Americans from ethnic minorities use mental health care at a lower rate than white Americans. But among ethnic minorities, Asian Americans have the lowest rate of mental health care.

When you look at some of the barriers that prevent Asian Americans from accessing care, especially senior care, it is clearer why. Economic, language, and cultural barriers all make it less likely that Asian Americans will seek out and start mental health care.

Here, we’ll look at some of those cultural barriers. The best care outcomes happen when care fits a client’s language and culture. Mental health care is no exception.

Asian Americans Underuse Mental Health Care

The Substance Abuse and Mental Health Services Administration (SAMHSA) compared Asian Americans (AA) and white Americans. They found that AA adults are almost three times less likely to use mental health services. That is, 6.4% of AA adults compared with 17.6% of white adults.

Furthermore, Asian Americans usually wait until they are more ill to enter treatment. The journal Psychiatric Services looked at Asian patients with schizophrenia who entered treatment. On average, they waited for three years after symptoms started. Compare that to white patients, who typically only waited a year.

Asian Americans who are foreign-born fare even worse. They use mental health services even less than their native-born counterparts. But these lower rates are not because AA adults have less need for mental health services.

The World Health Organization (WHO) studied the number of people diagnosed with mental disorders during their lifetime. They looked at parts of Asia, Europe, and North American, and the numbers were consistent across all areas.

Studies of Korean Americans show a high level of overall need. On average, Korean American subjects had:

• Higher levels of need
• Greater depressive symptoms
• More psychotic symptoms
• Worse treatment outcomes

Asian Americans may be at greater risk because of stress from adapting to a new culture or anti-Asian racism. Researchers from Social Science Medicine found that racial discrimination resulted in worse mental health.

Asian seniors are particularly at risk. According to Connie Chung Joe, executive director of Korean American Family Services (KFAM) in Los Angeles, depression is particularly common for Asian seniors. Seniors are potentially vulnerable because of:

• Poverty and low income
• Isolation from friends or family
• Less familiarity with American culture (if they are recent immigrants)
• Low English proficiency
• Attachment to cultural values associated with lower help-seeking

Why Don’t Asian Americans Use Mental Health Care More?

The data is clear: Asian American adults use fewer mental health services. The obvious follow-up question is why?

There are two main factors to look at. The first are barriers that keep AA adults from starting care. The second are barriers that stop them from sticking with it.

According to the Department of Health and Human Services, fewer Asian Americans access mental health resources because of:

• Cost of care
• Social stigma and cultural attitudes toward mental illness
• Fragmented or hard-to-reach services
• Limited English
• Cultural bias or ignorance among doctors
• Historical racism and discrimination in health care

It’s impossible to unpack all of these issues here. Many are complicated, multifaceted, and long-standing. Notably, many barriers (and maybe the most important ones) are structural. They affect all minority groups and have to do with how the US health care system and society are set up.

Still, many researchers agree on one reason clients from all ethnic minorities use mental health services at lower rates than white patients. Most specialists and therapists cannot provide culturally appropriate care.

According to the American Psychological Association Center for Workforce Studies, 87.5% of service providers are European American.  Only 3.6% are Hispanic, 2.7% are Black, 1.7% are Asian/Pacific Islander, and less than 1.0% are Native American. That is a problem. Interventions are twice as effective when patients and providers share the same language.

When providers tailor the care they provide to the patient and their culture, that care is more effective. For that reason, it is worth looking more deeply at how cultures can differ in how they look at mental illness. That may give us an idea of what may be unique to AA adults.

Cultural Difference #1: Social Stigma

Different cultures apply different meanings to mental illness. Culture influences the answers to important questions. Is an illness “real”? Does it come from problems with the mind or the body? What might cause it? What type of person might have it? The answers can then affect whether people seek treatment. And they can affect the amount of support friends or communities provide.

Many studies have looked at how such cultural factors influence attitudes Asian Americans have around mental health. Stigma is especially relevant. These studies suggest stigma is so bad in some cultures that one person with mental illness can reflect badly on the whole family. It can make it harder for everyone in the family to get married or hired for certain jobs.

In a study of Asian Americans living in Los Angeles, only 12% would mention mental health problems to a friend (versus 25% of white residents). Only 4% would seek help from a specialist (versus 13% of white residents). And only 3% would seek help from a physician (versus 13% of white residents). The researchers blamed stigma as one big cause.

