American Indians and suicide: a neglected area of research

Suicide is a major public health problem for American Indians in the United States. Published studies indicate that American Indians experience the highest rate of suicide of all ethnic groups in the United States. This article synthesizes the epidemiology and risk factors associated with suicide among American Indians, barriers to research, prevention, mental-health services, and recommendations for research and practice. The authors' recommendations arise from the current literature as well as interviews with practitioners and academics in the field of suicide prevention. The authors present significant substantive and methodological issues that inform research on suicide in American Indian communities, as well as existing contemporary interventions. Overall, socioeconomic characteristics, substance abuse, barriers to mental health services and acculturation play a role in the occurrence of suicide in American Indian communities. These findings suggest suicide is an important public health problem that needs to be addressed for American Indians.

Coping variables that mediate the relation between intimate partner violence and mental health outcomes among low-income, African American women

Coping variables that mediate the relation between intimate partner violence (IPV) and mental health outcomes among African American women were investigated. The study sample included 143 economically disadvantaged African American women ranging in age from 21 to 64 years old who were receiving services at an urban public health system. Sixty-five had experienced IPV within the past year and 78 had never experienced IPV. Results indicated that (a) the IPV status-depressive symptoms link was mediated by multiple ways of coping, spiritual well-being, and social support; (b) the IPV status-anxiety symptoms link was mediated by multiple ways of coping, social support, and ability to access resources; and (c) the IPV status-parenting stress link was mediated by multiple ways of coping, spiritual well-being, and social support. Implications of these findings for clinical practice with abused women are discussed.

Why psychiatric conditions are special: an evolutionary and cross-cultural perspective

In non-Western and premodern societies, approaches to sickness involved moral considerations laden with existential and spiritual implications. Healers and physicians had access to this aspect of their patient's lives, were expected to use it constructively, and often did so. The contemporary biomedical theory of disease no longer assigns to illness such metaphysical connotations. While general physicians are permitted - perhaps even advised - to avoid involvement in morally laden dialogues tied to illness and the self, such dilemmas are more prominent and qualitatively different in psychiatry, as psychiatric conditions often entail changes in self-conception, psychological disaffection, unacceptable behavior, and untoward personal reactions to social circumstances. Manifestations of psychiatric conditions can overwhelm an individual's control in areas of cognition, emotion, autonomy, social responsibility, behavior, and body functions - exactly those matters that "modern" individualistic minds are supposed to master. Consequently, psychiatric conditions challenge basic presuppositions of the modern, secular credo about personhood, disease, and behavior. They comprise a species of human problems ontologically distinct from the conditions handled by other medical disciplines.

Ethnicity, deprivation and mental health outcomes

Aims: To describe and measure differences between ethnic groups on standard measures of mental health outcome. Methods: Clinical staff in eight New Zealand Health Districts collected consumer outcomes data at the start, end and review of episodes of care. Consumers were allocated to one of three ethnicity groupings ? Maori, Pacific Island and ?All Other?. Results: There were large differences between the three ethnicity groupings on the measures. Maori and Pacific Island consumers appeared to demonstrate more psychotic phenomena and overall worse scores, and the All Other group, more depression. Changes in scores between start and end of episodes of care were proportionately similar across the three groups. Differences between ethnic groupings varied according to socio-economic deprivation level. Conclusions: Potential reasons for some of the effects observed are discussed, including differing pathways to care, clinician and selection bias, and differing models of mental health.

Specifying race-ethnic differences in risk for psychiatric disorder in a USA national sample

BACKGROUND

Epidemiological studies have found lower than expected prevalence of psychiatric disorders among disadvantaged race-ethnic minority groups in the USA. Recent research shows that this is due entirely to reduced lifetime risk of disorders, as opposed to persistence. Specification of race-ethnic differences with respect to clinical and social characteristics can help identify the protective factors that lead to lower lifetime risk among disadvantaged minority groups.

