Populations

ETHNICITY, POVERTY, AND DEPRESSION

 

JOHN, an African American aged 10, entered an elevator with his father. Two men inside started arguing, one drew a gun and fired. One of the bullets hit John's father in the stomach, who died almost instantly on the moving elevator. The boy's first reaction was to vomit, a nausea his mind would not let him forget.

Welcome to the dark side of the rainbow coalition, where a perfectly normal boy can be turned into a mental health case in just a few short seconds. John's story is from the Surgeon General's 2000 Mental Health: Culture, Race, and Ethnicity, which is a supplement to his 1999 landmark "Report on Mental Health."

According to the Supplement: "More than 40 percent of inner city young people have seen someone shot or stabbed. Exposure to community violence, as victim or witness, leaves immediate and long-term effects on mental health, especially for youth." Not surprisingly, between 1980 and 1995 the suicide rate amongst African American youths aged 10 to 14 increased 233 percent.

An Ethnic View of Mental Illness

The Supplement examines mental health issues facing four broad ethnic groups, including African Americans, American Indians and Alaskan Natives, Asians and Pacific Islanders, and Hispanic Americans. Even though there is very wide diversity across and within these groups, the Supplement notes they all face a social and economic environment of inequality that takes its toll on mental health.

In addition, if these people happen to be poor, they share a decided lack of access to treatment. Other common factors include mistrust of the system, stigma, communication difficulties, and stereotyping. To cite a small sampling of facts from the Supplement:

• 43 percent of African Americans and 28 percent of Latinos felt their healthcare provider treated them badly because of race or economic background as opposed to five percent of whites.
  In some Asian cultures, mental illness is thought to reflect badly on family lineage, and diminishes marriage and economic prospects for other members.
• African Americans are overdiagnosed for schizophrenia and underdiagnosed for bipolar disorder.
  African Americans and Asians in general are slow metabolizers of certain antipsychotics and antidepressants. Physicians unaware of this may prescribe doses that are too high, resulting in severe side effects and noncompliance.
• One third of American Indians and Native Alaskans do not have a doctor or clinic that can provide regular or preventive health care.
• Many Southeast Asian refugees are at grave risk as a result of the traumas they experienced before and during immigration to the US - for Vietnamese the fall of Saigon, for Cambodians the killing fields, for Laotians losing one-third of their population in war.
• Mexican immigrants who lived fewer than 13 years in the US had surprisingly lower prevalence rates for depression and other disorders than Mexican Americans born in the US.

 

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Hispanics

In California, in a matter of years, latinos will outnumber whites. By 2020, whites will comprise 37 percent of the population while hispanics will make up 41 percent. By 2050, this "minority" will be in a "majority" at more than 50 percent of the population, with whites at one in four. Meanwhile, immigrant populations are fanning out throughout the US.

At a conference put on in Dec 2009 by the Senior Mental Health Partnership (a program of NAMI San Diego), Concepcion Barrio PhD of the USC School of Social Work talked about mobilizing "culturally salient protective factors" in working with latinos. These include strong family attachments, supportive community networks, and deep spiritual/religious convictions. For instance, according to a 1998 study, of those with severe mental illness, 75 percent of latinos and 60 percent of African-Americans lived with their families, as opposed to just 30 percent of whites.

A 2006 meta-analysis of 56 studies found that interventions targeted to specific cultural groups were four times more effective than non-targeted interventions and that those conducted in a client's native language were twice as effective as those conducted in English.

Simply having providers employ ethnically-matched staff, along with other surface strategies, is only part of the picture, Dr Barrio argued. Deeper approaches incorporate the traditions of the ethnic group. She cited the well-known "Mexican Paradox," which has to do with first-generation Mexican-Americans faring a lot better mentally than assimilated earlier generations.

In addition, Dr Barrio pointed out, families from third-world nations tend to manifest lower "expressed emotions," such as hostilities. Acceptance and warmth in Mexican-American families, for instance, predict better outcomes from schizophrenia.

American Indians

At the same conference, Martina Portillo RN, MPH, who is a member of the Hopi Tribe and has had a distinguished career in the Indian Health Service, reported that 57 percent of 3.3 million American Indians/Alaskan Natives now reside in urban areas. "This is a complete reversal since I was little," Ms Portillo observed. Indians are moving to the cities for the same reasons the rest of us do - jobs and education.

Indian life expectancy, at 72.3 years, is about four years less than non-natives, a "complete improvement" according to Ms Portillo. Where the death rates are significantly higher: TB (750% higher), alcoholism (550% higher, but lower among older men than their counterparts among other races), diabetes (190% higher), unintentional injuries (150% higher), homicide (100%), and suicide (70%, very high in the young population but lower in elders than the general population).

