CHAPTER 5

Mental Health Care for Asian Americans and Pacific Islanders

Availability, Accessibility, and Utilization of Mental Health Services

Disparities exist in the provision of adequate and effective mental health care to Asian Americans. Culturally competent and effective services are often unavailable or inaccessible.

Availability of Mental Health Services

Nearly half of the Asian American and Pacific Islander population’s ability to use the mental health care system is limited due to lack of English proficiency, as well as to the shortage of providers who possess appropriate language skills. No reliable information is available regarding the Asian language capabilities of providers. Of the mental health care professionals who were practicing in the late 1990s, approximately 70 Asian American providers were available for every 100,000 Asian Americans in the United States; this is about half the ratio for whites (Manderscheid & Henderson, 1998).

Accessibility of Mental Health Services

Access to mental health care often depends on health insurance coverage. About 21 percent of Asian Americans and Pacific Islanders lack health insurance. However, within Asian American subgroups, the rate varies significantly. For instance, 34 percent of Korean Americans have no health insurance, whereas 20 percent of Chinese Americans and Filipino Americans lack such insurance. Furthermore, the rate of Medicaid coverage for most Asian American and Pacific Islander subgroups is well below that of whites. It has been suggested that lower Medicaid participation rates are, in part, due to widespread but mistaken concerns² among immigrants that enrolling themselves or their children in Medicaid would jeopardize their applications for citizenship (Brown et al., 2000). Nevertheless, even among U.S. citizens who live in families with children and have family incomes below 200 percent of the Federal poverty level (i.e., those who are most likely to be eligible for Medicaid), only 13 percent of Chinese Americans have Medicaid coverage, compared to 24 percent of whites in the same income bracket (Brown et al., 2000). These findings are important to consider because there is evidence that the lack of insurance coverage is associated with lower access to and utilization of health care (Chin et al., 2000).

Utilization of Mental Health Services

Community Studies

The Chinese American Psychiatric Epidemiological Study (CAPES) did not include a large enough sample of Asian Americans and Pacific Islanders to determine an accurate percentage of how many use care. In the study, participants with and without mental disorders indicated whether or not they had sought help for problems with emotions, anxiety, drugs, alcohol, or mental health in the past six months. Unfortunately, few of those experiencing problems (17%) sought care. Less than 6 percent of those who did seek care saw a mental health professional; 4 percent saw a medical doctor; and 8 percent saw a minister or priest (Young, 1998). Likewise, in the small sample of Asian Americans who participated in the National Comorbidity Study (NCS), less than 25 percent of those who had experienced a mood or anxiety disorder had sought care.

Zhang and colleagues (1998) compared Asian Americans and whites from a randomly selected sample based on the first wave of the Epidemiologic Catchment Area study on help seeking for psychological problems. Asian Americans were significantly less likely than whites to mention their mental health problems to a friend or relative (12 versus 25%), psychiatrist or mental health specialist (4 versus 26%), or physician (3 versus 13%). Asian Americans used health services less frequently in the past 6 months than whites (36 versus 56%). Compared with white Americans, Asian Americans less frequently visited a mental health center, a psychiatric outpatient clinic in a general hospital, an emergency unit, or a community mental health program, natural therapist, or self-help group. However, Asian Americans and whites did not differ in their use of out-patient clinics located in psychiatric

Box 5–2: Avoidance of Mental Health Service

An (age 30)
Gee and Ishii (1997) describe a case that illustrates the difficulties that some Asian Americans have in using mental health services. An was a 30-year-old bilingual, Vietnamese male who was placed in involuntary psychiatric hold for psychotic disorganization. After neighbors found him screaming and smelling of urine and feces, they called the police, who escorted him to a psychiatric emergency room. An had been hospitalized several previous times for psychotic episodes. He was the oldest of five children and was living at home while attending college.

His parents had a poor understanding of schizophrenia and were extremely distrustful of mental health providers. They thought that his psychosis was caused by mental weakness and poor tolerance of the recent heat wave. They believed that they themselves could help An by providing him with their own food and making him return to school. Furthermore, the family incorrectly attributed An’s facial injury, sustained while in the locked facility, to beatings from the mental health staff.

These misconceptions and differences in beliefs caused the parents to avoid the use of mental health services.

Mental Health Systems Studies

Another way to determine whether Asian Americans and Pacific Islanders are using mental health care is to look at mental health systems of care. What must be deter-mined is whether individuals from different groups served by the same system use care in proportion to their representation in the community. A problem with this approach is that it assumes, perhaps incorrectly, that groups have identical needs for mental health care. Three comprehensive studies that examined the entire formal mental health system found that Asian Americans used fewer services per capita than did other groups (Snowden & Cheung, 1990; Cheung & Snowden, 1990; Matsuoka et al., 1997).

