Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Anderson K. Immigration and Lifetime Prevalence of DSM-IV PsychiatricDisorders Among Mexican Americans and Non-Hispanic Whites in the United StatesResults From the National Epidemiologic Survey on Alcohol and RelatedConditions. Arch Gen Psychiatry. 2004;61(12):1226-1233. doi:10.1001/archpsyc.61.12.1226
Copyright 2004 American Medical Association. All Rights Reserved.Applicable FARS/DFARS Restrictions Apply to Government Use.2004
There exist no national prevalence data on specific DSM-IV Axis I psychiatric disorders among foreign-born and US-born
Mexican Americans and non-Hispanic whites.
To present nationally representative data on the prevalence of DSM-IV lifetime psychiatric disorders among foreign-born
and US-born Mexican Americans and non-Hispanic whites.
Face-to-face survey conducted in the 2001-2002 National Epidemiologic
Survey on Alcohol and Related Conditions.
The United States and District of Columbia, including Alaska and Hawaii.
Household and group-quarters residents, aged 18 years and older (n = 43 093).
Main Outcome Measures
Prevalence of DSM-IV substance use disorders
and mood and anxiety disorders.
With few exceptions, foreign-born Mexican Americans and foreign-born
non-Hispanic whites were at significantly lower risk (P<.05) of DSM-IV substance use and mood
and anxiety disorders compared with their US-born counterparts. Although the
risk of specific psychiatric disorders was similar between foreign-born Mexican
Americans and foreign-born non-Hispanic whites, US-born Mexican Americans
were at significantly lower risk (P<.05) of psychiatric
morbidity than US-born non-Hispanic whites.
Data favoring foreign-born Mexican Americans with respect to mental
health may extend to foreign-born non-Hispanic whites. Future research among
foreign-born and US-born Mexican Americans and the foreign-born and US-born
of other origins and descents is needed to understand what appears to be the
protective effects of culture and the deleterious effects of acculturation
on psychiatric morbidity in the United States.
In 2003, Hispanics residing in the United States became the largestethnic minority group in the country. The Hispanic population rose from about9.1% (22 million) in 1990 to 13.4% (39 million) in 2003.1 Currentcensus projections predict that the number of Hispanics in the United Stateswill double by 2050 to more than 25% of the total US population.2 MexicanAmericans are by far the largest Hispanic subgroup today, constituting about60% of the US Hispanic population. In light of this large representation amongthe US population, knowledge of psychiatric morbidity among Mexican Americansis becoming increasingly important. A major aspect of this is whether immigrantstatus affects the risk of psychiatric disorders.
Three large-scale epidemiological studies have addressed the mentalhealth of Mexican Americans, including comparisons of foreign-born MexicanAmericans with their US-born counterparts and/or with non-Hispanic whites.The first was the Los Angeles, Calif, site of the Epidemiologic CatchmentArea (LAECA) survey conducted in 1983-1984.3 US-bornMexican Americans were significantly more likely than foreign-born MexicanAmericans to have lifetime diagnoses of major depression, dysthymia, phobia,alcohol abuse and/or dependence, and drug abuse and/or dependence.4 Compared with non-Hispanic whites, US-born MexicanAmericans were significantly less likely to have drug abuse and/or dependencebut significantly more likely to have dysthymia, phobia, and alcohol abuseand/or dependence. In another study using LAECA data,5 US-bornMexican Americans had higher rates of specific phobia and agoraphobia butnot of generalized anxiety disorder than foreign-born Mexican Americans. US-bornMexican Americans also had greater rates of specific phobia but lower ratesof generalized anxiety disorder relative to US-born non-Hispanic whites.