Overall, cultural stigma exacerbates structural barriers.

Cultural Difference #2: Different Symptoms

Cultural differences can make it hard for AA adults to find effective care and stick with it. Often, specialists may not even diagnose their issues correctly.

Individual people can present mental and physical illnesses differently. Symptoms depend on age, gender, race, ethnicity, and culture. Diagnosis only gets harder if a patient and doctor do not share a language. That makes it hard to communicate the complex feelings or thoughts associated with mental illnesses.

Historically, psychotherapy focused on white European and North American patients. Diagnoses for mental disorders still reflect this bias today.

But patients from these groups and patients from ethnic minorities may experience and communicate their symptoms differently. This can lead doctors to misdiagnose Asian patients if those doctors have a strict definition of how a condition should look.

For instance, studies have noted that Asian American patients often focus on the physical symptoms of a mental illness. So, an Asian American patient with depression may focus on fatigue, loss of appetite, back pain, or trouble sleeping. A white patient may focus on sadness, anger, anxiety, or feelings of worthlessness.

This focus on physical symptoms is called somatization. There are multiple potential explanations for it. It could be the result of the stigma we mentioned above. Many patients are unwilling to talk about mental illness. It could be because patients don’t want to talk about their emotional life too much. Or, it could be because of a cultural tendency to see mind and body as more linked than separate.

Whatever the reason, this focus on physical symptoms can make diagnosis harder. Patients will usually discuss mental or emotional symptoms eventually. But that depends on finding a provider who knows enough to probe past physical symptoms.

Cultural Difference #3: Different Conditions

Culture affects more than just the symptoms people focus on. It can also affect the conditions they experience.

Cultural syndromes are groups of symptoms that occur together among people from a specific culture. For instance, Korean patients may experience hwa-byung (HB), or suppressed anger syndrome (literally “anger disease” or “fire disease”).

The Korean Counseling Association describes HB as a Korean folk illness that includes tightness in the chest, feelings of heat, flushing, headache, anxiety, irritability, anger, or depression. It happens when negative emotions like anger, disappointment, sadness, and misery are not expressed openly. Over time, these emotions build up. These repressed feelings then emerge as the symptoms of HB.

HB is most common among older women, especially those living in rural settings. Studies in Korea suggest somewhere between 5% and 13% of older women experience HB. Studies have not looked at Korean Americans as much. But one group of researchers found that approximately 12% of Korean American women suffered from HB symptoms.

So, culturally competent caregivers need to know how different cultures might experience the same illness. But they also need to know about culturally specific illnesses as well.

How Is Tailored Care Different?

Finding care that fits you and your culture is always important. But it can be even more important for mental health care. Mental health treatment relies on communication and trust between patients and providers.

So culturally tailored care definitely involves a shared language. But it also includes a lot more. Certain techniques may be more effective for people from certain cultures. For instance, group therapy might be more effective for people from more collective cultures.

Likewise, studies from the Psychiatric Services suggest incorporating the family more when working with Asian clients. Help-seeking can involve the entire family. The therapy should incorporate them as much as possible as well.

Cultural tailoring may even influence the medications a psychologist prescribes, according to the Department of Health and Human Services.

Recent research suggests that Asian patients may respond to lower doses of certain medications than white patients. Drugs like lithium may be effective at much lower levels. Likewise, Asian patients may experience more severe side effects if treated with the same dosages as white patients.

There are a few guesses about what causes this difference. It may be due to diet or environmental factors. Certain enzymes that affect how our body processes drugs are also less active among East Asians.

Of course, not all Asian American patients respond the same way to low or high levels of medication. So, doctors should not follow some rule automatically. Instead, they should pay attention to how individual patients react.

As always, the best advice is to start low and go slow, especially with seniors who need care. Then, you can adjust as needed.

Tailored Care Fits Better

The important thing to remember is that care works better when it fits an individual’s language and culture. That is especially true for mental health.

Patients want to know that their caregivers understand them, their language, and their history. That will make it easier to create a connection and reveal details about their lives. Ultimately, one of the best ways to encourage more Asian Americans to seek out mental health care may be training more professionals to provide culturally tailored care.