There is a critical need to understand perceptions of mental health in the older Hispanic population and determine the best way to address mental health care needs, promote mental health care, and prevent mental health issues. Currently, Hispanic individuals are the largest minority group in the United States and are expected to comprise approximately 30% of the total U.S. population by 2050. Over the next several years, the number of Hispanic individuals older than 65 is expected to double, and the number of Hispanic individuals older than 85 is expected to triple (National Hispanic Council on Aging [NHCOA], 2016; Ortman, Velkoff, & Hogan, 2014).
Unfortunately, disparities exist in the recognition and treatment of mental health issues among Hispanic older adults (NHCOA, 2016; Salude-Rios, 2012; Shattell, 2010; Zhan, 2004). As a group, Hispanic older adults are disproportionately exposed to social circumstances that are associated with negative physical and mental health outcomes (Alegría et al., 2008; Yang, Cazorla-Lancaster, & Jones, 2008). In addition, Hispanic individuals are approximately twice as likely as non-Hispanic White individuals to experience depression (Alegría et al., 2002; Alegría et al., 2008), but use mental health services less often and are less likely to receive appropriate treatment (Crystal, Sambamoorthi, Walkup, & Akincigil, 2003; Delgado et al., 2006; NHCOA, 2016; Schmaling & Hernandez, 2005; Stacciarini, 2009). In addition, Hispanic individuals face considerable disparities in the quality of care they receive for mental health problems. For instance, Hispanic individuals are less likely than non-Hispanic White individuals to receive evidence-based depression treatment (NHCOA, 2016; Young, Klap, Sherbourne, & Wells, 2001) and are more likely to have a mental health condition not identified by their primary care provider (Borowsky et al., 2000).
Lack of health insurance, inability to pay for care, and lack of culturally congruent mental health services have led to significant disparities in mental health outcomes for Hispanic older adults (Ojeda & McGuire, 2006; Salude-Rios, 2012). Although most research has focused on identifying barriers to mental health care, little is known about Hispanic older adults' perceptions of mental health issues, more specifically their perceptions of stress, anxiety, and depression. Knowledge of these factors is important in planning and designing programs that promote mental health care and prevent mental health problems, as well as in identifying and treating mental health issues (Cabassa, Lester, & Zayas, 2007; Izquierdo, Sarkisian, Ryan, Wells, & Miranda, 2014; Jimenez, Bartels, Cardenas, Dhaliwal, & Alegría, 2012; Letamendi et al., 2013; Salude-Rios, 2012; Salude-Rios, Tappen, Williams, & Rosselli, 2014; Shattell, 2010; Tyson & Flaskerud, 2009). The purpose of the current qualitative study was to explore perceptions of mental health problems among Hispanic older adult immigrants living in a low income community with a population of individuals who immigrated predominately from the Dominican Republic, Colombia, and Guatemala. It was anticipated that differences would exist among participants, as they reflected three distinct ethnic groups.
The aim of the current study was to understand how Hispanic older adults who had immigrated from the Dominican Republic, Colombia, and Guatemala living in a low-income area in the United States perceive mental health problems, specifically those related to stress, anxiety, and depression.
Participants needed to be at least 65 years old and to have been living in the United States for at least 3 years. An inductive, qualitative, descriptive research design, including interviews with 17 Hispanic older adults, was used to address the questions: (a) How do Hispanic older adults from the selected three countries identify, label, and describe mental health problems related to stress, anxiety, and depression? and (b) To what extent and how do these individuals differentiate among different types of mental health problems?
Setting and Participants
A convenience sample of 17 Hispanic older adult volunteers (eight from the Dominican Republic, five from Colombia, and four from Guatemala) were recruited from a free clinic for uninsured residents in a low income urban neighborhood in New England by way of a flyer and a monetary incentive of a $25 gift card. All participants had entered the United States as adults anywhere from 4 to 39 years ago, with most having spent more than 20 years in the United States. All participants had family in the United States or had brought family members with them. The 11 women and six men ranged in age from 65 to 83, with an average age of 71. Nine had some elementary education, three had been to high school, and two were college graduates.
