation, 284, 290 trauma, 4, 107, 142, 178, 179, 180, 231, 234, 276, 301, 313, 314, 315, 316, 317, 318, 319 traumatic events, 114, 251, 315, 318 traumatic experiences, 4, 107, 218 treatment methods, 275 trust, 194, 299, 301, 305 tuberculosis, 233 Turkey, 22, 23, 26, 28, 32, 287, 292

U UK, 22, 23, 24, 26, 27, 29, 71, 74, 76, 77, 79, 84, 102, 109, 130, 201, 203, 208, 325 Ukraine, 166, 167, 168, 170, 171, 177, 178, 181, 184, 185, 268, 285, 333, 334 uncertainty, 51, 297, 301 unemployment, 80, 89, 107, 114, 128, 216, 232, 235, 239, 288, 299, 304 UNESCO, 262

Index United Kingdom, 26, 83, 115, 233 United Nations, 1, 2, 7, 201, 283, 291, 306 universities, 167 upward mobility, 90 urban areas, 14, 23, 251, 264, 287, 299 urban population, 109, 290 urbanization, 284 Uruguay, 137 USSR, 2, 78, 268, 285

V validation, 17, 84, 183, 184, 208, 238, 258 variability, 134, 165 variables, 27, 33, 46, 57, 60, 61, 65, 66, 67, 102, 107, 113, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 134, 136, 142, 156, 157, 158, 159, 172, 173, 174, 175, 176, 177, 184, 191, 198, 199, 216, 257, 258, 272, 275, 287, 310, 313, 316 variance, 149, 155, 156, 179, 210, 220, 246 victims, 27, 315 violence, 15, 27, 34, 35, 98, 218, 252, 269, 274, 276, 279, 299, 301, 303, 309, 310, 314, 317, 318 visas, 296, 298, 300 vulnerability, 1, 5, 6, 26, 27, 29, 59, 191, 210, 217, 224, 246, 260, 261, 296, 297, 298, 299, 301, 303, 305, 309, 313, 315, 316 vulnerability to depression, 59

W wage level, 287

349

wages, 287, 288 Wales, 32, 71, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84 war, 6, 8, 102, 114, 128, 129, 231, 285, 314, 317, 333 weakness, 128, 218 welfare, 1, 3, 194, 297, 300, 301, 302, 305, 311 welfare state, 305 West Africa, 71, 77, 78, 81 Western countries, 116, 117, 121, 125, 126, 127, 236 western culture, 22, 328 Western Europe, 77, 78, 102, 117, 118, 285 workers, 88, 135, 202, 219, 226, 288, 299, 300 working conditions, 299, 300 working hours, 17 World War I, 284

X xenophobia, 308

Y young adults, 70, 96, 110, 262

Z Zimbabwe, 298, 309 ziprasidone, 195