Thursday, Sept. 6, at 1p.m. ET

Immigrants and Mental Health

Dr. Hochang Benjamin Lee
Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University
Thursday, September 6, 2007; 1:00 PM

Dr. Hochang Benjamin Lee was online Thursday, Sept. 6 at 1 p.m. ET to take your questions about the cultural barriers that prevent some immigrant families from seeking treatment for mental health problems.

A transcript follows.

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Dr. Hochang Benjamin Lee: Hi Everyone, I am Dr. Ben Lee, and I am a psychiatry faculty at the Johns Hopkins Hospital. I have special interest in the mental issues related to minority populations, especially among Asian Americans. I hope to discuss and answer some of the questions you posted.

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Dallas: To have access to treatment the immigrants need to have a culturally and linguistically sensitive place. Research on Latinos indicates that there are 29 mental health professionals for every 100,000 Latinos in the United States. What is your recommendation to increase the number of mental health professionals that are culturally sensitive and able to speak the immigrants language?

Dr. Hochang Benjamin Lee: This is a great question that many cross-cultural, clinical investigators are wondering about how to maximize available human resource of bilingual health workers. By definition, there are few. One approach is to train bilingual "community health workers" under supervision of nurses and doctors as a gate keeper. Another approach would be to work with unique aspect of each ethnic community. Among Koreans, utilizing churches as the outreach center has been successful.

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District Heights, Maryland: Not a question but a comment. I am a member of the Mental Health Committee at the church that I attend in MD and I feel this issue not only deals with immigrants but residents who were born and raised here as well. And they, like many immigrants, are less likely to seek help with their mental health issues. The real issue is that it takes a caring community to assist those that have problems. We have to help them get help for themselves.

Dr. Hochang Benjamin Lee: You are absolutely right. Stigma and lack of knowledge about mental health issues are pervasive in all communities. I admire your church for having a committee devoted to this issue. For immigrant communities, however, there are additional barriers such as language issues, lack of insurances, etc.

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Oklahoma City, Okla.: I feel stigma of mental illness is the greatest barrier, that prevents many individuals of marginalized communities from seeking treatment for mental helth problems. What can we in the grassroots efforts do to get past the preceived stigma?

Dr. Hochang Benjamin Lee: At the grassroots level, I believe continuing to bring these issues to the public attention is the greatest service to the community. At the same time, working with the locally influential people (e.g. politicians and government officials) to direct resources to these areas that are often neglected in our community. It is very hard to make a career for many well-intentioned health workers and researchers in minority health issues at the moment.

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Baltimore: How can immigrant clinicians and therapists overcome the fact that while they are immigrants from other countries, they have been trained in their profession in the Western education system? Many theories and "evidence-based practices" do not apply to non-Western cultures.

Dr. Hochang Benjamin Lee: While they are trained in the Western educational system, they often have developed special rapport with the patient population. There is one study, I recall, that matched the ethnicity of the clinician and the patient improved compliance and outcome of mental health services. We also need a way of training these ethnic physicians in these intracacies of detecting culturally specific symptoms.

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Raleigh, N.C.: Dr. Lee,

I work with several communities in the Midwest that have significant new populations of Latino immigrants. Domestic violence and substance abuse in some of the households contribute to mental health needs, but fear of discovery of undocumented immigration status is compounding the challenge of effective engagement of these immigrants by the mental health and social service systems that are committed to offering help and support.

What strategies can you suggest that might help these communities to effectively connect with those who are in need?

Frank Rider, Federation of Families for Children's Mental Health

Dr. Hochang Benjamin Lee: I am not sure how to answer this question about the plight of illegal immigrants and their mental health issues. General health of illegal immigrants in U.S. is a major issue in our society that is beyond my knowledge. Whether this is a responsbility or burden to our health system is also beyond me as well.

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Baltimore: This is more of a comment. I am a psychology major and one class assigned the book "The Spirit Catches You and You Fall Down". Although I cannot remember the author, the book was an account of a small village family from Asia coming to the US and the chaos in diagnosing their young daughter who suffered from seizures. The dialect they spoke was so rare, it took months to find a translator. In the meantime, the family brought in herbalists and even a healer from their village to heal the girl and refused to give her medications from the doctors. The translator said the family had a name for her illness which translated into "the spirit catches you and you fall down." It was a very true account of what both sides face when dealing with this issue such as mistrust and science versus religion.

