social epidemiology of mental disorders

Review article
Acta psychiatr. scand. 1987:75:1-10
Key words epidemiological methods, health survey, cultural
characteristics
Social epidemiology of mental disorders
A review of Latin-American studies
N. de Almeida-Filho
Department of Preventive Medicine, Faculty of
Medicine of the Federal University of Bahia. Brazil
ABSTRACT - This paper reviews the literature about the relationships between cultural
change and psychopathology produced by Latin American researchers. With the analysis of
22 epidemiological studies, the author shows how culture has been traditionally viewed by
social psychiatric research in Latin America as an independent variable associated with the
prevalence of mental disorders. Two basic approaches have been analyzed: one of anthropological origin and the other based on sociological explanations. The hypotheses of cultural
shock, stress of acculturation and cultural marginalization belong to the first approach, while
the second one is manifested by the notions of urban stress, life change, social support and
goal-striving stress. Methodological issues were brought about to evaluate the results on the
association of cultural processes and psychopathology available in contemporary socio-psychiatric research in Latin America.
Received June 7, 1986; accepted for publication July 18, 1986
The health consequences of economic development
have frequently been ignored in epidemiological research in Third World countries. Most comprehensive analyses of the problem have approached
health indicators at a national or regional level, and
the bulk of research on this issue does not attach
much importance to individual-level outcomes,
such as the psychopathological effects of modernizing experiences. The social epidemiology of mental
disorders in Latin America seems to be an intriguing exception to this overall pattern. The basic
question of social psychiatric research in our continent can be stated as follows: in these countries, is
poor mental health due to modernizing pressures
which require rapid and difficult acculturation, including the migratory attraction to urban centers (in
itself a life-crisis event) or is it due to changes in the
economic system, which expels labor without providing sufficient employment opportunities for the
full reincorporation of these social groups within a
modernized productive process?
This paper is an attempt to present the scientific
literature about the relationships between social
factors and mental health/illness that has been produced in Latin America. With this aim, I have
covered not only material published in indexed
scientific periodicals, but also papers appearing in
regional publications as well as unpublished manuscripts. As a result, I have reviewed two papers
based on clinical impressions, three “anthropological” studies, one investigation of mental hospital
first admission, three small scale studies and 13
community surveys. A summary on methods and
results of these studies is provided below, by classifying them into three categories: “pre-epidemiological” studies, community surveys of the first phase
(1950-1970) and epidemiological studies of the
second phase (1970-present). Finally, an evaluation
of this body of literature is presented, particularly in
terms of theoretical models adopted to explain research findings from the studies covered by the
present review.
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N. DE ALMEIDA-FILHO
“Pre-epidemiological” studies
In 1956, Seguin (1) reported that a large number of
mountain Indians were referred to a Peruvian psychiatric service after having passed through several
clinical sections without being diagnosed and
treated. In his account, those patients shared three
characteristics: they were Indians, they had recently
migrated, and they had problems in adjusting to city
life. The clinical picture included several non-specific body symptoms (he listed up to 15 symptoms,
classified into five groups: circulatory, gastrointestinal, respiratory, rheumatic and neurological), plus
depression and anxiety. According to Seguin, the
patients were young men and women, aged 15 to
25, most of them Indians, but also a few mestizos;
the symptoms generally appeared following a short
period of latency after the patients arrived in the
city of Lima. Seguin labeled it the “psychosomatic
disadaptation syndrome”, and submitted that it was
“only a particular and quite exaggerated case of the
very common picture of homesickness or nostalgia”, and that the syndrome should be an example
of “flight into illness” (1). Fried (2), elaborating on
Seguin’s clinical findings, suggested a “sociocultural
stress” interpretation for the etiology of the illness.
