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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Soc Psychiatry Psychiatr Epidemiol. Author manuscript; available in PMC 2013 August 29.
Published in final edited form as:
PMCID: PMC3756540
NIHMSID: NIHMS404825

Mental health service utilization for psychiatric disorders among Latinos living in the United States: the role of ethnic subgroup, ethnic identity, and language/social preferences

Abstract

Purpose

To examine aspects of Latino experience in the US as predicting service utilization for mood, anxiety, and substance disorders.

Methods

Latino participants 18 and older in the NESARC (N = 6,359), a US national face to face survey. Outcomes were lifetime service utilization for DSM-IV lifetime mood/anxiety or substance disorders, diagnosed via structured interview (AUDADIS-IV). Main predictors were ethnic subgroup, ethnic identity, linguistic/social preferences, nativity/years in the US, and age at immigration.

Results

Higher levels of Latino ethnic identity and Spanish language/Latino social preferences predicted lower service utilization for mood disorders [ethnic identity OR = 0.52, language/social OR = 0.44] and anxiety disorders [ethnic identity OR = 0.67, language/social OR = 0.47], controlling for ethnic subgroup, disorder severity, time spent in the US, and economic and practical barriers Service utilization for alcohol/drug disorders was low across all Latino subgroups, without variation by examined predictors.

Conclusion

Ethnic/cultural factors are strong determinants of service utilization for mood/anxiety, but not substance use disorders among Latinos in the US strategies to increase service utilization among Latinos with psychiatric disorders should be disorder specific, and recognize the role of ethnicity and identity as important components of a help-seeking model.

Keywords: Hispanic, Service use, Mental health, Ethnic identity

Introduction

Latinos are the fastest growing minority group in the US, and will comprise approximately 20% of the population by 2020 [71, 83]. Disparities in health and health care utilization between Latinos and non-Latino Whites are increasing across a range of medical conditions, including psychiatric disorders [2, 4, 56, 66, 79, 80, 84, 85, 89, 91,94, 96]. Disparities in care arise partly from structural barriers to access. For example, compared with non-Latino Whites, Latinos have, on an average, more limited health insurance and income, constraining financial resources for mental health services [12, 13, 21, 62]. However, differences in health and health care utilization remain even after controlling for economic barriers to care, suggesting the need to better understand other mechanisms through which differences may arise across racial/ethnic groups. Broader cultural and social factors may play an important role in treatment-seeking behavior and may in part explain the continued disparities between Latinos and non-Latino Whites.

Examining characteristics of the Latino population with respect to health care utilization may assist in the interpretation of overall treatment disparities by identifying important factors that disproportionately affect this group, relative to non-Latino Whites. For example, Latinos’ experiences of immigration and adaptation to living in the US involve multi-dimensional processes of acculturation and/or assimilation, whereby individuals over time adopt cultural elements of the host society and become structurally integrated, into the prevailing social fabric. These processes hypothesized to impact health in a number of domains. Indicators of acculturation and assimilation, often approximated by immigrants’ nativity or length of residence, are associated with a number of negative health consequences (for example, higher rates of substance use and abuse [63, 98], higher rates of infant mortality [16], and less nutritious diets [31]) but also health benefits (for example, more positive self-ratings of health [62]). Substantial evidence indicates a positive effect of acculturation/assimilation on medical service use, including preventative care, such as cancer screening [37]. In addition, available evidence also suggests that acculturation/assimilation has a generally positive impact on mental health service use; many epidemiologic studies have shown that more recent immigrants with a psychiatric disorder are less likely to use mental health services as compared to immigrants who have been in the US longer [3, 10, 23, 44, 91]. Foreign-born status or years in the US alone, however, may not adequately capture more specific psychological, cultural, or social processes that impact service utilization.