METHOD

Data on 5424 Hispanics, non-Hispanic Blacks, and non-Hispanic Whites came from the National Comorbidity Survey Replication, a nationally representative survey conducted with the World Mental Health version of the Composite International Diagnostic Interview. Race-ethnic differences in risk of disorders were compared across specific diagnoses, ages of onset, cohorts and levels of education.

RESULTS

Both minority groups had lower risk for common internalizing disorders: depression, generalized anxiety disorder, and social phobia. In addition, Hispanics had lower risk for dysthymia, oppositional-defiant disorder and attention deficit hyperactivity disorder; non-Hispanic Blacks had lower risk for panic disorder, substance use disorders and early-onset impulse control disorders. Lower risk among Hispanics, relative to non-Hispanic Whites, was found only among the younger cohort (age

CONCLUSION

The pattern of race-ethnic differences in risk for psychiatric disorders suggests the presence of protective factors that originate in childhood and have generalized effects on internalizing disorders. For Hispanics, but not for non-Hispanic Blacks, the influence of these protective factors has emerged only recently.

Collapse

Key Words Collapse

MESH Headings

• Adolescent
• Adult
• Black People/statistics & numerical data
• Demography
• Diagnostic and Statistical Manual of Mental Disorders
• Ethnicity
• Female
• Hispanic or Latino/statistics & numerical data
• Humans
• Male
• Mental Disorders/diagnosis
• Mental Disorders/ethnology
• Middle Aged
• Prevalence
• Risk Assessment
• Risk Factors
• United States/epidemiology
• White People/statistics & numerical data

Collapse

Grants

• R01 DA016558 NIDA NIH HHS
• MH46376 NIMH NIH HHS
• K01 MH066057 NIMH NIH HHS
• U01-MH60220 NIMH NIH HHS
• R01 MH52861 NIMH NIH HHS
• K01 MH66057-02 NIMH NIH HHS
• K01 MH066057-03 NIMH NIH HHS
• R01 MH046376 NIMH NIH HHS
• R01 MH069864 NIMH NIH HHS
• R01-MH069864 NIMH NIH HHS
• R01 MH049098 NIMH NIH HHS
• K05 DA015799 NIDA NIH HHS
• U01 MH060220 NIMH NIH HHS
• R13-MH066849 NIMH NIH HHS
• U13 MH066849 NIMH NIH HHS
• R13 MH066849 NIMH NIH HHS

Collapse

The Correspondence of Bruno Bettelheim and Rudolf Ekstein

This paper provides the historical, cultural, and clinical context for the relationship between Bruno Bettelheim (1903-1990) and Rudolf Ekstein (1912-2005). Both were Viennese-born and trained intellectuals who received doctorates in the human sciences from the University of Vienna in 1937. Both were deeply identified with lay analysis, emphasizing that for psychoanalysis to perpetuate itself it needed to promote serious and rigorous forms of research. Because Bettelheim was the better known of the two, this introduction focuses on Ekstein's family history, with special emphasis on his experience of loss and trauma and his capacity to recover from personal and educational obstacles. It argues that Ekstein was a representative product of Austro-Marxism in the period between the wars, embracing the ethical brand of democratic socialism and group solidarity that was integral to the theory and practice of Austrian Social Democracy. It discusses Ekstein's training with Moritz Schlick in philosophy and his immersion in the Vienna Circle of logical positivism. From Schlick, Ekstein evolved into a philosophical thinker who learned how to think his own thoughts. Ekstein joined the circle of psychoanalytic pedagogues who clustered around the Vienna Psychoanalytic Society, under the tutelage of Willi Hoffer, August Aichhorn and, above all, Anna Freud. The clinical component of psychoanalysis emanated from his commitment to understanding the inner world of the child. Bettelheim and Ekstein first became aware of each other from reading the analytic literature and finally met in America in the 1950s. They shared a professional interest in conducting research and doing clinical work on severely disturbed children and adolescents, including those with psychotic, borderline and autistic diagnoses. They debated the value of milieu therapy versus psychoanalytically oriented psychotherapy on such children. As their relationship evolved, the two collaborated and began a fascinating correspondence that gradually evolved into an intimate friendship. They both engaged in a polemic with Bernard Rimland, who was massively critical of their clinical work and a hostile critic of psychoanalytic approaches to the treatment of disturbed children. Rimland was an advocate of a neurological approach to mental illness, with an emphasis on biology and psychopharmacology. The 22 letters that constitute the Bettelheim-Ekstein exchange began with clinical concerns, including the varieties of solitude, isolation and countertransference disruptions that may trouble the psychoanalytic researcher and clinician in dealing with primitively disordered children. It moves to other issues, including mutual support during the Rimland Affair. As the two became more friendly, a pattern of good-natured competition and envy appeared. The two engaged in a heated exchange on the question of whether contemporary Vienna remained as anti-Semitic as it had been in their respective youths: Bettelheim, the concentration camp survivor, argued that nothing had changed and that most Austrians remained viscerally anti-Semitic; Ekstein, the Austro-Marxist, contended that one could not blame a generation born after World War II, holding that in his experience many Austrians had examined their consciences and held distinctly different options from their parents or grandparents. Toward the end of their correspondence, we encounter Ekstein's tender sensitivity to Bettelheim's descent into depression as a result of the death of his wife, Trude, leading eventually to recurrent episodes of suicidal ideation and plans for his own suicide. The letters testify to a unique friendship with a somewhat old-world quality.

