Tuggle et al. Journal of Physiological Anthropology (2018) 37:28 Page 2 of 11
adaptability to stressors is beneficial to organisms during living in the US, 26.8% of whom were born in Mexico
everyday life, such responsiveness and flexibility come at a [17]. Research documenting how migrants adapt to
cost. Over time, activation of allostatic mechanisms in stressors, subsequent internal stress, and related physio-
response to stressors results in cumulative wear and tear. logical dysregulation leads to deteriorating health of
This long-term accumulation of somatic damage is an migrants is timely as around 244 million people world-
allostatic load. As allostatic load increases, it may manifest wide currently are migrants [18]. This research also sup-
as chronic disease following deterioration of internal ports achieving goals of Healthy People 2020 [19] and
regulatory systems, cognitive function, and physical per- reducing racial and ethnic health disparities within the
formance [3–5]. US. During the current period of heightened anti-
immigrant sentiment worldwide, it is more pertinent
Stressors abound in everyday life, and some are more than ever to acknowledge hardships experienced by a
likely to instigate chronic allostatic responses than others. large and growing proportion of many populations (e.g.,
For example, migration is a significantly disruptive life economic, climate, and refugee migrants).
event that impacts multiple dimensions of health. Chronic
exposures to stressors associated with migration may take The decision to migrate in the first place is often
their toll on migrant health and lead to multisystem driven by insecurity in the home country. This complex
physiological dysregulation, or allostatic load. Hardships decision may be influenced by stressors such as conflict,
before and during migration, combined with trials while economic hardships, political instability, and trauma at
acculturating to a new society, may substantially disrupt the point of origin. It may then be followed by stressors
an individual’s life manifesting as higher allostatic load. stemming from unanticipated problems at the point of
Estimates of allostatic load are associated significantly with destination [20, 21]. For those who arrive on foot, the
morbidity, mortality, and declines in physical and cogni- journey across the US southern border is physically and
tive function among samples of older adults across popu- mentally demanding [22]. However, physical stressors
lations [6–9]. Because allostatic load is cumulative over are but one of many. Exposures to poor living conditions
time, negative health outcomes resulting from chronic in their home country prior to deciding to migrate,
exposures to stressors may be disproportionately along with separation from their family and local
expressed by elders. support systems play an important role in migrants’
response to stressors during their sojourns. After arriv-
We begin with a review of existing research on stress ing at their point of destination, migrants face additional
responses and the effects of stressors on the health of stressors that may include entry/passport control, docu-
international migrants. While extensive research has mentation status, finding a stable local setting, job inse-
examined relationships of stressors and stress to the mi- curity with often low-paying, physically demanding
grant experience, only recently have migration researchers work, restricted mobility due to fear of deportation or
utilized biomarker assays of physiological function to as- inability, stigmatization, and discrimination by the local
sess stress-related physiology and allostatic load. A major- population, and marginalization, as well as long-term
ity of early research approached migration-related stress acculturative stressors [23, 24]. Additional stressors of
by focusing on proposed measures of acculturation and acculturation include language difficulties, age at arrival,
the “healthy immigrant effect.” The healthy immigrant and adoption of unhealthy lifestyles [11, 25, 26]. All may
effect describes the phenomenon wherein immigrants heighten chronic stress and thereby shape immigrant
experience a health advantage compared to native-born health in complex ways continuing research is only be-
individuals that declines with time spent in the destination ginning to untangle.
country [10]. More recent research on migrant health has
incorporated assessments of allostatic load into research We propose that by pairing objective health profiles
design [11–16]. Next, we report a specific example with narratives of migration and self-reports of health,
wherein biomarkers of allostasis, self-reports of health, we will better capture risks faced by migrants and
and narratives of migration and settlement were examined discern interconnecting pathways that result in their
in a sample of Mexican migrants residing in Columbus, greater health challenges. Because immigration, accul-
Ohio. We use these data and analyses to propose a model turation, and health are biologically and culturally
for the multiple pathways we observe linking migration, embedded, they must interactively affect health.
perceptions of health, and stressors. Following this model Examining one without assessing the other provides a
may help us, and others, continue testing the complex one-sided and likely inaccurate picture of current and
and competing social, ideational, and physiological future health risks.
stressors, and possible outcomes migrants experience
during their settlement. Acculturation, health, and the “Healthy Immigrant Effect”
Immigrant populations are naturally diverse. Therefore,
Latinos are the second fastest growing minority group researchers have studied immigrants from multiple
in the US. In 2015, there were 43.2 million immigrants
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Tuggle et al. Journal of Physiological Anthropology (2018) 37:28 Page 3 of 11
perspectives [27]. Acculturation models are used fre- Seeman et al.’s [5] 10-biomarker index, but using clinic-
quently in other minority health research [26], but are ally defined high-risk cut points rather than quartiles).
the most common framework in migrant-specific As a general pattern they observed, recent immigrants
health research. Acculturation, or processes of cultural exhibited the best health, followed by long-term immi-
adjustment and acclimatization by migrant popula- grants, non-Hispanic whites, and US-born Mexican
tions to their destination country, are important influ- Americans, who exhibited the poorest overall health.
ences on health and health disparities [28–32]. Recent immigrants were healthier across all three health
However, the reported ways acculturative factors affect assessments and for all biomarkers of allostatic load,
immigrant health are not consistent throughout the excepting inflammatory biomarkers. Smoking was a sig-
literature [32–36] and appear to differ across migrant nificant influence on health, while the estimated propor-
populations examined, as the reality of migration is tion of smokers was lowest in more recent immigrants.
different for everyone. Stress results from an individ-
ual’s perception and appraisal of their current life Riosmena et al. [34] investigated the relationship
circumstances. For example, acculturative stressors between time spent in the US and poorer health out-
may reflect migrants’ separation from their family and comes as a problem with negative acculturation, suggest-
friends, need to learn a new language, adapt to new ing most measures of acculturation used to explain
and different cultural behaviors, and enter a new health disparities between migrants and natives neglect
workforce, and sometimes problems with legal docu- important structural aspects of the process. First and
mentation. Since physiological responses to stressors foremost, acculturation is a process, not an event.
are so closely associated with individual and cultural Migrants are continually acculturating, and different
perceptions, it might be expected that acculturative types of assessments may reflect different patterns and
stress research would yield inconsistent conclusions as pacing thereof. Riosmena et al. [34] suggest cross-
to influences of these factors on health across study sectional sampling common to migrant health research
populations. mask experiences of poverty and hardship prior to mi-
gration. When assessing negative acculturation as a
One theme widely recognized across this research is the determinant of negative associations between mortality
healthy immigrant effect. The healthy immigrant effect and length of residence in the US, Riosmena et al. [34]
was based on findings that immigrants to the US experi- estimated acculturation using duration of residence in
enced a health advantage compared to US-born individ- the US, English language preference, legal status, and
uals [10], an advantage that declined with time spent in sex differences, along with additional factors.
the US. This commonly is hypothesized to represent posi-
tive selection for pre-migration health—only the healthiest In this sample of 80,472 Latinos residing in the US
undertake the journey that marks successful immigration from the National Health Interview Survey (NHIS) from
[25, 32, 37]. The associated health decline most often is 1998 to 2006, among both sexes, English language profi-
attributed to assimilation of unhealthy behaviors associ- ciency and, for women, acquired citizenship are associ-
ated with acculturative stressors, usually smoking or ated with better health [34]. Their results suggest
drinking [38, 39], worsening diet, and decreased physical acculturation is neither the sole nor even the main
activity [25]. Additional stressors influencing health explanation for negative association between duration of
disparities among migrants are discrimination and legal stay in the US, greater chronic disease, and poorer sur-
concerns [23, 24, 40]. vival. Although accounting for behavioral differences,
body mass index (BMI), and socioeconomic status (SES),
In a 2009 paper, Finch and colleagues [10] tested a their use of mortality data may influence conclusions as
new model of immigrant health called the “Oliver Twist there are constraints on mortality reports. Death is a
theory,” a variation of the healthy immigrant effect. This hard endpoint, but potential for bias remains. For
theory posits immigrants moving from less-developed example, return migrants may be the least healthy of
countries to more socioeconomically advantaged ones those who arrived, possibly biasing mortality estimates.
initially will show health advantages due to a lower Similarly, less acculturated migrants likely are more
infectious disease load and lower infant mortality at their likely to return home when ill or they have failed to
destination. However, their advantage declines as they succeed.
adapt to or adopt local cultural patterns and practices
that may promote chronic disease. Using NHANES data, Arbona et al. [23] explored unique stressors dispar-
Finch et al. [10] examined four groups: non-Hispanic ately affecting documented and undocumented Latino
white Americans, US-born Mexican Americans, recent immigrants to the US. Undocumented migrants
Mexican immigrants, and long-term Mexican immi- experience more immigration-related stressors, for
grants using three different outcomes: self-rated health, example, separation from their family, traditionality,
physician-reported health, and allostatic load (based on language difficulties, and legal issues. However, both
groups experienced similar levels of deportation fear.
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Arbona et al. [23] also investigated differences in reunite with family. Although they are significantly
effects of extrafamilial (e.g., occupational, immigration, disadvantaged in education, a familial source of social
legal) and intrafamilial (e.g., marital, parental, cultural, support and the possibility of living in a healthier envir-
family) stressors. Both immigration stressors and legal onment apparently lead to significant mortality advan-
status were uniquely associated with extrafamilial fac- tages among older migrants.
tors. Fear of deportation commonly predicted both
extrafamilial and intrafamilial stressors across all Incorporating biomarkers of allostatic load
groups regardless of documentation, making it a poor More recently, migrant researchers have incorporated
proxy for legal status. Additionally, a sex difference measures of allostatic load into their research designs.
was revealed in experienced stressors. Women were Indicators of acculturation are correlated with stress, but
more likely to be documented. Thus, men, being more are subjective and vary widely based on subgroup char-
often undocumented, were more susceptible to extra- acteristics. Allostatic load indices have the distinct
familial stressors such as separation from family and advantage of being relatively unbiased in revealing the
occupational stressors, suggesting their possible physiological dysregulation that is associated with
greater stress and physiological dysregulation. chronic stressors. In a landmark study, Kaestner et al.
[14] tested the “unhealthy assimilation” hypothesis to
To investigate the connection between self-rated explain worsening health of Mexican immigrants to the
health, acculturation, and health inequalities, Todorova US using allostatic load. Their results agreed with the
et al. [36] sampled 1357 Puerto Rican immigrants to healthy immigrant effect. Mexican immigrants often are
Boston, mean age 57.2. More successfully acculturated healthier upon arrival than US-born Mexican Ameri-
respondents rated their health more positively. cans. However, they also experience health declines in a
Self-reports of better health also correlated with better direct association with time they spend in the US. While
indicators of assessed psychological and physical health. stress is cited as the cause of such health disparities,
Low self-reported health was associated with being Kaestner et al. [14] measured allostatic load, a health
female, low emotional support, engaging in risky behav- outcome believed to be directly associated to chronic
iors, and poverty. Self-reported health differed by level stress, rather than relying on participants’ subjective
of acculturation, and the less acculturated tended to self-assessments. Allostatic load increased significantly
minimize their perceived health problems. Todorova with time living in the US among 2459 Mexican Ameri-
et al. [36] concluded self-reports of health may be cans aged 45–60 years, supporting the healthy immigrant
inaccurate and even mask health disparities and related effect.
contributing factors, an important consideration in our
proposed model. In a 2010 paper, Peek and colleagues [16] investigated
allostatic load among white Americans, African Ameri-
Another approach to migrant health research uses age cans, and people of Mexican origin (immigrants and US
at migration as a factor in the relationships between born) to examine the influence of ethnicity and accultur-
migration stressors and health outcomes. In a sample of ation on health disparities. Using a 12-biomarker allo-
2848 Mexican Americans (immigrants and US-born) in static load index and a verbal interview to measure
the US, Angel et al. [41] used proportional hazard acculturation, they observed a pattern similar to that
models to assess differential mortality risk correlated hypothesized by the healthy immigrant effect. Interest-
with age at migration. They found that “immigrant” does ingly, Peek et al. [16] also observed Mexican immigrants
not constitute a collective risk category. Those who had lower allostatic load than “white” Americans, but
migrated at younger or middle ages experienced similar that there was no association of acculturation with
mortality as did US-born Mexican Americans. Con- allostatic load. This is surprising as previous research
versely, those who migrated during late life experienced suggested migrants living in the US for 10+ years exhib-
a considerable mortality advantage. This may be due to ited poorer health than observed among more recent
different qualities of migrants in each age group. The immigrants. They did not however explore age and sex
youngest migrants generally are selected based on their differences in their analysis. The “healthy migrant effect”
parents’ characteristics. Parents or middle-aged adults implies more acculturation is damaging to immigrants’
who migrate to the US are generally able-bodied, healthy health. However, Peek et al.’s [16] analyses do not sup-
individuals who find work in service sector jobs that are port such an association.
physically demanding and often lack health benefits.
