CHAPTER 2

Culture Counts: The Influence of Culture and Society on Mental Health, Mental Illness

Culture of the Patient

The culture of the patient, also known as the consumer of mental health services, influences many aspects of mental health, mental illness, and patterns of health care utilization. One important cautionary note, however, is that general statements about cultural characteristics of a given group may invite stereotyping of individuals based on their appearance or affiliation. Because there is usually more diversity within a population than there is between populations (e.g., in terms of level of acculturation, age, income, health status, and social class), information in the following sections should not be treated as stereotypes to be broadly applied to any individual member of a racial, ethnic, or cultural group.

Symptoms, Presentation, and Meaning

The symptoms of mental disorders are found worldwide. They cluster into discrete disorders that are real and disabling (U.S. Department of Health and Human Services [DHHS], 1999). As noted in Chapter 1, mental disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association [APA], 1994). Schizophrenia, bipolar disorder, panic disorder, obsessive compulsive disorder, depression, and other disorders have similar and recognizable symptoms throughout the world (Weissman et al., 1994, 1996, 1997, 1998). Culture-bound syndromes, which appear to be distinctive to certain ethnic groups, are the exception to this general statement. Research has not yet determined whether culture-bound syndromes are distinct¹ from established mental disorders, are variants of them, or whether both mental disorders and culture-bound syndromes reflect different ways in which the cultural and social environment interacts with genes to shape illness (Chapter 1).

One way in which culture affects mental illness is through how patients describe (or present) their symptoms to their clinicians. There are some well recognized differences in symptom presentation across cultures. The previous chapter described ethnic variation in symptoms of somatization, the expression of distress through one or more physical (somatic) symptoms (Box 1-3). Asian patients, for example, are more likely to report their somatic symptoms, such as dizziness, while not reporting their emotional symptoms. Yet, when questioned further, they do acknowledge having emotional symptoms (Lin & Cheung, 1999). This finding supports the view that patients in different cultures tend to selectively express or present symptoms in culturally acceptable ways (Kleinman, 1977, 1988).

Cultures also vary with respect to the meaning they impart to illness, their way of making sense of the subjective experience of illness and distress (Kleinman, 1988). The meaning of an illness refers to deep-seated attitudes and beliefs a culture holds about whether an illness is “real” or “imagined,” whether it is of the body or the mind (or both), whether it warrants sympathy, how much stigma surrounds it, what might cause it, and what type of person might succumb to it. Cultural meanings of illness have real consequences in terms of whether people are motivated to seek treatment, how they cope with their symptoms, how supportive their families and communities are, where they seek help (mental health specialist, primary care provider, clergy, and/or traditional healer), the pathways they take to get services, and how well they fare in treatment. The consequences can be grave — extreme distress, disability, and possibly, suicide — when people with severe mental illness do not receive appropriate treatment.

Causation and Prevalence

Cultural and social factors contribute to the causation of mental illness, yet that contribution varies by disorder. Mental illness is considered the product of a complex interaction among biological, psychological, social, and cultural factors. The role of any one of these major factors can be stronger or weaker depending on the disorder (DHHS, 1999).

The prevalence of schizophrenia, for example, is similar throughout the world (about 1 percent of the population), according to the International Pilot Study on Schizophrenia, which examined over 1,300 people in 10 countries (World Health Organization [WHO], 1973). International studies using similarly rigorous research methodology have extended the WHO’s findings to two other disorders: The lifetime prevalence of bipolar disorder (0.3–1.5%) and panic disorder (0.4–2.9%) were shown to be relatively consistent across parts of Asia, Europe, and North America (Weissman et al., 1994, 1996, 1997, 1998). The global consistency in symptoms and prevalence of these disorders, combined with results of family and molecular genetic studies, indicates that they have high heritability (genetic contribution to the variation of a disease in a population) (National Institute of Mental Health [NIMH], 1998). In other words, it seems that culture and societal factors play a more sub-ordinate role in causation of these disorders.

Cultural and social context weigh more heavily in causation of depression. In the same international studies cited above, prevalence rates for major depression varied from 2 to 19 percent across countries (Weissman et al., 1996). Family and molecular biology studies also indicate less heritability for major depression than for bipolar disorder and schizophrenia (NIMH, 1998). Taken together, the evidence points to social and cultural factors, including exposure to poverty and violence, playing a greater role in the onset of major depression. In this context, it is important to note that poverty, violence, and other stressful social environments are not unique to any part of the globe, nor are the symptoms and manifestations they produce. However, factors often linked to race or ethnicity, such as socioeconomic status or country of origin can increase the likelihood of exposure to these types of stressors.