Ethnic identity, language use, and ethnic homophily (i.e., preferences for co-ethnic social interaction) reflect some of these psychological, linguistic, and social domains of the Latino experience in the US that may be associated with service access and use [12, 13, 18, 19, 34, 69]. Models of health services behavior hypothesize that Latino immigrants adapt to their surroundings and learn about health resources as a result of interactions with those in the host culture; Latinos with little interaction among those not in their ethnic group may not receive information about access to health resources [17, 78, 97]. Further, this theory posits that Latino ethnic homophily may exacerbate the stigma of help seeking for a mental health problem, as available evidence suggests that Latinos view mental health conditions are more stigmatizing than non-Latino peers [20, 70]. Indeed, these constructs have been documented to be associated with a wide range of health behaviors and general well-being among Latino immigrants, including colorectal cancer screening [1], condom use, pain sensitivity [76], academic achievement [68], self-efficacy and self-esteem [72, 82]. Further, the National Latino and Asian American Study (NLAAS), an important source of information on racial/ethnic patterns in psychiatric outcomes, has shown that individuals who mostly speak Spanish and/or mostly interact with other Latinos are less likely to be diagnosed with a psychiatric disorder [10, 46]. Although ethnic identity and linguistic/social preferences are associated with a wide range of health and well-being outcomes, relatively not much is known about whether these factors also affect receipt of mental health services among those with the disorders. Data from the Epidemiologic Catchment Area Study-Los Angeles (ECA-LA) found that Mexican-Americans with any diagnosis of a DSM-III-R psychiatric disorder scoring low on acculturation scales were less likely to utilize specialty mental health services when compared with more acculturated counterparts [96]. The NLAAS indicates that mental health service use among immigrants with any psychiatric disorder increases with years in the US and younger age of immigration, but only at the sub-clinical end of the psychopathology spectrum rather than among those diagnosed with a psychiatric disorder [3]. There may also be important differences in service utilization patterns and their determinants depending on the specific diagnostic categories. Mood/anxiety and substance disorders differ considerably in their risk factors, symptoms, treatment, and treatment settings. Therefore, determining whether the findings from ECA-LA and NLAAS extend across specific diagnostic domains is warranted. In addition, understanding the social, cultural and linguistic processes associated with service utilization among those with a DSM-IV psychiatric disorder could aid in improving access to services among underserved groups.

An important additional consideration in the assessment of service use among Latinos is ethnic heterogeneity. Many US Latino subgroups have a distinct relationship with US culture and health care. For example, Puerto Ricans are born US citizens and tend to spend more time on the US mainland prior to or in the absence of immigration as compared to other Latino ethnic subgroups. Further, rates of psychiatric disorder [7, 9] and mental health service use [3, 48] among people of Puerto Rican origin are more similar to non-Latino Whites than to other Latino ethnic subgroups. Combining Latinos into a single category can obscure this potentially important variation, although few studies have had large enough sample sizes to adequately disaggregate the pan-ethnic “Latino” designation. Available evidence indicates that there are substantial differences among Latino ethnic subgroups in the likelihood of mental health service utilization [4, 6, 20, 32, 67, 95], with Puerto Ricans mental health service utilization generally higher than all other Latino subgroups. However, previous studies have not examined domains of the Latino immigrant experience in the US as potential explanatory indicators of subgroup differences.

In summary, previous research has been important in documenting that more recent immigration among Latinos is associated with the lower use of mental health services, but information on ethnic subgroup heterogeneity and on the specific roles of key dimensions of immigrant adaptation—e.g., ethnic identity and homophily, language use—is necessary for the identification of subgroups at high risk of being missed by the mental health service sector, and for more comprehensively understanding the processes influencing immigrant mental health service utilization. Further, understanding these effects by diagnostic categories will provide important information on whether the effects are general, spanning all psychiatric disorders, or/are disorder specific. The large sample size of the present national survey allows for examination of these questions. Therefore, we investigated mental health service use among US Latinos diagnosed with mood, anxiety and substance disorders, examining whether four dimensions of the Latino adaptation in the US explain variation in disorder-specific service utilization: (1) age at immigration, (2) years in the US, (3) language/social preferences, and (4) ethnic identity. We further examine variation across five prevalent self-identified subgroups (Puerto Rican, Mexican, Mexican-American, Cuban, and South American). Importantly, we controlled for economic and practical barriers and disorder severity to better understand the ethnicity factors.

