Lisa R. Fortuna

Why do so many latina teens attempt suicide? A conceptual model for research.

Rates of suicide attempts among adolescent Latinas have been reported to be higher than for their non-Hispanic counterparts. Yet researchers know very little about the attempts, their antecedents, and why the girls attempt suicide. Latina girls have been included in research on suicidal adolescents and typically show higher rates of attempts relative to similar psychopathology when compared with other young women. A few small studies have focused on Latinas, but none have explored why suicide attempt rates are higher. The authors constructed a conceptual model to provide a formulation of this phenomenon on the basis of a review of the literature on suicide attempts among Latinas and their clinical experience. This model can serve as a framework to guide research on the unique sociocultural processes present in Latina adolescent suicide attempts and may also benefit the work of clinicians.

Political violence, psychosocial trauma, and the context of mental health services use among immigrant Latinos in the United States

Objectives. We present the prevalence of exposure to political violence (PV) among Latino immigrants in the US, and perceived need for and correlates of mental health services use among this population. Methods. We use the National Latino and Asian American Study (NLAAS), a nationally representative epidemiological survey of US Latinos, including a probability sample of 1630 immigrant Latinos. Our conceptual framework assumes a strong role of social and cultural factors in understanding the risk for psychopathology and mental health service use. Results. Eleven percent of all immigrant Latinos reported PV exposure and 76% described additional lifetime traumas. Among those with a history of PV, an increased likelihood of using mental health services was associated with female gender, English language proficiency, experiencing personal assaults, higher perceived discrimination, and having an anxiety or substance disorder. Latino men and specific subgroups of Latinos were less likely to access mental health services after experiencing PV. Perceived need for mental health services use is the strongest correlate of any lifetime and last-12-months service use. Conclusions. Individuals who come from countries with a history of political violence often have multiple traumatic experiences. This suggests a need for systematic screening for trauma and related psychiatric disorders. Specific outreach interventions focused on perceptions of need could be helpful for subgroups of Latinos including men who are particularly underrepresented in mental health services but who exhibit significant trauma histories.

Childhood trauma and psychiatric disorders as correlates of school dropout in a national sample of young adults

The effect of childhood trauma, psychiatric diagnoses, and mental health services on school dropout among U.S.-born and immigrant youth is examined using data from the Collaborative Psychiatric Epidemiology Surveys, a nationally representative probability sample of African Americans, Afro-Caribbeans, Asians, Latinos, and non-Latino Whites, including 2,532 young adults, aged 21-29. The dropout prevalence rate was 16% overall, with variation by childhood trauma, childhood psychiatric diagnosis, race/ethnicity, and nativity. Childhood substance and conduct disorders mediated the relation between trauma and school dropout. Likelihood of dropout was decreased for Asians, and increased for African Americans and Latinos, compared to non-Latino Whites as a function of psychiatric disorders and trauma. Timing of U.S. immigration during adolescence increased risk of dropout.

Retention in Depression Treatment among Ethnic and Racial Minority Groups in the United States

Background: Premature discontinuation of psychiatric treatment among ethnic–racial minorities is a persistent concern. Previous research on identifying factors associated with ethnic–racial disparities in depression treatment has been limited by the scarcity of national samples with adequate representation of minority groups and especially non‐English speakers. In this article, we aim to identify variations in the likelihood of retention in depression treatment among ethnic–racial minority groups in the United States as compared to non‐Latino whites. Second, we aim to identify the factors that are related to treatment retention. Methods: We use data from the Collaborative Psychiatric Epidemiology Surveys to examine differences and correlates of depression treatment retention among a representative sample (n=564) of non‐Latino whites, Latinos, African‐American, and Asian respondents with last 12‐month depressive disorder and who report receiving formal mental health treatment in the last year. We define retention as attending at least four visits or remaining in treatment during a 12‐month period. Results: Being seen by a mental health specialist as opposed to being seen by a generalist and having received medication are correlates of treatment retention for the entire sample. However, after adjusting for demographics, clinical factors including number of co‐occurring psychiatric disorders and level of disability, African‐Americans are significantly less likely to be retained in depression treatment as compared to non‐Latino whites. Conclusions: Availability of specialized mental health services or comparable treatment within primary care could improve treatment retention. Low retention suggests persistent problems in the delivery of depression treatment for African‐Americans. Depression and Anxiety, 2010.© 2010 Wiley‐Liss, Inc.