Dr. Hochang Benjamin Lee: Language barrier is indeed the greatest barrier in terms of access to health care for minority groups. Imagine that your symptoms are not physical and only mental, and that you can only express it to the physician in a foreign language. In psychiatry, this language barrier becomes much more magnified than any other medical fields.

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Washington, D.C.: Dr. Lee, I am helping to develop a federally funded online curriculum, Promoting Healthy Mental Development. The curriculum is geared toward primary care providers (PCPs) who work with children and their families.

Although lots of information has been published on cultural competence, much of it is rather general. As a faculty member, do you have any specific training resources or links to suggest that might help PCPs effectively engage and support families from diverse cultures? Thank you.

Dr. Hochang Benjamin Lee: I cannot think of specific resources at the moment. However, at the state level (especially New York), there has been efforts to develop screening tools (especially depression: PHQ-9) for the primary care physicians as they are dealing with patients from various ethnic backgrounds. Outside of this, I cannot think of a consolidated effort to train primary care physicians in terms of detection, diagnosis, treament, and follow-up for mental disorders among minority patients.

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Raleigh, NC: I work for a United Way agency that assists people with HIV as a bilingual client advocate. One of the most important parts of my job with Latino clients is informing and convincing them that here in the U.S. HIV can be lived with and that it is nothing to be ashamed of. I take the same road with mental illness. I explain to them that it is very common here in the U.S. to treat depression or whatever other mental health issue is going on. I also let them know that going to a therapist is common in this culture and can be very helpful. I try to get them away from the idea - common in the Latino culture - that mental health meds and therapy is for folks that are crazy.

Dr. Hochang Benjamin Lee: Thank you for your comments. Indeed it is very important to address the stigma issues. National Alliance on Mental Illness (NAMI) website also lists specific resources for Spanish-speaking patients.

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Washington, DC: The question of mental health and immigrants is obviously spurred by the Va. Tech. tragedy last spring. The mentally ill student who killed 33 people that day had been through an interview with a mental health social worker in Dec. 2005. During that interview, would it be normal for the interviewer to ask questions like whether the student had ever been diagnosed with a mental health condition or if he had ever received medical treatment/medication for a mental illness?

Dr. Hochang Benjamin Lee: Appropriateness of the privacy questions depends on the context of the interview. If it is within a clinical context or counseling context, it would be appropriate. Could you tell me more about it?

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Dr. Hochang Benjamin Lee: Thank you.

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Philadelphia, Pa.: I am reminded of the episode of "The Sopranos," where art imitates life, on how it is considered weakness that an Italian American would get mental health assistance, and Tony Soprano has to gently break the news before the rumor gets out that he is seeing a psychiatrist. I like how Paulie Walnuts comes to his rescue where just about the most psychotic character in TV history admits that even he "has issues." My question: I don't know if you saw this scene, but did it accurately portray the feelings of some people in the Italian American community that only weak people get help (the show is supposedly written with an air of authenticity by people who grew up in New Jersey)? Even if you did not see this, does television portrayal of people like Tony Soprano seeing a psychiatrist help send a message to the viewers that it is alright to get help, and maybe TV helps break down some of these barriers?

Dr. Hochang Benjamin Lee: I haven't been keeping up with the HBO specials, but mass media does play a major role in lifting the stigma attached to mental disorders. I certainly hope that the biological aspect of psychiatric disorders continues to be highlighted in the mass media to emphasize the need for health services.

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Philadelphia, Pa.: What mental health programs? They've been cut so much, how does anyone get help? There are parents in Philadelphia asking judges to adjudicate their children because the only available youth mental health programs are in the correctional facilities? Thus, for your purposes, I guess it would be harder for immigrants who have difficulty understanding our mental health operations to even understand these intracacies where people have to bend the system to get help?

Dr. Hochang Benjamin Lee: Yes, I agree.

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