Earlier age at migration also results in longer exposure While most of the previously detailed research relies
to negative acculturative processes. Older migrants come on nationally representative datasets (e.g., NHANES),
to the US for different reasons and thus represent a smaller regional samples are effective at detecting
unique risk group. Migrants over age 50 rarely come small-scale local patterns in migrant health that may be
seeking work opportunities and generally come to masked by larger samples. In a study of 238 African
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Tuggle et al. Journal of Physiological Anthropology (2018) 37:28 Page 5 of 11
immigrants to the US, Bingham et al. [12] utilized a A model based on Mexican immigrants to Columbus,
10-biomarker index to examine associations between
allostatic load, age of immigration, reason for immigra- Ohio
tion, and unhealthy assimilation behavior. They found Columbus, Ohio, is not a traditional destination for
that overall, African immigrants are not likely to develop Mexican immigrants to the US; however, the city’s
unhealthy assimilation behaviors such as alcoholism, Mexican community has grown rapidly over the past
smoking, and decreases in their physical activity. They 20 years with some long-term residents having arrived
further reported, although older age of immigration and over 40 years ago [42]. This long-term occupation and
a longer stay in the US were associated with higher relatively large population (N = 67,000) [43] makes
allostatic load, there was no association with region of Columbus an ideal setting to explore models linking
origin, education, gender, nor income. They also migration and health with allostatic load. Here, we
reported that among all possible migration reasons, fam- develop a model incorporating assessments of allo-
ily reunification was associated with the lowest allostatic static load with cultural narratives of migration and
load scores. Bingham et al. [12] also posited that a large self-reports of health, based on interviews with Mexi-
proportion of their sample self-identified strongly as can migrants in Columbus, Ohio. Data were obtained
African; therefore, they adhered largely to their birth across multiple domains with mixed-methods includ-
country traditions and were less likely to acquire ing interviews, narratives of migration, self-reports of
unhealthy behaviors as a result of acculturation. health, self-reported discrimination, and assessments
of several biomarkers often used to estimate allostatic
McClure et al. [15] investigated associations be- load. Narrative and interview data were obtained from
tween allostatic load, perceived stress, and settlement 34 individuals, of whom 28 participated in biometric
community context among Mexican immigrant farm- measurements. Our original hypothesis was that mea-
workers in a small Oregon community (N = 126). sures of allostatic load would be positively associated
Their sample included two different social settings: with self-reports of health and discrimination, as well
one, a majority Mexican immigrant enclave and, two, as reflective of participants’ narratives of migration
“White” English-speaking residential areas. While and settlement.
migrant groups in both settings exhibited higher allo-
static load, social stressors and buffers differed by Methods
community. Low family support, a stressor generally
thought to be associated with high allostatic load Sampling
among Mexican immigrants, was associated signifi- Data presented here were obtained in 2009 from 34
cantly with allostatic load only among Mexican informants to explore Mexican immigration and
women residing in the White-majority communities. settlement in Columbus, Ohio. The sample represents
Suggesting, women in Mexican-majority communities three distinct areas of the Columbus metropolitan
may experience greater social buffering from stressors region, specifically the Hilltop neighborhood on the
associated with residence in the US. Additionally, city’s southwest side; Whitehall on the city’s east side
women residing in the Mexican enclave reported and Worthington on the city’s north side, both inde-
lower discrimination-based stressors than their coun- pendent municipalities [44]. This original sample
terparts in predominantly white communities. How- included 17 men and 17 women, ages 18 to 62 years
ever, women’s allostatic load scores did not differ (mean = 35 years). All informants originally migrated
significantly between sites. Such results support a from Mexico. Length of residence in Columbus varied
model that stressors perceived and narratives of infor- (range 5–30 years). Most participants (N = 30) had set-
mants are not necessarily reflective of their physio- tled elsewhere in the US before moving to Columbus.
logical responses or their measurable biomarkers in a In general, these migrants came from both rural and
linear fashion, nor do they parallel each other. urban settings in the southern Mexican state of Oax-
Although theirs was a small sample (N = 126) com- aca. Most report they quickly found jobs in service
pared to research utilizing large, nationally represen- and light industry in the US although they had little
tative databases like NHANES, these analyses provide education, advanced training, or work experience.
insights into the complex interactions between biol- Most participants stated they had crossed the border
ogy, culture, psychology, and stressors. Regional to access higher hourly wages in the US and rendered
research, such as that of McClure et al. [15], Bingham their decision to migrate in blatant economic terms.
et al. [12], and Peek et al. [16], provide a basis for
suggesting research utilizing large, nationally repre- Thirty-four individuals were interviewed. To docu-
sentative samples may mask local patterns and vari- ment physical outcomes, we asked 28 of those 34 to par-
able responses to stressors. ticipate in a series of anthropometric and physiological
measurements and to complete self-assessments of their
health and well-being. These 28 informants self-reported
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Tuggle et al. Journal of Physiological Anthropology (2018) 37:28 Page 6 of 11
perceptions of their own health and well-being and Self-reported health
allowed us to measure physiological biomarkers. Mea- Questionnaires, consent forms, and instructions for par-
sured biomarkers included systolic and diastolic blood ticipants were presented in Spanish by a native speaker.
pressure, blood glucose, weight, height, and four skin- A self-report questionnaire was used to elicit informa-
folds. Several of these physiological measures are estab- tion on age, sex, years lived in Columbus and the US,
lished secondary modulators of stress response and personal and family medical history, lifestyle, social
biomarkers of stress-related physiological dysregulation activities, and health using the SF-36 health survey [53].
[45–48]. To assess participants’ perceptions of their Written in English, the questionnaire was translated to
current physical and mental health status and well- Spanish by a native speaker. Participants responded
being, each completed a series of self-report questions mainly in Spanish. The SF-36 requires participants to
from the Medical Outcome Study 36-Item Short-Form self-administer a 36-item questionnaire to describe their
Health Survey [49]. self-perceptions of their own physical health and emo-
tional well-being in relation to normal social activities
Biomarkers with family, friends, neighbors, and co-workers. Infor-
All anthropometric assessments followed standard pro- mants could score a maximum of 24 points based upon
tocols as published by Lohman et al. [50] and were their responses. A low total score indicates the inform-
completed by the same researcher. Anthropometric ant perceived her or himself to be in poor health, while
measurements were completed while participants were a high score indicates a perception of good health.
wearing light clothing. Height was quantified using a
GPM® Anthropometer. While each participant stood in Results
the proper anthropometric position described by Loh-
man et al. [50], their height was measured twice and Blood pressure
recorded to the nearest millimeter. The average of these Following internationally established clinical guidelines
two measurements is used as our measure of height. [51], over half of our 28 informants had normal blood
Body weight was measured twice to the nearest kilo- pressure (Table 1). Systolic blood pressure averaged
gram using a Health-O-Meter® portable scale. The aver- 114.4 mmHg (sd = 12.7, range 90–148 mmHg). Dia-
age of these two measurements is used as our measure stolic blood pressure averaged 78.3 mmHg (sd = 9.9,
of weight. Body mass index (BMI = weight (kg)/height range 60–92 mmHg). Of the 28 persons measured, 6
(m2)) was determined from the average weight and (21%) showed a blood pressure level indicative of
height measures. hypertension.
Systolic and diastolic blood pressures were measured Glycemia
according to Systolic Hypertension in the Elderly Program Glycemia averaged 142 mg/dl (sd = 55.3; range 83–289
protocols using a Baumanometer® mercury sphygmoman- mg/dl) among our informants. For the majority of our
ometer, a Littman® stethoscope, and appropriately sized sample (9 men/12 women) blood glucose fell within the
cuffs while participants were seated [6]. Blood pressures normal range (70–125 mg/dl; Table 2). However, 25% of
were measured three times with 5-min intervals between the sample were hyperglycemic according to international
measures. This protocol also conforms to guidelines standards (glycemia ≥ 126 mg/dl) [54].
established by the Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Anthropometrics
Treatment of High Blood Pressure published by the In 1988 and later, the World Health Organization sug-
American Heart Association [51]. The average of all three gested that BMI (kg/m2) is a useful index of obesity-
measurements is used for analyses. related health risks, recommending specific international
guidelines for assessing body habitus. According to WHO
Skinfolds reflect body composition and fat patterning
and are significantly associated with chronic disease Table 1 Distribution of sample by systolic (SBP) and diastolic (DBP)
morbidity, including coronary artery disease, stroke, and blood pressure (N = 28)
diabetes. Skinfolds were measured at the triceps, calf,
subscapular, and suprailiac locations as specified by Loh- Systolic (mmHg) N Diastolic (mmHg) N
man et al. [50] on the skin or with light coverings using
a Lange® Skinfold Caliper. 90–120 22 60–80 17
Blood glucose was assessed using a Glucometer3 that 121–139 5 81–89 8
was tested for reliability on a daily basis [52]. A random
glucose level either at or above 125 mg/dl was used to 140–159 1 90–99 6
determine hyperglycemia.
≥ 160 0 ≥ 100 0
Total 28 Total 28
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Tuggle et al. Journal of Physiological Anthropology (2018) 37:28 Page 7 of 11
Table 2 Distribution of sample by glucose level and sex (N = 28) or better health. However, 39.3% responded fair and
7.1% as poor health (Table 4), almost half of all respon-
Category Indication Male (n = 13) Female (n = 15) dents (46.4%). Those indicating fair or poor health
frequently noted experiencing persistent bodily pain
70 mg/dL and Lower-than-normal 0 0 along with back and knee pain associated with their
work. Problems with chronic pain also were attributed
below (hypoglycemic) to Ohio’s winter climate and the respondents’ inability
to adapt to the cold.
70–125 mg/dL Normal 9 12
126 mg/dL Higher-than-normal 4 3
and above (hyperglycemic)
[55], a BMI between 18.5 and 25.0 kg/m2 reflects normal Self-reported health status
body habitus, while a BMI between 25 to 30 kg/m2 is Based upon the SF-36 [49], we probed how our infor-
considered overweight and one of 30 or over indicates mants perceived their health. The total possible score
obesity. The distribution of BMI observed in this sample on the SF-36 is 24 points. Responses ranged from 6
is broad, 19.5–41.2 kg/m2, averaging 29.1 kg/m2 (sd = 5.7). (poor health status) to 21 points (good health status)
Forty-three percent show a BMI between 25 and 30 kg/ with a mean of 10.2 (sd = 4.3), indicating a relatively
m2. Thirty-six percent show a BMI of 30 kg/m2 or more, a low self-perception of well-being overall within this
group including equal percentages of men and women. sample. Nearly a third (32%) of our informants scored
seven or lower, indicating a frequent perception of
We measured skinfold thickness at the triceps, extremely poor health. Another third of our sample
suprailiac, subscapular, and medial calf to estimate fell between 8 and 11. In their narratives and discus-
subcutaneous fat deposits. As with BMI, skinfolds sions, informants often attributed their perceived poor
show a broad range of variation (Table 3). For ex- health to economic changes in the US, living in the
ample, the subscapular skinfold ranged from 10 to 40 Midwest, job loss, and limited access to health ser-
mm and averaged 24.5 mm (sd = 7.30 mm: Table 3). vices. Several informants were undocumented immi-
Weight and height also varied widely among our grants; they noted their lack of ability to access
informants. Minimum weight was 45.4 kg, while the health, employment, and life style opportunities be-
maximum was over twice the minimum, 105.7 kg. cause of their legal status.
