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Native Population

Puerto Rico's native Taíno population-whose hunter-gatherer ancestors settled the island more than 1,000 years before the Spanish arrived-called it Borinquén, and referred to themselves as boricua (a term that is still used today).

During his second expedition to the Indies in 1493, Christopher Columbus returned several Taíno captives to Borinquén and claimed the island for Spain, calling it San Juan Bautista. In 1508, Juan Ponce de León founded the first European settlement, Caparra, near a bay on the island's northern coast; Caparra was renamed Puerto Rico (or "rich port") in 1521.

Over time, people began referring to the entire island by that name, while the port city itself became San Juan. Smallpox soon wiped out the vast majority of the Taíno, with many others enslaved by the Spanish to mine silver and gold and to construct settlements.

Spanish Rule

In order to produce cash crops such as sugar cane, ginger, tobacco and coffee, the Spanish began importing more slaves from Africa in the 16th century. They also spent considerable resources turning San Juan into an impregnable military outpost, building a fortified palace for the governor (La Fortaleza) as well as two massive forts-San Felipe del Morro and San Cristobál-that would withstand repeated attacks by rival powers such as England, the Netherlands and France.

Under Spanish colonial rule, Puerto Rico experienced varying levels of economic and political autonomy over the centuries. By the mid-19th century, however, a wave of independence movements in Spain's South American colonies had reached Puerto Rico.

In 1868, some 600 people attempted an uprising based in the mountain town of Lares. Though the Spanish military efficiently quashed the rebellion, Puerto Ricans still celebrate "El Grito de Lares" (The Cry of Lares) as a moment of great national pride.

Foraker Act

In July 1898, during the brief Spanish-American War, U.S. Army forces occupied Puerto Rico at Guánica, on the island's south side. Under the Treaty of Paris, which formally ended the war later that year, Spain ceded Puerto Rico, Guam, the Philippines and Cuba to the United States.

The interim U.S. military government established on the island ended in 1900 after Congress passed the Foraker Act, which formally instituted a civil government in Puerto Rico. Having enjoyed considerable autonomy in the latter years of Spanish colonial rule, many Puerto Ricans bristled under the control exercised by the United States.

In 1917, Congress passed the Jones-Shafroth Act, which granted U.S. citizenship to all Puerto Ricans and made Puerto Rican males eligible for the military draft; some 18,000 of the territory's residents were subsequently drafted into World War I.

Operation Bootstrap

Big political, economic and social changes swept Puerto Rico after World War II. In 1948, Congress passed an act permitting Puerto Ricans to elect their own governor. Four years later, Puerto Rico would officially become a U.S. commonwealth, which enabled the island to create its own constitution and granted other powers of self-government.

By that time, the U.S. and Puerto Rican governments had jointly launched an ambitious industrialization effort called Operation Bootstrap. Even as Puerto Rico attracted an influx of big American companies, and became a center for manufacturing and tourism, the decline of its agricultural industries led many islanders to seek employment opportunities in the United States.

Between 1950 and 1970, more than 500,000 people (some 25 percent of the island's total population) left Puerto Rico, an exodus known as La Gran Migración (the Great Migration). Today, more than 5 million people of Puerto Rican descent live in the United States, with huge communities centered in Chicago, Philadelphia, Miami and especially New York City.

Is Puerto Rico Part of the U.S?

Puerto Rico is a territory of the United States, but the island's ambiguous status in relation to the United States has driven heated debate over the years between those who support its commonwealth status, those who favor full-fledged Puerto Rican statehood and those who want the island to be its own independent nation.

As citizens of a commonwealth, Puerto Ricans can elect a non-voting representative in Congress and vote in presidential primaries, but cannot vote for president because Puerto Rico is not part of the electoral college.

After three separate votes in 1967, 1993 and 1998 reaffirmed Puerto Rico's commonwealth status, a majority of residents who voted in a 2012 referendum said they were not satisfied with the status quo, and indicated their preferred choice was statehood.

Hundreds of thousands of voters left the second part of the referendum blank, however, leaving the question open for further debate. A fifth referendum in 2017 ended in a majority vote for statehood, but only 23 percent of voters (a historic low) turned out.

Economic Crisis

In the first decade of the 21st century, Puerto Rico's economic growth slowed, even as its national debt rapidly expanded. In 2015, the worsening economic crisis led its governor to announce that the commonwealth could no longer meet its debt obligations.

Two years later, under legislation passed by Congress to help Puerto Rico deal with its economic crisis, the commonwealth declared a form of bankruptcy, claiming debt of more than $70 billion, mostly to U.S. investors.

In September 2017, Puerto Rico's economic woes were compounded when Hurricane Maria, a Category 4 hurricane with some 150 mph winds, made direct landfall on the island. In Maria's aftermath, Puerto Rico's inhabitants-some 3.4 million American citizens-found themselves in a humanitarian crisis, facing debilitating shortages of water, food and fuel and a deeply uncertain future.

HISTORY Vault

Sources

Doug Mack, The Not-Quite States of America: Dispatches from the Territories and Other Far-Flung Outposts of the USA. W.W. Norton, 2017.
Puerto Rico, History, Art & Archives: U.S. House of Representatives.
Smithsonian.
Library of Congress.
Puerto Rico statehood referendum draws big support-but small turnout, CNN.

Fact Check

We strive for accuracy and fairness. But if you see something that doesn't look right, click here to contact us! HISTORY reviews and updates its content regularly to ensure it is complete and accurate.

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Puerto Rico is a large Caribbean island of roughly 3,500 square miles located in the West Indies. After centuries of Spanish rule, Puerto Rico became a territory of the United States in 1898 and has been largely self-governing since the mid-20th century.

