Acculturation stress, anxiety disorders, and alcohol dependence in a select population of young adult Mexican Americans

Abstract

Objectives

Mexican Americans comprise one of the most rapidly growing populations in the U.S. and within this population the process of acculturation has been suggested to be associated with some mental health problems. This study sought to ascertain quantitative information indexing acculturation stress and its association with mental health disorders in a select community sample of Mexican Americans.

Methods

Demographic information, DSM-III-R diagnoses, and information on cultural identity and acculturation stress were obtained from 240 Mexican American young adults that were recruited by fliers and were residing in selected areas of San Diego.

Results

No associations were found between measures of cultural identification and lifetime diagnoses of drug or alcohol dependence, major depressive disorder, anxiety disorders or antisocial personality disorder/conduct disorder in this sample of Mexican American young adults. However, lifetime diagnoses of alcohol dependence, substance dependence, and anxiety disorders were associated with elevations in acculturation stress.

Conclusion

Quantitative measures of acculturation stress, but not cultural identity per se, were found to be significantly associated with substance dependence and anxiety disorders in this select population of Mexican American young adults. These data may be helpful in designing prevention and intervention programs for this high risk population.

Alcohol use and use disorders in Hispanic Americans

Data on drinking patterns and problems between different racial/ethnic groups highlight the importance of studying the etiology of alcohol involvement in Hispanics (Dawson, 1998; Nielsen, 2000; Grant et al., 2004). Adult male Hispanics, particularly those born in the U.S., are more likely to drink frequently and to consume larger quantities of alcohol than Whites or Blacks (Caetano, 1984; Caetano and Kaskutas, 1995; Stinson et al., 1998; Reardon and Buka, 2002). Additionally, while it has been found that the percentage of White men who are frequent heavy drinkers declined between 1984 and 1995, it did not decline and in fact remained high for Hispanic men (Caetano and Clark, 1998a). Further, while it appears that Whites tend to “age out” of heavy drinking after their 20’s (Caetano, 1984; Herd, 1990; Johnson et al., 1998; Nielsen, 1999), for Hispanics, 30–39 years is the peak drinking age (Caetano and Clark, 1998a, 1998b). The Epidemiologic Catchment Area (ECA) study collected data on alcohol and other substance abuse and dependence diagnoses from five U.S. sites (Helzer et al., 1991). In that study the total lifetime prevalence rate of alcoholism (alcohol abuse and dependence) was higher among Hispanic American men than among White men. The higher rates of alcoholism and heavy drinking by some Hispanics also take a heavy toll in health consequences. A study evaluating the age-adjusted death rates for liver cirrhosis using data from the National Center for Health Statistics found that Hispanic men had the highest cirrhosis mortality rates of any ethnic group studied (Stinson et al., 2001; Caetano, 2003).

Alcohol use and use disorders in Mexican Americans

Hispanic American subgroups bring with them a diversity of racial heritage as well as cultures that vary in psychosocial, religious, and economic bases. The importance of specifying subgroups of Hispanics to avoid inaccurate generalizations has been stressed (Caetano et al., 1998). Mexican Americans represent the largest subgroup of Hispanic Americans, nearly two thirds of the total U.S. Hispanic population, followed by Puerto Ricans, Cubans, Caribbeans, Central and South Americans. Within the Hispanic American population, Mexican Americans are an important target population in need of further study. The prevalence rate of past heavy drinking in Mexican Americans was estimated in one report to be three times higher than that reported for a non-Hispanic male population (Lee et al., 1997). Mexican American men are also less likely to abstain than other Hispanic men. Data from the Los Angeles site of the ECA study found that Mexican American men had higher alcoholism rates at all age categories than those of White men, with the highest rates occurring in the 30–39 year age range (Burnam, 1989). However, in a study by Vega and colleagues, higher overall alcoholism rates were only found in U.S. born Mexican Americans (Vega et al., 1998b). More recent studies comparing Hispanic national groups in the U.S. show that Mexican Americans, together with Puerto Ricans, have the highest rates of binge drinking, driving under the influence of alcohol, alcohol abuse and dependence (Caetano et al., 2008a, 2008b, 2009)

