The two articles are: Schizophrenia outcome measures in the wider international community; and A Longitudinal Study of the Use of Mental Health Services by Persons With Serious Mental Illness: Do Spanish-Speaking Latinos Differ From English-Speaking Latinos and Caucasians?
You need subscription or academic access for the full text. I've linked to the abstracts, which are openly accessible. There are two open commentaries for the second article (1 2). The abstracts and discussion follow...
Schizophrenia outcome measures in the wider international community
The British Journal of Psychiatry (2007) 191: s71-s77. doi: 10.1192/bjp.191.50.s71
Mohan Isaac, MD, DPM, FRCPsych, Prabhat Chand, MD, DNB, and Pratima Murthy, MD, DPM
Declaration of interest None.
Background Outcome of schizophrenia has been described as favourable in low- and middle-income countries. Recently, researchers have questioned these findings.
Aims To examine the outcome studies carried out in different countries specifically looking at those from low- and middle-income countries.
Methods Long-term course and outcome studies in schizophrenia were reviewed.
Results A wide variety of outcome measures are used. The most frequent are clinical symptoms, hospitalisation and mortality (direct indicators), and social/occupational functioning, marriage, social support and burden of care (indirect indicators). Areas such as cognitive function, duration of untreated psychosis, quality of life and effect of medication have not been widely studied in low- and middle-income countries.
Conclusions The outcome of schizophrenia appears to be better in low- and middle-income countries. A host of sociocultural factors have been cited as contributing to this but future research should aim to understand this better outcome. There is a need for more culture-specific instruments to measure outcomes.
A Longitudinal Study of the Use of Mental Health Services by Persons With Serious Mental Illness: Do Spanish-Speaking Latinos Differ From English-Speaking Latinos and Caucasians?
Am J Psychiatry 164:1173-1180, August 2007
doi: 10.1176/appi.ajp.2007.06071239
David P. Folsom, M.D., M.P.H., Todd Gilmer, Ph.D., Concepcion Barrio, Ph.D., David J. Moore, Ph.D., Jesus Bucardo, M.D., Laurie A. Lindamer, Ph.D., Piedad Garcia, Ed.D., William Hawthorne, Ph.D., Richard Hough, Ph.D., Thomas Patterson, Ph.D. and Dilip V. Jeste, M.D.
OBJECTIVE: Reports of mental health care use by Latinos compared to Caucasians have been mixed. To the authors’ knowledge, no large-scale studies have examined the effects of language on mental health service use for Latinos who prefer Spanish compared to Latinos who prefer English and to Caucasians. Language is the most frequently used proxy measure of acculturation. The authors used the administrative database of a mental health system to conduct a longitudinal examination of mental health service use among Spanish-speaking versus English-speaking Latinos and Caucasians with serious mental illness. METHOD: There were 539 Spanish-speaking Latinos, 1,144 English-speaking Latinos, and 4,638 Caucasians initiating treatment for schizophrenia, bipolar disorder, or major depression during 2001–2004. Using multivariate regressions, the authors examined the differences among the groups in the type of service first used. The authors also examined the probability of use of each of four types of mental health services and the intensity of outpatient treatment. RESULTS: Spanish-speaking Latinos differed from both English-speaking Latinos and Caucasians on most measures. Compared to patients in the other groups, the Spanish-speaking Latinos were less likely to enter care through emergency or jail services and more likely to enter care through outpatient services. There were no group differences in the proportion that stayed in treatment or used inpatient hospitalization. CONCLUSIONS: This study suggests that for Latinos, preferred language may be more important than ethnicity in mental health service use. Future studies comparing mental health use may need to differentiate between Spanish- and English-speaking Latinos.
These two studies are different in scope and methodology, so it may not be valid to put the two together and try to synthesize some kind of general conclusion. In order to really answer the question, of whether American culture is bad for mental health, one would have to do some kind of large-scale adopted-twin study, using a methodology that would never pass a review board. Even so, we may be able to get some clues.
The first study looked at just one diagnostic group: persons with schizophrenia. It did not evaluate any particular intervention. They did consider a variety of potential confounding factors, and appeared to deal with them adequately. The study can only describe correlations, thus cannot discern causation. Nonetheless, it does appear that persons with schizophrenia have better outcomes in low to middle income countries.
Possible explanations include the fact that persons with schizophrenia who live in such countries are more likely to be employed. Also, they are more likely to be accepted in the family, community, and workplace, than they would in a more fast-paced, highly competitive environment. They tend to be exposed to less expressed emotion, particularly the intense, negative expressed emotion that is well established as a negative prognostic indicator. Additionally, they are more likely to be married, and to have a lasting marriage. Support from immediate and extended family tends to be better.
In Western countries, one of the strongest predictors of repeat hospitalization is the lack of good family support. Thus, it would make sense that a culture with strong family ties would provide a better environment for relapse prevention.
With regard to substance abuse, the authors found that there were few studies on the comorbidity of substance abuse and schizophrenia in low to middle income countries. The studies that were done, indicated that there is a lower incidence of alcohol and nicotine abuse among persons with schizophrenia. This would be expected to have a significant positive effect on prognosis.
I would expect that additional factors, such as clarity of social roles, stability of social roles, and rate of change in society would also be important factors. Those, however, are difficult to quantify and study.
