Mental Health Status, Need, and Unmet Need for Mental Health Services Among U.S. Pacific Islanders

Participant characteristics are presented in Table 1. Among the 223 NHPI participants, the mean age was 40.9, 57% were women, and 55% were Samoan. Mean scores on the PIACCULT scale indicated that NHPI acculturation exceeded U.S. acculturation (p<.05). Scores on the Level of Contact Report reflected a mean level of familiarity–contact with persons with mental illness consistent with working with someone with severe mental illness.

Mean scores indicated that depression and anxiety severity were high; 21% (N=45) and 12% (N=26) of participants exceeded the 10-point diagnostic thresholds for major depression and generalized anxiety disorder, respectively. Eight percent (N=16) exceeded both diagnostic thresholds, suggesting comorbid major depression and generalized anxiety disorder. For alcohol use, 22% of participants (N=50) met diagnostic thresholds for alcohol use disorder: 29% (N=27) of men and 18% (N=23) of women. Comorbidity of alcohol use disorder with major depression was 4% (N=8), and with generalized anxiety disorder it was 2% (N=5). No gender differences in the severity of depression and anxiety were noted; however, alcohol use was significantly higher among men compared with women (AUDIT-C mean±SD score=2.27±2.93 versus 1.18±2.18; t=–.27, df=217, p<.01).

Over the past year, 35% of participants reported needing services and 26% reported delaying services. Among those with positive screens, need for services was reported as follows: depression, 59% (N=26); generalized anxiety disorder, 54% (N=14); and alcohol use disorder, 35% (N=17).

Compared with Samoan participants, Marshallese participants were younger and had significantly (p<.05) lower levels of formal education (e.g., 26% of Marshallese had not graduated from high school, compared with 4% of Samoans), U.S. nativity (18% versus 59%), and U.S. acculturation. No significant differences were found in mean scores on measures of depression, anxiety, or alcohol use; however, compared with Samoans, a significantly higher proportion of Marshallese participants reported needing past-year services (p<.05) and avoiding or delaying services (p<.05).

To inform future approaches to NHPI service engagement, logistic regression analyses explored which demographic, cultural, mental health, and other key variables accounted for participants’ high past-year perceived need for and avoidance or delay of services.

Table 2 presents adjusted odds ratios (AORs) for past-year perceived need for services. Compared with men, women were 4.4 times more likely (p<0.01) to report a need for services in the past year. Participants who had some college education were significantly less likely than those who had not competed high school to report a past-year need (AOR=0.2, p<0.05). In addition, a 1-point increase in PHQ-9 score (indicating greater depression severity) was associated with a greater likelihood of reporting past-year need (AOR=1.2, p<0.01), as was a 1-point increase in the familiarity-contact scale (AOR=1.2, p<0.01).

Table 3 presents AORs for past-year avoidance or delay of services. Compared with men, women were nearly three times more likely to report avoidance or delay of services (AOR=2.9, p<0.05). Compared with participants who had not completed high school, those who completed high school were less likely to report avoidance or delay (AOR=0.1, p<0.01), as were those who completed college (AOR=0.1, p<0.05). A 1-point increase in the familiarity-contact scale was associated with a greater likelihood of reporting avoidance or delay (AOR=1.3, p<0.01).

As hypothesized, although the presence of depression, anxiety, and alcohol use disorder was high in our sample, mental health help seeking was relatively low. One of every four participants reported avoiding or delaying needed services in the past year, indicating a high degree of community unmet mental health need.

Unsurprisingly, having more years of formal education was associated with lower likelihood of avoiding or delaying needed services, suggesting that formal education may be a useful tool for increasing help seeking among NHPIs. In contrast, female gender and greater familiarity or contact with persons with mental illness were both associated with greater likelihood of avoiding or delaying services. Therefore, individuals with these characteristics may be at especially high risk of having unmet mental health need.

In particular, NHPI women were far more likely than men to avoid or delay services, even though women reported a greater perceived need for services. Because many cultures (including NHPIs) are more accepting of women expressing emotional distress and using emotion-focused coping (19, 44), NHPI women may be recognizing the need to seek help for their mental health problems (i.e., problem recognition) more readily than NHPI men; however, the women may be relying on the greater array of informal emotional coping options afforded NHPI women (e.g., mobilizing social support and women’s groups) in lieu of formal care.

