National Resource Center for Hispanic Mental Health®
Changing Minds, Advancing Knowledge, Transforming Lives™
Presenters:
Peter J. Guarnaccia, Ph.D. - Rutgers University
Igda Martinez, Psy.D. – Albert Einstein College of Medicine
Henry Acosta, MA, MSW, LSW –
National Resource Center for Hispanic Mental Health
Training Held on May 5, 2012 on behalf of the agency’s project:
Partners for Culturally Competent
Behavioral Health Service Delivery to Hispanics
1
 Funding
for Partners for Culturally
Competent Behavioral Health Service
Delivery to Hispanics was made possible
through a grant from the Bristol-Myers
Squibb Foundation.
 BMSF
had no control over the contents
of today’s training or any other program
development or intervention activities
2
Henry Acosta, MA, MSW, LSW
National Resource Center for
Hispanic Mental Health
3

10:00 am-10:15 am
Welcome, Overview &
Introductions: Henry

10:15 am-10:45 am
Assessing Diversity among
Latinos: Peter

10:45 am – 11:00am
Break

11:00 am-12:30 pm
Latino Mental Health: Focus on
Depression and Its Treatment: Igda

12:30 pm-1:30 pm
Lunch
4

1:30 pm-2:30 pm
DSMIV, Cultural Formulation and
Latinos: Peter

2:30 pm – 2:45 pm
Break

2:45 pm-3:30 pm
Using Genograms to Elicit Cultural
& Family Issues: Igda

3:30 pm-3:45 pm
Social & Cultural Assessment of
Hispanics: Peter

3:45 pm-4:00 pm
Evaluation & Wrap-Up
5
Peter J. Guarnaccia, Ph.D.
Rutgers,
The State University of New Jersey
6
7
8


One of the most popular debates and one of
the least likely to be solved
Hispanic adopted by U.S. Census in 1970
◦ Seen as an imposed term by U.S. government
◦ More identified with Spanish origins

Latino refers to Spanish, Indian & African
origins of people from the Americas
9
Source : U.S. Census, 2000
10
 Principal
Investigators
◦ Margarita Alegria, Harvard Medical School
◦ David Takeuchi, University of Washington
 Funding:
National Institute of Mental
Health, SAMHSA/CMHS and OBSSR
 Latino Sample:
◦ Nationally representative household sample:
adults 18 and older
11




75.5% response rate
Instrument fully translated
and adapted into Spanish
Administered by trained
bilingual/bicultural lay
interviewers
Analyses performed with
sample weights to account
for complex sample design
NLAAS Latino
Sample (N=2554)
614
868
495
577
Mexican
Puerto Rican
Cuban
Other
12
Cubans are significantly older than the
other Latino groups
13
Mexicans and Cubans include slightly more
males than the other Latino groups
14
Mexicans have less education than
the other Latino groups
15
Mexicans have significantly lower incomes
than the other Latino groups
16
Puerto Ricans are all citizens. About 60%
of the other 3 groups are citizens.
17
About 85% of Cuban respondents were born in Cuba.
Over half of Puerto Ricans were born on the mainland.
18
More likely that both parents born In US than 1 parent;
Cubans least likely to have US born parents
19
Puerto Ricans have spent more of their
life on the U.S. mainland
20
Cubans were the only group where a large
majority expressed a desire to move to the US
21
Cubans were more likely to have carefully
planned their move to the US
22
% Very Important
Reason for
Move
Puerto
Rican
Cuban
Mexican
Other
Latinos
p
Employment
66
52
75
65
.001
Join Family
51
53
48
52
.75
Improve Future
for Children
78
84
84
79
.05
Political
Situation
9
91
17
34
.001
Seek Medical
Attention
22
17
8
12
.003
Seek Education
60
56
56
62
.42
Family
Problems
10
6
8
5
.03
23
For Cubans visiting relatives in their home country was
very difficult. For Puerto Ricans it was easy.
24
Cubans were most likely to prefer the interview in Spanish, followed
by Mexicans. Puerto Ricans more often preferred English. The bilingual
group was small and of similar proportions across the groups.
25
There was a trend for Cubans to prefer Spanish and
Puerto Ricans English in general use. But there was
more expressed bilingualism for this question.
26
Overwhelmingly, everyone spoke Spanish as children.
27
Puerto Ricans are most English proficient;
Cubans are least.
28
Cubans are most Spanish proficient,
with the other groups being similar.
29
Everyone identifies closely with their
Latino group.
30
Relatively few think it is important to marry
within their Latino group.
31
Puerto Ricans experienced significantly lower acculturative distress;
Mexicans reported the highest levels of acculturative distress.
32
Puerto Ricans reported significantly higher levels of
Family Cultural Conflict than Cubans or Mexicans
33
Puerto Ricans and Other Latinos report a significant decline.
Cubans on average report a slight increase in social position in the US.
34


