Sex Differences and Depression in Puerto Rico

Depression among Puerto Rican Women: Culture, Etiology and Diagnosis

As in most of the societies that have been studied, more than twice the number of Puerto Rican women compared to men suffer from diagnosed depression. The aim of this article is to examine depression in women in Puerto Rico from epidemiological, etiological, and especially, experiential perspectives. This study includes a comparison of women’s complaints around negative mood states in cases within the public mental health system and equivalent cases encountered within a traditional healing system, Espiritismo . Several general questions are raised concerning the effect on the etiology of depression of cultural constructions regarding female roles and statuses, reproductive events, and negative life events in general, as well as the value of closely examining the experience of depressed women relative to standard diagnostic assessments in mental health care.

A Retrospective on "The Suicidal Fit" in Mainland Puerto Ricans: Research Issues

The so-called "suicidalfit"among Puerto Ricans in New York City was reported by Trautman (1961a, 1961b) over two decades ago. Based on a sample of 93 Puerto Ricans who, under severe emotional stress, attempted suicide in almost identical circumstances, his writings provide an early view of suicidal behavior among Puerto Ricans in the South Bronx during the late-1950s. In the intervening time, very little has appeared further documenting and elucidating suicidal behavior among Puerto Ricans, and other Hispanics, in the mainland United States. The paucity of available knowledge for clinicians and researchers about the nature of suicide among contemporary New York Puerto Ricans poses seriousproblemsfor mental health programs and practice. This article reviews Trautman's research, commenting on methodology and interpretations of findings, and discusses implications for mental health research with mainland Puerto Ricans and other Hispanic groups.

Family and Work Predictors of Psychological Well-Being Among Hispanic Women Professionals

This study examines the relative contributions of job- and gender-related variables to the mental health of Hispanic women professionals. Hispanic women professionals, managers and business owners ( n = 303) were surveyed using the mailing list of a Hispanic professional women's organization. Results of multiple regression analyses indicate that income and Hispanic group were consistently related to mental health measures. Spouse support and ethnicity of spouse were associated with measures of stress in balancing roles and psychological distress symptoms. Marital status was related to personal life satisfaction (married women reported more satisfaction), and having young children was negatively associated with personal and professional satisfaction. Experience of discrimination, job stress and peer support were also significantly related to mental health measures. Although preliminary, this study underscores the importance of both job- and gender-related factors in research on the effects of employment on Hispanic women's mental health.

The Use of Inpatient Mental Health Services by Hispanic Women

Concern has been expressed about underrepresentation of Hispanics in mental health facilities, but little has been done to examine Hispanic gender differences in the use of such facilities. This descriptive study provides a broader and more detailed profile of Hispanic women's use of selected inpatient mental health facilities than is currently available. It presents gender differences in number, percent, and rate per 100,000 population for Hispanic and nonHispanic inpatient admissions with respect to age, marital status, and diagnosis. Results suggest that women use these inpatient facilities less than men, and this gender difference is greater for Hispanics. This greater gender difference in admissions among Hispanics was found across age and marital status categories, but not in all diagnoses. Regardless of ethnicity, men had higher admission rates for schizophrenia and alcohol-related disorders, but not for affective disorders. Marital status was related to diagnosis differently for Hispanics and nonHispanics. The gender difference in favor of higher rates for men with schizophrenia was not found for married nonHispanics. The gender difference in favor of higher rates for women with affective disorders was not found for separated/divorced Hispanic women. These findings point to the importance of and need for psychological research that examines the relationship between gender and sex roles and mental health, the inclusion of the resultant knowledge in mental health education and training, and the application of that knowledge to the design of mental health services.

Linking Femininity, Weight Concern, and Mental Health Among Latina, Black, and White Women

Studies examining women's appearance ideals and weight concern have predominantly relied on samples of White women. This study addresses this oversight, examining the different relations among embodied femininity, weight concern, and depressive symptomatology that exist for different groups of women. Using a nationally representative sample of women between the ages of 18 and 45, bivariate analyses were conducted using three samples of Latina, Black, and White women. When sample size allowed, a multivariate model was tested (i.e., for Black and White respondents). Results confirm, as hypothesized, different patterns of relations between embodied femininity, weight concern, and depressive symptomatology for each of the samples. At the bivariate level, embodied femininity, weight concern, and depressive symptomatology were positively intercorrelated among Latina respondents. Whereas weight concern fully mediated the relation between embodied femininity and depressive symptomatology for the White respondents, the mediational model was not borne out for the Black respondents. For the latter, although embodied femininity and weight concern were related, weight concern was unrelated to depressive symptoms. Both of these patterns are discussed, as well as the need for greater empirical sensitivity to various constructions of femininity among women of different ethnicities.

