Milagros Bravo

The prevalence of ataques de nervios in the Puerto Rico disaster study. The role of culture in psychiatric epidemiology

This paper presents one of the few epidemiological studies of a popular category of distress, ataques de nervios (attacks of nerves), in the cross-cultural psychiatric literature. As part of a major study of the psychological consequences of the 1985 floods and mudslides which caused considerable damage and death in Puerto Rico, a question was added to the Diagnostic Interview Schedule/Disaster Supplement concerning ataques de nervios. This additional item provided the opportunity to carry out the first study of this important Puerto Rican popular category of distress using a representative, community-based sample. This paper addresses several key questions about ataques de nervios which come from previous psychiatric and anthropological literatures concering the social correlates of who experiences an ataque de nervios and the relationship of ataques to social distress and psychiatric disorder. People who reported an ataque de nervios were more likely to be female, older, less educated, and formerly married. They were also more likely to meet criteria for anxiety and depressive disorders than those who had not experienced an ataque. The picture that emerges from our analyses is that those who suffer from a combination of social disadvantage, psychiatric disorder, and poor perceived health are more likely to experience an ataque de nervios.

Test-retest reliability of the Spanish version of the Diagnostic Interview Schedule for Children (DISC-IV).

The test-retest reliability of the Spanish Diagnostic Interview Schedule for Children (DISC-IV) is presented. This version was developed in Puerto Rico in consultation with an international bilingual committee, sponsored by NIMH. The sample (N = 146) consisted of children recruited from outpatient mental health clinics and a drug residential treatment facility. Two different pairs of nonclinicians administered the DISC twice to the parent and child respondents. Results indicated fair to moderate agreement for parent reports on most diagnoses. Relatively similar agreement levels were observed for last month and last year time frames. Surprisingly, the inclusion of impairment as a criterion for diagnosis did not substantially change the pattern of results for specific disorders. Parents were more reliable when reporting on diagnoses of younger (4–10) than older children. Children 11–17 years old were reliable informants on disruptive and substance abuse/dependence disorders, but unreliable for anxiety and depressive disorders. Hence, parents were more reliable when reporting about anxiety and depressive disorders whereas children were more reliable than their parents when reporting about disruptive and substance disorders.

The Spanish translation and cultural adaptation of the Diagnostic Interview Schedule for Children (DISC) in Puerto Rico

This article illustrates a comprehensive cross-cultural adaptation model used to translate into Spanish and to culturally adapt the Diagnostic Interview Schedule for Children (DISC). The process strived to identify similar phenomena to those identified by the original English version in a dissimilar context. To attain cross-cultural equaivalency five important dimensions were addressed: semantic, technical, content, criterion and conceptual. To meet this challenge various steps were taken, including bilingual committee, back-translation, reliability and validity testing. The result is an instrument which could be used, not only in Puerto Rico, but also in other Spanishspeaking child and adolescent populations after appropriate cultural adaptations.

The Impact of Disaster on Mental Health: Prospective and Retrospective Analyses

The first major islandwide survey of mental disorders of the adult population of Puerto Rico was completed in 1984 [1]. This survey provided estimates of prevalence rates and correlates of specific mental disorders according to DSM-III criteria [2] by using the Diagnostic Interview Schedule (DIS). A year later, in October 1985, torrential rains throughout Puerto Rico caused extensive and disastrous mudslides that left 180 people dead and disrupted the lives of thousands of others. As a consequence of the mudslides, more than four thousand people were forced to live in public shelters for months, and more than nineteen thousand people had to rectify serious damage to property. Since the area covered by the 1984 islandwide survey included the regions affected by the rains, there was an unusual opportunity to assess the effects of the disaster on a sample of the people previously interviewed. And since only a portion of the island was inundated, a control group of subjects previously interviewed and not affected by the floods was also available. Here we shall report the results of a survey of people exposed and not exposed to the 1985 floods. The survey was designed to determine the effect of the disaster on mental health symptoms and diagnoses and to determine the extent to which this effect was influenced by either demographic characteristics or previous symptoms. The main question posed is whether a specific disaster is related to the onset of symptoms and/or psychiatric diagnoses not present before that disaster. We also present information on the onset of new symptoms following the disaster and analyze them retrospectively and prospectively. A number of disaster characteristics and consequences have been previously associated with the risk of developing mental symptoms or disorders in the victims. In fact, disasters characterized by a high proportion of affected to nonaffected

The psychological sequelae of disaster stress prospectively and retrospectively evaluated

Aimed to document the psychological sequelae of a disaster in the adult (17-68 years) population of the Caribbean island of Puerto Rico, by surveying 912 persons (including 375 previously interviewed) with a Spanish version of the Diagnostic Interview Schedule. A rigorous methodology, which included both retrospective and prospective designs, was used, enabled by the occurrence of a catastrophic disaster only a year after a comprehensive survey was completed. Framed in a stress theoretical perspective, disaster effects for new depressive, somatic, and posttraumatic stress symptoms were identified, even after adjusting for demographic and methodologic factors. All the effects, however, were relatively small, suggesting that most disaster victims were rather resilient to the development of new psychological symptoms. Comparison of results with previous findings and its implications for both disaster and stress research are discussed, as well as the role of community psychologists in disaster action.