Methods

Sample

Data are drawn from two waves of the National Epidemiologic Survey on Alcohol and Related Conditions (NES-ARC), a nationally representative survey of US residents of households and group quarters. Interviews were conducted face to face by extensively trained interviewers of the US Bureau of the Census. In 2001–2002, 43,093 individuals were assessed for a lifetime history of psychiatric disorders as well as other information. In 2004–2005, 34,653 of these individuals were re-interviewed. The cumulative response rate across NESARC waves of data collection was 70.2%. The present study focuses on Latinos who participated in both the 2001–2002 and the 2004–2005 survey (N = 6,359) as complete measures of ethnic identity and linguistic/social preferences were assessed among this subset. Latinos lost to follow-up between waves were more likely to be male (p < 0.01), young (p < 0.01), low income (p < 0.01), and less educated (p < 0.01), but did not differ on lifetime mood, anxiety, and substance disorders. Further information on the study methods are found elsewhere [45].

Among the Latino subsample used for the present study (N = 6,359), 50.9% were male; 24.9% were 20–29 years; 40.1% were 30–44, 25.4% were 45–64, and 9.6% were 65 and older; 20.4% were married or living with someone as if married, and 84% lived in an urban area. As anticipated, the socioeconomic profile of the Latino sample suggested disadvantage: 34.8% reported less than a high school education, 24.4% reported high education; 51.0% reported below $19,999 past year personal income, whereas 25.7% reported $20–34,9999, 15.6% reported $35–64,999 and 7.8% reported $65,000+; finally, 72.0% reported having some form of current health insurance. When compared with the non-Latino NESARC sample, Latino participants are on an average younger (χ2 = 16.6, df = 3, p < 0.001), more likely to be male (χ2 = 8.3, df = 1, p < 0.001), less educated (χ2 = 19.7, df = 2, p < 0.001), have lower income (χ2 = 11.4, df = 3, p < 0.001) and are less likely to be currently insured (χ2 = 49.2, df = 1, p < 0.001).

Measures

DSM-IV diagnoses

The NESARC survey used the NIAAA Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV (AUDADIS-IV) [42] designed for experienced lay interviewers. The AUDADIS-IV includes detailed assessment of DSM-IV [11] abuse and dependence criteria for alcohol and 10 drug classes, as well as three mood disorders (major depressive, dysthymic and manic/hypomanic disorder) and four anxiety disorders (social phobia, specific phobia, generalized anxiety and panic disorder). Substance diagnoses evidenced good to excellent reliability in international, clinical, and US general population samples [22, 24, 41, 42, 51, 77]; test–retest of mood and anxiety diagnoses were fair to good [22, 41, 42]. Test–retest reliability in Latinos was good to excellent for alcohol dependence and depression diagnoses [22]. Validity was also demonstrated in numerous studies [39, 40, 43, 49, 50, 52, 54], including a WHO/NIH study [24, 30, 52, 75, 87, 93].

The present analysis included psychiatric diagnoses made at any point in the respondents’ lifetime. We repeated all analyses in the past 12 month time frame to examine the concurrent cross-sectional association between predictor variables and psychiatric outcomes, included as an online supplement to this report.

Service utilization

Thirteen types of intervention are assessed in separate modules for alcohol and drugs. These interventions fall into three main categories: 12-step self-help (e.g., alcoholics anonymous), professional services (e.g., detoxification, inpatient psychiatric, halfway house) and other (e.g., employee assistance program). Any lifetime reported service use was included in the present analysis.

Respondents were also asked specifically about lifetime mental health service utilization for each mood and anxiety disorder, measured in separate modules. These were administered to all respondents passing general screening questions for the relevant disorder. The treatment questions covered outpatient (physician or other professional, therapist, counselor), inpatient (hospitalized overnight or longer), emergency room, and prescribed medication. Any lifetime reported service use was included in the present analysis.

Domains of immigrant adaptation

Linguistic/social preferences

Eleven items were used to measure language/social preferences at Wave 2. Examples include “What languages do you read and speak?,” “In what language do you speak with friends?,” and “You prefer going to social gatherings and parties in which people are⃨”. Five response options ranged from “Only Spanish” to “Only English” or “Only Latinos” to “Only other ethnic groups” as appropriate. These items, the “Language” and “Media” subscales of the Short Acculturation Scale [64] had excellent internal consistency in this sample (Chronbach’s α = 0.93). Possible scores on the scale ranged from 8 to 59. Higher scores indicate greater Spanish speaking relative to English speaking, and greater interaction with Latinos relative to non-Latinos in daily life. Owing to non-normal distribution, the total score was categorized by quartile (analyses were also conducted with a continuous scale).