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How Puerto Rico Became a U.S. Commonwealth | PBS LearningMedia

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Learn how Puerto Rico became a Spanish colony, then an unorganized U.S. territory as a result of the Spanish-American War, and then a U.S. commonwealth in 1952. Discover what commonwealth status means for Puerto Ricans and what the relationship between the United States and Puerto Rico is today.

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Talking About Mental Health In The Latino Community

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Making Mental Health Accessible in the Latinx Community

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Linda Bucay-Harari, MPH, ¹ Kathleen R. Page, MD, ² Noa Krawczyk, PhD, ³ Yvonne P. Robles, MPH, ¹ and Carlos Castillo-Salgado, MD, JD, MPH, DrPH ¹

Abstract

Over the last decade, Baltimore has become a non-traditional sanctuary city, receiving an unprecedented influx of Latino immigrants, mostly from Central America's Northern Triangle, who are often fleeing violence in their home countries. This study explored the nature and frequency of healthcare utilization for mental health problems among uninsured/uninsurable Latinos who received outpatient care between 2012 and 2015 through an academic hospital-affiliated program that covers primary and specialty services to uninsured patients without regard to documentation status. Encounters for mental health disorders were the most common category, accounting for 14.88% of all visits. Mood (78%) and anxiety disorders (16%) were the most prevalent mental health diagnoses. The most frequent reason to seek care was symptom, signs, and ill-defined conditions (37.47%), and within this subgroup, pain was the leading cause of seeking care (88%), which may indicate high rates of somatization of mental health distress. This study presents a unique opportunity to explore the burden and nature of mental health needs among a population for which healthcare information is rarely attainable and highlights the need for culturally competent screening mechanisms and interventions to address the stressors faced by emergent communities.

Keywords: Mental health, Migration, Immigrant community, Latino health, Undocumented immigrant, Social health inequities

Introduction

Latinos are the largest and fastest-growing minority in the USA. In 2015, 17.6% of the population (56.6 million people) were identified as Hispanic or Latino,1 and by 2060, this proportion is estimated to increase to 28.6%.2 US-born Latinos outnumber foreign-born Latinos in most states with the exception of the District of Columbia and Maryland3, 4, and around 11 million Latino immigrants in the USA are undocumented.5 Immigration trends have changed in recent years, with an unprecedented number of people coming from Honduras, El Salvador, and Guatemala, a region known as Central America's Northern Triangle (NT), shifting the social fabric of some communities that are traditionally mostly comprised of individuals of Mexican descent and forming new ones.6-8 Latino immigrants have traditionally moved to border states or regions with large well-established Latino communities and strong social support networks for newly arrived populations. In the last two decades, however, the influx of Latino immigrants has expanded to non-traditional areas, such as Baltimore City, where the Latino population increased 135% between 2000 and 2010.9 According to the Maryland Department of Health and Mental Hygiene, in 2013 around 40% of the Latino population in Maryland was from the NT.10 Immigrant communities in emergent settlement areas like Baltimore face challenges due to a lack of social support and culturally and linguistically competent services that are more accessible in traditional Latino destinations.

Migration is a process that involves several stressors.11 Undocumented immigrants are particularly vulnerable since they face unique risks and exposure to traumatic experiences before, during, and after migrating that put them at high risk of mental health distress.12-15 The NT countries have among the highest social inequality rates in the Western Hemisphere and homicide rates in the world6, 16 In 2012, all three NT countries had among the top 5 highest murder rates in the world,6 and hundreds of thousands have fled the increasing violence in the area by migrating north, either to Mexico or the USA. In addition, the journey through Mexico is particularly risky for Central American migrants.15, 17 A high proportion suffer unintentional injuries and various forms of violence, such as theft, extortion, mugging, kidnapping, trafficking, and sexual abuse perpetrated by Mexican gangs and federal officials that take advantage of their vulnerable status.15, 17, 18 Once in the USA, immigrants face additional stressors related to their documentation status, language and cultural barriers, fear of family separation, discrimination, and limited access to healthcare and public services.19, 20

Despite these challenges, some evidence indicates that Latin American immigrants living in the USA have better overall health than US-born Latinos and non-Latino Whites.21 A study that analyzed data from a national representative survey found that Mexican immigrants had a lower lifetime risk of developing mental disorders compared to US-born Latinos and non-Latinos.22 This phenomenon has been described as the "Hispanic paradox,"21 which is often attributed to either a "healthy migrant effect,"23 in which migration itself requires a physical and mental level of fitness and is a self-selecting process or that coping skills inherent to Latino culture such as positive reframing and religion may be protective factors against stress and mental health problems.24 Some researchers, however, have argued that aggregating Latinos into one group might hinder the identification of specific vulnerabilities and protective factors among subgroups.11 It has been reported, for example, that health among Latinos varies based on country of origin, specific mental health disorder, time living in the USA, and other socioeconomic variables.25

Assessing mental health among this population is highly relevant in today's sociopolitical climate, given recent changes to border control, refugee, and immigration policies that may impact the experience of new Latino immigrants to the USA. In addition, older studies do not reflect the impact on the mental health of immigrants related to changes in immigration policy over the last two decades, starting with the Bush administration (2001-2008) deporting 2 million immigrants, continued by the Obama administration deporting 3 million immigrants (2009-2016),26 and followed by increasing anti-immigrant rhetoric and the zero-tolerance policy of the Trump Administration.27 Migrants, including families with children, facing violence and extortion continue to migrate to the USA in hopes of receiving asylum protection.28 However, the Department of Justice has been asked to prosecute "all adult aliens apprehended crossing the border illegally, with no exception for asylum seekers or those with minor children."27 The deleterious impact of these policies on the mental health of immigrants is beginning to be documented in the literature.29 For example, recent studies indicate that Latina mothers have reported high rates of anxiety, stress, and depressive symptoms caused by different stressors such as persecution, physical and sexual abuse, extortion, and separation from their children.30, 31

There is limited information about healthcare utilization for mental health disorders among undocumented immigrants. This is largely due to formidable barriers to healthcare for this population due to restrictions in access to public health insurance, as well as limited to private and employer-based health insurance.32 Uninsured patients have also shown to face poor access to care, quality of care, and health outcomes.33, 34 Gaining a better understanding of the mental health needs and the way in which this group reports symptoms of emotional distress will help providers and health systems to better serve the needs of immigrants, especially in communities such as Baltimore that are facing unprecedented new waves of immigration.

