Latinos, particularly UIs and their US-born children, for whom such negative health effects may become reality over time. Identifying protective factors to ameliorate the negative health effects of poverty, marginalization and harsh living environments in this population is necessary to develop prevention interventions, reduce healthcare cost, and inform policy. II. BACKGROUND Immigrant health has been a seriously neglected area of research, although this is gradually changing with a recent increase in studies focusing in quality and use of healthcare among at-risk immigrants, including UIs. Unfortunately, research to understand the effects of immigration legal status, particularly undocumented status, on physical and mental health is limited. Given that UIs make up a considerable proportion of the US population and its workforce, facilitating understanding of their wellbeing and mental health challenges is important to decrease inappropriate use of healthcare services, and ensure a healthier workforce and community, as well as to inform the development of interventions and policies. Mental health of undocumented immigrants in the United States According to Healthy People 2020, mental health is 1 of 12 leading health indicators given it is essential to a person’s wellbeing, quality of life, physical functioning, interpersonal relationships, and productivity (US Department of Health and Human Services). The association between mental health and quality of life is widely documented, with better mental health associated to increased wellbeing. In a
of fluttering in the stomach). Thus, somatic disturbance is an important characteristic of Nervios and Ataque de Nervios that merits further study. Among Latino immigrants, Nervios and Ataque de Nervios have been identified as prevalent conditions. In a recent study of 422 Latino migrant farmworkers the prevalence of Nervios was 22%, with lower income, drug use, higher acculturation and poor housing conditions more likely to be associated with a Nervios diagnosis (O’Connor, Stoecklin-Marois, & Schenker, 2013). In addition, Nervios has also been found to be significantly associated with poor or fair self-reported health, symptoms of depression, and high-perceived stress (O’Connor, et al., 2013). In regards to Ataque de Nervios, a study using data of 2554 Latinos from the NLAAS found the prevalence of Ataque de Nervios among Latinos to range between 7-15% varying by Latino subgroups, with Puerto Ricans reporting the highest prevalence (14.9%) and Mexican immigrants the lowest (6.0%) (Guarnnacia, Lewis-Fernandez, Martinez-Pincay, Shrout, Guo, Torres, et al., 2010). In that study, Ataque de Nervios was found to be more prevalent among women, those with disrupted marital status, and those with higher acculturation to the US. Ataque de Nervios was also prevalent among those meeting criteria for anxiety and substance use disorders. Given the association of Nervios/Ataque de Nervios and distress, the high prevalence of Nervios among Latino immigrants, and the multiple and complex distressing events often faced by UIs, studies are needed to identify the prevalence of Nervios and Ataque de Nervios among UIs, as well identify patterns of comorbidity with more traditional DSM-V diagnosis. Most information on the clinical description of Nervios and Ataque de Nervios has been gathered from qualitative data, with studies using quantitative data to define
Ulysses Syndrome. For over a decade, and given the large inflow of UIs into Europe, researchers overseas have worked diligently to contextualize the distress experienced by different at-risk immigrant subgroups. Among such efforts has been the study of the Immigrant Syndrome with Chronic and Multiple Stress or Ulysses Syndrome, named as such in reference to the Greek hero Ulysses, who endured countless adversities and dangers away from his homeland (Achiotegui, 2002). The Ulysses Syndrome is defined as a behavioral and emotional “response [experienced by immigrants] when faced with a situation of [chronic and severe] stress, [which] is superior to the adaptation capacities of the [immigrant]” (Achiotegui, 2002). From this perspective, the Ulysses Syndrome is a cluster of emotional and somatic symptoms, as well as a prodromal for more severe forms of mental health distress if experienced over time and without access to treatment, support systems or coping strategies. Specifically, the clinical expression of Ulysses Syndrome involves: (1) symptoms of depression, particularly sadness, crying spells and difficulty concentrating, but not necessarily apathy, low self-esteem or thoughts or death/dying as often characterized in depressive disorders; (2) symptoms of anxiety, for example tension, worry, irritability, and nervousness; (3) somatic symptoms (e.g., headaches, fatigue, body aches); (4) migration-related grief in one or more of seven identified areas including: (a) family and friends left in country of origin; (b) language difficulties; (c) loss/change of cultural values; (d) missing of cultural practices (i.e., food, landscapes); (e) loss of/change in social status; (f) marginalization/discrimination; and (g) threat to physical and mental health. Similar to the research on Nervios and Ataque de Nervios, most information regarding the conceptualization of Ulysses Syndrome comes from