Human subject approval was obtained from the Institutional Review Board at the respective university. Each participant was contacted by telephone to schedule a home visit to obtain informed consent and conduct the interview. Advanced bilingual undergraduate research assistants (A.A.G., D.M.P., E.C., N.V.) conducted the interviews, which lasted from 1 to 2 hours, in the participant's home. A second visit was scheduled with each participant to check the accuracy and comprehensiveness of the transcript and thus enhance credibility of the data.
Data Collection and Analysis
A semi-structured interview guide with open-ended questions was used to assess older adults' understanding of mental health problems in general, and specifically their understanding of stress, anxiety, and depression, as well as the extent to which they differentiated among these mental health issues (Fontana & Frey, 2000). To better understand the sociocultural context in which ideas of mental health are often formed, participants were first asked to talk about their lives growing up in their countries of origin. This activity was then followed by a series of open-ended questions and follow-up probes related to identifying, describing, and labeling stress, anxiety, and depression. For example, participants were asked: “Can you tell me about stress?” This question was followed by probes such as: “Do you know anyone who has experienced stress? Can you describe what it is like to be stressed?” A similar sequence of questions and probes was used to ask about anxiety and depression, with a final series focusing on similarities and differences between participants' descriptions of anxiety and depression. Interviews were digitally recorded, transcribed, and translated verbatim by the bilingual research assistants. Demographic data including age, gender, educational level, year of immigration, and economic status were collected.
Interviewers (A.A.G., D.M.P., E.C., N.V.) were closely supervised by researchers (A.J.C., D.C.M., D.S.-B.), who provided 12 hours of training and practice in recruiting, interviewing, and transcribing. Interviewers and participants shared similar ethnic backgrounds, and interviewers were often familiar with the culture and Spanish dialect of participants. All participants chose to be interviewed in Spanish. Several techniques used with older adults (e.g., wording questions in a non-judgmental way, providing positive reinforcement, giving the individual control, allowing time to respond, adapting to hearing impairments) were implemented to enhance credibility of the interview data (Domarad & Buschmann, 1995). In addition, a second interview was conducted with each participant to ensure accuracy and completeness of the transcriptions.
Transcripts were analyzed by the three researchers and four research assistants. Each researcher reviewed the transcripts several times and prepared preliminary analyses of data based on the overall aim of the study and each research question (Kvale, 1996; Sandelowski, 2000, 2010). A joint meeting was arranged, and researchers discussed analyses. Analyses were performed using immersion/crystallization and template organizing styles, two approaches frequently employed in content analysis (Crabtree & Miller, 1999). Initial analysis began with a phase of immersion/crystallization in which the authors cycled back and forth through the transcriptions, immersing themselves in and reflecting on the content of each interview individually, interviews by country of origin, and all interviews. It was during this phase that participants' initial lack of reference to emotional distress or mental health problems when talking about extreme life events appeared in contrast with participants' descriptions of depression later in the interviews. During the second phase of analysis, the template analysis style was used to address research questions by using stress, anxiety, and depression as the initial codes for identifying and assembling content related to each research question. Within each code, transcripts were further sub-coded and analyzed in regard to each participant's (a) familiarity with, (b) labeling of, and (c) description of stress, anxiety, and depression. It became apparent during the cross-interview analyses that participants recognized and were most able to describe depression, rather than stress or anxiety.
The trustworthiness of findings was enhanced by use of member checks, an audit trail, and confirmability by interactive comparison and consensus on analyses and findings among researchers (Lincoln & Guba, 1985).
Three major findings emerged in relation to participants' perception of mental illness and description of stress, anxiety, and depression. First, experiences related to emotional distress or mental health problems were not initially shared or easily described despite significant social, economic, and family tragedies. Second, depression was the most familiar term to participants, and was viewed as a significant illness or mental health problem. Third, depression was most often described as “sadness” and was clearly differentiated from stress and anxiety, whereas stress and anxiety had multiple and at times overlapping meanings. In addition, no distinctions were found in regard to the three countries of origin.
