Disparities in Mental Health Care Utilization and Perceived Need Among Asian Americans: 2012–2016

Asian respondents had higher educational achievement, were more likely to reside in urban metropolitan statistical areas, and were less likely to be divorced compared with whites (Table 1). Asians also had lower household incomes but slightly higher rates of health insurance coverage. They perceived less need for mental health treatment and had lower rates of SPD and MDE in the past year compared with whites.

Asians were significantly less likely than whites to have received any mental health treatment in the past year (Table 1). These disparities were also significant when the data were stratified by those with perceived need, SPD, and MDE. Among white and Asian participants, rates of past-year mental health treatment utilization were highest among those with perceived need compared with those in other need definition groups (Table 2).

After adjustment for health and sociodemographic factors, the analyses showed that Asians were significantly less likely to receive mental health treatment in the past year in the overall sample (Table 1) and in subgroups defined by each of the need definitions (Table 3). Compared with whites with perceived need, Asians with perceived need were less likely to have received mental health care in the past year (odds ratio [OR]=0.57, 95% confidence interval [CI]=0.44–0.75). Asians with past-year SPD (OR=0.32, 95% CI=0.25–0.42) and past-year MDE (OR=0.31, 95% CI=0.21–0.45) were also less likely to have received mental health care in the past year. Among respondents reporting perceived need for mental health care, 87.1% of whites received mental health care in the past year, compared with 80.0% of their Asian counterparts (p<0.001) (see online supplement). Among those with past-year SPD, 53.3% of whites received past-year mental health treatment compared with 28.9% of Asians (p<0.001). Among those with a past-year MDE, 70.0% of whites received mental health treatment in the past year compared with 35.3% of their Asian counterparts (p<0.001).

After adjustment of the analyses for sociodemographic factors, two barriers to treatment were endorsed at significantly different rates between Asians and whites with perceived unmet need. Asians were less likely than whites to endorse cost as a treatment barrier (OR=0.63, 95% CI=0.43–0.94, p=0.024), and Asians were more likely than whites to endorse not knowing where to go for treatment (OR=1.61, 95% CI=1.09–2.39, p=0.017) (see online supplement]).

The findings from this study demonstrate that significant disparities in mental health treatment utilization exist for Asians across both respondent-perceived need for mental health treatment and need as determined by structured psychiatric diagnostic instruments. These disparities persisted after controlling for sociodemographic factors, even within the population endorsing perceived need for mental health treatment. Greater than half of whites with SPD went without mental health treatment in the last year. The rate of treatment utilization was even lower among Asians: three in four Asians with SPD did not receive any mental health treatment in the past year. Although rates of mental health treatment were highest among Asians with perceived need, there was still a significant disparity with whites, demonstrating that racial differences in perception of need did not fully explain the disparity in treatment utilization.

Rates of mental health treatment for Asians were greater when the need for treatment was recognized by the patient. Interventions to improve mental health treatment rates among Asians could target culturally informed views of mental health to improve perceived need among Asians. Increasing recognition of emotional disturbances as medically treatable may be especially important in this population (12). Partnering with Asian-American communities to develop culturally relevant interventions that integrate the Western philosophy of mental health care with existing Asian cultural views may help Asian Americans recognize when treatment is needed.

Stigma is a key contributing factor in whether Asian Americans seek mental health care. Stigma-related barriers, such as “Concerned neighbors or community would have a negative opinion” and “Didn’t want others to find out about needed treatment,” were measured; they were not endorsed significantly more by Asians with perceived need for mental health treatment than by whites with perceived need, despite prior studies suggesting that stigma plays a large role in unmet need for Asians (4, 37–41). This finding could represent a shift in how mental health treatment is perceived in the Asian-American community, or it could be due to a lack of nuance in the questions within the survey that were meant to capture stigma. Stigma within Asian communities may manifest more as shame within the family and a need to “save face” (4, 16) than as concern over the negative opinions of neighbors or community members as posed by the survey questions. Future research conducted within Asian populations should take these cultural factors into account to better capture the social and cognitive processes that prevent Asians from seeking care.

