"It's Like Going through an Earthquake": Anthropological Perspectives on Depression among Latino Immigrants
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J Immigrant Minority Health (2007) 9:17–28
DOI 10.1007/s10903-006-9011-0
ORIGINAL PAPER
“It’s Like Going through an Earthquake”: Anthropological
Perspectives on Depression among Latino Immigrants
Igda E. Martı́nez Pincay · Peter J. Guarnaccia
Published online: 28 September 2006
C Springer Science+Business Media, LLC 2006
Abstract Depression is one of the most prevalent mental Introduction
illnesses in the community and is responsible for a signifi-
cant amount of disability. According to epidemiological and Depression is one of the most prevalent mental illnesses in
primary care studies, Latinos suffer from depression at high the community and is responsible for a significant amount
rates. This paper examines in depth Latinos’ conceptions of of disability. The quote above describes how one Latino
depression and their attitudes towards and expectations of immigrant who participated in our focus groups described the
mental health treatment. The aim of this paper is to summa- immigration process. At the same time, the quote can be read
rize several qualitative studies examining Latinos’ cultural as a graphic description of how devastating and disabling
understandings of mental health in general and depression in depression can be and links the losses of immigration to the
particular, as well as to obtain information about the barriers depression experience.
to care that this community experienced. The results are a According to epidemiological and primary care studies,
compilation of findings from four different research projects Latinos suffer from depression at high rates [1–4]. How-
in New Jersey and New York that examined diverse Latinos’ ever, recent studies have demonstrated the importance of
conceptions of mental health, treatment and barriers to care. distinguishing between Latino immigrants and those Lati-
nos born in the U.S. While immigrant Latinos experience
Keywords Depression . Latinos . Immigration . Barriers lower rates of depression than their U.S.-born compatriots
to care . Attitudes towards treatment and than non-Hispanic Whites, they are also less likely to
seek mental health services when they are depressed [5].
Es como perder su techo, perder todo, es como cuando We chose to study depression not only due to its preva-
uno ha pasado por un terremoto y perdió todo. . . es lence in the community, but also because there are clear,
como una acumulación de pérdidas. [It’s like losing the well-developed treatment guidelines for both therapeutic and
roof over your head, losing everything, it’s as if one had medication interventions for depression. Yet studies consis-
gone through an earthquake and lost everything. . . it’s tently show that Latinos have very low rates of use of mental
an accumulation of losses.] health services [6–13]. Immigrants are even less likely to
use mental health services than U.S. born Latinos. When
Latinos do seek help for mental health problems, they are
I. E. Martı́nez Pincay ()
Graduate School of Applied and Professional Psychology, more likely to do so in the general medical sector than in
Rutgers University, 152 Frelinghuysen Road, specialty mental health services.
Piscataway, NJ 08854-8085, USA There are a wide range of barriers to seeking mental
e-mail: igda martinez@hotmail.com
health care that have been identified in the Latino men-
P. J. Guarnaccia tal health literature [7, 9, 10, 12, 13]. These barriers can
Institute for Health, Health Care Policy, and Aging Research, be organized into several dimensions: barriers in the ser-
Rutgers University, vice system, community-level barriers, barriers in the social
New Brunswick, NJ, USA
networks of people in the community, and person-centered
barriers. The most important system level barriers include
Springer18 J Immigrant Minority Health (2007) 9:17–28
lack of health insurance, language barriers, immigration to care that this community experienced. The results pre-
status, discrimination from the system and lack of infor- sented in this paper are a compilation of findings from four
mation about services (especially in Spanish). Community different research projects in New Jersey and New York that
centered barriers include the stigma of mental illness and were carried out to examine diverse Latinos’ conceptions of
the density of family and other support networks. Person- mental health, treatment and barriers to care.
centered barriers include lack of recognition of mental
health problems, stigma of mental illness, and a self-reliant
attitude. Methods
Few studies have gone beyond identifying and confirming
in correlational analyses this same set of barriers. They have We chose focus groups as the method of data gathering be-
not delineated the dimensions of these barriers nor have they cause it is an excellent qualitative methodology for exploring
looked at how Latinos in the community assess these barriers. group ideas about an issue and eliciting the perspectives of
Cooper and colleagues [14] report on one of the most com- people in the community [16]. We were bolstered in our
prehensive analyses of multi-ethnic patients’ perceptions of approach by a paper on the needs of people with psychotic
the acceptability of treatment for depression. Using data from disorders that took a similar perspective in a cross-national
three NIMH quality improvement interventions to improve study of psychiatric services users’ needs for care [17]. In or-
the quality of depression care, they compared the attitudes der to get beyond the same list of issues and barriers already
of African-Americans, Hispanics and Whites towards de- identified in the Latino mental health literature, we felt that
pression treatment. Their sample consisted of 829 patients, it was important to more fully discuss with a diverse group
of whom 73 were Hispanic. The investigators used a highly of Latinos their understandings of depression and their as-
structured interview to assess attitudes towards depression sessments of different treatment alternatives. By conducting
care. They found that Hispanics, like African Americans, multiple focus groups in different sites with diverse Latino
expressed lower acceptance of anti-depressant medication populations, we could identify cultural diversity and cross-
than Whites and more acceptance than Blacks of counsel- cultural similarities among Latinos. Each study was designed
ing services. They also found that Hispanics and African separately and therefore not designed to parallel each other.