There are major differences among the 4 groups in
terms of their migration experiences
◦ Puerto Ricans are migrants; the other groups are
immigrants
◦ Cubans reported coming overwhelmingly for political
reasons; the reasons for the other groups were more
diverse
◦ The reception by U.S. society of the four groups was
different depending on how and why they came
◦ Acculturation processes begin in people’s home countries
given the impact of globalization
The 4 groups are also different in terms of the historical
relationships between their home countries and the U.S.
35
The majority of Puerto Ricans, Mexicans and
other Latinos (compared to one-third of
Cubans) have spent more than 70% of their
life on the mainland
 This has led to the emergence of new cultural
“mosaics” which include the Nuyorican
culture of Puerto Ricans in NYC and the
Chicano and Hispano cultures of Mexicans in
the southwest

36
There is considerable diversity among the 4
Latino groups in language preference and use.
 Language use looks different depending on
the context you ask about
◦ For example, the distribution of language
use is quite different for language of
interview compared to language of thought

37




Differences in social capital and in reception by U.S.
society result in significant differences among the
groups in social status
Cubans are the only group that report a status
increase
Puerto Ricans and Other Latinos report a large status
decline, while Mexicans report a small status decline
The reasons for these differences are not currently
well understood
38

Cubans reflect one end of the continuum where they
strongly maintain Spanish language in all contexts
◦ By transforming Miami, they were able to succeed without
giving up important aspects of their culture

Other Latino groups are more diverse in their
cultural experience, more dispersed geographically,
and have more diversity in social capital
◦ They have not come to economically and politically
dominate one area leading to very different acculturation
experiences
39
Igda E. Martinez, Psy.D.
Albert Einstein
College of Medicine
40
•
“Es como perder su techo, perder todo, es como
cuando uno ha pasado por un terremoto y perdió todo
… es como una acumulación de perdidas”
•
It’s like losing the roof over your head, losing
everything, it’s as if one had gone through an
earthquake and lost everything … it’s an
accumulation of losses
41
Richer understanding of Latinos’ conceptions
of depression
 Fuller understandings of Latinos’ attitudes
towards, concerns about, and expectations for
treatment
 Identify barriers to care from the perspective
of community members

42

Based on four different projects in New Jersey
and New York to examine:
◦ diverse Latinos’ conceptions of mental health,
treatment and barriers to care
◦ elderly Latinos’ understandings of depression and
reactions to standard depression measures
◦ community concerns about health and mental health
and needed services
◦ recognition of depression and attitudes towards care
43
94 participants in 12 different focus groups
throughout New Jersey and New York City
 Diverse group of Latinos in terms of country
of origin, time in U.S., age, gender,
education
 All of the groups were held in Spanish
 All groups led by Peter Guarnaccia
 Majority of the groups facilitated by Igda
Martinez

44
Social relationships and supports are key to
mental health
 Mental health was defined as being able to
function in and contribute to society
 It is being able to live una vida tranquila
 Being in control of one’s emotions and not
being aggressive
 Not abusing alcohol or drugs

45

Para mi una buena vida sería llevar una vida de
tranquilidad, sentirse con un poco de salud, que es lo
principal, y ... sentirse para mi bienestar con su familia
unida y vivir tranquilo.

A good life would be living a tranquil life, being
in good health, that’s the most important … to
feel a sense of well-being about my family’s
unity and to live peacefully
46
•
•
•
Depression is widely recognized among Latinos as a
mental health problem
Recognize both emotional and somatic aspects of
depression
Depression is seen as the result of social stressors
and losses:
– death of a family member, isolation/loneliness, loss of a
job and financial stresses, events of September 11th
•
Depression often connected to diabetes (and other
conditions such as high blood pressure)
47

Cuando una persona está triste, está nostálgica, se pone
a llorar facilmente, está muy cansada y no sabe por que,
no tiene ganas de hacer nada. Uno no tiene amigos, no
tiene familia, ni nada. Le hace falta más la familia.