He reasoned that mental ill health was already
shown to be “statistically correlated with migration”, and provided the following explanation for
the etiology of that “syndrome”: “Since immigrants
in Europe and America are reported as having excessively high rates of physical and mental illnesses,
Indian migrants who come from Andean regions
and must endure special psychological stress, must
be even more susceptible (0 illness. If urban European immigrants in urban American centers can experience rejection and social isolation, then the rural, very backward, illiterate Indian coming to Lima
must overcome even greater cultural barriers” ( 2 ) .
“Anthropological” studies were also conducted
in Lima, Peru (3-5). Initially, these authors tried to
refute the traditional view of the migrant as a victim
of extreme biological, social and psychological
stresses, and of migration itself as a source of such
stresses. They argued that their data did not support
the hypothesis that specific stresses of migration are
responsible for the “psychosomatic disadaptation”
which Seguin and Fried described. According to
Mangin & Cohen: “We are dealing then with a con-
dition of stress rather than the specific condition of
migration, that leads to certain psychological phenomena. Thus, we might find that in the home area
of the rural mountain group extreme stress of a variety other than migration would enable one to see
the same basic picture that we reported as the ’migrant syndrome”’ (4). However, reasonable as this
statement might appear, it is based on poor quality
data and vague methodology. In addition to “traditional anthropological techniques such as observation, conversation and participation”, Mangin ( 3 )
applied the Cornell Medical Index to a convenience
sample of 65 residents in a Lima “barriada” (squatter settlement). In a later paper, this same author
presented a set of stories told by two rural migrants
in response to selected TAT cards ( 5 ) . All of these
papers purported to be preliminary results. Despite
the authors’ claims that the material would be systematically analyzed, I failed to find final reports of
these studies with definitive data analyses.
In the late 1960’s, the Instituto Venezolano d e
Accion Comunitaria conducted a small-scale survey with a stratified sample of 270 residents in a
barrio of Caracas, Venezuela, inhabited predominantly by migrants from rural areas (6). The basic
objective of that research was to study some demographic characteristics in relation to “subjective
anomie”, and to feelings of Zogm (frustration). With
this aim, they developed an adapted “aspirationachievement” questionnaire and translated Srole’s
anomie scale. Among other results, they found that
length of urban residence was positively correlated
with feelings of logro and to subjective anomie, but
not at significant levels. In addition, the results indicated that income was negatively correlated with
both sociopsychological variables at borderline levels of significance. There was no association between any of these variables and migration taken
alone. The authors did not report any controlled
analysis for potential confounding factors nor did
they try to relate their findings to any defined theoretical frame of reference.
Two of the small-scale studies were completed in
Santiago, Chile. Stephan & Stephan (7) dealt with
the relationships between role differentiation, empathy, and neurosis among 60 lower class individuals, half of whom were migrants from rural areas.
The authors did not present in detail the research
instruments nor the sampling procedures. They
EPIDEMIOLOGY OF MENTAL DISORDERS IN LATIN AMERICA
found that both groups had similar levels of “empathy”, but the urban-born group scored higher in
“role differentiation” and had lower rates of neurosis than the migrant group. No information about
matching or controlled analyses for other variables
was given. Years later, Willamson (8) applied a
shorter version of Langner’s 22-item Scale to a
“representative” sample of 111 middle class and 64
lower class individuals, to study the associations between socialization practices, social class and emotional disorders. His conclusions were that the
lower class had disproportionately more socialization problems than the middle class, and that most
symptoms were nearly twice as frequent for the
lower as for the middle class. For both studies, the
lack of methodological information prevents a better assessment of the quality of these data and the
scientific value of these results.
Finally, I should like to make a special mention
of Brody’s investigation, reported in a 1973 book
appropriately titled The Lost Ones (9), because it is
perhaps the most eclectic theoretical treatment of
the problem among all such studies conducted in
Latin America. The research was based on a sample
of 254 first admissions to an emergency hospital
and two private asylums in Rio de Janeiro, Brazil,
which was seriously biased by the arbitrary selection of sources of cases, and by the non-inclusion of
patients who had received heavy sedation directly
after admission. Two questionnaires, one “sociocultural” and the other psychopathological, were used
in that collection of data. The analysis presented is
highly descriptive, and many generalizations are
made, based on comparisons of some demographic
characteristics of the sample with the general population profile. In short, the author found a concentration of male, uneducated, “brown”, migrant,
married, unemployed, and low socioeconomic status individuals in the hospital sample. Among migrants, it was found that recent arrivals were overrepresented in the sample. He also reported a
higher proportion of married migrants than married
nonmigrants among the patients, and speculated
that unattached migrants would be more likely to
remain anonymous, untreated or involved with the
police instead of under psychiatric care (9).