Psychosocial Stressors, Psychiatric Diagnoses and Utilization of Mental Health Services Among Undocumented Immigrant Latinos

Abstract The combined effects of minority status, specific ethnic group experiences (political, economic, trauma and immigration history), poverty, and illegal status pose a set of unique psychiatric risks for undocumented Latinos in the United States. Restrictive legislation and policy measures have limited access to health care, and other basic human services to undocumented immigrants and their children throughout the nation. However, little is known about the patterns of mental health care use, psychiatric diagnoses and psychosocial problems prevalent among the undocumented who do succeed in presenting to clinical settings and to the mental health sector. To begin to address the need for further understanding in this area, we completed a clinical chart review of 197 outpatient adult psychiatric charts in a Latino mental health outpatient treatment program located in an urban hospital system. We compared the diagnoses and mental health care use of undocumented Latino immigrants (15%) with that of documented (73%) and US born Latinos (12%) treated in this clinical setting. The undocumented Latinos in our study were more likely to have a diagnosis of anxiety, adjustment and alcohol abuse disorders. The undocumented also had a significantly greater mean number of concurrent psychosocial stressors (mean number = 5, p < .001) ascompared to documented immigrants and US born groups, which both had a mean number of 3 stressors identified at evaluation. The undocumented were more likely to have psychosocial problems related to occupation, access to healthcare and the legal system. However, the undocumented had a lower mean number of total mental health appointments attended (mean visits = 4.3, p < .001) in which to address these stressors as compared to documented immigrants (mean visits = 7.9) and US born (mean visits = 13.3). In terms of other previous mental health service use, the undocumented group had lower rates of lifetime inpatient and outpatient treatment use. The results of this study suggest the importance of early assessment of psychosocial stressors, substance use and barriers to care when treating undocumented immigrants. Although all Latino groups included in this investigation demonstrated numerable concurrent stressors, our investigation highlights the particular importance of accessible social services and supports for addressing psychosocial stressors in the lives of undocumented patients. Our results stress the importance of reexamining policies, that restrict access to social services and healthcare for the undocumented. Our results also suggest the importance of culturally appropriate evaluation and treatment of substance abuse disorders as well as addressing other psychological and behavioral responses to multiple stressors among undocumented individuals.

A systematic review of the Diagnostic and Statistical Manual diagnostic criteria for nicotine dependence

The Diagnostic and Statistical Manual diagnostic criteria for nicotine dependence (DSM-ND) are based on the proposition that dependence is a syndrome that can be diagnosed only when a minimum of 3 of the 7 proscribed features are present. The DSM-ND criteria are an accepted research measure, but the validity of these criteria has not been subjected to a systematic evaluation. To systematically review evidence of validity and reliability for the DSM-ND criteria, a literature search was conducted of 16 national and international databases. Each article with original data was independently reviewed by two or more reviewers. In total, 380 potentially relevant articles were examined and 169 were reviewed in depth. The DSM-ND criteria have seen wide use in research settings, but sensitivity and specificity are well below the accepted standards for clinical applications. Predictive validity is generally poor. The 7 DSM-ND criteria are regarded as having face validity, but no data support a 3-symptom ND diagnostic threshold, or a 4-symptom withdrawal syndrome threshold. The DSM incorrectly states that daily smoking is a prerequisite for withdrawal symptoms. The DSM shows poor to modest concurrence with all other measures of nicotine dependence, smoking behaviors and biological measures of tobacco use. The data support the DSM-ND criteria as a valid measure of nicotine dependence severity for research applications. However, the data do not support the central premise of a 3-symptom diagnostic threshold, and no data establish that the DSM-ND criteria provide an accurate diagnosis of nicotine dependence.

Prevalence, risk, and correlates of posttraumatic stress disorder across ethnic and racial minority groups in the United States.

Objectives:We assess whether posttraumatic stress disorder (PTSD) varies in prevalence, diagnostic criteria endorsement, and type and frequency of potentially traumatic events (PTEs) among a nationally representative US sample of 5071 non-Latino whites, 3264 Latinos, 2178 Asians, 4249 African Americans, and 1476 Afro-Caribbeans. Methods:PTSD and other psychiatric disorders were evaluated using the World Mental Health-Composite International Diagnostic Interview (WMH-CIDI) in a national household sample that oversampled ethnic/racial minorities (n=16,238) but was weighted to produce results representative of the general population. Results:Asians have lower prevalence rates of probable lifetime PTSD, whereas African Americans have higher rates as compared with non-Latino whites, even after adjusting for type and number of exposures to traumatic events, and for sociodemographic, clinical, and social support factors. Afro-Caribbeans and Latinos seem to demonstrate similar risk to non-Latino whites, adjusting for these same covariates. Higher rates of probable PTSD exhibited by African Americans and lower rates for Asians, as compared with non-Latino whites, do not appear related to differential symptom endorsement, differences in risk or protective factors, or differences in types and frequencies of PTEs across groups. Conclusions:There appears to be marked differences in conditional risk of probable PTSD across ethnic/racial groups. Questions remain about what explains risk of probable PTSD. Several factors that might account for these differences are discussed, as well as the clinical implications of our findings. Uncertainty of the PTSD diagnostic assessment for Latinos and Asians requires further evaluation.

