The Central ATTC supports and celebrates May as Asian American and Pacific Islander (AAPI) Heritage Month. This month we are happy to share the following article written for the Central East ATTC by Vishesh Agarwal, M.D.
“My daughter won’t be able to marry into a good family…he will understand” (patient said while looking at me).
It was my first year of Psychiatry residency, and we were evaluating a patient of South Asian descent (sometimes referred to as Desi Americans, Desi means 'of the homeland' referring to South Asia). He was admitted with fulminant hepatic failure from alcoholic cirrhosis and had not sought formal treatment until recently. Unable to make sense of that statement, my attending psychiatrist looked at me quizzically. I later explained to him the serious stigma and shame around substance misuse in our community.
Asian American Pacific Islanders (AAPIs) are among the fastest growing ethnic minority population in the United States. While the two large subgroups, Asian Americans and Pacific Islanders may be separated by ethnicity or national origin, there is significant overlap in their cultures. Studies and census data report lower overall prevalence of mental health and substance misuse conditions among AAPIs, but this finding may not be true for all AAPI subgroups. Additionally, there is marked underutilization of mental health services among AAPIs.
When controlling for prevalence, AAPIs are three times less likely to seek care. In a smaller study on Pacific Islanders, the prevalence of behavioral health conditions was 36%, yet less than 10% sought any kind of treatment. Pharmacological treatment remains at a low of 3.6% compared to 15.4% for non-Hispanic Whites. In the age group 15-24, suicide is the leading cause of death for Asian Americans!
There are several cultural, lingual, and systemic barriers that result in underreporting of mental health and substance misuse, and underutilization of available treatment. There are also certain cultural nuances that may increase the incidence of stress related conditions. We will discuss these below with some approaches to address them in clinical settings.
Cultural
AAPI cultures are diverse and varied, with each subgroup having its own traditions, values, and beliefs.
Stigma: It is one of the biggest deterrents to treatment. Seeking mental health care can be considered a sign of weakness and is stigmatized within the community and can deter receiving treatment. Sometimes the symptoms are dismissed or hidden away until they are so severe that forced treatment through hospitalization and/or criminal justice system is required.
Isolation: In some AAPI subgroups, behavioral conditions are considered because of bad life choices. Individuals experience significant guilt and may isolate themselves, thereby delaying treatment. Families may be dishonored and shamed within their community (as in the case example above) and disagree with treatment.
Model Minority: AAPIs have high parental expectations and societal pressure to succeed in academics and attend to family obligations. This success is portrayed as equivalent to their pursuit of the American Dream. These unrealistic expectations are a major stressor affecting their overall health.
Identity crises / acculturation stress: Both first- and second-generation individuals, have difficulty balancing and developing their sense of self as they assimilate and adapt to the American culture. The first-generation individuals have their lived experiences that are shaped by where they were born, how closely they relate to their family’s ethnic origins, and how they engage with the American society.
For the second generation, the cultural disharmony and identity conflict is much worse. In fact, among the South Asian community, "American-born confused desi" (ABCD) is used as an informal term referring to South Asian Americans born or raised in the United States. The confusion stems from the struggle to balance their cultural values and traditions practiced at home with the practices that are more conducive to the American culture.
Historical trauma and discrimination: AAPI communities have experienced historical trauma, such as forced migration, colonization, internment, and face discrimination due to racial or cultural background. These collective traumas can have intergenerational effects on mental health and well-being of all individuals.
Linguistic
Language: Limited English Proficiency can be a significant obstacle to accessing mental health care for many AAPI individuals, particularly first-generation immigrants. They cannot communicate effectively with healthcare providers, especially around mental health symptoms, and may sometimes report them as physical symptoms.
Lack of Knowledge / awareness: AAPIs may intentionally or unintentionally ignore mental health care due to lack of understanding of symptoms. They also deny or neglect symptoms. AAPIs may believe in alternative treatments in place of modern medicine which could delay care.
Systemic
Access: AAPIs commonly experience lack of culturally competent services, especially for mental health care.
Inadequate insurance coverage and immigration status concerns could be additional barriers.
What can we do?
As clinicians, we need to be sensitive and respectful to the cultural nuances and tailor our approach to individuals seeking mental health and substance use treatment. Create safe spaces for clients to share their mental health concerns. Another important aspect is to have a low threshold for treatment. This means that if an AAPI client is seeking treatment, we should assume the condition is already severe and needs clinical intervention urgently.
Clinicians (especially ones from AAPI backgrounds) can partner with religious and social organizations in the AAPI communities to share education on behavioral health.
Engage religious and community leaders to help reduce stigma not just around diagnosis but also treatment. Encourage professional consultation in lieu of help from friends and family.
Availability of multilingual information packets (especially if located in areas with higher AAPI demographic) and proactive involvement of interpreters or bilingual staff to ensure effective communication with clients. This will help capture nonverbal and indirect communication styles, which are common amongst AAPI clients.
Advocacy for policies and practices to improve access to care for AAPI communities. Increase collaboration between formal healthcare delivery systems and community-based AAPI organizations.
In summary, behavioral health clinicians working with AAPI clients need to be culturally competent, sensitive to diverse experiences, and be mindful of the unique challenges they may face in accessing and accepting mental health care. Building trust, reducing stigma, and addressing systemic barriers are key steps in providing effective care for AAPI clients.
--Dr. Vishesh Agarwal is the Vice-Chair of the Department of Psychiatry at ChristianaCare in Wilmington, Delaware. He is a board-certified general adult psychiatrist, with additional board certification in addiction psychiatry and obesity medicine. Along with his clinical duties, he is engaged in psychiatric research and publication, and has been mentoring, supervising, and instructing resident physicians and student learners receiving clinical training at ChristianaCare.
References:
CDC, 2021. Health United States, 2019.
SAMHSA, 2020. Results from the 2019 National Survey on Drug Use and Health
Spencer, M., Chen, J., Gee, G., Fabian, C., Takeuchi, D. (2010). "Discrimination and Mental Health-Related Service Use in a National Study of Asian Americans." American Journal of Public Health, 100(12), 2410-2417.
Subica AM, Aitaoto N, Link BG, Yamada AM, Henwood BF, Sullivan G. Mental Health Status, Need, and Unmet Need for Mental Health Services Among U.S. Pacific Islanders. Psychiatr Serv. 2019 Jul 1;70(7):578-585.
Varma SC, Siris SG. Alcohol abuse in Asian Americans: Epidemiological and treatment issues. Amer. J. Addict 1996; 5:136–143
Lee, S., Juon, H., Martinez, G., Hsu, C., Robinson, S., Bawa, J.,Ma, G. (2009). Journal of Community Health: The Publication for Health Promotion and Disease Prevention, 34(2), 144-152.
Office of the Surgeon General (US); Center for Mental Health Services (US); National Institute of Mental Health (US). Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2001 Aug. Chapter 5 Mental Health Care for Asian Americans and Pacific Islanders.
