Depression in Immigrant and Minority Children and Youth

ANDRES J. PUMARIEGA

EUGENIO M. ROTHE

KENNETH M. ROGERS

KEY POINTS

The United States and other developed Western countries are facing a rapidly changing demographic and cultural landscape, with their population becoming increasing multiracial and multicultural.
Native, minority, and immigrant children and youth face many barriers to effective mental health care. These include population barriers (socioeconomic disparities, stigma, poor health education, lack of documentation), provider factors (deficits in cross-cultural knowledge and skills and attitudinal sensitivity), and systemic factors (services location and organization, lack of culturally competent services).
Cultural groups’ understanding of depression varies and influences their help-seeking behaviors. They often invoke spiritual, supernatural, sociological, and interpersonal explanatory models. Stigma is also high.
Diagnosing depression in these children is challenging for clinicians. For example,
- Somatization and anger are frequent.
- Depressed individuals of Asian origin show heightened reactivity during depression; Whites show less.
- Comorbidity is very common (anxiety, disruptive behavioral symptoms, substance abuse, posttraumatic stress disorder), particularly in disadvantaged groups.
Drug pharmacokinetics and pharmacodynamics can vary according to ethnicity. For example, there is a large percentage of slow metabolizers among Asian children; as a result they often experience Western medicines as “too strong” and suffer more side effects.
The diagnosis and treatment of immigrant and minority children must be contextual, addressing psychosocial and cultural needs, and consonant with their values and beliefs. This is facilitated by including key members of the extended family, such as grandmothers, and other “adopted” relatives.
Clinicians need to be aware of variations in the expression of affect and behavior. For example,
- Subdued expressiveness in Asian and American Indian children and adolescents.
- Aversion of eye contact with adults in Asian, African Americans, or mainland Latino children and adolescents.
- Feelings, particularly anger, are not to be expressed openly or verbally by Native Americans, whose culture emphasizes nonverbal communication.
Use of alternative treatments is very high in these groups.
Home-based or community-based alternatives to hospitalization usually result in better outcomes for these youth, whereas involuntary hospitalization tends to recreate past traumas of oppression and reduce access to natural supports from the ethnic minority community or church.
Because depression is usually recurrent, the need for continuous treatment—not only when the child is in crisis—should be stressed.

Introduction

The United States faces a rapidly changing demographic and cultural landscape, with its population becoming increasing multiracial and multicultural. This is largely a result of three major factors: progressive aging and low birthrate of the European-origin population, lower mean ages and increasing birthrates in non-European minority groups, and a significant rise in immigration from developing countries, especially from Latin America and Asia. There will no longer be a numeric majority of Euro-Americans by 2050; this will happen before 2030 among children younger than 18 years and is already true among 6-year-olds.1

Such changes are occurring in European and other European-origin nations as a result of similar dynamics. Here the predominance of legal and illegal migrants is from Africa, the Middle East and Asia, frequently Muslims, and often escaping extreme poverty or civil strife.

These changes are highly significant for child mental health services. First, the acceptability of such services and their use are highly governed by cultural attitudes, beliefs, and practices. The current science base around diagnosis and treatments is derived from research primarily involving European-origin populations, so its validity for these emerging populations is questionable. At the same time, these populations face many challenges around mental illness and emotional disturbances, including lower access to treatment services and evidence-based treatments, and higher burdens of morbidity and mortality than Euro-Americans. In regard to depressive symptomatology and disorders, these challenges are exemplified by the rapidly rising rates of suicidality and suicide attempts among Latino and African American youth as compared with Euro-Americans, as highlighted by the most recent Youth Risk Behavior Survey.2 As a result, cultural and racial factors relating to depressive symptomatology and disorders deserve closer attention and consideration.

EPIDEMIOLOGY AND RISK FACTORS

Whereas earlier studies showed lower rates of depressive disorders among African American youth compared with Whites,3 more recent studies have found higher rates of depressive symptomatology and disorders among minority youth (including African American, Latino, and American Indian) compared with white youth.4,5 These differences are further confounded by gender interactions, with depressive symptoms higher in African American versus white males but nearly equal between African American and white female children.6 Suicide rates for minority youth have been lower historically, but these rates have increased substantially in recent years and now equal or surpass those for Whites. These changes have been most striking among African American males and Latino females, leading the U.S. Surgeon General to declare suicide among African American males an emerging public health issue.7

Latinos are the largest, fastest growing, and youngest minority population in the United States, with 39% of Latinos younger than 20 years compared with 29% for other ethnic groups.1 Risk factors for depressive symptomatology and disorders and suicide among Latino youth are numerous and influenced by their cultural background and immigration status. Risks for certain morbidities associated with psychopathology, including substance abuse and suicidality, increase with exposure to Western cultural values and practices.8, 9, 10 This increased risk may result from the loss of protective cultural values and beliefs (such as family support and taboos on substance use and suicide) and exposure to risk-enhancing factors (such as acculturation stressors, media exposure, and peer pressure). Many minority and immigrant youth also live in impoverished conditions, with limited family supports and exposed to increased levels of community violence, domestic violence, abuse, and neglect. These circumstances subject them to stressors and traumas associated with increased rates of depression and suicidal symptoms in all populations, but which are exacerbated by the stressors associated with acculturation and discrimination.11

Native populations (such as American Indians, Native Alaskans, aboriginal populations in Australia, New Zealand Maoris, and other Native Pacific Islanders) share many of the disadvantages of other minority groups, such as poverty and high incarceration rates, often magnified by the loss
of their cultural identity through forced assimilation by the colonizing culture and feelings of dispossession. At the same time, these populations suffer from some of the highest suicide rates recorded. For example, American Indian youth in the United States have the highest suicide rate of all ethnic groups in the United States.12, 13, 14 Australian aboriginal youth account for a high percentage of the increase of rural suicides over the last decade,15 and suicidality in Sami adolescent youth in the Arctic Circle, although equal to dominant culture youth, is associated with divergence from traditional cultural norms.16 Contributing factors for these increases include acculturation pressures, discrimination, gender role pressures, past traumas and losses, and poverty, in addition to mental illness.