When asked to talk about their life in their country of origin, all but one participant described hardships that one would commonly associate with high levels of stress. These hardships included periods of extreme poverty, child labor, abuse from alcoholic fathers, and death of children, as well as destruction of homes and lives due to drug trafficking and civil wars. For example, one participant spoke of how she and her brothers and sisters “…had to work with our parents to harvest the food we ate. I only went until the third grade because my mother and father were very poor. They couldn't help us out.” Another participant described:
To get water, we had to wait for it to rain where then these holes that the ground had would fill and we would get our water from there, or we would have to travel to the nearest water well which was at least an hour distance on horse.
One participant talked of life with his mother:
Throughout my childhood I did experience a strong lack of resources, I became a shoe cleaner at a young age then sold empanadas [meat pies]. I also sold candy in the streets.
One participant married a man she thought was a “good man but ended up being a bad man.” The participant stated:
He used to drink so much. He would beat me and I would end up at the hospital. I would suffer from hunger, too. He used to get drunk and leave no money for food [for the participant and her children].
Another participant lost two of her seven children and then became the mother for two of her grandchildren. Yet another participant's family was forced from its village by violence: “Already the chusma [riffraff] and then the violence…. We were made to go to Medellín.” Her family's farm and everything in it was burned. The participant acknowledged, “In Medellín, we passed a very bad period of time.”
When talking about these situations at the beginning of the interviews, only two of the above participants spontaneously spoke of the stress these situations had caused or used any word that might indicate some level of emotional distress in general, or anxiety or depression specifically. When asked later in the interviews about stress, anxiety, and depression, however, 10 of the remaining 15 participants noted experiencing high levels of stress, anxiety, and/or depression while living in their country of origin. For example, when one participant was asked later in the interview if she could talk about depression, she responded, “Oh! That I know a lot about.” She then went on to describe depression as she experienced it.
Mental Illness: “Loco”
The most common word participants used to talk about mental illness (enfermedad mental) was “loco.” All participants used the word “loco” to describe the extreme behavior of others, behaviors that a mental health specialist might refer to as psychotic. For example, one participant described someone who is “loco” as someone who is:
...crazy, deranged, does not coordinate ideas, doesn't know what he is doing, no sense of direction, lives in a fiction world, dreams and acts like people they aren't, for example a king or someone famous.
Likewise, another participant described it as: “…you talk and they do not understand…they're like in another world.” When asked to talk about someone who has a mental illness and how they describe that person, one participant spoke about her cousin:
He believed there were Martians visiting him. The Martians would talk to him. In the Dominican Republic, I also had family members like that. They don't know what they are doing. It's not like they want to act that way it's just that they can't help it. They're demented…
Stress, Anxiety, and Depression
Depression was a term that all participants recognized, believed they could describe, and were familiar with. Nine participants based their descriptions on their own experiences with depression. Five additional participants based their descriptions on having seen depression in others, whereas three other participants did not give a specific individual as a basis of their descriptions. The most common term used to define depression was sadness. Loneliness and crying were also frequently mentioned as part of depression. The most vivid descriptions of depression tended to be from participants who experienced depression. As one participant described:
Depression is one of the worst things that can happen. I didn't want to take a shower. I cried over everything and I didn't know why I was crying. I didn't want to eat and I just wanted to stay in bed all day.
Another participant stated:
That it is one of the saddest things that can happen to a human being… All thoughts are negative...all you're thinking about is ending your life. You feel that only death will be able to solve the problem.
Some participants talked about depression on a continuum from sadness to suicide. One participant stated, “It is a very cruel sickness, because it can take you to death or suicide…so depression is something terrible.” Another participant described depression as a “sickness.” He continued, “…I wouldn't recommend it to anyone…you start crying and not wanting to do anything… some people even want to commit suicide.” Most participants associated depression with stressful life situations, such as death of a spouse or child or domestic violence, although one participant believed that depression was hereditary.