Cultural factors that influence drinking in Hispanic Americans

Many issues concerning the etiology of drinking problems in Hispanic Americans in general and Mexican Americans in particular are unresolved and there is a need for further research. Most theoretical models developed to explain Hispanic American drinking practices have focused on socio-cultural variables. These theories posit that social factors such as poverty, lack of education, job discrimination, social prejudice, and the stress of acculturation lead to heavy drinking. Many findings in this area are complex and do not support a simple explanation. For instance, while several investigators have suggested that low income and job discrimination may lead to increased drinking in Hispanics, data suggest that rates for frequent heavy drinking in men increase and rates of abstention in women decrease, as income levels rise (Caetano, 1989). Likewise, in comparing drinking among groups differing in levels of education, men and women with some college education were less likely to abstain, and Hispanic American men with some college education were more likely to have higher rates of frequent heavy drinking (Caetano, 1989). An analysis of the 2002 NESARC data revealed that Hispanic women who were cohabiting and had a higher income were at a higher risk for heavier drinking (Caetano et al., 2006).

Acculturation and acculturation stress and drinking in Hispanic Americans

The relationship between level of acculturation and drinking practices has also been explored in Hispanic Americans. In one study, the rates of daily drinking were found to increase with each successive generation in the U.S. (Gilbert, 1985; Caetano and Medina-Mora, 1988; Caetano and Clark, 2000). Lower rates of other psychiatric disorders have also been reported in Mexican American immigrants (Vega et al., 1998b; Alderete et al., 2000a, 2000b). In addition, gender differences have been found with stronger associations between drinking and acculturation seen in women in some surveys (Gilbert, 1985; Caetano and Medine-Mora, 1988; Polednak, 1997). In other studies measures of acculturation have failed to differentiate drinking patterns among Hispanics seeking treatment for alcohol-related problems (Arciniega et al., 1996).

Acculturation stress has been defined as a stress that emerges when an individual develops problems or conflicts associated with adjustment between the immigrant culture and that of the host society (see Born, 1970; De La Rosa, 2002; Berry, 2003). There have been a number of studies of Hispanic communities that have reported positive associations between a measure of acculturation stress and a wide range of self-rated mental health behaviors (Gil et al., 1994; Gil and Vega, 1996; Hovey and Magaña, 2000; Finch et al., 2001; Finch and Vega, 2003; Firestone et al., 2003; Romero and Roberts, 2003; Caetano et al., 2007; Crockett et al., 2007). However, fewer studies have indexed the amount of acculturation stress actually associated with mental health disorders. In one study acculturation-related family stress was found to be associated with substance and psychiatric disorders among Puerto Ricans with substance use disorders (Conway et al., 2007).

The present study was designed to assess associations between alcohol dependence, cultural identification, and acculturation stress in a select sample of young adult Mexican Americans with and without alcohol use disorders. We have previously reported a high prevalence of alcohol dependence in this population. Additionally, there was significant co-morbidity between alcohol dependence and anxiety, affective, conduct/antisocial, and other substance dependence disorders (Gilder et al., 2007). Therefore the role of acculturation stress on other disorders co-morbid with alcohol dependence was also assessed.

Materials and Methods

The aim of the study was not to obtain an epidemiological sample of the population of Hispanics or even Mexican Americans in San Diego but rather to get a sample of young adult Mexican Americans with and without alcohol use disorders from the community. Therefore, participants were recruited using a commercial mailing list that provided the addresses of individuals with Hispanic surnames in 11 zip codes in San Diego County that were identified as having a population that was over 20% Hispanic heritage and were within 25 miles of the research site. The mailed invitation stated that potential participants must be of Mexican American heritage, be between the ages of 18 and 30 years, be residing in the United States legally, and be able to read and write in English. Potential participants were requested to phone research staff for more information. During the phone interview potential participants were screened for the presence of the inclusion criteria as listed on the invitation, and were excluded it they were: pregnant or nursing, currently had a major medical or neurological disorder, or a head injury. Participants were asked to refrain from alcohol or any other substance use for 24 hours prior to testing.

