Lack of resources
Asian Americans have been seen as “the model minority” with household incomes higher than the national average. Behind this glamorous facade is the fact that Asian Americans are a highly heterogeneous group with 14% of the population living in poverty. In 2004, 16.8% of Asian Americans were uninsured, which was comparable to the rate of the national uninsured population (15.7%).10 Approximately 62% of Asians living in the United States are foreign born, and English proficiency poses a problem for many of them in seeking health services, particularly for mental health issues that require more advanced language skills. Kung11 analyzed data from the Chinese American Psychiatric Epidemiological Study and concluded that language barrier, financial resources, time constraints, and knowledge of access to treatment are factors related to the limited use of mental health services among Asian Americans.
Understanding and bridging cultural differences As pointed out earlier, providers treating less acculturated Asian Americans should treat somatic complaints because they are an essential and legitimate indicator of mental distress. Such complaints should not be seen as a lack of psychological sophistication. Many Asian Americans who present with physical symptoms have no difficulty in reporting and talking about their mood and anxiety symptoms when prompted by clinicians.
Talking to Asian Americans about psychiatric illness
In addition to understanding the characteristic profiles of symptoms presentation among less acculturated Asian Americans, clinicians should strive to use frameworks and language that resonate with their patients. Since many Asian Americans with traditional illness beliefs who are depressed may have different perceptions about psychiatric disorders, clinicians need to skillfully explore how the psychiatric terminology will be perceived and to clarify misunderstandings of the terminology that may exist. For instance, in traditional Chinese medicine, all illness is the result of imbalance in the elements and forces within the body and nature. Therefore, reframing depression as an imbalance in the body's system (ie, monoamines) that can be helped with an SSRI would be better received than an explanation that focuses on neurotransmitter reuptake mechanisms or distorted cognitive perceptions. It is frequently helpful to use a patient's own terminology and framework to help him or her understand the nature of the illness and the benefits of treatment.
Mental health programs for
Specialized mental health programs have been established to provide services to minority populations, including Asian Americans in cities with a high concentration of ethnic groups, such as Boston, New York, Los Angeles, and San Francisco. These programs are generally staffed with bilingual bicultural professionals and support personnel. It has been shown that ethnic minorities feel more at ease going to these programs, and consequently, the delay between onset of symptoms and contact with the mental health system is shortened.12 This should come as no surprise because ethnic match between therapist and client has been shown to lead to better treatment outcomes.13
The Bridge Program
Less acculturated Asian Americans who are not familiar with mental health services frequently present to primary care physicians, herbalists, acupuncturists, or other alternative practitioners for help when they suffer from psychiatric illnesses. It is therefore important that primary care physicians be skilled in identifying mental illness. Many studies have shown, however, that patients in primary care with mood and anxiety disorders often go unrecognized. Improving the recognition and treatment of mental illness in primary care settings is a major public health issue, particularly among ethnic minorities.
The New York Chinatown Clinic pioneered the Bridge Program to integrate primary care and mental health services. The key elements of the Bridge Program include co-location and collaboration between mental health service providers and primary care physicians in treating mental illness and training of primary care physicians and support staff in handling patients with psychiatric disorders. The Bridge Program has been successfully replicated at Asian health centers in Boston and in Oakland, Calif. Preliminary results suggest that integrating mental health and primary care increases referrals to and treatment acceptability of mental health services by Asian Americans.14
Videoconferencing brings tremendous opportunities to clinical care, education, research, and administration. With available technologic support, it is possible to provide mental health services anywhere on the globe. This rapidly evolving technology can address the problem of disparities in mental health services caused by the shortage of bilingual and bicultural clinicians. A study has documented that immigrants and refugees in Denmark prefer treatment by ethnic specialists with similar language and cultural backgrounds through videoconferencing, compared with a face-to-face interview with a nonethnic specialist assisted by an interpreter.15 While the promise of delivering mental health services through telemedicine is great, there are obstacles that need to be overcome before telepsychiatry can become a mainstream service. These include issues of credentialing and licensing of providers, obtaining liability coverage, and health insurance reimbursement for services provided through videoconferencing.
Cultural sensitivity training
for all clinicians
With the changing demographics in the United States, it is important that all clinicians be able to provide culturally sensitive care. These skills are especially important in psychiatry, where clinical judgments are invariably influenced by the ethnicity and culture of both psychiatrist and patient.16 In an effort to reduce and eliminate health care disparities, the Accreditation Council for Graduate Medical Education has required that training programs provide supervised experience of treating patients from culturally diverse backgrounds.17 Many states have also established guidelines for professional development for mental health service providers to ensure culturally competent practices.
Ethnicity is an important factor in an individual's response to medications. CYP2D6 and CYP2C19, the 2 cytochrome enzymes that are important for metabolizing psychotropic medications, are known to have polymorphic variations or genetic mutations that give rise to different forms of the same enzyme (isoenzymes). Many studies have shown that higher proportions of Asians than whites have the less active forms of CYP2D6 and CYP2C19 isoenzymes.18 These findings are consistent with other studies that show that Asians as a whole tend to metabolize antipsychotics more slowly than whites.19-21 In addition to genetic differences, many environmental factors, such as diet, use of herbal medicines, and other lifestyle differences, play important roles in determining drug metabolism rates and clinical responses to medications. All of these need to be considered when prescribing medications to minority patients since, thus far, most of the data on pharmacologic treatment are based on white subjects.
Few studies have been published on the effectiveness of psychotherapy for Asian Americans, and questions remain about whether conventional psychotherapy principles and skills apply. Kozuki and Kennedy22 used case-study methods to analyze 8 psychotherapy cases of Japanese individuals seen by Western therapists. They found various forms of misunderstanding and culturally ignorant treatment practices, and these ineffective and often harmful practices went unrecognized by the Western therapists. Such a study highlights the importance of providing ethnically sensitive psychosocial intervention. Rosenberg and associates23 proposed that physicians who treat diverse cultural populations be provided with formal training in intercultural communication to improve quality of care.
Asian Americans often use traditional Chinese treatment for their medical and psychiatric problems, either in isolation or in combination with Western medical treatment. Common practices include meditation, tai chi, bonesetting, acupuncture, and various herbs. While the use of alternative and complementary treatment has increased in the United States in the past decades, there is inadequate evidence from rigorous scientific research regarding its effectiveness and potential side effects. Although this is a tedious and complex process, it is necessary to systematically investigate the effects of these treatment modalities on mental illness so that patients will be able to make informed decisions.
Culture plays an important role in influencing the formation and presentation of psychiatric problems and patients' beliefs about illness. Asian Americans, with their characteristic cultural background and specific immigrant status, pose a challenge to clinicians. Improvement in the recognition and treatment of mental illness in Asian Americans can be achieved by training clinicians in cultural sensitivity, redesigning the structure of service delivery in outpatient clinics, educating immigrants about mental illness, and broadening the nomenclature and practices in psychiatry to incorporate the belief systems of other cultures.
Dr Yeung is a psychiatrist at Massachusetts General Hospital and assistant professor at Harvard Medical School, Boston. Dr Kam is a child psychiatrist at Children's Hospital in Boston and instructor at Harvard Medical School. Dr Yeung and Dr Kam are also staff psychiatrists at the South Cove Community Health Center, Boston. They report no conflicts of interest concerning the subject matter of this article.