Mental health articles

OF mental health care and mentally ill

substance abuse and dependence disorders

Substance abuse refers to the overuse of alcohol and/ or drugs that results in harmful physical, social, legal, or interpersonal consequences; substance dependence is marked by continued use of alcohol or other drugs, despite these consequences. The WHO has argued that an individual’s cultural context must be considered when diagnosing an alcohol problem. For a drinking problem to exist, individuals must drink more than is considered acceptable by their culture, must drink during times that are not culturally acceptable, and must drink to the extent that their health and social relationships are harmed.

Obviously, these criteria can be applied to other substances as well. Like anxiety, there is relatively little cross-cultural work on substance abuse and dependence. In part, this may be because alcoholism and other forms of substance abuse have been considered actual diseases only in the past few decades. Therefore, we expect to see more cross-cultural work on alcoholism and substance abuse and dependence in the near future. Ethnic differences in rates of alcohol consumption have been found. However, these studies received much criticism (Trimble, 1991). Within the United States, Native Americans have the highest alcohol consumption rate, followed by White Americans, African-Americans, and HispanicAmericans. Among Native American tribes, there is considerable variation in alcohol consumption: May  found that whereas a minority of Navajo (30%) reported drinking during the last year, a majority of Ojibwa (84%) reported drinking during the last year. White Americans tend to use more nonalcoholic recreational drugs than other ethnic groups, except inhalants and cocaine. Weatherspoon, Danko, and Johnson found that Koreans living in Korea drink more than Chinese living in Taiwan; however, these differences did not carry over to Korean-Americans and Chinese-Americans living in Hawaii. Across cultural groups, men engage in greater substance use than women. It is unclear whether cultural and ethnic differences in consumption rates of alcohol and other substances translate into different prevalence rates for substance abuse and dependence. Evidence from cross-cultural studies of alcohol consumption suggests they do not. Cultures that have the most severe alcohol-related problems actually have the lowest rates of alcohol consumption. Cockerham, Kunz, & Lueschenfound that whereas for Americans, alcohol use was associated with depression, for West Germans (who have higher levels of alcohol consumption), it was not. Thus, it appears that cultural attitudes and norms regarding drinking influence the occurrence of alcoholism. Grant and Harford also found that within the United States, the relationship between alcohol abuse and depression was stronger for females and African-Americans than for males and nonAfrican-American groups. Thus, drinking may also be a form of coping with life stress. Interestingly, for some Hispanic groups, alcohol consumption is not related to acculturative stress. For example, Caetanofound that the more acculturated to mainstream American culture Hispanic women were, the more they engaged in drinking. However, these higher alcohol consumption rates were related to more positive associations with drinking rather than to higher levels of acculturative stress (Cervantes et al., 1991). Specifically, American-born Mexicans associated drinking with social pleasure, assertiveness, elevated mood, decreased tension, and disinhibition. These findings suggest that for Mexican groups, acculturating to American cultural norms may render alcoholism more culturally and socially acceptable behavior. The MAPSS figures support this prediction: Rates of alcohol dependence were lowest for recent immigrants (8.6%), higher for immigrants residing in the United States for 13 years or more (10.4%), and highest for U.S.-born Mexican-Americans (18.0%). The latter rates were most similar to the NCS U.S. National sample (15.1%). In summary, most major mental disorders occur across cultures.

Cases of schizophrenia, depression, anxiety, and substance abuse have been found in a variety of cultural and ethnic contexts. The prevalence rates of these disorders, however, vary among cultural and ethnic groups. Consistent with Marsella, the prevalence rates of disorders that are more neurologically based (i.e., schizophrenia and bipolar depression) vary less than those that are less neurologically based (i.e., unipolar depression and generalized anxiety). These different prevalence rates may stem from a variety of sources. They may reflect greater exposure to life stress for some groups than others. Interestingly, several studies have found that groups presumed to be under greater environmental stress (e.g., minority groups and recent immigrants) do not demonstrate higher rates of affective disorders. Another possibility is that cultures vary in how syntonic or dystonic specific disorders are with particular cultural values and beliefs. For example, the emphasis placed on interpersonal relationships in many Asian and Latino cultures may serve as a buffer against depression and explain why Mexican and Taiwanese nationals demonstrate lower levels of depression than their American counterparts. Yet another possible explanation is that the expression and meaning of symptoms related to major mental disorders may be culturally shaped. As a result, these symptoms may not be easily classified by Western diagnostic systems. We discuss these latter two possibilities next.

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