-
[show abstract]
[hide abstract]
ABSTRACT: Racial and ethnic disparities in mental health care access in the United States are well documented. Prior studies highlight the importance of individual and community factors such as health insurance coverage, language and cultural barriers, and socioeconomic differences, though these factors fail to explain the extent of measured disparities. A critical factor in mental health care access is a local area's organization and supply of mental health care providers. However, it is unclear how geographic differences in provider organization and supply impact racial/ethnic disparities. The present study is the first analysis of a nationally representative U.S. sample to identify contextual factors (county-level provider organization and supply, as well as socioeconomic characteristics) associated with use of mental health care services and how these factors differ across racial/ethnic groups. Hierarchical logistic models were used to examine racial/ethnic differences in the association of county-level provider organization (health maintenance organization (HMO) penetration) and supply (density of specialty mental health providers and existence of a community mental health center) with any use of mental health services and specialty mental health services. Models controlled for individual- and county-level socio-demographic and mental health characteristics. Increased county-level supply of mental health care providers was significantly associated with greater use of any mental health services and any specialty care, and these positive associations were greater for Latinos and African-Americans compared to non-Latino Whites. Expanding the mental health care workforce holds promise for reducing racial/ethnic disparities in mental health care access. Policymakers should consider that increasing the management of mental health care may not only decrease expenditures, but also provide a potential lever for reducing mental health care disparities between social groups.
Social Science [?] Medicine 02/2013; · 2.70 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: There is evidence that ethnic/racial minorities are conferred differential risk for substance use problems based on where they live. Despite a burgeoning of research focusing on the role of neighborhood characteristics on health, limited findings are available on substance use. Our study uses nationally representative data (N=13,837) to examine: (1) what neighborhood characteristics are associated with risk of substance use disorders?; (2) do the associations between neighborhood characteristics and substance use disorders remain after adjusting for individual-level factors?; and (3) do neighborhood characteristics associated with substance use disorders differ by race/ethnicity after adjusting for individual-level factors?
Data were drawn from the Collaborative Psychiatric Epidemiology Studies (CPES-Geocode file) with 836 census tracts. Analyses included African Americans, Asians, Caribbean Blacks, Latinos, and non-Latino whites. Separate logistic regression models were fitted for any past-year substance use disorder, alcohol use disorder, and drug use disorder.
Living in more affluent and residentially unstable census tracts was associated with decreased risk of past-year substance use disorder, even after adjusting for individual-level factors. However, when we investigated the interaction of race/ethnicity and census latent factors with past-year substance use disorders, we found different associations for the different racial/ethnic groups. We also found different associations between neighborhood affluence, residential instability and any past-year substance use and alcohol disorders by nativity.
Characteristics of the environment might represent differential risk for substance disorders depending on a person's ethnicity/race and nativity status.
Drug and alcohol dependence 06/2012; 125 Suppl 1:S35-43. · 3.60 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To estimate whether racial/ethnic behavioral health service disparities are likely to be reduced through insurance expansion coverage expected through the Affordable Health Care Act.
Pooled data from the nationally representative NIMH Collaborative Psychiatric Epidemiological Studies (2001-2003).
We employ a novel reweighting method to estimate service disparities in the presence and absence of insurance coverage.
Access to care was assessed by whether any behavioral health treatment was received in the past year. Need was determined by presence of prior year psychiatric disorder, psychiatric diagnoses, physical comorbidities, gender, and age.
Improving patient education and availability of community clinics, combined with insurance coverage reduces service disparities across racial/ethnic groups.However, even with expanded insurance coverage, approximately 10 percent fewer African Americans with need for behavioral health services are likely to receive services compared to non-Latino whites while Latinos show no measurable disparity.
Expansion of insurance coverage might have different effects for racial/ethnic groups, requiring additional interventions to reduce disparities for all groups.
Health Services Research 06/2012; 47(3 Pt 2):1322-44. · 2.16 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The objective was to analyze disparities in unmet need for substance use treatment and to observe variation across different definitions of need for treatment.