Given the methodological limitations of treated
population studies in general, as well as the many
problems with that sampling method in particular,
3
Brody’s theoretical interpretations were clearly beyond the explanatory reach of the reported results.
For example, he suggested that a lack of social support from extended family members, as well as the
hostility of neighbors and the pressure of unshared
family responsibilities, “contribute to a higher risk
of mental hospitalization among recent than settled
migrants into Rio de Janeiro” (9). With the type of
research design and data analysis reported, it was
impossible to calculate crude risk estimates, as well
as relative risks for the different sociological
variables suggested above. By the same token,
Brody’s “refutation” of the social selection hypothesis - by identifying a wide array of factors, such
as the breaking of social networks, loneliness, life
change stress, urban environmental stress, marginalization, and lack of social support as more related to the patient’s illness than earlier predispositions - sounds weak and not logically connected
with the study results.
Community surveys of the first
phase (1950-1970)
The first community surveys on the relationships
between migration, cultural change and mental disorders in Latin America were conducted in Peru,
during the 19503, explicitly as an attempt to support Seguin’s clinical findings through epidemiological research. The results of these early studies are
collected in a volume titled Estudios de Psiquiatria
Social en el Peru (10). First, I will discuss, briefly,
some of their methodological issues. The Cornell
Medical Index was applied to a stratified sample of
239 residents in Mendocita, a medium-size barriada of Lima. The research team interviewed those
individuals who had “indications of psychopathology”, in order to classify them diagnostically and
collect “data about their social participation and
their morale” (10). The authors did not report any
revalidation studies of the research instrument nor
the criteria used for the screening of the suspected
population. Also, they applied the screening questionnaire to a random sample of 124 individuals
drawn from a coastal village near Lima called Pachacamac, without further psychiatric examinations.
The urban-rural comparisons, based only on the
CMI results, revealed that the urban population had
4
N. DE ALMEIDA-FILHO
higher levels of depression and aggressiveness, as
well as “greater feelings of inadequacy, a tendency
to go to pieces under stress, more distrust and a lack
of confidence in personal relationships, and an extremely high incidence of alcoholism” (11). In discussing the findings of similar levels of anxiety in
both samples, Rotondo used Redfield’s folk-urban
continuum, pointing out that the village would not
be at the extreme rural limit of the continuum, and
suggested that “the high incidence of anxiety may
be an indication of insecurity in relation to the cultural and social changes now taking place”.
With regard to comparisons between migrants
and nonmigrants within the urban slum sample, the
authors found prevalence rates of epilepsy, depressive reactions, and psychosomatic disorders to be
higher among migrants, and of psychoses and anxiety reaction to be more prevalent among nonmigrants. They classified the migrants as coastal or
mountain in origin, and reported higher rates of all
conditions but epilepsy to be greater among mountain peasants who emigrated to the city. O n the basis of the CMI results, Rotondo et al. (12) indicated
that more severe symptomatology was related to
constitutional selection, urban stress, cultural
shock, goal-striving stress, and modal personality
factors at once. This is summarized in their conclusion: “The worsening emotional symptomatology
among peasants newly arrived to Lima, who have
settled down in Mendocita, suggests a probable influence of negative factors which perhaps are related with the new living conditions and with the
demands of an urban environment, where major
stresses and uncertainties. are more present than in
the simple and rural environment they come from.