Americans were more likely to see medications as addictive In this paper we are integrating the findings across the four
and less likely to see them as effective compared to Whites. studies.
While Cooper and colleagues [14] argue that there is a need
to understand attitudes and social norms towards treatment Focus group participants
in more depth than can be captured using categorical re-
sponses on a structured questionnaire, their study relies on Focus group participants were recruited from various sites
just such responses. Even so, their research represents one of for the multiple studies. All were community samples re-
the few studies to compare African American, Hispanic and cruited through a range of community mental health and
White attitudes towards treatment in the same study using social service agencies as well as community resources such
the same methods. Also, while their study is comparative, as churches and day care centers. Overall there were 94 par-
it only includes 73 undifferentiated Hispanics (across three ticipants in 12 different groups throughout New Jersey and
different interventions) representing less than 10% of the New York City. This is a larger sample than the number of
total sample. The study was also limited because all of the Hispanics in three national quality improvement interven-
Hispanics spoke English and were insured, limiting the di- tions [14]. The focus groups consisted of a diverse group of
versity of the Hispanic sample and likely excluding most Latinos in terms of country of origin, time in U.S., age, and
recent immigrants. education (please see Table 1).
This paper, along with the companion paper by Cabassa A total of 12 focus groups are included in this paper.
and colleagues [15], examines in more depth Latinos’ con- Five of the focus groups (40 participants, total) were from
ceptions of depression and their attitudes towards and expec- Study 1 and were held within New Jersey to assess concep-
tations of mental health treatment. The combined papers pro- tions of mental health, treatment and barriers to care. These
vide a fuller comparison among Latinos from diverse parts focus groups consisted primarily of females (72%). Two
of the United States. The papers provide richer understand- groups were held with Puerto Ricans (37.5%) and Domini-
ings of the concerns Latinos express about mental health cans (7.5%), 2 groups were held with Mexicans (currenly
treatment; insights that can inform both future research and says 1), and one group was held with Cubans (22.5%). The
clinical treatment. The aim of this paper is to summarize groups were also varied in terms of urban/rural community
several qualitative studies examining Latinos’ cultural un- settings. The participants in these groups ranged in age from
derstandings of mental health in general and depression in 20 to over 60 and had been in the United States anywhere
particular, as well as to obtain information about the barriers from less than one year to over 20 years. These participants
SpringerJ Immigrant Minority Health (2007) 9:17–28 19
Table 1 Demographics
Study 1 (NJ): 5 FG Study 2 (NY): 3 FG Study 3 (NJ): 2 FG Study 4 (NJ): 2 FG
N 40 22 14 18
Gender (% female) 72 68 90 94
Age range 20–60 Over 65 24–64 28–71
Country of Origin (%) Diverse Latino Groups Diverse Latino Groups
Puerto Rico 37.5 50 No majority From any One group No majority From any One group
Dominican Republic 7.5 50
Mexico 32.5
Cuba 22.5
Time in U.S. Range20 J Immigrant Minority Health (2007) 9:17–28
Analysis of the focus groups ticipants linked mental health to staying away from “vices,”
particularly not abusing alcohol or drugs. In addition, one of
All of the focus groups were transcribed for review and the key roles of the family is to protect and nurture children
analysis. After debriefing each focus group and comparing and one of the major challenges for immigrants is to pro-
general notes, each transcript was read over several times and tect and support their children in the complex and difficult
a basic content analysis was performed by each member of transition to moving to the United States. Families fear that
the research team. Each coder created a list of major themes their children will not be safe in the urban centers in the
that arose in the groups and these lists were compared in U.S. where many immigrants live and that they will become
team meetings. Consensus on key themes from the coding American too quickly.
was obtained through discussion and elaboration on each
Para mi la buena vida es conservar las amistades y creer
coder’s conceptualization of the construct being discussed in
en Dios, alejarnos de vicios y mantener nuestros hijos
the focus group. Based on the content analyses and on the
fuera de peligro. [For me, a good life is maintaining
specific transcripts, the principal investigators identified key
friendships and believing in God, staying away from
themes that emerged from the focus groups. Finally, quota-
vices and keeping our children out of danger.]
tions from the transcripts were selected to better illustrate
the core themes. Mental health is intimately tied to spirituality; to believing
in and seeking God’s protection in life.
