CHAPTER 5

Mental Health Care for Asian Americans and Pacific Islanders

The Need For Mental Health Care

Historical and Sociocultural Factors That Relate to Mental Health

Historical events and circumstances shape the mental health profile of any racial and ethnic group. For example, refugees from Cambodia were exposed to trauma before migrating to the United States because of persecution by the Khmer Rouge Communists under Pol Pot. During the four years of Pol Pot’s regime (1975–1979), between 1 and 3 million of the 7 million people in Cambodia died through starvation, disease, or mass executions. This national trauma, as well as the stressors associated with relocation, including English language difficulties and cultural conflicts, continues to affect the emotional health of many Cambodian refugees and other immigrants.

Somatization

Another important factor related to mental health is culture. Culture shapes the expression and recognition of psychiatric problems. Western culture makes a distinction between the mind and body, but many Asian cultures do not (Lin, 1996). Therefore, it has long been hypothesized that Asians express more somatic symptoms of distress than white Americans. The influence of the teachings and philosophies of a Confucian, collectivist tradition discourages open displays of emotions, in order to maintain social and familial harmony or to avoid exposure of personal weakness. Mental illness is highly stigmatizing in many Asian cultures. In these societies, mental illness reflects poorly on one’s family lineage and can influence others’ beliefs about how suitable someone is for marriage if he or she comes from a family with a history of mental illness. Thus, either consciously or unconsciously, Asians are thought to deny the experience and expression of emotions. These factors make it more acceptable for psycho-logical distress to be expressed through the body rather than the mind (Tseng, 1975; Kleinman, 1977; Nguyen, 1982; Gaw, 1993; Chun et al., 1996). It has been found that Chinese Americans are more likely to exhibit somatic complaints of depression than are African Americans or whites (Chang, 1985), and Chinese Americans with mood disorders exhibit more somatic symptoms than do white Americans (Hsu & Folstein, 1997).

Hsu and Folstein (1997) and Leff (1988) also suggest that psychological expression of distress is a relatively recent Western phenomenon, and that physical expression of psychological distress is normal in many cultures. Others have argued that somatization is often under the control of display rules that dictate when, where, and what symptoms are shown (Cheung, 1982). In this view, it is not so much that Chinese suppress or repress affective symptoms, but that the context of the situation influences what is presented. Chinese may display somatic symptoms to mental health workers but show depressive symptoms to others. Mental health professionals who rely solely on the standard psychiatric diagnoses used in the United States may not identify these somatic expressions of distress.

Key Issues for Understanding the Research

Methodology

The history of AA/PI groups reveals the tremendous diversity within the population. Unfortunately, in the past, research studies have typically classified Asian and Pacific Islander Americans as belonging to a homogenous ethnic category. Chapter 1 outlined some of the serious methodological problems (e.g., the high cost of screening rare populations) that partially explain why AA/PIs are often lumped together or into an “other” category. Despite the practical basis for creating a single racial designation for AA/PIs, using it has had real scientific and policy con-sequences. One consequence, as demonstrated later in this chapter, is that very little is known about the rates of mental illness, access to care, quality of care, and outcomes of treatment for different groups of Asian Americans and Pacific Islanders. The AA/PI category is a social and political convenience because the use of the term allows researchers, service providers, and policymakers to easily describe and discuss groups who seemingly share similar backgrounds. Unfortunately, this classification masks the social, cultural, and psychological variations that exist among AA/PI ethnic groups and constrains analyses of the interethnic differences in mental illness, help-seeking, and service use. The conclusions drawn from analyses using AA/PIs as a single racial category may be substantively different than ones made when specific AA/PI ethnic groups are examined (Uehara et al., 1994).

