main depre

SOC. Sci. Med. Vol. 22, No. 6. pp. 645-652. 1986 0177.9536 86 53.00 + 0.00 Pnnted in Great Britain. All rights reserwd Copyright 1 1956 Pe&mon Press Ltd

DEPRESSIVE SYMPTOMS AND THEIR CORRELATES AMONG IMMIGRANT MEXICAN WOMEN IN THE

UNITED STATES

WILLIAM A. VEGA, BOHDAN KOLODY, RAWON VALLE and RICHARD HOUGH San Diego State University, San Diego, CA 92182, U.S.A.

Abstract-Correlates of depressive symptomatology and caseness are examined for a survey sample of N = 1825 poor Mexican immigrant women in San Diego County, California. The Center for Epi- demiologic Studies-Depression (CES-D) checklist is tested against a variety of demographic variables as well as health status and service utilization rates. Statistically significant associations were found between CES-D and education, years in the United States, income, marital status and number of adults in household. Also significant were associations with health status, confidant support and recent, traumatic life event. Utilization rates point to medical doctors as the major source of formal treatment and a heavy reliance on family and friends. The implications of the high disorder rates for diagnosis and treatment among immigrants are discussed.

The phenomenon of world wide immigration in the twentieth century has been a focal point of research and a concern of health planners for some time, and broad speculation has taken place regarding the relationship of migration to mental disorder. Conclu- sive evidence on this issue has not been forthcoming, and studies have appeared that both support and refute [l-3] the assertion that migrants and imrqi- grants are more likely to suffer from mental disorders and related symptomatology. However, to date, most of the research concerning levels of psychiatric disorders among immigrants has been based on treatment data which inherently limits its generalizability. The data reported herein describes the prevalence of depressive symptoms in a cohort of Mexican immigrant women residing in a metropolitan community in the United States, examines the relationship between these symptoms and a number of factors that have been identified in the epidemiological literature as salient predictors of psychopathology [4], and looks at help-seeking patterns of depressive women.

Mexican immigration to the United States consti- tutes one of the largest sustained migratory move- ments in the world. The economic disparity that distinguishes the United States and Mexico is reflected in the incessant flow of undocumented aliens as well as legal migrants and temporary visitors. By 1980, there were 4S43.770 Hispanic heritage people in California (U.S. Census), not counting illegal aliens, and this population is characterized by high fertility rates, low median age and far lower levels of educational and economic attainment. In other words, the structure of the Hispanic population resembles that of a developing country, in contrast to the socioeconomic characteristics of the general population in California. Nowhere else in the world can such a differential in standards of living be found distinguishing two nations sharing a common border. Furthermore, no single area better exemplifies the

The research described in this paper is supported in part by the Center for Prevention Research, National Institute of Mental Health-M.H. No. 38745-OIAI.

abruptness of the transition from underdevelopment to affluence than the San Diego-Tijuana urban cor- ridor which transcends the international boundary. The traffic through this region is impressive and illustrates both the degree of geographic mobility and the permeability of the international border. Accord- ing to the Mexican Tourist Authority in Tijuana, Mexico, approximately 38 million people legally crossed the San Diego-Tijuana border (in either direction) at San Ysidro, and that an additional 405,000 were apprehended at the same border cross- ing attempting to enter without documentation, during the 1984 calender year. Although these figures include tourism and commuters working in San Diego but residing in Mexico (including multiple crossings), it also includes numerous short stay and long stay immigrants. This drama of human migration serves as a backdrop for the study reported below, since the cross-sectional data was collected in communities contiguous to the international border.

This paper reports data from a cross sectional survey conducted in San Diego County, Calif., which included 1825 immigrant women of Mexican descent. The survey was part of the enumeration phase of a multi-year prospective preventive intervention study [5] targeting depressive symptoms among Mexican American women. The goal of the enumeration phase was to identify a large number of low income Mex- ican American women who were neither seriously depressed nor demoralized, and to develop a sample suitable for a community based randomized trial. In the course of the enumeration, several types of information were gathered, including: (a) the prevalence of depressive symptoms, (b) demographic factors, (c) health status-including symptom chronicity, (d) services utilization, (e) family structure, (f) life events and (g) social support.