All but two participants were able to talk about anxiety, although only two reported experiencing it. Two participants talked about anxiety as a kind of nervousness. For others, it was a feeling of desperation. One half of participants spoke of anxiety in terms of wanting but not being able to obtain someone or something. For some, this feeling of want was the essence of their descriptions of anxiety. For three participants, wanting something without being able to obtain it was described as the cause of the anxiety. As noted above, only two participants reported experiencing anxiety. One participant described anxiety as being “when you want something you can't have. This creates anxiety and you get desperate.” Another participant stated:
I know all about this. I feel this. It is like having despair over something. Like anxious over something, like you can't be calm about something… desperate, desperate.
Regarding stress, participants never used the term stress as readily or freely as they did depression or anxiety, although all had some familiarity with the word and most, when asked, spoke of a time when they had experienced stress. The situations described as causing stress varied widely and included examples from participants' lives in their country of origin and in the United States. Four participants drew on the examples mentioned earlier in growing up outside the United States and two talked about the stress of not being able to return to their country of origin. Participants reported experiencing stress while living in the United States due to loss of a loved one, health problems, and major financial loss. The feeling of stress was described in many ways. Some spoke of it as “feeling nervous,” or when your “nerves begin to deteriorate.” Others described stress as “sadness, low of spirit, lack of sleep or over-sleeping a lot of the times,” as well as a sense of “worry” or “desperation.” There was no consistency among participants when distinguishing stress from depression and anxiety, although for approximately one half of participants, stress was different from depression and anxiety. Other participants described stress as related to either depression or anxiety, and four participants believed that unrelieved stress leads to depression and/or anxiety.
At the beginning of the interviews, participants shared experiences and challenges living in their country of origin and the United States; however, it was not until the latter half of the interview when participants shared their perceptions and experiences of mental illness, stress, anxiety, and depression. It appeared as though the health care provider's ability to develop a trusting interpersonal relationship with each participant was necessary for participants to talk about mental health issues. The lack of such a relationship may be an important added factor to other variables (e.g., stigma, English as a second language, lack of insurance) considered by previous researchers as barriers to identifying mental health issues among Hispanic older adults (Interian, Martinez, Guarnaccia, Vega, & Escobar, 2007; Salude-Rios et al., 2014). For example, in the current study, interviewers provided an informal and non-intrusive approach and allowed enough time to develop a rapport when exploring depression among Hispanic older adults. In addition, a more effective strategy may be to elicit the patient's definition of the problem and use his/her description rather than beginning with a standardized screening instrument or imposing a diagnostic category of mental illness (Caplan et al., 2013; Izquierdo et al., 2014).
Similar to findings in the general literature on depression, participants in the current study described depression as feelings of sadness and lack of will to perform personal care activities (Caplan et al., 2010; Martinez Pincay & Guarnaccia, 2007; Martinez, Arriola, & Corvin, 2016). Furthermore, most participants attributed their depression to economic, family, and social stress-ors, similar to other research findings (Berkman, Guarnaccia, Diaz, Badger, & Kennedy, 2009; Jimenez et al., 2012; Letamendi et al., 2013). One social stressor, living alone and/or loneliness, was often viewed as a symptom as well as a cause of depression, similar to the findings of Berkman et al. (2009). Unlike most other research, apart from a study by Letamendi et al. (2013), few participants in the current study reported physical symptoms and/or somaticizing in their descriptions of depression. Somewhat unique was the description of depression as an illness, but not a mental illness, which was a term participants used almost exclusively for psychotic behavior.