The second epidemiologic survey to examine the effect of immigrant statuson the mental health status of Mexican Americans was the Mexican AmericanPrevalence and Services Survey (MAPSS) conducted in the early 1990s. Thisstudy was conducted among 3012 adults of Mexican origin in Fresno County,California.6 In this study, rates of mood,anxiety, and substance use disorders were greater among US-born relative toforeign-born Mexican Americans. Rates of psychiatric disorders among US-bornand foreign-born Mexican Americans from the MAPSS also were compared withrates among all Hispanics in the United States and the total US population,using data from the 1990-1992 National Comorbidity Survey (NCS).7 Theprevalence of psychiatric disorders among the foreign-born was lower thanthat found among the total US-born Hispanic population and the total US populationin the NCS. In contrast, rates of psychiatric disorders among US-born MexicanAmericans in the MAPSS were comparable with those found in the NCS. The thirdstudy8 made use of a small subset of MexicanAmericans within the NCS, also showing that US-born Mexican Americans hadhigher rates of any psychiatric disorder and posttraumatic stress disorderthan their foreign-born counterparts.
Although all of these studies found that immigrant status had a significanteffect on the prevalence of psychiatric disorders, they do not provide uswith current information and have several other limitations. The LAECA andMAPSS samples consisted of Mexican Americans in Los Angeles and Fresno County,precluding generalization to the entire US Mexican American population. TheNCS was a national survey but the number of Mexican Americans (n = 484)was quite small, precluding analyses of specific disorders to determine ifimmigration status affected some disorders but not others. The NCS also didnot interview in Spanish, which may have excluded some of the less-acculturated,Hispanic, foreign-born population.Further, none of these surveys assessedpsychiatric disorders according to the American Psychiatric Association’sclassification DSM-IV.9 TheLAECA survey used DSM-III10 criteria,whereas the MAPSS used DSM-III-R11 criteria.
Non-Hispanic white comparison groups in these studies also were limited.The MAPSS, NCS, and 1 LAECA study compared US-born and foreign-born MexicanAmericans with the entire non-Hispanic white population without regard toimmigration status, thereby confounding race-ethnicity and immigration status.Only 1 LAECA study5 used a US-born non-Hispanicwhite comparison group, and no study has compared US-born and foreign-bornMexican Americans with foreign-born non-Hispanic whites. The latter comparisongroup is critical in determining if the lower rates of disorders found amongforeign-born Mexican Americans are generalizable to foreign-born non-Hispanicwhites.
The issue of immigrant status is of general importance, both in termsof policy and needs for service delivery and for a better understanding ofthe etiology of mental disorders. Given the large proportion of Mexican Americansamong immigrant groups to the United States during the last few decades, afocus on this group is timely and important. Therefore, the major objectiveof this study was to examine the relationship between immigration status andspecific DSM-IV mood, anxiety, and substance usedisorders in a nationally representative sample of Mexican Americans as assessedin the National Institute on Alcohol Abuse and Alcoholism’s (NIAAA)2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions(NESARC).12 Oversampling of Hispanics in theNESARC importantly yielded a sample of 7995 Hispanics, of which 4558 wereof Mexican American origin. These sample sizes allowed for precise comparisonsof specific psychiatric disorders by immigration status. In addition, US-bornand foreign-born Mexican Americans could be compared with US-born and foreign-bornnon-Hispanic whites.
The 2001-2002 NESARC is a representative sample of the United Statessponsored by the NIAAA that has been described in detail elsewhere.12,13 The target population of the NESARCwas the civilian, noninstitutional population, aged 18 years and older, residingin households as well as in group quarters. The survey included those residingin the continental United States, the District of Columbia, and Alaska andHawaii. Face-to-face personal interviews were conducted with 43 093 respondents.The overall survey response rate was 81%. African Americans and Hispanicsand young adults (aged 18 to 24 years) were oversampled in the NESARC.
The data were weighted to reflect the design characteristics of theNESARC and to account for oversampling. Adjustment for nonresponse acrossnumerous variables, including age, race, ethnicity, sex, region, and placeof residence, was performed at the household level and person level. The weighteddata were then adjusted to be representative of the US civilian populationon a variety of sociodemographic variables, including region, age, race, ethnicity,and sex, based on the 2000 Decennial Census.
Approximately 1800 professional interviewers from the census bureauadministered the NESARC using laptop computer–assisted software thatincluded built-in skip, logic, and consistency checks. On average, the interviewershad 5 years’ experience working on census and other health-related nationalsurveys. Training was standardized through centralized sessions under thedirection of NIAAA.