An exploration of how psychotic-like symptoms are experienced, endorsed, and understood from the National Latino and Asian American Study and National Survey of American Life

Objective. To examine racial-ethnic differences in the endorsement and attribution of psychotic-like symptoms in a nationally representative sample of African-Americans, Asians, Caribbean Blacks, and Latinos living in the USA. Design. Data were drawn from a total of 979 respondents who endorsed psychotic-like symptoms as part of the National Latino and Asian American Study (NLAAS) and the National Survey of American Life (NSAL). We use a mixed qualitative and quantitative analytical approach to examine sociodemographic and ethnic variations in the prevalence and attributions of hallucinations and other psychotic-like symptoms in the NLAAS and NSAL. The lifetime presence of psychotic-like symptoms was assessed using the World Health Organization Composite International Diagnostic Interview (WMH-CIDI) psychotic symptom screener. We used logistic regression models to examine the probability of endorsing the four most frequently occurring thematic categories for psychotic-like experiences by race/ethnicity (n > 100). We used qualitative methods to explore common themes from participant responses to open ended questions on their attributions for psychotic-like symptoms. Results. African-Americans were significantly less likely to endorse visual hallucinations compared to Caribbean Blacks (73.7% and 89.3%, p < .001), but they endorsed auditory hallucinations symptoms more than Caribbean Blacks (43.1% and 25.7, p < .05). Endorsing delusions of reference and thought insertion/withdrawal were more prevalent for Latinos than for African-Americans (11% and 4.7%, p < .05; 6.3% and 2.7%, p < .05, respectively). Attribution themes included: supernatural, ghosts/unidentified beings, death and dying, spirituality or religiosity, premonitions, familial and other. Respondents differed by race/ethnicity in the attributions given to psychotic like symptoms. Conclusion. Findings suggest that variations exist by race/ethnicity in both psychotic-like symptom endorsement and in self-reported attributions/understandings for these symptoms on a psychosis screening instrument. Ethnic/racial differences could result from culturally sanctioned beliefs and idioms of distress that deserve more attention in conducting culturally informed and responsive screening, assessment and treatment.

A qualitative study of clinicians' use of the cultural formulation model in assessing posttraumatic stress disorder.

The Cultural Formulation (CF) of the Diagnostic and Statistical Manual (DSM) provides a potential framework for improving the diagnostic assessment of Posttraumatic Stress Disorder (PTSD) in culturally diverse patients. We analyzed data from the Patient-Provider Encounter Study, a multi-site study that examines the process of diagnosis and clinical decision-making during an initial clinical intake session, in order to examine use of CF for PTSD diagnosis. We find that while the CF is generally used inconsistently or underutilized in routine community settings, when employed appropriately it may assist the formulation and interpretation of traumatic experiences. We discuss the implications for improving the assessment of PTSD in the time-limited setting of the clinical intake encounter and across race/ethnicity.

Distal and Proximal Religiosity as Protective Factors for Adolescent and Emerging Adult Alcohol Use

Data from emerging adults (ages 18–29, N = 900) in the National Comorbidity Survey Replication Study was used to examine the influence of childhood and emerging adult religiosity and religious-based decision-making, and childhood adversity, on alcohol use. Childhood religiosity was protective against early alcohol use and progression to later abuse or dependence, but did not significantly offset the influence of childhood adversity on early patterns of heavy drinking in adjusted logistic regression models. Religiosity in emerging adulthood was negatively associated with alcohol use disorders. Protective associations for religiosity varied by gender, ethnicity and childhood adversity histories. Higher religiosity may be protective against early onset alcohol use and later development of alcohol problems, thus, should be considered in prevention programming for youth, particularly in faith-based settings. Mental health providers should allow for integration of clients’ religiosity and spirituality beliefs and practices in treatment settings if clients indicate such interest.