The disorientation, the detachment, the disappointment, are not unusual consequences of this urbanization phenomena. Many people who arrive in
Lima bring with them, on the other hand, great
aspirations which are not always materialized. We
have identified a picture of emotional symptoms
and inadequate attitudes in the migrant who came
from the mountains which is not as frequent among
shore-men and Lima-born. Such a symptom picture
is formed by depressive manifestations, hypochondriac preoccupations, feelings of inadequacy, attitudes of fear and sensitivity, indecison, a clear necessity of dependency, and, unlike the other inha-
bitants of Lima, a lower incidence of expressions of
aggressiveness” (12).
Ponce (13) conducted a more ambitious community survey on the same subject, also using the
CMI as the basic data collection device. The study
used a stratified subsample of 779 individuals
drawn from the whole Lima-Calla0 area. The main
objective was to study the housing, health and mental health conditions of inmigrants to that metropolitan area. In addition to an association between
mental health and socioeconomic status (measured
by an ecological classification of neighborhoods),
Ponce reported that migrants had slightly worse
mental health conditions than nonmigrants. Among
migrants, those from the mountains and rural areas
had higher rates of anxiety, depression and stress.
With regard to length of urban residence, Ponce’s
findings point to an increase in depression and anxiety and a decrease in stress levels along the time
scale. For none of these results did the author present any significance-testing of the differences between rates, nor any controlled analysis for age, sex
or other variables. However, he stratified his sample
by the socioeconomic ecological classification,
which resulted in a clear excess of cases in the lower
strata for both migrant and nonmigrant groups. In
his discussion, Ponce emphasized that “there was a
clear relationship between economic level and reactions of maladaptation, which are more intense in
the lower economic levels”, and that poverty should
be considered “an aggravating factor for the adaptation process” (13). In additon, he states that the
“cultural contrast” is also a basic element in the relationship, given that maladaptive reactions are
more severe for those who came from the mountains and from rural areas than for city-born individuals. Unlike the preceding studies, this author
did not develop or indicate a defined conceptual
framework to explain his findings.
The Harvard Project on the Social and Cultural
Aspects of Development provided some data on
the relationships between social factors and mental
health in two Latin-American countries. Its basic
findings were summarized by Inkeles & Smith in a
1970 paper (14). They applied a battery of questionnaires, including a Psychosomatic Symptoms
Test, to selected samples of rural cultivators, urban
migrants, urban service workers and industrial
EPIDEMIOLOGY OF MENTAL DISORDERS IN LATIN AMERICA
workers in six countries: Argentina, Chile, East Pakistan, India, Nigeria, and Israel. The basic hypothesis being tested was that “modernizing” experiences, and eventually “individual modernity”, were
related to psychological maladjustment. In general,
the authors concluded that their results gave virtually no support to the assertion that education, urban experience, factory work, mass media contact,
and individual modernity in developing countries
are regularly associated with increased psychic
stress. The comparisons between psychosomatic
symptom scores of newly settled migrants and of
rural dwellers revealed no significant differences.
Among factory workers, the rural-urban origin also
was not related to higher psychological stress levels,
even after matched comparisons by education and
length of factory experience. When they compared
non-industrial workers with rural dwellers, they
found that the former had higher stress levels in all
six countries. Making this last point, they conclude:
“Indeed, taking all the measures into account, moving in itself seems to be neither here nor there with
regard to psychic health. Perhaps the critical factor
is whether or not your post-migratory status permits you to become integrated into a stable, meaningful and rewarding role in your new environment. In this connection, it is revealing to consider
the fate of those who migrated to the city but did
not succeed in finding the higher paying, more secure, and generally more prestigious jobs represented by those in industry. It seems, then, that it is
much less the fact of moving, and more the kind of
reward the migrant wins after his move, which determines the presence or absence of psychosomatic
symptoms” (14).
Several other surveys carried out in Latin-American urban areas did not directly deal with the issue
of social factors and mental illness, even though
they provided valuable information on the overall
unequal distribution of these conditions. Since the
objective of these studies was to generate preliminary data to be used to plan community mental
health programs, the authors did not attempt to integrate their findings into any explanatory frame of
reference (15-20).