Results consistent with the findings of these national studies were found in studies of many local mental health systems, such as Los Angeles County. The proportion of Asian Americans among those who use psychiatric clinics and hospitals was found to be lower than their proportion of the general population (Kitano, 1969; Brown et al., 1973; Sue, 1977; Los Angeles County Department of Mental Health, 1984; Cheung, 1989; Snowden & Cheung, 1990; Sue et al., 1991; Uba, 1994; Durvasula & Sue, 1996; Snowden & Hu, 1997; Shiang et al., 1998). This disparity occurred whether the Asian American groups considered were students or nonstudents, inpatients or outpatients, children or adults, or whether they were living in neighborhoods with many or few other Asians. One exception to this finding has been published (O’Sullivan et al., 1989). Asian Americans in Seattle were found to use services at rates similar to their representation in the community. However, representation in the community was based on earlier census data, and the Asian American population grew rapidly during the subsequent period.

Another large-scale study focused on use of mental health services by Asian Americans and Pacific Islanders in Hawaii (Leong, 1994). This study examined outpatient and inpatient utilization rates from 1971 to 1981. Consistent with the findings of mainland studies, all Asian American and Pacific Islander groups used fewer inpatient services than would be expected given their representation in the population. However, lower utilization of outpatient care was not consistent across different groups of Asian Americans. Although both Chinese and Japanese Americans used less outpatient care than would be expected, Filipino Americans used these services at rates similar to their proportion in the population.

Many studies demonstrate that Asian Americans who use mental health services are more severely ill than white Americans who use the same services. This pattern is true in many community mental health centers (Brown et al., 1973; Sue, 1977), county mental health systems (Durvasula & Sue, 1996, for adults; Bui & Takeuchi, 1992, for adolescents), and student psychiatric clinics (Sue & Sue, 1974). Two explanations for this finding are that (1) Asian Americans are reluctant to use mental health care, so they seek care only when they have severe illness, and (2) families tend to discourage the use of mental health facilities among family members until disturbed members become unmanageable. Sue and Sue have found evidence that the reluctance to use services is attributable to factors such as the shame and stigma accompanying use of mental health services, cultural conceptions of mental health and treatment that may be inconsistent with Western forms of treatment, and the cultural or linguistic inappropriateness of services (Sue & Sue, 1999).

Complementary Therapies

Asian Americans and Pacific Islanders are not represented in the national studies that report on use of alternative or complementary health care sources (both home-based and alternative providers) to supplement or substitute for care received from mainstream sources (Eisenberg et al., 1998; Astin, 1998; Druss & Rosenheck, 2000). Nevertheless, some smaller studies conducted within subgroups of Asian Americans and Pacific Islanders suggest use of complementary therapies at rates equal to or higher than those used by white Americans. For example, one study of first- and second-generation Chinese Americans seeking care in an emergency department near New York City’s Chinatown found that 43 percent had used Chinese therapies within one week of the visit (Pearl et al., 1995). Another study found that 95 percent of Chinese immigrants in Houston and Los Angeles used home remedies and self-treatments, including dietary and other approaches. Of this group, a substantial number of immigrants consulted traditional healers (Ma, 1999). Similarly, 90 percent of Vietnamese immigrants in the San Francisco Bay area used indigenous health practices (Jenkins et al., 1996). Almost half of the older Korean immigrant participants in Los Angeles County reported seeing a traditional healer (Pourat et al., 1999). Like members of other ethnic groups, these individuals generally use traditional therapies and healers to complement care from mainstream sources.

Asian Americans use a range of healing methods. For example, traditional Chinese medicine has existed for almost 3,000 years, and traditional Vietnamese healing derives from these historical roots. However, the healing practices of Laotians and Cambodians are influenced more by India and South Asia and have origins in ayurvedic medicine. Polynesian culture and healing practices are influential in Hawaii and other Pacific Islands.

Little is known about how Asian Americans and Pacific Islanders use indigenous therapies specifically for mental illness. Nevertheless, medications prescribed by mainstream health care providers can interact with herbal remedies or other forms of traditional medicine, so an awareness of the potential use of complementary methods of healing is essential.

² These concerns originate from, among other things, confusion on the part of immigrants and providers about who is eligible for benefits and in fears relating to the application of the public charge doctrine. “Public charge” is a term used by the Federal Government to describe someone who is, or is likely to become, dependent on public benefits (Fix & Passel, 1999). The Immigration and Naturalization Service does not include Medicaid or other public health benefits in public charge determinations. Furthermore, the public charge doctrine applies to admission and deportation , but not to the naturalization of immigrants (Edwards, 2001).