By Avantika Kapadia -UNC CEED Summer Fellow 2022

Avantika Kapadia (@KapadiaAvantika) was a CEED Summer Fellow for 2022. One of her major research interests centers on the intersection between obsessive-compulsive disorder (OCD), eating disorders and social anxiety and ways in which treatment outcomes, dissemination and accessibility can be improved for these conditions.

Seeking treatment and gaining access to mental health services is always difficult, but more so for certain ethnic communities. Add to that a lack of research in mental health conditions amongst racial and ethnic populations, sociocultural factors and the prevalence of stigma and stereotypes and it appears apparent why accessing mental health services is frequently so challenging for these groups!

In South Asian communities, mental illness is often “taboo”- either avoided at all costs or rationalized and attributed to a physical condition. It is also not uncommon for therapeutic treatment to be met with distrust and suspicion. As a South Asian woman, living and working in a psychiatric hospital in India, I have been able to observe first hand the struggles of gaining access to mental healthcare, attributed to both the mental healthcare system and societal factors and determinants. In addition, there are plenty of misconceptions surrounding mental health conditions, particularly when it comes to eating disorders.

Initial research in eating disorders put forth the belief that these conditions were only seen in White women from industrialized and Westernized countries- however, now we know that this is not true. Eating disorders have been observed across race, ethnicity, geographical locations, genders and religion (Schaumberg et al., 2017) yet, individuals of colour are much less likely to be treated, screened and referred for eating disorder treatment (Marques et al., 2011). Similarly, although research in eating disorders amongst all ethnic groups is little, it is especially lacking amongst Asian populations (Soh & Walter, 2013) and referrals to eating disorder care are significantly low in South Asian groups (Abbas et al., 2010). While this is certainly changing for the better, South Asian populations continue to face barriers associated with eating disorder treatment, that prevent them from acquiring the help they need and subsequently maintain health disparities.

In South Asian communities, a major barrier to treatment is the struggle in accessing mental healthcare services and provisions. Within the US and abroad, Asian groups, including South Asians seem to use mental healthcare much less, likely due to the societal stigmatization associated with mental illness (Fountain & Hicks, 2010; Arora et al., 2016). Moreover, treatment is usually sought only when symptoms become severe, unmanageable and physically visible and even then, South Asians tend to first visit primary care providers (PCP) who may not have the adequate training, knowledge or skills to detect psychiatric illnesses (Shidhaye & Kermode, 2013; Leung et al., 2011). There are also factors associated with difficulties even when seeking treatment- racial discrimination, prejudice, lack of knowledge regarding cultural experiences and treatment services only provided in English (Quay et al., 2017). These aspects further limit access to mental healthcare and may dissuade South Asians from utilizing or continuing with treatment.

There are also specific cultural factors that may be driving treatment disparities in South Asians; these include poor understanding amongst South Asians about mental illness, not perceiving eating disorders as a serious issue and viewing disordered eating behaviours as a physical condition.

South Asians report reduced knowledge and understanding about EDs in their communities, with younger individuals more aware of these conditions than parents and grandparents. This tends to result in feelings of isolation and difficulties in communicating experiences. In addition, eating disorders are reported as “less serious” than other mental health conditions like anxiety and depression, due to the misconception that eating disorders can be easily tackled by consuming more or less food. Similar to other mental illnesses, eating disorders are also viewed as “physical problems” determined by weight loss or gain and treatment for these conditions are met with suspicion and doubt (Wales et al., 2017). Moreover, in more traditional South Asian families, family members such as parents, grandparents, uncles and aunts exercise a great deal of control over younger members, particularly daughters- this restriction may even extend to seeking treatment, if treatment is not deemed to be required or fit by these family members.

The mental health stigma and stereotypes seen in South Asian communities also contribute immensely to treatment barriers and may largely prevent South Asian individuals from finding and utilizing mental health services. In several instances, South Asians may commonly resort to mental illness stigma where those with mental health conditions and all their family members are alienated and perceived as “socially contaminated”. Thus, treatment may not be sought for the fear of causing community stigma towards family. South Asians may also engage in the “model minority stereotype” which notes that Asians believe they have qualities that increase their chances of success, as compared to other groups- these qualities include dedication, good work ethic, obedience and focus on education (Chaudhry & Chen, 2019, p. 155; Gupta et al., 2011) Such a stereotype could result in feelings of failure or “giving up” if treatment is sought, subsequently resulting in South Asians delaying treatment or avoiding treatment all together (Yip et al., 2021).