Epidemiological studies of the
second phase (1970-present)
Coutinho (21) completed an epidemiological study
5
of psychiatric disorders in Maciel, a small slum of
Salvador, Brazil, with a census of all residents (approximately 1600 individuals) in the area. He employed a 38-item screening instrument developed
specifically for that research, which was previously
tested for validity. Cases indicated as suspect by the
questionnaire score were interviewed by the author
for diagnostic purposes. Coutinho reported an extremely high prevalence of mental illness, around
49%, mostly alcoholism and neurosis (both with a
rate of 23%), with higher specific rates for females,
unmarrried, uneducated, and migrants. The differences for the migrant-nonmigrant comparison,
however, were not statistically significant. The author oriented the interpretation of his findings toward a mixed cultural disintegration and “culture of
poverty” approach (21).
The most recently reported research on the
problem conducted in Peru was more concerned
with the relations between social environmental
stresses and illness in general, but it included emotional symptoms as well (22). The researchers took
a stratified random sample of 325 adults, all from
the lower socioeconomic class, who lived in the
town of Cocachacra in southern Peru. They applied
to that sample a health questionnaire adapted from
the Cornell Medical Index and from the KaiserPermanente Medical Questionnaire, translated into
Spanish and Quechua. No validation or reliability
testing procedures were reported. Dutt & Baker
(22) reported higher levels of emotional symptoms
for migrants compared with nonmigrants, and,
among migrants, those who came from mountain
areas had higher rates than those who came from
low-altitude environments. These differences were
significant for men but not for women, and for older males but not for youngsters. Among low-altitude migrants, the time since migration was positively correlated to stress levels, while the opposite
was true for mountain migrants, regardless of sex
differences in both cases. The authors examined
three possible hypotheses and concluded that poor
living conditions and selective migration did not explain their results. The remaining hypothesis, that a
“change of physical and cultural environment may
be detrimental to health and the more extreme the
change, the more serious the health loss”, was considered as the most plausible one (22).
Santana (23) reported preliminary results of an-
6
N. DE ALMEIDA-FILHO
other epidemiological study of mental disorders
conducted in Salvador, Brazil, with a representative
sample of 1.500 adults living in an urban squatter
settlement. The author employed the QMPA
(Adult Psychiatric Morbidity Questionnaire) as the
study screening instrument, which was tested for
sensitivity and specificity by means of a 2-step
study. As a second phase of the data-collection,
psychiatrists double-blindly interviewed all suspects
identified by the instrument and a sub-sample of
the non-suspected.
Santana found an overall prevalence of psychiatric disorders of 20%, with neurosis (14.5%) and
alcoholism (3.5%) as the most frequent diagnoses.
Among specific findings, females, older, less educated, and lower class showed higher prevalence
rates. In relation to migration, the finding that migrants have higher rates than nonmigrants, even
controlling for age and sex, and that recent arrivals
have higher rates than late arrivals, did not reach
statistical significance. The author argued that sociocultural theories were not adequate to explain
her results, which should be better interpreted
through concepts of political economy. While she
pointed to several important issues, mainly with respect to epidemiological problems of the survey approach in epidemiological studies of mental disorders, Santana did not elaborate a clear theoretical
model to deal with the problem of political and
economic factors involved with phenomena of
mental ill health (23).
Micklin & Leon (24) reported perhaps the most
sophisticated of all large-scale specific studies on
the association between social factors and psychological disturbance in Latin America which was
carried out in the Colombian city of Cali. They applied to a multistage sample of 681 respondents, all
aged between 20 and 59 years, employed or seeking work, a questionnaire on occupational and residential history, as well as a Spanish translation of
Langner’s 22-item scale. The study’s independent
variables received detailed definitions, with the distinction of “migrant status”, classified according to
six life-cycle intervals, from “migrant type”, classified by size of place of residence. In addition, they
also defined “social mobility types”, based on a
cross-classification of respondents’ and fathers’ occupational status, with five categories.
