Mental health services research in Asian Americans.

Local studies consistently show that the pressing mental health care needsof Asian American communities are not being met by using traditional mentalhealth care approaches. The “real world” approach of the BridgeProgram and other similar programs addresses the lack of early interventionfor Asian Americans with mental health problems, the stigma that AsianAmericans attach to mental illness, and the differing clinical presentationsthat lead to misdiagnosis or underdiagnosis. But is there any evidence tosupport the need for these types of programs? Information about the characteristics of the people in need and the factorsthat facilitate or constrain their use of services is critical in developingeffective and quality health care. A review of studies of Asian Americansshows many early estimates about prevalence of mental disorders relied ontreatment data from hospitals and clinics. These studies typically compare theproportion of Asian Americans who use mental health services in a geographiclocation with the proportion of Asian Americans who live in that area. Moststudies of this type show that Asian Americans are underrepresented in mentalhealth facilities; that is, the proportion of Asian Americans using servicesis lower than the proportion of Asian Americans residing in the area. Likeother treatment studies, however, these calculations omit the estimate of thenumber of people who actually have a mental health problem but are not usingservices. Community surveys are one way to include respondents who may have a mentalhealth problem but who have not sought care from a mental health professional.Large community studies have often included Asian Americans, but theytypically classify Asians as belonging to a homogenous ethnic category. TheAsian American category is a social and political convenience because the useof the term allows researchers, service providers, and policy makers to easilydescribe and discuss groups who seemingly share similar backgrounds. Howdiverse is the Asian American category? As one measure, Asian Americansinclude at least 43 different ethnic groups who have their origins in suchunique countries as China, Japan, Pakistan, Korea, India, the Philippines,Vietnam, and Laos.1Accordingly, the conclusions drawn from analyses using Asian Americans as asingle ethnic category may differ from those made when specific ethnic groupsare examined.2 Some community studies have focused on specific Asian American ethnicgroups using mental disorder symptom scales. These studies seem to indicatethat Asian Americans have more severe symptoms compared towhites.3 But fewcommunity studies have focused on a specific Asian American ethnic group usinga standard diagnostic interview. The Chinese American PsychiatricEpidemiological Study (CAPES) included immigrant and native-born Chineseliving in Los AngelesCounty.4 Interviewswere conducted in Chinese or English, depending on the language preference ofthe respondent. The lifetime prevalence rates for depressive disorders werewell below the rates found in the National ComorbidityStudy5 but wereslightly higher than those from the Epidemiologic Catchment Areastudy.6 One advantage of a study like CAPES, which included a large sample of aspecific ethnic group, is the opportunity to investigate social and culturalvariations in symptom reporting. For example, CAPES included a measure ofneurasthenia, an illness that involves persistent and distressing fatigueafter mental effort or bodily weakness and exhaustion after minimal physicaleffort (see p 257). In a random sample of Chinese Americans living in LosAngeles, close to 7% (122 of 1747) reported that they had experiencedneurasthenia.7 Morethan half of the respondents who had the syndrome did not meet criteria forhaving a mood or anxiety disorder. One implication of this finding is clear.Mental health professionals using standard diagnostic tools may not correctlyevaluate Chinese Americans who are likely to experience a psychiatric syndromesuch as neurasthenia. Despite the limited data on the mental health status of Asian Americans,there are three reasons to be optimistic about the future of research on themental health and service use among Asian Americans. First, several federalinitiatives and reports, such as Healthy People 2010, minority supplement tothe Surgeon General's Report on Mental Health, and NationalInstitutes of Health initiatives to eliminate racial disparities, suggest agreater awareness and openness to pursue important scientific questions thatwill lead to effective interventions. These initiatives will direct energy,resources, and commitment to study the pressing mental health issues in AsianAmerican communities. Second, at least two current investigations are likely to produce importantfindings that may improve access and quality of care for Asian Americans. TheNational Latino and Asian American Study will be the first large-scalenational study of Latino and Asian Americans. Approximately 7,200 respondents(3,600 from each ethnic category) will be interviewed using a standardizeddiagnostic interview schedule administered by layinterviewers.8 Thisstudy will produce data on the prevalence of mental illness and the social andcultural correlates of these problems among Latinos and Asian Americans. Theother investigation is the PRISMe study (Primary Care Research in SubstanceAbuse and Mental Health for theElderly).9 Thismultisite national study will provide data on the prevalence of mental healthproblems of the elderly in primary care and the barriers to receiving neededmental health care. The Bridge Program in New York City was a PRISMe studysite that was able to recruit and enroll elderly Chinese Americans. With theenrollment of diverse ethnic groups (Asians, Latinos, African Americans, andwhites), comparative data will be analyzed and used for program planning toenhance access to mental health services in primary care and specialtysettings. Finally, junior investigators representing a broad range of disciplines andprofessions including psychiatry, medicine, social work, psychology,sociology, economics, and anthropology, are beginning to focus their effortson mental health issues among Asian Americans and other ethnic minorities. Theinfusion of different ideas from a range of perspectives, with a focus on realworld applications, will be an important and critical component in improvinghealth care delivery to Asian Americans. Until consistent data emerge from studies involving Asian Americans thatallow the development of a sound evidence base, we hope that the articles inthis theme issue will improve treatment and highlight opportunities forfurther research on improving clinical care.