Cultural and social factors have the most direct role in the causation of post-traumatic stress disorder (PTSD). PTSD is a mental disorder caused by exposure to severe trauma, such as genocide, war combat, torture, or the extreme threat of death or serious injury (APA, 1994). These traumatic experiences are associated with the later development of a longstanding pattern of symptoms accompanied by biological changes (Yehuda, 2000). Traumatic experiences are particularly common for certain populations, such as U.S. combat veterans, inner-city residents, and immigrants from countries in turmoil. Studies described in the chapters on Asian Americans and Hispanic Americans reveal alarming rates of PTSD in communities with a high degree of pre-immigration exposure to trauma (Chapters 5 and 6). For example, in some samples, up to 70 percent of refugees from Vietnam, Cambodia, and Laos met diagnostic criteria for PTSD. By contrast, studies of the U.S. population as a whole find PTSD to have a prevalence of about 4 percent (DHHS, 1999).

Suicide rates vary greatly across countries, as well as across U.S. ethnic sub-groups (Moscicki, 1995). Suicide rates among males in the United States are highest for American Indians and Alaska Natives (Kachur et al., 1995). Rates are lowest for African American women (Kachur et al., 1995). The reasons for the wide divergence in rates are not well understood, but they are likely influenced by variations in the social and cultural con-texts for each subgroup (van Heeringen et al., 2000; Ji et al., 2001).

Even though there are similarities and differences in the distribution of certain mental disorders across populations, the United States has an aggregate rate of about 20 percent of adults and children with diagnosable mental disorders (DHHS, 1999; Table 1-1). As noted in Chapter 1, this aggregate rate for the population as a whole does not have sufficient representation from most minority groups to permit comparisons between whites and other ethnic groups. The rates of mental disorder are not sufficiently studied in many smaller ethnic groups to permit firm conclusions about overall prevalence; how-ever, several epidemiological studies of ethnic populations, supported by the NIMH, are currently in progress (Chapter 7). Until more definitive findings are available,

this Supplement concludes, on the basis of smaller studies, that overall prevalence rates for mental disorders in the United States are similar across minority and majority populations. As noted in Chapter 1, this general conclusion applies to racial and ethnic minority populations living in the community, because high-need subgroups are not well captured in community household surveys.

Family Factors

Many features of family life have a bearing on mental health and mental illness. Starting with etiology, Chapter 1 highlighted that family factors can protect against, or contribute to, the risk of developing a mental illness. For example, supportive families and good sibling relation-ships can protect against the onset of mental illness. On the other hand, a family environment marked by severe marital discord, overcrowding, and social disadvantage can contribute to the onset of mental illness. Conditions such as child abuse, neglect, and sexual abuse also place children at risk for mental disorders and suicide (Brown et al., 1999; Dinwiddie et al., 2000).

Family risk and protective factors for mental illness vary across ethnic groups. But research has not yet reached the point of identifying whether the variation across ethnic groups is a result of that group’s culture, its social class and relationship to the broader society, or individual features of family members.

One of the most developed lines of research on family factors and mental illness deals with relapse in schizophrenia. The first studies, conducted in Great Britain, found that people with schizophrenia who returned from hospitalizations to live with family members who expressed criticism, hostility, or emotional involvement (called high expressed emotion) were more likely to relapse than were those who returned to family members who expressed lower levels of negative emotion (Leff & Vaughn, 1985; Kavanaugh, 1992; Bebbington & Kuipers, 1994; Lopez & Guarnaccia, 2000). Later studies extended this line of research to Mexican American samples. These studies reconceptualized the role of family as a dynamic interaction between patients and their families, rather than as static family characteristics (Jenkins, Kleinman, & Good, 1991; Jenkins, 1993). Using this approach, a study comparing Mexican American and white families found that different types of interactions predicted relapse. For the Mexican American families, interactions featuring distance or lack of warmth predicted relapse for the individual with schizophrenia better than interactions featuring criticism. For whites, the converse was true (Lopez et al., 1998). This example, while not necessarily generalizable to other Hispanic groups, suggests avenues by which other culturally based family differences may be related to the course of mental illness.

