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A Fatal Cultural Gap: Depression Among Minorities

New America Media, News report, Viji Sundaram Posted: Oct 08, 2009

Editors Note: Trained mental health professionals find it difficult to diagnose depression in minorities, most of whom are already reluctant to seek psychiatric care, because the psychiatric framework for evaluating behavior is Euro-centric. National Depression Screening Day is October 8.

For years, Ram Subramaniam hid his gender preference from friends and family, and, in some ways, even from himself.

When he was 28, his parents began pressuring him to come back to India and get married to someone they would select for him. After all, he was a post-doctoral fellow in a college in Cleveland, Ohio, and his future prospects in the United States seemed bright. They saw no reason why he should remain single any longer.

Subramaniam believes that the familial pressure, as well as the fact that his fellowship program wasnt going very well and his struggle with his sexual identity, triggered the onslaught of his depression.

I went spiraling down, Subramaniam, now 38, and a chemistry instructor at De Anza College in Cupertino, Calif., said.

Subramaniam began to lose his appetite, started drinking heavily, experienced insomnia and a sharp dip in his productivity level at work some of the classic signs of depression. But it didnt once cross his mind that he could be depressed, until the man he was dating suggested he get himself screened.

Subramaniam said his initial reaction was shock. Oh my God, I dont want to go to a mental health clinic. Thats not what Indians do, he thought. Maybe if I ignore it, it will go away.

Subramaniams reaction was typical of many Asians, mental health providers say.

Asian Americans are unique in that they have a negative attitude about depression, said Berkeley-based psychotherapist Dr. Will Courtenay. They feel their family would be disappointed if they are depressed. So theres a code of silence around it.

Major depressive disorder is a common disease, occurring in approximately three out of every 20 people in the United States.

However, members of minority communities, especially first-generation immigrants, often express their illness in a manner that is different from their white counterparts, which makes it more difficult to diagnose depression in them, said Dr. Russell Lim, who teaches cultural psychiatry at UC Davis School of Medicine.

We (who are trained in Western medical schools) are defining depression though our cultural lenses, said U.S.-born Lim. A cultural psychiatrist, on the other hand, looks for less specific signs than those outlined in medical textbooks.

For example, a markedly diminished interest in pleasure is one of the signs Western-trained psychiatrists are asked to look for in a patient.

But if youre a Buddhist, your belief is you dont seek pleasure, Lim said. You dont ask that patient what do you do for fun?

Or, if you are an immigrant who has come to the U.S. from a refugee camp, like many Hmong and Vietnamese have, their concept of the pursuit of happiness would likely differ from their white counterparts, he said.

Lim pointed out that in some Asian languages, there is no word for depression. A Hmong patient, for instance, would come in and say, I have a troubled liver. And the interpreter would tell me the patient is depressed.

Ive never had an Asian immigrant patient tell me that he or she is depressed, unless theyre second or third generation Asian, said Lim, who practices at the multi-lingual Sacramento-based Adult Psychiatric Support Services, where the patients are mostly indigent.

In 2001, the U.S. Surgeon General released the findings of a study that indicated that mental health problems among minorities are related to cultural differences that created barriers to treatment. For instance, mental health providers are often unaware of their patients cultural values and backgrounds, including the meaning of illness within their culture.

The study also indicated that while Latinos and Asian Americans were no more likely than whites to have mental disorders, Latinos might suffer disproportionately from mental health problems because their community has the lowest rate of health insurance coverage. African Americans suffer from a similar lack of diagnosis due to their lack of health insurance

Minorities in the United States, according to the report, suffer a disproportionate burden of mental illness because they often have less access to services than other Americans, receive lower quality care and are less likely to seek help when they are in distress.

The Surgeon Generals report also noted that disparities in mental health care for minorities can be related to language differences, to racism and discrimination, and to the stigma that some cultures ascribe to mental illness.

Another interesting finding was that African Americans with mental health problems were less likely than whites to be diagnosed and receive proper care for those problems, even though the rates of depression are similar.

John Head, a Bay Area resident, suffered from depression for more than 20 years before he sought help.

I didnt have a name for what I was going through, and I resisted going to see a (therapist) even when my wife asked me to, said Head, author of the book Depression and Black Men. Part of it was the stigma, he said, noting: Its there in the general community, too, but its greater in minority communities.

Unlike most whites, minorities tend to be diagnosed as depressed by primary health care physicians in community clinics because thats where they go with what they believe are physical maladies.

Lim and other psychiatrists who work in community clinics worry that Californias budget cuts, which have forced a number of mental health treatment centers to shutter or curtail admissions, are going to have a tremendous impact on minorities access to psychiatric care.

Already, many uninsured psychiatric patients are showing up in emergency rooms across the state, Lim said. In recent weeks, the UC Davis Medical Center has seen three times its typical number of psychiatric patients.

The four community mental health centers in Sacramento were cut by 50 percent, leaving 4,000 patients without a psychiatrist, he said. Our clinic took 10 percent (of them), or 400. Primary care took some, and TCORE (which provides intensive services to psychiatric patients in Sacramento who are not linked to any outpatient services) took some.. . . It seems like 1,000 are left without a doctor, and show up in emergency rooms.

The general implications of these state cuts are that the community safety net has growing, gaping holes, particularly for adults with serious mental illness, said Patricia Ryan, executive director of nonprofit California Mental Health Directors Association.

The budget cuts have affected mental health care, asserted Head, adding The impact will be especially felt by minority communities.

Even as it is, he said, many blacks believe that mental health treatment is not something you have to pay for, a belief that keeps some in his community from seeking psychiatric help.

Like many African Americans, Head said he viewed mental illness as something that was not a real illness, and not something that could be cured. Before long, a sense of hopelessness towards life set in.

But once he began treatment, his despondency began to disappear and I realized there are things I could do to get back up again, Head said.

Subramaniam said things began looking up for him too once he began treatment. Even the family drama that ensued when I announced I was gay didnt set me back, he said.

Thats why these days, when someone I know sounds depressed, I tell that person to see a doctor before things get out of control, he said.

Related Articles:

Asian Americans' Rising Suicide Rates -- Three Students Take their Lives

Suicidal Thoughts: Suicide Rate Among Southern Calif. Muslims Increases

Family Rejection a Health Risk for Lesbian, Gay and Transgender Youth

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