An ethnographic study of job seeking among people with severe mental illness

An ethnographic study employing intensive participant observation methods identified critical differences in styles of searching for competitive employment among people with severe mental illness and explored the social/cultural correlates of these job-seeking styles. Propensity for active job seeking was strongly associated with younger age, with participants' involvement in interdependent kin networks or households, with ethno-racial minority background, and with capacity for coherent discourse. Active job seekers did particularly well in a supported employment program, but also were able to find employment when assigned to other programs; passive job seekers had little success in any vocational program. The authors discuss several implications of these findings for vocational services.

Prevalence of dopamine and 5HT2C receptor polymorphisms in Amerindians and in an urban population from Argentina

We report on the frequency of DRD2A1, DRD3A1, DRD4/2R-10R, and 5HT2CA1 variants in the population of the city of La Plata (Argentina) and in Amerindians from Argentina, Paraguay, and Chile. In the Amerindian sample, the prevalence of DRD2A1 and DRD4/4R variants were, respectively, significantly lower and significantly higher than frequencies reported in other Native Americans. Comparison of average allele and genotype frequencies between La Plata and Amerindians showed significant differences for 5HT2CA1 and DRD4. As La Plata is a population with predominant European and Amerindian components, we used mtDNA and Y-specific markers to subdivide the La Plata sample into two strata: Amerindian La Plata and non-Amerindian La Plata. Significant variations between the two strata were detected for DRD2A1, DRD3A1, and DRD4/4R allele frequencies, and for the homozygous DRD4/4R/4R genotype. Several controversial reports suggest a possible association between a variant of DRD and/or 5HT2C receptor genes and the clinical expression of several psychiatric disorders. We suggest that ethnic variations in the prevalence of the allelic forms of these genes may be a confounding factor to be taken into consideration in studies of association between dopaminergic and serotonergic receptor genotypes and neuropsychiatric and mood disorders.

Nativity and DSM-IV psychiatric disorders among Puerto Ricans, Cuban Americans, and non-Latino Whites in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

This study examined the risk of lifetime substance use disorders and mood and anxiety disorders between Island-born Puerto Ricans, foreign-born Cuban Americans, and foreign-born non-Latino whites and their U.S.-born counterparts.

METHOD

Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; N = 43,093) were used to derive lifetime prevalence rates of specific DSM-IV psychiatric disorders by subethnicity and nativity group. Logistic regression models were constructed to detect variation in the odds of each psychiatric disorder across groups.

RESULTS

A protective effect of foreign-born nativity in risk for psychiatric disorders was present for all groups but varied according to the assessed disorder. For non-Latino whites, the effect was observed for most specific psychiatric disorders, whereas, for Puerto Ricans and Cuban Americans, the effect was only evident for specific substance use disorders.