Regional supervisors recontacted a random 10% of all respondents forquality control purposes and to verify the accuracy of the interviewers’performance. In addition, 2657 respondents were randomly selected to participatein a reinterview study after completion of their NESARC interview. Each respondentwas readministered 1 to 3 complete sections of the NESARC interview. Theseinterviews not only served as a check on survey data quality but formed thebasis of an additional test-retest reliability study of wave 1 NESARC measures.14
The census bureau maintains a cadre of Spanish-speaking interviewersat each of their 12 regional offices, who were rigorously trained in the administrationof the Spanish version of the NESARC instrument. Hispanic respondents preferringto have their interviews conducted in Spanish (15.5%) were interviewed bythese specially trained interviewers. Because these interviewers were regionallybased, they possessed extensive knowledge of cultural and linguistic adaptationsappropriate for use with Mexican-origin populations. Translation and back-translationof the survey instrument were done by the linguistic experts at the censusbureau.
Mexican origin or descent was established by the respondent’sself-identification as Chicano, Mexican, or Mexican American. Sociodemographicmeasures included age, sex, race-ethnicity (Mexican American vs non-Hispanicwhite), immigration status (US-born vs foreign-born), marital status (married/livingwith someone as if married, widowed/divorced/separated, or never married),place of residence (urban, rural, or town), and region of the country (Northeast,Midwest, South, or West). Socioeconomic measures included education (lessthan high school, high school graduate, or some college or beyond) and familyincome, measured as a continuous variable. Race-ethnicity and immigrationwere cross-classified to yield 4 groups for comparative purposes: (1) foreign-bornMexican Americans; (2) US-born Mexican Americans; (3) foreign-born non-Hispanicwhites; and (4) US-born non-Hispanic whites.
The NESARC diagnostic interview used to generate diagnoses presentedin this report was the NIAAA Alcohol Use Disorder and Associated DisabilitiesInterview Schedule-DSM-IV Version (AUDADIS-IV), astate-of-the-art, structured diagnostic interview designed for use by layinterviewers.15 The DSM-IV mood and anxiety diagnoses included in the AUDADIS-IV were major depression,dysthymia, mania, hypomania, panic disorder, social phobia, specific phobia,and generalized anxiety disorder.
Lifetime mood and anxiety diagnoses presented in this report are definedin the DSM-IV as “primary” or independentdiagnoses. In the DSM-IV, the term primary is used as shorthand to indicate those mental disorders thatare not substance induced and that are not due to a general medical condition.9(p192) Respondents classified with disordersthat only were substance induced and/or due to a general medical conditionwere not included in the analyses presented herein. Depressive episodes entirelyaccounted for by bereavement also were excluded.
The reliability of AUDADIS-IV measures of DSM-IV moodand anxiety disorders is documented in test-retest studies among several generalpopulation and clinical samples, some of which included substantial percentagesof Hispanics (21.7%, 33.9%, and 41.1% in Denver,Colo; Dallas, Tex; and LosAngeles samples, respectively).14,16- 18 Atest-retest of major AUDADIS-IV diagnostic measures also was conducted ina Hispanic population.19 In these test-reteststudies, the reliabilities of mood and anxiety disorders were fair to good,ranging from κ = 0.42 for specific phobia to κ = 0.64for major depression.
The validity of AUDADIS-IV mood and anxiety disorders was assessed ina series of linear regression analyses, using the NESARC data, that examinedthe associations between each mood and anxiety disorder and 4 Short Form-12v2mental disability scores, controlling for age, alcohol and drug use disorders,and all other mood and anxiety disorders. The Short Form-12v220 isa reliable and valid measure of generic quality of life used in large populationsurveys. The focus was on 4 mental disability Short Form-12v2 scores: themental component summary score; the social functioning score; the role emotionalfunction score; and the mental health score. Each mood and anxiety disorderassessed in the NESARC was shown to be a highly significant (P<.01 to P<.001) predictor of the mentalcomponent summary, social functioning, role emotional, and mental health scores.Respondents with these mood and anxiety disorders had significantly greaterdisability and social/occupational dysfunction than respondents who did nothave the particular mood or anxiety disorder.