Coping Styles

Culture relates to how people cope with everyday problems and more extreme types of adversity. Some Asian American groups, for example, tend not to dwell on upsetting thoughts, thinking that reticence or avoidance is better than outward expression. They place a higher emphasis on suppression of affect (Hsu, 1971; Kleinman, 1977), with some tending first to rely on themselves to cope with distress (Narikiyo & Kameoka, 1992). African Americans tend to take an active approach in facing personal problems, rather than avoiding them (Broman, 1996). They are more inclined than whites to depend on handling distress on their own (Sussman et al., 1987). They also appear to rely more on spirituality to help them cope with adversity and symptoms of mental illness (Broman, 1996; Cooper-Patrick et al., 1997; Neighbors et al., 1998).

Few doubt the importance of culture in fostering different ways of coping, but research is sparse. One of the few, yet well developed lines of research on coping styles comes from comparisons of children living in Thailand versus America. Thailand’s largely Buddhist religion and culture encourage self-control, emotional restraint, and social inhibition. In a recent study, Thai children were two times more likely than American children to report reliance on covert coping methods such as “not talking back,” than on overt coping methods such as “screaming” and “running away” (McCarty et al., 1999). Other studies by these investigators established that different coping styles are associated with different types and degrees of problem behaviors in children (Weisz et al., 1997).

The studies noted here suggest that better under-standing of coping styles among racial and ethnic minorities has implications for the promotion of mental health, the prevention of mental illness, and the nature and severity of mental health problems.

Treatment Seeking

It is well documented that racial and ethnic minorities in the United States are less likely than whites to seek mental health treatment, which largely accounts for their under-representation in most mental health services (Sussman et al., 1987; Kessler et al., 1996; Vega et al. 1998; Zhang et al., 1998). Treatment seeking denotes the pathways taken to reach treatment and the types of treatments sought (Rogler & Cortes, 1993). The pathways are the sequence of contacts and their duration once someone (or their family) recognizes their distress as a health problem.

Research indicates that some minority groups are more likely than whites to delay seeking treatment until symptoms are more severe (See Chapters 3 & 5). Further, racial and ethnic minorities are less inclined than whites to seek treatment from mental health specialists (Gallo et al., 1995; Chun et al., 1996; Zhang et al., 1998). Instead, studies indicate that minorities turn more often to primary care (Cooper-Patrick et al., 1999a; see later section on Primary Care). They also turn to informal sources of care such as clergy, traditional healers, and family and friends (Neighbors & Jackson, 1984; Peifer et al., 2000). In particular, American Indians and Alaska Natives often rely on traditional healers, who frequently work side-by-side with formal providers in tribal mental health programs (Chapter 4). African Americans often rely on ministers, who may play various mental health roles as counselor, diagnostician, or referral agent (Levin, 1986). The extent to which minority groups rely on informal sources in lieu of, or in addition to, formal mental health services in primary or specialty care is not well studied.

When they use mental health services, Some African Americans prefer therapists of the same race or ethnicity. This preference has encouraged the development of ethnic-specific programs that match patients to therapists of the same culture or ethnicity (Sue, 1998). Many African Americans also prefer counseling to drug therapy (Dwight-Johnson et al., 2000). Their concerns revolve around side effects, effectiveness, and addiction potential of medications (Cooper-Patrick et al., 1997).

The fundamental question raised by this line of research is: Why are many racial and ethnic minorities less inclined than whites to seek mental health treatment? Certainly, the constellation of barriers deterring whites also operates to various degrees for minorities — cost, fragmentation of services, and the societal stigma on mental illness (DHHS, 1999). But there are extra barriers deterring racial and ethnic minorities such as mistrust and limited English proficiency.

Mistrust

Mistrust was identified by the SGR as a major barrier to the receipt of mental health treatment by racial and ethnic minorities (DHHS, 1999). Mistrust is widely accepted as pervasive among minorities, yet there is surprisingly little empirical research to document it (Cooper-Patrick et al., 1999). One of the few studies on this topic looked at African Americans and whites surveyed in theearly 1980s in a national study known as the Epidemiologic Catchment Area (ECA) study. This study found that African Americans with major depression were more likely to cite their fears of hospitalization and of treatment as reasons for not seeking mental health treatment. For instance, almost half of African Americans, as opposed to 20 percent of whites, reported being afraid of mental health treatment (Sussman et al., 1987).

