1

The Bridge Program

An Effective Model of ProvidingBehavioral Health to Asian Americans

Teddy Chen, PhD, MSSWDirector

Mental Health Bridge ProgramCharles B. Wang Community Health Center

Asian AmericansAsian Americans

Black or

African

American,

12.3%American

Indian and

Alaska Native,

0.9%

White, 75.1%

Native

Hawaiian and

Other Pacific

Islander, 0.1%

Asian, 3.6%

Other Race,

5.5%

Two or More

Races, 2.4%

Source: US Department of Commerce Economics and Statistics Administration U.S. CENSUS BUREAU

United States Population

Other Race,

7.1%

Native

Hawaiian and

Other Pacific

Islander, 0.1%

American

Indian and

Alaska Native,

0.4%

Asian, 5.5%

Two or More

Races, 3.1%

Black or

African

American,

15.9%

White, 67.9%

New York State Population

Source: US Department of Commerce Economics and Statistics Administration U.S. CENSUS BUREAU

New York State – Asian Groups(2000)

Asian American FederationCensus Information Center

*Does not include Asian in Combination with any other race.Source: U.S. Census Bureau, Census 2000.

TOTAL ASIAN POPULATION: 1,044,976

Asian Indian,

24.1%

Chinese,

40.6%

Japanese,

3.6%

Vietnamese,

2.3%

Korean, 11.5%

Other Asian,

7.0%

Pakistani,

3.1%

Filipino, 7.8%

New York City New York City –– Asian Groups (2000) Asian Groups (2000)

Asian American FederationCensus Information Center

*Does not include Asian in Combination with any other race.Source: U.S. Census Bureau, Census 2000.

TOTAL ASIAN POPULATION: 787,047

Pakistani, 3.1%

Bangladeshi,

2.4%

Japanese, 2.9%

Filipino, 7.0%

Korean, 11.0%

Other Asian,

6.0%

Asian Indian,

21.7%

Chinese, 45.9%

Indicators of NeedsIndicators of Needs

API Females Age 65 and Over still haveAPI Females Age 65 and Over still haveHighest Suicide RatesHighest Suicide Rates

* Except for 1994 and 1996, fewer than 20 deaths reported in these years for Hispanic females, American Indian females, or Alaska Native females.SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, Grove RD And Hetzel AM. Vital Statistics rates in the United States, 1940-60.

Washington: Public Health Service, 1968; Vital statistics of the United States, vol.88,mortality, part A, for data years 1950-97. Washington:Public Health Service;data computedby the Division ofHealth and Utilization Analysis from data compiled by the Division of Vital Statistics and from national population estimates for race groups from table 1 and unpublished Hispanic populationestimates prepared by the Housing and Household Economic Statistics Division, U.S. Bureau of the Census.

Detailed Race, Hispanic Origin: United States, Selected Years 1990 - 2001

0

1

2

3

4

5

6

7

8

9

1990* 1993* 1994* 1995-97* 2001

65+ Female

Black Female Asian or Pacific Islander Female

Hispanic Female White, non-Hispanic Female

API Rates for Suicide, Female Age 15-24API Rates for Suicide, Female Age 15-24Remain HighRemain High

* Fewer than 20 deaths reported in these years for American Indian or Alaska Native females.SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, Grove RD And Hetzel AM. Vital Statistics rates in the United States, 1940-60.Washington: Public Health Service, 1968; Vital statistics of th United States, vol II, mortality, part A, for data years 1950-97. Washington: Public Health Service; data computedby the Division of Health and Utilization Analysis from data compiled by the Division of Vital Statistics and from national population estimates for race groups from table 1 andunpublished Hispanic population estimates prepared by the Housing and Household Economic Statistics Division, U.S. Bureau of the Census.

Detailed Race, Hispanic Origin: United States, Selected Years 1990-2001

0

1

2

3

4

5

6

1990* 1993 1994* 1995-97 2001

Black Female

Asian or Pacific Islander Female

Hispanic Female

White, non-Hispanic Female

6.9%

16.9%

3.4%

10.0%

5.2%6.4%

0.9%2.5%

7.0%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Dysthymia

Lifetime 12-month Lifetime 12-month Neurasthenia

Major Depressive Episode

CAPES NCS

Takeuchi, D.T., et al.(1998) American Journal of Psychiatry, 155, 1407-1414.