CONCLUSION

The protective effect of nativity against psychiatric morbidity found in other studies among Mexican Americans and non-Latino whites does not entirely generalize to Puerto Ricans and Cuban Americans and may not generalize to individuals of other origins. The results of this study are discussed in terms of potential mechanisms involved in variations in the risk of specific psychiatric disorders among groups defined by nativity and race-ethnicity and the importance of identifying specific cultural components that may serve as risk and protective factors of psychiatric morbidity.

Validation of the Arabic Strengths and Difficulties Questionnaire and the Development and Well-Being Assessment

We examined the validity of the Arabic versions of 2 main measures of child psychopathology: the Strengths and Difficulties Questionnaire (SDQ) and the Development and Well-Being Assessment (DAWBA). They were administered to the parents and teachers of 2 samples of 5-12-year-old Yemeni children, one from psychiatric clinics (n=87) and the other from the community (n=100). The SDQ scores distinguished well between the 2 samples and also between children with different psychiatric diagnoses. The DAWBA showed substantial agreement with independent clinic diagnosis. The brevity of the SDQ and the respondent-based nature of the DAWBA interview make these tools feasible for use in countries where there is a severe shortage of skilled manpower.

Provider Recognition of Psychosocial Problems in Low-Income Latino Children

The purpose of this study was to determine the frequency of identification of psychosocial problems in Latino children by primary care providers (PCPs). This was a cross-sectional study of 269 low-socioeconomic status (SES), Latino children, ages 2-16 years, seen at a community clinic for well-child care. Primary care providers completed a World Health Organization checklist, which organized provider assessment of child psychosocial problems. Clinicians identified one or more psychosocial problems in 39.8% of children. Clinicians recognized only 20% of children with clinically significant aggression symptoms, 18% of children with clinically significant attention/hyperactivity symptoms, and none (0%) of the children with clinically significant anxiety/depression symptoms with clinical data from parent-completed child-behavior checklists used as the benchmark. Despite high rates of identification of psychosocial problems in a low-SES, Latino population, PCPs still miss symptoms of mental health difficulties, especially anxiety and depression. Since symptoms of anxiety and depression are likely to be more pronounced in Latino populations, there is a continued need for improvement in detection of mental health concerns among these children.

A cross-cultural analysis of the Brief Symptom Inventory-18

The Brief Symptom Inventory-18 (BSI-18: Derogatis, 2000) is an abbreviated version of the nine dimension, 53-item BSI (Derogatis, 1993) which is a shortened form of the 90-item Symptom Checklist-90-Revised (SCL-90-R: Derogatis, 1994). Criticism focused on factor structure (cf. Boulet & Boss, 1991; Ruipérez, Ibáñez, Lorente, Moro, & Ortet, 2001) and the two older versions' poor discriminant validity suggest the scales' usefulness is limited to global scores only. Using principal component analysis, the authors explore the three-dimension factor structure of the BSI - 18 with the understudied population of Central American immigrants to the U.S. (N = 100). Results suggest one underlying factor best used in aggregate as a general screening for overall levels of psychological distress. Cultural differences are discussed.

Madness and disability in contemporary Chinese film

This article draws on recent research in the medical humanities to analyze two contemporary Chinese films: Zhang Yuan's Sons (1996) and Zhou Xiaowen's The Common People (1998). By portraying psychic and physical anguish in ways that refuse to divorce biology from culture, such films offer rare moral dialogues on biomedical issues and contribute a cross-cultural perspective invaluable to the task of responding to illness and suffering.

The Early History of Psychoanalysis in San Francisco

The early history of psychoanalysis in San Francisco begins in 1918 and ends in 1953. During those 35 years the San Francisco Bay Area witnessed the awakening of interest in psychoanalysis, the arrival of the European émigré analysts and the emergence of individuals and groups engaging in extraordinarily creative work and doing so in an ecumenical spirit and with a social commitment. This article provides an overview of this illustrious history and the people who participated in it.