In 2009, Johns Hopkins Medicine established the Access Partnership (TAP) to provide specialty services to uninsured residents of the East Baltimore community surrounding Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center.35 Since the expansion of Medicaid through the Affordable Care Act, and as uninsurance rates have declined in Maryland,36 undocumented Latino immigrants (who are ineligible to enroll in Medicaid) have become the primary utilizers of TAP, providing a unique opportunity to evaluate patterns of healthcare utilization among uninsured/uninsurable Latinos who qualify for the program. To be eligible for the TAP program, patients must be referred to care by a community primary care provider, be uninsured/uninsurable, and demonstrate financial need. The purpose of this study is to explore the nature and frequency of healthcare utilization for mental health and related problems among uninsured/uninsurable Latinos who received outpatient care at the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center through the TAP program in Baltimore City between 2012 and 2015.

Methods

Data for TAP-enrolled male and female patients over age 16 from outpatient visits at the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center were analyzed. An integrated database of demographic and healthcare utilization information for all outpatient encounters among patients who identified as Latino and received care through the TAP program between 2012 and 2015 was used. Descriptive statistics were used to illustrate the demographic characteristics of the patients and their medical diagnoses using the International Classification of Diseases, Ninth Edition (ICD-9)37 and non-personal identifiers that allowed the integration of the data. This study was approved by the Johns Hopkins School of Medicine Institutional Review Board.

All ICD-9 categories and codes were specified for each patient encounter in the dataset. First, the number and proportion of encounters were calculated by gender and by broad ICD-9 categories in order to assess the frequency of different types of health conditions for which care was being sought among the population of interest. To analyze the frequency of encounters for specific mental health diagnoses, the ICD-9 mental disorder category was further subdivided into six broad diagnostic categories based on how the codes were used in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).38 These versions were used on the present report because the ICD-10 and DSM-V were only used widely after the data collection period. The DSM provides a more comprehensive framework to understand the most important groups of mental health disorders. This reclassification was based on the methods used by Hogue and colleagues in 200239 and include the following eight categories: substance-related disorders, adjustment disorders, mood disorders, personality disorders, psychotic disorders, anxiety disorders, somatoform/dissociative disorders, and other mental disorders.

Results

Between 2012 and 2015, a total of 1735 patients received outpatient medical care through the TAP program, generating a total of 17,010 encounters (with a median of 5 visits per patient). Of all patients in the TAP database, 870, or 50%, identified as Hispanic/Latino, accounting for 6464 or 38% of the encounters in the database. Among encounters involving Latino patients, the average age was 44 years old (range 16 to 82), and females received a greater proportion of care (57%) than males.

A total of 65 patients, or 7.47% of all Latino patients in the dataset, received a mental health diagnosis (Table ​(Table1). 1 ). However, healthcare utilization (number of visits/encounters) was highest for mental health disorders compared to other diagnostic categories, accounting for 784 or 14.88% of all encounters among Latinos. Encounters for symptoms, signs, and ill-defined conditions (SSIDC) were the second highest diagnostic category (10.82%), followed by a range of other health conditions, presented in order of frequency in Table ​Table1 1 .

Table 1

ICD-9 Category

Female encounters

Males encounters

All encounters N (%)

Number of unique patients N (%)

Most mental health encounters occurred in a psychology community physician setting (84%), followed by the intensive outpatient community psychiatry program (11%), which is a specialty service with several levels of intensity formed by a team of therapists and psychiatrists. Females accounted for the majority of mental health encounters (67%, Table ​Table2). 2 ). The majority (78%) of mental health encounters was for mood disorders, with 530 encounters for major depression and depressive disorders. Anxiety disorders accounted 16% of mental health encounters, followed by adjustment, psychotic, and alcohol-related conditions.

Table 2

ICD-9 codes

Females

Males

All encounters N (%)

The most frequent reason to seek care among Latino patients was SSIDC (37.47%). Previous research has linked SSIDC with physical non-specified symptomatology that can be rooted in mental health distress.40, 41 A high number of isolated signs and symptoms were found, and the ones associated with mental health causes42-44 were selected and categorized according to their clinical manifestation. Within this subgroup of categories, pain was the leading cause to seek care (88%). The most common form of reported pain was abdominal (55.91%), followed by headache, head and neck symptoms (19%) and chest (10%). Females also made up the majority of patients with SSIDC (61%).