Acculturation, hazardous drinking and depressive symptomatology among Hispanics enrolled in a clinical trial

BACKGROUND

Among Hispanics in the U.S., lower acculturation level has been found to be protective against alcohol abuse and depression. However, this relationship may not hold within at-risk samples. The prevalence and co-occurrence of hazardous drinking and depressive symptoms and their relationship to acculturation were examined among Hispanics enrolled in a study to reduce heavy drinking. At enrollment, all participants reported past-month heavy drinking (one or more occasions of >4/5 drinks for females/males, and average weekly consumption >7/14 drinks per week). We explored whether gender moderated the effects of acculturation on hazardous drinking and depressive symptoms.

METHODS

Participants (N = 100) completed measures at baseline.

RESULTS

Eighty-nine percent of participants met criteria for hazardous alcohol use as assessed by the AUDIT and of those, 55% (n=49) also reported elevated depressive symptoms. Of those who reported elevated depressive symptoms, nearly all (94%) met AUDIT criteria for hazardous drinking. Acculturation was not related to hazardous drinking or depressive symptoms in the full sample. Highly acculturated women reported more hazardous drinking than less acculturated women. Acculturation was not associated with hazardous drinking in men, but less acculturated men reported higher levels of depression than highly acculturated men.

DISCUSSION

Depression should be assessed in alcohol interventions for Hispanics. Alcohol interventions should be tailored for acculturation level and gender to improve relevance and efficacy. Clinical Trial Registration #NCT01996280.

Functional impairment in adults with past posttraumatic stress disorder: findings from primary care

BACKGROUND

Although many patients with posttraumatic stress disorder (PTSD) experience a reduction in posttraumatic symptoms over time, little is currently known about the extent of their residual functional impairment. This study examines functional impairment in primary care patients with a history of PTSD as compared to patients with current PTSD, and those who never developed PTSD following exposure to trauma.

METHODS

The sample consisted of 321 trauma-exposed low-income, predominantly Hispanic adults attending a large urban primary care practice. PTSD was assessed with the Lifetime Composite International Diagnostic Interview and other psychiatric disorders with the SCID-I. Physical and mental health-related quality of life was assessed with the Medical Outcome Health Survey (SF-12), and functional impairment with items from the Sheehan Disability Scale and Social Adjustment Scale Self-Report.

RESULTS

Logistic regression analyses controlling for gender, psychiatric comorbidity, and interpersonal traumas showed that although patients with past PTSD function significantly better than patients with current PTSD, they experience persisting deficits in mental health-related quality of life compared to trauma-exposed patients who never developed PTSD. Overall, results revealed a continuum of severity in psychiatric comorbidity, functioning, and quality of life, with current PTSD associated with the most impairment, never having met criteria for PTSD with the least impairment, and history of PTSD falling in between.

CONCLUSIONS

In this primary care sample, adults with a history of past PTSD but no current PTSD continued to report enduring functional deficits, suggesting a need for ongoing clinical attention.

Prevalence of psychiatric disorders across Latino subgroups in the United States

OBJECTIVES

We examined the prevalence of depressive, anxiety, and substance use disorders among Latinos residing in the United States.

METHODS

We used data from the National Latino and Asian American Study, which included a nationally representative sample of Latinos. We calculated weighted prevalence rates of lifetime and past-year psychiatric disorders across different sociodemographic, ethnic, and immigration groups.

RESULTS

Lifetime psychiatric disorder prevalence estimates were 28.1% for men and 30.2% for women. Puerto Ricans had the highest overall prevalence rate among the Latino ethnic groups assessed. Increased rates of psychiatric disorders were observed among US-born, English-language-proficient, and third-generation Latinos.

CONCLUSIONS

Our results provide important information about potential correlates of psychiatric problems among Latinos that can inform clinical practice and guide program development. Stressors associated with cultural transmutation may exert particular pressure on Latino men. Continued attention to environmental influences, especially among third-generation Latinos, is an important area for substance abuse program development.