Three California studies [6-81 have reported prevalence data about depressive symptoms among Mex- ican Americans, and their findings are in accord: Mexican Americans have higher uncontrolled rates when compared with non-Hispanic whites. TWO of these used the same checklist reported on in this

645

646 WILLIAM A. VEGA el a/

paper: the Center for Epidemiologic Studies- Depression (see discussion of the depression checklist in Methods section). For example, Vernon and Roberts [6] found a caseness of 28.5% for Mexican Americans, 18. I % for Blacks and 14.6% for Angles; and Frerichs er al. [7] reported 27.4% for Hispanics, 21.4% for Blacks and 21.8% for Angles, in two California studies which did not publish discrete rates for immigrants. Vega er al. [S] did find significantly higher prevalence of depressive symptoms for a small sample of immigrants, when compared to native born Mexican Americans or non-hispanic whites in Santa Clara County, Calif.; however since a different depression checklist was used to determine rates, the results are not comparable to the present research, or the studies cited above.

These epidemiological studies contradict the earlier body of research literature [9, 101 which suggested that Mexican Americans had lower levels of psychopathology due to the cohesive and nurturing qualities of their social support systems. Indeed, the persistent underutilization of mental health servcies by this ethnic group was seen as verification of this supposed resistance to psychopathology. In part this discrep- ancy in findings may well be due to the use of disparate theoretical and methodological designs, including the use of anthropological observation and treatment data in the earlier studies.

The data below represents the most significant sample of immigrants yet reported in a cross- sectional study of depression in the United States. This paper will contribute new information to the data base concerning the prevalence of depressive symptoms among Hispanic immigrants, and perhaps shed some light on associated issues of risk factors and help-seeking patterns among depressed women, and immigrants more generally.

METHODS

The survey was conducted in San Diego County, Calif., which was estimated to have a population in 1985 of 2,041,300. Approximately 14.8% of the population is Hispanic, or about 302,112 persons. Of course. these estimates are based on United States and California State Census projections which do not include undocumented aliens. The exact number of such people are not known, but estimates [I I] range from 25 to 48 thousand undocumented Mexican immigrants living in San Diego County.

Since the target group for the parent study are low income women of Mexican descent between 35 and 50 years of age, the sampling plan called for a virtually total enumeration of women in all block groups with a proportion of Mexican Americans ranging from 25 to 76% (the upper limit). These residential zones were uniformly low income and characterized by housing ranging from modest to very crude. the latter exemplified by such things as large families living in small one-room trailers. The interviewers were Mexican American women who

*Copies are available from the senior author

were fully bilingual. and trained and supervised by the research team. Since the survey was used as a combination enumeration and screen. the interviews were quite short. lasting an average of only fifteen minutes. Efforts were made to contact households with no responses either in person or by telephone using a reverse telephone directory. High density areas were covered twice to provide better assurance that all eligible respondents were being identified. Interviewing was done face-to-face after ascertaining the eligibility of the respondent with regards to ethnicity and age. If a respondent could not take the interview at the time of initial contact. arrangements were made for another appointment. Respondents were informed that the interview was part of a university based health promotion study concerned with their health and psychological well being. Ap- proximately 40,000 residences were screened in order to gather a sample of 2600 respondents. with a refusal rate under 10%. This paper is limited to reporting data on the subsample of immigrant women (X = 1825).

The interview instrument included the Center for Epidemiological Studies-Depression measure (CES-D) [12], a non-diagnostic screening measure, which has been tested for validity and reliability and found to be acceptable for use in community studies [13], as well as cross-ethnically for use with Mexican heritage Hispanics [14]. In addition, the CES-D has been used in numerous studies throughout the United States so that a large comparative data base is available. The CES-D is a 20 item inventory* which includes a range of symptoms covering mood, feelings and perceptions-including vegetative motor indicators associated with depression [ 15Z_as well as their relative duration during the past week. The scoring range is O-60, with higher scores indicating greater symptomatology. The accepted caseness threshold, which emerged from studies with psychiatric patient populations, is a score of 16 or over. This threshold represents the upper 20% of mean scores in previous community studies.