The findings of this study clearly indicate that
sex, educational level and social mobility experience were associated with levels of psychiatric disturbance as measured by the symptom index. Females, illiterate, and lower class people had the
highest scores. In terms of social mobility, Micklin
& Leon found that the stable upper class had the
lowest mean scores, while among the mobiles, skidders showed the highest levels. Females consistently
had more symptomatology than males throughout
all the social mobility categories. The findings on
migration are far more complicated to analyze.
There were no clear-cut differences in scores by migrational status, once controlled for life-cycle interval of migration. With regard to the type of migration, the authors found that, for definitive moves,
which implied urban residence from ages 5. and 1.5
to present, individuals of rural origin consistently
had higher scores in the symptom scale. Migrants
from other large urban areas had the lowest score
levels, regardless of the life-cycle of migration. Analyses of variance of these findings indicated that
when “all variables were considered simultaneously, however, the effect of migration on psychiatric disturbance virtually disappears. Sex, educational attainment and social mobility type, in that
order, emerge as the important determinants of average symptom scores” (24). Although they had
suggested, in their presentation of the problem, that
mobility should be treated as a subcategory of social change, the authors discussed their findings
only in terms of methodological problems in the research design and in the data analysis, with references to its implications for “primary prevention”
and for future research in the field.
Almeida-Filho (25) investigated the relationships between social factors and mental health in
the same sample studied by Santana (23) in Bahia,
Brazil. He found stress levels to be higher among
migrants than nonmigrants, and among individuals
outside the labor market (unemployed and underemployed) compared with those regularly working.
In addition, there was no association between stress
levels and the time of urban residence or the cultural background. After controlling for combined and
isolated effects of nine potential confounding factors through covariance analyses, only the hypotheis of a positive association between placement
into labor force and mental health was not falsified.
The author concluded that “geographical mobility
EPIDEMIOLOGY OF MENTAL DISORDERS IN LATIN AMERICA
as a life-change or as a culture-change may not be
the basic process of interest for the study of social
factors and mental illness in Third World social formations. Indeed, the fundamental process that
should be taken into account in such research is the
process of formation of an urban labor force and a
reserve industrial army, essential conditions for the
dependent capitalist development in those countries” (25).
Some critical points
The review of literature presented above provokes
the easy conclusion that we are facing a confused
picture, with a wide variety of methodologies producing contradictory results. In addition, one may
think that scientific research into the relationships
between social factors and mental illness has failed
to contribute to the development of a coherent set
of theories on the subject matter. But these conclusions are too easy and simple, and they may well be
equivocal. A closer look at the overall content of
this body of literature reveals not only some consistent findings, but also structured (even though
sometimes not explicit) systems of explanation at
the basis of such research. In other words, there is
an order in that “disorder”.
The investigations reviewed above had basic methodological problems, which ranged from several
kinds of sampIing biases to the use of nonvalidated
translations of foreign symptom scales as a measurement of individual mental health status. From
this perspective, two af the most methodologically
sophisticated studies (14,24) had similar sampling
bias, insofar as both did not include urban unemployed or underemployed in their samples. On the
other hand, only the Brazilian investigations
(20,21,23,25) employed screening questionnaires
especially developed for their socio-cultural context, as well as tested for validity and reliability. In
addition, except for Inkeles & Smith (14), Micklin
& Lion (24) and Almeida-Filho ( 2 5 ) , these studies
did not control for the effect of potentially confounding factors. All these investigations had crosssectional designs, which severely limited the validity
of their conclusions.
