Psychiatry and Primary Care1Prevalence of physical symptoms and their association with race/ethnicity and acculturation in the United States
Introduction
General physical symptoms are prevalent in the community and are associated with functional impairment, psychopathology and health service use [1], [2], [3], [4], [5]. Although many believe that physical symptoms vary across cultures, the data suggesting associations between race/ethnicity, acculturation and physical symptoms are inconsistent. Some have suggested that physical symptoms themselves or their presentation as an expression of distress is especially common among racial/ethnic minorities [6], [7], [8], [9], [10], [11], [12] and that the process of acculturation may shape the expression of physical symptoms among racial/ethnic minorities in the United States [13]. In contrast, there are evidence that physical symptoms are common across countries and cultures [3], [14], evidence of considerable cross-cultural overlap in idiopathic or unexplained physical symptoms [15] and studies indicating that physical symptoms are more common among non-Latino White Americans than certain racial/ethnic minorities [2], [5].
Because physical symptoms are the most common reason for primary care visits, are a common clinical presentation of mental disorders and are associated with disproportionate use of general medical rather than mental health services for mental health care [1], [2], [14], [16], it is important to understand how race/ethnicity and acculturation are associated with physical symptoms in the general population. Prior epidemiological data on lifetime physical symptoms in the community derive from the Epidemiological Catchment Area (ECA) studies of the early 1980s [17], which revealed mixed results on how lifetime physical symptoms are associated with race/ethnicity. Findings from the Los Angeles ECA study revealed a higher prevalence of physical symptoms among Latina women compared to White women, but this pattern was not evident among men [6]. Compared to Whites and Mexican Americans in the ECA sample, island Puerto Ricans in a parallel survey had higher rates of somatization disorder and abridged somatization [8]. In contrast, in Los Angeles, Latinos, African Americans and Asian Americans were significantly less likely than Whites to meet criteria for somatization disorder [18]. Across respondents from four communities in the study, there were few differences in lifetime physical symptom prevalence by race, although most symptoms were slightly more common among White compared to non-White respondents [2]. Among the full ECA sample, after adjustment for sociodemographic variables, compared to Whites, significantly more African Americans but fewer Asian Americans met the full criteria for somatization disorder, whereas rates did not differ among Latinos and Whites [18]. Although the authors of the latter report conclude that the assumption that somatization is more common among Latino and Asian Americans may be erroneous [18], nevertheless, the notion that somatization is particularly common among racial/ethnic minority groups was embedded into the highly influential Surgeon General's report and the subsequent supplement on culture, race and ethnicity [19], [20]. Physical symptoms were not included in recent epidemiological surveys such as the National Comorbidity Survey, the National Comorbidity Survey replication or the National Survey of American Life. Consequently, the National Latino and Asian American Survey (NLAAS) is the only nationally representative survey with data on the prevalence of physical symptoms in the United States.
The present study reports the prevalence of physical symptoms and their association with race/ethnicity and acculturation among the NLAAS sample, a nationally representative community-based sample of non-Latino White, Latino and Asian Americans. This research tests the following two hypotheses: (1) Latino and Asian Americans experience more physical symptoms than non-Latino White Americans, and (2) less acculturated Latino and Asian Americans experience more physical symptoms than their more acculturated counterparts.
Section snippets
Participants
This study analyzed data from the NLAAS, part of the National Institute of Mental Health Collaborative Psychiatric Epidemiology Studies [21]. Participants were a nationally representative sample of noninstitutionalized adults (age 18 years or older) living in one of the 50 states or the District of Columbia. The final NLAAS sample consisted of 2554 Latino Americans (Mexican, Puerto Rican, Cuban and “other”), 2095 Asian Americans (Chinese, Vietnamese, Filipino and “other”) and 215 non-Latino
Sociodemographic data
Table 1 reports the demographic characteristics for Latino, Asian and non-Latino White participants adjusted for age and gender. Relative to non-Latino Whites, more Latinos had low income, whereas both Latinos and Asians were more likely to be married or cohabitating, have lower education, be foreign-born, be with foreign-born parents and have lived a smaller proportion of their lives in the United States.
Clinical data
After adjustment for age and gender, psychological distress was higher among Latinos than
Discussion
The prevalence of physical symptoms in the United States is associated with race/ethnicity and acculturation. Overall, non-Latino Whites and Latinos report a similar number of physical symptoms, and the percentages experiencing any physical symptom or a high symptom burden are similar. Some prior research has found higher rates of physical symptoms among Latinos [6], [8], [18], whereas our findings indicate that rates do not differ once the influence of other individual characteristics are
Acknowledgments
The NLAAS data used in this analysis were provided by the Center for Multicultural Mental Health Research at the Cambridge Health Alliance. The authors gratefully acknowledge financial support from the Dupont–Warren and Livingston Fellowships of the Department of Psychiatry at Harvard Medical School, training grant T32 MH20021 from the National Institute of Mental Health, National Institutes of Health Research Grant U01 MH62209 funded by the National Institute of Mental Health as well as the
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Recent epidemiologic studies have found that most patients with mental illness are seen exclusively in primary care medicine. These patients often present with medically unexplained somatic symptoms and utilize at least twice as many health care visits as controls. There has been an exponential growth in studies in this interface between primary care and psychiatry in the last 10 years. This special section, edited by Jürgen Unutzer, M.D., will publish informative research articles that address primary care-psychiatric issues.