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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2006.098541
DISENTANGLING MENTAL HEALTH DISPARITIES |
Jennifer Abe-Kim is with Loyola Marymount University, Los Angeles, Calif. David T. Takeuchi, Seunghye Hong, Hoa Appel, and Ethel Nicdao are with the University of Washington, Seattle. Nolan Zane and Stanley Sue are with the University of California, Davis. Michael S. Spencer is with the University of Michigan, Ann Arbor. Margarita Alegría is with the Cambridge Health Alliance, Cambridge, Mass, and the Harvard Medical School, Boston, Mass.
Correspondence: Requests for reprints should be sent to Jennifer Abe-Kim, PhD, Loyola Marymount University, One LMU Drive, Suite 4600, Los Angeles, CA, 90045–2659 (e-mail: jabekim{at}lmu.edu)
ABSTRACT
Objectives. We examined rates of mental health–related service use (i.e., any, general medical, and specialty mental health services) as well as subjective satisfaction with and perceived helpfulness of care in a national sample of Asian Americans, with a particular focus on immigration-related factors.
Methods. Data were derived from the National Latino and Asian American Study (2002–2003).
Results. About 8.6% of the total sample (n=2095) sought any mental health–related services; 34.1% of individuals who had a probable diagnosis sought any services. Rates of mental health–related service use, subjective satisfaction, and perceived helpfulness varied by birthplace and by generation. US-born Asian Americans demonstrated higher rates of service use than did their immigrant counterparts. Third-generation or later individuals who had a probable diagnosis had high (62.6%) rates of service use in the previous 12 months.
Conclusions. Asian Americans demonstrated lower rates of any type of mental health–related service use than did the general population, although there are important exceptions to this pattern according to nativity status and generation status. Our results underscore the importance of immigration-related factors in understanding service use among Asian Americans.
Most Asian Americans were born outside the United States, which results in a tremendous amount of cultural and linguistic diversity within this population.1 The high proportion of immigrants in the Asian American population presents challenges for mental health systems in many communities, particularly in determining whether current services can adequately meet the needs of diverse Asian American groups. Asian immigrants may have unique patterns of help-seeking and may receive a different quality of care from mental health service providers than do their US-born counterparts.1,2 Without adequate data on the differences between Asian immigrants and US-born Asian Americans, it is difficult to plan for appropriate mental health services. Empirical findings on the association between immigration-related variables and mental health service use are somewhat mixed,3–5 although they suggest that US-born Asian Americans may be more likely to use mental health services than Asians who have immigrated to the United States.6–8 Information regarding Asian Americans’ satisfaction with mental health care is scarce. However, data on perceptions of general health services suggest that Asian Americans are less satisfied with their medical care than their European American counterparts.9–12
Levels of mental health service need and corresponding rates of service use may vary across different Asian American groups,13,14 as well as being affected by the availability of culturally responsive services.15,16 Nonetheless, in general, Asian Americans seem reluctant to seek services in response to their emotional distress.17–19 Even among Asian Americans who have a probable mental disorder (i.e., they met criteria for a diagnosis according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV],20 based on a structured interview, the World Health Organization Composite International Diagnostic Interview21), only a small proportion (17%), according to the US Department of Health and Human Services, appear to seek services.1 Barriers identified as negatively affecting the use of mental health–related services include cultural barriers (e.g., stigma, loss of face, causal beliefs),2,22,23 culturally unresponsive services (lack of language match, lack of ethnic match, poor cross-cultural understanding),18 limited access to care (cost, lack of insurance coverage),24 and lack of awareness or understanding of services.1,25–27 Indeed, for this population, familiarity with Western modes of treatment for mental health problems may be associated with more positive attitudes toward counseling, but not necessarily a greater willingness to seek help.28
Previous studies of Asian Americans have been largely based on unrepresentative samples of that population, including (1) treated populations seen in public sector mental health service settings,18,29,30 (2) college students seen in university counseling settings,3,5,31,32 and (3) convenience samples of nonclinical community-based populations.4,33,34 Help-seeking, immigration factors, and treatment experiences have typically not been the major focus of these investigations. These studies have focused on a limited number of psychiatric disorders, usually major depression or psychological distress, and hence could miss the effects of other mental health conditions on service use among immigrant and US-born Asian American populations. We addressed some of these limitations by using a national sample of Asian Americans that included a wide range of psychiatric disorders among both Asian immigrants and US-born Asian Americans.