Although the CES-D is not a diagnostic instrument, it was found to have a concordance of approximately 85% for current major depression using a diagnostic protocol, the Diagnostic Interview Sched- ule (DIS) [16]. In other words, of those identified as cases on the DIS, 85% reached or surpassed the threshold of 16 on the CES-D. On the other hand, of those scoring 16 or over on CES-D, 60% were found to reach caseness criteria on the DIS [ 161 which indicates that the CES-D has acceptable predictive validity as a community screen for depression, though it does not purport to be measuring a clin- ically verifiable syndrome(s) as does the DIS. More- over, the type of symptoms found in the CES-D have been found to be good predictors of mental health services utilization, even better than diagnostic measures such as the DIS [ 171. It is well suited for use in poorly educated populations because of very short administration time and simple wording of questions. Furthermore, this depression checklist, perhaps more than any other, minimizes the confounding effects of somatic compiaints since the tendency to present physical health problems rather than psychological ones is well established for Hispanic populations.

Depressive symptoms among immigrant Mexican women

Table I. CES-D mean scores and caseness rates for demoerauhc variables

641

Total

In N category Mean SD F % CES-DB 16 x! C CES-D 5 4 %=

I825 100.0 A8e

35-39 603 40-u 558

15.71 Il.46 41.5 22.6

45-50 664 Education

0-j kr 805 68 kr 5x5 9-11 >r 228 I?+ 184

Years in U.S. &5 ?r 251 &IO )r 395 I I-15 )r 401 I&?0 yr 379 II T 386

Employment status Full time 270 Pars lime 209 Unemployed 81 Housewife 1229

Income (monthly) < 5600 428

60&999 678 1000-1399 409 1400-1999 I67 2000 + 48

Manta1 swtus Marncd 1318 Never mar. 95 Widoued 65 Separated I79 Divorced IS3

33.0 30.6 36.4

15.56 II.16 15.43 11.09 16.09 12.03

44.7 17.13 II.56 32.5 15.25 II.25 12.1 I-l.14 Il.73 IO.? 12.57 IO.21

13.9 17.79 12.17 21.8 15.74 II.27 22. I 14.33 10.66 20.9 16.20 I I.50 21.3 15.03 I I .67

15.1 15.61 I I.51 I I.7 14.62 IO.51 4.5 17.23 Il.75

68.7 15.84 I I.67

24.1 17.84 11.76 39.2 16.27 II.36 23.6 13.70 II.01 9.7 13.38 Il.43 2.8 il.88 9.57

72.8 5.2 3.6 9.9 8.5

14.96 I I.18 14.71 9.29 17.52 II.46 18.82 13.15 18.61 12.04

O.j80t 10.6 0.45 ~1.6 1.96 0.671: II 1 21.1 0.4599 42.5 24.8

10.68**? 25.69***: O.Zl$

48.0 39.3 31.1 32.1

32.32 26.7 17.;0*** 20.9 IS.1 11.7

1.07**t 6.26.: 3.94J

1.17t

10.53***t 17.06: 0.86:

7.54***+

47.4 10.33 29. I 9.72 42.3 21.8 36.9 19.2 44.1 23.7 37.8 21.0

41.1 4.06 ?1.9 3.01 36.1 IS.? 48.1 22.2 42.3 23.5

50.5 43.7 33.5 29.9 27. I

38.6 41.1 47.7 50.8 54.2

39.8.; 29.4 31.95*** 23.6 15.9 18.0 6.3

22.19*** 20.9 7: &$*.* _. 12.6 27.7 33.0 29.4

*P c 0.05; l *P < 0.01: +**p < 0.001. tBetvecn groups. :Linear F. SAdditional non-linear f.

FIXDINGS

Table 1 reports the demographic characteristics of the cohort. They have very low levels of educational attainment, over half are in the lowest quartile of family income for the County, and most are house- wives. In addition, most are married (72.8%) and average about three children still living in the household. Overall, the respondents are long stay immigrants since only 13.9% have been in the United States for five years or less. The cohort is quite homogenous, as could be expected given the selection criteria.