What are the reasons behind the lack of trust? Mistrust of clinicians by minorities arises, in the broadest sense, from historical persecution and from present-day struggles with racism and discrimination. It also arises from documented abuses and perceived mistreatment, both in the past and more recently, by medical and mental health professionals (Neal-Barnett & Smith, 1997; see later section on “Clinician Bias and Stereotyping”). A recent survey conducted for the Kaiser Family Foundation (Brown et al., 1999) found that 12 percent of African Americans and 15 percent of Latinos, in comparison with 1 percent of whites, felt that a doctor or health provider judged them unfairly or treated them with disrespect because of their race or ethnic background. Even stronger ethnic differences were reported in the Commonwealth Fund Minority Health Survey: It found that 43 percent of African Americans and 28 percent of Latinos, in comparison with 5 percent of whites, felt that a health care provider treated them badly because of their race or ethnic background (LaVeist et al., 2000). Mistrust of mental health professionals is exploited by present day antipsychiatry groups that target the African American community with incendiary material about purported abuses and mistreatment (Bell, 1996).

Mistrustful attitudes also may be commonplace among other groups. While insufficiently studied, mistrust toward health care providers can be inferred from a group’s attitudes toward government-operated institutions. Immigrants and refugees from many regions of the world, including Central and South America and Southeast Asia, feel extreme mistrust of government, based on atrocities committed in their country of origin and on fear of deportation by U.S. authorities. Similarly, many American Indians and Alaska Natives are mistrustful of health care institutions; this dates back through centuries of legalized discrimination and segregation, as discussed in Chapter 4.

Stigma

Stigma was portrayed by the SGR as the “most formidable obstacle to future progress in the arena of mental illness and health” (DHHS, 1999). It refers to a cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid, and discriminate against people with mental illness (Corrigan & Penn, 1999).

Stigma is widespread in the United States and other Western nations (Bhugra, 1989; Brockington et al., 1993) and in Asian nations (Ng, 1997). In response to societal stigma, people with mental problems internalize public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment (Sussman et al., 1987; Wahl, 1999). Stigma also lowers their access to resources and opportunities, such as housing and employment, and leads to diminished self-esteem and greater isolation and hopelessness (Penn & Martin, 1998; Corrigan & Penn, 1999). Stigma can also be against family members; this damages the consumer’s self-esteem and family relationships (Wahl & Harman, 1989). In some Asian cultures, stigma is so extreme that mental illness is thought to reflect poorly on family line-age and thereby diminishes marriage and economic prospects for other family members as well (Sue & Morishima, 1982; Ng, 1997).

Stigma is such a major problem that the very topic itself poses a challenge to research. Researchers have to contend with people’s reluctance to disclose attitudes often deemed socially unacceptable. How stigma varies by culture can be studied from two perspectives. One perspective is that of the targets of stigma, i.e., the people with symptoms: If they are members of a racial or ethnic minority, are they more likely than whites to experience stigma? The other perspective is that of the public in their attitudes toward people with mental illness: Are members of each racial or ethnic minority group more likely than whites to hold stigmatizing attitudes toward mental illness? The answers to these cross-cultural questions are far from definitive, but there are some interesting clues from research.

Turning first to those who experience symptoms, one of the few cross-cultural studies questioned Asian Americans living in Los Angeles. The findings were eye-opening: Only 12 percent of Asians would mention their mental health problems to a friend or relative (versus 25 percent of whites). A meager 4 percent of Asians would seek help from a psychiatrist or specialist (versus 26 per-cent of whites). And only 3 percent of Asians would seek help from a physician (versus 13 percent of whites). The study concluded that stigma was pervasive and pronounced for Asian Americans in Los Angeles (Zhang et al., 1998).

Turning to the question of public attitudes toward mental illness, the largest and most detailed study of stigma in the United States was performed in 1996 as part of the General Social Survey, a respected, nationally representative survey being conducted by the National Opinion Research Center since the 1970s. In this study, a representative sample was asked in personal interviews to respond to different vignettes depicting people with mental illness. The respondents generally viewed people with mental illness as dangerous and less competent to handle their own affairs, with their harshest judgments reserved for people with schizophrenia and substance use disorders. Interestingly, neither the ethnicity of the respondent, nor the ethnicity of the person portrayed in the vignette, seemed to influence the degree of stigma (Pescosolido et al., 1999).