Results What is depression?
What is mental health? We then turned our attention to asking participants to de-
scribe or recognize depression, depending on the approach
In most of the focus groups, we decided it was impor- of the focus group. We were struck that in all the groups and
tant to understand how participants conceptualized mental across Latino ethnicities, depression was widely recognized
health before we discussed mental illness. Throughout the among Latinos as a mental health problem. Participants in the
focus groups, participants defined mental health as being focus groups recognized both emotional and somatic aspects
dependent on the quality and quantity of social relation- of depression.
ships and supports available to an individual. Mental health
was described as being able to live a “good life” [una vida Cuando una persona esta triste, esta nostálgica, se pone
buena]; to be able to function in and contribute to soci- a llorar fácilmente, esta muy cansada y no sabe por que,
ety. There was also a strong emphasis on being able to no tiene ganas de hacer nada. Uno no tiene amigos, no
live a “tranquil life” [una vida tranquila]. To better under- tiene familia, ni nada. Le hace falta más la familia.
stand these concepts, we asked them what made up a good [When a person is sad, is nostalgic, s/he cries easily,
life. feels very tired and doesn’t know why, s/he has no
desire to do anything. One doesn’t have friends, doesn’t
Para mi una buena vida serı́a llevar una vida de tran- have family or anything. When you feel like this, you
quilidad, sentirse con un poco de salud, que es lo princi- miss your family even more.]
pal, y. . . sentirse para mi bienestar con su familia unida
y vivir tranquilo. [A good life would be living a tranquil Uno ha perdido su identidad. Es una persona adolorida,
life, being in good health, that’s the most important . . . que está triste, está enojada. No se quiere ni peinar, no
to feel a sense of well-being about my family’s unity se quiere ni bañar. Esa persona no es la que era un
and to live peacefully]. mes antes. [One has lost one’s identity. It is a person in
great pain, who is sad, who is angry. One doesn’t want
In many of the comments, ideas about the centrality of to comb one’s hair nor bathe. This person isn’t the same
social relationships, especially family relations, emerged as as the person s/he was a month earlier.]
keys to mental health.
These descriptions are very representative of how Latinos
Para mi la buena vida serı́a una buena unión familiar across our focus groups discussed depression. Many of the
y poder compartir con los demás cualquier necesidad elements could come right out of a standard diagnostic man-
que haya. [For me a good life would be to have good ual, as they describe affective, behavioral and interpersonal
family unity and to be able to share with others whatever aspects of depression.
necessity there might be.] Related to the intense sociality of Latinos, being alone
Other important aspects of mental health included being or isolated from others was seen as very damaging to one’s
in control of one’s emotions and not being aggressive. Par- mental health. Participants tended to view isolation as a cause
SpringerJ Immigrant Minority Health (2007) 9:17–28 21
for depression, rather than the loneliness being the result of participants would say they worked one job to support
depression. their family here and the second to support family back
home.
La soledad también. La soledad hace mucho daño. Por
eso uno debe compartir con otras personas porque una
Barriers to seeking help
sola en la casa es triste. [Loneliness, too. Loneliness is
very harmful. That is why one should share with other
Participants were very articulate about the barriers they con-
people, because being home alone is sad.]
fronted when seeking help. Focus group participants were
In addition to being a response to social isolation, depres- asked what barriers they encountered when seeking help;
sion was seen as resulting from social stressors and losses, based on their responses we created a list of the most com-
such as: the death of a family member, the loss of a job monly mentioned barriers: stigma of mental illness, prob-
and financial stresses, and traumatic events like those of lems with health insurance or financial concerns, transporta-
September 11, 2001. tion to and from mental health providing agencies, their own
immigration status and fear of being discovered, lack of
. . . son momentos emocionales de estrés porque le he
knowledge of where to go for help, language and other cul-
puesto caso a esas dos muertes tan queridas; se fue mi
tural barriers, the relative “coldness” of providers, and a lack
mamá y mi esposo junto y de repente que yo no esperaba
of understanding of what mental health treatment involves.
que fueran a morir. . . . Y no me encontraba con ello,
It was as if they had read the research literature on barriers
y nunca se me habı́a muerto una persona que fuera de
to mental health services for Latinos and were providing us
mi familia. . . Ya yo estoy en una mejor etapa pero al
a summary of that research!
principio si me dió diabetes, me dió depresión. [They
are emotional and stressful moments because I focused [Nosotros] inmigramos, y nos encontramos con muchas
on those two deaths of my loved ones. My mother and barreras como el idioma, no tenemos papeles, no ten-
my husband died at the same time. They were sudden emos información de muchas cosas, no sabemos cuales
and unexpected deaths. No one from my family had son nuestros derechos. . . la vida aquı́ es muy difı́cil.
ever died before. . . . Now I’m in a better place, but at Estamos muy aisladas aquı́. [We immigrate here and
first, I suffered from diabetes and depression.] find ourselves with many barriers: such as language,
we don’t have papers, we don’t have information about
Interestingly, participants, particularly those who were older,
many things, we don’t know what our rights are . . . Life
connected depression to diabetes.
here is very difficult. We are very isolated here.]