The AUDADIS-IV included an extensive list of symptom questions thatseparately operationalized DSM-IV criteria for alcoholand drug-specific abuse and dependence for 10 classes of drugs, includingsedatives, tranquilizers, opiates (other than heroin or methadone), stimulants,hallucinogens, cannabis, cocaine (including crack cocaine), inhalants/solvents,heroin, and other drugs.
Consistent with the DSM-IV, lifetime AUDADIS-IVdiagnoses of alcohol abuse required a respondent to meet at least 1 of the4 criteria defined for abuse either in the 12-month period preceding the interviewand/or before that 12-month period. TheAUDADIS-IV dependence diagnoses requiredthe respondent to satisfy at least 3 of the 7 DSM-IV criteriafor dependence either during the past year and/or prior to the past year.Diagnoses of alcohol dependence prior to the past year were required to satisfythe time-clustering criteria defined in the DSM-IV.That is, to meet criteria for “prior to the past year,” at least3 dependence symptoms must have occurred within the same 1-year period. Thedrug-specific diagnoses of abuse and dependence were derived using the samealgorithm described for alcohol use disorders.
The reliability14,16- 19 andvalidity21- 35 ofthe AUDADIS-IV alcohol and drug diagnoses are well documented in numerouspsychometric studies conducted in clinical and general population samples,including a Hispanic population (in which reliability and validity coefficientsranged from good to excellent).19 The psychometricproperties of the alcohol and drug use disorders modules of the AUDADIS-IValso were examined and found to be excellent in several countries as partof the World Health Organization/National Institutes of Health InternationalStudy on Reliability and Validity.16,36- 41
Cross-tabulations were used to calculate prevalences of lifetime DSM-IV substance use disorders and mood and anxiety disordersby immigration status among Mexican Americans and non-Hispanic whites. Oddsratios were then used to examine associations between the 4 comparison groupsand each specific psychiatric disorder, controlling for a broad range of sociodemographicand socioeconomic factors. Standard errors and 95% confidence limits relatedto all of these analyses were estimated using SUDAAN,42 asoftware package that uses Taylor series linearization to adjust for complexsample survey design characteristics.
The distribution of sociodemographic and socioeconomic characteristicsby immigration status among Mexican Americans and non-Hispanic whites is shownin Table 1. There were 4558 respondentswho identified themselves as being of Chicano, Mexican, or Mexican Americanorigin or descent, of which 2227 (49%) were immigrants and 2331 (51%) wereUS-born. Of the 24 803 non-Hispanic white respondents, 1541 (6%) wereimmigrants and the remaining 23 262 (94%), US-born.
Compared with non-Hispanic whites, Mexican Americans were much morelikely to have less than a high school education (11.1% vs 47.6%), to earnless than $20 000 a year (43.5% vs 65.5%), to live in an urban area (23.3%vs 45.9%), and to reside in the West (19.5% vs 54.7%).
Striking differences in socioeconomic indicators (educational attainment,family income) and marital status were found between US-born and foreign-bornMexican Americans. The foreign-born Mexican Americans were much more likelythan the US-born Mexican Americans to have less than a high school education(64.0% vs 26.1%) and to earn less than $20 000 a year (71.1% vs 58.0%).However, foreign-born Mexican Americans were more likely than US-born MexicanAmericans to be married (73.4% vs 55.3%). In contrast, the distributions ofthese and other sociodemographic and socioeconomic indicators across the US-bornand foreign-born non-Hispanic whites were quite similar.