A revised Spanish version of the Beck Depression Inventory: psychometric properties with a Puerto Rican sample of college students

The Beck Depression Inventory (BDI) is a widely used self-report measure for depression. This study has two objectives: (a) to revise, develop, and adapt a Spanish language BDI (BDI-S) that takes the criteria for the diagnosis of major depression according to the DSM-IV into consideration; and (b) to evaluate the psychometric properties (internal reliability and construct validity) of the revised version of the BDI (BDI-S). A sample of 351 undergraduate students at the University of Puerto Rico participated in this study. The participants who agreed to participate in the study and signed the consent form completed self-report measures related to depression (BDI-S, CES-D, and LCSd-7), dysfunctional cognition (DAS-A and IBT), stressful life events (LES), and social support (CAS). The coefficient of internal consistency obtained for the 22 BDI-S items was.88. The correlation coefficients between the BDI-S and instruments that measured other constructs (not depression) were lower than the correlation coefficients between instruments that measured the same constructs. Factor analysis revealed that the factor loading for the BDI-S was congruent with dimensions of depression reported in the literature. These results generally support the internal consistency and the construct validity of the BDI-S.

Al Ain community survey of psychiatric morbidity II. Sex differences in the prevalence of depressive disorders

AIM

To examine sex differences in the prevalence of depressive disorders in an Arab community.

METHODS

One thousand three hundred and ninety-four subjects (n=1394) were systematically sampled from the general population in Al-Ain city, United Arab Emirates. All subjects were interviewed and assessed with the modified version of the Composite International Diagnostic Interview (CIDI) and a specially designed socio-demographic questionnaire. The lifetime male and female prevalence rates were estimated. Multivariate logistic regression of various socio-demographic variables was carried out to assess independent risk factors for depression. Statistical significance of sex differences in rates of depression by various socio-demographic groups were also assessed.

RESULTS

The lifetime rates in males and females were 2.8 and 10.3%, respectively. F:M ratio found in this study is highest reported ratio in the literature. Sex, life events, chronic difficulties and to a certain extent age were found to be risk factors for depression in the studied community. The prevalence rates of depression were higher in females in all above categories but such differences reached statistical significance in age category before 55, regardless of marital status, when the number of children is four or more and among those exposed to recent life events and chronic difficulties. Females were found to to be more exposed to chronic life difficulties but only depressed females were significantly more subjected to recent life events.

CONCLUSION

Sex differences in depression is a robust finding but more studies are needed to explain the high F:M ratio found in this survey.

Depressive symptomatology in three Latino groups

The purpose of this study was to examine depressive symptomatology in three Latino groups: Mexicans living in Mexico City, Latino immigrants living in the South Bay area of San Francisco, and Puerto Ricans living on the island of Puerto Rico. The Spanish version of the Center for Epidemiological Studies Depression Scale (CES-D) was used as part of a larger study on stress and coping. The levels of depressive symptomatology in all three Latino groups were significantly higher than those reported in other Latino samples and in White Americans. Mexican immigrants reported the highest levels of depressive symptomatology.

Women's help-seeking patterns for depression

Depression tends not to be accurately identified and treated in primary care settings. Women of color are especially likely to use these settings for mental health issues but are less likely to be diagnosed appropriately. A study was conducted within four Florida primary care clinics serving primarily low-income families. Participants included 321 women (Black, 22%, Hispanic, 23.5%, White, 38.6%) who completed a confidential questionnaire while waiting to be seen by clinic staff. Ten percent reported recent major depression, with 26.7% indicating depressive symptoms during the past two years. Depressed women were significantly more likely to report physical violence during the past year. Respondents turned primarily to family, friends, and medical clinics for their depression. They found turning to clinic staff to be helpful and described psychosocial interventions as useful. Members of all ethnic/racial groups reported barriers to seeking help, including perceived separation between mental health and general health and stigma. Implications are discussed in terms of appropriate community education and screening procedures.

The effects of the cultural context of health care on treatment of and response to chronic pain and illness

Qualitative data from two studies in Puerto Rico and New England are used to show how cultural values, standards and beliefs in different health care contexts affect (1) health care professionals' responses to patients' problems, (2) the relationships between providers and patients, and (3) the patients' responses to chronic pain and illness. Influencing elements in the care setting include the world view of the relationship of mind and body in illness processes, the dominant values and standards regarding pain and illness behaviors and the degree of cooperation between the providers and other agencies the patient depends on for compensation, rehabilitation and health insurance. In the New England study, the biomedical world view of mind-body dualism was shared by providers and most patients, but this shared belief often contributed to substantial patient stress and alienation. In contrast, in the Puerto Rican study providers and patients often shared a view of mind-body integration in illness and valued treatments which addressed chronic pain as a biopsychosocial experience. In this setting, shared views and values contributed to more supportive patient-provider relationships, and patients thus experienced less treatment-related stress.