Data were analyzed from the 2002 to 2005 National Survey of Drug Use and Health and the National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regressions estimated the likelihood of specialty substance use treatment across the two data sets. Parallel variables for specialty, informal and any substance abuse treatment were created. Perceived need and normative need for substance use treatment were defined, with normative need stratified across lifetime disorder, past twelve month disorder, and heavy alcohol/any illicit drug use. Treatment rates were analyzed, comparing Blacks, Asians and Latinos to non-Latino whites across need definitions, and adjusting for age, sex, household income, marital status, education and insurance.
Asians with past year substance use disorder had a higher likelihood of unmet need for specialty treatment than whites. Blacks with past year disorder and with heavy drinking/illicit drug use had significantly lower likelihood of unmet need. Latinos with past year disorder had a higher likelihood of unmet need for specialty substance abuse treatment. Asians with heavy drinking/illicit drug use had lower likelihood of unmet need.
The findings suggest that pathways to substance abuse treatment differ across groups. Given high rates of unmet need, a broad approach to defining need for treatment is warranted. Future research to disentangle social and systemic factors from factors based on diagnostic criteria is necessary in the identification of need for treatment.
Drug and alcohol dependence 06/2012; 125 Suppl 1:S44-50. · 3.60 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Although many believe that low rates of perceived mental health need and service use among racial/ethnic minorities are due, in part, to somatization, data supporting this notion are lacking. This study examined two hypotheses: (1) increased physical symptoms are associated with lower perceived need for mental health services and actual service use; and (2) physical symptoms are most strongly associated with perceived mental health need and service use among first-generation individuals. Data come from the National Latino and Asian-American Study, a nationally-representative household survey in the United States conducted from 2002 to 2003. Participants reported on the presence of fourteen physical symptoms within the past year. Perceived mental health need was present for individuals who endorsed having an emotional or substance use problem or thinking they needed treatment for such a problem within the past year. After adjusting for sociodemographic and clinical covariates, the number of physical symptoms was positively associated with perceived mental health need and service, an effect that differed by generation. Among first-generation individuals, physical symptoms were associated with increased perceived need and service use. Physical symptoms were not significantly associated with perceived need or service use among third-generation Latinos, but were associated with service use among third-generation Asian-Americans. Physical symptoms do not appear to interfere with mental health problem recognition or service use. In contrast, individuals, especially of the first-generation, with more physical symptoms were more likely to perceive need for and utilize mental health services. Our findings do not support the notion that physical symptoms account for low rates of perceived mental health need and service use among Latino and Asian-Americans.
Social Science [?] Medicine 05/2012; 75(6):1128-33. · 2.70 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Physical symptoms are common and a leading reason for primary care visits; however, data are lacking on their prevalence among racial/ethnic minorities in the United States. This study aimed to compare the prevalence of physical symptoms among White, Latino and Asian Americans, and examine the association of symptoms and acculturation.
We analyzed data from the National Latino and Asian American Study, a nationally representative survey of 4864 White, Latino and Asian American adults. We compared the age- and gender-adjusted prevalence of 14 physical symptoms among the racial/ethnic groups and estimated the association between indicators of acculturation (English proficiency, nativity, generational status and proportion of lifetime in the United States) and symptoms among Latino and Asian Americans.
After adjusting for age and gender, the mean number of symptoms was similar for Whites (1.00) and Latinos (0.95) but significantly lower among Asian Americans (0.60, P<.01 versus Whites). Similar percentages of Whites (15.4%) and Latinos (13.0%) reported three or more symptoms, whereas significantly fewer Asian Americans (7.7%, P<.05 versus Whites) did. In models adjusted for sociodemographic variables and clinical status (psychological distress, medical conditions and disability), acculturation was significantly associated with physical symptoms among both Latino and Asian Americans, such that the most acculturated individuals had the most physical symptoms.
The prevalence of physical symptoms differs across racial/ethnic groups, with Asian Americans reporting fewer symptoms than Whites. Consistent with a "healthy immigrant" effect, increased acculturation was strongly associated with greater symptom burden among both Latino and Asian Americans.
