Initial behavioral health assessment of Asian Americans. Part 1. Keyprinciples

Journal List > West J Med > v.176(4); Sep 2002

West J Med. 2002 September; 176(4): 233–236.

PMCID: PMC1071739

Initial behavioral health assessment of Asian Americans. Part 1. Keyprinciples

Henry Chung,¹ Dustin Nguyen,² and Francesca Gany³

¹Pfizer, Inc., 235 East 42nd St., New York, NY 10017

²NYU Downtown Hospital, 170 William St, New York, NY 10038-2649

³New York University School of Medicine, 550 First Ave, New York, NY10016-2002

Correspondence to: Dr Chung,hchung/at/pol.net

Summary points

In the initial assessment, put your patient at ease, clarify your patient'sgoals in seeking help, and communicate concepts in simple and clear terms
During history taking, ask about use of traditional medicines andpharmaceutical products
Always screen for substance abuse or misuse and assess suicide risk
Be aware that Asian patients with psychiatric disorders may exhibit“stoicism,” denying sadness or depressed mood, or otherpsychiatric symptoms
Maintain privacy by reassuring patients that what they discuss with youremains confidential
Tailor explanations in a way that is appropriate to Asian culture; giving abio-psychosocial explanation will resonate with the Asian“mind-body” view of illness

In this article, we provide practical information on how to perform theinitial assessment of an Asian American patient you suspect may have abehavioral health problem. In the article that follows, we show how theseprinciples can be put into practice.

INTERVIEWING SKILLS

The following interviewing techniques, well described and put forth byKates and Craven,¹have been modified for use with Asian American patients.

1 Put your patient at ease

Show your patient that you have a holistic view of health, which isfamiliar to Asian patients
Acknowledge that patients and families often use many different types ofinterventions (eg, social, pastoral, alternative, Western) to improvesymptoms
Be willing to work with concerned families, and with their ideas of healthand healthy behavior, in caring for your patient
If the patient appears reluctant to discuss emotional issues, you may say,“You look tense or uncomfortable. Is this hard to talk about?”Acknowledging tension may help to ease it. A follow-up statement, targeted toa less insightful patient, can be, “We know that stress and emotionaltroubles affect physical health, and I believe that addressing these concernscan be helpful in making some of these symptoms decrease in intensity or goaway.”
Maintain a respectful physical distance from the patient and do not beoverly concerned about making eye contact
To show respect and to avoid spreading germs to the physician, some olderAsian patients cover their mouths when speaking. If this practice interfereswith your assessment, gently let your patient know that you appreciate thepolite gesture but discontinuing it would help you to understand theircondition better
Always use formal titles (Mr, Mrs, etc) when addressing adults unless theyrequest that you do not

2 Clarify your patient's goals

Once the problems are assessed, discuss the goals of the visit and/orfuture visits to determine whether you and the patient agree about what needsto be done
Ask about emotional or psychological concerns that you consider important.Even if they deny them initially, patients often make use of these connectionslater in the course of treatment

3 Communicate clearly

Use clear, supportive, and nonpejorative statements or questions to enhancethe patient's ability to understand your diagnostic rationale and treatmentplan
Tell the patient, “Your symptoms could indicate a new heart problem,or they might mean you have a nervous condition; both could explain yoursymptoms. Let's do some simple but important tests for your heartfirst.” Avoid statements such as, “You may have a heart conditionthat I must rule out or it might all be in your head.”
If you as a health care provider have continual difficulty discussingpsychiatric issues with Asian patients, you may need to assess your own biasesor conceptions about treating mental disorders or treating these disorders inAsians. For example, perhaps the avoidance of discussing such issues is anattempt to avoid embarrassing or stigmatizing your patient. In fact, manypatients are relieved when asked about them. Patients may present with asomatic complaint as a “ticket to admission” to a clinician'soffice, but they will avoid emotional complaints out of respect for thepractitioner. Inquire sensitively about possible psychological issues and showcomfort in doing so; otherwise, patients may sense your reluctance and denysymptoms
Always avoid using jargon. Even knowledgeable patients may differ in themeaning they apply to words such as “palpitations,” which may beinterpreted as anything from irregular heart rhythms to fast heart rate tochest pain

TAKING THE HISTORY

Elements of the basic history are shown inbox 1. With Asian Americanpatients, two specific cultural issues are important to remember.

Box 1

Key elements in taking a history

First, although the patient and family are requesting symptom relief andexpert consultation, they often have their own ideas about the etiology andtreatment of the symptoms. For example, in many East and Southeast Asianpatients, some psychiatric symptoms are thought to result from an imbalancebetween yin and yang, the complementary life forces. Manytraditional treatments attempt to restore that balance instead of eradicating“disease.” It is common for patients to have seen severaltraditional practitioners and to have tried acupuncture, several courses ofherbal remedies, possibly qi-gong, and meditative exercises beforetrying antidepressants and other psychotropic medicines.

Second, some patients will have obtained pharmaceutical products fromrelatives and friends in their homelands that have helped others with similarsymptoms. These include herbal pharmaceutical preparations, antipsychoticmedication, benzodiazepines, and medicines that are not available in theUnited States.

Therefore, practitioners should ask patients nonjudgmentally about theiruse of alternative or traditional modes of therapy and of medicines obtainedfrom their country of origin.

MENTAL STATUS EXAMINATION

Many Asian patients, particularly immigrants and older individuals, exhibit“stoicism” during this assessment. Many will deny feelings ofsadness or depressed mood despite meeting many of the criteria for a personwith a depressive disorder.

