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When it comes to treating Asians with depression, Asians underutilize mental health services. Many are ashamed to seek or participate in treatment.Study after study has shown that Asians underutilize mental health services much more than other populations, according to Stanley Sue, PhD, director of the National Research Center on Asian American Mental Health in Davis, California.

It's a trend that Dr. Sue discovered in the seventies when he was a graduate student intern at the University of California, Los Angeles Psychiatry Clinic. The clinic assessed information on the number of Asian student clients, as well as therapists' impressions of those clients.

"Not only did we find that Asians underutilized services," Dr. Sue said. "We also found that the Asian students exhibited more severe mental disturbances than the non-Asian students."

The same patterns can be seen today. The National Research Center evaluated records of thousands of clients of the Los Angeles County mental health system for a six-year period. "What we found," said Dr. Sue, "was that Asians were underrepresented in the outpatient system, and they were more likely than African Americans, Whites, and Hispanics to have psychotic disorders."

Contrary to popular belief, the fact that a certain population is not using mental health services does not indicate that the population is free of mental health problems, Dr. Sue added.

A key question then is why? Why aren't Asians seeking and receiving treatment from state services if their mental health needs are so significant? Several factors play into why people use or don't use mental health services, including the ease of accessing services and willingness to seek help. According to experts, culture is at the heart of such factors.

"For example, in traditional Chinese culture, many diseases are attributed to an imbalance of cosmic forces--yin and yang," Dr. Sue explained. "So the goal is to restore the balance, and that might be accomplished through exercise or diet," and not necessarily through a mainstream mental health system.

While there are cultural attitudes that can be seen across the Asian population, there are important differences between groups, according to Deborah S. Lee, CSW, director of Asian American Mental Health Services in New York City.

"For all Asian groups, there is a stigma attached to going to an outsider to obtain treatment for mental health problems," Ms. Lee said. "But depending on the group, the stigma is expressed differently." This also can depend on educational background and how long a person has been in this country.

Ms. Lee's Chinese clients often interpret mental illness as punishment for some wrongdoing carried out by themselves, by their family members, or by their ancestors. For this reason, they may feel ashamed to seek or participate in treatment.

People in the Chinese community often call Ms. Lee's clinic to say they have a friend who is experiencing some problems. After telling the caller to bring in the friend, she frequently discovers that the friend is really a relative of the person who called. "The caller was simply ashamed of having such problems in the family," she said.

For Asians, the individual is commonly viewed as a reflection of the entire family. "That's why the family should be included in treatment," Lee suggests.

In the case of a Cambodian woman who suffers from depression, her husband is against her receiving treatment from Lee's clinic. "He believes she has mental health problems because she is haunted by evil spirits," Ms. Lee said. "So we had to work on convincing him to keep letting us treat her here, while they also use cultural practices at home to ward off bad spirits. We had to let him know that we could include him in the process of developing a treatment plan for his wife. We also had to make sure that each practice would not interfere with the other."

Ms. Lee finds that because the Korean community is very religious, her Korean clients often confuse their hallucinations with spiritual voices. "Our Korean clients also rely very heavily on treating themselves with medication. We have to educate them and their families about the dangers of misusing drugs and the importance of understanding that treatment for mental health problems involves more than just medication." Lee also treats Japanese clients, who are very concerned about who knows that they are in treatment. Many people have failed to show up for appointments for fear of being seen. "Sometimes, we block in an extra 15 minutes between appointment so that there is less of a chance that people might run into someone they know," Lee noted.

Asian American Mental Health Services, a state-licensed program, is specifically designed for the New York Asian community. The program operates a Chinese unit, which has a continuing treatment program for patients who are chronically mentally ill. There is also a Japanese unit, a Korean unit, and a Southeast Asian unit, all with outpatient clinics.

Ms. Lee and her staff are Asian, and they possess specialized knowledge and skills about delivering mental health services to Asians. They know, for instance, that when a client comes in complaining of an inability to move a part of the body, it's important to conduct a culturally-sensitive psychological evaluation, rather that automatically sending the client away for a physical check-up. "It's very common among Asians," Ms. Lee said, "to report physical problems that are really a reflection of mental or emotional problems."

But what about those mainstream clinics that don't have insight into Asian culture? How can services be reorganized so that Asians can be treated there? According to Dr. Sue, mental health workers need to be trained on aspects of Asian culture, and mainstream facilities should make use of Asian consultants.

"Another valuable strategy," he added, "is targeting Asians through community education." It is possible to modify attitudes this way. Important points to make are that talking with others about problems can help, that early identification is crucial, and that providers are required to keep problems confidential.

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