We examined use of mental health–related services during a 12-month period, as well as the associations among different immigration-related characteristics, including nativity status, years in the United States, age at time of immigration, and generational status, on the basis of data from the first national epidemiological household survey of Asian Americans in the United States: the National Latino and Asian American Study (NLAAS).35–37
The objectives of our study were to (1) examine rates of mental health–related service use among immigrant and US-born Asian Americans during a 12-month period, (2) identify patterns of help seeking as they varied by need and immigration-related characteristics, (3) explore perceptions of satisfaction with care and helpfulness, and (4) compare differences in patterns of mental health–related service use among individuals who had a probable need for services (i.e., a DSM-IV diagnosis within the 12 months on the basis of the structured interview21) and those who had no probable need for services (because the need for treatment is a major factor in seeking help38). These analyses were made in coordination with the broader Collaborative Psychiatric Epidemiology Studies effort, which provided the opportunity to compare how immigration-related factors are associated with use of mental health services across 3 major racial/ethnic populations (Asians, Blacks, and Latinos).37
METHODS
Participants and Sample Design
Data for this study were taken from the NLAAS, which was part of a broader effort, the Collaborative Psychiatric Epidemiology Studies.36,37 These studies also included the National Comorbidity Survey Replication (NCS-R) and the National Survey of American Life. The sample for our study included Asian American individuals aged 18 years or older and residing in any of the 50 states or the District of Columbia. Three nationalities were targeted for the Asian American sample: Chinese, Filipino, and Vietnamese, but individuals of other Asian ancestry were also included.
The sampling procedure has been previously documented35,36 and included 3 stages: (1) core sampling, in which primary sampling units (defined as metropolitan statistical areas or county units) and secondary sampling units (formed from contiguous groupings of census blocks) were selected with probability proportionate to size); from the primary and secondary units, housing units and household members were sampled; (2) high-density supplemental sampling to oversample census block groups with 5% or greater density of target ancestry groups; and (3) second respondent sampling to recruit participants from households in which 1 eligible member had already been interviewed. Individuals of Asian ancestry who did not belong to the target groups under which these geographical areas were classified were still eligible to participate. Weighting corrections were developed to take into account the joint probabilities for selection under the 3 components of the NLAAS sampling design.
A total of 2095 Asian Americans (1611 primary respondents; 484 second respondents) were recruited between May 2002 and November 2003 as part of the larger NLAAS survey. The final weighted response rate for the combined sample was 65.6%. Detailed sample characteristics have been reported in other NLAAS studies.35,36,37 All participants were interviewed by trained bilingual interviewers, who used computer-assisted interviewing software. Face-to-face interviews were conducted with participants in the core and high-density samples, unless the respondent specifically requested a telephone interview, or if face-to-face interviewing was not feasible. Interviews were conducted via telephone with second respondents. As a measure of quality control, a random sample of participants who had completed interviews was re-contacted to validate the data. A $50 incentive initially provided to participants was later increased to $150 to reduce nonresponses.37
Measures
The NLAAS instruments were available in English, Spanish, Mandarin, Cantonese, Tagalog, and Vietnamese and were translated with standard translation and back-translation techniques. The selection of the variables and the categories within each variable were uniform across the collaborators in the Collaborative Psychiatric Epidemiology Studies to allow maximal comparisons among samples of Asians, Blacks, and Latinos. Sociodemographic variables included age and self-reported ethnicity (subsequently classified as Chinese [n = 600], Filipino [n = 508], Vietnamese [n = 520], and other Asian [n = 467]). Immigration-related characteristics included variables such as nativity status (US-born or foreign-born), years in the United States (categorized as 0–5, 6–10, 11–20, and 
21 years), age at time of immigration (
12, 13–17, 18–34, and 35 years), generational status (first generation [immigrants], second generation [born in United States and at least 1 parent immigrant], and third generation and later [born in the United States and at least both parents born in the United States]), and English-language proficiency. English-language proficiency was assessed using the question "How well do you speak English?" Responses were separated into 2 categories, "excellent/good" or "fair/poor."
Use
Service use was assessed with the question "In the past 12 months, did you go to see [provider on list] for problems with your emotions, nerves, or your use of alcohol or drugs?" Three types of services were assessed for the study: (1) specialty mental health care (psychiatrist, psychologist, other mental health professional, or hotline); (2) general medical care (general practitioner, nurse, occupational therapist, other health professional, or any other medical doctor), and (3) any services that represented endorsement of human service providers (social worker, counselor, religious or spiritual adviser) and alternative services (healer such as herbalist, doctor of Oriental medicine, chiropractor, spiritualist, internet support group, or self-help group), as well as specialty mental health or general medical care. This variable was dichotomously coded (0 = none, 1 = at least once).
Treatment Ratings
Satisfaction with care was assessed with the question "In general, how satisfied are you with the treatments and services you received from [service provider] in the past 12 months—very satisfied, satisfied, neither satisfied or dissatisfied, or very dissatisfied?" Percentages of respondents who provided ratings of "very satisfied and satisfied" were identified. Perceived helpfulness of services was assessed with the question "Did the [service provider] help you a lot, some, a little, or not at all?" Percentages of respondents who provided ratings of "a lot" were identified.
