When lifetime prevalence estimates of psychiatric disorders are examined for Latinos in aggregate, our findings are consistent with existing literature. First, Latinos are at lower risk of all lifetime psychiatric disorders compared to non-Latino whites, except for agoraphobia without panic. Second, consistent with the immigrant paradox, U.S.-born Latinos report higher lifetime rates for most disorders than Latino immigrants. These higher rates are not surprising, given that most psychiatric disorders are more prevalent in the U.S. than in many other parts of the world (26
); contexts and lifestyles unique to the U.S. appear to result in higher rates of psychiatric disorders.
However, when our sample is disaggregated by sub-ethnic group and nativity, a more complicated picture of Latino mental health emerges, exhibiting a more limited application of the immigrant paradox. Overall, the immigrant paradox is only reliably observed for Mexicans. In particular, the paradox is only evident for depressive and anxiety disorders among Mexicans. However, the paradox is consistently observed among Mexicans, Cubans, and Other Latinos for substance disorders. No evidence for the immigrant paradox was found for Puerto Ricans. These findings have significant implications for the assessment and treatment of psychiatric disorders within the U.S. Latino population. Our findings emphasize the importance of not over-generalizing the protective effect of nativity for all Latinos, and the differential effect of nativity depending on the type of disorder.
The immigrant paradox is most strongly apparent for substance disorders. The protective impact of foreign nativity on lifetime substance disorders for most immigrants, particularly Latinos, could be related to strong social controls in their countries of origin against alcohol and drug use (27
). International comparisons of prevalence rates of substance use disorders across different cultures indicate that cultural and social assimilation, or longer stays in cultures with high rates of drug use accelerate the rates of substance use disorders for immigrant groups from nations with lower rates (27
). Puerto Ricans are U.S. citizens, making their migratory patterns and exposure to U.S. culture different than those of other Latino groups. Our findings thus suggest that the protective context in which immigrants lived in their country of origin possibly inoculated them against risk for substance disorders, particularly if they immigrated as adults. Recent findings also support that the context where Latinos reside in the U.S. is an important influence in risk of substance disorders (28
). For example, perceived level of neighborhood safety is associated with lower risk for substance use disorders even after controlling for individual-level socioeconomic status (28
The question that remains to be answered is what factors in U.S. society place the U.S.-born population and those who migrate early in childhood at greater risk for substance abuse. The high availability of drugs in the U.S. may be a contributing factor. However, greater availability of drugs in the U.S. alone cannot explain these results, since countries like Mexico with extensive drug production and trafficking consistently show low rates of substance use disorders (6
). One hypothesis may be the U.S. societal convention to self-medicate as a way to cope with hardship (30
). U.S. cultural norms, such as pressure to be productive at work and over-prescription of medication, are thought to fuel recent increases in self-medication in the U.S. (31
). In other countries, different coping mechanisms may be socially prescribed. In one study, Mexican citizens were found more likely than non-Hispanic whites to use positive reframing, denial and religion and less likely to use substances (30
In , evidence for the immigrant paradox for depressive and anxiety disorders is only present for Mexicans. Several mechanisms could explain the immigrant paradox for depressive and anxiety disorders in Mexicans. Mexican immigrants in their country of origin experience relative deprivation and inequality as common to the majority of the population (32
). These beliefs may decrease the likelihood of demoralization among Mexican immigrants in the new environment (1
), with greater resignation for negative outcomes resulting in lower risk of depression and anxiety. Traditional family values of affiliation as well as fatalism may serve as protective factors against psychiatric morbidity for Mexicans (1
). However, the buffering effect of these factors does not translate to other Latino sub-ethnic groups (6
). In these groups, confronting social injustice, low opportunities for social mobility and hardship may be internalized as personal failure (34
); thereby leading to depression and anxiety. An alternative explanation is that Mexican families, because of their proximity to Mexico, have less intergenerational conflict between themselves and their family members (35
) than other Latino subgroups, allowing for a sustained sense of belonging that can buffer adversity. A third explanation is that Mexican immigrants, because of their high numbers in the U.S. and because they tend to arrive at an older age, may be less likely to intermingle with non-Latinos in multiple settings; decreasing exposure to cultures different from their own, which may reduce the likelihood of incidents of discrimination (36
). This decreased exposure to perceived discrimination may relate to lower rates of depression and anxiety as compared to other Latino groups, as Puerto Ricans, who come earlier and tend to live in ethnically-diverse neighborhoods.
In addition to providing valuable data on the presence of the immigrant paradox, our findings also give insight into the great subgroup variability within the Latino population. The data presented in and show significant variation by subethnic group for sociodemographic characteristics and for lifetime risk of psychiatric disorders, with Puerto Ricans a particularly vulnerable group. In contrast to the other Latino groups, Puerto Ricans have lived with more than a century of U.S. influence, are more likely to be bilingual and to have adopted many lifestyle patterns of U.S. society (37
). This high degree of integration with U.S. culture may explain the similarity in rates of disorder between Puerto Ricans and non-Latino whites. Furthermore, although U.S. citizens, the first Puerto Rican migrants came into the United States stigmatized by the public perception that they migrated because of massive unemployment on the Island and the desire to be supported by welfare (6
), perhaps subjecting them to more discrimination and stereotyping than other Latino sub-ethnic groups (6
), and resulting in higher rates of psychiatric disorders. Our findings provide further evidence that the common practice of aggregating Latinos into a single group masks great variability in the prevalence and risk of psychiatric disorders.
This study has certain limitations. Our results are based on cross-sectional comparisons of Latino and non-Latino white subgroups, which could mask cross-generational differences that explain some sub-ethnic group differences. Our lifetime prevalence rates could be even higher if Latinos with severe mental illness were overrepresented in the non-response group; severe disorders such as bipolar disorder and schizophrenia were not included in this study. However, we did not measure the prevalence for schizophrenia or bipolar disorders, as lay-administered diagnostic instruments substantially overestimate the prevalence of schizophrenia (38
) and meaningful estimates for bipolar disorders were considered to be difficult due to low prevalence in community samples (39
) Another potential limitation is that the diagnostic interview seems to require substantial education to comprehend some of the more elaborate probes. If Latinos with low education and literacy did not understand the questions, they might report not having the symptom, making these prevalence rates conservative estimates of psychiatric disorders in the Latino population. However, this seems unlikely since we find the same differences after adjusting for education. Finally, as with many studies of this sort, where many specific comparisons are made, one must be mindful of the issue of multiple comparisons and be careful not to overly focus on a particular finding as the probability that the finding is due to statistical chance is non-negligible.
In the field of mental health research, it is commonly believed that Latinos are at lower risk of psychiatric disorders than foreign-born non-Latino whites. As a result, Latinos, and Latino immigrants in particular, have been largely ignored in mental health research and the development of treatment interventions (40
). However, our results demonstrate that within the Latino population, some subgroups suffer from psychiatric disorders at rates comparable to non-Latino whites. Therefore, we urge the exercise of caution in generalizing the immigrant paradox to all Latinos, since the protective effect of nativity varies by type of psychiatric disorder and sub-ethnicity. Studies that fail to disaggregate by Latino subgroup may be inaccurately reporting the immigrant paradox as a universal phenomenon, thereby overlooking the risk experienced by some immigrant groups. In order to guide effective and culturally-appropriate prevention and treatment efforts, it is critical to identify and understand specific components of various cultures that are protective against psychopathology, as well as those factors that increase risk of psychiatric morbidity.