A second consequence of using a single ethnic category in research analyses is that it can lead to the conclusion that AA/PIs are a model minority. On average, AA/PIs have relatively high levels of educational, occupational, and economic achievement, and low rates of certain health problems. A simple interpretation of these types of data has resulted in portrayals of AA/PIs as extraordinarily successful, which justifies the lack of research attention and resources allocated to this population. However, recognition of the diverse ethnic groups that comprise the AA/PI category helps to cast doubt on the model minority image. It should be noted that occasionally research on an aggregate group (e.g., Asian Americans) might be appropriate, particularly when the characteristic under observation is common to many Asian American groups. Nevertheless, care must be exercised to avoid stereotyping this population. The needs of specific AA/PI ethnic groups must be considered in order to fully understand the mental health of Asian Americans and Pacific Islanders.

Diagnosis

Establishing the rates of psychiatric disorders among AA/PIs is important in determining the need for mental health care in this population. As mentioned earlier, a common standard in setting the criteria for different mental disorders is the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (1994). A critical issue is whether or not AA/PIs manifest symptoms similar to those found in Western societies as defined by the DSM–IV. Marsella and colleagues (1985) note that there is a tendency in the mental health field to overlook cultural variations in the expression of mental disorder when developing nosological categories. Groups vary in how they define such constructs as “distress,” “normality,” and “abnormality.” These variations affect definitions of mental health and mental illness, expressions of psychopathology, and coping mechanisms (Marsella, 1982).

In addition, ethnic and cultural groups may have unique ways of expressing distress. As discussed later, neurasthenia, a condition often characterized by fatigue, weakness, poor concentration, memory loss, irritability, aches and pains, and sleep disturbances, is recognized in China. It is an official category in the International Classification of Diseases (Version 10) but not in the DSM–IV. Neurasthenia is a common diagnosis in China (Yamamoto, 1992), although it is not an official category in the DSM–IV. It is sometimes classified as undifferentiated somatoform disorder (if symptoms last at least six months) or as a rheumatological disorder. Some of the symptoms found in neurasthenia (loss of energy, inability to concentrate, sleep disturbances, etc.) overlap with those in depressive disorders. However, in neurasthenia, the somatic symptoms rather than depressed moods are critical, and any depressive symptoms are not sufficiently persistent and severe to warrant a diagnosis of a mood disorder.

Acculturation

An important factor in understanding the symptom expression, rates of illness, and use of services by immigrants and refugees is their acculturation, or adoption of the worldviews and living patterns of a new culture. Asian Americans differ in how they are integrated with-in the dominant U.S. culture, how they remain tied to the cultures of their ethnic origins, or how they are able to negotiate life in multiple cultures. Although many advances have been made in measuring acculturation, this area of research still has unresolved conceptual and methodological problems. Many factors affect the way and extent to which immigrants become involved in a new culture and remain connected with their earlier heritage. For example, age at time of immigration, presence of similar immigrants, and interaction with others from the new environment all influence adaptation. The influence of acculturation on mental health has not been clearly identified, in part because of problems with measuring acculturation. Nonetheless, the level of exposure to and involvement in U.S. culture is important when examining mental health factors for Asian Americans.

Mental Disorders

Adults

Less is known about the rates of psychiatric disorders using DSM categories for AA/PIs than for most of the other major ethnic groups. Even when AA/PIs are included as part of the sample of large-scale studies, it is not often possible to make estimates of mental disorders for this population. Two major studies, the Epidemiologic Catchment Area (ECA) study and the National Comorbidity Study (NCS), examined the need for mental health care in the U.S. population. In the 1980s, researchers who were conducting the Epidemiologic Catchment Area study (Regier et al., 1993) included residents of Baltimore, St. Louis, Durham, Los Angeles, and New Haven in their sample. English-speaking Asian Americans, who were classified in a single ethnic category, comprised less than 2 percent of the total sample (N = 242). Because of the limited sample size and the unclear composition of the AA/PI category, accurate conclusions could not be drawn about this population’s need for mental health care (Zhang & Snowden, 1999).

