In closing this chapter it is useful to review some of the issues that make comparisons among ethnic groups difficult at best and otherwise quite misleading. The first of these is the specification of the ethnic group or population being studied. For the most part "ethnic" groups are inadequately identified by broad categories. Subgroups within broad categories are likely to differ in cultural as well as social and economic circumstances. One of these elements is their historical experience with mental health services, which may serve to offer definitions and models for understanding psychological processes.
There are numerous sampling issues. The greatest of these is whether the locations of samples from the different groups are comparable. A national sample may include Blacks from the rural south and northern cities, Mexican Americans from the Southwest, and Asians from the far West. One must ask whether these populations are from comparable circumstances. Do they have comparable demographics such as age, sex, and socioeconomic status? Are there local neighborhood stress or contagion effects? One would expect different results for Native Americans living on reservations from those who have moved to the cities. Ultimately, sampling deals with the generalizability of results.
Interview methods are also likely to make a difference in observed rates of disorder, and may effect ethnic differentials because the methods may be experienced differentially by the groups being compared. Major choices are between face-to-face and telephone interview methods. Face-to-face interviews are preferred because they provide more direct interaction with respondents, visual observation of responses, and direct observation social contexts. Telephone interviews usually cost less and may facilitate the use of native language interviewers, but telephones introduce issues of who can be reached by telephone, and who is willing to disclose personal information through that mode of communication.
Telephone interviews hide many characteristics of the interviewer and may introduce a sense of social distance or cultural neutrality that may help or hurt disclosure. Any perceived risk of loss of confidentiality is important. Complicated sentences and lists are difficult to communicate over the telephone thus changing some of the modes of interaction. The biggest ongoing controversy over telephone interviewing is who can be reached by telephone and whether sampling methods such as random digit dialing can find a representative population sample. Often the poorest minorities lack residential telephones, and the most mobile may have pager and/or cell phones instead. One should note, however, that telephone usage is not limited by language spoken, so telephone access to immigrant groups may actually be easier than access through a more intrusive and potentially threatening attempt to contact in person.
The content of a mental health interview is also likely to influence results. Familiarity with current mental health concepts and linguistic identifiers varies among ethnic groups and by cohort within those groups. The recall and communication of mental health symptoms is strongly influenced by prior familiarity with the language and concepts of mental health, so that just as there is a generational effect in symptom reporting in the mainstream, it is likely that the reporting of symptoms and diagnostic criteria may be less developed in new immigrants from regions with less psychologically oriented discourse. These cultural norms may also make some concepts more stigmatizing and less socially acceptable to report. The availability of mental health concepts to individuals and groups is influenced by the availability and utilization of mental health services in the past, so that groups with historically high mental health service availability are also more likely to report certain kinds of symptoms.
Finally, we return to the issue of nature versus nurture and ultimately whether any of the ethnic differences reported in mental health surveys reflect constitutional or other intrinsic factors of ethnic group membership versus being direct consequences of the experiences of a group and its membership. Although there are some well-documented genetic influences on mental illness, their relationship to group ethnicity is largely unknown. From an epidemiologic perspective, one would want to know whether or not ethnicity is an independent risk factor. More likely, it is a surrogate for historical and recent experience of many other risk factors that change the true prevalence of disorders in a population. That is the reason that analyses of ethnic differences usually attempt to discover whether statistical controls for risk factors such as age, sex, socioeconomic status, trauma, recent life events, immigration and acculturation reduce or modify the differences among groups. Finding reduced differences removes the stigma of mental illness from a particular ethnic group and redirects the concern toward inequities in our nation and the world. From a services perspective, however, the observation of ethnic differences should lead the mental health services system to direct resources to where the need is greatest.
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