Ethnic identity

Ethnic identity was measured with eight items at Wave 2, an expansion of the 3-item Ethnic Identity Scale (EIS) from the National Comorbidity Survey-Replication and the NLAAS. Internal consistency was excellent in this sample (Chronbach’s α = 0.90) [46]. Examples of items include “Have a strong sense of yourself as a person of Hispanic/Latino origin” and “Hispanic/Latino heritage is important in your life”. Six response options ranged from “Strongly agree” to “Strongly disagree”. Possible scores on the scale ranged from 8 to 59. Higher scores indicate stronger identity with Latino heritage, whereas lower scores indicate weaker identity with Latino heritage. Owing to non-normal distribution, the total score was categorized by quartile (analyses were also conducted with a continuous scale).

Years in the US

All respondents were asked whether they were born in the US, and if not, the number of years spent in the US responses were categorized to be consistent with other studies [3]: <1–9 years, 10–19 years, 20 or more years, with US born as the reference group.

Age at immigration

Age at immigration range was 0 (born in the US) to 83. Age at immigration was categorized to be consistent with the previous studies [3]: ≤12, 13–17, 18–34, and ≥35, with US born as the reference group.

All measures of the domains of immigrant adaptation were significantly correlated at the p < 0.01 level. The highest correlation was between ethnic identity and linguistic/social preferences (correlation coefficient = 0.69, p < 0.01), and the lowest between language/social preference and years in the US (correlation coefficient = −0.23, p < 0.01).

Latino subgroup

Latino ethnic subgroup was defined from a list of 58 categories. We examined within-group differences among the five most prevalent Latino categories: Mexicans (N = 1,899), Mexican-Americans (N = 1,385), Puerto Ricans (N = 740), Central Americans (N = 386), and Cubans (N = 331). Remaining Latinos subgroups were too small to provide precise estimates. For analyses in which the main predictor was Latino subgroup, we excluded rather than combining these 1,618 respondents from over 30 cultures and countries because their heterogeneity could lead to misleading results. In all other analyses, these individuals were included. Sensitivity analyses on whether including the 1,618 individuals as an additional category or excluding them affected the results for the five specific subgroups indicated that the subgroup results were unaffected. The survey allowed choosing between Mexican and Mexican-American, but did not provide that option for other Latino subgroups. Because the sample was sufficiently large, we analyzed Mexican and Mexican-Americans separately to determine if they differed.

Statistical analyses

Prevalence and standard errors were computed among those with specific diagnostic profiles (e.g., anxiety service use among those with any anxiety disorder). An advantage to assess service utilization differences conditional on diagnosis is that the results are not dependent on known differences in rates of psychiatric diagnoses across Latino subgroups [7, 44]. Odds ratios (ORs) and 95% confidence intervals were derived from logistic regressions. All analyses were conducted using SUDAAN (56) to obtain standard errors adjusted for the complex sample design.

Following our previous research [55, 60], control variables from the Andersen model of health services utilization [12, 13] reflected predisposing factors (sex and age) and enabling factors (income, education, marital status, urbanicity, region, and current insurance status). Although indicators of socio-economic status, such as income and education were significantly correlated, the highest correlation coefficient was 0.29, indicating only a moderate degree of correlation and low risk of inaccurate results due to multi-colinearity. Further, to address need for treatment, each model contained a disorder-specific clinical covariate to control for the severity of the disorder (number of symptoms [mood and anxiety disorders] or frequency of use [substance disorders]). The severity indicators evidence a strong correlation (coefficients = 0.32–0.39) with functional disability (as measured by the Short Form Health Survey SF-12v2 [35]). Owing to concerns about multi-colinearity, we did not test a model with all domains of immigrant adaptation. Rather, our final model included only nativity/time spent in the US and nativity/immigration age to determine the direct effect of ethnic/cultural variables unexplained by nativity and time spent in the US. Although nativity/time spent in the US and nativity/immigration age are significantly correlated with other domains of immigrant adaptation used in these analyses, no correlation was higher than 0.3, indicating a low risk of inaccurate results due to multi-colinearity.