While the ECA study was limited to samples from five U.S. cities, the NCS (Kessler et al., 1994) estimated the rates of psychiatric disorders in a representative sample of the entire U.S. population. Just as in the ECA study, the NCS included a small sample of English-speaking Asian Americans and classified all ethnic groups into a single AA/PI category. Again, the group of Asian American respondents in the NCS was small, extremely diverse, and not representative of any particular Asian American subgroup.

The Chinese American Psychiatric Epidemiological Study (CAPES), was a large-scale investigation of the prevalence of selected disorders using DSM–IIIR (APA, 1987) criteria. This study, conducted in 1993 and 1994, examined rates of depression among more than 1,700 Chinese Americans in Los Angeles County (Sue et al., 1995; Takeuchi et al., 1998). The CAPES sample was comprised predominantly of Chinese immigrants; 90 per-cent of the sample was born outside the United States. Researchers conducted interviews in Cantonese, Mandarin, and English, and they used a multistage sampling procedure to select respondents. CAPES was similar in some ways to the ECA and NCS. Like the ECA, CAPES used one geographic site rather than a national sample. To measure depression, CAPES used the Composite International Diagnostic Interview Schedule—the University of Michigan version (UM–CIDI)—which is similar to the diagnostic instrument used in the NCS.

CAPES results showed that Chinese Americans had moderate levels of depressive disorders (Table 5–1). About 7 percent of the respondents reported experiencing depression in their lifetimes, and a little over 3 percent had been depressed during the past year. These rates were lower than those found in the NCS (Kessler et al., 1994). On the other hand, the rate for dysthymia more nearly matched the NCS estimates. It should be noted that the rates of lifetime and 12-month depression and dysthymia were very similar to the prevalence rates found in the Los Angeles site for the ECA. The implications of these findings are reviewed at the end of the discussion of other studies using symptom scales.

No study has addressed the rates of mental disorders for Pacific Islander American ethnic groups.

Table 5-1 compares data from the Chinese American Psychiatric Epidemiological Study and the National Comorbidity Survey for the 12-month and lifetime prevalence of Major Depression and Dysthymia among Chinese Americans and the general population.

Children and Youth

Very little is known about the mental health needs of the diverse populations of Asian American and Pacific Islander children and adolescents. No large studies documenting rates of psychiatric disorders in these youth have been conducted. However, several studies of symptoms of emotional distress have been conducted in small group samples of Asian American and Pacific Islander youth. Most of these studies find few differences between Asian American and Pacific Islander youth and white youth. For example, Filipino youth (Edman et al., 1998) and Hawaiian youth (Makini et al., 1996) attending high schools in Hawaii were found to have rates of depressive symptoms similar to those of white youth in the same schools. On the other hand, Chinese immigrant students have reported high rates of anxiety (Sue & Zane, 1985).

Older Adults

Little information is available on the prevalence of psychiatric disorders among older Asian Americans. Yamamoto and colleagues (1994) found a relatively low lifetime prevalence of most psychiatric disorders according to DSM–III (APA, 1980) criteria among a sample (N = 100) of older Koreans drawn from the Korean Senior Citizens Association in Los Angeles (Yamamoto et al., 1994). Researchers also compared older Koreans in Los Angeles with community epidemiological studies conducted in Korea. The prevalence of almost all psychiatric disorders was similar for older Koreans in Los Angeles and those in Korea (Yamamoto et al., 1994).

Four other studies have examined the psychological well-being of older Asian Americans. These studies are weak from a methodological standpoint because they involve small, non-random samples and use general measures of distress rather than measures of psychiatric disorders. Three studies used the translated version of the Geriatric Depression Scale (GDS). A convenience sample of Japanese American older adults in Los Angeles (N = 86) was found to be relatively healthy and not depressed (Iwamasa et al., 1998). In a sample of older Chinese American adults in Minneapolis–St. Paul (N = 45) between the ages of 59 and 89 years, 20 percent were found to have significant depressive symptoms. A study of older, community-dwelling Chinese immigrants (N = 50) in a Northeast urban area revealed that 18 per-cent of respondents were mildly to severely depressed (Mui, 1996). These rates are similar to those found in other community samples of older people. Raskin and colleagues (1992) compared Chinese and white Americans between the ages of 60 and 99 from senior citizen housing complexes, senior citizen centers, senior citizen clubs at churches, and other community locations. Chinese Americans reported somatic psychiatric distress similar to what their white American counter-parts reported. Finally, White and colleagues (1996) found a 9 percent prevalence for dementia among Japanese American men living in institutions or in the community in Honolulu, a rate lower than that for Japanese men in Japan, but similar to that for other American men in their age group.