General hospital psychiatry 03/2012; 34(4):323-31. · 2.67 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The present study focused on experiences of discrimination and acculturative stress and their potential role in depression among South Asians. Drawing from the National Latino and Asian American Study (NLAAS), we examined differences in perceived discrimination and depression among South Asians, other Asian subgroups (e.g., Chinese, Vietnamese, Filipino), and non-Hispanic Whites, and differences in acculturative stress between South Asians and other Asian subgroups. We further examined the relationship between perceived discrimination and depression, the relationship between acculturative stress and depression among the various ethnic groups, and the moderating role of family support and peer support in the relationship between perceived discrimination and depression in the South Asian sample (N = 169). There were mixed findings with respect to differences on perceived discrimination and acculturative stress across different Asian subgroups. Multiple regression analyses revealed that perceived discrimination was positively associated with depression for South Asians. Family support was found to moderate the relationship between perceived discrimination and depression in the South Asian sample. Implications of the findings for research and practice with South Asians are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Asian American Journal of Psychology. 02/2012; 3(1):3-16.
-
[show abstract]
[hide abstract]
ABSTRACT: There are no current psychiatric epidemiological studies examining prevalence estimates of neurasthenia across different racial and ethnic groups in the US. This study compares prevalence rates of International Classification of Diseases (ICD-10) lifetime and 12-month neurasthenia across racial/ethnic groups in the US (Asians, African Americans, Latinos, and non-Latino Whites) and by levels of acculturation. We examine comorbidity of neurasthenia with DSM-IV psychiatric disorders and the association between neurasthenia and impairment.
We used a pooled sample (N = 10, 118) from two nationally representative household surveys of adults ages 18 years and older: the National Comorbidity Survey-Replication (NCS-R) and the National Latino and Asian American Study (NLAAS).
Among the total sample, the adjusted prevalence rates of lifetime and 12-month neurasthenia with exclusionary criteria were 2.22 and 1.19%. The adjusted prevalence rates for lifetime and 12-month neurasthenia without exclusionary criteria were 4.89 and 2.80%. There were significant racial/ethnic group differences in prevalence for both lifetime and past-year neurasthenia, with Asians reporting significantly lower prevalence of neurasthenia than their non-Latino White counterparts. Less acculturated individuals were at a decreased risk for lifetime and past-year neurasthenia. Lifetime neurasthenia was associated with increased odds of meeting lifetime criteria for any depressive, any anxiety, and any substance use disorder. Respondents with lifetime or past-year neurasthenia had significantly greater levels of impairment compared to those without neurasthenia.
Neurasthenia is a prevalent condition deserving further research attention given its comorbidity with other psychiatric disorders and its association with functional impairment.
Social Psychiatry 02/2012; 47(11):1733-44. · 2.05 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Social anxiety disorder (SAD) is increasingly being recognized as a prevalent, unremitting, and highly comorbid disorder, yet studies focusing on this disorder among US Latinos and immigrant populations are not available. This article evaluates ethnic differences in the prevalence and comorbidity of SAD as well as the clinical and demographic characteristics associated with SAD. Cultural and contextual factors associated with risk of SAD are also examined within the Latino population more specifically.
Data are analyzed from the National Latino and Asian American Study and the National Comorbidity Survey-Replication. Both studies utilized the World Health Organization-Composite International Diagnostic Interview, which estimates the prevalence of lifetime and 12-month psychiatric disorders according to DSM-IV criteria.
Latinos reported a lower lifetime and 12-month SAD prevalence and a later age at onset than US-born non-Latino whites. On the other hand, Latinos diagnosed with 12-month SAD reported higher impairment across home, work, and relationship domains than their non-Latino white counterparts. Relative to non-Latino whites, Latinos who entered the United States after the age of 21 years were less likely to have lifetime SAD comorbidity with drug abuse and dependence and more likely to report lifetime SAD comorbidity with agoraphobia.
The pattern of risk and associated characteristics of SAD varies for Latinos as compared to non-Latino whites. This is reflected by differences between these 2 groups across SAD prevalence, onset, impairment, and comorbidity. The particularly high comorbidity found with agoraphobia among Latinos who arrive in the United States as adults suggests that cultural factors and timing of immigration play a role in the manifestation and course of anxiety disorders. Interventions designed to decrease the levels of impairment associated with SAD are needed as well as efforts to target Latinos suffering from this disorder, specifically.