We were struck with the consistency across Latinos in
how they viewed depression. The next definition, however, Nosotros como Hispanos no tenemos donde recur-
is culturally specific to the groups we did with Mexican rir. Y cuando no hablamos inglés es otro obstáculo
American immigrants. Mexican immigrants were intensely grandı́simo. [As Hispanics we don’t have anywhere to
aware of the difficult jobs available to them, particularly if turn to. And when we don’t speak English it is another
they were undocumented. In a state like New Jersey, with a huge obstacle.]
high cost of living, it was common for men (and women) to
Tiene miedo a lo que va a pasar, a lo desconocido. . . .
work more than one job to make ends meet. Both men and
¿Que van a preguntar, que va a pasar? Tiene miedo
women discussed the stresses produced by these work situa-
a discutir, a investigar . . . [One is afraid of what will
tions. They saw depression as intimately tied to alcohol use.
happen, of the unknown. . . . What are they going to
Women also saw this cycle as including domestic violence
ask, what’s going to happen? One is afraid, to discuss,
directed at them.
to investigate. . .]
[Los hombres] se deprimen, ellos buscan el alcohol The major stigma of seeking mental health services is the
para escaparse y no deprimirse. Tienen que hacerse a fear that they will be considered crazy (loco) or might really
cargo de la familia acá y también mandarle dinero a la be crazy if they need these services. One poignant example
familia allá. Conseguir trabajo aquı́ es difı́cil. [Men get in the groups was a woman who was in treatment for her
depressed. They seek out alcohol to escape and not get depression. She recounted that when she came back from
depressed. They are responsible for their family here therapy, she overheard her neighbors on the next stoop saying
and also have to send money to their family there, and to each other, “Ay, aqui viene la loca.” [Oh, here comes the
finding work here is difficult.] crazy woman.] At the same time participants recognized the
unjustness of such assumptions and the need for educational
This quote also highlights the pressure on immigrants interventions in the Latino community to combat the stigma
here to support family in their home countries. Some of mental illness.
Springer22 J Immigrant Minority Health (2007) 9:17–28
En la cultura Hispana, piensan que ir a ver a un that one should seek help if the problem grows to be out of
psicólogo es cosa de locos. Es la parte de ignoran- one’s control. In addition, many participants felt they would
cia, saber entender y saber donde pedir ayuda. [In the try remedies already known to them before going to mental
Hispanic culture, they think that going to a psycholo- health services.
gist is only for people who are really crazy. It’s due in
Nosotros los Hispanos, nos hemos acostumbrado en los
part to ignorance, not being able to understand and not
remedios caseros. . . la medicina en realidad no es muy
knowing where to go for help.]
receptiva. [We Hispanics have become accustomed to
This next quote illustrates not only the insurance and fi- using home remedies . . . in reality, medications are not
nancial problems Latinos face in getting mental health care, very well received by the Hispanic community.]
but the lack of sensitivity of public mental health services in
Participants preferred to seek out a “talking cure” first if
dealing with these issues.
they were to go to mental health services. Participants indi-
Nunca la cojı́ la conserjerı́a porque yo dije, pero si cated a need to “unburden oneself” [desahogarse] and thus
ellos me la están ofreciendo y yo fui y yo me presenté. thought talking to a professional would be most beneficial.
Pero me dijeron, “No, el seguro de su esposo no cubre Participants reported strong negative reactions towards med-
eso. Necesita $250 de down.” [I never received the ications; medications are only for people who are severely
counseling. They were offering me the counseling and mentally ill. To most participants, medications are seen as a
I went and presented myself. But then they said, “No, last resort and then only as a temporary solution until one
your husband’s insurance doesn’t cover this; we need a gains control of oneself; though others believed that if one
$250 down payment.] reached the point of needing medications, then it would be
necessary for life.
While this list of barriers is very similar to those identi-
fied in mental health services research, these quotes make Como último recurso, siempre se trata de buscar ayuda
the barriers more real, palpable, and provide a sense of profesional, pero a veces de necesidad usas medica-
the texture of how they are experienced in the Latino mentos a pesar de la ayuda, algo que se usa siempre,
community. no por un dı́a. [As a last resort, we always try to seek
professional help. But sometimes out of necessity one
Attitudes toward treatment uses medications in spite of the counseling. If it gets
to the point that you need medicine, it is medicine that
When asked how they felt that depression should be treated, you use always, not just for one day.]