When a person is sad, is nostalgic, s/he cries easily, feels
very tired and doesn’t know why, s/he has no desire to do
anything. One doesn’t have friends, doesn’t have family or
anything. When you feel like this, you miss your family
even more.
48
•
[Los hombres] se deprimen, ellos buscan el alcohol para
escaparse y no deprimirse. Tienen que hacerse a cargo
de la familia acá y tambien mandarle dinero a la familia
allá. Conseguir trabajo aquí es difícil.

Men get depressed. They seek out alcohol to escape and
not deal with their depression. They are responsible for
their family here and also have to send money to their
family there, and finding work here is difficult.
49
•
Nunca la cojí la consejeria porque yo dije, pero si
ellos me la están ofreciendo y yo fui y yo me
presenté. Pero me dijeron, no, el seguro de su esposo
no cubre eso. Necesita $250 de down.

I never received the counseling. They were offering
me the counseling and I went and presented myself.
But then they said, no, your husband’s insurance
doesn’t cover this, we need a $250 down payment.
50
•
[Nosotros] inmigramos, y nos encontramos con muchas
barreras como el idioma, no tenemos papeles, no
tenemos información de muchas cosas, no sabemos
cuales son nuestros derechos… la vida aquí es muy
difícil. Estamos muy aisladas aquí.

We immigrate here and find ourselves with many
barriers: such as language; we don’t have papers; we
don’t have information about many things; we don’t
know what our rights are … Life here is very difficult. We
are very isolated here.
51
•
En la cultura Hispana, piensan que ir a ver a un
psicólogo es cosa de locos. Es la parte de ignorancia,
saber entender y saber donde pedir ayuda.
•
In the Hispanic culture, we think that going to a
psychologist is only for people who are really crazy.
It’s due in part to ignorance, not being able to
understand depression, and not knowing where to
go for help.
52
Seek help from primary care providers because
are not aware of mental health as a specialty
service
 Language barriers and cultural issues in
understanding American style of mental health
treatment
 Need to be accessible, to build trust [confianza],
and to treat people with respect [respeto]

53

Yo he ido a unos cuantos psicoterapias... yo fui a uno que
se sentaba y me decía “habla” y parecía que le estaba
hablando a una pared. Pero el de ahora habla, da sus
opiniones, se ve que está interesado en conocerme a mi.
El trata de obtener mi confianza y así me hace sentir mas
cómoda...

I’ve gone to several psychotherapists… I went to one who
sat down and said “talk” and it felt like I was talking to a
wall. But the one I see now talks, gives his opinions, I can
tell that he is interested in getting to know me. He tries to
obtain my trust and thus makes me feel more
comfortable...
54
 Belief
that depression is a consequence
of difficult life circumstances, not an
illness
 Feeling of trying to deal with problems
on one’s own [hay que ponerse de su
parte]
 Medications are only for people who
are severely mentally ill
55
 Tendency
to seek out “talking cure”
first
 Need to “unburden oneself”
[desahogarse]
 Medicine seen as a last resort and a
temporary solution
◦ Fear of side effects and addictive potential
of psychiatric medications
56
Fear of addiction is very strong
 Use models of sleeping pills and coffee to
understand medicines

◦ Over time people need more and more to have an
effect, and it is difficult to stop

When a doctor directly explains the difference
and that the medicine can be stopped, people
are much more likely to accept the medicines
57

Nosotros los Hispanos, nos hemos
acostumbrado en los remedios caseros … la
medicina en realidad no es muy receptiva.

We Hispanos have become accustomed to
using home remedies … in reality, medications
are not very well received by the Hispanic
community.
58
Therapists need to be sensitive to cultural
expressions of depression (ie, somatization,
coraje, and various forms of nervios)
 Therapists need to orient Latino patients to
the process of mental health treatment
 Therapists need to directly explain
medications and address concerns about
addiction

59
 Programs
to help new Latino immigrants
to adjust to life in the U.S.
 Programs to reduce the stigma of mental
illness and mental health care
 More public information in Spanish about
where to get mental health help and how
to access care
60
 “¿Que
hace uno cuando hay un
problema? Se preocupa. Pero para
resolver hay que quitarle el ‘pre’ y
ocuparse”