The effect of lifetime victimization on the mental health of children and adolescents

This paper examines the cumulative prevalence of victimization and its impact on mental health in a nationally representative sample of 2030 children aged 2-17 in the USA. Telephone interviews conducted with both caregivers and youth revealed socio-demographic variations in lifetime exposure to most forms of victimization, with ethnic minorities, those lower in socio-economic status, and those living in single parent and stepfamilies experiencing greater victimization. Sexual assault, child maltreatment, witnessing family violence, and other major violence exposure each made independent contributions to levels of both depression and anger/aggression. Other non-victimization adversities also showed substantial independent effects, while in most cases, each victimization domain remained a significant predictor of mental health. Results suggest that cumulative exposure to multiple forms of victimization over a child's life-course represents a substantial source of mental health risk.

Social and economic determinants of disparities in professional help-seeking for child mental health problems: evidence from a national sample

OBJECTIVE

To test the role of social determinants-including race, education, income, and demographic factors-of child mental health services use, defined as having had a visit to a mental health professional for depression, attention-deficit, or for any reason.

DATA SOURCES/STUDY SETTING

National Longitudinal Survey of Youth and the Child/Young Adult supplement, a nationally representative sample of 7-14-year-old children born to women who were 14-22 years old at the start of data collection, in 1979. African Americans and Latinos were over-sampled, and population weights are available to make nationally representative inferences.

STUDY DESIGN

Indicators of mental health service use were regressed on social and economic determinants, family structure variables, and insurance variables, controlling for need as captured by several different symptom scales.

PRINCIPAL FINDINGS

Girls are much less likely to obtain needed treatment for externalizing behavior disorders than are boys, and are somewhat less likely to obtain needed treatment for depression than boys. Middle children are less likely to obtain needed treatment for any mental health problem than are oldest, youngest, or only children. The presence of the father inhibits the likelihood that the child will receive treatment, particularly for depression. African Americans and Latinos are less likely than white children to receive treatment. In contrast to these rich results for the social and demographic determinants of children's specialty mental health utilization, the economic and insurance variables (including maternal education and income) seem to hold little predictive power.

CONCLUSIONS

These results argue for interventions to sensitize parents-especially fathers-to the need to pay attention to the mental health needs of their children, in particular girls and middle children. The analysis also suggests that the literature on intrahousehold decision making and on the gender dimensions of investment in children is worth extending to mental health treatment decisions.

Association between psychiatric disorders and smoking stages among Latino adolescents

OBJECTIVE

We examined the prevalence of smoking behaviors and their association with psychiatric disorders within a representative sample of youth from Puerto Rico.

METHOD

A complex sampling design was used and analyses were conducted to account for the unequal selection probability, stratification and clustering. All analyses were weighted back to the population from which they were drawn. Psychiatric and substance use disorders were assessed using the parent and youth versions of the Diagnostic Interview Schedule for Children, Version 4.0 (DISC-IV).

RESULTS

After controlling for other comorbidity, major depression and oppositional defiant disorder were significantly associated with nicotine dependence, rather than with lower levels of use. In contrast, conduct disorder was generally associated with lower levels of use rather than with nicotine dependence. As expected, the alcohol and drug use disorders demonstrated some of the strongest associations with individual smoking stages.

CONCLUSIONS

By examining psychiatric correlates of smoking stages within an island-wide sample of adolescents, the present study highlights those disorders that may play a role in the development and/or persistence of smoking behavior in Puerto Rico and further clarifies the appropriate targets for smoking intervention conducted in community settings.

Mental illness and principal physical diagnoses among Asian American and Pacific Islander users of emergency services

The stigma of mental illness is one of the factors that prevents Asian Americans/Pacific Islanders (APIs) from seeking formal mental health services. A somatic complaint is more acceptable in expressing psychiatric/emotional distress. Admission diagnoses in API emergency service users with secondary psychiatric diagnoses were identified from the 2001 National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP). The sample consisted of 10,623 adult APIs. The study examined the differences in the six leading principal physical admission diagnoses between API emergency service users with psychiatric diagnoses and those without psychiatric diagnoses. Several of the study findings create concern (e.g., the higher percentage of APIs with psychiatric diagnosis who were discharged against medical advice, the high percentage admitted with medication intoxication). Further study is needed to provide guidance for clinical practice.