On the test day, after a complete description of the study to the participants, written informed consent was obtained using a protocol approved by The Institutional Review Board of The Scripps Research Institute. Information on demography, personal medical and psychiatric history, drinking history and family history of alcohol and other substance dependence was obtained using a family history interview and the face-to-face Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA). There have been several studies that have evaluated the concurrent diagnostic validity of the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA) across alcohol and drug dependencies, major depression, anxiety disorders and ASPD. The Schedule for Clinical Assessment in Neuropsychiatry (SCAN) was used as a comparison instrument in one study because it arises from a different tradition and uses a different format for its administration. The Kappa statistic was used to measure concordance between the SCAN and the SSAGA. Kappa for alcohol dependence was 0.63, Kappa for other drugs ranged from 0.48–0.85, Kappa for ASPD and major depression were high (0.71 and 0.70). Test-retest studies were conducted both within and across sites in order to study the reliability of the SSAGA. Findings from these studies indicated that reliability for the SSAGA was high for DSM-III-R substance dependence disorders and good for depression. These data indicate that the SSAGA is a highly reliable and valid instrument for use in studies of psychiatric disorders, including substance dependence (see Bucholz et al., 1994; Hesselbrock et al., 1999).

Participants were eliminated from the current data analyses if they were taking psychoactive medication or had a positive breath-analyzer test on the day of the evaluation. Lifetime history of alcohol dependence in this population was defined by the Diagnostic and Statistical Manual (DSM)-III-R criteria as originally formulated by the Collaborative Study on the Genetics of Alcoholism (COGA). Family history of alcoholism was assessed using the Family History Assessment Module (FHAM). A participant was classified as family history positive if they had a first degree relative with alcohol dependence. Family history negative participants had no first degree relatives with alcohol dependence.

Diagnoses of lifetime alcohol dependence and other psychiatric disorders were made on the basis of DSM-III-R criteria generated by the SSAGA. Four anxiety disorders (panic disorder with or without agoraphobia, agoraphobia without panic, social phobia, and obsessive-compulsive disorder), major depressive disorder, childhood conduct disorder (CD), and adult antisocial personality disorder (ASPD) were evaluated. Diagnosis of major depressive disorder, for the purposes of the data presented here, required that the participant report inability to function in her or his major role responsibility for 2 days or more, have had psychotic symptoms, and/or have undergone ECT or psychiatric hospitalization for a major depressive episode. Because of the difficulties in diagnosing hypomania, Bipolar II disorder was included with major depressive disorder as a single major depressive disorder category. Childhood CD was diagnosed if the participant had the onset of three or more criteria for conduct disorder before the age of 15 years but did not meet the adult criteria for ASPD. Diagnosis of drug dependence was made if the participant met criteria for dependence on one or more of the following substances: cannabis, cocaine, stimulants, sedatives, opiates, phencyclidine, hallucinogens, or solvents.

Cultural identification was assessed using the Orthogonal Cultural Identification Scale (OCIS) (Oetting and Beauvais, 1990–1991). The OCIS consists of 30 items with six base questions assessing attitudes and behaviors for five ethnic groups (Anglo, Asian, Latino, African and Native American), however in this case Mexican American was substituted in the instrument for “Latino”. The OCIS has been validated among Native American and Hispanic youth (see Oetting et al., 1998; Moran et al., 1999) and Native American adults (Venner et al., 2006). Level of acculturation stress was assessed using an instrument developed by Caetano and colleagues, using items from Mena et al.’s (1987) scale of acculturative stress, Vega et al., (1993) scale of acculturative stress, and additional items. This acculturation stress scale has been used in two studies. The first interviewed 387 Hispanic couples in a study of intimate partner violence (see Caetano et al., 2007). The second study interviewed 5,224 Hispanics in five U.S. metropolitan areas (Miami, New York, Philadelphia, Houston and Los Angeles) (see Caetano et al., 2009). Principal components factor analysis confirmed that scale items represented then acculturation stress construct as proposed. Results showed a main factor with an Eigen value of 4.7 accounting for 43% of the variance in the data. Loadings on this factor varied from 0.412 to 0.813. The scale’s reliability was also high as the Cronbach’s alpha for the scale was 0.86.