In sum, researchers must be cautious about generalizations based on the limited findings on the mental health of older Asian Americans. Subjects for these studies are often recruited through Asian American senior organizations; the extent to which these findings can be generalized to less active older adults is limited. However, these results do not reveal high rates of psychopathology among older Asian adults.

Mental Health Problems

Symptoms

Much more is known about mental health problems measured by symptom scales as opposed to DSM criteria. In these studies, AA/PIs do appear to have an increased risk for symptoms of depression. Diagnoses of psychiatric disorders rely both on the presence of symptoms and on additional strict guidelines about the intensity and duration of symptoms. In studies of depressive symptoms, individuals are often asked to indicate whether or not they have specific depressive symptoms and how many days in the past week they experienced these symptoms. In several studies, Chinese Americans, Japanese Americans, Filipino Americans, and Korean Americans in Seattle (Kuo, 1984; Kuo & Tsai, 1986), Korean immigrants in Chicago (Hurh & Kim, 1990), and Chinese Americans in San Francisco (Ying, 1988) reported more depressive symptoms than did whites in those cities. One interpretation of the findings suggests that AA/PIs show high rates of depression, or simply have more symptoms but not necessarily higher rates of depression. Few studies exist on the mental health needs of other large ethnic groups such as Indian, Hmong, and Pacific Islander Americans.

Culture-Bound Syndromes

Even if Asian Americans are not at high risk for a few of the psychiatric disorders that are common in the United States, they may experience so-called culture-bound syndromes (APA, 1994). Two such syndromes are neurasthenia and hwa-byung.

As described earlier, Chinese societies recognize a disorder called neurasthenia. In a study of Chinese Americans in Los Angeles, Zheng and his colleagues (1997) found that nearly 7 percent of a random sample of respondents reported that they had experienced neurasthenia. The neurasthenic symptoms often occurred in the absence of symptoms of other disorders, which raises doubt that neurasthenia is simply another disorder (e.g., depression) in disguise. Furthermore, more than half of those with this syndrome did not have a concomitant Western psychiatric diagnosis from the DSM–III–R. Thus, although Chinese Americans are likely to experience neurasthenia, mental health professionals using the standard U.S. diagnostic system may not identify their need for mental health care.

Koreans may experience hwa-byung, a culture-bound disorder with both somatic and psychological symptoms. Hwa-byung, or “suppressed anger syndrome,” is characterized by sensations of constriction in the chest, palpitations, sensations of heat, flushing, headache, dysphoria, anxiety, irritability, and problems with concentration (Lin, 1983; Prince, 1989). A community survey in Los Angeles found that 12 percent of Korean Americans (total N = 109), the majority of whom were recent immigrants, suffered from this disorder (Lin, 1983; Lin et al., 1992); this rate is higher than that found in Korea (4%) (Min, 1990).

Suicide

Little research is available to shed light on the mental health needs of Asian Americans, but some information may be obtained by looking at suicide rates (Table 5-2). It is thought that Asian Americans are generally less likely to commit suicide than whites. A study by Lester (1994) compared suicide rates (per 100,000 per year) in the United States for various groups. Chinese (8.3), Japanese (9.1), and Filipino (3.5) Americans had lower suicide rates than whites (12.8). However, other sub-groups of Asian Americans and Pacific Islanders may be at higher risk for suicide. For example, Native Hawaiian adolescents have a higher risk of suicide than other adolescents in Hawaii.