What do you do when you have a problem?
You worry. But to resolve a problem, you have
to take off the “pre” and take care of it!
61
•
Immigrant Latinos experience lower rates of
depression than their U.S.-born compatriots and
than non-Hispanic Whites
– However, Latinos are more likely to endorse depressive
symptoms on item checklists
•
Latinos are less likely to seek mental health services
when they are depressed compared to Whites (Vega et al,
1998)
•
Immigrant Latinos have lower rates of service
utilization compared to US born Latinos (Alegria et al, 2004)
62
•
Minority group members have additional concerns
when entering treatment settings (Atdjian & Vega, 2005 )
•
Latinos are more likely than whites to have negative
beliefs about antidepressants (Cooper et al, 2003; Miranda & Cooper,
2004)
•
Latinos may not initially seek treatment for depression
because they see it as a natural reaction to life’s
problems, not as an illness
– Latinos show a preference for psychotherapy over
medications (Martinez & Guarnaccia, 2007)
– Fear of addiction and stigma attached to taking medications
– Cultural value placed on desahogo, or unburdening oneself
63
 Multiphase
study to adapt Motivational
Interviewing (MI) techniques to increase
adherence to antidepressants among
Latinos
◦ Phase I: Focus Groups & MI Adaptation
◦ Phase II: Pilot test of MI Adaptation
◦ Phase III: Randomized Control Trial
64
•
•
•
What cultural values influence people’s
decisions to take medications or not?
What do participants know about
antidepressant medications and what fears do
they have about this treatment?
Are participants able to accept the treatment
recommendations of their providers? What
influences their willingness to accept
treatment?
65
•
Tendency to value family relationships over other
social relationships
– Includes concepts such as respeto (respect)to refer the hierarchical
nature of family dynamics (Garcia-Preto, 2005).
•
A manifestation of the collectivist nature of
Latinos
– Benefits, status, and general well-being of the group take precedence
over those of an individual.
•
Dynamic concept
– Represents family unity, respect and responsibility
– Creates both positive and negative pressures
– Can lead to covering up severity of depressive symptoms in order to
protect family members
66

Instances in which family was mentioned
◦ Not necessarily describing the overall value of
familismo.
◦ Tendency to focus more on instrumental support

Important in the individual’s conceptualization
of depression or its treatment
◦ Directly challenged or influenced client’s
understanding or behavior.
67
 Multiphase
study
◦ Results presented are data from Phase I
 6 focus groups, 30 participants
 Completed between April – August 2006
 Average group size = 5 participants
 Audio-taped and transcribed
 Analyzed using ATLAS.ti
68