Asians with a perceived need for treatment had higher treatment utilization rates than Asians in other clinical need categories but lower utilization rates than whites with perceived need. Intervening on perceptions of need would thus not be sufficient to reduce disparities in treatment rates, and a better understanding of other barriers is necessary. In our analyses of barriers to care endorsed by people with perceived need, Asians were more likely to endorse “not knowing where to go,” perhaps a byproduct of relative social isolation or lack of connection to mainstream health care agencies.

Past research has shown that Asian students seeking mental health treatment reported a lack of social support (40), and older Asian-American adults were less willing than adults of other races to discuss mental health issues with anyone (42). A lack of social support may make seeking care more difficult because consulting with friends and family is often an important step in the pathway to treatment (43). Not knowing where to go might also be a consequence of a lack of referrals by clinicians. Asians are more likely to describe their mental distress in terms of physical symptoms or other symptoms that do not correspond with traditional definitions of mental illness (44, 45); therefore, mental illness may go underdetected, resulting in a lack of referrals and treatment (46).

Although Asians endorsed cost less frequently than whites, it was the most highly endorsed barrier to care for Asians after adjustment for insurance status and income level. The cost of mental health care is a widely acknowledged structural barrier for patients (47) and has been reported previously as a barrier to treatment seeking among Asians (16). Although cost is only one of many contributing factors to the wide disparities in mental health treatment utilization, our findings suggest that insurance reform and other structural changes that decrease the cost of treatment will contribute to the reduction of Asian-white disparities in mental health treatment utilization.

The implementation of culturally sensitive and specific interventions are needed to improve Asian Americans’ utilization of care. Evidence shows that culturally targeted interventions are more effective than more generalized interventions (48) in linking Asians to treatment. Developing outreach programs with community health workers is one way to increase awareness of available treatments within racial-ethic communities (49). A pilot study of a community intervention to increase awareness of mental health issues among older Chinese Americans showed an increase in intention to consult a mental health professional for psychiatric symptoms postintervention (50).

Within communities heavily populated by Asian Americans, having clinics specifically focused on addressing their unique health concerns will likely improve treatment rates and outcomes; patients receiving treatment at ethnicity-specific mental health programs in Los Angeles were found to be more likely to stay in treatment over time (18). Integration of mental health treatment and primary care within these clinics may be an effective way to improve utilization (51). Unfortunately, many intervention studies examining the mental health treatment of racial-ethnic minority groups have few Asian participants, and results show less improvement in Asian engagement in mental health treatment compared with members of other races (52). Innovative interventions are thus needed.

This study has several limitations. First, the analysis lacks detailed information about the specific ethnic backgrounds or immigration statuses of respondents. Mental health treatment usage rates have been found to vary depending on ethnic group and immigrant status (53, 54), the nuances of which are lost when Asians are treated as a monolithic group. Second, the reliability of self-reported measures of need and treatment may be weakened by recall bias and by feelings of shame for reporting mental illness. Third, although racial differences in measures of external stigma (e.g., “Concerned neighbors or community would have a negative opinion”; “Didn’t want others to find out about needed treatment”) were investigated in this article, a more nuanced scale of “loss of face” (55) was not assessed. Future studies should assess the role of loss of face as a variable explaining the Asian-white disparity in mental health care utilization. Finally, the survey is available only in English and Spanish. Given that our population of interest was Asian Americans, these data may not fully reflect the experiences of members of this community whose primary or preferred language is not English or Spanish. Therefore, our results may be conservative given that language incongruity is a barrier to mental health treatment.

Health care systems should strive to improve the cultural sensitivity of their mental health care to better serve Asian-American patients. Training in cultural competency and implicit biases (56) and in asking questions such as those proposed in the Outline for Cultural Formulation in the DSM-5 (57) that better elicit cultural explanations of mental illness should be provided to clinicians to improve detection and referral to treatment for Asian Americans with mental illness. Pipelines within clinical training programs that include more members of racial-ethnic groups may prove beneficial.

Outreach conducted in Asian communities could improve awareness of mental illness and make care more accessible for those in need. Peer outreach in particular may be helpful, and health centers should consider recruiting community-specific volunteers to encourage information dissemination. Future research should explore the meaning of mental illness and treatment in different Asian subcultures within the United States and develop patient-centered care models based on these cultural understandings.