Crisis in Mental Health for Asian Americans: Opportunities for Intervention

 Henry Chung, M.D.

(presented at the Chinatown Health Clinic Foundation reception, June 9, 2004)

Epidemiology:

Data was presented showing that suicide rates have been increasing in China with a three to fivefold greater suicide rate in rural vs. urban communities.  The risk groups were the 15-30 year old cohort and the over 65 cohort.  Similarly, in the United States, suicide rates that have been tracked since 1990 indicate that Asian females between the ages of 15-24 and over 65 remain high risk groups.  Although suicide rates for Asian males over age 65 are significantly lower than Whites, it is important that this cohort is the only cohort for which the suicide rate has not decreased in the past decade.   Moreover, a recent analysis of  a 4 year national mental health in primary care study in which CBWCHC took part  confirmed that among all racial and ethnic groups, depressed Asian elderly (over 95% ethnic Chinese) had the highest rates of suicidal thinking (Bartels et al, Am J of Geri Psychiatry 2003).  Although there is high need, Asians are at greater risk of under-recognition of depression than Latinos in primary care (Chung et al., Community Mental Health J, 2003).  Depression is important to recognize and treat because:

1. Depression is the second most disabling illness in the world (WHO 1998)

2. Depression most often affects persons in their productive and reproductive years; age 30-50

3. Depression results in absenteeism, presenteeism, and lost productivity

4. Depression increases morbidity and mortality in CVD, diabetes, asthma, and   arthritis           

 Cultural factors leading to underutilization

 There is evidence of dramatic mental health services underutilization which leads to serious delays in treatment.  For example, Asian Americans Constituted 8.7% of Los Angeles County Population, But Only 3.1% of Mental Health Service Clients in Los Angeles County.  In addition, Asian Americans Constituted 9.1% of San Diego County Population, but Only 3.6% of Mental Health Service Clients in San Diego County in the late 1990’s.  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).

 Reasons for avoidance of mental health services include: Stigma and Shame

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).

Symptom Presentation: Somatization

1.      Asians are thought to deny the experience and expression of emotions.  These factors make it more acceptable for psychological distress to be expressed through the body rather than the mind.

2.   Attention to the emotional and interpersonal symptoms or concerns are positively correlated with increased acculturation (Chen at al, 2003)

Barriers to Care

 1.    Language – lack of available bilingual MH professionals

2.      Economic – lack of insurance coverage for MH services

3.      Education – less awareness of the treatability of MH illnesses

 Primary Care Interface: Adults and adolescents 

1.       Mental Disorders May Be Difficult to Recognize in busy primary care practice

2           Lack of Training and Expertise with Mental Health Issues

3           Encountering Patient and Family Stigma

4           Somatic Problems that often Mask Psychiatric Difficulties. BUT THERE ARE  OPPORTUNITY FOR EARLY ENGAGEMENT and INTERVENTION if these elements can be incorporated into care

5           Training and Supporting Primary Care Physicians to Provide Mental Health Care

6      Early Detection and Treatment of Mental Health Problems

7      Providing Mental Health Care in a Primary Care Setting

8      Helping Patients Enter the Specialty Mental Health System, when Necessary

 Treatment: Tailoring Pharmacotherapy and Psychotherapy

 Diagnosis and Treatment Engagement

1.   Start where the patient is: what do you think is causing your problems? (Kleinman). Elicit explanatory model

2    Use modified biopsychosocial paradidm: mind (brain) / body (physical) linkage for patients with somatic symptoms

3.   Use cultural idioms of distress as long as it fosters a reasonable treatment plan, ie: neurasthenia, or hwa byung, but educate on DSM diagnosis 

4.   Engage the healthcare family decision maker if possible or available

5.   Be confident in your knowledge and your expertise, but allow for patient and family to be experts also

6.   Advise patience and expected timeframe for response 

 Starting Psychotherapy and Counseling

    1.      Try and establish importance of “working through” current problems that may be exacerbating condition,         stress  confidentiality!

    2.      Let patient know how you think psychotherapy works for them, or how it might work in combination with medications

3.      Use cognitive behavioral techniques and skills to help with symptoms first to establish alliance, then can consider moving to more dynamic/supportive therapy

4.      With patient assent, meet with key supports when necessary

5.      With adolescents: early identification of stress, pressure, and acculturation distance from parents is important

6.      With elderly: accepting the value of their life experience and wisdom can build alliance 

 Antidepressants and Anxiolytics in Asian Americans

1         Small studies that need further confirmation.       

2.  Genetic polymorphisms in P450 enzyme systems may account for observations that lower target dosages may be needed in some Asian, Hispanic and African American patients.  

3.   Benzodiazepines: data is variable, but possible Cmax and AUC higher in    Asian subjects than whites (Lin 1988, Psychopharmacology).  Body weight and volume of distribution effects may play a key role

4    Clinical Guideline:  start with half the usual dose, titrate to minimum effective dose slowly over 4 wks.  If no response, and no major limiting side effects, titrate further.

 Psychotropic Medication Management

1.   Medicines should be explained as restoring necessary brain chemicals that alleviate troublesome symptoms

2.      Give relief: use hypnotics to alleviate symptoms and to decrease side effects of antidepressants.  Take time to educate patients on what the medicines do and how fast or slow they work.  A useful incentive can be the possibility of improved work functioning

3.      Benzodiazepines: can be problematic but avoid prn usage and give low regular doses

4.      SSRI’s: give the lowest possible dose.  If no response, and no major limiting side effects, titrate further.

5.      Constantly be vigilant about perceived stigma and help patient to keep eye on goal.   Proactively address this issue.

6.      Assess suicide risk during acute treatment, if possible , in less stigmatizing terms, especially in elderly 

 Dr. Chung is Sr. Director for Research and Strategic Management, Charles B. Wang Community Health Center