Is American Culture is Bad For Mental Health?

I
happened to run across a couple of articles pertaining to cultural
influences on mental health.  Neither presented modern
first-world culture in a positive light.



The two articles are: href="http://bjp.rcpsych.org/cgi/content/abstract/191/50/s71">Schizophrenia
outcome measures in the wider international community; and rev="review"
href="http://ajp.psychiatryonline.org/cgi/content/abstract/164/8/1173">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 ( href="http://ajp.psychiatryonline.org/cgi/content/full/ajp;164/8/A36">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 face="Helvetica, Arial, sans-serif">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 href="http://en.wikipedia.org/wiki/Quality-adjusted_life_years">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?