Diagnosis
The primary mental disorder diagnostic instrument was the World Health Organization Composite International Diagnostic Interview.21 The trained interviewers used this instrument to assess the presence of psychiatric disorders at any time during the 12-month period according to criteria from the DSM-IV. 20 Because of the highly skewed distribution of the number of mental disorders, the presence of any probable mental disorder during the 12-month period was treated dichotomously (0 = none; 1 = any). "Any" disorder was on the basis of the diagnosis of at least 1 disorder in any of the following 3 categories: (1) mood disorders (major depressive disorder or dysthymia), (2) anxiety disorders (panic disorder, agoraphobia without panic, social phobia, generalized anxiety disorder, or posttraumatic stress disorder), or (3) substance disorders (alcohol abuse, alcohol dependence, drug abuse, drug dependence).
Analyses
The weighted prevalence of service use during a 12-month period and ratings of subjective satisfaction and perceived helpfulness of care were computed for general medical care, mental health care, and any services, stratified by ethnicity and various immigration-related characteristics (nativity status, years in the United States, English-language proficiency, age at time of immigration, and generational status). We also completed separate multivariate analyses (data not shown) to examine the potential influence that age and the presence of a disorder during the 12 months might have on differences in service use across groups. We fitted a series of separate logistic regressions for each service sector, in which each of the correlates (ethnicity, nativity status, language, and immigration-related characteristics) was entered separately, after control for respondents’ current age and the presence of a mental disorder during the 12 months.
The prevalence of use of any service during the 12 months was also compared for individuals with and without a probable DSM-IV diagnosis during the 12 months. Weighted percentages and 95% confidence intervals are reported. We conducted significance tests for differences among estimates for proportions using a Rao–Scott statistic for contingency tables. Stata version 9.2 (Stata Corp, College Station, Tex) software survey commands that allow the estimation of standard errors in the presence of stratification and clustering were used to account for sample design effects. Sampling weights37 were applied to all analyses to generalize results to the Asian American population in the United States
RESULTS
Among all respondents, in the previous 12 months, 8.6% sought help from any service, 4.3% sought help from general medical providers, and 3.1% sought help from mental health providers. Table 1
presents rates of service use across different sectors of care, according to ethnicity and immigration-related characteristics. US-born individuals used any services at significantly higher rates than did individuals born outside the United States, and had higher rates for specialty mental health care (6.2% vs 2.2%, respectively), but not for general medical care. However, after control for individual age and the presence of a probable mental disorder during the previous 12 months, differences between US-born and immigrant Asian Americans for use of any services disappeared (data not shown), although differences in specialty mental health care use remained. At the same time, differences between Chinese and Filipinos for use of general medical services became significant after control for age and the presence of a probable mental disorder during the previous 12 months (P = .029, data not shown).
|
Individuals who were categorized as third or later generation had higher rates of use of any services (19.3%) than did individuals who were first (7.4%) or second (8.1%) generation, as well as higher rates of both specialty mental health and general medical care use. Years in the United States and English-language proficiency were not associated with service use at all; age at time of immigration was associated with seeking help from the general medical sector only.
We were also interested in the experiences of Asian Americans who used different services for their problems. Among respondents who gained access to different mental health–related services, ratings did not vary significantly by immigration-related characteristics but did vary by ethnicity (Table 2). A higher proportion of Filipinos (92.2%) reported that they were satisfied with the care they received from any service than did other ethnic groups (Chinese=72.1%; Vietnamese=74.9%; other Asian=88.1%).
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By contrast, a significantly lower proportion of individuals born outside the United States (51.5%) than US-born individuals (72.6%) reported that treatment helped a lot (Table 3
). In addition, when we specifically examined US-born individuals according to their generation, third-generation or later individuals had significantly higher perceptions of helpfulness (81.1%) than did second-generation individuals (60.2%).
|
A critical issue that affects the use of services is whether people have a mental disorder. We stratified the sample into respondents with and without a DSM-IV diagnosis during the 12-month period to assess the use of services for the ethnicity and immigration-related characteristics described in the "Methods" section. As shown in Table 4
, the use of any services during the 12 months was higher among individuals who had a probable DSM-IV diagnosis (34.1%) during that period than among individuals without a diagnosis (6.0%). Among respondents with a probable diagnosis, no significant differences in service use were evident for ethnicity, nativity status, English-language proficiency, years in the United States, or age at time of immigration. However, respondents who were third generation or later who had a DSM-IV diagnosis during the 12 months sought help from any services at significantly higher rates (62.6%) than did first-generation (30.4%) or second-generation (28.8%) respondents.