Data Analyses

Data analyses focused on the specific aims that were generated based on previous research investigating cultural identification and acculturation stress in Hispanic populations. The first aim was to investigate the relationship between DSM-III-R alcohol dependence and cultural identification as assessed using the OCIS and alcohol dependence and acculturation stress with the Caetano acculturation stress scale. The second aim was to assess associations between acculturation stress and other disorders previously shown to be co-morbid with alcohol dependence in this population (Gilder et al., 2007). Exploratory analyses were also conducted to evaluate whether men and women differed in their relationship between alcohol dependence and acculturation stress.

Comparisons between demographic, diagnoses, cultural affiliation, and acculturation stress were conducted using analysis of variance (ANOVA) for continuous variables and Chi square analyses for 2 dichotomous variables. Statistical significance was set at the probability level: p >0.05. Power analyses indicated there was sufficient power (0.80) at alpha=0.05 to detect differences in our primary analyses.

Results

The young adults who participated in the study included 59% women and the sample had a mean age of 23 years (SD= + 3.9 years). Demographic data including age, gender, number of years of education, marriage, and current drinking history (quantity and frequency/month) are presented in Table 1. Participants with alcohol dependence did not differ from those without a diagnosis on age, income or number of years of education, however they were less likely to be married (Chi square=6.9; df=2; p<0.008), reported drinking more often (F=7.4, df=1,195; p<0.007) and more drinks per occasion (F=15.0; df=1,195; p<0.0001) than those participants without an alcohol dependence diagnosis. There were no significant differences in age, number of years of education, income, employment or marriage status between men and women. With respect to the drinking variables, women did not report drinking significantly less frequently, however, men reported drinking two more drinks per occasion than women (F=21.9; df=1,195; p<0.0001). The relationships between the two drinking variables (drinking quantity, drinking frequency) and cultural identification and acculturation stress, were explored and found to be non-significant.

TABLE 1.

Demographic and drinking variables in Mexican American men and women (n=237)

	No Alcohol Dependence			Alcohol Dependence
Variable	Males (n=68)	Females (n=108)	All (n=176)	Males (n=30)	Females (n=31)	All (n=61)
Age (mean ± S.D.)	23.0 ± 3.8	23.1 ± 3.8	23.1 ± 3.8	23.8 ± 4.1	24.3 ± 3.9	24.0 ± 4.0
Years of education	13.4 ± 1.6	13.4 ± 1.7	13.4 ± 1.7	13.7 ± 1.6	14.0 ± 1.8	13.9 ± 1.7
Income (median)	$40 – <$50K	$40 – <$50K	$40 – <$50K	$50K – <$75K	$30K – <40K	$50K – <$75K
Not Married (n)	58	81	139	27	30	57
Not Employed	19	32	51	7	8	15
Drinking Quantity (drinks per occasion)	3.3 ± 2.9	2.2 ± 1.7	2.7 ± 2.3	5.6 ± 3.6	2.9 ± 2.5	4.2 ± 3.4
Drinking Frequency (drinks per month)	2.5 ± 3.4	2.7 ± 3.4	2.6 ± 3.4	4.4 ± 5.8	4.3 ± 5.0	4.3 ± 5.4

To address the first major research question, associations between scores on the five OCIS scales (Anglo, Mexican American, Asian, African and Native American) were compared between those participants with a lifetime diagnosis of alcohol dependence and those without. No significant differences were found. Associations between total score on the Caetano acculturation stress scale and lifetime diagnosis of alcohol dependence was also evaluated. As seen in figure 1a, a significant association between endorsement of more acculturation stress and alcohol dependence was found (F= 6.14, df= 1,237, p<0.01). An exploratory analyses revealed that 4 out of the 11 items on the scale were also significantly associated with alcohol dependence: close family members and I have conflicting expectations about my future (F=11.9, df=1,237, p<0.001), it is hard to express to my friends how I really feel (F=3.94, df=1,237, p<0.048); I don’t feel at home (F=5.86, df=1,237, p<0.016); I have more barriers to overcome than most people (F= 7.06, df=1,237, p<0.008). No significant differences were found between men and women on any of the acculturation stress scales.