The distributions of depressive symptoms by demographic variables are presented in Table I. Sub- group N. mean and standard deviation are given as well as subgroup proportions falling at or above two selected CESD cutpoints; 16 which is the customary caseness cutpoint, or. 24 which represents the upper quintile of scores and is used to represent very high risk for caseness. For each variable a one-way ANOVA was performed to test differences among means. A test for linearity followed by one for non-linearity was added for ordered or continuous variables. F ratios for these tests are reported as are x test outcomes for differences among subgroup proportions falling above the selected cutpoints.

The most impressive finding is the very high prevalence of symptoms as illustrated in the 15.71 grand mean reported for the cohort. Using the probable case standard of 16 on the CES-D, 41.53% of the

cohort reaches or exceeds this threshold, and approximately 22.63% of the total sample reaches 24 on the CES-D. These caseness rates are twice the average reported in previous community studies. Further- more, they also surpass the caseness rates of 28.5%, reported by Vernon and Roberts in Alameda County, and 27.4%, reported by Frerichs er al. in Los Angeles County, for community samples of adult Mexican Americans who were interviewed using the CES-D.

DE.MOGRAPHIC VARIABLES

A statistically significant (P cc 0.001) negative linear association was found between educational attainment and depression scores, and a similar result obtained for income level. In fact, of those with less than 5 years of education 48.1 reach caseness criteria and, for those with a monthly income of less than 5600.00 a month 50.5% reach criteria. On the other hand, those respondents with income in excess of SZOOO per month had much lower mean scores. with only 6.3% reaching or surpassing the 24 cutpoint. Although extraordinarily pronounced in this cohort, this patterning has been reported in numerous epidemiological studies of depressive symptoms for both income and education in the United States [18-221.

Marital status also has the expected relationship, with those in disrupted marital statuses having significantly higher symptom levels than the married

6-e WILLl4Sl x

or the never married. Those respondents who were currently. separated were highest however there is little vacation in mean scores for those in disrupted marital statuses. and those reaching criteria range from 47.7 to 54.2%. This relationship between marital status and depressive symptoms has also been widely reported [23-X].

Years in the United States was significant (P < 0.01) with respondents reporting five or fewer years of residence having the highest mean scores. caseness rates and percentages reaching 24 or over. However. beyond this marked association there is no consistent relationship between depressive symptoms and time in country. These data suggest a higher lev$el of stress is being experienced by the more recent arrivals reflected in significantly higher percentages at both symptom cutpotnts.

Neither age nor employment status demonstrated any remarkable predictive value ris-Li-ris depressive symptoms. although subtle trends are present in both cases. For example, older respondents are more likely to be symptomatic and meet criteria. Similarly. the unemployed also had higher symptom mean scores and caseness rates but the small number of respondents in the cell precludes finding statistical significance.

VEGA e: al.

If we use the cutpoint of 2-I or higher as our standard for very high risk of being a case, rather than the 16 cutpoint which represents a probable case, we find the following demographic variables to be highly associated with depressive symptoms in this immigrant population. Note that the variables are arranged according to their respective values from high to love. The most important are: (I) separation; (2) family income under 5600 per month; (3) divorced; (4) 5 years or fewer in the U.S.; (5) widowed and (6) 5 years or less of educational attainment. Note that three of the six variables are disrupted marital statuses, and that items (2) and (3) have identical rates meeting criteria.

PSYCHOSOCI.AL CORRELATES

Table 2 presents data covering five factors that are frequently associated with v-ariations in psychopathology. These five factors are household composition, health status and services utilization, life events and confidant social support.