In terms of theory, how did researchers in this
field treat their findings? How did they arrange
them into logical structures of explanation? A
7
superficial content analysis of this body of scientific
literature made possible the identification of nine
basic factors that have been regarded as causes, determinants, or independent variables in this research. As these factors are not mutually exclusive,
different combinations of them have been used by
some authors to build their proposed models of
sociocultural causation of mental illness. They are
here tentatively classified as part of a “sociologism”
or a “culturalism” orientation. As part of a “sociologism” orientation, I include the notions of urban
stress, goal-striving stress, life change, social support, and labeling. As explanations oriented by a
“culturalism” approach to the problem, I will consider the notions of nostalgia (loss of culture), marginal man, cultural shock, and acculturation.
The idea of urban stress is intimately connected
with an ecological paradigm, as developed by the
so-called Chicago school of human ecology, during
the 1930’s. For these authors, the urban environment can be a source of many stressors that would
make a normal personality development impossible, and would provoke abnormal behavioral responses. According to Faris & Dunham (26), in
some areas in the inner city, social life “is terrifically
harsh, intensely individualistic, highly competitive,
extremely crude, and often violently brutal, and
consequently more personalities have difficulty in
coping with it.” Applying this interpretation to explain higher rates of mental disorders among migrants to urban areas, one could say that people
who migrate tend to live in those deprived urban
areas, the slums, where they become easy targets for
those psychosocial stressors produced by such a
“morbid” environment. Among Latin American
studies, Rotondo ( l l ) , Brody (9), and Coutinho
(24) employed this hypothesis without adequate
connections to their respective frames of reference.
From a critical standpoint, on the one hand, such
an explanation indicates an abstract and loosely defined entity, the urban environment, as a source of
determinants of psychopathology; on the other
hand, it does not seek the basic conditions which
forced the poor to get settled down, and to remain
in what are, to follow their argument, the most unhealthy of all places.
The notions of goal-striving stress, life change,
social support and labeling will not be discussed
here in detail because they have not been very influ-
8
N. DE ALMEIDA-FILHO
ential in research covered by this review. Stephan &
Stephan (7) and the IVAC survey (6) direct their
analyses toward a goal-striving model, while only
Micklin & Leon (24) mention the issue of life
change in their explanation of mental health levels.
Lack of social support and labeling phenomena
were considered by Brody (9) as related to the risk
of mental hospitalization among underprivileged
social groups.
The idea that psychopathology could be related
to the experience of suddenly broken ties with the
culture of origin was developed mainly among European authors, who were more concerned with labor immigration into certain countries like France,
West Germany and Switzerland (27). In the literature sampled here, Seguin is the only one who explicitly mentioned this factor as a basic explanation
for the etiology of his “migrant psychosomatic syndrome”. The notion “cultural marginality” was first
proposed by anthropologists concerned with the issue of mental disorders and acculturation processes
(28). Basically, this notion attempts to explain psychological problems of persons caught between two
cultural systems, through stresses and anxieties related to this experience of double rejection. Among
the Latin-American studies, Fried’s “sociocultural
stress” and Brody’s explanation of the mental illnesses of Black migrants to Rio de Janeiro seem to
be oriented by such a theory of the “marginal man”.
Nonetheless, both interpretations, loss of culture
and cultural marginality, are not part of the main
stream of scientific research in this particular field.
Undoubtedly the dominant paradigm in this literature has been the notion of culture change, and
its correlate, modernization. As a result, in the literature concerned with the social and psychological
consequences of modernization, predominantly
produced by anthropologists, a general trend has
been set, in which the notion of culture has been
ascribed the status of a basic variable in causal
models (29).
Cassel et al. (30) give a model of health implications of cultural change which is perhaps paradigmatic of such an approach. These authors are explicitly concerned with acculturation as manifested by
geographical moves from a rural traditional context
to a modern industrial society. They assume that a
traditional folk culture provides the rural migrant
with a “design for living quite appropriate to the so-
cial situation of the folk community, but a culture
adapted to rural life may increase rather than decrease the stresses of the rural migrant to an urban
situation” (30). This model holds that rural-urban
migration may lead to cultural incongruency, depending upon the “fit” between the migrant’s culture and his new social situation. Such incongruities, in turn, tend to arouse excessive stress on the
migrant’s affiliative network and on the individual
personality that may or may not be absorbed by
either system. In summary, the theory states that the
nonabsorption of those “sociocultural stresses” is
associated with the onset of psychiatric and psychosomatic symptoms.