A European approach to rural-urban differences in mental health: the ESEMeD 2000 comparative study

OBJECTIVE

The study aimed to answer the following questions: Are there any rural-urban differences in mental health, once sociodemographic variables are controlled for, and are any of these differences observed in EU countries? Did the individuals suffering from mental health disorders have the same characteristics in rural and urban areas, particularly concerning self-reported impairment?

METHOD

The European Study of the Epidemiology of Mental Disorders (ESEMeD 2000 study) is a cross-sectional, in-person, household interview survey based on probability samples representative of the adult population of 6 European countries: Belgium, France, Germany, Italy, the Netherlands, and Spain. The rural population is defined as those living in towns with fewer than 10,000 inhabitants, and the urban population is defined as those living in towns or cities with 10,000 or more inhabitants. A stratified, multistage, random sample without replacement was drawn in each country. The overall response rate of the study was about 61.2% (weighted response rate).

RESULTS

The study results confirmed previous findings on the variation in mood disorders between rural and urban areas. Overall, urbanicity seemed to be linked to a higher risk of mental health disorders, particularly depressive disorders, whereas the link to anxiety disorders was only moderate and there was no link at all to alcohol disorders. Country differences concerned male respondents and not female respondents, with the exception of Belgium, where the differences concerned women only (and showed fewer disorders in rural areas).

CONCLUSIONS

This study will, hopefully, stimulate further intra-European studies using comparable methods and instruments to look at the experience across the European continent and introduce steps to harmonize rural-urban population limits across diverse countries.

Racism, psychosis and common mental disorder among ethnic minority groups in England

BACKGROUND

The aim of this study was to explore the relationship between risk of psychosis, common mental disorder (CMD) and indicators of racism among ethnic minority groups in England and how this relationship may vary by particular ethnic groups.

METHOD

A multivariate analysis was carried out of quantitative, cross-sectional data from a nationally representative community sample of people aged between 16 and 74 years from the largest ethnic minority groups in England: those of Caribbean, Indian, Pakistani, Bangladeshi and Irish origin.

RESULTS

Experience of interpersonal racism and perceiving racism in the wider society each have independent effects on the risk of CMD and psychosis, after controlling for the effects of gender, age and socio-economic status. There was some variation in the findings when they were conducted for separate ethnic and gender groups.

CONCLUSIONS

An understanding of the relationship between racism and mental health may go some way towards explaining the ethnic variations found in both CMD and, particularly, psychosis.

Stigma of mental illness among American Indian and Alaska Native nations: historical and contemporary perspectives

Among American Indian and Alaska Native (AIAN) people, the concept of mental illness has different meanings and is interpreted in various ways. This paper describes the realities of mental health care that confront AIAN people. Stigma is associated with mental illness, which can be a barrier for those individuals who are in need of mental health services. Within the context of the AIAN historical and contemporary experiences, the paper details domains that negatively influence the lives of AIAN people. Included are the failure of the U.S. government to fulfill its treaty agreements with AIAN people; the disparities in income and education, and the pervasiveness of poverty; and access to care issues. These domains help to set the stage for health disparities that frequently catapult AIAN people to early morbidity and mortality. Importantly, many of these conditions are preventable. The paper concludes with recommendations for a more diverse workforce that will include AIAN mental health professionals who are available to provide culturally competent care to AIAN people in a variety of settings.

Community educators as supporters in ethnographic research

The present article describes ethnographic research on the structure and function of bilingual community educators (CEs) as brokers of information involving culturally and linguistically diverse (CALD) communities. An important aspect of CE involvement was supporting the chief investigator to engage CALD communities to interpret their understanding of mental health and mental illness, and make appropriate choices about their health care. CEs advised the chief investigator on the appropriate use of language when dealing with mental and emotional health issues so that CALD community people were not isolated from the research process. The author contends that the benefit of CEs in ethnographic research is to help research teams synthesize different viewpoints to shape research questions and create workable solutions in local situations.