Implications for Behavioral Health

This descriptive study found high levels of healthcare utilization for mental health disorders - particularly depressive and anxiety disorders - among uninsured/uninsurable Latino immigrants in an emerging community. It also presents a unique opportunity to explore the burden and nature of health and mental health disorders among an emerging Latino community for which healthcare information is rarely attainable. Most of the available research on Latino mental health has been conducted in regions where there are larger and well-established communities composed mainly by Mexican immigrants, with stronger social networks, and, in some cases, more available health and social services. Latino immigrants living in new settlement areas, especially those without documents and as immigration policy has toughened, face considerable stressors that might place them at risk for mental health disorders. Previous studies have shown that Latinos are less likely to seek and access mental healthcare than other racial/ethnic groups.14, 45 We found that only 7.47% of Latinos who accessed the TAP program were referred to mental health services, which is consistent with previous findings that suggest that immigrants (Hispanic and non-Hispanic) have lower lifetime risk of developing psychiatric disorders than natives, pointing out how the "Hispanic" or "immigrant" paradox influences mental health outcomes. Still, mental health visits accounted for the largest number of encounters and utilization of healthcare in the TAP program. This might indicate a higher mental health symptom severity among this group. Alternatively, this may also reflect a lack of effective and culturally appropriate services that may lead to continued symptomology and repeated use of services. Mood and anxiety disorders emerged as the most common mental health problems among this population, which is consistent with general global population-level prevalence estimates in which mood and anxiety disorders are often the most common mental health conditions.46

The TAP patient population of uninsured/uninsurable individuals due to documentation and socioeconomic status may be particularly vulnerable to mental health disorders given their unique experiences before and after migrating to the USA. Family separation associated with migration may be particularly stressful for people arriving in emergent immigrant areas with less established social networks and services than more traditional settlement areas. In addition, exposure to violence is common in this population and has shown to cause profound damage in the physical and mental health of the victims,47 commonly expressed as anxious and depressive symptomatology.48, 49 Moreover, populations that face the cumulative effect of poverty, malnutrition, lack of political representation, and other socioeconomic stressors might suffer an exacerbation of their prior mental health distress when they are exposed to other forms of violence such as armed conflict.50 Indeed, previous evidence shows that the new wave of migrants from the NT have significant mental health symptoms as consequence of violence and persecution. A study conducted at the US-Mexico border48 showed that the vast majority (83%) reported violence as a reason to migrate and at least half were exposed to highly traumatic experiences in their home countries. Respondents in this study reported high rates of psychological distress (one third PTSD, one quarter major depressive disorder, and 17% reported symptoms that satisfied criteria for both conditions).

Latinos have also been shown to be more likely than non-Latinos to somatize psychological distress 41, 43 and tend to rely on the general medical sector rather than seeking specialty mental health services.51 This information is important to note given that SSIDC was both the most common diagnostic category to seek care among Latinos receiving TAP services and second most common health service encounter. This ICD-9 category refers to symptoms, signs, and laboratory results where no diagnosis classifiable elsewhere was recorded and could potentially be related to a certain degree with mental distress.

Members of different sociocultural groups have shown to experience stress and emotional suffering in diverse ways.42, 52 In some cases, symptoms fit the description of a specific disorder according to the DSM, but at other times, affective distress can be expressed as an undefined and generalized form of anxiety or depression.43, 53 Medically unexplained symptoms represent an important burden to the healthcare system, and it has been estimated that they account for approximately a quarter to half of all patient visits in primary care settings in the USA.41, 43, 54

In clinical settings, SSIDC such as that found frequently in this study may present as isolated symptoms, but it has been argued that in some cultural contexts, these symptoms might be more sensitive indicators of traumatization than those warranting a psychiatric diagnosis (e.g., PTSD).42 Since the 1980s, the concepts of "idioms of distress," "cultural syndromes," and "culture bound syndromes" have opened research lines focused on understanding the different ways in which diverse sociocultural groups communicate individual and collective suffering via reference to shared beliefs and local ideas about the functioning of the body and mind.42, 52, 53, 55 For example, previous literature has described an idiom of distress common among Latinos, padecer de los nervios, which is usually characterized by chronic anxiety, pain, depression, somatization, and/or dissociation, as well as acute symptoms such as palpitations, shortness of breath, or trembling.44, 56

Further research is needed to understand the different markers or expressions of how members of emerging communities face adversity and vulnerability, which can inform the development of better screening mechanisms and tools to identify mental health problems in a culturally appropriate way, improving the detection of those in need of services.52 As the US population grows more diverse, it is important to develop culturally and linguistically competent services and a diverse healthcare workforce that are familiar with the culturally specific manifestations of mental health distress among different groups, so they can frame the treatment options in an appropriate and non-threatening way.57 Also, as suggested by Kaiser and colleagues,52 incorporating this knowledge into effective public health communication to target specific populations can decrease stigmatization around psychopathology and promote treatment-seeking behavior. More accurate detection can also increase effective care delivery.42, 58

In our study, Latino women were more likely than men to use health services in general and mental healthcare in particular. This is consistent with previous studies that show that men are less likely to seek treatment than women, even when they are experiencing the same levels of distress, a tendency that is even more pronounced among men from racial and ethnic minority backgrounds.59 One reason men may underutilize mental health services is that they have less favorable attitudes toward mental health services, rooted in traditional masculine norms and stigma surrounding mental health problems.60 Additionally, women may have had a higher utilization of healthcare compared to men because pregnancy is an important point of entry to healthcare services, and many women in Baltimore's Latino community are of reproductive age.4

The present findings should be interpreted in light of several limitations. The TAP database had limited information about the demographic characteristics of the patients, such as country of origin, documentation status, and time living in the USA. However, the eligibility criteria for TAP (uninsured/uninsurable) selects for people without documentation status since the expansion of Medicaid through the Affordable Care Act. Nonetheless, the generalizability of this data is limited to those who have access to TAP, which excludes the most vulnerable and disenfranchised migrants who do not have a primary care provider to refer them to TAP. These migrants may not have the social capital to seek care, and the inability to reach these individuals suggests that our findings may underestimate the burden of disease. The database also lacks information on severity of disorder and type of treatment received, as well as data about the nature, intensity, duration, and effects of treatment. Despite these limitations, this paper presents valuable information on the mental health needs of a unique and growing Latino community in the mid-Atlantic. The presented clinical manifestations in the particular case of an emerging community with a high proportion of immigrants from the NT suggest that these new communities have important mental health needs that need to be further studied. Studying factors, such as country of birth, time living in the USA, and acculturation, might be important in learning more about the extent to which the "Hispanic paradox" plays a role in mental health outcomes among emerging Latino communities comprised of non-Mexican immigrants. Given the increasing number of immigrants arriving from the NT in Baltimore and other cities in the USA,61 the medical and public health community must be aware and receptive to the type of unmet mental health needs of this marginalized population.