Methodological Challenges in Cross-Cultural Mental Health Research

The article discusses some of the main challenges involved in carrying out culturally informed mental health research and the usefulness of a cross-cultural approach to psychiatric epidemiology, focusing on its benefits for hypothesis formulation, the ascertainment of etiologies and risk factors, and the creation of policies for illness prevention. Also described is the ongoing theoretical debate regarding the extent to which cultural diversity should be incorporated directly into research methodologies used in the assessment of psychopathology. Specifically, how much local cultural diversity can be incorporated into an established diagnostic instrument before the degree of alteration renders the instrument incapable of measuring the original constructs for which it was designed? Some of the most salient methodological challenges encountered in cross-cultural research, and how several researchers have tried to resolve them are also discussed, e.g. definition of what constitutes a case and what constitutes outcome; maintaining meaning and procedural equivalence throughout the translation and cultural adaptation of diagnostic instruments; and ensuring that the significance of various sociodemographic factors is actually equivalent across the different cultural samples studied. Finally, the article discusses several directions for future research offering examples from research carried out in Puerto Rico.

The adaptation and testing of diagnostic and outcome measures for cross-cultural research

Specific symptom presentations as well as patterns of onset, duration, risk and outcome of mental illness have been shown to vary across cultures. Cross cultural research aims to understand the processes which explain these differences in the expression of mental illness. This endeavor can give clues to the etiology of disorders and can provide evidence on whether different societal responses to mental illness affects its course, thus ultimately providing clues to the improvement of treatment. However, cross-cultural research is affected by a number of methodological and substantive issues, namely, the definition of what constitutes a “true” case, the use of culturally sensitive diagnostic tools and the need for evaluating outcomes in the particular context in which they occur. The present paper focuses on these main issues and describes a particular cross-cultural method consisting of obtaining content, semantic, technical, and criterion equivalence. The method has been found successful in achieving the ...

Stimulant and Psychosocial Treatment of ADHD in Latino/Hispanic Children

OBJECTIVE To examine to what extent Latino/Hispanic children with and without attention-deficit/hyperactivity disorder (ADHD) are receiving treatment and to identify variables that predict treatment with stimulant medication. METHOD Primary caretakers of a probability household sample (N = 1,897) of Puerto Rican children aged 4-17 years were administered structured interviews (response rate: 90.1%) from 1999-2000 to ascertain psychiatric disorders and types of services received. RESULTS Only 7.0% of children with ADHD received stimulant medication during the last year; moreover, only 3.6% had actually continued this treatment at the time of the interview. One fourth or less of those with ADHD received school-based services or psychosocial treatment. The male-female ratio in stimulant medication use was 10 to 1. In addition, only 0.2% of those with no psychiatric diagnosis received this treatment. ADHD and ADHD-not otherwise specified, impairment, and being male significantly predicted stimulant treatment. CONCLUSIONS Children with ADHD in this Latino/Hispanic population are not receiving the most efficacious treatments based on scientific findings and relevant clinical consensus. This population is undertreated rather than overtreated.

Children of parents with psychiatric disorder in the community

The relationship between parental psychopathology and risk for maladjustment in the offspring was investigated in a community sample. The children of 130 parents who met criteria for 12 DIS/DSM-III disorders were compared to the children of 235 normal parents. Significantly more children of disturbed parents were functionally impaired and had higher scores in the parent and youth Child Behavior Checklist total behavior scores as compared to children of normal parents. These associations were maintained even after accounting for an adverse family environment, suggesting a strong relationship between parental and childhood psychopathology as well as a mediating influence of environmental adversity.

SEX DIFFERENCES AND DEPRESSION IN PUERTO RICO

Sex differences in rates of depressive disorders and depressive symptomatology, as measured by the Diagnostic Interview Schedule, are examined for an island-wide probability sample of Puerto Rico. Consistent with previous research, depression is significantly more prevalent in Puerto Rican women than men. Risk factors associated with depressive symptomatology are examined from a sex-role perspective. The results of multiple regression analyses show that even after demographic, health and marital and employment status variables are controlled, women continue to be at higher risk of depressive symptomatology than men. These results are interpreted within a cultural and sex-role perspective.