the focus group participants generally agreed that depression
Many expressed a fear of potential side effects and the
is a consequence of difficult life circumstances, and therefore
addictive potential of psychiatric medications. The fear of
not always an illness. This is one of the key reasons why
addiction to psychiatric medications is very strong. Members
Latinos do not often seek mental health services right away.
of the community tended to use models of sleeping pills and
Given the myriad stresses in the lives of Latino immigrants,
coffee to understand medicines; in these models people need
it is not difficult to find reasonable explanations for why one
more and more sleeping pills or coffee over time to have an
might be deeply sad, feel lost and disoriented, experience life
effect, and it is difficult to stop taking the pills or drinking
as overburdening, be tired all the time, and express a sense
the coffee.
of hopelessness about the future. To decide that the feelings
and bodily experiences that are often associated with the
challenges of being a Latino immigrant in the U.S. have Attitudes towards providers
gone on too long and are too disabling so that mental health
treatment might be indicated is a difficult process. Often Most focus group members explained that they seek help
the social networks that would help make that decision are from primary care providers because they are not aware of
disrupted by the immigration process itself, and those family mental health as a specialty service. Language barriers and
members who are here are often also working long hours and cultural clashes in understanding the style of mental health
may not be aware or be able to be sensitive to the problems treatment in the United States are also an issue. Participants
a person is facing. explained that providers need to be accessible, need to build
Latinos often expressed a strong value for trying to deal trust [confianza] with their clients, and need to treat peo-
with problems on one’s own [hay que poner de su parte] be- ple with respect [respeto]. Participants clearly needed more
fore seeking professional help. This value is a further reason orientation to how psychotherapy is often carried out in the
why a delay in seeking help is the norm, not the exception. U.S. Their expectations were in line with the strong emphasis
At the same time, participants expressed the strong opinion on sociality in Latino culture; that if I unburden myself and
SpringerJ Immigrant Minority Health (2007) 9:17–28 23
share my emotions with you, I will get a warm and emotional Discussion
response in turn.
One participant shared one experience of going to a ther- This paper, along with the paper by Cabassa and colleagues
apist: [15], provides rich context to the growing quantitative studies
concerning different ethnic groups’ attitudes towards mental
Yo he ido a unos cuantos psicoterapias. . . yo fui a uno
health treatment generally and depression care more specif-
que se sentaba y me decı́a “habla” y parecı́a que le
ically. The first important finding is that Latinos recognize
estaba hablando a una pared. Pero el de ahora habla,
and label depression clearly. It is not tenable to argue that
da sus opiniones, se ve que esta interesado en cono-
Latinos do not recognize depression and do not have terms
cerme a mi. El trata de obtener mi confianza y ası́
for it. Many of the descriptions of depression from our focus
me hace sentir más cómoda. . . [I’ve gone to several
group participants clearly mirrored the symptoms of depres-
psychotherapists. . . I went to one who sat down and
sion incorporated in DSM-IV. Their descriptions integrated
said “talk” and it felt like I was talking to a wall.
emotional and physical symptoms of depression, not priori-
But the one I see now talks, gives his opinions, I can
tizing the psychological over the somatic, as DSM-IV does.
tell that he is interested in getting to know me. He
Participants’ descriptions of depression also included social
tries to obtain my trust and thus makes me feel more
dimensions of the experience, especially isolation or loneli-
comfortable. . .]
ness. In this sense, depression is a sociosomatic experience
Lo que pasó es que yo llegaba y el me escucha y está con among Latinos [19, 20]. This tight linking of depression to
el reloj. Y yo le estoy platicando todo lo que yo siento, life’s problems, what Finkler [21] describes as “life’s le-
lo que pasó, todo. Y el me dice, “Bueno te espero en sions,” means that many Latinos do not initially see depres-
la próxima cita.” Era todo lo que me decı́a. [everyone sion as an illness, but rather as a consequence of the many
laughs] Yo ya no voy. Yo no tengo tiempo para perder disruptions caused by the immigration process and chal-
ası́. [What happened is that I arrived [at therapy] and lenges that Latino immigrants face in surviving in the U.S.
he listened to me and he was looking at his watch. And Latinos do see the experiences associated with depression as
I was telling him everything I felt, everything that had serious and needing help, but not necessarily mental health
happened. And he said, “I’ll wait for you at our next care.
appointment.” That was all he said. [everyone laughs] That Latinos may emphasize the more somatic aspects of
I don’t go anymore. I don’t have time to waste like depression when seeking help in primary care can be seen
that.] as more a strategic decision than a lack of awareness or in-
sight into the emotional components of depression. Their
In reaction to comments such as this one, the conversation
own and providers’ expectations that you come to the clinic
turned to what community members expect from therapy.
