Tuesday, August 25, 2009

An Introduction (and some unfortunate barriers) ...

Let me start off by saying that I am a Child and Adolescent psychiatrist (yes, that makes me a physician). Prior to completing a fellowship and specializing in working with “kids”, I completed training as an Adult psychiatrist (for the record - my patients would be the adults, I’m not sure if I qualify).  These levels of training were preceded immediately by 4 years of medical school and a double major during my undergraduate years, prior to that.  Sounds like a lot of fun to all of you, I’m sure.

Anyway, imagine the excitement on your Desi (Indian) parents' face when you tell them that you're planning on becoming a doctor or some other professional!  Stereotypically (and maybe realistically) speaking, the sound of their own voices saying, "My son/daughter is a doctor" brings more smiles to their faces than a lifetime supply of butter chicken, samosas and gol gappe!  So, I'm sure you could understand my parents' excitement when I announced that I, too, was pursuing a degree in medicine!

That lasted a good 5 minutes and then the song-and-dance Bollywood version of a positive reaction took a bit of a turn.  Suffice it to say, my chosen goal of being a psychiatrist did not resonate the same way (initially) as the more ideal notion of having a cardiologist or surgeon for a son.  I think the best illustration of this is my mother’s first expression of her concern; "Tu pagalaan da doctor banda peyain?" (You're going to be a doctor of crazy people?).

It took a little bit of time for my parents’ “Are you serious?” dust to settle.

That was then, and this is now.  All kidding aside, my parents and family have been supportive from that time forward.  This is in no small part due to my insistence that the issue of mental health is a very serious one, and that, indeed, the vast majority of those who suffer from mental health issues are not remotely "crazy" in the truest sense of the word.

That actually brings me to the purpose of this brief introduction . . . .

As we can see from this personal anecdote, there is a certain amount of misinformation about the field of psychiatry, as well as some stigma that is pervasive within the larger culture and, perhaps even more, in our subculture.

It may not come as a surprise to you that we, as a community, generally do not talk about mental illness with people outside the family because of certain social conventions which unfortunately promote shame and guilt surrounding these topics.  Once we get past the point of keeping things "under wraps" and actually approaching a health care provider, we still often have difficulty gaining access to appropriate services due to linguistic, economic, and educational barriers.  In some cases, once the aid of a provider has finally been sought, the targeted problem may not be identified accurately (misdiagnosis) because of linguistic and cultural mismatches again, or because of the patient's focus on somatic (physical) symptoms, family shame, or fear of reprisal.

The "fault" of receiving inadequate mental health care is does not lie solely with our community.  It is a known (and researched) fact that misdiagnosis often occurs in cross-cultural situations due to the fact that assessment tools developed in one cultural setting may be found invalid when translated or applied elsewhere.

Other barriers to treatment which are present for society as a whole, and not just our community, include a lack of providers, incompetent models of care, inadequate reimbursement from insurance companies, and fragmented services.  These barriers in and of themselves make it difficult to get mental health services to those who need them, not to mention the additional weight of the factors pertinent to us as a group.

As a result of this confluence of factors, the pattern that has emerged is one of Asian Americans, in general, tending not to seek services until they are truly desperate. Consequently, they are thought to become more severely ill than Caucasian Americans by the time they approach the same services for assistance.

Let us presume that the barriers have been broken and a mental health provider has evaluated the “patient”.  Once an appropriate diagnosis is uncovered and addressed, the next hurdle is the understanding and implementation of recommended measures and treatment.  It has been found that if a Western treatment is at odds with the treatment traditional in South Asian communities, the family may ignore the provider and stay with tradition.  I don’t think that this comes as a shock to many of us (here you may wish to reference the millions of uses of “moti laachi” or "elaichi" [cardamom], “lassan” [garlic], and “shaid” [honey]).  This indirectly highlights the overwhelming influence of the social and practical value of a family unit in our community, as opposed to a more individualistic approach to these topics in a "Western" culture.

The concern that arises from the above issues is quite simply that people who would benefit from mental health treatment are falling through the cracks every day.

In fact, a University of Toronto study revealed that students from South Asian (and South European) ethnic backgrounds scored higher on a scale for depression (the Beck Depression Inventory) and were also more likely to be classifiable as mildly depressed than those from either East European or Anglo-Celtic backgrounds.  The authors proposed an explanation for this which clearly emphasized the role of societal discrimination in producing feelings of learned helplessness and subsequent depression that were observed.

A somewhat surprising finding in a study done in the United Kingdom was that suicide rates of young women immigrants from the Indian subcontinent were consistently higher than those of their male counterparts.  Interestingly, this study found that family conflict appears to be a precipitating factor in many suicides, whereas mental illness is rarely cited as a cause.  However, depression, anxiety, and domestic violence may contribute to the high rates of suicide, and there is a growing concern that affective (mood) disorders may be underdiagnosed in the South Asian population.

This is just another illustration of the aforementioned notion that Indians, and South Asians in general, are often not getting the mental health assistance that they may desperately need.

There is much work to be done in order to begin to combat this problem.  The first step in this is just to raise awareness, which I hope to have done here.  The second, and more important step, is proper education about these matters.  In the coming articles I will discuss specific types of mental health issues and signs about which one should remain vigilant when 'screening' for such mental health needs.  I will also discuss some specific details on the reactions and attitudes that researchers have found among the  Indian/South Asian community with regard to those specific 'diagnoses'.

In all seriousness, if you are struggling with depression, anxiety, other mood symptoms, ADHD, or just having a difficult time with conflicts within yourself or with others around you, get help as soon as you can.

If someone you know is struggling with something similar and is not speaking up for themselves, encourage them to do so.  Better yet, be a voice for them.  Remember the story of Anne Frank - we don't always take a stand when we think we're not directly impacted by something, but no one knows what the future holds and whether we may be affected ourselves one day.

Thank you for reading this far.  Please get the help you or your loved ones need, regardless of whether you choose to avail my professional services, or those of another provider.

If you would be interested in visiting my website to learn about these issues in more detail and to get some resources, please feel free to navigate to http://www.gsinghmd.com and browse the site.

I hope that you don't know anyone who needs this number right now, but it is important to have: 

Toll Free National Suicide Prevention Hotline: 1-800-SUICIDE (784-2433)