Weight averaged 74.8 kg (sd = 17.4 kg). Minimum
height was 141.0 cm, the maximum was 179.0 cm with Discussion
a mean of 162.2 cm (sd = 10.8 cm). Both the tricep and Our different sources of data do not produce clear
subscapular skinfold average measurements were well associations with one another: this is not an original
above the US national average values, 14.9 mm and observation. Others have failed to observe significant
20.2 mm, respectively (Table 3) [56]. associations among self-reports, narratives, and clinical
measures of health among migrants also [15, 16]. Con-
Perceptions of health status sequently, many have considered these domains separ-
Our informants self-assessed their well-being and health ately [16, 23, 24]; however, we suggest viewing them as
by responding to a series of Likert-type questions. In re- a system. Independently, participant narratives were
sponse to the question: Would you say your health is as overwhelmingly positive. Conversely, assessments of
follows: excellent = 1, good = 2, fair = 3, and poor = 4; biomarkers revealed poor health profiles among a large
14.3% responded excellent and 39.3% good, suggesting proportion of our sample. Informants also reported
the majority (53.6%) perceive themselves to be in good experiences of discrimination, while tending to self-
report their health as good. Although small, in this
Table 3 Anthropometric measurements (N = 28) sample, neither narratives nor self-reports of health are
valid proxies for participants’ clinically assessed physio-
Biomarker Min Max Mean SD logical health. We propose people’s narratives reveal
17.4
Weight (kg) 45.4 105.7 74.8 10.8
5.7
Height (cm) 141.0 179.0 162.2 15.5
BMI (kg/m2) 19.5 41.2 29.1 12.4
7.0
Waist circumference (cm) 69.0 135.0 98.5 7.3 Table 4 Self-assessed health status (N = 28)
6.3
Hip circumference (cm) 84.0 136.0 106.7 5.8 Rank Health status N Percentage
14.3
Tricep (mm)* 12.0 39.0 24.1 1 Excellent 4 39.3
39.3
Subscapular (mm)* 10.0 40.0 24.5 2 Good 11 7.1
100.0
Suprailiac (mm)* 15.0 43.0 27.0 3 Fair 11
Medial calf (mm)* 13.0 35.0 22.0 4 Poor 2
*Indicates skinfold thickness measurements Total 28
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Tuggle et al. Journal of Physiological Anthropology (2018) 37:28 Page 8 of 11
more about self-perceptions of their current circum- health and well-being in this sample. For example, while
stances and how they self-situate themselves within narratives generally focused on positives of their migra-
their current and previous environments than their tion experiences, elevated blood pressure and hypergly-
health or physical well-being, thereby providing a view- cemia in a large proportion of the sample suggest they
point or mindscape [57] for organizing their migration may be experiencing physiological responses to stress.
experience.
All migrants are imbedded within sociocultural
As part of their narratives, informants often spoke of systems while their physiology responds to a constella-
discrimination, which they viewed as something that tion of stressors permeating their everyday lives. We
happened outside the household. They spoke of home as view narratives as providing a social and personal tool
a safe haven, a place to relax, speak Spanish, and enjoy for coping with and managing the uncertainty, negativ-
family life. Discrimination and harassment were ity, and ambiguity encountered as marginal members of
described as real and important issues confronting our their receiving societies. Differences among narratives
informants as they moved about in the city, while at people tell, their objectively measured biomarkers, and
work, and to their children when they were in schools. their self-reports of health illustrate some of the com-
By sharing narratives in their homes, respondents were plexities characterizing their migration and settlement.
removed from the challenges of life in the city and freely This lack of coherence across different domains of per-
discussed and commented on experiences of discrimin- ceived and assessed health likely reflects experiential
ation and harassment. Home provided participants the variation among our informants and a general disson-
space they likely required to negotiate the meanings of ance between maintenance of self-image and their expe-
their experiences and think through the significance of rienced stressors and outcomes of migration over time.
previous events and social interactions. Physiological data reference measurable health out-
comes, while narratives are what people live. Thus, we
Narratives are a lens through which migrants perceive, cannot explore them as similar data types or sets; rather,
process, and relate their experiences that may influence they must be contextualized in relation to one another
biomarkers of stress and health outcomes. Constructing to produce a broader picture of migrant health.
narratives of oneself is a natural and normal human
practice. Narratives serve to compartmentalize hard- Based on this review and data, we propose a model in-
ships, organize events, feelings, and doubts and provide tegrating the various aspects of migrant health we have
individuals with a sense of control over their experiences enumerated (Fig. 1). Our suggestion is that these
and likely promote contentment with life [58]. Although domains are integrated by the narratives people compose
narratives are a singular source of data, they provide to tell their migration stories. We suggest informants’
information across multiple domains. Narratives largely variable sociocultural responses (narratives), reports of
are subjective, qualitative, and personalized accounts discrimination, self-reports of health, and clinical bio-
and retellings of experiences and feelings. Similarly, markers are filters through which people manage a
self-reports of health are subjective assessments of one’s diverse range of situations and stressors experienced by
personal health relative to themselves at earlier ages and them throughout their lives. Narratives that migrants
others around them. As such, they are interpretations of compose are used to process their circumstances and
both how one feels and known aspects of their physio- color their perceptions of their own health. Any discrim-
logical function. In contrast, physiological biomarkers ination a migrant may experience stems from the way
are objective, quantitative, and reproducible assessments they are perceived by others in their community. Factors
of current function and health at a specific point in life. that influence type and severity of discrimination include
Qualitative assessments of health were not strongly asso- age, sex, language abilities, and appearance. Encounters
ciated with quantitative measures, suggesting narratives with discrimination likely affect both their self-reports of
and self-reports are not indicative of actual somatic health and their physiological health, conceivably through
Fig. 1 Allostatic load model incorporating self-reports of health, clinical reports of health, discrimination, and migration narratives
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Tuggle et al. Journal of Physiological Anthropology (2018) 37:28 Page 9 of 11
embodiment of social inequality, disproportionate eco- from informants while also measuring physiological bio-
nomic inequality, and poor access to resources such as markers and determining how informants assess their
health care [59–61]. Therefore, discrimination begins our own health and well-being. Connections between the
model as it affects all later domains (Fig. 1). Jointly, these narratives people share, biomarkers, and self-reports of
three components influence conceptualizations of each health may not always be obvious, but should be viewed
individual’s narrative of their migration experiences. Nar- as indicative of the individual’s dynamic responses to
ratives themselves also moderate allostatic load. Perceived migration.
stressors influence not only our worldview, but our
responses. As narratives conceptualize experience, they Conclusions
moderate allostatic responses to stressors, influencing We propose variation among different measures of
clinical assessments of physiological function. The rela- migration stress and lack of obvious associations among
tionship between narratives and allostatic load is repre- these measures are to be expected as a consequence of
sented with a dashed double arrow to symbolize the variable adaptive responses and strategies by different
recursive relationship between perceptions, responses, migrants to their own issues. Narratives, biomarkers,
and physiological health. and self-assessments of health measure different aspects
of the migration experience. Taken together, these mea-
Additionally, clinical reports of health influence self- sures bridge ethnographic and physiological data, define
reported health as do narratives, although in unpredict- the dynamic complexities of migration, and reveal the
able ways. Because self-reported health is imbedded in a multiple ways by which people adapt and cope with the
social system, it is not a proxy for physiological health. difficult and multi-dimensional challenges that come
Jointly, clinical and self-reports of health along with nar- with migration. People may feel or experience something
ratives interact in a complex relationship that modulates much different from what they say, and the inconsisten-
allostatic load and later life health outcomes. Based on cies between biomarkers, self-reports, and narratives
this model, successful migration and settlement reflect may reflect this discrepancy [63, 64].
adaptive, time-dependent responses to a changing
multi-dimensional environment and the construction of Incorporating physiological measures of allostatic load
a successful migration narrative. Settlement success is with narratives of migration and settlement will aid in
also moderated by a migrant’s adherence to their trad- unraveling the complex relationships that define accul-
itional cultural practices during their adjustment to a turation and its influences on health. Mexico’s residents,
new society. This can even manifest as migrants coopt- like those from other countries, are not homogenous
ing aspects of the local culture within a framework of and neither are Mexican migrants to the US. Although
their traditional cultural practices to achieve social mo- many migration stressors are ubiquitous, migrants from
bility in a new country [62]. Narratives, self-reports, and different regions often present unique challenges and
clinical assessments each provide a unique data set, and may incorporate different buffers from stressors (e.g.,
therefore, different views of the processes and outcomes demographics, local legislation, quality of education, and
of migration as social and physiological adaptations con- healthcare). Narratives of perceived stress and physio-
tinue over time. By determining how these different do- logical data often are contradictory. Thus, continued
mains interact and individuals differentially respond to exploration of regional patterns may help elucidate
stressors of migration, we will better understand how in- subtleties in how stressors of migration and locally based
dividuals construct their lives and maintain physiological buffers moderate allostatic load across samples.
balance within a complex nexus of social, ideological,
and physiological stressors related to migration. Disson- Abbreviations
ance across these different data sources illustrates the BMI: Body mass index; SES: Socioeconomic status; US: United States
complexity of factors accompanying the migrant experi-
ence and why conflicting results often arise from differ- Acknowledgements
ent studies. We would like to thank Nidia Merino-Chavez for her work on the Mexicanidad
project, as well as the 2017 Joint Symposium of the Society for the Study of
Migration is a physiological and cultural process that Human Biology and the International Association of Physiological Anthropology
includes multiple complex social, behavioral, dietary, in Loughborough, UK, and the 4th International Conference on Evolutionary
and physiological interactions. As a complex process, Medicine in Vilnius, Lithuania where this research was presented.
migration and the stress that come with it are defined
and managed through the narratives people tell, their Funding
physical abilities and perceptions, individual health sta- This study was financially supported by the Ohio State University Center for
tus, and perceptions of their own well-being. To capture Urban and Regional Analysis.
the sociocultural as well as the physical realities of
migration, it is necessary to hear narratives of migration Availability of data and materials
The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.
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Tuggle et al. Journal of Physiological Anthropology (2018) 37:28 Page 10 of 11
Authors’ contributions 16. Peek KM, Cutchin MP, Salinas JJ, Sheffield KM, Eschbach K, Stowe RP,
AT, JC, and DC wrote and revised the manuscript and developed the model. Goodwin JS. Allostatic load among non-Hispanic whites, non-Hispanic
JC and DC conceptualized the research and design. JC conducted the blacks, and people of Mexican origin: effects of ethnicity, nativity, and
fieldwork and completed the statistical analyses. DC advised on the statistical acculturation. Am J Phys Anthropol. 2010;100(5):940–6.
analyses. All authors read and approved the final manuscript.
17. Flores A. Facts on U.S. Latinos, 2015. In: Hispanic trends. Pew research
Ethics approval and consent to participate center; 2017. http://www.pewhispanic.org/2017/09/18/facts-on-u-s-latinos/.
An ethical committee from the Institutional Review Board approved this Accessed 18 Sept 2017.
research (Study ID #2009B0201 Mexicanidad in Ohio: Identity and Stress
in Columbus). 18. Connor P. International migration. In: Key Findings from the U.S., Europe
and the World. Pew Research Center; 2016. http://www.pewresearch.org/
Competing interests fact-tank/2016/12/15/international-migration-key-findings-from-the-u-s-
The authors declare that they have no competing interests. europe-and-the-world/. Accessed 16 Dec 2016.
Publisher’s Note 19. Healthy People 2020. www.healthypeople.gov (2018). Accessed 19 Mar 2018.
20. Sirkeci I, Cohen JH. Cultures of migration and conflict in contemporary
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations. human mobility in Turkey. Eur Rev. 2016;24(3):381–96.
21. Cohen JH, Sirkeci I. Migration and insecurity: rethinking mobility in the
Author details
1Department of Anthropology, Ohio State University, 4034 Smith Laboratory, neoliberal age. In: Carrier JG, editor. After the crisis, anthropological
174 W. 18th Avenue, Columbus, OH 43210, USA. 2College of Public Health, thought, neoliberalism, and the aftermath. London, New York:
Ohio State University, 250 Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, Routledge; 2016. p. 96–113.
USA. 22. Hamilton ER, Hale JM. Changes in the transnational family structures of
Mexican farm workers in the era of border militarization. Demography.
Received: 23 July 2018 Accepted: 26 November 2018 2016;53:1429–51.
23. Arbona C, Olbera N, Rodriguez N, Hagan J, Linares A, Wiesner M.
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838424 JMHXXX10.1177/1557988319838424American Journal of Men’s HealthHill et al.
research-article2019
Racial and Ethnic Diversity and Disparity Issues - Original Article American Journal of Men’s Health
March-April 2019: 1– 12
Help Wanted: Mental Health and Social © The Author(s) 2019
Stressors Among Latino Day Laborers Article reuse guidelines:
sagepub.com/journals-permissions
DhttOpsI:://1d0o.i.1o1rg7/71/01.15157779/185853719898833189482384424
journals.sagepub.com/home/jmh
Clara M. Hill1,2, Emily C. Williams1,2, and India J. Ornelas2
Abstract
Latino day laborers may be especially vulnerable to poor mental health due to stressful life experiences, yet few studies
have described patterns of mental health outcomes and their correlates in this population. Patterns of depression
(PHQ-9) and anxiety (GAD-7), and associations with demographic characteristics, social stressors, and substance use
in a recruited sample of male Latino day laborers (n = 101) are described. High rates of depression and anxiety were
identified. Specifically, 39% screened positive for moderate or severe depression and 25% for moderate or severe
anxiety. Higher levels of depression and anxiety symptoms were associated with being single, being homeless or in
temporary housing, experiencing discrimination, acculturation stress, and marijuana use. While tobacco and unhealthy
alcohol use were common in this sample (39% and 66%, respectively), they were not associated with depression and
anxiety. These findings suggest that depression and anxiety are common among Latino day laborers and associated
with stressful life experiences. Future research should further assess ways to ameliorate social stressors and reduce
risk for poor mental health.