with physical symptoms shape how they report their prob-
One person described how the first session should be:
lems. The stigma in the community against mental health
La primera sesión debe ser individual para que se re- problems also leads Latinos to defend against the possibil-
cobre su autoestima, se siente confianza. Ya después, ity that they may be labeled as “crazy’ because they are
buscar una terapia en grupo será lo último, ya cuando seeking mental health services. In their home countries, par-
una persona está superando su depresión. [The first ticularly in rural areas, the paucity of mental health services
session should be individual so that the person can re- also means that people are not used to and are not familiar
cover his/her self esteem, can feel confidence and trust. with mental health treatment. Social and emotional prob-
Then later, seeking group therapy would be the last lems are more likely dealt with in the family, church and
thing, when one is in the process of overcoming one’s alternative medical sectors in Latinos’ home countries. All
depression.] of these factors combine to influence Latinos’ presentation of
self when they come to primary care and even mental health
Overall, many could identify the benefits of talk therapies
services.
and why they can be helpful.
Latinos, even fairly recent immigrants, are painfully aware
Porque uno se desahoga. Si uno platica, uno llora y of the many barriers they face to getting primary care and
llora y llora y hay alguien que le escucha a uno, y mental health services for depression. In our focus groups,
uno saca todo, pues saca todo y desahoga el alma. they listed many of the factors that have been regularly iden-
Uno necesita llorar. [Because one unburdens oneself. tified in the services literature: lack of insurance, costs of
If one talks, then cries and cries and cries and there is treatment and medications, lack of Spanish-speaking staff,
someone who can listen and one gets it all out, well one stigma, concerns about immigration status, and many others.
gets it all out, and unburdens one’s soul. One needs to What comes through as different in the focus groups from
cry.] reading the research literature is that these factors are all
Springer24 J Immigrant Minority Health (2007) 9:17–28
intertwined and connected to the particular circumstances Limitations
and life experiences of Latino immigrants. That is, these
are not a series of separate factors to be put into a regres- This study involved a series of focus groups composed of
sion model to identify the “most important” barriers to care. community members in various heavily populated Hispanic
Rather, all of these factors come together in the lives of Latino areas of New York and New Jersey. While our sample was
immigrants as a result of their social and economic positions larger than in many other studies, it was not random, but was
in the U.S. From the perspective of Latino immigrants, all based on convenience samples from a range of communities
the factors stem from the same sets of issues—the kinds of and service and community agencies. It reflects the diversity
work and wages they can find in the U.S., the uncertain- of Latinos in the Northeast, but not in other parts of the coun-
ties produced by their immigration status, the discrimination try. In addition, our sample consisted primarily of females,
they experience because of who they are and how they speak, so the content herein might not accurately reflect the Latino
the multiple demands of supporting family here and family male sample though some gender differences were noted in
there, and the separation from supportive social networks. the group discussions. This oversampling could be due to
While the confluence of all these factors seem overwhelm- various factors including the higher prevalence of depres-
ing, it is also important to remember that research indicates sion among women, the fact that women are more likely to
that immigrants as a group have better mental health than seek services than men, and that the samples were recruited
U.S.-born Latinos [5]. But for those Latino immigrants who from community social service or community health agen-
do develop depression, both the sources of the depression cies. Future studies should work to include more men in their
and the barriers to care are multiply determined. samples.
Several studies have now found that Latinos are more It is important to note that despite the different method-
supportive of psychotherapeutic interventions than other mi- ologies across the focus groups, the themes that arose across
norities and less receptive to medications than European groups were strikingly similar. Experiences in the service
(currently says that) Americans. Our focus groups further system are also reflective of services in New York and New
elucidate these findings and provide meaning to them within Jersey, which are uneven in their efforts to develop service
Latino cultural frameworks. The preference for psychother- adaptations to meet the needs of the rapidly growing and
apy results from several factors. The cultural idea of the value diversifying Latino community in these areas.
of “unburdening oneself” [desahogarse] as an important as-
pect of maintaining emotional health makes psychotherapy Improving care for depression
seem attractive [20]. The idea that depression is a result of
stressors in the social world also means that social inter- With regards to therapies, especially psychotherapies, the re-
ventions make sense to Latinos. Building more supportive sults of this study clearly emphasize that therapists need to
social relationships fills a need for Latino immigrants who orient Latino patients to the process of mental health treat-
have often lost those relationships in the process of immigra- ment. Latinos are not aware of the professional codes of
tion. To the extent that therapy provides a context for sharing conduct that govern relationships between therapists and
emotions and for building new supportive relationships, it consumers. The interpersonal models that Latinos bring to
fits with Latinos’ conceptions of depression and how to cope therapy are based on traditional models of relationships
with it. among family and friends. Building the therapeutic alliance
Medications, on the other hand, are less congruent with is especially important when working with Latinos. It should
Latinos’ models of depression. Medications signal that the include an orientation towards the treatment in general as
person’s problems are a disorder, not a problem in living, and well as an explanation of specific treatment approaches, the
open the person to community stigmatization as someone therapeutic model and the goals for treatment. The more
who is loco. Medications also signal long term disability and the Latino client can be involved in this process, the more
an inability to care for oneself. That these assumptions about confianza is built between the therapist and client.