The Journal of Clinical Psychiatry 08/2011; 72(8):1096-105. · 5.80 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The study compared the prevalence, correlates of functional impairment, and service utilization for eating disorders across Latinos, Asians, and African Americans living in the United States to non-Latino Whites.
Pooled data from the NIMH Collaborative Psychiatric Epidemiological Studies (CPES;NIMH, 2007) were used.
The prevalence of anorexia nervosa (AN) and binge-eating disorder (BED) were similar across all groups examined, but bulimia nervosa (BN) was more prevalent among Latinos and African Americans than non-Latino Whites. Despite similar prevalence of BED among ethnic groups examined, lifetime prevalence of any binge eating (ABE) was greater among each of the ethnic minority groups in comparison to non-Latino Whites. Lifetime prevalence of mental health service utilization was lower among ethnic minority groups studied than for non-Latino Whites for respondents with a lifetime history of any eating disorder.
These findings suggest the need for clinician training and health policy interventions to achieve optimal and equitable care for eating disorders across all ethnic groups in the United States.
International Journal of Eating Disorders 07/2011; 44(5):412-20. · 2.95 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Epidemiologic studies of obesity have not examined the prevalence and relationship of mental health conditions with obesity for diverse ethnic and racial populations in the United States.
(1) To assess whether obesity was associated with diverse psychiatric diagnoses across a representative sample of non-Latino whites, Latinos, Asians, African-Americans, and Afro-Caribbeans; and (2) to test whether physical health status, smoking, sociodemographic characteristics, and psychiatric comorbidities mediate any of the observed associations.
Our analyses used pooled data from the NIMH Collaborative Psychiatric Epidemiology Surveys (CPES). Analyses tested the association between obesity and psychiatric disorders in a diverse sample of Americans (N=13,837), while adjusting for factors such as other disorders, age, gender, socioeconomic status, smoking and physical health status (as measured by chronic conditions and WHO-DAS scores) in different models.
The relationship between obesity and last-year psychiatric disorders varied by ethnicity/race. The likelihood of having mood or anxiety disorder was positively associated with obesity for certain racial/ethnic groups, but was moderated by differences in physical health status. Substance-use disorders were associated with decreased odds for obesity in African-Americans.
The role of physical health status (as measured by chronic conditions and WHO-DAS scores) dramatically changes the pattern of associations between obesity and psychiatric disorders, suggesting the important role it plays in explaining differential patterns of association across racial and ethnic groups.
Eating behaviors 01/2011; 12(1):1-8.
-
[show abstract]
[hide abstract]
ABSTRACT: Limited research in health valuation analyzes samples with high proportions of racial/ethnic minorities within the United States. The primary objective was to explore patterns of health valuation across race/ethnicity using the Collaborative Psychiatric Epidemiology Surveys. A secondary objective was to analyze whether mental health disorder and immigrant status were associated with these estimates.
Health valuation questions using different metrics (time and money) were analyzed. Ordered logit models stratified across poor and moderate health tested differences by race/ethnicity, with mental health disorder and immigrant status as covariates.
Asians in moderate health and Latinos were willing to pay more for health than non-Latino whites. Asians in moderate health were willing to trade more time for health. Latinos in poor health were less willing to trade time and gave disproportionate zero-trade responses. Lifetime history of anxiety disorder was positively associated with both metrics. Immigrant status confounded money valuation for Asians in moderate health, and time valuation for Latinos in poor health.
Health valuation estimates vary across race/ethnicity depending upon the metric. Time valuation scenarios appear less feasible for Latinos in poor health. More research is necessary to understand these differences and the role of immigrant status in health valuation.
Quality of Life Research 12/2010; 19(10):1529-40. · 2.30 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The impact of language proficiency as a potential contributor to ethnic disparities in mental health care has received less attention than other factors. Data from the National Latino and Asian American Study were examined to assess the impact of limited English proficiency (LEP) on access to and quality of mental health care for community-dwelling Latino and Asian Americans with mental disorders.