Finally, it is important to acknowledge that, as emphasized by multiple authors, Latinos are not a monolithic group.11 The history of each Latin American country entails complex historical, cultural, and social dynamics. Therefore, the study of contextual factors among different Latino groups, such as prior immigration experiences, exposure to violence during migration, as well as the development of social support networks and access to services during resettlement, will allow us to design comprehensive public health programs to address mental health needs of communities across the USA.

Acknowledgments

We thank Dr. Barbara Cook, medical director of The Access Partnership program, for her support during the course of this research. Noa Krawczyk received support from the National Institute of Drug Abuse Training Grant T32-DA007293 (PI: Renee Johnson).

Funding Information

The authors received no specific funding for this work.

Compliance with Ethical Standards

Conflict of Interest

The authors have no conflict of interest to declare.

Footnotes

Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

6. Stinchcomb D, Hershberg E. Unaccompanied Migrant Children from Central America: Context, Causes, and Responses.; 2014. doi:10.2139/ssrn.2524001.

9. US Census Bureau. American factfinder. doi:10.5860/CHOICE.43-1925.

12. Cabassa LJ, Lester R, Zayas LH. "It's like being in a labyrinth": Hispanic immigrants" perceptions of depression and attitudes toward treatments. [ Journal of Immigrant and Minority Health. 2007;9(1):1-16. doi:10.1007/s10903-006-9010-1. PMC free article] [ PubMed]

16. Economic Commission for Latin America and the Caribbean. Statistical Yearbook for Latin America and the Caribbean. 2013.

19. Simich LF. Hidden Meanings of Health Security: Migration Experiences and Systemic Barriers to Mental Wellbeing among Non-status Migrants. International Journal of Migration, Health and Social Care. 2006;2(3/4):16-27. doi: 10.1108/17479894200600024. [[ CrossRef] Google Scholar]

21. Markides KS, Coreil J. The health of Hispanics in the southwestern United States: an epidemiologic paradox. Public Health Reports. 1986;101(3):253-265. [[ PMC free article] [ PubMed] Google Scholar]

26. Radford J. Key findings about U.S. immigrants. Pew Research Center. Pew Research Center. doi:10.1146/annurev.matsci.38.060407.132434.

37. World Health Organization. International Classification of Diseases, 10th revision (ICD-10). World Health Organization. 2013.

38. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: American Psychiatric Association. 2000.

48. Keller A, Joscelyne A, Granski M,et al. Pre-Migration Trauma Exposure and Mental Health Functioning among Central American Migrants Arriving at the US Border. [ PLoS One. 2017:1-11. doi:10.1371/journal.pone.0168692. PMC free article] [ PubMed]

49. Molesky J. Pathology of Central American refugees. Migration World Magazine. 1986;14(4):19-23. [[ PubMed] Google Scholar]

55. Simons R, Reidel CH-D, 1985 U. The culture-bound syndromes. Springer.

57. Primm AB, Vasquez MJT, Mays RA, et al. [ The Role of Public Health in Addressing Racial and Ethnic Disparities in Mental Health and Mental Illness. Vol 7.; 2010. http://www.cdc.gov/pcd/. Accessed August 23, 2019. PMC free article] [ PubMed]

Articles from The Journal of Behavioral Health Services & Research are provided here courtesy of Springer

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Mental Health Needs of an Emerging Latino Community

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Over the last decade, Baltimore has become a non-traditional sanctuary city, receiving an unprecedented influx of Latino immigrants, mostly from Central America's Northern Triangle, who are often fleeing violence in their home countries. This ...

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Mental health stigma is the largest community barrier to improving global mental health, and in Latin American cultures, this stigma may be more prevalent.

The World Health Organization (WHO) claim that stigma surrounding mental ill-health is the biggest obstacle in the way of people seeking treatment. Stigma refers to a set of negative, and often unfair or inaccurate, beliefs that society associates with certain circumstances, qualities, or people.

This article will explore what mental health stigma is, why it is a problem in Latin American countries and communities, and how to combat it.

Mental health stigma refers to negative attitudes or beliefs that lead to the "devaluing, disgracing, and disfavoring by the general public of individuals with mental illnesses."

There are three commonly recognized types of mental health stigma:

Social or public stigma: This refers to the negative discriminatory beliefs or attitudes about mental health conditions promoted in one's cultural group or broader society.

Self-stigma: This occurs when a person internalizes negative societal attitudes about mental health conditions.

Institutional stigma: This refers to governmental or private institutional policies that unintentionally or intentionally discriminate against people with mental health conditions.

Mental health stigma remains a major negative influencing factor in how people both treat and perceive mental health conditions. Some research indicates that in many countries, around 80-90% of people with a mental health condition experience the negative impact of stigma.

Social, cultural, regional, religious, and family beliefs, as well as media portrayals, can influence stigma surrounding mental health conditions. These beliefs are usually due to a combination of ignorance and misinformation, negative attitudes or prejudice, and discrimination.
Learn more about mental health stigma in general here.
Mental health stigma exists everywhere in the world, but it may be particularly strong in Latin American cultures and communities.