Social indicators used as proxy measures of need for mental health services, such as the Mental Health Demographic Profile System [27], often include family composition; especially items identifying single

Table 2. CES-D mean scores and caseness rates for psychosocial correlales

Sb In ,Y category Mean SD F % CES-D > 6 %: 0 CES-D > 24 1:

Total Children ,n home

None

j+ Adults in home

Health in last I2 months

Excellent Good Fair Poor bad

Illness or disability

NO

Yes M.D. visits last I2 months

None

2-3 tj 6-9 lot

Life event last I? months

No Yes

Confidant ruppor1

NO

Yes

1825 100.0

204 I I.2 302 16.5 372 20.4 406 22.2 296 16.2 245 13.4

15.71 1 I .16

15.70 II.67 0.65+ I5 31 Il.63 0.77: 15.53 Il.57 0.57% 15.31 II.17 16.68 I I.51 16.00 II.37

41.5 22.6

42.2 39. I 39.5 41.1 45.6 42.9

201 Il.0 18.54 Il.64 3.69**+ 52.2 770 42.2 15.29 10.92 4,lSt 39.7 417 28.8 15.06 II.85 4.2Y.P 37.4 267 14.6 15.85 II.75 44 2 170 9.3 15.68 Il.53 42.9

248 13.7 9.17 7.65 139,40***t 15.3 699 38.6 12.16 9.04 344.w**: 27.8 626 34.6 18.77 Il.55 6.3 I5 55.0 237 13.1 24.74 12.65 73 0

1477 82. I 321 Il.9

14.34 IO.71 132.90***t 22.21 12.64

36.4 65.1

512 28.7 13.77 10.96 14.72***t 34.5 400 22.2 13.87 IO.95 63.56***: 32.5 376 20.9 16.04 II.09 0.99s 43. I I64 9.1 lb.91 II.17 48.2 II5 6.4 17.83 10.95 52.2 229 12.7 20.47 12.74 59.4

722 42.3 II.91 9.15 148.42***+ 27.6 986 57.1 18.40 Il.98 51.4

560 30.8 10.28 12.05 l38.08*** 60.2 I257 69.2 13.69 IO.56 33.3

3.64

14.34

268.12*

88.16***

62.79

96.85***

I IJ.53**

22. I 23.5 21.2 20.0 26.0 24.5

30.3 21.2 21.3 23.2 22.4

5.2 I I.6

30.04 52.3

17.9 44.5

19.2 16.5 22.9 23.5 27.8 35.8

12.5 29.4

36.6 lb.4

4.67

8.23

232.78

103.90***

36.88

68.22

89.33

P < 0.05: l *P

Depressive symptoms among immigrant hlexicar, women 649

heads of families in poverty and the number of adults and children present in such households. Using the family data collected in this survey we were able to test some of these suspected associations. In contrast to the expected relationships, we found that the number of children and adults in the household was not related to depressive symptoms or caseness rates. However, being a single head of household was strongly associated with higher mean scores (P < 0.001) and rates above the two cutpoints.

Three items were used to tap health status, and all have a strong association with mean scores and caseness rates. The self-perception of health in the previous I2 months is a dramatic indicator of psychological distress, with 73% of those describing their health as poor or very bad scoring above the caseness threshold, and 52.3% scoring at 24 or higher. The items identifying disabilities and M.D. visits also produce very strong associations. The associations between health status or health behavior and symptomatology are in the direction predicted by the literature [28, 291, and these are probably magnified because of the homogenous nature of the sample. i.e. low income, immigrant, middle aged and female. Link and Dohrenwend [30] believe health problems are an important antecedent of demoral- ization, which is perhaps one of the most prevalent maladies in urban society requiring medical services.

A large literature has chronicled the importance of life events in the onset of psychological distress, especially depression [3 I, 321. Although the nature of the etiological relationships and temporal sequencing is poorly understood, life events remain a viable predictor of symptomatology. In this study our respondents were asked if they had experienced an upsetting event (death of family member, serious injury, loss of job, etc.) during the preceding 12 months. The results were highly statistically significant in the expected direction. In fact, respondents reporting a life event had rates approximately twice as high at both symptom cutpoints than those who had not experienced an event.

Perhaps the single most reliable predictor of psychological well being found in the social support research is the presence of a confidant. In this case, respondents were asked if they had anyone with whom they could share their innermost thoughts and feelings? The results clearly mark the trend for psychological well-being among respondents who have such support. with twice as many respondents lacking confidant support meeting caseness criteria or scoring at the cutpoint of 24, or above it. Again the

results were very significant for all three associations tested in Table 2.