Results

Service utilization: any service use

Among those with any psychiatric or substance disorder, less time in the US was associated with lower odds of service utilization (Table 1). Cubans, Mexicans, and Mexican-Americans were less likely to utilize services than Puerto Ricans, but these subgroup differences were no longer significant after controlling for symptom severity. Individuals reporting strong Latino ethnic identity (OR = 0.62 [95% CI 0.42–0.92]) and mostly or completely Spanish language/Latino social preference (OR = 0.68 [95% CI 0.50–0.94]) were less likely to utilize services after adjustment for disorder severity, time in the US, and age at immigration. When language/social preference scales were analyzed as continuous variables rather than quartiles, results were similar (not shown).

Table 1
Mental health service utilization among Latinos in the US with any lifetime DSM-IV diagnosed psychiatric disorder (N = 3,392)

Service utilization: mood and anxiety disorders

The results for specific mood and anxiety disorders paralleled those for any service utilization. No Latino subgroup differences emerged once severity was included as a control variable, except that Mexican-Americans with anxiety disorders were less likely to utilize services as compared to Puerto Ricans (OR = 0.44, 95% CI 0.26–0.76). Fewer years in the US, stronger ethnic identity and stronger Spanish language/Latino social preference were strongly associated with lower odds of service utilization (Table 2). The results considering ethnic identity and language/social preference as continuous scales rather than quartiles were very similar (results not shown).

Table 2
Mental health service utilization among US Latinos with a lifetime DSM-IV diagnosed mood or anxiety disorder (N = 2,514)

Service utilization: drug/alcohol disorders

Service utilization was considerably lower for substance use disorders than for mood or anxiety disorders (Table 3). Age at immigration was associated with drug/alcohol treatment utilization when controlling for barrier and severity factors (OR = 0.15 [95% CI 0.04–0.57]), but this finding was not significant after controlling for time in the US. We also examined service utilization differences for alcohol and drugs separately (not shown). No significant findings emerged.

Table 3
Service utilization among Latinos living in the US with a lifetime DSM-IV diagnosed alcohol or drug disorder (N = 1,752)

Online supplement: past 12-month diagnoses

We also analyzed service utilization and psychiatric disorders in the past 12 months only (see online supplement). Although limited power restricted the ability to obtain statistically significant estimates, these odds ratios showed similar direction and magnitude to the lifetime estimates, suggesting not much recall bias or differential misclassification in the lifetime results. There were some minor differences in the two analyses. For example, ethnic subgroup was not a predictor of lifetime service utilization, but was predictive of past 12-month service utilization (Cubans (OR = 0.36 [0.14–0.90], Mexicans (OR = 0.55 [0.33–0.91]), and Mexican-Americans (OR = 0.49 [0.30–0.81]) were less likely to utilize psychiatric disorder services when compared with Puerto Ricans.

Discussion

In a large, nationally representative sample of adult US Latinos, we found strong and significant associations between Latino ethnic identity and language/social preferences on service utilization for mood and anxiety disorders. Respondents reporting stronger ethnic identity and Spanish language/Latino social preferences were less likely to utilize mental health services, even after controlling for numerous factors associated with service utilization, including insurance, income, and symptom severity. Further, these factors exerted a direct effect unexplained by years in the US or immigration age.

Because many economic and practical barriers were controlled, these results suggest that language and cultural factors are important in explaining differences among Latinos service use for mood and anxiety disorders. These findings indicate the need for an increased programmatic emphasis explicitly recognizing factors that are unique to Latino immigrants to improve care. Programmatically, the shortage of Spanish-speaking mental health clinicians is well documented [57, 86], a factor that clearly impairs diagnosis and treatment of mental health problems among non-English speaking Latinos. Further, even among Latinos in the US who speak English, the need for cultural competency in health care treatment, both broadly and in mental health specifically [14, 19, 61, 62, 90, 92], remains an important public health research and policy area. As has been documented for medical health systems more generally [36, 58], Latinos with fewer English language skills or less connection to non-Spanish social networks may also lack the knowledge regarding the appropriate pathways to obtain care. In addition, Latinos are more likely to distrust the medical community and the health care system due to ineffective and/or discriminatory health care practices received in the past [15, 27, 33]. Programs that address these shortcomings are under continuous development. For example, Markowitz et al. [65] recently developed an innovative interpersonal psychotherapy adaptation for Latinos with depression focusing specifically on conflicts arising due to immigration and other issues pertinent to Latinos? (e.g., the centrality of family). This treatment, as well as the emerging research focus on immigrant Latinos, reinforce calls for public health intervention and prevention efforts to engage in a broader focus on the community contexts in which diverse Latino subgroups live and work to increase service utilization and quality of care for groups facing language, cultural, and other non-economic barriers [5, 19, 61, 88, 90, 92].