The examination involves assessing:

Appearance and behavior
Affect (the emotions you observe) and mood (emotions thepatient reports)
Communication patterns and processes (whether the patient is able todiscuss clearly several domains of daily life—at home, at work, withfriends, etc)
Thoughts In particular, assess for unusual thoughts, perceptions, orexperiences, such as hallucinations (hearing or seeing things) and delusions(organized paranoid or grandiose thoughts that have an extremely lowprobability of truth and are outside the patient's cultural norm). If thepatient admits to having hallucinations, ask whether these might be ancestralfigures and spirits and whether they have heard these voices in the past. ManyAsian cultures emphasize ancestral worship and filial piety, and some types ofperceptual experiences may be a culturally appropriate adaptation to stress.If hallucinations occur in the absence of other psychotic symptoms, watchfulwaiting and periodic reassessment should be adequate
Cognitive and intellectual functioning Are patients aware of theirsurroundings? Is short term and long-term memory impaired?
Risk for self-harm and harm to others (see below)

Assessment of suicidal risk

Many practitioners have difficulty assessing suicide and homicide risk outof concern that:

asking about suicidal or homicidal ideation increases the risk of thepatient acting on these thoughts
they will open a “Pandora's box,” lengthening the visit from 20minutes to an hour
if the assessment shows that the patient is at risk for suicide, they willnot have the knowledge or management skills to decrease that risk

These concerns can be addressed by using a structured approach to assessingsuicide risk (see box 2)

Box 2

Assessing suicide risk in Asian patients: a structuredapproach

What factors increase suicide risk?

History of self-harm
History of impulsiveness
Any current drug or alcohol use
Severe depression with anxiety, or psychosis
A sense of hopelessness
Poor or little reliable social support

PHYSICAL EXAMINATION AND INVESTIGATIONS

Taking a structured history and performing a thorough mental statusexamination confirm your role as an expert to the patient and give you thenecessary clues to develop a working diagnosis and a treatment plan.

The physical examination and laboratory studies can be helpful if yoususpect and want to rule out some common physical causes of fatigue, lowenergy, anxiety, and poor concentration, all common symptoms of depression.Laboratory testing may include a complete blood count to rule out anemia,blood chemistries and urinalysis to assess for the presence of diabetes orrenal disease, B₁₂ and folate vitamin levels, and thyroid functiontests. Other studies, such as electrocardiography, electroencephalography, andCT scanning of the brain, should be reserved for patients with clearindications of organic disease.

PATIENT CONFIDENTIALITY AND FAMILY INVOLVEMENT

Many Asian patients are deeply concerned about the nature of chartdocumentation and the importance of privacy in discussions related to mentalhealth conditions. At the same time, some patients ask that family members beinvolved in treatment planning. There are a few things you can do to reassureyour patient:

Tell the patient that all discussions with them are confidential
Explain that, if the patient prefers, you can limit chart documentation todescriptions of symptoms and treatment but sparing in details of psychosocialdifficulties
Involve a family member whom the patient trusts to increase the therapeuticalliance between you and your patient. Always ask the patient for consent todo this, however, before approaching that individual. Also, reserve some timeat each encounter with the patient to speak privately about any confidentialmatters

TREATMENT PLANNING

Reaching agreement on the nature of the problem

Once an assessment is completed, a mutual understanding about the nature ofthe problem and how it can be treated needs to be reached.

Asian patients may be particularly resistant to accepting a psychiatricdiagnosis and are more comfortable when an organic or physical one is offered.Try to tailor your explanations so that a realistic treatment plan can befollowed.

Tailoring explanations

If your patient has an explanation for symptoms, take your direction fromthe patient first. For example, a new immigrant may say that her symptoms area result of work stress, that she is working a 7-day week, has had little timefor ancestor worship, and worries that bad luck may be responsible. You maysupport the patient's notion that work stress could be a precipitating orrelated factor. In addition, tell her you understand how important ancestorworship might be in this new environment and encourage her to find time forthis activity. Emphasize, however, that regardless of the cause, the patientcan benefit from treatment. This approach validates the patient's assessmentand values but also sets up the expectation that treatment can help.

If possible, avoid defining the problem as an illness while developingalliances. For example, if a patient's symptoms can reasonably be attributedto a recent death, loss, or job change, try to help the patient understand thesymptoms in that context. This approach decreases patient stigma. Even ifpatients require medication, this need can be explained as part of the processof healing, adjustment, and recovery from whatever life stresses they areexperiencing.

If the patient's ability to function is impaired, an explanation of thediagnosis and its relationship to their symptoms is warranted. We have foundthat giving a bio-psychosocial explanation for mental illness (seebox 3) is acceptable given theholistic view of health and illness held by many Asians.

Box 3

Explaining mental illness to Asian patients: the Chinatown HealthClinic experience

CONCLUSION: A PRIMARY CARE APPROACH TO TREATMENT

Primary care is an important setting for the mental health care of Asianpatients. Primary care practitioners have the opportunity to providehigh-quality, culturally sensitive care. Inbox 4, we summarize oursuggestions for providing such care.

Box 4

Suggestions to providers of primary mental health care for Asianpatients

Figure 1

Amelia Bateman

Notes

Competing interests: Henry Chung is Medical Director, Depression andAnxiety Disease Management Team, Pfizer, Inc.

References

Kates N, Craven M. Managing Mental Health Problems: APractical Guide For Primary Care. Seattle: Hogrefe and Huber;1998.