The article by Folsom and colleagues published in this issue of the Journal describes a large-scale study of the effect of language preference on mental health service utilization. Latinos who prefer to speak Spanish were compared to Latinos who prefer to speak English, as well as to Caucasians. In this context, language was identified as the most frequently used proxy measure of acculturation. The study encompassed 539 Spanish-speaking Latinos, 1,144 English-speaking Latinos, and 4,638 Caucasians who initiated treatment for schizophrenia, bipolar disorder, or major depression in San Diego County’s Adult and Older Adult Mental Health Services system during the period 2001–2004. Latinos constitute 23% of the San Diego County population, and Caucasians constitute 60% of the population in this county. The database used for this study was derived from San Diego County’s Adult Mental Health Services system, which serves persons with Medi-Cal or without health insurance. The patients included in this study received no mental health services during a 12-month period prior to their inclusion in the study and thus represent new users of the mental health system, presumably with recent onset of mental illness. The four mental health services included in the study were 1) inpatient and crisis residential, 2) emergency and the psychiatric emergency response team, 3) jail, and 4) outpatient.
Spanish-speaking Latinos were less likely to enter mental health care through emergency or jail mental health services and more likely to enter mental health care through outpatient services. There were no group differences in the number of patients who stayed in treatment or used inpatient care. The authors conclude that language, an established marker of acculturation, may be more important than ethnicity in determining mental health services utilization among Latinos. It is of note, however, that Spanish-speaking Latinos had the lowest proportions of schizophrenia and bipolar disorder diagnoses, as well as the highest proportion of major depression diagnoses. Likewise, the rates of being homeless, living in board-and-care-homes, and being incarcerated were lower among Spanish-speaking patients.
This study is one of the first to compare Spanish-speaking and English-speaking Latinos with each other, as well as to the Caucasian population. Strengths of the study are the large-scale sample used in the investigation and the excellent reputation and expertise of the authors in this area.
Despite the strengths of this study, it is reasonable to question its assumption that language preference is a proxy for acculturation. The study assumed that the English-speaking Latinos in the sample were more acculturated than Spanish-speaking Latinos. Examination of the Spanish-speaking Latino sample strongly suggests that they were socioeconomically more stable and thus exposed to less stress, which in turn might have resulted in less severe mental illnesses than in either the English-speaking Latino sample or the Caucasian sample. For instance, the Spanish-speaking Latino patients entered the mental health care system more frequently through outpatient services than did the English-speaking Latino patients or the Caucasian patients. Likewise, they less frequently used emergency or jail services than the English-speaking or Caucasian samples. Similarly, Spanish-speaking Latinos had lower rates of living in board-and-care homes or being homeless than the English-speaking Latinos or Caucasian group. Spanish-speaking Latinos were indeed more often living independently or with families than their counterparts in the two other samples of the study. Additionally, the rate of incarceration, as well as the prevalence of substance use disorders, was lower among Spanish-speaking Latinos in comparison to the English-speaking Latino and Caucasian samples. All these advantages may be reflected in the finding that the diagnoses of the Spanish-speaking Latino sample were primarily major depression, in comparison to schizophrenia and bipolar disorder for the English-speaking Latino and Caucasian samples. A major limitation of this study was to not include socioeconomic levels in the study methodology, which might have better clarified the differences between the groups.
It is quite possible that the Spanish-speaking sample was paradoxically better integrated into the United States culture than the English-speaking sample. Although they preferred Spanish, they might well speak English also. They felt more at ease with their own culture, but their selection of outpatient treatments indicates that they had no problems interrelating with the Caucasian population or with the Anglo-Saxon culture. The successfulness of this type of acculturation pattern, which preserves the core of the family’s culture of origin, has already been described in other cross-cultural studies in the medical literature (1, 2).
There is no question that the impact of immigration on mental health is significant. Other reports focusing on Hispanic migrants in the United States have found that the length of time in this country has much to do with the increasing level of psychopathology manifested by the immigrants (3). During their first 5 years after entry into the United States, Hispanic migrant groups have shown a higher level of substance use and abuse, including alcoholism, than they do after 5 years. However, the use of the family environment to maintain the original culture, while permitting acculturation into the United States, can play a major role in preventing mental illness or substance abuse among Hispanic migrants in the United States (4, 5). Hispanic migrants who preserve Spanish when speaking at home have lower levels of substance use and abuse than Hispanic migrants who prefer to speak in their acquired English language (3). Preservation of Spanish speaking may also have encouraged recent immigrants to seek clinicians fluent in Spanish. The stress induced in Spanish-speaking mentally ill patients when interviewed by English-speaking mental health professionals can lead to more severe diagnoses than when these patients are interviewed by Spanish-speaking mental health professionals (6, 7).
Cross-cultural psychiatry has certainly received much attention in recent years and should be more carefully considered when addressing clinical issues pertaining to ethnic minority populations who reside in this country (8). Globalization is producing a migration pattern that is felt all over the world, especially in the Western hemisphere. About 100 million residents in the United States belong to ethnic minority groups. Obviously, psychiatrists and other mental health professionals need to provide them high-quality psychiatric care. Becoming culturally competent should be a first step in this direction (9, 10).