One 2016 review analyzing research on mental health stigma found that Latin American cultures tend to hold some similar prejudices toward people with mental health conditions as Western European cultures.

Commonly identified stigmas include ideas that people with mental health conditions are:

violent, aggressive, or likely to act bizarrely

incapable of getting better

dangerous and should be isolated or kept away from the public

cannot perform the same activities or duties as others

As detailed below, some specific elements of Latin American culture or society may influence how mental health stigma is set, perceived, and impacted.

Familismo

Several studies suggest that the cultural value of Familismo, or the collective value of family unity, can play a role in shaping and enforcing mental health stigma.

Some researchers claim that this value is associated with increased rates of emotional closeness and openness within the family, which may reduce the impact of mental health stigma.

On the other hand, some research cites family as a major source of discrimination against people with mental health conditions in several Latin American countries. Examples of negative family factors include hostile attitudes from family and extended family, as well as family members underestimating someone's abilities.

Another study found that most Latin and Hispanic families would deny the presence of depression or another mental health condition in a family member unless they were unable to cope or the symptoms of the condition were life threatening. In the same study, many of the survey participants believed that children's mental health conditions are due to the sinful behaviors of their parents.

Furthermore, a 2013 study found that the value of Familismo can lead people to hide their condition in order to protect their family. Family members may also discourage people from seeking treatment or taking medications due to a lack of education or spiritual or cultural beliefs.

Taboos

Discussing mental health conditions is also often taboo in Latin American cultures and communities. This means that parents, children, and teachers often do not talk about this topic enough.

Some people may also see it as inappropriate to discuss family affairs outside of the home.

Religion

Faith also seems to play a large role in shaping the stigma that Latin American people may hold about mental health conditions. This makes sense, given that these communities tend to rely on religious institutions as an important spiritual, educational, and social resource.

According to one 2019 study exploring beliefs about mental health conditions in faith-based Latin communities in the United States, religious beliefs may contribute to stigmas by enforcing the misconceptions that:

Mental ill-health is a moral failing or spiritual dilemma.

Mental ill-health is a spiritual, rather than a medical, condition.

Mental ill-health is a punishment or form of divine justice.

Depression is due to a lack of faith, not praying enough, sinful behaviors toward parents or others, or demonic influence.

Praying and having faith in God can help reduce the risk of or treat mental health conditions.

Self-harming acts, such as cutting or suicide, are due to a lack of true faith.

However, the study also points out that, "[w]ith the exception of beliefs about suicide, stigmatizing attitudes were predominantly derived from socialization in participants' countries of origins rather than religious doctrine per se."

Other

Latin American communities living abroad may also have reduced access to proper mental healthcare due to the following factors:

language barriers

a lack of healthcare providers aware of Latin American cultural differences, beliefs, language nuances, or practices

a lack of proper insurance

poverty

a lack of specialized healthcare resources in the community

a reduced ability to identify the symptoms of mental ill-health due to a lack of information or understanding

legal status or status of loved ones

how much someone adjusts and accepts the predominant culture of where they are living

Regardless of the cause, mental health stigma can have negative social, economic, and public implications for people living with mental health conditions. In some cases, this can also reduce or restrict someone's confidence or ability to access and engage with certain resources, services, or legal rights.

Mental health stigma can also discourage someone from seeking treatment for mental health conditions. However, most of these conditions do improve with treatment - especially early treatment.

According to one 2019 study, Hispanic and Latin populations access mental healthcare 50% less than non-Hispanic white people in the U.S. Also, according to the WHO, around 5% of Latin American adults have depression, though few receive treatment for it.

Some research has also found a very low perceived need for mental healthcare regardless of ill-health severity in Latin or Hispanic communities living in the U.S. However, this perception is not accurate, given that the WHO reports that mental and neurological conditions make up almost one-quarter of the disease burden in Latin America and the Caribbean.

Negative stigma can also make it more difficult for someone with mental ill-health to recover. Additionally, it can also negatively impact those who care for people with mental health conditions, such as their family, friends, or loved ones.

Research suggests that one of the best ways to reduce stigma is to know someone with a mental health condition.

Contact-based interventions, wherein someone engages with a person who has lived experience with mental ill-health, also tend to be much more effective than educational programs or materials. These interventions involve activities such as face-to-face discussions and presentations or reading, listening to, or watching blogs, podcasts, or videos.

Faith-based mental health educational resources may also help reduce stigma in Latin American communities.

To reduce the stigma surrounding mental ill-health, the National Alliance on Mental Illness also recommend:

talking openly about mental health

educating oneself and others about mental health

promoting the idea that physical and mental ill-health are the same

being aware of language that may be stigmatizing, such as the terms "crazy," "insane," or "psychotic"

letting media outlets know when they are promoting negative stigma

showing compassion to people with mental health conditions

Stigma surrounding mental health exists globally. However, according to limited available research, this stigma may be especially strong in Latin American countries and communities.

People affected by mental health stigma, either directly or indirectly, may consider addressing this with their loved ones and seeking help from culturally competent mental healthcare professionals.

Click here and scroll to the bottom of the page to see a list of campaigns and organizations committed to reducing mental health stigma.

Read this article in Spanish.

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Mental health stigma in Latin America: Culture, resources, and more

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Stigma is the largest community barrier to improving global mental health. In Latin American cultures, this stigma may be more prevalent. Learn more here.

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The interview went so well that I did part two. This is a bonus for general knowledge. Enjoy.

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Living through natural disasters is just one of the reasons that Puerto Ricans have a higher risk of experiencing depression.