English-proficient (EP) and LEP individuals with mental disorders were compared on lifetime use of healthcare services for a mental disorder, duration of untreated disorders, receipt of minimally adequate care, and barriers to treatment (eg, lack of identification of need for treatment, language barriers, and embarrassment or discomfort related to treatment).
Compared with EP individuals, LEP individuals with mental disorders were significantly less likely to identify a need for mental health services, experience longer duration of untreated disorders, and use fewer healthcare services for mental disorders, particularly specialty mental health care. Receipt of minimally adequate care did not differ significantly by language proficiency. Embarrassment and discomfort were not more common among LEP individuals. Perceived need for treatment predicted lifetime mental healthcare use, whereas embarrassment and discomfort did not.
Among Latino and Asian Americans with mental disorders, LEP contributes to disparities in access to care and longer duration of untreated disorders. Potential disparities in quality of care were difficult to detect in the context of low overall rates of mental healthcare use and quality of care among both LEP and EP individuals.
Medical care 11/2010; 48(12):1097-104. · 3.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To compare lifetime and 12-month prevalence of psychiatric disorders in a nationally representative sample of older Latino, Asian, African-American, and Afro-Caribbean adults with that of older non-Latino white adults.
Cross-sectional study conducted in 2001 through 2004.
Urban and rural households in the contiguous United States.
Two thousand three hundred seventy-five community-dwelling residents aged 60 and older living in noninstitutional settings. Data are from the National Institutes of Mental Health Collaborative Psychiatric Epidemiological Studies.
The World Mental Health Composite International Diagnostic Interview assessed lifetime and 12-month psychiatric disorders. Bayesian estimates compared psychiatric disorder prevalence rates of ethnic and racial groups.
Older non-Latino whites exhibited a greater prevalence on several lifetime diagnoses than older Asian, African-American, and Afro-Caribbean respondents. Older Latinos did not differ from older non-Latino whites on any lifetime diagnosis and had higher 12-month rates of any depressive disorder. No differences were observed in the 12-month diagnoses between older non-Latino whites and the other racial and ethnic minority groups. Older immigrant Latinos had higher lifetime rates of dysthymia and generalized anxiety disorder (GAD) than U.S.-born Latinos. Older immigrant Asians had higher lifetime rates of GAD than U.S.-born Asians. Older immigrant Latinos had higher 12-month rates of dysthymia than older U.S.-born Latinos.
Caution should be taken when generalizing the protective effects of ethnicity into old age. Older Asians and African-Americans exhibited lower prevalence rates of some psychiatric disorders, whereas older Latinos exhibited rates equal to those of older non-Latino whites. Also, the protective effect of nativity seems to vary according to age, psychiatric disorder, and ethnicity.
Journal of the American Geriatrics Society 02/2010; 58(2):256-64. · 3.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Anxiety disorders are the most prevalent class of psychiatric disorders (Kessler, et al., 2005) and their early onset places individuals at risk for a wide range of subsequent problems (Weissman, et al., 1999). Data from the National Latino and Asian American Study (NLAAS) and the National Comorbidity Survey-Replication (NCS-R) were used to investigate the prevalence and correlates of childhood-onset anxiety disorders among U.S.-born whites, U.S.-born Latinos, and foreign-born Latinos. Significant differences in rates of childhood-onset anxiety disorders were found, with foreign-born Latinos reporting the lowest rates. Across all three ethnicity/nativity groups, individuals with childhood-onset anxiety disorders had equal or higher levels of past-year impairment, relative to individuals with adult-onset anxiety disorders. The chronic course associated with childhood-onset anxiety disorders was also revealed to be present regardless of ethnicity and nativity, as indicated by the similarities across groups in the mean number of lifetime disorders and comorbidity rates. Treatment and assessment recommendations are discussed with respect to the findings.
Behavioral Psychology/Psicologia Conductual 04/2009; 17(1):89-109. · 0.68 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Prior research on racial and ethnic disparities in depression treatment has been limited by the scarcity of national samples that include an array of diagnostic and quality indicators and substantial numbers of non-English-speaking individuals from minority groups. Using nationally representative data for 8,762 persons, the authors evaluated differences in access to and quality of depression treatments between patients in racial-ethnic minority groups and non-Latino white patients.