Similar to most research on anxiety, participants in the current study described anxiety in multiple ways, including “desperation” and “nerves.” In the few studies that have addressed anxiety and emotional distress in Hispanic immigrant older adults (Berkman et al., 2009; Jimenez et al., 2012; Letamendi et al., 2013), researchers found that anxiety was often described as sadness, desperation, and/or nerves. In contrast, participants in the current study carefully depicted sadness as aligned with depression, but not with anxiety or stress. Furthermore, some participants believed that stress and anxiety were associated with and/or led to depression. One of the more common expressions used by participants to describe anxiety, not seen in other research studies, was the phrase, “wanting something but not being able to get it.” In addition, participants' descriptions of anxiety most often aligned with state anxiety, a temporary emotional state, rather than trait anxiety, a relatively stable personality trait (Spielberger, 2010).
As with much qualitative research, the findings of the current study are not intended to be generalizable and may not be generalized to other U.S. immigrant populations. Inclusion of participants from a higher economic level, however, may have been helpful in further clarifying the unique description of anxiety as “when you want something you can't have” and in providing additional terms for distinguishing between stress and anxiety as mental health problems. As noted previously, it was difficult for older adults in the current study to talk about emotional experiences involved in mental health issues. A series of informal interviews over time may have allowed for increasing comfort and self-disclosure, and in turn allowed a deeper level of dialogue around participants' experiences with mental health issues. In addition, considerable efforts were made to decrease potential bias and increase participants' comfort in talking about such an emotional topic by using bilingual research assistants who served as interviewers and translators and who used established techniques for interviewing older adults.
Understanding the perception of mental health issues among Hispanic older adult immigrants is vital for health care professionals to recognize and provide appropriate care for mental health issues. Although a body of research exists on mental health, most researchers have focused on diagnostic categories derived from specialized psychiatric studies (Zhan, 2004). This narrow focus limits the ability to recognize mental health problems in general, and specifically those related to stress, anxiety, and/or depression among Hispanic older adults whose symptoms may not fit readily within the existing diagnostic categories. Moreover, screening for depression and anxiety is based on translated instruments derived from characteristics and symptoms of non-Hispanic cultures. A biomedical view may hinder health care providers' understanding of the challenges faced by older Hispanic immigrants. Based on the current study, the relationship between the provider and the Hispanic older adult may be central to assessing and understanding the older adult's perception of stress, anxiety, and depression.
The current study adds valuable insights into the perceptions of mental illness, stress, anxiety, and depression among Hispanic older adult immigrants and has implications for health care providers across all health care settings. Understanding Hispanic older adults' perceptions of mental health issues and developing a therapeutic relationship between the patient and provider provides a unique opportunity for the clinician to explore immigration experiences, life stressors, and the language used to talk about these factors and their impact on Hispanic older adults who may experience late-life depression. Further research should focus on piloting programs aimed at preventing and coping with stress, as well as recognizing subclinical or depressive symptoms among Hispanic older adults across health care settings .
- Alegría, M., Canino, G., Rios, R., Vera, M., Calderón, J., Rusch, D. & Ortega, A.N. (2002). Inequalities in use of specialty mental health services among Latinos, African Americans, and non-Latino whites. Psychiatric Services, 53, 1547–1555. doi:10.1176/appi.ps.53.12.1547 [CrossRef]