Concerns have been raised regarding high rates of suicide among young women who immigrate to the United States from the Indian subcontinent (Patel & Gaw, 1996) and among Micronesian adolescents (Rubinstein, 1983), but these groups have not been well studied. Finally, older Asian American women have the highest suicide rate of all women over the age of 65 in the United States (DHHS, 1999). Clearly, more information is needed on suicide among subgroups of Asian Americans.

Table 5-2 provides suicide rates for Asian Americans, white Americans, Native Hawaiian adolescents and non-native Hawaiian adolescents in Hawaii.

High-Need Populations

Refugees

The mental health needs of a population may be indicated by rates of mental disorders in the population as a whole, or by the existence of smaller subpopulations that have a particularly high need for mental health care. The relationship between poverty, poor health, and mental health is very consistent in the mental health literature. Given the relative economic status of Asian Americans and Pacific Islanders, it is not surprising that they are not present in large numbers among the Nation’s homeless (U.S. Census Bureau, 1996). Furthermore, they make up less than 1 percent of the national incarcerated population (Bureau of Justice Statistics, 1999). Although there are inadequate data to draw conclusions about how often Asian American and Pacific Islander children are exposed to violence, this exposure is often related to socioeconomic deprivation. Most studies indicate that Asian Americans are less likely to have substance abuse problems than are other Americans (Makimoto, 1998). In sum, Asian Americans and Pacific Islanders are not heavily represented in many of the groups known to have high need for mental health care. However, many do experience difficulties, such as the lack of English proficiency, acculturative stress, prejudice, discrimination, and racial hate crimes, which place them at risk for emotional and behavioral problems. Southeast Asian refugees, in particular, are considered to be at high risk.

Many Southeast Asian refugees are at risk for post-traumatic stress disorder (PTSD) associated with the trauma they experienced before they immigrated to the United States. Refugees who fled Vietnam after the fall of Saigon in 1975 were mainly well-educated Vietnamese who were often able to speak some English and prosper financially. Although subsequent Vietnamese refugees were less educated and less financially secure, they were able to join established communities of other Vietnamese in the United States. Cambodians and Laotians became the second wave of refugees from Indochina. The Cambodians were survivors of Pol Pot’s holocaust of killing fields. Several groups of Laotians, including the Mien and Hmong, had cooperated with American forces and left Laos after the war from fear of retribution. One-third of the Laotian population had been killed during the war, and many others fled to escape the devastation.

Studies document high rates of mental disorders among these refugees. A large community sample of Southeast Asian refugees in the United States (Chung & Kagawa-Singer, 1993) found that premigration trauma events and refugee camp experiences were significant predictors of psychological distress even five years or more after migration. Significant subgroup differences were also found. Cambodians reported the highest levels of distress, Laotians were next, then Vietnamese. Studies of Southeast Asian refugees receiving mental health care uniformly find high rates of PTSD. One study found 70 percent met diagnostic criterion for the disorder, with Mien from the highlands of Laos and Cambodians having the highest rates (Kinzie et al., 1990; Carlson & Rosser-Hogan, 1991; Moore & Boehnlein, 1991).