Access to mental health care was assessed by past-year receipt of any mental health treatment. Adequate treatment for acute depression was defined as four or more specialty or general health provider visits in the past year plus antidepressant use for 30 days or more or eight or more specialty mental health provider visits lasting at least 30 minutes, with no antidepressant use.
For persons with past-year depressive disorder, 63.7% of Latinos, 68.7% of Asians, and 58.8% of African Americans, compared with 40.2% of non-Latino whites, did not access any past-year mental health treatment (significantly different at p<.001). Disparities in the likelihood of both having access to and receiving adequate care for depression were significantly different for Asians and African Americans in contrast to non-Latino whites.
Simply relying on present health care systems without consideration of the unique barriers to quality care that ethnic and racial minority populations face is unlikely to affect the pattern of disparities observed. Populations reluctant to visit a clinic for depression care may have correctly anticipated the limited quality of usual care.
Psychiatric services (Washington, D.C.) 11/2008; 59(11):1264-72. · 2.81 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Motivated by the need to meaningfully implement the Institute of Medicine's (IOM's) definition of health care disparity, this paper proposes statistical frameworks that lay out explicitly the needed causal assumptions for defining disparity measures. Our key emphasis is that a scientifically defensible disparity measure must take into account the direction of the causal relationship between allowable covariates that are not considered to be contributors to disparity and non-allowable covariates that are considered to be contributors to disparity, to avoid flawed disparity measures based on implausible populations that are not relevant for clinical or policy decisions. However, these causal relationships are usually unknown and undetectable from observed data. Consequently, we must make strong causal assumptions in order to proceed. Two frameworks are proposed in this paper, one is the conditional disparity framework under the assumption that allowable covariates impact non-allowable covariates but not vice versa. The other is the marginal disparity framework under the assumption that non-allowable covariates impact allowable ones but not vice versa. We establish theoretical conditions under which the two disparity measures are the same and present a theoretical example showing that the difference between the two disparity measures can be arbitrarily large. Using data from the Collaborative Psychiatric Epidemiology Survey, we also provide an example where the conditional disparity is misled by Simpson's paradox, whereas the marginal disparity approach handles it correctly.
Statistics in Medicine 07/2008; 27(20):3941-56. · 1.88 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Although widely reported among Latino populations, contradictory evidence exists regarding the generalizability of the immigrant paradox, i.e., that foreign nativity protects against psychiatric disorders. The authors examined whether this paradox applies to all Latino groups by comparing estimates of lifetime psychiatric disorders among immigrant Latino subjects, U.S-born Latino subjects, and non-Latino white subjects.
The authors combined and examined data from the National Latino and Asian American Study and the National Comorbidity Survey Replication, two of the largest nationally representative samples of psychiatric information.
In the aggregate, risk of most psychiatric disorders was lower for Latino subjects than for non-Latino white subjects. Consistent with the immigrant paradox, U.S.-born Latino subjects reported higher rates for most psychiatric disorders than Latino immigrants. However, rates varied when data were stratified by nativity and disorder and adjusted for demographic and socioeconomic differences across groups. The immigrant paradox consistently held for Mexican subjects across mood, anxiety, and substance disorders, while it was only evident among Cuban and other Latino subjects for substance disorders. No differences were found in lifetime prevalence rates between migrant and U.S.-born Puerto Rican subjects.
Caution should be exercised in generalizing the immigrant paradox to all Latino groups and for all psychiatric disorders. Aggregating Latino subjects into a single group masks significant variability in lifetime risk of psychiatric disorders, with some subgroups, such as Puerto Rican subjects, suffering from psychiatric disorders at rates comparable to non-Latino white subjects. Our findings thus suggest that immigrants benefit from a protective context in their country of origin, possibly inoculating them against risk for substance disorders, particularly if they emigrated to the United States as adults.
American Journal of Psychiatry 04/2008; 165(3):359-69. · 12.54 Impact Factor
