One in five people suffer from some kind of mental health condition. That number is lower among Asian Americans — but it’s not because they are any less affected. A new study out this week shows a glaring disparity between whites and Asians when it comes to diagnosis and treatment of mental disorders.
When psychiatrist Xiaoduo Fan was working at Massachusetts General Hospital, he started to notice a pattern.
“I noticed that Asian Americans rarely present to the outpatient setting to seek mental health care,” Fan said.
It was more common to see Asian Americans with mental health disorders when things got dire, like in the emergency room or among hospitalized patients. Fan wanted to know why. He and his team of researchers at UMass Medical school examined more than 360,000 MGH patient records from 2009. In their study, they found that whites were more than twice as likely to be diagnosed with mental health disorders than Asian Americans, and even among those diagnosed, whites were twice as likely to receive medication.
Fan says a couple things account for this disparity. Mental health continues to carry a deep stigma in Asian cultures.
“In Asian cultures in general, when someone is talking about emotional experiences, psychological disturbances and challenges, it’s considered a character defect or personal weakness," Fan said.
But a lack of cultural competence on the part of the healthcare providers is another part of the equation.
Asian Americans are the fastest-growing minority group in the country. Despite that, they are largely underrepresented in mental health professions. They’re not alone. Other research has shown similar significant disparities among Latinos and blacks. And even if care is available in the community, racial and ethnic minority groups are less likely to use it.
Fan said if providers were better able to understand this stigma and the vocabulary many Asian-American patients use to communicate emotional or mental distress — often through physical aches and pains, they could facilitate patients to better describe their emotional experiences.
“In Asian cultures in general, sharing feelings or psychological experience in general [is] not encouraged, so that’s why people who grow up in Asian cultures, they may not develop that vocabulary to describe their emotional experiences or feelings,” Fan said.
Susanna Yee, a 25-year-old graphic designer in Boston, can relate. Her immigrant parents juggled multiple jobs while raising her and her brother in Dorchester. Even when there was time to talk, they didn’t talk about feelings.
“I feel like anxiety was always something that was really hard to portray to my mom, so I would just say like, 'Oh, I'm not feeling good,' or that sort of thing. So it would really be pretty vague, if even discussed at all,” Yee said.
She said other priorities were getting food on the table and making sure bills were paid and that she and her brother got to school on time and kept up their grades.
It wasn’t until Yee was in college that she learned about counseling. It came at a time when grief and stress were mounting. Her father had died suddenly before school started. Then her grandfather passed away. She was trying to keep it together while enrolled in a rigorous graphic design program.
“I didn't know there was a doctor there for your mental health,” said Yee. “It seemed really foreign to me but when I was talking to my classmates it's, like, well, 'There are some days that you're really stressed out and having someone as a counselor is a really good way to talk about your feelings.’”
The counseling helped, and then she stopped going for a while. Shortly after college, though, Yee was dealt another tragic blow. Her mother died after battling cancer. All the losses in the span of five years left Yee reeling, but seeing her therapist regularly has given her the tools to cope. Yee only wishes more Asian Americans would feel comfortable doing the same.
“I would like for people to have more of an open conversation about it," Yee said. "I feel like the stigma is, ‘You should only see one if you're crazy or you're sick.’”
Xiaoduo Fan of UMass Medical says that's a common belief among Asian Americans. There’s also widespread skepticism of Western medicine, particularly among immigrants, who prefer personalized alternative therapies, such as acupuncture or traditional Chinese medicine.
“In Asian cultures people don’t like to take these types of medications. They feel like these types of medications are toxic and not good for the body,” Fan said.
There may be some evidence to support that in the way some patients initially respond to treatment. The recommended dosage of psychotropic drugs is based on clinical trials made up primarily of white patients. Fan says he generally prescribes his Asian patients with dosages lower than recommended because of reports of adverse initial reactions.
There’s growing emphasis on understanding stigma and the values of other cultures in hospitals. In 2015, the American Hospital Association launched the #123forEquity campaign, an initiative to eliminate healthcare disparities. Mass General Hospital joined 1,500 hospitals in this pledge, and Joseph Betancourt of MGH’s Center for Diversity and Inclusion said MGH has ramped up its cultural competence training.
“We don't aim to teach them the do's and don'ts of how to take care of Asians or Blacks or Latino patients,” Betancourt explained. “But instead, we say there are a key set of cross-cultural issues that are important in different cultures, and that it's incumbent upon you to have a radar screen to pick up what, for example, words people might use to express depression in different cultures.”
Nhi-Ha Trinh, director of MGH’s Department of Psychiatry Center for Diversity, says clinicians are now required to document a cultural and ethnic history in every new patient evaluation.
“Eventually, the goal is to include this information/consider these factors in treatment plans for every patient we see. We are planning department-wide training to further these clinical targets,” she said in an e-mail.
Meanwhile, UMass Medical School is teaching cultural competence it to its students. Xiaoduo Fan is cautiously optimistic about this growing attention but says there’s a long way to go.
“This racial disparity is real, and I’ve seen so many Asian Americans suffer from mental illness, but they remain kind of underground and remain in this dark tunnel of struggle for years or for decades or for life," Fan said. "On the other hand, there are now treatments available in terms of medications or different types of therapy, even though there are not enough resources. But there are resources available.”
Correction: This story has been updated to reflect the correct title of Nhi-Ha Trinh, director of MGH’s Department of Psychiatry Center for Diversity.