80% female
Age range 27-66

◦ Average: 47yrs

Time in U.S. 1-40 yrs

◦ Average: 18 yrs

Time w MDD <1-30 yrs
◦ Average: 11 yrs

Time on meds <1-24 yrs
◦ Average: 9 yrs



50% PR; 23% DR; 17% MX;
10% other
73% completed HS or more
80% read Spanish
Well/fairly well
83% do not speak English
73% speak mostly Spanish
with family
63% speak mostly Spanish
with friends
69
 Familismo
◦ 50 instances were coded
◦ Brought up by 73% of the participants
(n=22)
 Family
Influence
◦ 84 instances were coded
◦ Mentioned by 80% of participants (n=24)
70
•
Queremos mucho a los hijos, los
papas, todo, como queremos estar
siempre unidos…y todavía se casan y
uno quiere los nietos y to’l
mundo…que este reunido en la
familia, somos la familia muy unidas.
•
We care for our children, our
parents, everyone, very much; we
want to be always united… and
even when they get married …one
would like one’s grandchildren
and everyone … to join together
in the family, we are very united
families.
71
•
Otra cosa que no me gusta de aquí…uno no le puede
decir nada a los hijos…hacen lo que le da la
gana…aquí no hay niños y los hijos son los padres,
como quien dice. Ellos no obedecen, ni na’. En
nuestros países no. Todavía yo vieja obedecía a mi
mama y mi papa.
•
Another thing that I don’t like about here…one can’t
say anything to one’s children…they do whatever
they want…here there is no youth and the children
are the parents, in a way. They don’t obey or nothin’.
In our countries, no. Even in my old age I obeyed my
mom and my dad.
72
•
A mi lo que me motivo fue mi familia, porque mi familia
ahorita no esta conmigo pero ya va a venir mi hija y mi
esposa. Entonces yo, yo, mi problema fue que yo no quería
hablar con nadie y yo no le tenia confianza a nadie y fue lo
que me motivo a tomarla, el querer estar bien para cuando
viniera mi hija y mi familia.
•
What motivated me was my family, because my family right
now is not with me but soon my daughter and my wife will
come. So then I, I, my problem was that I did not want to talk
with anyone and I did not trust anyone, and what motivated
me to take [the antidepressants], was wanting to be well for
when my wife and my family came.
73
•
…el ver que eran ellos los que ya me lo estaban
bañando o dando de comer porque yo pasaba
llorando, tirada en la cama, eso fue lo que me hizo a
mi…claro, que era yo la que tenía que hacerme
responsable de mi hijo y dejar que mis otros dos hijos
tengan su niñez.
•
…to see that it was they who were already bathing
him and feeding him because I spent my time crying,
lying in bed, that was what made me… Of course, it
was I who needed to make myself responsible for my
son and let my two other children have their
childhood.
74
•
Yo no comparto con mi familia mis problemas porque no
quiero molestarlos …cuando ellos me preguntan que
como estoy yo les digo que bien o que a veces me siento
triste para no preocuparlos y ya todo lo que siento lo
cuento a la doctora
•
I do not share my problems with my family because I
do not want to bother them… when they ask me
how I am doing I tell them that I am fine or that
sometimes I feel sad so that I do not worry them and
then everything that I feel I tell the doctor.
75
•
… es preferible uno hablar esas cosas con un particular que
con la misma familia. Con mis hijos yo no hablo nada de lo
que siento...pero fíjate, yo a veces me siento que seria bueno
uno poder hablar con los hijos o con la familia y compartir el
dolor que uno siente, pero al fin y al cabo lo que salen son
problemas, mas problemas.
•
… it is preferable for one to speak about those things with
someone in particular than with your own family. With my
children I do not say anything about what I feel...but you
know I sometimes feel it would be good to be able to speak
with one's kids or with the family and share the pain that one
feels, but in the end what you get are problems, more
problems.
76


Treatment Supportive family influence
◦ 60% of participants mentioned (n=18)
◦ Help access care
◦ Providing support and reminders to take medications
◦ Help to obtain medications
Treatment Discouraging family influence
◦ 30% of participants mentioned (n=9)
◦ Expressed disagreement with the concept of
depression as an illness or the need for medications
as treatment.
77
•
Ella sale a, trata de buscar el dinero para comprar la
pastilla. Si ve que me falta, me la busca. Cuando la
dejo en la farmacia, ella va y me la recoge. Si por
caso, no tengo tiempo, ella trata de ser pendiente.
Me dice, ‘¿Tienes las pastillas contigo?’
•
She goes out to, she tries to find the money to
buy the pill. If she sees that I am short, she looks
for it. When I leave it at the pharmacy, she will
go and pick it up for me. If for any reason I don’t
have time, she always tries to pay attention, she
says to me, ‘Do you have the pills with you?’
78
•
Y mi hermana fue la que me llevo y yo estaba como
muy, pa’donde quiera que ella me tiraba yo me iba…
Ella era la que me decía a mi, “Gloria, te tienes que
tomar este medicamento.” Y yo decía, “¿Pa’ que es
eso?” Entonces dice, “Para curarte, para que estés
bien como antes.”
•
And my sister was the one who took me and I
was very, where ever she took me I would
go…She was the one who would say to me,
“Gloria, you have to take this medication.” I
would say, “What’s that for?”and then she’d say,
“To cure you, so you can be well, like before.”
79
•
…mis padres me enseñaron …que podíamos bregar
con los problemas sin necesidad de medicamentos. Y
a la vez que uno empezó con medicación …yo me
sentí como si hubiera sido como de otro planeta
vamos a decir. Era algo que estaba fuera de mis
manos.
•
…my parents taught me that …we could deal with
problems without medication. And the minute
that I started with the medication …I felt as if I
was from another planet, let’s say. It was
something that was out of my hands.
80
•
A veces mi mama me dice, “Yo tantos problemas que he
tenido y nunca he tenido que ir a un psiquiatra. ¿En que
fallaste tú? ¿Qué tu hiciste?” Y yo bueno, “Cada cual es
un mundo diferente,” le dije yo. “A lo mejor tú pudiste
con tus problemas pero yo con los míos no.”
•
Sometimes my mom says to me, “Me with all the
problems that I’ve had and I’ve never had to go to a
psychiatrist. What did you fail in? What did you
do?”And I well, “Everyone is different,” I tell her,
“Maybe you could deal with your problems but I
can’t with mine.’”
81
 Families
are important
◦ Familismo served in some cases as a
motivating factor to seek treatment, and in
some cases as a trigger for depression.
◦ A new issue arose within the value of
familismo: the idea of protecting the family
from self
◦ Families influenced the ways FG participants
understood their symptoms and viewed their
treatment.
82
 What
cultural values influence
people’s decisions to take
medications or not?
◦ Familismo
◦ Religion
◦ Poner de su parte (Do one’s part)
◦ Trabajar/luchar/aprovechar
(Work/Struggle/Take Advantage)
83
•
Clinicians need to be culturally sensitive
– It is not always wise to include or exclude family members in
treatment
•
– Should listen to the patient’s own experience of family
relationships and decide together
– If family is included, focus should be on
psychoeducation
Patients should be encouraged to take an active role in
treatment planning
– Patients should be empowered to negotiate with
clinician and decide their family’s role in their own
treatment.
84
Peter J. Guarnaccia, Ph.D.
Rutgers,
The State University of New Jersey
85
 Cultural
Identity of the Client
 Cultural Explanations of the Client’s Illness
 Cultural Factors Related to the Psycho-Social
Environment and Levels of Functioning
 Cultural Elements of the Relationship between
the Provider and Client
 Overall Cultural Formulation
Outline for Cultural Formulation, DSM-IV
86
Cultural
Explanations of the Client’s
Illness
◦ Predominant illness idioms
◦ Relation of client's signs and symptoms to
cultural norms
◦ Local illness categories
◦ Perceived causes used to explain illness
◦ Current preferences and past experiences of
help-seeking
87