Prevalence of Depression Among ChinesePrevalence of Depression Among ChineseAmericansAmericans

Suicide and Death Ideation in DepressedSuicide and Death Ideation in DepressedPrimary Care Elderly Primary Care Elderly (Bartels et al. Am J Geriatric Psychiatry, 14(4) 2002, p 417-427)(Bartels et al. Am J Geriatric Psychiatry, 14(4) 2002, p 417-427)

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Black (N=530) Asian or Pacific

Islander (N=111)

Hispanic or Latino

(N=299)

White (N=1228)

Death Ideation

Suicidal Ideation

High Rates of Major Depression in PrimaryHigh Rates of Major Depression in PrimaryHealth CareHealth Care

A two-phase of epidemiological survey of the prevalence ofA two-phase of epidemiological survey of the prevalence ofmajor depressive disorder among Asian Americans in themajor depressive disorder among Asian Americans in theprimary care setting in Boston (N= 503)primary care setting in Boston (N= 503)

The Chinese version of the Beck Depression Inventory wasThe Chinese version of the Beck Depression Inventory wasusedused

Positive cases were validated by clinical interviewPositive cases were validated by clinical interview

The prevalence rate of MDD among Asian-American in theThe prevalence rate of MDD among Asian-American in theprimary care setting was estimated to be 19.6% primary care setting was estimated to be 19.6% ± 0.06± 0.06

Yeung A, Chan R, Mischoulon D, et al: Prevalence of major depressive disorder among Chinese-Yeung A, Chan R, Mischoulon D, et al: Prevalence of major depressive disorder among Chinese-Americans in primary care. General Hospital Psychiatry 26:24-30, 2004Americans in primary care. General Hospital Psychiatry 26:24-30, 2004

The New York Times ReportThe New York Times Report

Cornell is making a special effort to reach out to Asian andCornell is making a special effort to reach out to Asian andAsian-American students. Of 16 students there who haveAsian-American students. Of 16 students there who havecommitted suicide since 1996, 9 were of Asian descent.committed suicide since 1996, 9 were of Asian descent.

The New York Times, December 3, 2004The New York Times, December 3, 2004

Persistent UnderutilizationPersistent Underutilization

Stigma and ShameStigma and Shame

The reluctance to use services isThe reluctance to use services isattributable to factors such as the attributable to factors such as the shameshameand and stigmastigma accompanying use of mental accompanying use of mentalhealth services, health services, cultural conceptionscultural conceptions of ofmental health and treatment that may bemental health and treatment that may beinconsistent with Western forms ofinconsistent with Western forms oftreatment, and the cultural or linguistictreatment, and the cultural or linguisticinappropriateness of services (Sue & Sue,inappropriateness of services (Sue & Sue,1999).1999).

(U.S. Department of Health and Human Services. (2001). Mental Health:(U.S. Department of Health and Human Services. (2001). Mental Health:Culture, Race, and Ethnicity-A Supplement to Mental Health: A Report of theCulture, Race, and Ethnicity-A Supplement to Mental Health: A Report of theSurgeon General. Rockville, MD: U.S. Department of Health and HumanSurgeon General. Rockville, MD: U.S. Department of Health and HumanServices, Public Health Services, Office of the Surgeon General)Services, Public Health Services, Office of the Surgeon General)

Underutilization of Mental Health ServicesUnderutilization of Mental Health Services

Asian Americans Constituted 8.7% of LosAsian Americans Constituted 8.7% of LosAngeles County Population, But Only 3.1%Angeles County Population, But Only 3.1%of Mental Health Service Clients in Losof Mental Health Service Clients in LosAngeles CountyAngeles County(Sue, et al. 1983-1988)(Sue, et al. 1983-1988)

Asian Americans Constituted 9.1% of SanAsian Americans Constituted 9.1% of SanDiego County Population, but Only 3.6% ofDiego County Population, but Only 3.6% ofMental Health Service Clients in San DiegoMental Health Service Clients in San DiegoCountyCounty(Chen, et al. 1991-1994)(Chen, et al. 1991-1994)

Underutilization of Mental Health ServicesUnderutilization of Mental Health Servicesby AAPIby AAPI

AAPI populations re 3 times less likely than White populations toAAPI populations re 3 times less likely than White populations touse available mental health services (Marsuoka, Breaux, & Ryujin,use available mental health services (Marsuoka, Breaux, & Ryujin,1997) .1997) .

Only 17% of Chinese Americans who experienced problems withOnly 17% of Chinese Americans who experienced problems withemotions, anxiety, drugs, alcohol, or mental health in the past 6emotions, anxiety, drugs, alcohol, or mental health in the past 6months sought care; less than 6% of them saw mental healthmonths sought care; less than 6% of them saw mental healthprofessionals, 4% saw medical doctors, and 8% saw a minister orprofessionals, 4% saw medical doctors, and 8% saw a minister orpriest. (Young, 1998).priest. (Young, 1998).