modeled from the 2009 San Diego Prevention Research Center (SDPRC) Community Survey, which assessed various aspects of health and health behaviors among Latinos in the US, including UIs. These questions are available in Spanish and have been previously used with UIs in San Diego. Immigration history. Participants will be some questions about their immigration history (see Appendix H). Immigration history information to be collected includes country and state of birth, country and state where migrant spent most of his/her life, age of arrival in the US, and length of time in the US. These questions were modeled from the 2009 SDPRC Community Survey, as well as from the San Diego Labor Trafficking Survey Questionnaire (Zhang, 2012). These questions have been previously translated into Spanish and have been used to assess immigration history among undocumented Latinos. Respondent driven sampling questions. Four questions will be used exclusively for the purpose of mapping recruitment location and to calculate RDS estimates (see Appendix I). These questions include area of residence (town name only), size of the respondent’s personal network who are UIs, relationships to the referral source (person who provided the coupon to the participant), and length of time that the participant has known the referral source. These questions were modeled from the San Diego Labor Trafficking Survey Questionnaire (Zhang, 2012), which are available in Spanish and have been previously used in studies with UIs. Health-related quality of life assessment. This will be done using two measures. First, a shortened and adapted version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) Chronic Conditions Module Version 3.0 will be used to assess the past (prior to immigration) or present history of commonly occurring chronic health conditions known to influence QOL including arthritis, chronic pain, heart disease, hypertension,
trauma/loss and/or difficulties may be less likely associated to the presence of a mental health disorder/perceived psychological distress among immigrants reported to be proficient in the English language when compared to with less English language proficiency. 1 Demographic and socio-economic characteristics by immigration legal status categories* US-Born Legal Residents Undocumented Age % Men ages 20-39 % Population ages ≥ 65 % Children 14.0 12.0 27.0 18.0 16.0 6.0 32.0 1.2 13.0 Household Characteristics % Couple with family Mean family size 21.0 35.0 47.0 Education % < High school (ages 25-64) 8.0 22.0 47.0 Language % Speaks English proficiently 100 23.0 (1st gen) 88.0 (> 1st gen) NR Financial Status Median household income (< 10 yrs in US) Median household income (≥ 10 yrs in US) % Homeownership (< 10 yrs in US) % Homeownership (≥ 10 yrs in US) % Adults living in poverty % Children living in poverty 50.000 50,000 70,0 70.0 10.0 18.0 50,000 41,300 54,100 40.0 68.0 NP NP NP 35,000 38,000 27.0 45.0 20.0 30.0 36,000 Employment % In the force (Men) % In the labor force (Women) 83 73 85 66 94 58 Insurance % Uninsured 14 25 59 *Information based on 2008 estimates from the Pew Research Center (2008)
Nervios 1. Cultural Syndrome a. Current acknowledgment of Nervios b. Somatic symptoms (including specified in c. Emotional distress symptoms d. Functional limitation EMIC: 1. Have you ever suffered from “Nervios” in your life? 2. Do you suffer from “nervios” now or in the past 12 months? BSI-46 BSI-18 Adapted from NLLAS: On a scale from 0-10…How much your Nervios interfered with: 1.Household chores 2. Quality of your work 3. Social life/relationships Response: Yes/No Yes/No Total score ≥ 14 T ≥ 63 in general distress OR T ≥ 63 in any of the individual subscales Frequency per domain from 0=no interference to 10= most interference 2. Cultural Idiom of Distress a. Life time Prevalence b. Nervios as a trait c. Cultural expression of distress EMIC: Have you been “nervous” since childhood”? EMIC: Are you a “nervous” person? EMIC: How do you describe your experiencing of “Nervios”? Yes/No Yes/No Qualitative description 3. Cultural Explanation a. Causal explanation of perceived distress EMIC: What is the most probable cause of your “Nervios”? Qualitative description a. Current acknowledgment of Ataque de Nervios EMIC: 1. Have you ever had an “Ataque de Nervios” where you felt totally out of control? 2. Have you had an “Ataque de Nervios” where you felt totally out of control within the past 12 months? Response: Yes/No Yes/No