Figure 1.

Acculturation stress levels, as indexed by the Caetano acculturation stress scale, in study participants with (in black bars) and without (open bars) alcohol dependence (fig 1A) and in participants with (in black bars) and without (open bars) anxiety disorders (fig 1B). Values are given as mean ± SEM. Lower values on this scale indicate the participants endorsed higher levels of stress. Asterisk indicates significant difference between groups (p<0.05). For each graph the letters indicate the following items on the acculturation stress scale:

A. It bothers me that family members I am close to do not understand my new values.

B. Close Family members and I have conflicting expectations about my future.

C. It is hard to express to my friends how I really feel.

D. I don’t feel at home.

E. People think I am unsociable when, in fact, I have trouble communicating in English.

F. It bothers me when people pressure me to assimilate or live the Anglo-American way.

G. I often think about my cultural background.

H. I have more barriers to overcome than most people.

I. Because of my ethnic background, I feel that others often exclude me from participating in their activities.

J. People look down upon me if I practice customs of my culture.

K. People dislike me because I am Hispanic.

The second research question sought to determine if acculturation stress was also significantly associated with disorders known to be co-morbid with alcohol dependence in this population. Those disorders included: any anxiety disorder, major depressive disorder, other drug dependence and ASPD/CD (see Gilder et al., 2007). No significant associations were found between acculturation stress and CD/ASPD or major depressive disorder. However a significant association was found between total scores on the acculturation stress scale and a lifetime diagnosis of “drug dependence other than alcohol or tobacco” (F= 4.39, df=1,237, p<0.027). Additionally, two items were also found to be significantly associated with drug dependence: I don’t feel at home (F= 8.4, df=1.237, p<0.004) and I have more barriers to overcome than most people (F= 4.22, df=1,237, p<0.041). As seen in figure 1b, a significant association was found between a lifetime diagnosis of “any anxiety disorder” and acculturation stress. This was significant for the total score (F=22.73, df=1.237, p<0.0001), and all items except one (because of my ethnic background, I feel that other often exclude me from participating in their activities (F=1.05, df=1,237, p<0.31)).

Discussion

An important finding in first generation (immigrant generation) Mexican Americans is that alcohol use and other psychiatric disorders increase in frequency with time spent in the U.S. These disorders increase further in subsequent (U.S. born) generations of Mexican Americans. U.S. born Mexican Americans have rates of alcohol use and psychiatric disorders that are two to three times higher than their Mexican born ancestors (Burnam et al., 1987; Golding and Burnam, 1990; Kessler et al., 1994; Vega et al., 1998b, 2003; Grant et al., 2004; Strunin et al., 2007). This increase in rates suggests that the trans-generational process of adapting to living in the U.S. may play an important role in the development of alcohol use, as well other psychiatric, disorders (Burnam et al., 1987; Escobar, 1998; Ortega et al., 2000).

The rates of independent anxiety and affective disorders found in this sample of young adult, suburban-urban dwelling Mexican Americans have been reported previously (Gilder et al., 2007). The rates for these disorders were found to be comparable to those observed in the National Co-morbidity Survey (NCS) and also in studies of predominantly urban dwelling U.S. born Mexican Americans (Karno et al., 1987, 1989; Kessler et al., 1994; Vega et al., 1998b; Grant et al., 2004). The most recent epidemiologic data on Mexican Americans suggest that, as generational time in the U.S. increases, rates of anxiety and affective disorders increase until they approach those of U.S. born Euro Americans (Vega et al., 1998b; Grant et al., 2004). Since 88% of the present sample was second and later generation Mexican Americans, these data are consistent with the finding that rates of anxiety and affective disorders in U.S. born Mexican Americans are similar to rates seen in the general U. S. population. A high rate of alcohol dependence was observed in this study population, which may also be a result of the fact that the participants in this study were predominantly second and later generation immigrants.