NYS Public Mental Health System MentalNYS Public Mental Health System MentalHealth UtilizationHealth Utilization

Source: Source: CarpinelloCarpinello, S. (2004). Providing Quality Services in Culturally Diverse Settings. , S. (2004). Providing Quality Services in Culturally Diverse Settings. Mental HealthMental HealthNews, News, Fall 2004, 9.Fall 2004, 9.

Total persons served = 630,000

Other/American

Indian

5%

Asian

1%

White

50%

Hispanic

20%

Black

24%

Ethnic composition of population servedEthnic composition of population served

Greater Delay of Treatment:Greater Delay of Treatment:Increased SeverityIncreased Severity

Many studies demonstrate that Asian Americanswho use mental health services are moreseverely ill than white Americans who use thesame services. This pattern is true in manycommunity mental health centers (Brown et al.,1973; Sue, 1977), county mental health systems(Durvasula & Sue, 1996 for adults; Bui &Takeuchi, 1992, for adolescents), and studentpsychiatric clinics (Sue & Sue, 1974).

(U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity-A Supplement to Mental Health: A(U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity-A Supplement to Mental Health: AReport of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Services, Office of theReport of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Services, Office of theSurgeon General)Surgeon General)

Access to Mental HealthAccess to Mental HealthServicesServices

Barriers To CareBarriers To Care

Lack of AccessLack of Access–– LanguageLanguage–– EconomicEconomic–– EducationEducation

Lack of IdentificationLack of Identification–– Cultural and Linguistic MismatchCultural and Linguistic Mismatch–– Focus on Somatic SymptomsFocus on Somatic Symptoms–– Family Shame and GuiltFamily Shame and Guilt–– Fear of ReprisalFear of Reprisal

Lack of TreatmentLack of Treatment–– Patient and Family ResistancePatient and Family Resistance–– Lack of ProvidersLack of Providers–– Models of Care Not CompetentModels of Care Not Competent–– Fragmented ServicesFragmented Services

Community FactorsCommunity Factors2000 Statistics2000 Statistics

Distribution of Psychiatric Diagnoses

in Bridge Program (CHC & FPCC)

Psychotic

Disorders

23%

Anxiety

Disorders

17%

Mood

Disorders

54%

Other

6%

Distribution of Psychiatric Diagnoses

at a Community Mental Health Clinic

Anxiety

Disorders

5%

Psychotic

Disorders

60%

Other

10%

Mood

Disorders

25%

Over-Crowed Community Mental Health SystemOver-Crowed Community Mental Health System

What about Primary Care?What about Primary Care?

Mental Disorders May Be Difficult to Recognize in busyMental Disorders May Be Difficult to Recognize in busyprimary care practiceprimary care practice

Lack of Training and Expertise with Mental Health IssuesLack of Training and Expertise with Mental Health Issues

Encountering Patient and Family StigmaEncountering Patient and Family Stigma

Somatic Problems that often Mask Psychiatric DifficultiesSomatic Problems that often Mask Psychiatric Difficulties

BUTBUT

OPPORTUNITY FOR EARLY ENGAGEMENT andOPPORTUNITY FOR EARLY ENGAGEMENT andINTERVENTION!!INTERVENTION!!

Prevalence of Depression in ChinesePrevalence of Depression in ChinesePatients in Primary CarePatients in Primary Care

Using structured diagnostic interviews,Using structured diagnostic interviews,20% of 503 consenting Chinese adult20% of 503 consenting Chinese adultpatients met criteria for major depressionpatients met criteria for major depression(Yeung et al, 2004)(Yeung et al, 2004)

Symptom Presentation:Symptom Presentation:SomatizationSomatization

Asians are thought to deny the experience andAsians are thought to deny the experience andexpression of emotions. These factors make itexpression of emotions. These factors make itmore acceptable for psychological distress to bemore acceptable for psychological distress to beexpressed through the body rather than theexpressed through the body rather than themind.mind.