An idiom of distress particularly prominent among
Latinos from the Caribbean, but recognized among
many Hispanic groups

Commonly reported symptoms include: screaming
uncontrollably, attacks of crying, trembling, heat in
the chest rising into the head, and becoming verbally
or physically aggressive

Dissociative experiences, seizure-like or fainting
episodes and suicidal gestures are prominent in
some ataques but absent from others
Glossary of Culture-Bound Syndromes, DSM-IV
88

A general feature of an ataque de nervios is a sense
of being out of control

Ataques de nervios frequently occur as a direct result
of a stressful event relating to the family, such as
news of a death of a close kin or a separation/
divorce from a spouse

After the ataque de nervios, people often experience
amnesia of what occurred. However, they otherwise
rapidly return to their usual level of functioning.
89

While descriptions of ataques de nervios most closely
fit with panic episodes, factors that distinguish them
from panic include:
◦ association of most ataques with a precipitating event
◦ frequent absence of the hallmark symptom of acute fear or
apprehension

Ataques de nervios span the range from:
◦ normal expressions of distress not associated with psychiatric
disorder
◦ to expressions of distress associated with anxiety, depression,
dissociation, or somatoform disorders
90
No Ataque
Ataques de nervios Odds Ratio
Depression (5%)
19 (2%)
29 (20%)
9.84
Dysthymia (12%)
67 (9%)
40 (28%)
3.63
108 (14%)
55 (38%)
3.73
Panic Disorder (2%)
3 (0.4%)
13 (9%)
25.08
PTSD (6%)
29 (4%)
25 (17%)
5.30
Any Affective
49 (6%)
43 (30%)
6.18
Any Anxiety
109 (14%)
58 (40%)
4.02
Any DIS Diagnosis
214 (28%)
91 (63%)
4.35
N=767 (84%)
N=145 (16%)
Generalized Anxiety (18%)
N= 912
Guarnaccia, et al., 1993, JNMD
91
Ataques distinct from PD
Common to Ataques and PD