By contrast, another large, nationally representative study found a different relationship between race, ethnicity, and attitudes towards patients with mental illness. Asian and Hispanic Americans saw them as more dangerous than did whites. Although having contact with individuals with mental illness helped to reduce stigma for whites, it did not for African Americans. American Indians, on the other hand, held attitudes similar to whites (Whaley, 1997).

Taken together, these results suggest that minorities hold similar, and in some cases stronger, stigmatizing attitudes toward mental illness than do whites. Societal stigma keeps minorities from seeking needed mental health care, much as it does for whites. Stigma is so potent that it not only affects the self-esteem of people with mental illness, but also that of family members. The bottom line is that stigma does deter major segments of the population, majority and minority alike, from seeking help. It bears repeating that a majority of all people with diagnosable mental disorders do not get treatment (DHHS, 1999).

Immigration

Migration, a stressful life event, can influence mental health. Often called acculturative stress, it occurs during the process of adapting to a new culture (Berry et al., 1987). Refugees who leave their homelands because of extreme threat from political forces tend to experience more trauma, more undesirable change, and less control over the events that define their exits than do voluntary immigrants (Rumbaut, 1985; Meinhardt et al., 1986).

The psychological stress associated with immigration tends to be concentrated in the first three years after arrival in the United States (Vega & Rumbaut, 1991). According to studies of Southeast Asian refugees, an initial euphoria often characterizes the first year following migration, followed by a strong disenchantment and demoralization reaction during the second year. The third year includes a gradual return to well-being and satisfaction (Rumbaut, 1985, 1989). This U-shaped curve has been observed in Cubans and Eastern Europeans (Portes & Rumbaut, 1990). Similarly, Ying (1988) finds that Chinese immigrants who have been in the United States less than one year have fewer symptoms of distress than those residing here for several years. Korean American immigrants have been found to have the highest levels of depressive symptoms in the one to two years following immigration; after three years, these symptoms remit (Hurh & Kim, 1988).

Although immigration can bring stress and subsequent psychological distress, research results do not suggest that immigration per se results in higher rates of mental disorders (e.g., Vega et al., 1998). However, as described in the chapters on Asian Americans and Latinos, the traumas experienced by adults and children from war-torn countries before and after immigrating to the United States seem to result in high rates of post-traumatic stress disorder (PTSD) among these populations.

Overall Health Status

The burden of illness in the United States is higher in racial and ethnic minorities than whites. The National Institutes of Health (NIH) recently reported that compared with the majority populations, U.S. minority populations have shorter overall life expectancies and higher rates of cardiovascular disease, cancer, infant mortality, birth defects, asthma, diabetes, stroke, adverse con-sequences of substance abuse, and sexually transmitted diseases (DHHS, 2000; NIH, 2000). The list of illnesses is overpoweringly long.

Disparities in health status have led to high-profile research and policy initiatives. One long-standing policy initiative is Healthy People, a comprehensive set of national health objectives issued every decade by the Department of Health and Human Services. The most recent is Healthy People 2010, which contains both well defined objectives for reducing health disparities and the means for monitoring progress (DHHS, 2000).

Higher rates of physical (somatic) disorders among racial and ethnic minorities hold significant implications for mental health. For example, minority individuals who do not have mental disorders are at higher risk for developing problems such as depression and anxiety because chronic physical illness is a risk factor for mental disorders (DHHS, 1999; see also earlier section). Moreover, individuals from racial and ethnic minority groups who already have both a mental and a physical disorder (known as comorbidity) are more likely to have their mental disorder missed or misdiagnosed, owing to competing demands on primary care providers who are preoccupied with the treatment of the somatic disorder (Borowsky, et al., 2000; Rost et al., 2000). Even if their mental disorder is recognized and treated, people with comorbid disorders are saddled by more drug interactions and side effects, given their higher usage of medications. Finally, people with comorbid disorders are much more likely to be unemployed and disabled, compared with people who have a single disability (Druss et al., 2000).

Thus, poor somatic health takes a toll on mental health. And it is probable that some of the mental health disparities described in this Supplement are linked to the poorer somatic health status of racial and ethnic minorities. The interrelationships between mind and body are inescapably evident.

¹ In medicine, each disease or disorder is considered mutally exclusive from another (WHO, 1992). Each disorder is presumed, but rarely proven, to have unique pathophysiology (Scadding, 1996).