Despite these barriers to treatment currently faced by South Asian populations, there are numerous changes at community and service level that can be implemented to improve treatment access. Community level changes could include- providing accessible information about eating disorders to South Asian communities (for example- pamphlets distributed at local hospitals, schools, libraries) developing community education programs and involving South Asian media (for example- having mental health professionals on local radio programs and TV shows, mainly for South Asians, discussing eating disorders).  Service level changes could involve increasing awareness about eating disorders amongst general practitioners/PCP’s, including cultural sensitivity training and encouraging a focus on cultural competence for clinicians and healthcare professionals, working in collaboration with and encouraging feedback from patients and making greater use of family based interventions (Nazir, 2016). Additionally, increasing research in eating disorders amongst South Asians might aid in decreasing treatment barriers, improving treatment access and enhancing interventions for these groups.

References

Abbas, S., Damani, S., Malik, I., Button, E., Aldridge, S., & Palmer, R. L. (2010). A comparative study of South Asian and non-Asian referrals to an eating disorders service in Leicester, UK. European Eating Disorders Review : The Journal of the Eating Disorders Association, 18(5), 404–409. https://doi.org/10.1002/erv.1033

Arora, P. G., Metz, K., & Carlson, C. I. (2016). Attitudes towards professional psychological help seeking in South Asian students: Role of stigma and gender. Journal of Multicultural Counseling and Development, 44(4), 263–284. https://doi.org/10.1002/jmcd.12053

Chaudhry, T., & Chen, S. H. (2019). Mental illness stigmas in South Asian Americans: A cross-cultural investigation. Asian American Journal of Psychology, 10(2), 154–165. https://doi.org/10.1037/aap0000141

Fountain, J., & Hicks, J. (2010). Delivering race quality in mental health care: Report on the findings and outcomes of the community engagement programme 2005–2008. University of Central Lancashire, International School for Communities, Rights, and Inclusion (ISCRI)

Gupta, A., Szymanski, D. M., & Leong, F. T. L. (2011). The “model minority myth”: Internalized racialism of positive stereotypes as correlates of psychological distress, and attitudes toward help-seeking. Asian American Journal of Psychology, 2(2), 101–114. https://doi.org/10.1037/a0024183

Leung, P., Cheung, M., & Tsui, V. (2011). Asian Indians and depressive symptoms: Reframing mental health help seeking behavior. International Social Work, 55, 53–70. https://doi.org/10.1177/0020872811407940

Marques, L., Alegria, M., Becker, A. E., Chen, C. N., Fang, A., Chosak, A., & Diniz, J. B. (2011). Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders. International Journal of Eating Disorders, 44(5), 412–420. https://doi.org/10.1002/eat.20787

Nazir, B. (2016). Improving understanding and access to treatment for eating disorders among British South Asian females [Doctoral dissertation, University of Manchester]. UoM Student Theses. https://www.research.manchester.ac.uk/portal/en/theses/improving-understanding-and-access-to-treatment-for-eating-disorders-among-british-south-asian-females(f72ae258-d1a4-425e-836d-cc011ceb6726).html

Quay, T. A. W., Frimer, L., Janssen, P. A., & Lamers, Y. (2017). Barriers and facilitators to recruitment of South Asians to health research: A scoping review. BMJ Open, 7(5), 1–14. https://doi.org/10.1136/bmjopen-2016- 014889

Schaumberg, K., Welch, E., Breithaupt, L., Hübel, C., Baker, J. H., MunnChernoff, M. A., Yilmaz, Z., Ehrlich, S., Mustelin, L., Ghaderi, A. Hardaway, A. J., & Bulik, C. M. (2017). The science behind the academy for eating disorders’ nine truths about eating disorders. European Eating Disorders Review, 25(6), 432–450. https://doi.org/10.1002/erv.2553

Shidhaye, R., & Kermode, M. (2013). Stigma and discrimination as a barrier to mental health service utilization in India. International Health, 5(1), 6– 8. https://doi.org/10.1093/inthealth/ihs011

Soh, N. L., & Walter, G. (2013). Publications on cross-cultural aspects of eating disorders. Journal of Eating Disorders, 1, 4. https://doi.org/10.1186/2050-2974-1-4

Wales, J., Brewin, N., Raghavan, R., & Arcelus, J. (2017). Exploring barriers to South Asian help-seeking for eating disorders. Mental Health Review Journal, 22(1), 40-50. doi:10.1108/MHRJ-09-2016-001

Yip, T., Cheah, C. S. L., Kiang, L., & Hall, G. C. N. (2021). Rendered invisible: Are Asian Americans a model or a marginalized minority? American Psychologist, 76(4), 575–581. https://doi.org/10.1037/amp0000857