medication do not fit with the medical model make them no Psychoeducation about medication is also critically im-
less influential in the community. Medications also pose the portant. Addressing issues of the negative side effects and
threat of addiction. In part this arises from community mod- consequences of medication is essential. Having the therapist
els of other substances that are addictive like caffeine in cof- or doctor explain the difference between everyday models of
fee, nicotine in cigarettes, and older anxiolytics. Awareness the addictiveness of some substances and how antidepres-
of the difference in addictive potential and side effective pro- sants actually work and that the medicine can be stopped
files of the newer anti-depressants are limited in the Latino may help people to more readily accept the medicines as a
community. The challenge is to provide psychoeducation form of treatment. Providing consumers with realistic esti-
about anti-depressants in the Latino community without ap- mates of how long it will take for the medications to produce
pearing to be overly promoting medications for depression. therapeutic effects and what the likely course of treatment is
SpringerJ Immigrant Minority Health (2007) 9:17–28 25
will also help to prevent misconceptions and patient drop- it. But to resolve a problem, you have to take off the “pre”
out. Recent research has shown that depression treatment and take care of it (that is become occupied in finding the
in primary care combining therapy and medications is par- solutions to the problem)!].
ticularly effective for Latinos both in the U.S. and in Latin
America [22, 23].
Needs for community intervention APPENDIX A: Focus group guide concerning mental
health and mental health services (Studies 1 and 2)
Based on the barriers to help seeking described in the vari-
ous focus groups, several culturally competent intervention 1. Para Uds, que es salud emocional o salud mental?
programs are necessary to make mental health services ac- [For you, what is emotional or mental health?]
cessible to the Latino community. For example, there is a r Como saben Uds. que una persona es sana mental-
need for programs to help new Latino immigrants adjust
to life in the U.S., this could help to prevent the onset of mente?
depression. In addition, programs to reduce the stigma of [How do you know when someone is mentally healthy?]
r Que debe hacer una persona para mantener su salud
mental illness and mental health care in the Latino com-
munity would significantly increase help seeking behaviors. emocional?
More psychoeducation about mental health and its treatment [What should someone do to maintain their emotional
would encourage the Latino community to be psychologi- health?]
cally savvy; this could help community members to be their 2. Que tipos de problemas (enfermedades) de salud mental
own advocates for appropriate treatments. Finally, there is a hay?
need for more public information in Spanish about where to [What types of mental health problems (illensses) are
get mental health help and how to access such care. These there?]
kinds of interventions are supported both by our findings and Como saben Uds. que una persona tiene un problema (una
those of Cabassa and colleagues [15] in a different context enfermedad) de salud mental?
with a different mix of Latinos. [How do you know when someone has a mental health
problem (illness)?]
Clinical and research implication
3. Cuales son las reacciones de gente en la comunidad acerca
Based on the findings presented in this paper, one can see that de personas con problemas de salud mental?
community members echo ideas set forth by cross-cultural [How do people in the community react to people with
mental health practitioners about how to more effectively mental health problems?]
serve the Latino community. Mental health providers work- 4. Que debe hacer una persona que padece de un problema
ing with Latino clients should learn to address the con- de salud mental?
cerns expressed by these community members—including [What should someone do if they suffer from a mental
the stigma of mental illness, the fear of both the unknown health problem?]
structure of therapy and the unknown effects of psychotropic r Que tratamientos conocen Uds. para problemas (enfer-
medications—in short, professionals need to become cultur- medades) de salud mental?
ally competent. In addition, researchers can learn to adapt [What treatments do you know for mental health prob-
their research strategies to the cultural values and norms lems (illnesses)?]
within the population they wish to study. For example, we r Cuales de esos tratamientos piensan Uds. son mas efec-
used the focus group method, where you gather around a tivos?
table, usually with some refreshments, and talk about things [Which of these treatments do you think are most
that are important to you, a style that is culturally acceptable effective?]
within the Latino community and emphasizes values such as r Que puede hacer la familia de una persona con un prob-
personalismo. lema de salud mental?
We end this paper with a call to action for the mental [What can the family of a person with a mental health
health fields to become more involved in reaching out, ed- problem do for them?]
ucating, and helping the Latino community. As one focus
group participant so aptly phrased it, “Qué hace uno cuando 5. Que problemas encuentran personas con problemas de
hay un problema? Se preocupa. Pero para resolver hay que salud mental en buscar ayuda?
quitarle el ‘pre’ y ocuparse!” [What do you do when you [What problems do people with mental health problems
have a problem? You worry and become preoccupied with encounter in seeking help?]
Springer26 J Immigrant Minority Health (2007) 9:17–28
r Que problemas tiene en identificar servicios apropri- [What type of help does Marta need?]
adas?