Summarizing these results using the 24 cutpoint as the threshold of very high distress, the ordering of variables is as follows: (I) poor health; (2) suffering from a disability: (3) no confidant support; (4) ten or more M.D. visits: (5) fair physical health; (6) single head of household and (7) upsetting life event. Of the five factors assessed. health status clearly predom- inates as the most salient predictor of depressive symptoms. However, the other factors identified. confidant support and negative life events. clearly discriminate between high and low symptom cohorts as well.

SY\IPTO>l SEVERITY AND HELP SEEKING

During the course of the interview, and the conclu- sion of the symptom checklist. respondents were asked some questions about the severity and extent to which these symptoms had disturbed their normal life functioning. In those cases where the respondent indicated being bothered by their depressive symptoms. they were asked about help-seeking behavior in terms of the type of provider sought for relief of symptomatology. The results are presented in Table 3, and include both informal sources of social support and direct services.

Mean CES-D scores were lowest for those immigrant women who sought help from informal sources such as family, friends, and clergy than for those seeking more formal help. However, of the 479 women who reported being bothered by symptoms and who tried to talk to someone about them. about 67% used informal resources. Those seeking help from mental health providers had the highest mean CES-D scores (29.85), followed by users of human services providers (25.25) and medical doctors (21.98). However. medical doctors were the formal resource most likely to be used (19.9%). Obv-iously, women who were more depressed were much more likely to seek services from formal providers. and among these, the most depressed were likely to seek services from a mental health provider (P < 0.000).

In Table 3, x were used to test for the significance of the differences between the proportions using any of the informal or formal resources and the proportions using no resources. The tests were run for women scoring at or above the two CES-D cutpoints; the usual I6 caseness threshold, and a higher threshold of 24. Of those who turned to informal

,v % mean' SD CES-D > 16+ CES-D 3 14: Family I32 27.6 17.61 IO.05 49.2 2j.X Friends 122 2j.j 18.47 10.67 16.7 25.7 Clergy 67 11.0 19.31 13.28 j3.7 29.9 Hum. ser. prov. 16 3.3 ?j.?j 12.80 7j.0 50.0 !vledical doctor 9j 19.8 2 I .95 II.60 69-j 40.0 bkntal health 47 9.8 ?9.Sj 12.75 80.9 66.0 T01al 479 100.0 20.39

*ANOVA: F = 9.85. d.f. = j: P < 0.000. +Chi-squared: r = 27.87. d.f. = j: P < 0.000. :Chl-squared: % = 30.11. d.f. = j: P -z 0.000.

II.89 j7.2 34.7

650 WILLLM A. VEGA ef al.

resouces. about half were cas2s (16 or above) and half were not. However. those using formal providers were much more likely to bc cases or meet ths threshold of 24 or above (P < 0.000). Examining thz patterns in a different way, about half of those who sought help from family, friends and clergy met caseness criteria. The rates were substantially higher for those women who saw a medical doctor, human services provider. or mental health spscialist. The highest rate (80.9%) was for mental health utilization. The pattern is repeated when using the cutpoint of 24 and becomes even more pronounced. Therefore. it would appear that as the threshold of symptom severity increases so does the likelihood of seeking services from a general medical or speciality mental health provider.

DISCUSSION ASD CONCLLSIOS

Our findings have important ramifications for the assessment of risk and delivery of mental health services. Mexican female immigrants interviewed in the course of this research have extraordinarily high rates of depressive symptoms as well as caseness prevalence. The analyses identify several powerful associations between demographic variables and/or help-seeking with depressive symptoms in this population. Overall, many of these associations pattern like those reported in other epidemiological studies but at exceedingly high levels of symptomatology.

The finding which was not anticipated is that household composition did not have a remarkable relationship to symptomatology. Neither the number of children nor adults in a household seem to make an important difference in prognosticating symptom levels. However. the immigrant women who were single heads of households were, as expected, more likely to be designated as at risk for caseness.

The relationship between time in country and depressive symptoms provides the most direct evidence of psychological distress associated with the immigrant experience. Respondents with five or fewer years in country have higher levels of symptoms. Moreover, time in country has no consistent association with symptoms for respondents who have been in the United States over 5 years, although the mean scores remain high overall.