Lifetime rates of DSM-IV psychiatric disordersby immigration status among Mexican Americans and non-Hispanic whites areshown in Table 2. Overall, the non-Hispanicwhites’ rate of any psychiatric disorder (51.2%) was nearly twice thatfor Mexican Americans (36.7%). The rate of any disorder was much greater forthe US-born (47.6% and 52.5%) than for their foreign-born counterparts (28.5%and 32.3%). Prevalences of any alcohol use disorder, any mood disorder, andany anxiety disorder among US-born Mexican Americans and non-Hispanic whitesalso were nearly twice as large as the corresponding foreign-born rates. Therate of any drug use disorder among US-born Mexican Americans was 8.3 timesgreater than for foreign-born Mexican Americans, while for non-Hispanic whitesthe ratio was about 2.4:1.0.
A series of logistic regressions, adjusted for age, sex, marital status,place of residence, region of the country, education, and family income, wasused to examine associations between the 4 comparison groups and each specificpsychiatric disorder (Table 3).
Column 1 of Table 3 indicatesthat the odds ratios of all specific psychiatric disorders, except hypomaniaand panic disorder, were significantly lower among US-born Mexican Americanscompared with US-born whites.
Columns 2, 3, 4, and 5 compare the foreign-born with the US-born. Column2 indicates that US-born non-Hispanic whites are at greater risk of all psychiatricdisorders than foreign-born Mexican Americans. US-born Mexican Americans alsohad significantly greater rates of alcohol and drug use disorders (exceptany drug dependence) compared with foreign-born whites (column 3). However,there were no differences in the odds ratios of mood and anxiety disordersbetween these groups with the exception of panic disorder, which was significantlygreater among US-born Mexican Americans than among foreign-born whites.
US-born Mexican Americans were at significantly higher risk of all psychiatricdisorders except hypomania and social and specific phobias compared with foreign-bornMexican Americans (column 4). Similarly, the odds of most psychiatric disordersamong non-Hispanic whites were significantly greater among the US-born thanforeign-born individuals (column 5). However, there were no differences observedin the odds of mania and hypomania between US-born and foreign-born non-Hispanicwhites.
Column 6 of Table 3 indicatesthat the odds of all psychiatric disorders did not differ between MexicanAmerican and non-Hispanic white foreign-born individuals.
To our knowledge, this study is the first to show that, with few exceptions,foreign-born Mexican Americans and foreign-born non-Hispanic whites were atsignificantly lower risk of DSM-IV disorders comparedwith their US-born counterparts. These included alcohol and drug use disorders,major depression, dysthymia, mania, hypomania, panic disorder, social andspecific phobia, and generalized anxiety disorder. Similarly, foreign-bornMexican Americans also were at significantly lower risk of psychiatric morbiditycompared with US-born non-Hispanic whites. Previous studies compared ratesof disorder among US-born and foreign-born Mexican Americans with rates inthe entire non-Hispanic white population or the total US population withoutregard to immigration status4,6- 8 orwith rates only among US-born non-Hispanic whites5 andthus were unable to reveal this rather remarkable pattern. It appears thatthe results favoring foreign-born Mexican Americans with respect to mentalhealth may extend to foreign-born non-Hispanic whites.
In this set of results, foreign-born Mexican Americans as well as non-Hispanicwhites were at lower risk of major psychiatric disorders compared with theirUS-born counterparts, even though they may experience greater stress owingto low socioeconomic status and/or adapting to a new culture. In view of this,it is apparent that social stress hypotheses of immigration and mental health,which would predict greater risk of psychiatric disorders among the foreign-born,cannot explain these results. However, this set of findings is consistentwith the “selection” or “healthy migrant” model.4,6,43 This model assertsthat foreign-born individuals with good mental health are more likely to immigrateto the United States than those with poor mental health and thus are at lowerrisk of psychiatric morbidity. The selection model predicts that the foreign-bornwould have lower risk of disorder compared with the US-born. In most comparisons,the risk of psychiatric disorders examined in this study was lower among foreign-bornMexican Americans and non-Hispanic whites compared with their US-born counterparts.However, the healthy migrant hypothesis cannot account for the similarityin the risk of any drug dependence and specific mood and anxiety disordersamong foreign-born non-Hispanic whites and US-born Mexican Americans. Moreover,that rates for foreign-born immigrants were found to closely approximate ratesreported in Mexico City, Mexico, in the MAPSS6 weakensthe likelihood that lower psychiatric morbidity among foreign-born MexicanAmericans is primarily a selection effect. Taken together, these results suggestthat several processes may be operating to produce the observed effects ofimmigration found in this study.