- Alegría, M., Chatterji, P., Wells, K., Cao, Z., Chen, C.N., Takeuchi, D. & Meng, X.L. (2008). Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatric Services, 59, 1264–1272. doi:10.1176/ps.2008.59.11.1264 [CrossRef]
- Berkman, C.S., Guarnaccia, P.J., Diaz, N., Badger, L.W. & Kennedy, G.J. (2009). Chapter 4. Concepts of mental health and mental illness in older Hispanics. Journal of Immigrant & Refugee Services, 3, 59–85. doi:10.1300/J191v03n01_04 [CrossRef]
- Borowsky, S.J., Rubenstein, L.V., Meredith, L.S., Camp, P., Jackson-Triche, M. & Wells, K.B. (2000). Who is at risk of non-detection of mental health problems in primary care?Journal of General Internal Medicine, 15, 381–388. doi:10.1046/j.1525-1497.2000.12088.x [CrossRef]
- Cabassa, L.J., Lester, R. & Zayas, L.H. (2007). “It's like being in a labyrinth”: Hispanic immigrants' perceptions of depression and attitudes toward treatments. Journal of Immigrant and Minority Health, 9, 1–16. doi:10.1007/s10903-006-9010-1 [CrossRef]
- Caplan, S., Alvidrez, J., Paris, M., Escobar, J.I., Dixon, J.K., Desai, M.M. & Scahill, L.D. (2010). Subjective versus objective: An exploratory analysis of Latino primary care patients with self-perceived depression who do not fulfill primary care evaluation of mental disorders patient health questionnaire criteria for depression. Primary Care Companion to the Journal of Clinical Psychiatry, 12(5), e1–e12. doi:10.4088/PCC.09m00906yed [CrossRef]
- Caplan, S., Escobar, J., Paris, M., Alvidrez, J., Dixon, J.K., Desai, M.M. & Whittemore, R. (2013). Cultural influences on causal beliefs about depression among Latino immigrants. Journal of Transcultural Nursing, 24, 68–77. doi:10.1177/1043659612453745 [CrossRef]
- Crabtree, B.F. & Miller, W.L. (1999). Doing qualitative research (2nd ed.). Thousand Oaks, CA: Sage.
- Crystal, S., Sambamoorthi, U., Walkup, J.T. & Akincigil, A. (2003). Diagnosis and treatment of depression in the elderly Medicare population: Predictors, disparities, and trends. Journal of the American Geriatrics Society, 51, 1718–1728. doi:10.1046/j.1532-5415.2003.51555.x [CrossRef]
- Delgado, P.L., Alegría, M., Cañive, J., Diaz, E., Escobar, J.I., Kopelowicz, A. & Vega, W.A. (2006). Depression and access to treatment among U.S. Hispanics. Review of the literature and recommendations for policy and research. Focus, 4, 38–47. doi:10.1176/foc.4.1.38 [CrossRef]
- Domarad, B.R. & Buschmann, M.T. (1995). Interviewing older adults: Increasing the credibility of interview data. Journal of Gerontological Nursing, 91(9), 14–20. doi:10.3928/0098-9134-19950901-06 [CrossRef]
- Fontana, A. & Frey, H.F. (2000). The interview: From structured questions to negotiated text. In Denzin, N.K. & Lincoln, V.S. (Eds.), Handbook of qualitative research (2nd ed.) (pp. 645–672). Thousand Oaks, CA: Sage.
- Interian, A., Martinez, I.E., Guarnaccia, P.J., Vega, W.A. & Escobar, J.I. (2007). A qualitative analysis of the perceptions of stigma among Latinos receiving antidepressants. Psychiatric Services, 58, 1591–1594. doi:10.1176/ps.2007.58.12.1591 [CrossRef]
- Izquierdo, A., Sarkisian, C., Ryan, G., Wells, K.B. & Miranda, J. (2014). Older depressed Latinos' experiences with primary care visits for personal, emotional and/or mental health problems: A qualitative analysis. Ethnicity & Disease, 24, 84–91.
- Jimenez, D.E., Bartels, S.J., Cardenas, V., Dhaliwal, S.S. & Alegría, M. (2012). Cultural beliefs and mental health treatment preferences of ethnically diverse older adult consumers in primary care. American Journal of Geriatric Psychiatry, 20, 533–542. doi:10.1097/JGP.0b013e318227f876 [CrossRef]
- Kvale, S. (1996). Interviews: An introduction to qualitative research interviewing. Thousand Oaks, CA: Sage.
- Letamendi, A.M., Ayers, C.R., Ruberg, J.L., Singley, D.B., Wilson, J., Chavira, D. & Wetherell, J. (2013). Illness conceptualizations among older rural Mexican-Americans with anxiety and depression. Journal of Cross Cultural Gerontology, 28, 421–433. doi:10.1007/s10823-013-9211-8 [CrossRef]
- Lincoln, Y.S. & Guba, E.G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage.