Ataque de Nervios 1. Cultural Syndrome b. Somatic symptoms (including specified in c. Emotional distress symptoms (including those specified in d. Frequency of Attaques de Nervios e. Functional limitation NLAAS Ataque de Nervios Module (Symptoms section) NLAAS Ataque de Nervios Module (Symptoms section) EMIC: How many Ataque de Nervios have you had in the past 12 months? Adapted from On a scale from 0-10…How much the episode or Ataque de Nervios interfered with: 1.Household chores 2. Quality of your work 3. Social life/relationships 4 pt Likert Scale: Scores ≥ 4 suggest somatization 4 pt Likert Scale: Scores ≥ 4 suggest emotional distress Frequency Frequency per domain from 0=no interference to 10= most interference 2. Cultural Explanation a. Causal explanation of Ataque de Nervios NLAAS Ataque de Nervios Module (Causal section) Responses: List format Yes/No Contextual Concept of Distress: Ulysses Syndrome Ulysses Syndrome 1. Contextual Syndrome a. Emotional distress symptoms b. Somatic symptoms c. Functional limitation due to distress associated to loss BSI-18 BSI-46 MLS a. Distress associated to migration-related loss T ≥ 63 in general distress scale OR T ≥ 63 in any of the individual Total score ≥ 14 Total score ≥ 14 b. Total score for losses experienced as extremely distressing a. Contextual expression of distress Adapted from DSM-V CFI: 1. How would you describe your experience as an undocumented immigrant to others? Qualitative description
6. To what extent do you feel your life to be meaningful? 1 2 3 4 5 Not at all A little A moderate amount Very much Extremely 7. How well are you able to concentrate? 1 2 3 4 5 8. How safe do you feel in your life? 1 2 3 4 5 9. How healthy is your physical environment? 1 2 3 4 5 The following questions ask about how completely you experience or were able to do certain things in the last two weeks. Not at all A little Moderately Mostly Completely 10. Do you have enough energy for everyday life? 1 2 3 4 5 11. Are you able to accept your bodily appearance? 1 2 3 4 5 12. Have you enough to meet your needs? 1 2 3 4 5 13. How available to you is the information that you need in your life? 1 2 3 4 5 14. To what extent do you have the opportunity for leisure activities? 1 2 3 4 5 Very poor Poor Neither poor, nor good Good Very good 15. How well are you able to get around? 1 2 3 4 5 The following questions ask you to say how good or satisfied you have felt about various aspects of your life over the last two weeks. Very dissatisfied Dissatisfied Neither satisfied, nor dissatisfied Satisfied Very Satisfied 16. How satisfied are you with your sleep? 1 2 3 4 5 17. How satisfied are you with your ability to perform your living activities? 1 2 3 4 5 18. How satisfied are you with your capacity for work? 1 2 3 4 5 19. How satisfied are you with yourself? 1 2 3 4 5 20. How satisfied are you with your personal relationships? 1 2 3 4 5 21. How satisfied are you with your sex life? 1 2 3 4 5 22. How satisfied are you with the support you get form your friends? 1 2 3 4 5 23. How satisfied are you with the conditions of your living place? 1 2 3 4 5 24. How satisfied are you with your access to health services? 1 2 3 4 5
Social Phobia (Social Anxiety Disorder) Generalized Non-generalized 300.23 300.23 F40.10 F40.10 Trauma & Disorders Post-traumatic Stress Disorder (PTSD) Current (Past 309.81 F43.10 Substance-related & Addictive Disorders Alcohol Dependence Alcohol Abuse Substance Dependence (Non-Alcohol) Substance Abuse Past 12 months Past 12 months Past 12 months Past 12 months 30x.xx 30x.xx Varies by drug Varies by drug F10.x F10.x F1x.x F1x.x Suicidality Suicidality Current (Past month) Low, Moderate, High Not applicable Not applicable V.3 SCID-RV DSM-V The following disorders will be assessed using specific modules of the SCID-RV for DSM-V diagnosis: Category DSM-V /ICD-10 Specifiers DSM-V Code ICD-10 Code Duration of Administration Depressive Disorders Persistent Depressive Disorder (Dysthymia) Current (Only) Early/Late Onset Persistent Intermittent 300.4 F34.1 Approx 3 min Somatic Symptom & Related Disorders Somatic Symptom Disorder Current (only) With/Without Pain Persistent/Not persistent Mild/Moderate/Severe 300.82 F45.1 Approx 5 min Trauma & Stress-related disorders *Adjustment Disorder Current (Only) With Depression With Anxiety Mixed (Depression/Anxiety) Disturbance of conduct Disturbance of emotion 309.0 F43.2x Approx. 3 min. *Adjustment disorder must be evaluated as the last mental health disorder in this clinical assessment, and should ONLY be assessed if individual reports symptoms of psychological distress at a clinical level based on BSI-18 scores and if he/she does not meet criteria for any other DSM-V diagnosis.