Chinese American man with high risk of psychosis

Treatment team’s impressions

Clinical high risk (CHR) syndrome refers to the prodromal phase before a full psychotic disorder. As one of the three subcategories of CHR, genetic risk and deterioration (GRD) prodromal syndrome is defined by having a genetic risk for psychosis (first-degree relative with a psychotic disorder or meeting criteria for schizotypal personality disorder) and a recent decline in daily functioning equivalent to a 30% drop in Global Assessment of Functioning rating.¹ Due to Bill’s family history of psychosis, new difficulties in self-care, psychotic-spectrum symptoms, and declining social/executive function, he meets criteria for GRD prodromal syndrome. In addition, major depressive disorder should be considered on his differential diagnosis.

Dr. Emily Wu

Bill has not received a diagnosis of acute psychosis, and instead is judged to be in the CHR spectrum for psychosis, because of his level of insight that the occasional perceptual disturbance and abnormal thought content are in his own mind. Since 26% of individuals with CHR in mainland China² and 35% in the general U.S. population develop fully psychotic symptoms within 2-3 years, Bill’s current presentation warrants secondary preventive care (early intervention) to promote improved clinical outcomes. Given the high rates of comorbid depressive and anxiety disorders among individuals with CHR, Bill’s mood symptoms and passive suicidality also require psychiatric intervention. The treatment team raised three questions, which are answered below.

1. How can we understand Bill’s and his family’s resistance to mental health treatment?

Chinese Americans tend to access mental health services at a lower rate than that of the general U.S. population.³ They also tend to exhibit elevated discontinuation from mental health care, compared with non-Latino whites.⁴ Since first- and second-generation Chinese Americans have similar use rates, it is likely the barriers to care are not immigration specific but also related to factors that endure across generations, including culture-related aspects. These include cultural concepts of illness and how to interpret prodromal symptoms such as Bill’s, stigma and interpersonal shame regarding mental illness and psychiatric treatment, and value orientations such as self-reliance, avoidance of direct expressions of interpersonal conflict, and family privacy.

Dr. Francis Lu

Exploring cultural concepts of distress common among Chinese American families might help clinicians address barriers to mental health service use and persistence. For example, Chinese Americans tend to emphasize the physical-symptom components of psychiatric problems, partly because of mind-body holism – which combines physical and psychological symptoms into cultural syndromes and idioms of distress – and partly because of concerns about stigma and shame regarding mental health symptoms. Hence, they are more likely to seek help from primary care clinicians for psychological distress before any mental health provider. Many Chinese Americans interpret mild to moderate psychological distress as “mental weakness” or “excessive thinking” (xiang tai duo), which does not require clinical evaluation. In this view, only alarmingly bizarre or disruptive behaviors warrant formal psychiatric treatment.

Dr. John Sargent

Some Chinese parents perceive psychosocial stressors, including hardships, interpersonal conflicts, and academic burdens, as understandable triggers for symptoms that clinicians would classify as schizophrenia or attenuated psychosis syndrome.⁵ Those views of illness can be associated in the Chinese American community with delayed diagnosis and intervention for emerging psychiatric disorders.

Social stigma regarding mental illness is pervasive in many Chinese American communities. Stigma hinders service use, to avoid shame and save the family’s “face.” Although many Chinese Americans acknowledge the efficacy of biomedical treatments for mental illness, they also remain concerned about enduring shame in their communities if they access those services.⁶ In line with collectivistic values traditionally held by many Chinese Americans, individuals tend to turn to relatives for help first and keep mental illness confidential within the family group to avoid disgracing the family name.⁷ Hence, social stigma in the Chinese community can be a key barrier to early detection and early intervention for youth at high risk of psychosis.

Dr. Roberto Lewis-Fernandez

Culturally influenced cognitions, emotions, and values also might contribute to underuse of formal mental health services in this population. Many Chinese Americans perceive the roots of mental illness in a lack of willpower and the unwise indulgence of morbid thoughts. In these communities, direct communication of strong emotions can be discouraged – in the name of maintaining harmony, collective interests, and tolerance.⁸ Hence, many Chinese Americans find Western models of psychotherapy that focus on intrapsychic conflicts and/or intense interpersonal emotions incongruous with their treatment expectations. Psychiatric interview processes that explore gloomy or disturbing thoughts can be perceived as disquieting and antithetical to the goals of treatment. In addition, some individuals rooted in collectivist communities would rather keep personal psychological problems private within the family than seek counseling from an expert who is an out-group stranger.