- Martinez, T.D., Arriola, N. & Corvin, J. (2016). Perceptions of depression and access to mental health care among Latino immigrants: Looking beyond one size fits all. Qualitative Health Research, 26, 1289–1302. doi:10.1177/1049732315588499 [CrossRef]
- Martinez Pincay, I.E. & Guarnaccia, P.J. (2007). “It's like going through an Earthquake”: Anthropological perspectives on depression among Latino immigrants. Journal of Immigrant and Minority Health, 9, 17–28. doi:10.1007/s10903-006-9011-0 [CrossRef]
- National Hispanic Council on Aging. (2016). Status of Hispanic older adults: Insights from the field. Retrieved from http://www.nhcoa.org/wp-content/uploads/2016/09/2016-NHCOA-Status-of-Hispanic-Older-Adults-report-.pdf
- Ojeda, V.D. & McGuire, T.G. (2006). Gender and racial/ethnic differences in use of outpatient mental health and substance use services by depressed adults. Psychiatric Quarterly, 77, 211–222. doi:10.1007/s11126-006-9008-9 [CrossRef]
- Ortman, J.M., Velkoff, V.A. & Hogan, H. (2014). An aging nation: The older population in the U.S. Retrieved from https://www.census.gov/prod/2014pubs/p25-1140.pdf
- Salude-Rios, N. (2012). A review of the literature about depression in late life among Hispanics in the U.S. Issues in Mental Health Nursing, 33, 458–468. doi:10.3109/01612840.2012.675415 [CrossRef]
- Salude-Rios, N., Tappen, R., Williams, C. & Rosselli, M. (2014). Older Hispanics' explanatory model of depression. Archives of Psychiatric Nursing, 28, 242–249. doi:10.1016/j.apnu.2014.03.006 [CrossRef]
- Sandelowski, M. (2000). Whatever happened to qualitative description?Research in Nursing & Health, 23, 334–340. doi:10.1002/1098-240X(200008)23:4<334::AID-NUR9>3.0.CO;2-G [CrossRef]
- Sandelowski, M. (2010). What's in a name? Qualitative description revisited. Research in Nursing & Health, 33, 77–84. doi:10.1002/nur.20362 [CrossRef]
- Schmaling, K.B. & Hernandez, D.V. (2005). Detection of depression among low-income Mexican Americans in primary care. Journal of Health Care for the Poor and Underserved, 16, 780–790. doi:10.1353/hpu.2005.0105 [CrossRef]
- Shattell, M. (2010). Mental illness in older adults. Journal of Gerontological Nursing, 36(5), 3. doi:10.3928/00989134-20100407-01 [CrossRef]
- Spielberger, C.D. (2010). State-trait anxiety inventory. In Weiner, I. & Craighead, W.E. (Eds.), Corsini encyclopedia of psychology. Hoboken, NJ: Wiley & Sons.
- Stacciarini, J.M. (2009). A review of community-based participatory research: A promising approach to address depression among Latinos?Issues in Mental Health Nursing, 30, 751–757. doi:10.3109/01612840903177456 [CrossRef]
- Tyson, S. & Flaskerud, J.H. (2009). Cultural explanations of mental health and illness. Issues in Mental Health Nursing, 31, 650–651. doi:10.1080/01612840902838587 [CrossRef]
- Yang, F.M., Cazorla-Lancaster, Y. & Jones, R.N. (2008). Within-group differences in depression among older Hispanics living in the United States. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 63, 27–32. doi:10.1093/geronb/63.1.P27 [CrossRef]
- Young, A.S., Klap, R., Sherbourne, C.D. & Wells, K.B. (2001). The quality of care for depressive and anxiety disorders in the United States. Archives of General Psychiatry, 58, 55–61. doi:10.1001/archpsyc.58.1.55 [CrossRef]
- Zhan, L. (2004). Improving mental health for ethnic older adults. Journal of Gerontological Nursing, 30(8), 3. doi:10.3928/0098-9134-20040801-03 [CrossRef]