Los doctores piensan que Marta está deprimida. Al pre-
[What problems do they have in identifying appropriate
guntarle si considera que ha necesitado ayuda profesional
services?]
r Que problemas tienen en usar estos servicios? para algún problema emocional, dice que no.
[The doctors think that Marta is depressed. When they ask
[What problems do they have in using those services?]
her if she thinks she needs professional help for an emotional
problem, she says no.]
Focus group questions about educational campaign
r ¿Qué esta ocurriendo con Marta que a pesar de lo mal que
A nosotros, nos interesa desarollar un programa para educar se siente, no reconoce que tiene un problema emocional?
a la comunidad Latina acerca de la salud mental. [What is happening with Marta, that although she feels
[We would like to develop a program to educate the Latino really ill, she does not recognize that she has an emotional
community about mental health.] problem?]
r ¿Por qué personas como Marta se deprimen?
1. Que medios de comunicacion serian mejores para ese pro-
[Why do people like Marta get depressed?]
grama de educacion? (radio, television, periodicos, etc.) r Qué otras razones contribuyen a que personas como Marta
[What forms of communication would work best for
se depriman?
the educational program? (radio, television, newspapers,
[What are some other reasons why people like Marta might
etc.)]
become depressed?]
2. Utilizaria Ud. un numero 800 para informacion acerca de r Cuándo debe uno buscar ayuda para la depresión?
donde encontrar servicios de salud mental?
[When should one seek help for depression?]
[Would you use an 800 number for information about how r ¿Qué tipo de ayuda debe buscar Marta para su depresión?
to find mental health services?]
[What type of help should Marta seek for her depression?]
3. Que mensajes deberiamos presentar acerca de salud men-
tal en la comunidad Latina? (Informacion acerca de en- A pesar de que se siente mal con problemas fı́sicos y
fermedades, estigma, recursos o tratamientos, etc.) psicológicos y que el doctor le ha dicho que esta deprim-
[What messages should we present about mental health ida, Marta no busca ni ha entrado en tratamiento para la
in the Latino community? (Information about illnesses, depresión.
stigma, resources, treatments, etc.)] [In spite of how badly she feels due to her physical and
psychological problems, and that the doctor has told her she
Appendix B: Vignette on recognizing depression and is depressed, Marta does not seek nor enter treatment for
attitudes towards treatment (Study 4) depression.]
r Qué razones podrı́a tener Marta para no buscar ayuda?
Voy a comenzar por hablarles de un paciente, una mujer que [What reasons might Marta have for not seeking help?]
llamaremos Marta, de 38 años, divorciada con 2 hijos de 11
y 13 años. Marta expresa que durante el último año se ha Luego de pasar otro año en que los perı́odos de depresión
sentido muy triste. Indica que se le hace difı́cil dormir, tiene han ido aumentando, Marta ha pensado en algunas ocasiones
poco apetito, llora a menudo, y no puede realizar sus tareas. en buscar ayuda, pero no lo ha hecho.
Ella ha tenido que visitar al médico para dolores de cabeza, [During another year in which her periods of depression
estomacales y de los músculos. have increased, Marta has thought about seeking help on
[I am going to begin by telling you about a patient, a some occasions, but still has not gone.]
woman we will call Marta, who is 38 years old, divorced and r ¿Qué se podrı́a hacer para que alguien como Marta busque
has two children who are 11 and 13 years old. Marta says that la ayuda que necesita?
during the past year she has felt very sad. She has had trouble [What could be done so that someone like Marta would
sleeping, had little appetite, cries often and cannot get her seek the help she needs?]
tasks done. She has had to visit her doctor for headaches and
pains in her stomach and muscles.] Marta decide que desea recibir ayuda profesional pero
se ha encontrado con muchos problemas en conseguir
r ¿Qué piensan Uds. que esta pasando con Marta? tratamiento.
[What do you think is going on with Marta?] [Marta decides that she would like professional help, but
STOP HERE AND DISCUSS AFTER EACH QUES- she encounters many barriers in obtaining treatment.]
TION
r ¿Qué tipo de ayuda necesita (Marta)? r ¿Cuáles problemas consideran ustedes que hacen difı́cil
que las personas consiguen tratamiento?
SpringerJ Immigrant Minority Health (2007) 9:17–28 27
[What types of problems do you think make it hard for r ¿De quienes prefieren Uds. recibir tratamiento?
people to access treatment?] [From whom would you prefer to receive treatment?]
r ¿Qué recomendaciones tienen para resolver estos proble- r ¿Hay otro comentario que Uds. quieren hacer acerca de
mas? este asunto?
[What recommendations do you have for solving those [Is there anything else that you would like to say about
problems?] this topic?]
Si Marta decide buscar ayuda, [If Marta did decide to seek
treatment,]
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