European immigrants in the United States and immigrants of Islamic or Asian origin in Europe have demonstrated patterns similar to those seen in U.S. immigrant groups from developing countries with regard to increases in depressive and anxiety symptomatology in youth, with some studies showing higher rates than those found in dominant culture peers.17, 18, 19 There are some generational differences in the increases of depressive symptoms by gender, with one study citing first-generation immigrant females and second-generation males being most affected.20

EVIDENCE FOR DISPARITIES

Minority and immigrant children and youth face a number of barriers to effective mental health care. These include population barriers (socioeconomic disparities, stigma, poor health education, lack of documentation), provider factors (deficits in cross-cultural knowledge and skills and attitudinal sensitivity), and systemic factors (services location and organization, lack of culturally competent services, etc.). These barriers result in increased mental health disparities among these populations. Minority youth often lack public or private insurance or reside in neighborhoods where services are rarely available. These issues are particularly acute among young children and among Latino youth.21 Hispanic families underuse mental health services because of language and cultural barriers;22 Asian Americans experience shame around mental illness.23

Significant evidence indicates that psychiatric disorders are frequently misdiagnosed among culturally diverse youth; various studies have found an overdiagnosis of conduct disorder and underdiagnosis of depressive disorders.24, 25, 26 Misdiagnosis largely originates from difficulties that clinicians from majority and minority origins have in addressing cultural differences, including cognitive biases stemming from stereotyping, lack of systematic assessment, and lack of contextualization of information obtained in diagnostic assessments.27 The majority of care for depression is provided by primary care physicians who may have relatively little experience with depression in children and adolescents and have added disincentives such as decreased reimbursement for identifying a mental health versus a somatic health problem.28

Effectiveness in addressing cultural factors is not only related to knowledge about the family’s culture but also the clinician’s ability to form a patient- and family-centered alliance in which the clinician respects the family’s knowledge and unique perspectives on the child, avoids stereotyping, and empowers them to make treatment decisions. Cooper and colleagues29 demonstrated that the failure to form such alliances contributes to significant barriers in assessment and subsequent use of health services by minority patients, whereas race-concordant clinician-patient pairs tended to prevent such misalliance.

All of these factors result in significant underuse of community mental health services by minority youth and their families. Zito and colleagues,30 studying children 5 through 15 years old enrolled in the Maryland Medicaid system, found that white youth were 2.5 times more likely than African Americans to receive any type of psychotropic medication, and African Americans received fewer prescriptions and had fewer physician visits. These findings parallel those of Cuffe et al.31 that African American youth receive significantly lower rates of treatment than Whites and stay in treatment half as long as white children. Latino children receive an average of half as many counseling sessions32 and significantly fewer specialty mental health services and at a later age33 than Whites and African Americans. Additionally, there are fewer psychiatrists (and even primary care physicians) practicing in inner-city and low-income areas where minority populations live.34

CULTURAL CHALLENGES TO DIAGNOSIS AND TREATMENT

Diagnosing depression in minority and immigrant children can be challenging to clinicians unfamiliar with these issues. Children from diverse populations can demonstrate different symptomatology than Euro-Americans. Somatization and anger, for example, are symptoms more frequently associated with depression in minority youth.35,36 The degree of emotional reactivity can also vary during depression, with individuals of Asian origin showing heightened reactivity, whereas Whites show less.37 Diagnosis is more challenging with depressed minority children owing to the frequent presence of comorbidities. For example, stresses associated to immigration, acculturation, discrimination, and community violence contribute not only to depression but also to comorbid anxiety, disruptive behavioral symptoms, substance abuse, and posttraumatic stress disorder.38, 39, 40

Kleinman41 argues that culture shapes the way individuals not only express, but also the way they understand the symptoms of illness. Diverse cultural groups’ understanding of depression can vary significantly and influence their help-seeking behavior, invoking spiritual, supernatural, sociological, and interpersonal explanatory models. For example, African Americans often conceptualize depressive symptoms as part of their experience of sociopolitical oppression.42 Depressive symptoms can be even subsumed into culture-bound syndromes. For example, susto, a common culture-bound syndrome seen among mainland Latinos of Indian origin, involves acute anxiety followed by chronic depression; the explanatory model is one of a distressing experience causing the loss of the soul.43 Such expressions often lead families to seek help from a spiritual healer rather than a mental health professional.

As with many people of lower socioeconomic status, individuals of immigrant and minority backgrounds tend to postpone seeking treatment until either the child’s situation is fairly critical or the family is under significant distress from his or her symptoms. This may be partly related to their educational background, the multiple demands they face in their daily lives, and the perceived barriers to treatment, but also to cultural values that are more present focused and not as prevention oriented. At times, immigrant and minority families may even seek treatment under pressure from external authorities (such as school or child welfare officials), which starts treatment out on a less than amicable footing and on a more urgent basis, resulting in higher rates of involuntary commitment.24 These same factors may also contribute to premature termination from treatment. These trends have significant implications for the effectiveness of treatment, which may have to be more intensive from the outset. Symptomatic improvement without remission owing to premature termination is associated with poor prognosis, more recurrences, and poorer outcomes.

Only gold members can continue reading. Log In or Register to continue