Our results also concur with the previous studies suggesting that ethnic homophily, preference for interaction among individuals of similar racial/ethnic background, is associated with decreased engagement with the medical system [1, 68, 72, 76, 82]. The decreased use of services associated with ethnic homophily may reflect culturally specific stigma and attitudes towards psychiatric disorders and mental health services in general; non-Whites, including Latinos, endorse more stigmatizing attitudes towards mental illnesses [28, 29], and those embedded in ethnic social enclaves may adhere more to culturally based ideas regarding the causes and consequences of psychiatric disorders and mental health service use [74]. Alternatively, several studies have indicated that Latino individuals often seek help within their ethnic enclave from informal sources, such as family or clergy before or in replace of pursuing treatment within the medical system [20, 70]. Individuals will only engage in formal care if the symptoms of disorder intensify or if the resources embedded in the social network are depleted. Further study of Latino conceptions of mental illness and the impact of these conceptions on processes to care seeking are warranted.

Predictors were, in general, consistent for mood disorder service use and anxiety disorder service use. One difference of note is tat those in the Mexican ethnic subgroup with an anxiety disorder had a particularly low prevalence of anxiety disorder service use relative to other ethnic subgroups, whereas a similar pattern was not found among Mexicans with a mood disorder. Further investigation into specific cultural or contextual reasons for the low anxiety disorder service use among Mexicans in the United States is warranted.

A main strength of this survey is the statistical power to examine a range of Latino ethnic subgroups. Through these analyses, we were able to ascertain whether age at immigration and time in the US, ethnic identity, and/or language/social preference explain differences among Latino ethnic subgroups in predicting mental health service utilization. We found that these Latino experience indicators do not explain Latino ethnic subgroup variation; rather, differences among ethnic subgroups were largely explained by severity of symptoms. This suggests that subgroup variation in service use may be due to differences in disorder severity. When compared with other Latino subgroups, mean symptom levels were higher among Puerto Ricans with mood (p < 0.01) or anxiety disorders (p < 0.01), consistent with the higher prevalence of overall disorder in Puerto Ricans when compared with other Latino subgroups in these data [44]. Previous studies of Latino subgroup variation in service use did not control for severity [4, 6, 21, 32, 67, 95], which appears to be an important source of variation. While Latino subgroups vary in the prevalence of psychiatric disorders [710, 44, 47], surprisingly not much is known about ethnic differences in the disorder severity. Identifying the reasons for Latino subgroup severity differences is an important goal for future research.

No factors emerged as predictors of alcohol/drug service utilization, which was much lower overall than service utilization for mood or anxiety disorders, consistent with other findings [25, 26, 53]. These results are consistent with the previous studies showing not much evidence of racial/ethnic variation in service use for substance problems [55, 60]. The overall low usage of services across racial/ethnic groups [53] signals the need for programs that encourage better treatment utilization for substance use disorders across all racial/ethnic groups.

Our results that years in the US was associated with service use among those with a mood/anxiety diagnosis contrast with NLAAS findings that age at migration and years in the US were associated with service utilization only among those meeting partial, but not full diagnostic criteria for a current psychiatric disorder [3]. Our use of lifetime diagnoses that combined information from two waves of assessment conducted 3 years apart may have allowed us to capture more complete information, leading to findings among those meeting full diagnostic criteria for mood or anxiety disorders. Further, while our power was limited in analyses of past 12-month disorders (online appendix), the direction and magnitude of the odds ratio were generally similar to the lifetime analysis, suggesting the applicability of our findings to individuals meeting full diagnostic criteria for mood or anxiety disorders.