Depression affects roughly 280 million people worldwide, according to the World Health Organization (WHO). In 2020 alone, of adults - or approximately 21 million people - in the United States reported experiencing symptoms of depression.

Although depression can affect anyone from any background, some communities are more likely to experience mental health conditions like depression. Puerto Ricans, both in Puerto Rico and the United States, have higher rates of depression than the general U.S. population.

We'll explore what the research says about depression in Puerto Ricans, including where to get assistance as a Puerto Rican and how to support ongoing recovery efforts.

Research exploring depression in Puerto Ricans is somewhat limited, especially for people actually living in Puerto Rico. But there have been a few studies published on the subject over the last few years.

One large study from 2019 on the depression rate in Puerto Rico compared the rates of psychiatric disorders between Puerto Ricans and the general U.S. population.

Results of the study - which included 3,062 Puerto Ricans living on the island - found that people living in Puerto Rico had roughly 27% higher rates of major depressive disorder (MDD) than the U.S. population (9.7% versus 7.6%).

Plus, the 419 Puerto Ricans living in the United States that were included in the study also had higher rates of MDD than the U.S. population - roughly 9.6%.

Another study from the same year explored the mental health impact of Hurricane Maria on over 96,000 Puerto Rican youths living in Puerto Rico.

According to the study results, roughly 2.5% of Puerto Rican youths experienced symptoms of depression after Hurricane Maria. Girls appeared to be more affected by these symptoms than boys, with around 2.7% of girls reporting symptoms versus only 2.3% of boys.

Depression in Puerto Ricans living in the United States

Some research also suggests that Puerto Ricans living in the United States have higher rates of depression.

In a , researchers compared depression rates among different racial and ethnic groups who participated in Medicare Advantage plans.

Study results showed that Puerto Ricans ages 65 and older were 1.46 times more likely to screen positive for depression than non-Hispanic white adults within the same age range.

Research from 2020 explored the potential impact of depression on pregnancy outcomes in over 1,260 Puerto Rican women in Western Massachusetts. According to the researchers, at any point in their pregnancy, roughly 35% of Puerto Rican women in the study had probable minor depression and 25% had probable major depression.

Depression is a complex illness that's affected by a wide variety of factors - from genetics to environment - and so much more.

Puerto Ricans may experience several stressors that can increase their risk of developing depression.

For example, one explored some of the potential cultural stressors associated with depression in Latino and Latina adolescents.

According to the study, some of these stressors included things like discrimination, family conflicts, acculturative and bicultural stress, and immigration stress - the last of which is a significant source of trauma in Latino youth.

Other research found a similar relationship between perceived discrimination and depression in older Puerto Rican adults.

Other factors that can all have a significant effect on the mental health of Puerto Rican people include:

Millions of Puerto Ricans on the island lost their homes, jobs, and livelihoods during Hurricane Maria in 2017.

In fact, according to statistics from the United States Census Bureau, the poverty rate of Puerto Rico in 2018 was roughly 43% - more than double that of Mississippi, which had the highest U.S. poverty rate in 2018 at 19.7%.

Between billions of dollars in damages to the infrastructure of the island and the devastating loss of life, Puerto Rico still needs support during their recovery.

If you're interested in helping support recovery initiatives in Puerto Rico, here are a few organizations to consider checking out:

PRxPR, which sends 100% of the donations they receive to the most critically affected communities in Puerto Rico

Together Puerto Rico, which distributes equipment for disaster relief and helps connect Puerto Ricans to resources

Foundation for Puerto Rico, which works closely with community partners to support economic development

Hispanic Federation, which empowers Hispanic communities and families through different initiatives

Whether you're a Puerto Rican living on the island or the mainland, there are programs available to help with everything from housing and food to mental health services and more.

Here are a few organizations you can reach out to if you want to learn more:

CMS.gov: health insurance resources for Puerto Ricans

Childcare.gov: financial assistance resources for Puerto Rican families

SAMHSA.gov: mental health resources for Puerto Ricans on Medicaid or CHIP

FindTreatment.gov: mental health resources for those living on the mainland

CHFPR.org: mental health services and resources in Puerto Rico

findahelpline.com: national helplines in Puerto Rico

Some resources listed above are only available to Puerto Ricans living on the island, while others are only available to those living in the United States. If you're not sure which resources are available to you, consider reaching out to your local social services office for more information.

Puerto Ricans living in Puerto Rico and the United States appear to have higher rates of depression than the general population, according to research.

One of the reasons for this is that many Puerto Ricans experience increased mental health stressors - including racism and discrimination, migration and immigration stress, and other cultural, social, and economic factors.

If you or someone you love has been experiencing the symptoms of depression, consider reaching out to one of the organizations listed above for more resources and support.

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Understanding Depression Rates in Puerto Ricans

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Many studies show that Puerto Ricans are at higher risk of depression. Learn why and how to both give and get support.

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Puerto Rico’s Students and Educators Grapple With Trauma

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When it comes to depression, individual and collective backstories matter. Those of many Puerto Ricans may include the impact of colonialism and acculturation.

For more than 3 decades, reports have indicated high rates of depression for Puerto Ricans. This is particularly so for people living on the mainland.

Research from 1990 and 2014 backs this statement, although there aren't many other studies on the subject. In fact, the lack of more recent and comprehensive research in this area could be proof of the marginalization often experienced by this community.

What is the root of these mental health experiences for Puerto Ricans and how can change happen?