Another study examined the mental health of 404 Southeast Asian refugees during an initial clinical evaluation of patients seen for psychiatric assessment at a Southeast Asian mental health clinic in Minnesota. The sample was Hmong, Laotian, Cambodian, and Vietnamese. Clinical diagnoses were made according to DSM–III by two psychiatrists, who also used information from a symptom checklist. In this sample, 73 per-cent had major depression, 14 percent had post-traumatic stress disorder, and 6 percent had anxiety and somatoform disorders (Kroll et al., 1989). Blair (2000) found that a random, community sample of Cambodian adults (N =124) had high rates of trauma-related stress and depression. This study, which used a standard diagnostic interview, found that 45 percent had PTSD, and 81 per-cent experienced five or more symptoms. Furthermore, 51 percent suffered from depression. Most of these individuals (85%) had experienced horrible traumas prior to immigrating to the United States, including starvation, torture, and losing family members to the war. On aver-age, individuals in the sample experienced 20 war traumas (Blair, 2000). Similarly, 168 adults, recruited from a community of resettled Cambodian refugees in Massachusetts, were interviewed for a study of trauma, physical and emotional health, and functioning. Of the 161 participants who had ever had children, 70 parents (43%) reported the death of between 1 and 6 of their children. Child loss was positively associated with health-related concerns, a variety of somatic symptoms, and culture-bound conditions of emotional distress such as “a deep worrying sadness not visible to others” (Caspi et al., 1998).

Some subgroups of Vietnamese refugees may also be at high risk for mental health problems. Hinton and colleagues (1997) compared Vietnamese and Chinese refugees from Vietnam 6 months after their arrival in the United States and 12 to 18 months later. The ethnic Vietnamese had higher depression at the second assessment than did the Chinese immigrants.

Two studies have found high rates of distress among refugee youth. Cambodian high school students had symptoms of PTSD and mild, but prolonged, depressive symptoms (Kinzie et al. 1986). Researchers also have noted high levels of anxiety among unaccompanied minors, adolescents, and young adult refugees from Vietnam (Felsman et al., 1990). Likewise, in a study of Cambodian adolescents who survived Pol Pot’s concentration camps, Kinzie and colleagues (1989) found that nearly half suffered from PTSD, and 41 percent experienced depression approximately 10 years after this traumatic period. Clearly, because many Southeast Asian refugees experienced significant trauma prior to immigration, rates of PTSD and depression are extraordinarily high among both adult and youth refugees.

Researchers conducting the next generation of studies need not only to derive accurate estimates of psychopathology among AA/PIs, but also to identify the specific ways that social and cultural factors influence the expression of mental disorders among AA/PIs. The results might then prove or disprove several of the general hypotheses that are currently made about the prevalence of mental disorders among Asian Americans.

Box 5–1: The Plight of Southeast Asian Refugees

A Khmer woman (mid-40’s)
Because of premigration traumas and the adjustment to relocation in the United States, many Southeast Asian refugees are experiencing great stress. The following excerpts were elicited in a mental health interview of a mid-40-year-old, Khmer woman from Cambodia by Rumbaut (1985).

“I lost my husband, I lost my country, I lost every property/fortune we owned. And coming over here, I can’t learn to speak English and the way of life here is different; my mother and oldest son are very sick; I feel crippled, I can do nothing, I can’t control what’s going on. I don’t know what I’m going to do once my public assistance expires. I may feel safe in a way— there is no war here, no Communist to kill or to torture you—but deep down inside me, I still don’t feel safe or secure. I feel scared. I get scared so easily.” (p. 475)

The first hypothesis suggests that rates of disorders will be high because many Asian Americans are immigrants who undergo difficult transitions in their adjustment to American society, and many have experienced prejudice, discrimination, and major trauma in their homelands. Indeed, as reported earlier, studies have found that some Asian American ethnic groups do have higher symptom scores than whites. A second hypothesis argues that the rates of mood disorders will be low because Asian Americans, like Asians in other countries, are likely to express their problems in behavioral or somatic terms rather than in emotional terms. Available evidence, for example, does suggest that the rates of mood disorders are low in Taiwan, Hong Kong, and China (Hwu et al., 1989). A third hypothesis maintains that the rates of mental disorders will be lowest for recent immigrants and highest for native-born residents. Low rates of mental disorders have been found among recent Mexican immigrants, for whom culture may be protective against mental health problems at first; but these low rates erode over time as Mexican immigrants acculturate. With Asian Americans, however, the preliminary evidence suggests that acculturation is directly related to well-being, at least in the case of Asian American students (Abe & Zane, 1990; Sue et al., 1996)