Attention to the emotional and interpersonalAttention to the emotional and interpersonalsymptoms or concerns are positively correlatedsymptoms or concerns are positively correlatedwith increased acculturation (Chen at al, 2003)with increased acculturation (Chen at al, 2003)

(U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity-A Supplement to Mental Health: A(U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity-A Supplement to Mental Health: AReport of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Services, Office of theReport of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Services, Office of theSurgeon General)Surgeon General)

Charles B. WangCharles B. WangCommunity Health CenterCommunity Health Center

A federally qualified community health centerA federally qualified community health center

Established in 1970sEstablished in 1970s

Had 170,000 patient encounters and 34,700 patient in 2007Had 170,000 patient encounters and 34,700 patient in 2007

Only community health center services Asian AmericansOnly community health center services Asian Americans(Chinese American) in NYC(Chinese American) in NYC

Providing Internal Medicine, Pediatrics, WomenProviding Internal Medicine, Pediatrics, Women’’s Health,s Health,Mental Health, and Dental services.Mental Health, and Dental services.

Has 307 F/T and 162 P/T employeesHas 307 F/T and 162 P/T employees

A Bridge Between...A Bridge Between...

...Primary Care and Mental Health...Primary Care and Mental Health

Training and supporting primary care physicians toTraining and supporting primary care physicians toprovide mental health careprovide mental health care

Early detection and treatment of mental healthEarly detection and treatment of mental healthproblemsproblems

Providing mental health care in a primary careProviding mental health care in a primary caresettingsetting

Helping patients enter the specialty mental healthHelping patients enter the specialty mental healthsystem, if necessarysystem, if necessary

On-site Mental Health ServicesOn-site Mental Health Services10 Years Later10 Years Later

Number of EncountersNumber of Encounters

1053

3725 3782

4739

5475

622

869695 742 777 739

946

1514 1469

2388

258

648

1208

2755

3611

0

1000

2000

3000

4000

5000

6000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

CHC FPCC

Patients

317

395

559

665

167

729

416

801

895

0

100

200

300

400

500

600

700

800

900

1000

1998 1999 2000 2001 2002 2003 2004 2005 2006

GenderGender

Male : 918 (40%)Male : 918 (40%)

Female: 1397Female: 1397(60%)(60%)

Male

Female

N=2315N=2315

AgeAge

1-17: 418 (19%)1-17: 418 (19%)

18-24: 279 (12%)18-24: 279 (12%)

25-34: 261 (11%)25-34: 261 (11%)

35-44: 309 (13%)35-44: 309 (13%)

45-54: 352 (15%)45-54: 352 (15%)

55-64: 310 (13%)55-64: 310 (13%)

65-74: 202 (9%)65-74: 202 (9%)

75 and older: 177 (8%)75 and older: 177 (8%)

Age 1-17

18-24

25-34

35-44

45-54

55-64

65-74

75 and

older

N=2315N=2315

Diagnosis DistributionDiagnosis Distribution

Depression: 775 (34%)Depression: 775 (34%)

Anxiety: 276 (12%)Anxiety: 276 (12%)

Psychotic: 129 (6%)Psychotic: 129 (6%)

ADHD: 115 (5%)ADHD: 115 (5%)

Adjustment DisorderAdjustment Disorder–– W/Depressed Mood: 100W/Depressed Mood: 100

(4%)(4%)–– With Anxiety: 29 (1%)With Anxiety: 29 (1%)–– With Mixed Anxiety andWith Mixed Anxiety and

Depressed Mood: 90 (4%)Depressed Mood: 90 (4%)–– With Disturbance ofWith Disturbance of

Conduct: 51 (2%)Conduct: 51 (2%)–– With Mixed Disturbance ofWith Mixed Disturbance of

Emotions and Conduct: 31Emotions and Conduct: 31(1%)(1%)

Others:665 (29%)Others:665 (29%)

Depression

Anxiety

Psychotic

ADHD

Adj Dis w/Depressed

Mood

Adj Dis w/Anxiety

Adj Dis w/Mixed

Anxiety & Depressed

MoodAdj Dis w/Disturbance

of Conduct

Adj Dis w/ Mixed

Disturbance of

Emotions & ConductAdj Dis NOS

Others

Early Detections StrategiesEarly Detections Strategies

Adult Depression Screening and Treatment

Pediatric Services:– ADHD Detection and Treatment– Adolescent Screening and Treatment

ChallengesChallenges

Difficulties referring patients to specialty mental healthDifficulties referring patients to specialty mental healthclinicsclinics

Primary care physicians request more servicesPrimary care physicians request more services

Community specialty mental health clinics are notCommunity specialty mental health clinics are notaccepting accepting patientspatients

Medical professionalsMedical professionals’’ bias attitude towards mental bias attitude towards mentaldisordersdisorders

Are We Doing Enough?Are We Doing Enough?

““Commuting back to China to get treatmentCommuting back to China to get treatment””

““Yes, it is more than fifty percent.Yes, it is more than fifty percent.””

““You donYou don’’t need them. They can not help you.t need them. They can not help you.””