Provoked

Recurrence

Crescendo > 10

Symptoms during
episode
minutes

Followed by relief

Fear during episode

Sequelae
92
Community Sample (n = 1891)
Absence of AdN
(n=1723)
Presence of AdN
(n=168)
2
Any Depression
33 (2.3)
16 (15.2)
8.11**
Any Anxiety
87 (5.4)
38 (22.1)
17.88***
Any Disruptive
171 (9.7)
39 (24.8)
12.09***
Any Diagnosis
243 (14.0)
62 (40.9)
24.43***
Any Impairment
196 (10.5)
55 (39.6)
19.20***
Diagnoses
Guarnaccia, et al., 2005, JAACAP
93
Clinical Sample (n = 757)
Absence of AdN
(n=563)
Presence of AdN
(n=194)
2
Any Depression
39 (7.0)
57 (30.2)
45.66***
Any Anxiety
83 (14.6)
72 (37.7)
35.53***
Any Disruptive
190 (33.4)
98 (50.7)
18.50***
Any Diagnosis
251 (44.7)
125 (65.4)
27.75***
Any Impairment
245 (44.1)
118 (62.4)
21.55***
Diagnoses
Guarnaccia, et al., 2005, JAACAP
94
70
60
50
40
30
20
10
0
***
***
62
58 62
55
***
36
31
16
16
20
***
10
8
Any depression
disorder
Any anxiety disorder Suicidal Symptoms
Self-Label
Syndrome
23
Psychotic Symtpms
Total Sample
Guarnaccia, et al., 2008
95
 Social
and psychiatric vulnerability
 Relation to panic disorder
 Relation to depression and suicidal
ideation & attempts
 Relation to dissociation
 Relation to trauma
96

Folk illness prevalent among Latinos in the U.S. and
among people in Mexico, Central America and South
America

Susto results from a frightening event causing the
soul to leave the body and resulting in unhappiness
and sickness

Symptoms may appear anywhere from days to years
after the fright is experienced and may result in
death.
Glossary of Culture-Bound Syndromes, DSM-IV
97

The core symptoms include: lack of appetite or
appetite gain; sleeping too much or too little;
troubled sleep or dreams; feeling sad; lack of
motivation to do anything or go anywhere; feelings
of low self worth or dirtiness

Diagnosis of susto is often confirmed by family,
friends and especially by a traditional healer, who
will help the sufferer to identify the source of the
fright

Sufferers of susto also experience significant strains
in key social roles.
98

Treatment for susto often occurs simultaneously
from biomedical providers and traditional healers
◦ A ritual healing is performed to call the soul back to the
body and to "cleanse" the person to restore bodily and
spiritual balance

An interpersonal susto characterized by feelings of
loss, abandonment and not being loved by family
with accompanying symptoms of sadness, poor self
image, and suicidal ideation seems to be closely
related to major depression
99

Mexican Americans in Texas, Mexicans in
Guadalajara & mestizos in Guatemala all recognize
susto as an illness
◦ Puerto Ricans do not



Fright, but not necessarily soul loss, a key symptom
Core symptoms: agitation, crying, nervousness,
trembling, fear of unfamiliar places, sleep
disturbances
Serious illness that could cause diabetes and lead to
death
Weller, et al., 2002, CMP
100


Women with susto (cibih in Zapotec) more likely to
meet CES-D criteria for depression than those without
(72% vs. 24%; N=40)
Types of susto
◦ Interpersonal
Depression
 Feelings of loss, abandonment by family, sadness, poor self image,
suicidal ideation
◦ Traumatic event
◦ Somatic symptoms
PTSD
Somatoform
 Health care from several practitioners
Taub, 1992
101


69% reported susto and 65% nervios (N=400)
Higher depression scores (Zung scale) for both susto
and nervios sufferers
◦ Susto: 42 points vs. 38 (p<.04)
◦ Nervios: 44 points vs. 34 (p<.001)


Those with susto and nervios higher depression
scores
Those with nervios more likely to be diagnosed as
depressed compared to those with susto
Weller, et al., 2005
102
 Vulnerability
to distress
 Relation
to fright, anxiety and trauma
 Relation to depression
 Relation to somatization
 Link
to diabetes
 Greater risk of mortality
103
Source:
Communicating Effectively Through
an Interpreter. Cross-Cultural Health
Care Program, Seattle, WA, 1998.©
104

Incorporate a mixed anxiety-depression
diagnosis
◦ Included in ICD-10
◦ Fits with a number of cultural syndromes
◦ Common presentation in primary care
Refine and expand Outline for Cultural
Formulation
 Update Glossary of Culture-Bound Syndromes