Keywords
Latino immigrants, day laborers, mental health, acculturation stress, substance use, depression, anxiety
Received September 28, 2018; revised January 28, 2019; accepted February 22, 2019
Latinos are the largest ethnic minority group in the United National Institutes of Health & National Institute of
States and now comprise 18% of the population (U.S. Mental Health, n.d.).
Census Bureau, 2016). Previous studies have identified
that patterns of mental health among Latinos vary depend- The Minority Stress model theorizes that Latino immi-
ing on country of origin and immigrant generation grants may be at increased risk for poor mental health due
(Alegría et al., 2007; Oquendo, Lizardi, Greenwald, to stressors associated with their multiple minority sta-
Weissman, & Mann, 2004; Wassertheil-Smoller et al., tuses (Meyer, 2003). For example, Latino immigrants
2014). While Latino immigrants often have better mental may experience stressors related to migration and legal
health than U.S.-born Latinos, some studies have reported status, racial/ethnic discrimination, and lower socioeco-
that depression among immigrants increases with time nomic status, all of which have been associated with
spent in the United States (Grant, Stinson, Hasin, et al., depression and anxiety (Finch, Kolody, & Vega, 2000;
2004; Ortega, Rosenheck, Alegría, & Desai, 2000; Vega, Potochnick & Perreira, 2010; Ramos, Su, Lander, &
Sribney, Aguilar-Gaxiola, & Kolody, 2004; Wassertheil- Rivera, 2015). In addition to their impact on mental
Smoller et al., 2014). A recent national study reported a
depression prevalence of 27% among Latinos, while it is 1Veterans Health Administration (VA), Seattle-Denver Center of
estimated at 8% for the general U.S. population (Pratt & Innovation for Veteran-Centered & Value-Driven Care, VA Puget
Brody, 2014; Wassertheil-Smoller et al., 2014). The prev- Sound Health Services Research & Development, Seattle, WA, USA
alence of anxiety among U.S. Latinos is much lower at 2Department of Health Services, University of Washington, Seattle,
2%, close to levels in the general population, where prev- WA, USA
alence estimates range from 1% to 4% (Grant, Stinson,
Dawson, et al., 2004; Martin, 2003; Priest & Denton, Corresponding Author:
2012; U. S. Department of Health and Human Services, India J. Ornelas, University of Washington, Department of Health
Services, 4333 Brooklyn Ave NE, Box 359455, Seattle, WA 98105,
USA.
Email: [email protected]
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial
use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE
and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
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2 American Journal of Men’s Health
health, minority status stressors can also lead to increased low levels of social support among Latino immigrant
use of alcohol, tobacco, and other drugs as a coping strat- men, which may further exacerbate their risk for both
egy (Keyes, Hatzenbuehler, Grant, & Hasin, 2012). substance use and poor mental health (Quesada et al.,
Substance use is often associated with poor mental health, 2014; Organista, Arreola, et al., 2017).
and comorbidity between substance use disorders and
mood disorders is especially common (Degenhardt & This study aims to build on this literature by identify-
Hall, 2001; Grant, Stinson, Dawson, et al., 2004; Regier ing which specific stressors and forms of substance use
et al., 1990). The theory also stipulates that, when avail- are associated with poor mental health in a recruited sam-
able, social support can buffer the impact of stressors on ple of Latino day laborers in King County, Washington.
health behaviors. However, Latino immigrant men may
have limited access to social support due to social isola- Methods
tion, language barriers, discrimination, and norms of
masculinity (Duke, Bourdeau, & Hovey, 2010; Nelson, Participants and Data Collection
Schmotzer, Burgel, Crothers, & White, 2012; Steel,
Fernandez-Esquer, Atkinson, & Taylor, 2017). Data for this study were collected as part of Vida PURA, a
community-based study on alcohol use patterns of Latino
Latino immigrant men who seek employment as day day laborers (Ornelas et al., 2016). Participants were
laborers after arriving in the United States may be at par- recruited in 2013 at a day labor worker center in King
ticularly high risk for poor mental health. Latino day County, Washington, and considered eligible if they were
laborers are often undocumented immigrants who seek Spanish-speaking, foreign-born, adult (18+) men who
employment in the informal labor market doing construc- identified as Latino. Informed consent was obtained from
tion or landscaping (Valenzuela, 2003). Day laborers are all individual participants included in the study. Once eli-
often paid low wages, are prone to wage theft, and experi- gible men provided consent, they completed an interviewer-
ence difficult and dangerous working conditions (Díaz administered survey in a private location at the worker
Fuentes, Martinez Pantoja, Tarver, Geschwind, & Lara, center. Surveys were conducted in Spanish by bilingual,
2016; Fernández-Esquer, Fernández-Espada, Atkinson, Latino research staff and included measures of mental
& Montano, 2015; Negi, 2011, 2013). Day laborers are health, demographic characteristics, social stressors and
also vulnerable to exploitation, discrimination, and abuse supports, and substance use. Participants received a $25
by employers and law enforcement, especially if they are incentive after completing the survey. All human subjects
undocumented immigrants (Hall & Greenman, 2015; research procedures were approved by and conducted in
Negi, 2011, 2013; Quesada et al., 2014). In addition to accordance with the University of Washington Human
these economic and occupational stressors, day laborers Subjects Division. Staff from local health and social service
commonly experience unstable living conditions, includ- agencies also served as community advisors for the study.
ing homelessness and crowding in shared housing
(Organista, Ngo, Neilands, & Kral, 2017). Mental health. Depression was measured using the Patient
Health Questionnaire (PHQ-9), a nine-item screening ques-
Only a few studies have specifically assessed patterns tionnaire with scores ranging from 0 to 27 that has been
and correlates of mental health outcomes among Latino validated as a tool for depression screening in both clinical
day laborers. A mixed-method study of Latino day labor- and community settings (Löwe, Unützer, Callahan, Perkins,
ers in the Southwest reported that 39% experienced psy- & Kroenke, 2004; Martin, Rief, Klaiberg, & Braehler,
chological distress (Negi, 2013). In a Los Angeles area 2006). Its consistency was high in this community-based
study, Latino day laborers reported experiencing mild to sample (α = 0.83). In addition to total scores, established
moderate levels of depressive symptoms on average criteria were used to classify mild (≤5), moderate (≤10),
(Bacio, Moore, Karno, & Ray, 2014). A study in the San moderately severe (≤15), and severe depression (≤20;
Francisco area reported that Latino day laborers with dif- Kroenke, Spitzer, & Williams, 2001). A score of 10 or
ficult living conditions had higher levels of depression higher was used to identify individuals with moderate to
and desesperación (a culturally specific form of psycho- severe depression, which has high sensitivity (0.85) and
logical distress; Organista, Ngo, et al., 2017). Several specificity (0.89) for use in identifying major depressive
studies conducted in Latino migrant and day laborer pop- disorder (Manea, Gilbody, & McMillan, 2012). The PHQ-9
ulations have identified associations between poor men- has been validated in Latino populations and in Spanish
tal health outcomes and substance use, including (Huang, Chung, Kroenke, Delucchi, & Spitzer, 2006).
unhealthy alcohol use and other drug use (Organista,
Arreola, & Neilands, 2017; Ornelas, Torres, & Serrano, Anxiety was measured using the Generalized Anxiety
2016; Sánchez, 2015; Kissinger et al., 2008; J. Mills Disorder scale (GAD-7), a seven-item screening ques-
et al., 2013; Negi, 2011; Negi, Valdez, & Cepeda, 2015). tionnaire with scores ranging from 0 to 21. The GAD-7
Previous studies have also described social isolation and had high internal consistency in this sample (α = 0.87).
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Hill et al. 3
Established criteria were used to classify mild (≤5), The ISSS was developed specifically to examine elements
moderate (≤10), and severe anxiety (≤15; Spitzer, of social support that are relevant for immigrants (Ong &
Kroenke, Williams, & Löwe, 2006). A score of 10 or Ward, 2005; Rhodes et al., 2013). The five items asked par-
higher was used to indicate moderate or worse anxiety, ticipants whether they had people in their lives who would
which has been used in previous studies because of its offer them emotional support (e.g., “Do you have persons
high sensitivity (0.89) and specificity (0.82) when com- in Seattle who would listen and talk with you when you
pared to other diagnostic measures (Spitzer et al., 2006). feel lonely or depressed?”) and practical help (e.g., “Do
The GAD-7 has been validated with Spanish-speaking you have persons in Seattle who would tell you what can
U.S. Latinos (S. D. Mills et al., 2014). and cannot be done in the United States?”). Response
options were measured with a 5-point scale: No one would
Social stressors. The measure of discrimination used in do this (0), Someone would do this (1), A few would do this
this study was based on items used in the California (2), Several would do this (3), Many would do this (4).
Health Interview Survey, and included separate questions Total responses were summed, with total possible scores
about experiencing discrimination in different settings ranging from 0 to 20. Based on the distribution of responses,
(Ornelas, Mariscal, & Thompson, 2011; Shariff-Marco participants were categorized as having “low support” (if
et al., 2009). Participants were asked whether, since arriv- they had few people who would offer social support in
ing in the United States, they had been “treated unfairly each setting) and “any support” (if they had a few or more
or been discriminated against” at work, when getting who would offer support). Report of “low support” was
medical care, by the police and courts, or in other situa- considered a social stressor.
tions (other situations identified by participants included
public transportation, on the streets, and at school). Indi- Substance use. The Alcohol Use Disorders Identification
cator variables were created for each setting, as well as Test (AUDIT) screening questionnaire was used to assess
for having experienced discrimination in “any” setting unhealthy alcohol use. The AUDIT includes items related
(one of the settings listed above or any other setting not to consumption and frequency of alcohol use as well
explicitly asked about in the survey). alcohol-related problems with scores ranging from 0–40.
The measure had high internal consistency in this sample
Acculturation stress was measured using nine items (α = 0.88) and has been validated for use in Spanish-
from the Migrant Farmworker Stress Inventory (MFWSI), speaking populations (Bacio et al., 2014; Gómez, Conde,
which measures types of stressors as well as the level of Santana, & Jorrín, 2005; Ornelas et al., 2016). An indica-
stress experienced (Hovey, 2000). Items were selected tor for unhealthy alcohol use was created for participants
based on previous research on social stressors among day who scored 8 or higher, a commonly used cut-off score
laborers and community advisors’ input on the most rel- for higher risk drinking (Rubinsky, Dawson, Williams,
evant stressors for day laborers (Negi, 2011; Negi et al., Kivlahan, & Bradley, 2013).
2015; Organista, Ngo, et al., 2017; Ornelas, Allen,
Vaughan, Williams, & Negi, 2015). The selected items Frequency of tobacco use (not at all, some days, or
included: difficulty communicating in English, not being every day) was measured using items selected from the
able to make desired purchases, difficulty accessing National Adult Tobacco Survey, and participants were
health care, working long hours, difficulty being away categorized as current smokers if they smoked cigarettes
from friends and family, being taken advantage of by an at least some days (Centers for Disease Control and
employer or landlord, feeling like they do not belong in Prevention, 2014). Drug use was assessed with a question
the United States, difficulty finding housing, and diffi- asking whether marijuana, cocaine, heroin, or a different
culty finding a job. Each item was scored on a 4-point drug had been used in the past 30 days. Non-marijuana
scale, indicating how stressful participants found each drugs were reported infrequently and therefore collapsed
situation. Response options included Have not experi- into an “other drug” category.
enced (0), Not at all stressful (1), Somewhat stressful (2),
and Extremely stressful (3). Responses were summed for Demographic characteristics. Participants were asked
a total score, and participants were categorized as experi- about their age, marital (and cohabitation) status, living
encing “high” or “low” acculturation stress. The high/low situation (whether housed or living in a shelter, temporar-
categorization was based on a median split at a score of ily staying with friends/family, or homeless), educational
18, which also indicates that participants experienced all attainment, weekly income and weekly hours worked,
nine items on the measure as somewhat stressful or mul- country of origin, years living in the United States, and
tiple items as extremely stressful. This adapted measure language spoken (English and Spanish).
had moderate internal consistency (α = 0.78).