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DISCUSSION
We investigated patterns of mental health–related service use and ratings of subjective satisfaction and perceived helpfulness in a national sample of Asian American groups, and examined within-group variations by ethnicity and immigration-related characteristics. Our findings indicate that, overall, Asian Americans appear to have lower rates of mental health–related service use compared with the general population; only 8.6% of Asian Americans sought help from any services versus 17.9% of the general population in the NCS-R.39 Differences in rates of help seeking persisted among individuals who had a demonstrated need for services: 34.1% of all Asian Americans who had a probable DSM-IV diagnosis during a 12-month period sought any services compared with 41.1% of all individuals who had a DSM-IV diagnosis during a 12-month period in the NCS-R sample.39
However, our study also shows that, although the overall finding of low rates of help seeking among Asian Americans are consistent with findings from previous studies,18,19,29,30,40 there are important differences in service use between immigrants and US-born individuals. For instance, use of services differed according to nativity status: US-born individuals used mental health services at higher rates than did immigrants. Second-generation individuals (i.e., children of immigrants) were more similar to immigrants in their use of services than to third-generation individuals. Third-generation individuals were more similar in their pattern of service use to the general population sampled in the NCS-R (19.3% vs 17.9%, respectively, for seeking any service). Furthermore, among individuals with a probable diagnosis of a mental disorder, rates of service use among third-generation Asian Americans were higher than those of their counterparts in the NCS-R sample (62.6% vs 41.1%).39
The examination of immigration-related characteristics enabled a more refined view of service use among Asian Americans, and nativity status and generation emerged as the most important indicators of within-group differences. These differences partially extended into perceptions of their treatment experiences. Perceived helpfulness of care varied by immigration-related characteristics: US-born Asian Americans, particularly third-generation or later, gave higher helpfulness ratings for any services. Ratings of subjective satisfaction, however, did not differ by immigration-related characteristics. These findings probably reflect the fact that ratings of "highly satisfied" and "satisfied" were combined, so that a large majority of the sample endorsed being satisfied with care. Satisfaction ratings tend to be highly skewed even without combining categories.
We cannot determine from these data the nature of any barriers that may explain why birthplace and generation affect patterns of service use and perceived helpfulness of care. The finding that second-generation Asian Americans are similar to immigrants in their patterns of service use, along with treatment ratings of perceived helpfulness, suggests that more general factors, or even cultural factors (such as stigma or loss of face), may act as constraints on service use, beyond such immigrant-specific barriers as language or knowledge of services. For instance, our data showed that English-language proficiency was not associated with service use, despite the fact that language has been identified as a major barrier to service use in several other studies.23,40 Thus, in providing services to Asian American populations, mental health providers may benefit from knowing that second-generation individuals are more similar to their immigrant parents (than to their highly Americanized children) in their patterns of service use. Nevertheless, our data also indicate that immigrants require the most intensive outreach efforts to facilitate service use.
The limitations of this study must be noted. Data were based on a cross-sectional survey that used retrospective measures of service use and diagnosis, so our findings are subject to the recall and reporting biases inherent in these approaches. Further, although these measures have been used in other investigations of Asian American populations,40,41 their validity has not yet been thoroughly established across different ethnic populations, let alone across Asian American ethnic groups. Also, given our focus on immigration-related characteristics, we did not consider other factors that may affect patterns of service use, such as gender, regional variations, and income. Finally, all "other Asians" were lumped together in a single category, even though they represent a diversity of languages, ethnicities, cultures, and practices.
However, our study represents an initial effort to present a national picture of mental health–related service use and perceptions of treatment among different Asian American groups, further distinguished by differences in need, ethnicity, and immigration experiences. As such, it represents an important and provocative glimpse into immigrant and US-born Asian help-seeking patterns and perceptions of treatment in the United States.
Acknowledgments
The NLAAS is supported by the National Institute of Mental Health (grants U01 MH62209 and U01 MH62207), with additional support from the Office of Behavioral and Social Science Research at the National Institutes of Health and the Substance Abuse and Mental Health Services Administration.
Human Participant Protection
The institutional review boards at the University of Washington, Cambridge Health Alliance, and the University of Michigan reviewed and approved all study protocols and procedures.
Footnotes
Contributors
J. Abe-Kim originated the study and led the writing. J. Abe-Kim and D. T. Takeuchi supervised all aspects of study implementation. S. Hong completed the analyses and assisted in drafting the article. All other authors assisted in interpretation of the findings and with preparing drafts. M. Alegría and D. T. Takeuchi were principal investigators of the NLAAS and were instrumental in the design and implementation of the entire survey.
Accepted for publication September 1, 2006.
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