◦ Link syndromes to specific disorder chapters
105
Dissociation
Anxiety
Cultural
Syndrome
Depression
Somatization
106
107
 Rural
migrant from Puerto Rico
 13 years in U.S.
 Circular migrant
 Predominantly Spanish-speaking
 Poor English fluency
 Lived in Puerto Rican neighborhood
 Limited contact with broader society
108
Nervios and Ataque de Nervios
 Fits of anxiety and rage, followed by impulsive
suicidality
 Distressing, but culturally specific, dissociative
symptoms (hearing voices, seeing shadows)
 Children saw as difficult, overwhelming
 Nerves altered by unresolved family conflicts
 First saw internist, then accepted family
therapy and medical supervision of Latino
psychiatrist

109
 Key
stressor – estrangement from
children
 First husband abusive, second
murdered
 Daughter had drug problems and
lost her children
 Precarious social supports
110
 Treatment
prior to Latino clinic
hindered by lack of cultural
assessment of symptoms
 Latino clinic provided more
intensive assessment
 Focus on character pathology
111
Corrected psychotic label resulting from
dissociative symptoms and stopped
antipsychotic medications
 Focused on resolving family conflicts with
children through family therapy
 Diagnosis refocused on Borderline Personality
Disorder
 Recurrent dysphoria, but did not meet criteria
for Dysthymia

112
Igda E. Martinez, Psy.D.
Albert Einstein College of Medicine
113
•
•
•
•
•
•
•
Sociocultural, sociopolitical, & socioeconomic factors
Finances
Cultural Heritage
Belief systems, religion, spiritual beliefs
Language skills and acculturation of family members
Connections to community
Migration history
114
 Are
there sociocultural factors (ethnicity,
race, social class, legal status,
employment potential, education level)
that are impacting family’s current
functioning?
 Any past suffering/conflicts with family
members due to past political history?
 Where does family fit in the community?
115
 Pressures
from family – jealousy,
resentment, pressure to help other
family members
 Shame or conflict due to loss of status
◦ Upper class in country of origin
◦ Lower class in US
 Struggling
to meet ongoing needs
116
 Culture/ethnic
background of family
members
◦ Experiences with racism
 How
are they received in their local
communities?
 Are belief systems
accepted/encouraged?
117
 What
primary beliefs organize the
family?
 What is the history of the family’s beliefs,
what have been the changes, if any?
◦ Reactions to changes in the family?
◦ Differences within the community?
118
 What
languages are spoken in home?
◦ Among adults? Children?
 Power
imbalances?
 How much of heritage is retained?
◦ How are those decisions made?
119
How do family members maintain
friendships?
 How accessible are social support networks?

◦ Friends, family, school, religious organizations,
physicians, social service agencies, therapy, etc

Any moves from ethnic enclaves to other
communities?
◦ Stress of change, how adapted, who helped?
120
•
Why did family migrate? What were they looking
for? What did they leave behind?
– Premigration history: political/economic situation in
country of origin
– Migration history: trauma?
– Postmigration history and culture shock: arrival to US.
Language, immigration, poverty? Shock of cultural values?
Supportive/antagonistic community?
– Migration and life cycle: age of family members when
migrated, age of those left behind, change in family
dynamics (children ->adult status due to language),
reunifications?
121
Peter J. Guarnaccia, Ph.D.
Rutgers,
The State University of New Jersey
122
1. What language(s) do you currently speak with family,
friends, co-workers, store clerks?
2. English skills: Speaking___ Understanding_____
Reading_____ Writing_______
3. Spanish skills: Speaking_____Understanding_____
Reading_______ Writing________

Answer Key: 1 = fluent; 2 = very good; 3 = good; 4 = poor; 5 = no ability
123
1. Were you born in the United States? oYes o No
If not, where?
2. How long have you lived in the United States?
3. Where does most of your core (immediate) family
live?
4. How often are you in contact with your family (in
person, by phone, by letter, by e-mail)?
5. Who do you turn to for advice about where to go
for healthcare or other services?
124
1. What do you call your current health
problem?
2. Have you suffered from your current health
problem before? If so, what did you do
about it?
3. When you were sick in your home country,
what did you do?
4. When you have been sick in the United
States, where have you gone for treatment?
125
1. What religion are you? Do you consider
yourself a religious person?
2. Have you or your family consulted a religious
leader or healer about your health
problems?
3. Does your religion have any beliefs that
might affect your treatment (like not using
certain medicines; accepting transfusions)?
126
Peter J. Guarnaccia, Ph.D.
Rutgers,
The State University of New Jersey
127