Data analysis. Means and percentages were calculated to
Social support was measured with five items from the describe demographic characteristics, social stressors,
Index of Sojourner Social Support (ISSS) scale (α = 0.75).
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4 American Journal of Men’s Health
Table 1. Sample Description. Table 1. (continued)
Demographic N/mean % (SD) N/mean % (SD)
Age
20–34 46.5 (10.7) Mental health outcomes 8.0 (6.1)
35–49 14 14 62 61.4
50–70 45 44.6 Depression (Mean PHQ-9 score, SD) 39 38.6
Living situation 42 41.6 Mild or no depression (PHQ-9 = 0–9)
Living as single, even if married Moderate to severe depression 5.1 (5.4)
Living with partner 74 73.3 76 75.3
Marital status 27 26.7 (PHQ-9 = 10–27) 25 24.8
Single or divorced Anxiety (mean GAD-7 score, SD)
Married or living with partner 64 63.4 Mild or no anxiety (GAD-7 = 0–9)
Housing 37 36.6 Moderate or severe anxiety
Housed
Homeless, shelter or temporary 59 58.4 (GAD-7 = 10–21)
Education 42 41.6
Less than HS Note. Not all categories add to 101 due to missing data. HS = high
HS graduate or GED 61 60.4 school; GED = General Education Diploma; AUDIT = Alcohol Use
Weekly income 40 39.6 Disorders Identification Test; PHQ-9 = Patient Health Questionnaire;
$200 or less GAD-7 = Generalized Anxiety Disorder scale; SD = standard deviation.
More than $200 31 30.7
Hours per week worked 70 69.3 substance use, and mental health outcomes. One-sample
Country of origin 16.8 (15.4) tests of proportions and chi-square tests were calculated
Mexico to describe the prevalence of depression and anxiety
Other 67 66.3 across demographic characteristics, and to assess their
Years living in the United States 33 32.7 associations with social stressors and substance use.
0–10 15.5 (10.5) Finally, comorbidity of depression and anxiety were
11–20 39 38.6 examined by assessing the correlation between depres-
21–46 28 27.7 sion and anxiety. All data analysis was performed using
Language 33 32.7 Stata 14 (StataCorp, 2015).
Spanish and English
Only Spanish 69 68.3 Results
Social stressors 32 31.7
Discrimination Characteristics of Study Sample
Medical 24 23.8
Police 33 33 Participants (n = 101) ranged in age from 20 to 70 years,
Work 47 46.5 with a mean of 46.5 years (Table 1). Most men (n = 74,
Any 62 61.4 73%) were single or living apart from their spouse, and a
Acculturation stress 17.8 (3.9) large number (n = 42, 42%) were homeless or living in
Low 38 37.6 temporary housing. Most had low levels of education,
High 63 62.4 with 60% (n = 61) having less than a high school diploma.
Social support 7.1 (5.3) All of the men were low income, with 81% (n = 82) earn-
Low 48 47.5 ing less than $400 per week. Participants reported work-
Any 53 52.5 ing an average of 16 hours per week (with a range of 0 to
Substance use 70 hours per week). The majority of the men were from
AUDIT total score 13.3 (9.7) Mexico (n = 67, 67%), followed by El Salvador (n = 8,
Unhealthy alcohol use 67 66.3 8%), Guatemala (n = 7, 7%), Honduras (n = 6, 6%),
Cigarette smoking 39 38.6 Cuba (n = 4, 4%), Chile (n = 2, 2%), Peru (n = 2, 2%),
Marijuana use (past month) 18 17.8 Colombia (n = 1, 1%), and Venezuela (n = 1, 1%). On
Other drug use (past month) 6 5.9 average, men had lived in the United States for 15.5 years
(with a range of 0 to 46 years). All of the men spoke
(continued) Spanish, and 32% (n = 32) spoke only Spanish.
Most men (n = 62, 61%) reported experiencing dis-
crimination in at least one setting: at work, in a medical
setting, by the police or courts, or any other setting.
Twenty-four percent (n = 24) of men had experienced
discrimination when getting medical care, 33% (n = 33)
had experienced discrimination by the police or courts,
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Hill et al. 5
Table 2. Prevalence and Severity of Depression by Participant Characteristics. Moderate or Worse Depression
N % p-value
Total PHQ-9
9 64.3 .12
Mean SD p-value 13 28.9
17 40.5
Demographic 10.6 7.1 .12
Age 6.9 5.8 30 46.9 .03
20–34 8.3 5.6 9 24.3
35–49
50–70 8.8 6.1 .09 33 44.6 .04
Marital status 6.6 5.9 6 22.2
Single or divorced
Married or living with partner 8.8 6.1 .03 18 30.5 .05
Living situation 5.8 5.8 21 50.0
Living as single, even if married
Living with partner 6.9 6.1 .04 24 39.3 .85
Housing 9.5 5.9 15 37.5
Housed
Homeless, shelter or temporary 8.3 5.9 .13 .37
Education 7.5 6.4
Less than HS
HS graduate or GED 9.5 6.8 .11 25 37.3 .62
Weekly income 7.3 5.7 14 42.4
$200 or less
more than $200 7.8 5.7 .51 15 38.5 .94
Country of origin 8.6 6.9 12 42.9
Mexico 12 36.4
Other 8.3 6.5 .86
Years living in the United States 8.3 5.4 24 34.8 .25
0–10 7.6 6.3 15 46.9
11–20
21–46 7.8 6.3 .64 11 45.8 .41
Language 8.4 5.7 28 36.4
Spanish and English
Only Spanish 7.4 5.8 .08 22 32.8 .07
Social stressors and supports 9.9 6.8 17 51.5
Discrimination (setting)
Medical 7.0 5.8 .02 18 33.3 .24
No 10.0 6.4 21 44.7
Yes
Police 7.1 6.4 .11 13 33.3 .39
No 9.0 5.7 26 41.9
Yes
Work 7.1 5.9 .23 9 18.8 <.001
No 8.6 6.2 30 56.6
Yes
Any setting 5.5 5.4 <.001 16 42.1 .57
No 10.3 5.9 23 36.5
Yes
Acculturation stress 8.6 6.5 .41 (continued)
Low 7.6 5.9
High
Social support
Low
Any
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6 American Journal of Men’s Health
Table 2. (continued)
Total PHQ-9 Moderate or Worse Depression
Mean SD p-value N % p-value
Substance use 6.7 5.5 .14 11 32.4 .36
Unhealthy alcohol use
No 8.6 6.3 28 41.8
Yes
Current smoker 7.5 5.5 .34 23 37.1 .27
No
Yes 8.7 7.0 16 41.0
Marijuana use (last 30 days)
No 7.6 6.2 .21 28 33.7 .03
Yes
Other drug use (last 30 days) 9.6 5.4 11 61.1
No
Yes 7.6 6.0 .02 34 35.8 .02
13.5 5.8 5 83.3
Note. HS = high school; GED = General Education Diploma; PHQ-9 = Patient Health Questionnaire; SD = standard deviation.
and 47% (n = 47) had experienced discrimination at (8.8 vs. 5.8, p = 0.03), and 47% (n = 30) of men who
work. More than half (n = 63, 62%) of the participants were single were moderately or severely depressed ver-
reported that their experiences related to immigration, sus 24% (n = 9) of those who were married or living
communication, poverty, health care, work, and feelings with a partner (p = .03; Table 2). Those experiencing
of belonging were somewhat or extremely stressful. homelessness or living in temporary housing also had
Nearly half of participants (n = 48, 48%) reported low higher levels of depression (9.5 vs. 6.9, p = .04). Men
social support. Most men had alcohol screening scores who had experienced discrimination by the police or in
consistent with unhealthy alcohol use (n = 67, 66%), legal settings had higher depression scores (10.0 vs. 7.0,
with a mean AUDIT score of 13.3. Cigarette smoking p = .02), as did those with high compared to low accul-
some days or every day was common (n = 39, 39%), and turation stress (10.3 vs. 5.5, p < .01). Of the men who
18% (n = 18) had used marijuana in the last month. Few had used marijuana in the past month, 61% (n = 11)
(n = 6, 6%) had used other drugs in the past month. were moderately or severely depressed compared to
34% (n = 28) of nonusers (p = .03), and men who used
Mental Health Outcomes non-marijuana drugs had higher mean PHQ-9 scores
than nonusers (13.5 vs. 7.6, p = .02).
The mean PHQ-9 score was 8.0, considered mild depres-
sion (Table 1). More than a third of the sample (n = 39, Correlates of the Prevalence and Severity of
39%) had scores above 10.0, indicating moderate to Anxiety
severe depression. The mean GAD-7 score was 5.1, con-
sidered mild anxiety. A quarter (n = 25, 25%) of men had Men who were living as single were more likely to report
scores over 10.0, indicating moderate to severe anxiety. moderate to severe anxiety (n = 20, 31%) than those liv-
Total PHQ-9 scores were highly correlated with total ing with partners (n = 5, 14%, p = .05; Table 3). Those
GAD-7 scores (r = 0.77, p < .01). Of the 39 men who experiencing homelessness or living in temporary hous-
had moderate or severe depression, 24 (62%) of them ing also had higher levels of anxiety (mean GAD-7
also had moderate to severe anxiety. Of the 25 men who scores) than those who were stably housed (6.5 vs. 4, p =
had moderate or severe anxiety, 24 (96%) of them also .02). Men who experienced discrimination in medical set-
had moderate or severe depression. tings had higher levels of anxiety (7.5 vs. 4.3, p = .01), as
did those who experienced discrimination by the police
Correlates of the Prevalence and Severity of (7.8 vs. 3.8, p < .001) and at work (6.2 vs. 4.1, p = .05)
Depression compared to men who had not experienced discrimina-
tion in those settings. Those who had experienced dis-
Mean PHQ-9 scores were higher for men who were liv- crimination in any setting also had higher anxiety levels
ing as single compared to those living with a partner than those who did not report any discrimination (5.9 vs.
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Hill et al. 7
Table 3. Prevalence and Severity of Anxiety by Participant Characteristics. Moderate or Worse Anxiety
N % p-value
Total GAD-7
6 42.9 .16
Mean SD p-value 8 17.8
11 26.2
Demographic 7.5 6.1 .13
Age 4.2 4.6 22 29.7 .06
20–34 5.2 5.7 3 11.1
35–49
50–70 5.8 5.9 .08 20 31.3 .05
Marital status 3.8 4.0 5 13.5
Single or divorced
Married or living with partner 5.7 5.7 .06 10 17.0 .03
Living situation 3.4 4.0 15 35.7
Living as single, even if married
Living with partner 4.0 4.6 .02 15 24.6 .96
Housing 6.5 6.0 10 25.0
Housed
Homeless, shelter or temporary 4.9 5.1 .75 10 32.3 .25
Education 5.3 5.8 15 21.4
Less than HS
HS graduate or GED 6.1 5.7 .21 15 22.4 .39
Weekly income 4.6 5.2 10 30.3
$200 or less
More than $200 4.6 4.8 .18 9 23.1 .87
Country of origin 6.1 6.3 8 28.6
Mexico 8 24.2
Other 5.0 4.6 .96
Years living in the United States 5.4 5.6 17 24.6 .97
0–10 5.0 6.2 8 25.0
11–20
21–46 5.2 5.7 .64 15 19.5 .03
Language 4.7 4.7 10 41.7
Spanish and English
Only Spanish 4.3 4.8 .01 12 17.9 .02
Social stressors and supports 7.5 6.3 13 39.4
Discrimination (setting)
Medical 3.8 4.5 <.001 10 18.5 .12
No 7.8 6.1 15 31.9
Yes
Police 4.1 4.7 .05 5 12.8 .03
No 6.2 5.9 20 32.3
Yes
Work 3.7 4.6 .04 6 12.5 <.01
No 5.9 5.7 19 35.9
Yes
Any setting 3.5 4.8 <.01 11 29.0 .45
No 6.5 5.5 14 22.2
Yes
Acculturation stress 5.7 5.8 .34 (continued)
Low 4.7 5.1
High
Social support
Low
Any
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8 American Journal of Men’s Health
Table 3. (continued)
Total GAD-7 Moderate or Worse Anxiety
Mean SD p-value N % p-value
Substance use 3.9 4.6 .13 7 20.6 .49
Unhealthy alcohol use 5.6 5.7 18 26.9
No
Yes 4.6 4.9 .31 13 21.0 .27
Current smoker 5.7 6.1 12 30.8
No
Yes 4.9 5.5 .42 17 20.5 .03
Marijuana use (last 30 days) 6.0 5.01 8 44.4
No
Yes 4.9 5.3 .17 22 23.2 .14
Other drug use (last 30 days) 8.0 5.4 3 50.0
No
Yes
Note. HS = high school; GED = General Education Diploma.
