Mental Illness May Go Untreated in Asian-Americans

A few years ago, Dr. Lin Fang saw a patient at the Charles B. Wang Community Health Center in New York City's Chinatown. The man, a recent Chinese immigrant in his 30s, had come to see a physician and complained of five years of insomnia. The physician directed him to Fang, a clinician in the center's mental-health clinic, who quickly diagnosed the man with depression--something he hadn't even considered. A year and a half later, after taking medication and making regular appointments with the Wang Center's clinicians, the man was fine again, Fang says.

Fang can't count the number of patients like this man that she's seen over the years. There are indications that mental illness in the Asian-American community may be undiagnosed and undertreated, thanks in part to cultural stigmas against personal weakness, as well as some recent immigrants' ignorance of the Western concept of mental health. A 2003 study partly funded by the National Institute of Mental Health showed that while the rate of mental illness among Asian-Americans is lower than among whites, the former group is less likely to seek help than the latter. Now, though, community health centers across the country are finding that taking a holistic approach to mental health--combining primary and mental-health care, and integrating Western and Eastern philosophies--is often the most effective way to reach an underserved population.

And some of the national data point to a need for increased vigilance and treatment: Asian-American females, for instance, have the highest suicide rates among American females in the 15-24 age group, and Asian-American women who are 65 or older are 10 times more likely to commit suicide than are their white counterparts, according to numbers compiled by the Asian Counseling and Referral Service (ACRS). Forty percent of Southeast Asian refugees suffer from depression, and anxiety plagues significant parts of that population as well, according to the ACRS statistics. And because of language and insurance barriers, many Asian-Americans aren't particularly likely to seek professional help.

Unless there's an Asian-American in charge of a mental-health services organization, there tends to be little outreach to that population, says Dr. Marty Wong, a practicing psychologist in Boulder, Colo., and a fellow with the American Psychological Association. "In general, the squeaky wheel gets the grease, and Asian people tend not to squeak very loudly," he says.

In many cases, their problems are directly related to the immigrant experience: some Asian immigrants are depressed that they held highly respected positions in their home countries but can't translate their skills or their peers' esteem in America. Fang's patient had worked a high-powered bank job in China but could only find work at a restaurant in America. Others, especially older Cambodian and Vietnamese refugees, have posttraumatic stress syndrome.

Often, Asian immigrants who suffer from mental illness will assume it's a physical ailment and consult a physician instead of a mental-health professional; in some cases, they may even request or seek out treatment that doesn't address the mental roots of their symptoms. Ten years ago, a recent Korean immigrant was sent to Asian Counseling and Referral Services in Seattle. She'd complained of excruciating, unending backaches for years and had undergone several experimental surgeries, to no avail. But when Yoon Joo Han, now the center's behavioral-health program director, started speaking to the woman, Han found she was deeply depressed from an abusive marriage and culture shock. "She'd blocked her emotional senses completely and directed everything into the physical," Han says. In Seattle, "as many as half of Asian-Americans' visits to primary care physicians are due to conditions caused or exacerbated by mental or emotional problems," according to ACRS.

Collectively, Asian cultures tend to stigmatize mental illness by valuing silence, modesty and face-saving, according to ACRS. Physical symptoms of different mental illnesses tend to be explained as manifestations of spiritual or moral weakness, and some Asian languages don't even have a word for "depression," Han says. "In some cultures, they'll say, 'My liver is bad,' and that is translated into, 'I'm depressed and sad'," she says. "The perspective on mental illness as something that can be treated is a pretty new, Western concept for many of our clients, so it becomes a family secret and people don't seek help until it gets out of control or really, really bad."

Terry Gock, director of Pacific Clinics' Asian Pacific Family Center in Rosemead, Calif., explains that the Chinese are more likely to say that they're tired or that their "chi is low," than to admit to feeling blue. "And so if we don't integrate the understandings, physicians will sometimes look at it as just a physical problem and miss the psychological, mental-health implications of what people are saying," she says.

Because treating Asian-American patients sometimes requires a holistic approach, doctors at ACRS will try to fuse Western and Eastern sensibilities as they introduce their patients to the concept of mental illness. Often, Han says, doctors will tell patients stories about other patients who've had similar experiences, or explain treatment options in terms of physical symptoms instead of getting too deep into mental-health theory.

They also are sensitive to cultural nuances: some clients believe medications are poison, and doctors have to make sure not to force treatments onto patients, she says. "The most important thing is respecting where they are at and not discounting their beliefs, but bringing the best package of services we can offer to that individual," Han says. In many cases, as with Han's Korean patient, the physicians will refer their patients to a local community center, where doctors and therapists can try to straddle Western and Eastern understandings to address the patients' illnesses.

Potential patients who don't seek out mental-health help, and even some who do, may turn to alternative remedies. They go to fortune-tellers like the ones who sit outside a park a few blocks away from the Wang Center, hawking guidance and insight with Chinese written boldly on the faded red drop cloths behind them. Others turn to activities like tai chi or traditional medications for help. Not all of these options are harmful; in fact, treatments like acupuncture and yoga are often beneficial, Fang says.

In some cases, though, these alternative remedies can worsen mental conditions. Two years ago, Fang saw a pregnant schizophrenic woman whose relatives were adamant that her symptoms came from bad spirits and wanted her to perform rituals at a temple to get rid of the spirits. But performing the rituals made the woman's symptoms worse--she began to hallucinate about the spirits--and when she eventually came to the Wang Center, "it was even hard for us to say, 'Take medications,' because the spirits in her hallucinations were telling her, 'You shouldn't eat those things'," Fang recalls. Eventually, the woman's husband was able to persuade her to go on medication, and the woman improved significantly through the course of her pregnancy.

But while there may be an initial reluctance to recognize these types of illnesses or seek treatment, mental-health centers in Asian neighborhoods are constantly busy: the Charles B. Wang Community Health Center saw 7,800 mental health patients in 2007, and the Asian Pacific Family Center in Rosemead, Calif., has seen its staff grow to more than 100 but still has to keep a waiting list. "It's really hard to say what the prevalence rate for these kinds of mental-health conditions is," says Teddy Chen, director of the Charles B. Wang Center's mental health bridge program. "But when we start providing services, we have no problem finding patients."