The first study ( in the British Journal of Psychiatry) was a comparison across cultures, as defined by geography. In contrast, the second study (in the American Journal of Psychiatry) looked at persons within the same geographic area, but with different cultural attributes. The first study Specifically, they studied Caucasians and Latino/Latinas within California. The Latino/Latinas were divided into two groups: those who expressed a preference for speaking English, and those who expressed a preference for speaking Spanish. Choice of language was used as a proxy for acculturation.
In the second study, the authors found that the mental health outcomes were comparable between the Caucasians and the Latino/Latinas who expressed a preference for English.
The Latino/Latinas who preferred to speak Spanish were different. They were far less likely to have substance abuse problems. They were far less likely to enter into mental health treatment via referral from the criminal justice system, and less likely to enter via an Emergency Department. They were less likely to have bipolar disorder or schizophrenia.
It was not entirely rosy for the Spanish-preferring Latino/Latinas. They were more likely than the other two groups to have a diagnosis of depression. That is a small price to pay, though, in exchange for lower rates of incarceration, substance abuse, schizophrenia, and bipolar disorder.
So is American culture bad for mental health?
It would be difficult to make such a broad general statement based upon two studies. But there are some things to consider, hypotheses rather than conclusions.
Economic growth necessitates social change. Rapid economic growth necessitates rapid social change. Social change equates to stress. The more rapid the change, the greater the stress.
The ironic thing about this, is that much of our economic growth results from things that we think we are doing to reduce stress. Perhaps it does, in the short run. However, in the long run, perhaps it just makes things worse.
Do these hypotheses have any implications for public policy? For the sake of argument, suppose we could confirm what I've speculated here. Suppose we could quantify it: determine, say, the cost of a given rate of economic growth in terms of quality-adjusted life years or something like that. Would we voluntarily throttle back our economic growth in order to optimize our mental health?
No, of course we would not. But should we?
Perhaps it is too ambitious to think
is such broad terms. Are
there narrower policy goals that one could pursue? What about
the notion of expecting that immigrants start to act like us and sound
like us, as much as possible. We don't have a machine that
makes everyone look like Brad Pitt or Angelina Jolie, and we don't even
have a machine that will put big green stars on everyone's
abdomen. As a second-best alternative to getting immigrants
to look like us, we have tried strenuously to at least get immigrants
to act and sound like us. But it appears that coerced acculturation may not be best for the individual. Is the benefit to the majority culture worth whatever mental health cost there might be to the individual? Is there some healthier way we could strike a balance between the complacency of commonality versus celebration of differences?
Is there some way we can duplicate the benefits of a slower-moving culture, without giving up the benefits of rapid change? Can we do it at a reasonable cost?
Comments
Is rapid change genuinely as beneficial as we think it is? Is owning lots of stuff a good quality-of-life metric?
Posted by: Dunc | August 3, 2007 8:42 AM
There are many reasons why the family support element is weaker in the U.S. than in other countries. One reason that would be relatively straightforward (though not easy) to address is the difficulty of taking time off work to help care for a family member who's ill.
Over the past few years, two people I know have had serious mental health crises. If they hadn't had friends and family members who were able to drop everything else and spend several days with them (monitoring their conditions, helping them through the difficult process of getting mental health care, being a supportive presence, etc.), I'm not sure they'd be alive right now.
Posted by: Liz | August 3, 2007 10:08 AM
for years I have been wondering what causes; on occasion; a group of people/nation to behave so irrational. Why do nations exhibit self destructive, frenzy-like, or just behavior contrary its self interest. i.e. too many examples to list; but one I worry about, this one! I always thought it might be a bug, infection, or something in the water, but perhaps this points to a possible solution. It might be simply, a critical density of mental illness among the policy influencing class. Perhaps this is an effect can be modeled, and prevented. It may save the Republic...I mean empire..I mean the collection of people who are so eager to think warlike.
Posted by: Shawn | August 4, 2007 1:18 AM
Interesting stuff. I think rapid cultural change and acculturation could very well be stressful on a society. The former we may have difficulty dealing with in America, since we've gotten to used to developing things at a rapid pace -- but I think slowing down a bit could help other things than mental health. Perhaps if we slowed down we could also do much-needed repairs and upgrades to our infrastructure and learn to focus on longer-range problems like climate change.
-- also: minor nitpick, it kinda jolted me to read "Latino/Latinas" in your post. IME, "Latino" generally follows the Spanish pattern of using masculine plural for mixed groups -- with no sexist overtones. What you wrote isn't wrong, but it does put a kink in the flow.
Posted by: GAC | August 5, 2007 5:13 PM
I once attended a cultural sensitivity course, one of those workplace things that everyone has to go to, and I was told the Latino/Latina construction was the politically correct thing to say. I imagine it is one of those things that most people don't care about too much, sort of like always saying "his or her", "she or he," etc. But that is why I wrote it that way.
Posted by: Joseph j7uy5 | August 5, 2007 9:20 PM
this crap is wack ... im going to smoke your moms fat out of her butt ... And then im going to my friends niles haouse and were going to do the bong mon.
Posted by: your mom in bed | May 6, 2008 9:20 AM