3.7, p = .04). Men with high acculturation stress had research reporting high levels of psychological distress,
higher anxiety than those with low acculturation stress depression, and desesperación among Latino day laborers
(6.5 vs. 3.5, p < .01). More men who had used marijuana (Bacio et al., 2014; Negi, 2013; Organista, Ngo, et al.,
in the past month reported moderate to severe anxiety 2017). These findings are also comparable to the mental
symptoms (n = 8, 44%) than did nonusers (n = 17, 21%, health outcomes observed in previous studies of Latino
p = .03). migrant farmworkers (Hovey & Magaña, 2000; Ramos
et al., 2015; Sánchez, 2015).
Discussion
Consistent with previous studies on Latino day labor-
This study is one of the first to describe the patterns of ers, very high rates of unhealthy alcohol use (66%) and
depression and anxiety in a sample of Latino day labor- cigarette smoking (39%) were identified, further high-
ers. Men reported high rates of moderate to severe lighting substance use as an important health concern
depression (39%) and anxiety (25%). Higher levels of among Latino day laborers. Rates of unhealthy alcohol
depression and anxiety symptoms were associated with use were much higher than those described in the general
being single, homeless or living in temporary housing, U.S. population, including rates among U.S. Latinos, but
experiencing discrimination, higher levels of accultura- were consistent with previous studies of Latino migrant
tion stress, and marijuana use. While tobacco and workers and day laborers (Center for Behavioral Health
unhealthy alcohol use were very common in this sample Statistics and Quality [CBHSQ], Substance Abuse and
(39% and 66%, respectively), they were not associated Mental Health Services Administration [SAMHSA], U.S.
with depression and anxiety. These findings build on Department of Health and Human Services [HHS], &
prior literature and suggest that depression and anxiety Research Triangle Institute [RTI], 2015; Kissinger et al.,
are common among Latino day laborers and associated 2008; Nelson et al., 2012; Organista & Kubo, 2005;
with stressful life experiences that are commonly experi- Ornelas et al., 2016). Past-month rates of non-marijuana
enced in this population. drug use were comparable to rates in the general U.S.
population, but lower than those reported in a study of
In this recruited sample of Latino day laborers, both Latino day laborers in Baltimore, Maryland (CBHSQ,
depression and anxiety were substantially higher than pre- SAMHSA, HHS, & RTI, 2015; Negi et al., 2015).
viously described in the general population of U.S. Latinos,
of whom 27% report depression and 2-3% report general- Men in this study reported substantial experience with
ized anxiety disorder (Hong, Walton, Tamaki, & Sabin, difficult living conditions, including low incomes, low lev-
2014; Priest & Denton, 2012; Wassertheil-Smoller et al., els of education, inadequate housing, and limited English
2014). Consistent with prior literature, comorbidity proficiency. Consistent with the Minority Stress model,
between depression and anxiety was common in this sam- these conditions were compounded by several social
ple (Gorman, 1996; Hirschfield, 2001). Although few stud- stressors that were related to worse mental health (Meyer,
ies have documented patterns of both depression and 2003). More than half (62%) of the men had experienced
anxiety in day laborers, these findings align with previous discrimination, and those who reported discrimination had
higher levels of anxiety than those who did not. Consistent
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Hill et al. 9
with prior studies showing an association between per- health outcomes, and if increased social support can ame-
ceived discrimination and depression, men who reported liorate the impact of social stressors on poor mental health.
experiencing discrimination by the police (33%) were sig- Such studies can help identify targets and timing of inter-
nificantly more likely to be depressed than those who had ventions with this population. Latino day laborers may
not (Finch et al., 2000; Hunte, King, Hicken, Lee, & Lewis, benefit from regular screening for common mental health
2013). Those with high acculturation stress were also more conditions, as well as alcohol and tobacco use, in order to
likely to report higher levels of depression and anxiety than identify men who may need further assessment for mental
those with low acculturation stress, similar to findings health and/or substance use treatment. Addressing mental
from a previous study among Latino migrant farmworkers health among day laborers may also require increased
(Finch, Frank, & Vega, 2004). access to stable housing and health care for this popula-
tion. Health professionals and policy makers should con-
Despite living in the United States for an average of 16 sider the burden of Latino immigrants’ stressors on their
years, men in this study had very little social support, with mental health and work to mitigate these stressors through
half stating that they had only one person (or no one) to programs and policies that protect day laborers.
listen to them, help them, or otherwise offer social support
in various settings. Being married or living with a partner Ethical Approval
may decrease social isolation and thus protect against
poor mental health. However, most participants were liv- All procedures performed in studies involving human partici-
ing as single (74%), and those who were single or living as pants were in accordance with the ethical standards of the insti-
single were more depressed than those who were married tutional and/or national research committee and with the 1964
or living with their partner. These findings were consistent Helsinki declaration and its later amendments or comparable
with previous studies among day laborers documenting ethical standards.
social isolation and limited social networks, and their
association with poor mental and physical health (Negi, Informed Consent
2011; Organista, Ngo, et al., 2017; Steel et al., 2017).
Informed consent was obtained from all individual participants
Some limitations should be noted. First, given the included in the study.
cross-sectional design of the study, associations can be
reported, but no causal inferences can be made. For Declaration of Conflicting Interests
example, it cannot be determined from these data whether
unstable housing leads to more depressive symptoms or The author(s) declared no potential conflicts of interest with
whether the two are associated for another reason. In respect to the research, authorship, and/or publication of this
some cases, men may have reported lower levels of sub- article.
stance use due to social desirability bias. Because the
sample was small, the study may not have had the power Funding
to detect some smaller effects. Furthermore, recruitment
from only one day labor worker center may limit the gen- The author(s) disclosed receipt of the following financial sup-
eralizability of the findings. Participation in the Vida port for the research, authorship, and/or publication of this
PURA study was voluntary, and participants may have article: This study was funded by the National Institute on
learned that the study was about alcohol use and chosen Alcohol Abuse and Alcoholism (NIAAA) R34AA022696 and
to enroll (or avoided enrollment) based on that knowl- the Center for Studies in Demography and Ecology (CSDE) at
edge, leading to potential selection bias. the University of Washington.
Conclusions ORCID iD
While future research is needed in larger and more gener- India J. Ornelas https://orcid.org/0000-0003-2957-6452
alizable samples, overall, findings highlight the vulnera-
bility of this population. Specifically, poor mental health References
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Standard Review Article Received: July 17, 2020
Accepted: August 6, 2020
Psychother Psychosom 2021;90:11–27 Published online: August 14, 2020
DOI: 10.1159/000510696
Allostatic Load and Its Impact on Health:
A Systematic Review
Jenny Guidi a Marcella Lucente a Nicoletta Sonino b, c Giovanni A. Fava c
a Department of Psychology, University of Bologna, Bologna, Italy; b Department of Statistical Sciences, University of
Padova, Padova, Italy; c Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY, USA
Keywords ies, as well as clinical studies on consequences of allostatic
Allostatic load · Allostatic overload · Biomarkers ·
Clinimetrics · Diagnostic Criteria for Psychosomatic load/overload on both physical and mental health across a
Research · Stress
variety of settings. Conclusions: The findings indicate that
Abstract
Introduction: Allostatic load refers to the cumulative burden allostatic load and overload are associated with poorer
of chronic stress and life events. It involves the interaction of
different physiological systems at varying degrees of activi- health outcomes. Assessment of allostatic load provides
ty. When environmental challenges exceed the individual
ability to cope, then allostatic overload ensues. Allostatic support to the understanding of psychosocial determinants
load is identified by the use of biomarkers and clinical crite-
ria. Objective: To summarize the current knowledge on al- of health and lifestyle medicine. An integrated approach
lostatic load and overload and its clinical implications based
on a systematic review of the literature. Methods: PubMed, that includes both biological markers and clinimetric criteria
PsycINFO, Web of Science, and the Cochrane Library were
searched from inception to December 2019. A manual search is recommended. © 2020 S. Karger AG, Basel
of the literature was also performed, and reference lists of
the retrieved articles were examined. We considered only Introduction
studies in which allostatic load or overload were adequately The concept of allostatic load was introduced by Mc
described and assessed in either clinical or non-clinical adult Ewen and Stellar in 1993 [1] and refers to the cost of
populations. Results: A total of 267 original investigations chronic exposure to fluctuating or heightened neural and
were included. They encompassed general population stud- neuroendocrine responses resulting from repeated or
chronic environmental challenges that an individual re
acts to as being particularly stressful. It derives from the
definition of allostasis as the ability of the organism to
achieve stability through change [2], and the view that
healthy functioning requires continual adjustments of the
internal physiological milieu [3].
[email protected] © 2020 S. Karger AG, Basel Jenny Guidi
www.karger.com/pps Department of Psychology, University of Bologna
Viale Berti Pichat 5
IT–40127 Bologna (Italy)
jenny.guidi2 @ unibo.it
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Table 1. Clinical criteria for allostatic overload (A through B are required)
Criterion A The presence of a current identifiable source of distress in the form of recent life events and/or chronic stress; the
Criterion B stressor is judged to tax or exceed the individual coping skills when its full nature and full circumstances are evaluated
The stressor is associated with one or more of the following features, which have occurred within 6 months after the
onset of the stressor:
1. At least two of the following symptoms: difficulty falling asleep, restless sleep, early morning awakening, lack of
energy, dizziness, generalized anxiety, irritability, sadness, demoralization
2. Significant impairment in social or occupational functioning
3. Significant impairment in environmental mastery (feeling overwhelmed by the demands of everyday life)
The definition of allostatic load [1, 4, 5] reflects the cu end of the spectrum of associated symptomatology, sub
mulative effect of experiences in daily life that involve or sumed under the rubric of allostatic overload.
dinary events (subtle and long-standing life situations) as
well as major challenges (life events), and also includes Several studies have focused on identifying allostatic
the physiological consequences of the resulting health- load through biological markers [5, 7, 14, 16–25]. Seeman
damaging behaviors, such as poor sleep and circadian dis et al. [16, 17] identified 10 biological parameters: cortisol,
ruption, lack of exercise, smoking, alcohol consumption dehydroepiandrosterone (DHEA), epinephrine, norepi
and unhealthy diet. When environmental challenges ex nephrine, cholesterol, glycosylated hemoglobin, resting
ceed the individual ability to cope, then allostatic over systolic and diastolic blood pressure, body mass index,
load ensues [3, 6] as a transition to an extreme state where and waist-hip ratio. The first four parameters have been
stress response systems are repeatedly activated and buff considered as primary mediators of allostatic load be
ering factors are not adequate [7]. cause of their immediate correlation with adrenal func
tion, whereas the remaining parameters were defined as
Situations that may lead to the development of allo secondary mediators [16, 17]. Biological markers of dis
static load/overload are: (a) exposure to frequent stressors eases resulting from a condition of allostatic load were
that may determine a status of chronic stress and repeat defined as tertiary mediators [26]. Additional biomarkers
ed physiological arousal; (b) lack of adaptation to repeat (glucose levels, lipid profiles, interleukin-6, heart rate
ed stressors; (c) inability to shut off the stress response variability) have subsequently been recognized as having
after a stressor is terminated; (d) allostatic response not a role in the allostatic load response and were then in
sufficient to deal with the stressor [8, 9]. cluded in a cumulative index of allostatic load, common
ly known as the “allostatic load battery” [14, 17, 27]. This
In response to environmental demands, different index of allostatic load was found to be a better predictor
physiological systems interact at varying degrees of activ of mortality and decline in physical functioning than in
ity [1]. The neuroendocrine and immune systems re dividual biomarkers alone [28–31], yet a number of limi
spond to internal or external challenges and promote tations emerged due to the complexity and dynamic na
adaptation to threats or adversities [5, 8]. The hypotha ture of this multisystem network [22].