Study limitations are noted. First, ethnic identity and language/social preference scales were included only at Wave 2. Thus, their relationships with incident psychiatric disorders could not be assessed prospectively. Some individuals may have had psychiatric disorders and/or treatment before arriving in the US, indicating that the causal direction of observed associations remains in question (as a history of psychiatric disorders could influence feelings of ethnicity identity and language/social preferences). Third, loss to follow-up for male and low SES respondents may have introduced bias into the results, as low SES is associated with the recent immigration and lower service use. Therefore, our results are a conservative estimate of the effects of time in the US on service use. Fourth, respondents with Mexican origin in the NESARC could selfidentify as Mexican or Mexican-American. Given that the present analyses demonstrate that Mexicans generally have lower rates of service utilization as compared to Mexican-Americans, we kept these groups separate for the main analysis. Whether the results might have change if other groups were allowed the same choice as Mexicans is unknown and should be examined in future research. Fifth, while the NESARC survey contains one of the largest samples of Latinos in the US, due to the low prevalence of service utilization overall we did not have statistical power to subset the analyses by ethnic subgroup, or by demographic variables such as gender. Further, while we attempted to include a comprehensive set of control variables, statistical power diminished with each additional control, suggesting that our models should be interpreted with caution. Testing for effect modification by ethnic subgroup and demographic subgroups, such as gender are important areas for future research when larger samples become available. Further, questions on service use were more comprehensive for substance than for mood/anxiety disorders. More detailed information on mood/anxiety service use would improve future studies. Nevertheless, prevalence of service use for mood/anxiety disorders was substantially higher than for substance disorders, indicating that the diagnostic specificity of ethnic differences is unlikely to be a measurement artifact. In addition, further hypothesis testing should be conducted to confirm the present results in other sources of data given the number of statistical tests conducted as part of our research aims.

Finally, while the AUDADIS-IV is unique among large scale epidemiologic surveys in the coverage of questions regarding the Latino immigrant experience in the US, there are several important aspects of Latino immigration that are not addressed in the survey. For example, bicultural identity has been studied as an important aspect of the Latino experience in the US [17, 38, 73, 81]; adaptation and/or assimilation into US culture is multi-dimensional, and Latino individuals often have multiple identities that develop over time and co-exist. Measures capturing bicultural identity would be beneficial in future psychiatric epidemiologic work in this area.

Despite increasing overall rates of mental health service use in the US (including among Latinos) [59], continued disparities among Latinos with varying degrees of language/social preferences and ethnic identity signal the need for public health initiatives to expand access and culturally competent care for a broad range of psychiatric disorders. The present results, in the context of existing literature, indicate that cultural factors, such as ethnic identity and language/social preferences are potentially important drivers of mental health care among Latinos in the US. Although increasing the financial accessibility of mental health service use is an important priority, programs to improve access to care and management of illness should recognize the important role of language, cultural values and beliefs, and more explicitly address access to care for specific psychiatric disorders across diverse populations.

Supplementary Material

3 supp tables

Acknowledgments

This research was supported in part by Grants from the National Institute on Alcoholism and Alcohol Abuse (K05 AA014223, Hasin), the National Institute on Drug Abuse (RO1 DA018652, Hasin, R01 DA019606, Blanco, K DA023200, Blanco, R21 DA020667, Martins), the National Institute of Mental Health (T32 MH013043-36, Keyes, F31 MH083401, Hatzenbuehler, R01 MH076051, Blanco), and support from New York State Psychiatric Institute. The funding organizations had no role in the preparation or approval of the manuscript. The authors report no conflicts of interest. All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Footnotes

Electronic supplementary material The online version of this article (doi:10.1007/s00127-010-0323-y) contains supplementary material, which is available to authorized users.

Contributor Information

K. M. Keyes, New York State Psychiatric Institute, 1051 Riverside Drive #123, New York, NY 10032, USA; Department of Epidemiology, Columbia University, New York, NY, USA.

S. S. Martins, Department of Mental Health, Johns Hopkins Bloomberg, School of Public Health, Baltimore, MD, USA.

M. L. Hatzenbuehler, Department of Psychology, Yale University, New Haven, CT, USA.

C. Blanco, New York State Psychiatric Institute, 1051 Riverside Drive #123, New York, NY 10032, USA; Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA.

L. M. Bates, Department of Epidemiology, Columbia University, New York, NY, USA.

Deborah S. Hasin, New York State Psychiatric Institute, 1051 Riverside Drive #123, New York, NY 10032, USA; Department of Epidemiology, Columbia University, New York, NY, USA; Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA.

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