Elders in the Indian population recall their culture being looked down upon as "bad", with forced boarding schools, banned spiritual practices, and loss of land by the allotment system. Barriers to mental health include differences in cultural beliefs about mental illness, cultural labeling of different emotions, lack of mental health professionals in the system (101 per 100,000 compared to 173 per 100,000 in non-native populations, lack of large scale studies, and lack of cultural orientation for providers (such as in the healing traditions). Rarely do elders seek out available mental health services.

Asians and Pacific Islanders

At the same conference, a panel of presenters from the Union of Pan Asian Communities (UPAC, which serves a vast range of Asian and Pacific Island communities in San Diego) reported that, among other things, Asian elders are confronted by a difference between how Asians and Americans view the elderly. The family matriarch, for instance, rather than enjoying an exalted seat of honor, may suddenly find herself a stranger in a strange land, even within her own family, especially if dealing with Americanized children and grandchildren.

Asian Americans whose families experience a high interpersonal conflict have a three-fold greater risk of attempting suicide compared to the general Asian population. This is true even among those who never had a history of depression. As the panel noted, this points to the strength of family values in Asian communities. Family harmony, they pointed out, is a value coming from Confucianist (stressing values) and Taoist (stressing balance) beliefs.

An intervention UPAC is working on includes "Problem Solving Treatment" aimed at older adults. Since depression is often caused by problems in life, the object is to help clients regain a sense of control and thereby improve their mood. For instance, people who are engaged in social activities at least two times a week have less depression than those not engaged.

African Americans

At the DBSA annual conference in 2001, William Lawson MD, PhD of Howard University noted that 40 percent of African American children are raised in poverty. African Americans earn only 60 percent of the median income, and possess just ten percent of family wealth. They are more likely than whites to pay out of pocket, and their treatment is more likely to be terminated quickly.

Nevertheless, they end up in the hospital more and are more likely to be treated with old generation antipsychotics. Clinicians tend to misinterpret cultural idioms as psychotic features while underdiagnosing for bipolar and depression. Not surprisingly, African Americans distrust the mental health system, but that fear also harkens back to the bad old days when blacks were unethically experimented on (the Tuskegee experiments the most notorious example).

It's a damn confusing time to be black," wrote Erin Aubry-Kaplan in an article at Salon.com. "Never before in history have blacks loomed so large in the public imagination and public culture yet been granted so little space as real people."

The article took an extended look at the 2001 book, "Lay My Burden Down: Unraveling Suicide and the Mental Health Crisis Among African Americans" by Alvin Poussaint and Amy Alexander. While Alvin was going to Columbia University and staking out his future as a psychiatrist, his brother Kenneth was shooting heroin en route to an early death. Alvin calls his brother's destructive behavior a "slow motion suicide."

Ironically, black people are experiencing higher rates of depression and suicide at a time when they are entering the middle class in ever-increasing numbers. Young blacks also account for 50 percent of all homicide deaths in the US in what only can be described as a form of suicide, according to Dr Poussaint.

"Undoubtedly, great strength allowed black people to survive slavery and discrimination," the authors write, "but the notion that black men and women can easily handle burdens that would psychologically crush other people has been oversold."

Down and Out

When depression hits someone in the middle class," writes author Andrew Solomon in his 2002 "The Noonday Demon", "it's relatively easy to recognize. "You're going about your essentially okay life and suddenly you begin feeling bad all the time." And, inevitably, as you plunge toward the point of no return, you are going to attract the attention of your friends, coworkers, and family.

Way over on the other side of the tracks, by contrast, the unraveling is far less noticeable, hardly making ripples as it drains victims of their vital forces and lends new meaning to the term, life sucks.
According to figures cited in his book, 42 percent of heads of households receiving Aid to Families with Dependent Children meet the criteria for clinical depression - more than twice the national average - and 53 percent of pregnant welfare mothers are in the same condition.

"Virtually all of America's indigent," he writes, "are, for obvious reasons displeased with their situation; but many of them are, additionally, paralyzed by it, physiologically unable to conceive of or undertake measures to improve their lot. In this era of welfare reform, we are asking that the poor pull themselves up by their bootstraps, but the indigent who suffer from depression have no bootstraps and cannot pull themselves up."

Some Things Never Change

Few of their children in the country learn English ... the signs in our streets have inscriptions in both languages ... unless the stream of their importation could be turned ... they will soon so outnumber us, that all the advantages we have will not in my opinion be able to preserve our language, and even our government will become precarious.

Ben Franklin said that, back in 1753, not Lou Dobbs. Franklin was expressing his alarm over Germans settling in Pennsylvania.

This article replaces an earlier piece, Jan 20, 2011, reviewed Dec 4, 2016

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