lamic-pituitary-adrenal axis plays a key role in the patho
physiology of allostatic load [5, 10]. Brain architecture While the biological perspective does not allow for a
and neurochemical functions are affected by both ge comprehensive understanding of allostatic load and over
nomic and nongenomic mechanisms [11, 12]. Adjust load and related clinical phenomena, a substantial contri
ments in the immune system (e.g., leukocytes, cytokines, bution has come from clinimetrics, the science of clinical
inflammation) do occur, with immunosuppressive effects measurements [32, 33]. Clinimetric criteria for the deter
in the long run [13]. Alterations in body functions involv mination of allostatic overload and the underlying expe
ing cardiovascular and gastrointestinal systems, endo riential factors (Table 1), as well as a semi-structured in
crine-metabolic balances and sleep may ensue [5, 10, 14, terview, have been developed [6, 34] and included in the
15]. Diagnostic Criteria for Psychosomatic Research (DCPR)
[35]. The interview can be supplemented by the Psycho
Characterization of allostatic load has been carried out Social Index (PSI) [36, 37], a simple self-rated question
by two distinct approaches. One is concerned with the use naire, tailored to a busy clinical setting, for a comprehen
of biomarkers that reflect physiological derangements; sive assessment of stress, psychological distress, abnor
the other is a clinical approach targeted to the more severe
12 Psychother Psychosom 2021;90:11–27 Guidi/Lucente/Sonino/Fava
DOI: 10.1159/000510696
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mal illness behavior and well-being. The PSI may provide Results
a quantitative measurement of the degree of allostatic The initial search strategy provided 3,633 published
load, with opportunity to monitor its course over time. articles that were screened for potential inclusion in the
Use of cut-off points for identifying allostatic overload is review (online suppl. Fig. S1; for all online suppl. mate
also possible [36, 37]. The interview and the PSI may con rial, see www.karger.com/doi/10.1159/000510696). A to
tribute to formulating a global clinical judgment of indi tal of 524 full-text articles were assessed for eligibility, 267
vidual assets and coping skills in dealing with current life of which were included in the systematic review.
situations. The clinimetric evaluation of allostatic over General Population Studies
load may help identify a state that, by exceeding individ Sociodemographic Correlates
ual resources, could constitute a danger to health. Unlike Several studies focused on the association between so
in the DSM-5 diagnosis of adjustment disorder [38], the ciodemographic variables and allostatic load [18, 19, 22,
presence of a psychiatric disorder is not a source of exclu 23, 42–58].
sion from the criteria. Low socioeconomic status was associated with high
levels of allostatic load [59–68]. The findings were con
With this systematic review we try to summarize the firmed by other investigations where high socioeconom
current knowledge on allostatic load/overload and its ic position appeared to be related to low allostatic load
clinical implications. Previous systematic reviews [29, 30, [45, 53, 69–72]. Similarly, income level was negatively re
39, 40] were concerned with specific aspects such as lated to allostatic load in different populations [65, 73–
health disparities, workforce, socioeconomic position 76]. Perceived neighborhood quality may have an impact
and psychosocial resources. on allostatic load [77, 78], and high levels of allostatic load
were reported by individuals living in impoverished [79–
Methods 85] or segregated neighborhoods [86]. Nonetheless,
Search Strategy adults who grew up in low socioeconomic status house
The methods used fulfilled the PRISMA guidelines [41]. Pub holds showed lower levels of allostatic load when adapt
lished articles concerning allostatic load/overload were identified ing to life stressors maintaining a focus on the future [87].
by searching in PubMed, PsycINFO, Web of Science, and the Co Factors such as renting one’s home, having low income,
chrane Library from inception to December 2019. Search terms and smoking were found to mediate the association be
included “allostatic load” or “allostatic overload.” Only published tween socioeconomic position and allostatic load [88]
articles in the English language and involving human subjects were and explain socioeconomic disparities in allostatic load
considered for inclusion. A manual search of the literature was also [88]. Parental socioeconomic position was found to be
performed, and reference lists of the retrieved articles were exam inversely associated with midlife allostatic load, and part
ined for further studies not yet identified. of this association was mediated by education [89]. In a
Study Selection longitudinal community-based study on a multi-ethnic
We considered only those studies in which allostatic load or cohort of midlife women, high racial discrimination and
overload were adequately described and assessed in either clinical hostility, low income, and low education significantly
or non-clinical adult populations. Biological evaluation of allostat predicted high allostatic load levels [65].
ic load should be based on at least 3 biological markers. Allostatic In some studies, allostatic load was negatively associ
overload was determined according to clinimetric criteria. Studies ated with years of education [61, 73, 79, 90–92]. However,
involving pediatric or adolescent populations were excluded. two investigations [93, 94], examining the mediating role
Data Extraction of ethnicity in the relationship between allostatic load and
The first two authors (J.G. and M.L.) independently performed educational attainment, found the highest levels of allo
the search, screened titles and abstracts, assessed the full text of static load among minorities with a college degree or
articles appearing potentially relevant, and selected studies meet more.
ing the eligibility criteria. In case of disagreement, a consensus was Ethnicity was associated with allostatic load, with
reached through discussion with the senior authors (N.S. and Black Americans displaying higher levels of allostatic load
G.A.F). compared to Whites [95–99]. Among immigrants, a pos
Data Synthesis itive association between allostatic load and duration of
All selected original investigations were reported in the system residence was found [100–102], whereas studies on age at
atic review. Other studies (e.g., articles not primarily focused on
allostatic load and studies not involving adults) were not included.
The most relevant reviews were cited in the introduction and dis
cussion.
Allostatic Load and Health Psychother Psychosom 2021;90:11–27 13
DOI: 10.1159/000510696
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immigration yielded mixed results [101, 102]. The rela adults with canine companionship displayed lower levels
tionship between perceived racial discrimination and al of allostatic load compared to those without [144].
lostatic load was found to be mitigated by the effect of
educational attainment among African American women Data from a large community-based study on partici
[103]. Differential associations between everyday versus pants aged 60 years and over showed a significant asso
institution-specific racial discrimination and allostatic ciation between increased allostatic load levels and wors
load were found among black women [104]. Further ening of visual acuity, after adjustment for confounders
more, higher allostatic load was shown by individuals re [145]. Further, worse visual acuity increased mortality
porting greater perceived racial [105] or social inequali risk, with a potential mediating effect of allostatic load
ties [63, 106], or adversities over the life course [107, 108]. [145].
In addition to perceived racial discrimination [65, 109–
114], also acculturation stress [115] and weight discrimi Work and Environment
nation [116, 117] were found to be associated with high Several studies showed that high levels of allostatic
levels of allostatic load. load were correlated with work-related stress [108, 114,
146–151], poor quality job [152] and burnout syndrome
There was an association between allostatic load and [153, 154], but no significant associations were found in
gender-related characteristics (e.g., androgynous and un other studies [155–158]. A negative association between
differentiated individuals, masculinity levels), as well as allostatic load and heart rate variability in males em
sexual orientation (i.e., lesbian, gay, and bisexual indi ployed full-time was reported [159]. Allostatic load was
viduals) [118–122]. related to insufficient recovery from work stress in wom
en [160], job demand and reorganization at workplace
A negative association between allostatic load bio [150, 161, 162], self-employment [163] and effort-reward
markers and religious attendance has been reported imbalance that is regarded as the core dimension of the
[123]. Weekly religious service attendance was associated burnout syndrome [146, 164]. In a study on civil service
with lower allostatic load in older adults [124–126]. A sig workers [165], a non-linear, stable association between
nificant inverse association between church attendance negative emotional response to major life events and al
and all-cause mortality risk, partially explained by allo lostatic load was observed.
static load, was also found [127]. In two cross-sectional studies, greater vegetated land
cover near residence was associated with low allostatic
Aging load levels [166, 167]. Conversely, living in an unhealthy
Several studies have shown an association between al environment may have deleterious effects on health. Lead
lostatic load and frailty, a multidimensional loss of indi exposure [168, 169], perception of pollution [170], dan
vidual resources with aging [128–130]. Evaluation of gerous traffic [125], household crowding [171], and envi
data from two prospective population-based cohort ronmental riskscapes [172] may contribute to allostatic
studies [131] have suggested that several allostatic load load increased levels. Furthermore, poor indoor environ
parameters could be considered as a preclinical marker mental quality could raise allostatic load [173], whereas
of frailty. better housing conditions and satisfaction with own
Allostatic load was associated with a decline in cogni house appeared to reduce allostatic load [125].
tive and physical functioning in older adults [16, 17, 130, Early Life Events
132–135], changes in brain structure with aging [136], Adverse childhood experiences, including child abuse
brain-predicted age difference [137], and inversely relat and maltreatment, were found to be associated with high
ed to white-matter and brain volume [138]. A potential levels of allostatic load in adulthood [174–180]; only in
link between an immune risk phenotype and allostatic one study [181] childhood socioeconomic status and
load in very old adults was identified [139]. Allostatic load stress exposure in adulthood were found to predict allo
was also found to increase delirium in hospitalized elder static load, while adverse childhood experiences were not.
ly patients [140] and the risk of mortality [141, 142]. Data Perceived social support across the life span partially
from a representative longitudinal study on older adults mediated the association between child maltreatment
[143] showed that high allostatic load levels were associ and allostatic load in adulthood [182]. As to family envi
ated with several personality characteristics (neuroticism, ronment, some studies reported the association between
lower extroversion, lower conscientiousness) at baseline, either harsh parenting in adolescence [183], lower family
and with declines in extroversion, conscientiousness,
agreeableness and openness at a 4-year follow-up. Older
14 Psychother Psychosom 2021;90:11–27 Guidi/Lucente/Sonino/Fava
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support [184], or negative family interactions [185, 186] Consequences on Physical Health
and allostatic load in adulthood. Conversely, emotional A number of studies addressed the relationship be
and instrumental support in childhood [187], warmth tween allostatic load and health status and outcomes
within the family [174], and parental academic involve [204–208], including chronic conditions [209], disabili
ment [188] appeared to be associated with lower allostat ties [210], pain [211, 212], and mortality [17, 24, 56, 213–
ic load in adulthood. Allostatic load in adulthood seems 218].
to be related also to avoidant attachment patterns [189] Poor self-rated health, a measure of actual health status
and predicted by adult anxious attachment style [190]. as perceived by an individual, was associated with mark
ers of allostatic load, such as increased cytokine levels
Well-Being and Coping Strategies [219], higher body mass index and worse lipid profiles
Cross-sectional data derived from a multidisciplinary [220]. A negative association between self-rated health
prospective population-based cohort study showed an in and allostatic load has been documented by other studies
verse association between allostatic load and positive af [206, 221–223], and ethnicity seemed to play a mediating
fects, after adjusting for confounders, with a stronger as role [223].
sociation in women than men [191]. Allostatic load was found to be related to leukocyte
As to well-being dimensions, data from the Midlife in telomere length [224]. Levels of vitamin D [225] and se
the United States (MIDUS) survey showed that greater rum carotenoid concentrations [226] appeared to be in
purpose in life predicted lower levels of allostatic load at versely associated with allostatic load.
a 10-year follow-up [192], while studies on positive rela Lifestyle Habits
tionships and social support yielded mixed results [50, Physical activity was found to be associated with lower
193–196]. In a longitudinal study on middle-aged healthy allostatic load [227–229], whereas poor sleep quality
women, allostatic load at baseline was found to be a neg [230–233], unhealthy diet and overweight [52, 218, 228,
ative predictor of sense of coherence at a 6-year follow-up 234–239], alcohol consumption [52, 92, 228, 229, 240]
[197]. and smoking habits [241] were associated with high allo
In a cross-sectional analysis of data from a large com static load levels.
munity-based study on African American adults [198], Cardiovascular Diseases
women, but not men, using disengagement coping styles Allostatic load was linked to increased risk for cardio
displayed significantly higher allostatic load scores. vascular diseases, particularly coronary heart disease
Among self-employed individuals, problem-focused cop [242], ischemic heart disease [243] and peripheral arte
ing strategies were negatively associated with allostatic rial disease [244].
load [163]. Cognitive reappraisal was indirectly associat A clinimetric evaluation of allostatic overload by spe
ed with lower allostatic load, whereas the tendency to use cific criteria [6, 34, 35] was performed in a number of
emotion suppression was indirectly associated with great studies in cardiac settings. In outpatients with essential
er allostatic load [199]. Further, a significant inverse as hypertension and coronary heart disease [245], the pres
sociation was found between intrinsic capacity (i.e., phys ence of allostatic overload was characterized by a higher
ical and mental skills acquired and modified throughout disease-related emotional burden, poor psychosocial
life) and allostatic load among older adults [200]. functioning and high rates of psychopathology. Similarly,
Caregiving in patients with atrial fibrillation [246], allostatic over
Caring for an ill and/or disabled person (i.e., caregiving) load was associated with increased psychological distress
represents a risk factor for developing allostatic load, (e.g., depressive and anxiety disorders). In a study on pa
which, in turn, may affect individual health status [151]. tients undergoing implantable cardioverter defibrillator
The number of negative life events among caregivers of implantation [247], 16.2% reported moderate allostatic
patients with Alzheimer disease was found to be related to overload, while 4.3% reported severe allostatic overload.
allostatic load [201]. Caregivers of patients with Alzheimer The presence of allostatic overload before implantation
disease showed higher levels of allostatic load compared to was the only significant predictor of subsequent negative
controls, and this association was mitigated by personal cardiac outcomes, including complications and death af
sense of mastery [202]. Parents of children with develop ter implantation. In patients with congestive heart failure,
mental disorders had lower allostatic load when reporting prevalence of allostatic overload was as high as 32.9%
higher positive affects in a controlled study [203].
