Recognizing and Treating Depression in Asian Americans

There has been phenomenal growth in the Asian American population in recent years. In 1990, there were 7.3 million Asian Americans in the United States, accounting for 3.4% of the population. In 2000, the number increased by 38%, to 10.1 million, or 4% of the US population (2000 census),¹ and this growth rate is expected to continue.

Compared with other ethnic groups, Asian Americans underuse mental health services, resulting in delayed treatment and higher attrition rates. A report by the surgeon general² states that the underutilization is because of the shortage of bilingual services, the low percentage of health care insurance coverage, and the Asian American tradition of using mental health treatment only as a last resort.

Asian Americans tend to first seek help from families, friends, alternative medicine providers, and primary care physicians. Those Asian Americans who do use mental health services tend to have worse short-term treatment outcomes and lower patient satisfaction scores than do white Americans.³

Prevalence
A review of the literature reveals a paucity of published data on the prevalence of mental illness among Asian Americans, both in the community and in primary care settings. Takeuchi and colleagues⁴ conducted a large-scale community-based study of depression in Chinese Americans living in Los Angeles County using the Composite International Diagnostic Interview.⁵ They estimated the lifetime prevalence of major depressive disorder (MDD) in Chinese Americans to be 6.9%, much lower than the national estimate of 17.1%.⁶

Our team examined the prevalence of MDD among Asian Americans in the primary care setting of the South Cove Community Health Center in Boston. South Cove is an urban community health center with wide-ranging clinical services that primarily serves low-income Asian immigrants who face financial, linguistic, and cultural barriers to health care. Using a 2-phase epidemiologic survey, we found the rate of MDD in this population to be 19.6%, which is comparable to or higher than that found in nonminority populations in the United States.

Symptom presentation
In an earlier study, we examined the symptom profiles of Chinese patients with MDD and found that symptoms spontaneously reported by patients differed substantially from those they reported when asked directly about the presence or absence of mood symptoms. Mirroring results found by other researchers,^7,8 we discovered that only a small proportion (14%) of patients in this recently immigrated population spontaneously described symptoms from the psychological realm, such as depressed mood, irritability, rumination, and poor memory. A much higher proportion (76%) of patients with depression in this primary care setting presented with physical symptoms as their chief complaint (Table 1). In fact, none of the patients who were depressed in this study considered depressed mood as their chief problem. However, more than 90% of these same subjects endorsed depressed mood when asked to rate their symptoms using a depression rating scale.⁹

In the past, Chinese patients had been thought to be alexithymic (lacking the ability to understand their emotions) or else unwilling to report them. Findings from this study show that the majority of Chinese patients with depression have no problems in either identifying or reporting psychological symptoms.

This was also shown in another South Cove study in 1998, when our team explored the illness beliefs of 29 Chinese American immigrants from a primary care population who were depressed. When the subjects were asked what label they would give their condition, more than half did not ascribe their symptoms to depression or any other psychiatric condition (Table 2). When asked how the symptoms affected them, however, their responses showed an awareness of both an internal psychological state as well as a somatic, physical state. Twenty-six patients (90%) felt that the symptoms affected their mind, and 23 patients (79%) felt the symptoms affected their body, with 22 patients (76%) feeling that the symptoms affected both their mind and their body.

In light of these findings, we believe that Chinese Americans who have recently immigrated are not incapable of identifying or feeling emotions, but that in primary care clinics, they focus more on somatic symptoms and less or not at all on their mood symptoms. The clinical and public health implication is that clinicians treating this population need to actively elicit mood symptoms from Asian American immigrants to prevent the underrecognition and undertreatment of MDD.

BARRIERS TO ACCESSING MENTAL HEALTH SERVICES
Impact of mind-body relationship
Depression, as conceptualized in European and North American cultures, is a distinct and well-accepted psychiatric syndrome characterized by specific affective, cognitive behavioral, and somatic symptoms. In many non-European cultures such as Chinese, Japanese, and Southeast Asian, equivalent concepts of depressive disorders are not found. This lack of translatability of the illness construct from the dominant Western culture into Chinese and other Asian cultures represents a significant and difficult barrier to the effective treatment of depression.

In Western medicine, the reporting of internal mood and anxiety states has long been considered the norm for symptom conception and presentation in depression. Somatization, defined as replacing psychological needs with physical symptoms, has been considered a barrier to both the diagnosis and treatment of psychiatric disorders. The psychologizing of symptoms and the valuation of this ability to parse and analyze one's internal emotional states is particular to Westernized cultures. The separation between the body and spirit dates back to the Gnostic traditions before the time of the early Church; this Cartesian mindset continues in the modern conception of a separate body and mind.

A psychocentric focus in the understanding of mood states is a Western practice that does not fit well with Asian cultures. In traditional Chinese medicine, illnesses are conceptualized in a framework that centers around the organ systems and elements in nature (fire, wood, earth, metal, water). There is no dichotomy of the mind and body, whereby there would be physical illnesses that are distinct from illnesses of the mind. All illnesses, classified as psychiatric or not in Western tradition, are explained within this system. One can have "anxiety" over life, for example, but not an "anxiety" disorder. Anxious or depressive feelings are the natural emotional ripples in the course of life, secondary to a person's medical and interpersonal problems and not conceptualized as a disease entity.

For many Asian patients, therefore, the reporting of physical symptoms is a more familiar and culturally appropriate way to communicate their distress. By training providers to understand the symptom presentations in different cultures, and by broadening psychiatric classification systems to incorporate belief systems from other cultures in future psychiatric nomenclature, we believe that it is possible to begin bridging the gap between care providers and their patients.

Stigma of mental illness
For Asian Americans, mental disorders are highly stigmatized and typically associated with "craziness," mental retardation, severe autism, or hereditary defects. Only those persons who are unable to otherwise function in society seek psychiatric help, reinforcing the notion that only "crazy" people seek mental health services. In community-centric Asian cultures, the associated stigma of mental illness often leads to a loss of face and affects the social acceptability of the patients and their family members. As a result, psychiatric services are typically avoided altogether.

The use of literal translation of psychiatric terminologies can intensify the fear. For example, the term mental disorder is frequently translated in Chinese as jing shen bing, which in the minds of most Chinese and Chinese Americans means craziness. Similarly, the commonly used term you yu zheng (depressive disorder) is frequently perceived as a serious mental disorder leading to insanity or dementia among less acculturated Asian Americans.

Psychotherapy as a foreign tradition
While psychotherapy principles are applicable to and useful for treating Asian Americans, it needs to be pointed out that talk therapy provided by professionals has not existed in traditional Asian cultures. Less acculturated Asian Americans may feel awkward or anxious talking to a stranger about their worries and fears. In many traditional Asian societies, where privacy is almost nonexistent (and indeed, there is no word for privacy in the Chinese language), disclosure of behaviors that are not sanctioned by the society remains a risky and unfamiliar practice. During personal crises, a direct, pragmatic problem-solving approach, looking for immediate and tangible solutions to issues would be more culturally appropriate. The often nondirect role of therapists and their individualistic growth-oriented psychotherapeutic approaches may not be compatible with the needs and expectations of such patients.

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.

INCREASING ACCESS
Understanding and bridging cultural differencesAs 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 ethnic groups
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

Telepsychiatry services
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.

Pharmacologic treatment
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.

Ethnically sensitive interventions
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.

Alternative treatments
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.

Summary
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.

References:

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