By: Dr. Manny J. González is an Associate Professor at Fordham University Graduate School of Social Service and Dr. Gladys González-Ramos is an Associate Professor at New York University School of Social Work.  Drs. González and González-Ramos published Mental Health Care for New Hispanic Immigrants: Innovative Approaches in Contemporary Clinical Practice. (May 2007)

The Hispanic community in the United States is a highly diverse group consisting of 29 subgroups. It is estimated that there are over 41 million Hispanics in the United States making this the largest minority group in the country (Delgado, 2007).  Between 2000 and 2004, Hispanics increased by 17 percent, the most of any ethnic and racial group in the country.

Updated statistics reflect how the dynamic of Hispanic population growth has changed the distribution of group representation: Mexicans, with 20,641,000 (66.9 percent), Puerto Ricans, with 3,406,000 (8.6 percent), Cubans with 1,242,000 (3.7 percent), and Dominicans with 965,000 (2.2 percent), account for a total of almost 26 million or 75 percent of the entire Hispanic community (U.S. Bureau of the Census, 2001). 

The emergence of new Hispanic subgroups, however, represents a dramatic departure from demographic patterns noted in the 1980’s and before.  For example Salvadorans (655,000), Colombians (471,000), Guatemalans (372,000), Ecuadorians (261,000), and Peruvians (234,000) represent the five largest Central and South American groups in the United States (U.S. Census, 2001).  Presently, Central and South Americans represent 14.3 percent of the Hispanic population in the country.  It is important to note that there were almost six million Hispanics who did not provide specific information about their national origin in the 2000 census survey, perhaps making these figures conservative.

The distinction between Hispanics born and raised in the United States and those who are foreign-born or recently arrived in this country is one that social workers and other helping professionals cannot ignore in the provision of mental health services.

Underutilization of Services

The underutilization of mental health services by Hispanics has been well documented in the literature (González and González-Ramos, 2005, Guarnaccia, Martinez & Acosta, 2005, USDHHS, 2001).  Hispanics encounter numerous obstacles which prevent them from successfully navigating through the mental health system.  These obstacles include language barriers, lack of health insurance, affordable mental health services, limited access to bilingual and bicultural mental health care providers, and lack of information on accessing mental health services.  This reality is further compounded by the fact that research suggests there is an increased rate of mental health disorders among Hispanics (Guarnaccia, Martinez, & Acosta, 2005).  The U.S. Surgeon General’s Report on Mental Health noted that Hispanics, in comparison to other ethnic groups and non-Hispanic Whites, present with higher levels of prevalence rates in the area of major depression, other mood disorders, and cognitive impairments. Hispanics represent a growing population in disproportionate need of mental health services.

Acculturation, Refugee Status, and Risk

Based on Guarnaccia et al.’s (2005) review of three national mental health studies—the Hispanic Health and Nutrition Examination Survey [HHANES], the Los Angeles site of the National Institute of Mental Health Epidemiologic Catchment Area Program [ECA], and the Mexican American Prevalence and Services Study [MAPSS Study]—important statements about the mental health status of Hispanics in the United States may be made.  Predicated on the findings of the Hispanic Health and Nutrition Examination Survey, Guarnaccia et al. (2005) noted that in comparison to Cubans and Mexican Americans, Puerto Ricans had much higher rates of both symptoms of depression and depression cases, and a greater prevalence of Major Depression Episode (a major mental health disorder). In their analysis of the National Latino and Asian American Study [NLAAS], Alegria and colleagues (2007) have also observed that Puerto Ricans had the highest overall lifetime and past-year prevalence rates of psychiatric disorders (e.g., depressive disorders, anxiety disorders, substance use disorders, and overall psychiatric disorders) in comparison to Cubans, Mexicans, and other Hispanics. Perceived sense of discrimination and failed socio-economic attainment may be two factors that negatively affect the psychological status of Puerto Ricans. Review of the National Latino and Asian American Study appears to suggest that overall psychiatric disorder prevalence rates are higher among Hispanics who had migrated to the United States before the age of 13 years or after the age of 34 years than among those who had migrated at other ages (Alegria and colleagues, 2007).