Allostatic Load and Health Psychother Psychosom 2021;90:11–27 15
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[248], with a significant association with hyperglycemia stress [267]. In a sample of individuals with a first unpro
among cardiac risk factors. In essential hypertension, voked seizure or newly diagnosed epilepsy, allostatic load
32.5% of patients reported allostatic overload and dis was associated with a higher risk of seizures [268].
played significantly higher levels of psychological distress
and a greater prevalence of psychosomatic syndromes In a recent study [269], allostatic overload based on
[249]. The presence of allostatic overload among hyper clinimetric criteria was one of the most frequent psycho
tensive patients was associated with lower levels of well- somatic diagnoses among patients with either episodic or
being and quality of life [249], unlike in a previous study chronic migraine.
that used different criteria [250].
Cancer
Diabetes Women with breast and ovarian cancer displayed el
Patients with type 2 diabetes experienced higher allo evated basal cortisol levels and decreased acute cortisol
static load and greater depressive and hostile symptoms reactivity compared to healthy controls [270]. Among pa
compared to controls [251]. They were found to display tients with breast cancer, black women reported higher
a disruption of multisystem responses to stress, as indi levels of allostatic load compared to both white patients
cated by systolic and diastolic blood pressure, heart rate, and control subjects [271], after adjusting for confound
total cholesterol, salivary cortisol, and plasma IL-6 levels. ers. Allostatic overload was more common among cancer
Similarly, among patients with type 2 diabetes, allostatic survivors (52%) than healthy controls (33%) [272].
load was associated with high systolic and diastolic blood A randomized controlled trial reported the clinical
pressure, and glycated hemoglobin [252]. utility of a mentor-based supportive-expressive program
Gynecology and Obstetrics designed to help women with metastatic breast cancer,
There was an association between early age at men that obtained significant improvements in allostatic load
arche, retrospectively ascertained, and allostatic load parameters as well as in affective symptoms and quality
[253]. of life [273].
Allostatic load in early pregnancy was significantly Periodontal Diseases
higher in a sample of women with preeclampsia com Data from a large community-based investigation
pared to controls, suggesting a possible role of chronic [243] and a subsequent study [274] provided support for
stress in the development of this condition [254]. Al the association between allostatic load and periodontal
though some studies reported that allostatic load among diseases. Further, children of mothers with increased al
pregnant women may contribute to adverse pregnancy lostatic load were significantly more likely to have dental
and birth outcomes [255–257], research findings appear caries, suggesting the role of maternal stress in child oral
to be rather controversial [81, 258, 259]. health [275].
Musculoskeletal Disorders Consequences on Mental Health
In a cross-sectional study, greater allostatic load levels A clinimetric assessment in the general population
were associated with lower spine bone mineral density [276] revealed that subjects with allostatic overload had
and lower femoral neck strength values [260]. significantly higher levels of self-rated stress, psychologi
Symptom frequency and intensity were associated with cal distress and abnormal illness behavior than those
higher levels of allostatic load among chronic fatigue syn without. The clinimetric criteria for allostatic overload
drome patients compared to controls [261–263]. In this were able to discriminate the presence of psychological
condition, polymorphisms in angiotensin-1-converting distress in another sample of the general population as
enzyme linked to allostatic load were reported [264]. well [277]. In a primary care setting [278], allostatic over
A recent preliminary study on female outpatients with load was the most frequently reported psychosomatic
fibromyalgia found a prevalence allostatic overload, based syndrome according to the DCPR [35]; it was associated
on clinimetric criteria, as high as 25% of the sample [265]. with significantly greater psychological distress, lower
well-being and impaired quality of life.
Neurological Disorders Mood and Anxiety Disorders
Depressive symptoms after traumatic brain injury ap Several studies showed a significant association be
peared to be related to chronic stress [266] and perceived tween depressive and anxiety symptoms and allostatic
16 Psychother Psychosom 2021;90:11–27 Guidi/Lucente/Sonino/Fava
DOI: 10.1159/000510696
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load [279–283], not confirmed by others [233, 284–286]. static load appeared to be inversely related to psychoso
In the association between childhood physical abuse and cial [299] and cognitive functioning [301] in psychotic
depression in adulthood, allostatic load appeared to have patients.
a mediating role [287]. In a prospective study [288], reac
tion time in adolescence was found to be predictive of Alcohol Dependence
depressive symptoms in adulthood, with a mediating ef The combined contribution of hypothalamic-pitu
fect of cumulative allostatic load. Data from a large com itary-adrenal reactivity and environmental stressors to
munity-based study showed that high allostatic load was relapse severity in alcohol-dependent men following
more strongly associated with depression among white treatment was investigated [302]. Greater levels of ongo
women and black men than among their respective coun ing life stress strengthened the relationship between ad
terparts, with differences across gendered race groups renocortical sensitivity and post-treatment drinking. En
[282]. In emergency patients primarily diagnosed with vironmental stressors increased relapse intensity [302].
mood or anxiety disorders [283], higher levels of allostat
ic load were found than in those diagnosed with personal Discussion
ity disorders. Most research on allostatic load relies on biomarkers
that express a state of body systems, but do not provide in
In a study on older adults, higher levels of allostatic formation on the underlying individual causes. Moreover,
load were associated with both affective and somatic de substantial heterogeneity exists across studies as to the type
pressive symptoms [280] and were prospectively associ and number of parameters to be considered. It seems that
ated with depressive symptoms at a 3-year follow-up in use of clinimetric tools can increase the number of people
another [279]. Among older euthymic bipolar disorder screened, set the use of biomarkers in a clinical context,
patients [289], allostatic load was found to be associated and broaden dissemination of measures to prevent or de
with delayed memory performance. crease the negative impact of toxic stress on health.
The findings indicate that higher allostatic load and
Post-Traumatic Stress Disorder overload are associated with poorer health outcomes in
Allostatic load helped to understand the association both general and clinical populations. The results provide
between maternal post-traumatic stress disorder (PTSD) support to the clinical utility of the trans-diagnostic iden
and birth outcomes (i.e., pregnancy complications, pre tification of allostatic load and overload in a variety of
term birth) [290]. Mothers of pediatric cancer survivors settings, with a number of potential applications.
were found to display significantly higher levels of allo Consideration of allostatic load may increase the pre
static load compared to control mothers of healthy chil dictive power of the assessment procedure and may con
dren, and those meeting criteria for PTSD reported the tribute to the understanding of many symptoms that are
highest allostatic load levels [291, 292]. In adults with ear commonly encountered in clinical practice, but that, in a
ly life traumas, neuroendocrine biomarkers of allostatic predominantly disease focused model, fail to receive ade
load were significantly related to early life stress and sub quate attention and care [303, 304]. Clinical assessment of
sequent PTSD development [293]. In a study on women allostatic overload may help to demarcate important dif
veterans reporting multiple sexual assaults during child ferences in patients who otherwise seem deceptively simi
hood and civilian and military life, higher allostatic load lar because they share the same medical diagnosis, as it was
levels were detected compared to women reporting sexu found to be the case in cardiovascular diseases [242–244],
al assault in only one life circumstance [294]. particularly congestive heart failure [248], atrial fibrillation
Psychotic Disorders [246] and hypertension [249]. Allostatic load acknowledg
Allostatic load was associated with cortical thickness es the burden of different phases of medical disorders. Ex
[295] and fornix microstructure [296] in schizophrenic amples are provided by the post-hospital syndrome, a pe
patients. It seemed to have a role early in the course of riod of enhanced vulnerability to disease and to adverse
schizophrenia and in greater severity of positive psychot events [305]; difficulties related to the process of recovery
ic symptoms in its early stages [297], as well as in the or rehabilitation [306]; and the cumulative long-standing
chronic course of the disease [298]. Accordingly, higher chronic disease impairment [307]. In general, psychologi
levels of allostatic load were found in patients at their first cal distress was reported in subjects displaying allostatic
psychotic episode [299, 300] and at acute relapse of
schizophrenia [301] compared to control subjects. Allo
Allostatic Load and Health Psychother Psychosom 2021;90:11–27 17
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overload [276–278], which could also be linked to the onset situations [304, 318–320] may also be of value. The clinical
and course of psychiatric disorders [297, 308, 309]. diagnosis of allostatic overload may be helpful in a com
prehensive approach that seeks to understand how the in
General population studies indicate that allostatic load teractions among genetics, mind, body, behavior and the
is increased by low socioeconomic status, living in impov environment affect both the risk of disease and the re
erished neighborhoods, low educational attainment, eth sponse to treatment [321]. However, we still lack studies
nicity and racial discrimination [39, 93]. Further, most of that employ both clinimetric criteria and biological mark
the studies indicate a relationship between high levels of ers. Such investigations would shed some light on the cor
allostatic load and work-related stress (including caregiv respondence between clinical and biological parameters,
ing) with the ensuing risk of burnout syndrome [151, 153, and provide a determination of the state of allostatic over
154]. In this regard, allostatic overload has been used as a load better than either criteria used alone. In this context,
conceptual framework for understanding the physical and consideration of components that may buffer the impact
psychological state of medical health workers facing the of stress may be important [313]. In clinimetric terms, this
COVID-19 pandemic [310, 311]. In older adults, allostatic translates into consideration of psychological well-being
load was found to be associated with a decline in cognitive and euthymia [317, 322]. McEwen [314] has emphasized
and physical functioning, and with frailty, as a multidi how coping with daily life challenges is continuously shap
mensional loss of individual resources [128–132]. Adverse ing both brain circuitry and systemic physiology, which, in
experiences in childhood, including child abuse and mal turn, determine lifestyle choices in terms of protective or
treatment, were found to predict high levels of allostatic damaging health behaviors. Such adaptive changes may
load later in life [15, 312]. Altogether, individual psycho trigger epigenetic mechanisms [314, 323] that modulate
logical well-being and coping styles may modulate the as physiological and psychological sensitivity and are rele
sociation between socio-demographic factors and allostat vant for regenerative processes [313]. Consideration of the
ic load [87], and higher psychosocial resources were linked impact of allostatic load on health also calls for a multidis
to lower allostatic load [40, 194]. Environmental factors, ciplinary organization of health care to overcome the arti
such as work and living conditions, play an important role ficial boundaries among medical specialties, based mostly
in determining allostatic load [125, 149, 162], but their on organ systems (e.g., cardiology, endocrinology) that ap
modification is often not taken into account. Work condi pear more and more inadequate in dealing with symptoms
tions are modifiable factors to be targeted by specific inter and problems which cut across organ system subdivisions
ventions [313]. Work reorganization and stress manage [303, 324, 325].
ment in employees may reverse allostatic overload and
stimulate physiological regeneration processes and recu Acknowledgments
peration [313]. Inclusion of allostatic load in the clinical We are grateful to Emanuela Offidani, PhD, for helpful sugges
assessment allows to view illness within the interaction be tions.
tween the individual and the surrounding environment.
Conflict of Interest Statement
Allostatic load was associated with health-damaging The authors have no conflicts of interest to declare.
lifestyle habits, such as lack of physical activity, unhealthy
diet and poor sleep, in several investigations [52, 228, 229, Funding Sources
233, 239]. The metabolic syndrome, which may be fre None.
quently associated with allostatic load [17], is an important
example of the devastating effects of harmful lifestyles and Author Contributions
of the need to prevent its occurrence as early as possible in All authors conceived the project. J. Guidi and M. Lucente per
life [314]. Individuals may try to counteract manifestations formed the searches and collected the data. All authors analyzed
of allostatic overload by the use of medications (e.g., sleep the data, drafted and revised the paper.
ing pills). However, the adverse iatrogenic effects [315]
may cause a state of “pharmacological allostatic load” [27]
and medications do not entail solution to problems they
are used for. Promoting lifestyle modifications and pursuit
of psychological well-being, whose importance is increas
ingly recognized in clinical medicine [316] and psychiatry
[317], may provide more enduring effects. Psychothera
peutic strategies aimed at improving coping with stressful
18 Psychother Psychosom 2021;90:11–27 Guidi/Lucente/Sonino/Fava
DOI: 10.1159/000510696
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DOI: 10.1159/000510696
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