One factor that has been associated with problems with acculturation has been ethnic identity. It has been suggested that low levels of identity with any culture may be related to culturally deviant behavior such as problematic drinking (Ferguson, 1976; May, 1982; Oetting and Beauvais, 1990–1991). Whereas, high identification with at least one culture has been association with more well-being (Phinney, 1989; Oetting and Beauvais, 1990–1991; Moran et al., 1999). The orthogonal cultural identification scale was developed to index cultural identification with several cultures, and the orthogonal model recognizes that one may not be identified or well integrated with any culture or may have associations with more than one culture. Using this scale no associations were found with lifetime diagnoses of drug or alcohol dependence in this sample of Mexican American young adults. These findings are consistent with the results of Trimble (1995) who also did not find any relationships between ethnic identity and alcohol use or abuse.

The increase in alcohol use disorders and other psychiatric disorders seen in Mexican Americans that is associated with time spent living in the U.S. may not be associated with changes in cultural identification per se but may be the result of the “stress” of acculturation. Many analyses of the effects of acculturation on risk factors for mental health have assumed that these effects are a result of the “stress” inherent to the acculturation process. However, many studies have not actually measured acculturation stress directly. Additionally, it has been proposed that the assumption that acculturation is associated with stress may not be warranted with regards to alcohol usage, as the increase in drinking associated with acculturation could simply be a normal adaptation to more liberal U.S. drinking norms (Markides et al, 1990; Black and Markides, 1993; Caetano and Medina-Mora, 1998; Zemore, 2004, 2005; Caetano et al., 2007). In the present community based study of Mexican American young adults, lifetime diagnoses of alcohol dependence, substance dependence, and anxiety disorders were associated with elevations in acculturation stress.

An exploration of the items that were significantly elevated on the acculturation stress scale in participants who were alcohol dependent vs. those with no lifetime diagnoses of alcohol dependence revealed that these young Mexican American adults endorsed conflict with family members, difficulty in expressing feelings, not feeling “at home” and having more barriers to overcome than most people. Not feeling “at home” and having more barriers to overcome than most people were also significantly associated with a lifetime diagnosis of drug dependence in this population. More significantly, anxiety disorders were positively associated with all items on the acculturation stress scale except being excluded from activities because of ethnic background.

How acculturation stress may directly impact the development of alcohol and drug abuse disorders is not currently known. In one study, evaluating Latino males in middle school in south Florida, a path model was developed in which acculturation stress led to less positive identification with family values, which then led to a disposition to deviant behavior and ultimately alcohol involvement (Gil et al., 2000). This model, however, may not apply to Latinas who may be less likely to enter drug usage through deviant behaviors (Vega et al., 1998a). Additional studies have indicated that Hispanic adolescents from Arizona may be less vulnerable to stress than Caucasians (Barrera et al., 1995), thus it is not known whether such a model applies equally to men and women or to Hispanic groups not residing in south Florida. The data from the present study suggests that in this Mexican American population that anxiety disorders may be more associated with acculturation stress than disorders associated with deviant behavior such as ASPD/CD. What is not known is whether having an anxiety disorder makes one more susceptible to, or to experience more, the impact of acculturation stress or alternatively, whether acculturation stress increases the prevalence of anxiety disorders.

It is important to consider some of the present study’s limitations. The study was not an epidemiological sample of Hispanics living in San Diego County but rather a study of Mexican American young adults with and without alcohol use disorders who responded to a flier to participate in research. Therefore, the findings may not generalize to all Mexican Americans, or all Hispanic young adult Americans. Over half of the participants in the present study were women and thus findings may not generalize to previous studies that have focused on samples of mostly male participants. Second, the study was limited to young adults between the ages of 18 and 30 years and those who spoke English. This allowed the use of validated instruments and an investigation of the association between alcohol dependence and acculturation stress, however, since not all of the participants in the study had passed through the age of risk, the strength of this association with alcohol use disorders may be limited. Additionally, although the acculturation stress scale that was used has been validated it does contain items that may index “stress” in general rather than acculturation stress in particular. Therefore when an individual endorses such items generalized stress and acculturation stress may be confounded. Further studies employing a longitudinal design will be required to test the relationship of acculturation stress and eventual alcohol related morbidity and mortality. Despite these limitations, this report represents an important first step in an ongoing investigation to determine risk and protective factors associated with the development of substance use disorders in Mexican Americans.