The data do not confirm the observations that immigrants have low symptomatology. or that mental health providers will not be used by Mexican Americans. Although it is probable that unmet need continues to exist in this ethnic cohort. which is the case in the general population as well. our survey results indicate that both formal and informal support providers are operating to provide help in overcoming the dslsterious effects of depressive symptomatology. Prrhaps as reported by Lopez [33], the problem of utilization among Mexican Americans (and possibly other subpopulations with substantial immigrant representation) is neither as monolithic nor as widespread as is currently believed, and when appropriately staffed bicultural and bilingual clinics are available, as they are in San Diego County, they will be used.

The findings lend further support to what in- vestigators in the mental health field have been

reporting for some time; that most of the formal services for treating signs of psychological distress are being delivered by msdical doctors. ahich obscures the evaluation of rates-in-treatment and underscores the importance of appropriate diagnoses and treatment in general medical care settings.

The findings reported in this paper depict a poor. minimally acculturated cohort of women who ar2 socially isolated and have levels of sducational attainment that are far below what is considered normative in the United States, Cert;tinly. from the perspective of social psychological stress theory [34], these women are at far greater risk for depression than better integrated members of ths general population. However, there are other socially marginal groups subjected to multiple stressors in North America. and studies exist documenting their corre- spondingly high levels of psychopathology [3j-371. Indeed. it will be interesting to compare the symptom levels reported in this study, indexed for socioeconomic status, with the CES-D data forthcoming from the Epidemiological Catchment Area Program [38] and the Hispanic Health and Sutrition Exam- ination which include large multiregional samples, including Mexican Americans, encompassing the major sociodemographic groups found in the United States. It is our belief that when the major demographic variables are taken into account, differences in symptom counts between immigrants and native born American citizens will be greatly attenuated. although they probably will not disap- pear altogether. Further, the cohort of women we have assessed are in middle age, which appears to be a special risk group within the Mexican American population. It will be interesting to see whether diagnostic rates for minor depressive disorders also accentuate the risk proneness of Me.xican immigrant women over 40 when such data become available.

We would conjecture that the reasons for the extraordinary levels of depressive symptoms in this cohort of women has its basis in a combination of cultural and socioeconomic factors which may per- sonify poor immigrants more broadly, but which focus with particular intensity on ths middle aged woman. Family structure and normative expectations are unstable and deeply conflicted for women under- going the transitional processes implicit in the immigration experience. The effort to maintain traditional cultural role expectations within the context of highly urbanized and affluent social systems could be expected to increase stress, and economic marginality combined with lessened social support compound the severity of perceived stress and narrow the range of coping alternatives. Our measure of depressive symptoms, the CES-D, is known to be v2ry sensitive to situational stress. This context of high risk for depression should also be prevalent in populations with similar demographic and cultural diff2rences, such as the Turkish immigrants in Germany and Sweden.

Perhaps the most intriguing question suggested by this research but fundamentally unansvverable using cross-sectional data, is the potential for identifying factors that distinguish successful copsrs within the immigrant cohort. Given the homogeneity of the sample, many types of life stressors encountered by poor immigrant women are expected to be nearly

Depressive symptoms among immigrant Mexican women 651

universal. thus permitting an assessment of psycho- 14. logical coping processes and related behaviours in the various domains of life experience; i.e. marital re- 15.

lationships, parenting, work. economic, legal, etc. We are currently conducting such a prospective in- vestigation during the second and subsequent waves of interviews with this cohort using scales designed by 16, Pearlin [39], as well as others, to assess these inter- actions within a causal model. We are also testing the construct of migration and stress developed by Fa- brega [-lo] in order to determine if the factors have any predictive value for depressive symptoms within 17.

this immigrant cohort. Ideally, the information gleaned will better explain differences in immigrant adjustment and related social processes that affect health and psychological well being. 18.

The tindings in this paper forcefully suggest the importance of intervening with new immigrant populations using broad educational approaches as well as targeted public health interventions. The finding that 19. respondents are very sensitive to the impact of depressive symptoms on their functioning is important evidence supporting the viability of public health 2. interventions with this population.

21. REFEREKCES

I.

2.

3.

4.

5.

6.

7.

8.

9.

IO.

II.

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