Similarly, although increased contact with persons with mental illness was associated with greater perceived need for services, it was also associated with greater avoidance or delay of services. This seemingly contradictory finding may help to explain the push-and-pull pattern noted among our participants, who reported high perceived need but low help seeking. The finding suggests that gaining greater mental health awareness through exposure to persons with mental illness may be a double-edged sword for NHPIs. That is, boosting mental health awareness may make NHPI individuals more aware that their mental health problems require formal help (19, 22, 23) while also making more salient the risk of encountering stigma and discrimination (45, 46) associated with seeking help—thereby suppressing help seeking. Given that increasing mental health awareness and contact is an important element in many antistigma interventions, further research is needed to clarify the role of mental health stigma and awareness in NHPI help seeking.

With regard to NHPIs’ mental health burden—while keeping in mind that we did not assess a probability sample—a large number of participants screened positive for major depression, generalized anxiety disorder, or alcohol use disorder. Compared with the U.S. adult general population, participants screened positive at three times the national rate for major depression (47), over two times the national rate for generalized anxiety disorder (37), and four times the national rate of alcohol use disorder (48). Thus, our community NHPI populations appear to be more comparable to clinical primary care populations (36) than to the general population.

Yet not all disorders elicited help seeking equally. A relatively smaller proportion of NHPIs who screened positive for alcohol use disorders perceived a need for services, compared with NHPIs who screened positive for major depression or generalized anxiety disorder. Although this may be partly due to our perceived need item not specifically referencing alcohol use disorder treatment, some of this discrepancy likely stems from NHPI cultural norms that are generally accepting of risky drinking (49, 50), which may lead to a lower perceived need for treatment among NHPIs for what is considered problem alcohol use in U.S. populations. Unfortunately, because alcohol use disorders have many “downstream” effects, including heightened risk of fatal and nonfatal accidents, domestic violence, and suicide (51–53), the implications of participants’ high rates of alcohol use disorder but low perceived need for services could have broad social and health consequences for U.S. NHPIs.

No significant differences were found between the Samoan and the Marshallese subgroups in levels of depression, anxiety, and alcohol use, even though we found significant differences between the groups in many of the factors that we anticipated might influence mental health, such as age, formal education, nativity, and acculturation. Our findings of similar depression, anxiety, and alcohol use problems in these highly divergent NHPI subgroups living in very different parts of the U.S support exploring the mental health needs of other NHPI subgroups (e.g., Native Hawaiians and Chuukese) for commonalities that may inform the development of generalizable interventions for NHPIs.

From our findings, we offer two thoughts for addressing NHPIs’ unmet need. First, among NHPI participants who screened positive for alcohol use disorder, few perceived a need for services, which underscores the importance of tailoring alcohol prevention interventions to NHPIs so that fewer treatment services are needed. This may include interventions that combat NHPI myths about alcohol use (e.g., education about normal versus binge drinking) (54, 55) or training NHPIs to resist alcohol offers from relatives and friends (56, 57). Second, participants’ resistance to seeking needed services suggests that conventional engagement approaches may not be effective with community-dwelling NHPIs. The presence of many systems-level barriers, including a lack of NHPI-tailored outreach and engagement (e.g., absence of interpreters) likely creates an unwelcoming atmosphere for NHPIs who wish to seek services—thereby contributing to limited NHPI help seeking. Therefore, we recommend that public-sector settings develop and implement culturally grounded engagement approaches for NHPIs (58–60). This may be accomplished by first establishing relationships with NHPI leaders and organizations to access community-dwelling NHPIs, then training lay NHPIs as community health workers and peer navigators (61–63) to deliver mental health education and antistigma interventions in community settings.

As one of the first community studies of NHPI mental health, several limitations should be noted. First, use of respondent-driven sampling to recruit two hard-to-reach populations may have introduced bias, potentially reducing generalizability of our findings to the overall Samoan, Marshallese, and NHPI populations. Second, we did not screen for all mental health problems that may be affecting NHPIs, including nonalcohol substance use disorders and suicide. Third, we did not test all possible model relationships, including the potential relationship between perceived need for services and avoidance or delay of services. Finally, although we carefully prepared our measures for these specific populations, measurement error may have occurred with regard to symptom under- or overreporting. However, despite these limitations, we believe our data are compelling because so little is known about NHPI mental health and their rates of problems appear so high in our data that even with some estimate errors, the prevalence of mental health problems are likely to remain elevated among NHPIs compared with the general population.

Our findings indicate considerable mental health burden and high unmet need among individuals from two large NHPI communities. Developing culturally tailored engagement approaches may decrease this unmet need. Our exploratory study is among the first to rigorously quantify this burden within NHPI communities, and more research is needed to identify best practices for engaging these underserved communities in care. This includes investigating other community-dwelling NHPI populations and exploring the major service barriers (e.g., stigma) that engagement interventions must address to reduce NHPI communities’ heavy unmet need.

The authors thank the staff from their community partners—the Office of Samoan Affairs and the Arkansas Coalition of the Marshallese—for their hard work and contributions to this project.