The findings of the Los Angeles ECA Study (Guarnaccia et al., 2005) has shown that in comparing U.S. born Mexican Americans to immigrants from Mexico, U.S. born populations had higher rates of mental health disorders.  This finding parallels the central thesis of the literature on acculturation and mental health: Acculturation to the norms and mores of the United States increases the risk of substance abuse and psychiatric disorders (Delgado, 2007). The Mexican American Prevalence and Services Study [MAPPS] provides empirical support for the theoretical notion that the process of acculturation negatively impacts the mental health outcomes of Hispanics in the United States.  Guarnaccia et al. (2005) have observed that the most important finding of the MAPSS Study was that as Mexican immigrants acculturate to U.S. society their mental health worsened.

Hispanic groups who have entered the United States as refugees—such as Cubans—also experience significant mental health problems. The mental health outcomes of Hispanic refugee groups must be diagnostically assessed within a socio-political-economic context.  For example, in describing the family reunification issues that may impact the mental health functioning of Cuban Marielitos and balseros (rafters), González, Lopez, and Ko (2005) have noted that Marielitos often struggled in their adaptation to United States life as a result of cognitive dissonance in comprehending the political-economic principles of capitalism and the structure of a democratic government.

Understanding New Hispanics

Although we have an understanding of the mental health needs of the three largest Hispanic populations in the United States: Mexicans, Puerto Ricans and Cubans, the study of emerging Hispanics, such as Dominicans, South Americans and Central Americans should be of high priority for behavioral and social scientists.   The numbers of these Hispanic groups have expanded greatly during the last decade, but we know little about their specific mental health outcomes. The need for psychiatric epidemiological and services research with new Hispanic immigrants is both timely and important.

Understanding Hispanic mental health concerns requires accounting for political, economic, and social conditions in the United States, but also necessitates that attention be focused on cultural factors among Hispanics that affect mental health outcomes.  It is necessary to educate mental health professionals about delivery of care to patients from different cultures in the United States.  Socio-cultural differences between clinicians and patients may influence healthcare communication and clinical decision-making.  When these differences are not explored or understood within the clinical encounter, the results may lead to poor mental healthcare utilization outcomes.  There is a serious lack of research on best practices for mental health treatment of Hispanics.  Models of mental health treatment should incorporate and mirror the values of many Hispanic subgroups: respeto (respect), personalismo (personalism), and familismo (the centrality of the family).

Implications for Professionals

The recommendation made by the Institute of Medicine (2003) to increase the proportion of underrepresented U.S. racial and ethnic minorities among health professionals, comes from evidence about the benefits of having a larger pool of diverse practitioners delivering care.  It has been shown that minority clinicians are more likely than their non-minority colleagues to see patients from minority backgrounds.  It has also been seen that, when there is concordance of race and ethnicity, patients are more likely to be satisfied and to adhere to treatment recommendations.  Guarnaccia et al (2005) noted that ethnic matching, where Hispanic patients see Hispanic mental health practitioners, has been shown to be effective in some aspects of mental health treatment and for some Hispanic groups. This effect has mostly been studied for Mexican Americans in Los Angeles, but the finding has clear implications for the mental health treatment of other Hispanic groups.

In addition, one must consider not only the quality of mental health services, but also their physical accessibility.  Seeking care in more naturalistic settings, such as through primary care centers, makes sense for many Hispanics, given the close association between the body and the mind in the Hispanic culture.  Hispanics have long been recognized to have a holistic understanding of health; even the language reflects the close ties between body and the mind.  Estar sano (to be healthy) usually denotes both health and mental health, without the split that can exist between both in our delivery of services.