That US-born Mexican Americans (who are not subject to migration selectionfactors) had a mental health advantage over US-born non-Hispanic whites alsosuggests that factors other than migratory ones must be involved in producingthe lower Mexican American psychiatric morbidity. Evidence found in otherstudies examining mental health among Mexican Americans for the “frustratedstatus”4,6 hypothesis canalso not explain these results. This model posits that the foreign-born maybe at lower risk of disorder because of a lower set of expectations aboutwhat constitutes success in America. US-born Mexican Americans, having higherexpectations for status attainment, may be more distressed and experiencea greater sense of deprivation and greater risk of psychiatric morbidity thantheir foreign-born counterparts. This model predicts that US-born MexicanAmericans will have higher rates of disorder than US-born non-Hispanic whites.However, as previously mentioned, US-born Mexican Americans were at lowerrisk of most psychiatric disorders compared with US-born non-Hispanic whites.
Alternatively, some of the findings of this study may argue in supportof a negative effect of acculturation on mental health. Foreign-born MexicanAmericans and foreign-born non-Hispanic whites appear to share the lower riskstatus of their national origins, but acculturation appears to have a deleteriouseffect on their mental health.4,6,7,44 Further,the results of this study also, in part, support the role of traditional culturalretention as a protective factor of the mental health of individuals of Mexicandescent.4,6,44 Thetraditional Mexican family is more closely knit than most non-Hispanic whitefamilies, with many extended family members who offer a great deal of psychologicaland financial support. That traditional Mexican American family networks maybe protective against psychiatric morbidity is consistent with the findingsthat foreign-born Mexican Americans and non-Hispanic whites did not differin the risk of psychiatric disorders, but US-born Mexican Americans had aclear mental health advantage over US-born non-Hispanic whites. These resultsfurther suggest that the protective effects of cultural retention found forMexican Americans may not be generalizable to immigrants of other descentsand origins.
In addition to the explanatory models explored in this study, thereare 2 methodological artifacts that also may account, in part, for the patternof associations observed between place of birth and psychiatric morbidity.The first is bias owing to language (ie, the nonequivalent assessment of disorderwhen the interview was administered in English vs Spanish), which could leadto differential reliability and validity of the psychiatric measures acrosssubgroups of the population defined by race-ethnicity and immigration status.Differences in response tendencies (eg, social approval, trait desirability,or acquiescence) among English-speaking Mexican Americans can also be implicated.Further research is critically needed to ascertain the degree to which languagebias and differential response patterns influence the rates of psychiatricdisorders and, in turn, the reliability and validity of case ascertainment.
Reports from other countries45- 47 thathave found high rates of psychopathology among immigrants suggest that riskstatus of national origin, patterns of immigration, motivations for immigration,and characteristics of the host country are all likely to be important determinantsof the mental health status of immigrants. Further research among foreign-bornand US-born Mexican Americans is sorely needed to understand processes underlyingwhat appear to be the protective effects of culture and the deleterious effectsof acculturation on mental health. The findings of this study also suggestthat such research be extended to US-born and foreign-born individuals ofother origins and descents. Identifying the specific components of variouscultures that are protective against psychopathology and those componentsof acculturation that increase risk of psychiatric morbidity holds great promisein helping to guide future prevention and treatment efforts.
Correspondence: Bridget F. Grant, PhD, PhD,Laboratory of Epidemiology and Biometry, Room 3077, Division of IntramuralClinical and Biological Research, National Institute on Alcohol Abuse andAlcoholism, National Institutes of Health, MS 9304, 5635 Fishers Ln, Bethesda,MD 20892-9304 (firstname.lastname@example.org).
Submitted for Publication: March 3, 2004; finalrevision received May 14, 2004; accepted June 9, 2004.
Disclaimer: The views and opinions expressedin this article are those of the authors and should not be construed to representthe views of any of the sponsoring organizations, agencies, or the US government.