Latinas with arthritis: effects of illness, role identity, and competence on psychological well-being

Tested a theoretical model on the effects of social role identity, illness intrusion, and competence on psychological well-being among 109 low-income Latinas with arthritis. All six roles studied were rated as highly important identities. Sex-role nontraditionalism was associated with less importance of the homemaker, mother, and grandmother roles. Negative affect increased as a function of intrusions into valued identities. Having important role identities contributed to feelings of competence (i.e., self-esteem and self-efficacy), which in turn, contributed to psychological well-being. Competence also mediated the effects of pain, identity, and illness intrusions on psychological well-being. Results suggest competence processes play an important role in well-being.

Mental health utilization in women with symptoms of depression

This paper examines the help-seeking process of mental health services in women with high depressive symptoms. The data are based on an island wide probabilistic sample (n = 1,062) of 18- to 64-year-old women living in low socioeconomic areas in Puerto Rico. Symptoms of depression were measured by the Center for Epidemiological Studies Depression Scale (CES-D). Results show that one out of three women living in poor residential areas report high depressive symptoms. Of these women with high depressive symptoms, only 12% seek help from a mental health specialist and 14.5% from a general health care provider to deal with their emotional problems. Some factors related to the use of mental health services are: presence of an occupational disability, head of household status, having private insurance, and having a regular source of care. These data suggest that women underutilize mental health services and overutilize physical health services to deal with their emotional problems. The lack of recognition of emotional problems by these women may explain the low utilization of mental health services.

A critical incident model for considering issues in cross-cultural research. Failures in cultural sensitivity

This paper consider anecdotes obtained from researchers which relate to issues in cross-cultural studies. The anecdotes are described and the relevant cross-cultural issues are outlined and discussed. Recommendations are made to help researchers conduct studies which are more culturally sensitive.

Alcohol use and misuse among Hispanic women: selected factors, processes, and studies

This paper presents a critical review of epidemiologic studies of the use and misuse of alcohol on Hispanic women. Although there is a wide variation in alcohol use among different Hispanic groups, there is some uniformity. The findings of most studies point toward the fact that drinking and drunkenness, as well as "excessive drinking," is predominantly a male activity. Abstention rates are high among Hispanic women, and a pattern of infrequent "light" drinking and low prevalence rates of alcoholism is usually observed in most groups of Hispanic women. The role of societal mores and culture in shaping these patterns of alcohol use is discussed. Recommendations for needed future research with Hispanic women are also made.

Sex differences in lifetime depression rates: fact or artefact?

To isolate determinants of any female preponderance in depressive disorder, we earlier selected a sample of young adults, then similar in terms of several potential social determinants of depression and with equivalent rates of lifetime depression. We now report a 10-year review, which initially suggested a female preponderance in DIS-generated RDC and DSM-III lifetime depressive categories. The presence of sex differences in rates of lifetime depression was influenced by the definition of caseness used and the vantage point from which rates were determined. The longitudinal design and earlier corroborative witness reports established, however, clear evidence of instability in prevalence estimates, together with a sex effect on stability. Men were more likely to 'forget' episodes, while women were more likely to 'remember' episodes that had generally not previously reached 'case' criteria. When correction was made for such artefactual influences, a sex difference in lifetime depression rates was no longer evident. Such findings require review in general community samples, and suggest modifications to 'case' definition in epidemiological enquiries.

A cross-cultural adaptation of a psychiatric epidemiologic instrument: the diagnostic interview schedule's adaptation in Puerto Rico

The advent of the use of structured interview schedules that generate psychiatric diagnoses in epidemiologic studies has promoted an intense interest in its cross-cultural use. However, the valid use of these instruments across cultures requires a careful adaptation process which goes beyond mere language translation. In this article the authors illustrate the application of a comprehensive cross-cultural adaptation model to both the translation into Spanish and the adaptation to the population of Puerto Rico of a widely used psychiatric epidemiologic research instrument: the Diagnostic Interview Schedule (DIS). The process aimed to ensure the development of a research instrument that is not only in correct Spanish and comprehensible for most Spanish-speaking people, but also culturally adapted to Puerto Rico's population. Various steps were taken (including bilingual committee, back-translation, instrument testing and diagnostic comparisons) to address cross-cultural validity in five important dimensions (i.e., semantic, technical, content, criterion and conceptual equivalence). The result is an interview schedule that is not only linguistically and culturally adequate for the targeted population but also includes elements which can contribute to the development of the instrument both in its original English language and in its translated versions.