Although most of the research on the subject carried out in Latin America assumed theoretical
models based on the notion of modernization
(1,2,9-13,21,22), none made explicit such an elaborate model as Cassel et al. (30). The Peruvian
studies did mention a cultural shock mechanism to
account for the higher rates of psychological disorders among mountain Indian migrants to the cities.
Caravedo et al. (10) went further in suggesting a
conflict between modal personality traits and the
urban culture, while Ponce (13) used the expression
“cultural contrast” to describe better the preconditions of the cultural shock phenomenon. Indeed,
cultural shock implies the notions of adaptation and
cultural distance, in that large differences in symbolic patterns would lead to uncertainty and
unpredictability, with the subsequent arousal of levels of anxiety and stress in the individual. In this
sense, cultural shock is viewed as a consequence of
the migration process (which therefore is taken as a
change of cultures instead of a culture change), and
it is regarded as the immediate determinant of psychiatric disturbance.
On the other hand, the failure in finding a clean
positive association between psychopathology and
migration after controlled analyses led some authors to suggest alternative interpretations. Micklin
& Leon (24), who initially considered migration as
a life crisis causally related to psychological maladaptation, pointed out that insertion in the urban SOcia1 mobility system would be the main factor involved in being emotionally disturbed under such
circumstances. In relation to this issue, Inkeles &
Smith (14) made a similar suggestion. Despite indicating that, in this particular aspect, the problems of
EPIDEMIOLOGY OF MENTAL DISORDERS IN LATIN AMERICA
modernization in developing societies could be better interpreted as a process of formation of an urban labor force instead of a cultural change process,
these authors did not present any theoretical model
to explain their findings. Other authors (23,31),
have proposed a comprehensive model for better
understanding of such processes. According to
them, the so-called development process places increasing numbers of the traditional population into
a market economy, as a result of the penetration of
capitalism into the rural sector. Following upon
such changes, social classes may lose their position
in the social structure, and their members, therefore, may undergo a process of absorption by the
new emerging classes or be displaced from the new
social order, and both moves may be simultaneous
with geographical population movements. For Almeida-Filho (31), particularly in relation to the
manner of insertion into the modern productive
system, the condition of being displaced from the
labor force implies, for the individual, extreme uncertainty and social stress, with temporary or permanent repercussions at a psychological level.
Conclusion
The present review shows an unexpected concentration of scientific efforts around the same basic
question, the psychosocial outcomes of economic
development in a given geographic area. This fact
may be explained by the massivity and pervasiveness of the process of socio-economic change in
Latin America, compelling social scientists as well
as epidemiologists to try to understand better the
health consequences of such social phenomena. It is
also revealing that, in this area of research, the
paucity in methodology has been somewhat balanced by a wide variety of theoretical approaches.
In any event, despite all weaknesses, difficulties and
lack of exchange with scientists in developed countries, social epidemiologic research in Latin America can undoubtedly contribute to the overall advancement of the field of psychiatric epidemiology.
In this regard, I hope that the present review will be
able to disclose to epidemiologists of developed
countries some of the questions, problems and findings generated by Latin American researchers.
9
Acknowledgement
This paper was originally written when the author was a Rockefeller Foundation Fellow at the Department of Epidemiology of
the UNC School of Public Health at Chapel Hill. Berton Kaplan,
Sherman James and Nancy Scheper-Hughes gave helpful criticisms and editorial help on an earlier manuscript. An anonymous
reviewer of APS An contributed much to the present version of
the paper.
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Address:
Naomar de Afmeida-Filho, M.D.
Departamento de Medicina Preventiva
FMUFBA
Rua Padre Feijo, 29-4th Floor
Canela - Salvador - Bahia
Brazil CEP 40000