Cristalís Capielo-Rosario PhD, researcher and assistant professor in the department of counseling and psychology at Arizona State University, has observed the following factors as contributors to symptoms of depression in Puerto Ricans:

poverty

segregation

racism

ethnic discrimination

forced migration

migration-related stressors (language barriers, difficulty finding employment commensurate to one's training and experience)

challenging working conditions

trauma associated with natural disasters

Capielo-Rosario says other factors also often impact the mental health of people in the community:

colonial mentality: Colonial mentality refers to internalized oppression; it's the belief that your ethnic or cultural group is inferior to others or to the culture that colonized your territory.

circular migration: Circular migration refers to having to move back and forth from Puerto Rico to the United States, a process that can impact mental health, job opportunities, and family relationships, among others.

The impact of acculturation

Research from 2005 with Puerto Ricans living on the mainland highlights a strong relationship between acculturation and depression.

Acculturation refers to the cultural, social, and psychological changes you go through when moving from one culture to another. It may require understanding, adapting, and negotiating new social rules and customs, from what you eat to what you wear to the language you speak and how you interact with others.

Acculturative stress means you find the acculturation process particularly challenging and this may impact your mental health.

In the 2005 study, researchers found that low acculturation led to lower mood, and specifically in men, higher acculturation meant more symptoms of depression.

"Acculturative stress can be experienced as discrimination and racism [...] being stereotyped, and having to disconnect from family and friends in Puerto Rico," says Capielo-Rosario.

Further research is needed to contextualize the unique experiences of Puerto Ricans living both on the island and on the mainland that may lead to acculturative stress.

1. Culturally competent care

The inclusion of cultural elements may be essential for mental health care interventions.

In fact, from 2013 indicates that, for ethnic minority clients, treatment outcomes and satisfaction may be directly linked to cultural aspects.

For example, having a professional who belongs to your ethnic group, discusses race and ethnicity, or understands prejudice and discrimination, may lead you to feel more satisfied with the service.

Understanding the particular circumstances of the people of Puerto Rico is essential.

Ivette Gomez, a licensed mental health counselor based in Naples, Florida, explains that, when Puerto Rico transitioned from the Spanish empire to the United States, there was likely a "split in the Puerto Rican psyche."

Gomez attributes mental health disparities to that split.

The split refers to suddenly facing opposing and overwhelming thoughts, realities, or beliefs. Are you Puerto Rican, Spanish, or "American"?

Gomez says therapists working with Puerto Ricans on the mainland may benefit from discussing aspects such as the loss of identity. She also recommends that the mental health community consider the following:

training more psychotherapists and counselors in multiculturalism

training counselors to better understand Puerto Rico's unique culture and experience

expanding access to mental health centers that have Spanish-speaking therapists

making an effort to offer psychoeducation about the benefits of psychotherapy to Puerto Ricans

Gomez also says narrative therapy and art therapy hold particular promise for Puerto Ricans who face mental health challenges.

"[Narrative therapy] would allow the person to tell their stories and also re-script the stories of their families and experiences," Gomez says. "[Art therapy] would really tap into the cultural values, expressiveness of our culture, especially music and visual arts. Art therapy then is a bridge to the inner world of the Puerto Rican client."

Gomez suggests the following approaches to help treat depression in Puerto Ricans:

2. Reparations

"Psychological interventions that aim to eradicate depression disparities must include advocacy actions that also seek to eliminate systemic racism and support economic reparations," says Capielo-Rosario.

She advocates for the following:

return of land property, and restoration of occupied land

decolonization and sovereignty reconciliation to improve solidarity

psychological liberation

"​​Helping clients explore and challenge colonial logics that lead to inequality, intergroup conflicts, and psychological distress can, in turn, allow clients to experiment with new ways and patterns of thinking, feeling, and behaving," she explains.

"Mental health professionals can partner with Puerto Rican community organizations that are actively engaging in resistance against laws and institutions that foment settler colonialism in Puerto Rico," adds Capielo-Rosario.

Acknowledgment can also be an important aspect of healing.

Once interventions are in place, Gomez stresses the importance of constantly looking out for signs of growth and healing.

Puerto Ricans living on the mainland face higher rates of depression compared to other Latin American communities and to Puerto Ricans living on the island.

Acculturation and colonialism may be, in part, important contributing factors to these numbers.

Improving culturally relevant care and reparation processes can help.

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Depression in Puerto Ricans: Are Acculturation and History the Cause?

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Puerto Ricans have one of the highest rates of depression in the United States. Colonialism, racism, and unique challenges in acculturation may be involved.

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DEMI LOVATO

Lovato, who founded the Be Vocal: Speak Up For Mental Health initiative to erradicate stigmas, told HuffPost: "Exercising is [one] way I deal with anxiety. Painting and writing music and expressing myself through art are other ways that I can release emotions. Meditation is another one. Whatever it is, it's important to find what works for you."

MARÍA GABRIELA DE FARÍA

The Deadly Class star added to PEOPLE Chica that her fiancé helped her get over the panic attacks. "We talked it through and he really helped me out," she recalled. "I kept hiding it from my friends and co-workers. At parties I would have a panic attack, and I would lie and say I was tired and had to go home. It's taboo to talk about it."

GINA RODRIGUEZ

The actress and director of Puerto Rican descent revealed to Cosmopolitan that she had her first panic attack a couple years after landing the leading role in Jane the Virgin. "The anxiety started coming, like, two years into Jane," Rodriguez said, adding she had her first panic attack at a sushi restaurant. "All of a sudden, I thought I was going to die, and people are taking pictures. It was horrendous."

GINA RODRIGUEZ

"I let go of the anxiety and the fear of not looking beautiful. Because it's not about the picture. It's about the fact that I stand on this cover with every Latina who wished she saw herself reflected. Because it's not my face - it's the 55-million-plus girls who are like, 'Holy s***! We belong,'" the Jane the Virgin star added.

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These Latinx stars have opened up about their mental health struggles.