CHAPTER 2. LITERATURE REVIEW

Mental Health Issues Worldwide

Mental illness is a major concern affecting about 450 million children and adults

worldwide (WHO, 2001, October 4). According to the National Alliance on Mental Illness

(NAMI), mental illness it is defined as a condition affecting an individual’s thinking, mood, or

feeling, which may affect how a person is able to interact with others and their ability to function

on a daily basis (NAMI, 2016). Statistically, 1 in 4 people in the world will be affected with a

mental or neurological disorder sometime in their lifetime. Depression, bipolar affective

disorder, schizophrenia, and dementia are among the most prevalent mental illnesses found

worldwide (WHO, 2016, October 4).

Research has uncovered different causes to mental illness, such as environment (e.g.,

death, divorce), biological factors (e.g., genetics, infections, prenatal damage), lifestyle (e.g.,

living in poverty), and psychological trauma (e.g., emotional or physical abuse) (The Kim

Foundation, 2016). The impact of health issues, including mental health, found around the world

will differ due to the varying populations and the influence their environment has on them. For

example, physical circumstances (e.g., temperature, pollutants), economic conditions (e.g.,

access to health coverage, food supply), and social situations (e.g., access to care, social

networks) can affect the status of one’s health (National Academy of Sciences, 2016).

In addition to experiencing the effects of a mental health disorder, individuals will also

endure an impact to their day-to-day living (Salles & Barros, 2009), for example, not being able

to function well at home, work, or in relationships. Mental health issues will also interfere with a

person’s healthy behaviors, such as exercising, effectively coping with life stressors, getting

plenty of sleep, and avoiding any risky behaviors (e.g., alcohol and substance abuse, engaging

unsafe sexual practices) (AIDS.gov, 2014).

Mental Health Issues in the United States

In 2001, a study was conducted by the WHO that compared all diseases which discovered

that mental illness ranked as the leading cause for disability in the U.S., Western Europe, and

Canada. This study further determined that 25% of all disability in major industrialized countries

consisted of mental health cases (Bayer, 2005). The U.S. mental health crisis consists of an

alarming 43.8 million individuals – or 1 in 5 adults – who experience a mental illness in a given

year. Depression and anxiety are the common mental illnesses found affecting approximately

14.8 million and 40 million American adults ages 18 and older, respectively (NIMH, 2016).

Moreover, mental illness has been identified as one of the country’s most costly medical

conditions (Agency for Healthcare Research and Quality [AHRQ], 2014). The amount lost in

earnings for serious mental illness is $193.2 billion per year. This total encompasses both direct

and indirect healthcare-related expenditures (Insel, 2008). Direct expenditures consist of the

services/treatment, while indirect costs are those losses associated with disability caused by the

mental disorders (e.g., public expenses for disability support, cost so of loss of employment,

decrease productivity, accidents) (NIMH, 2002). A significant amount of the roughly $70 billion

of indirect costs is due in part to untreated mental illness (Bayer, 2005). One group raising great

concern by not only having a prevalence of having mental disorders but also notoriously known

to not receive appropriate treatment is the Asian population (Masuda et al., 2009).

Mental Health Issues among Asian Populations in the U.S.

The first known national study comprising of a 2,095-person sample size which analyzed

the prevalence of mental illness and treatment use among several of the large Asian-American

populations in the U.S. (Vietnamese, Chinese, and Filipino) revealed that there was an 18.1%

lifetime prevalence of any mental disorder among these groups (Hong, Walton, Tamaki, &

Sabin, 2014). The disorders that were found to be the most prevalent classes from the total study

sample included anxiety disorder (10.2%), mood disorder (9.5%), and substance use disorder

(4.0%). Within the mental disorder classes, the most predominant were major depressive

disorder (MDD) at 9.1%, social phobia at 5.3%, and alcohol abuse at 3.4% (George Washington

University, 2016).

Statistics provided through studies and surveys do not reflect the true sum of mental

health cases among Asians, as many go undiagnosed as symptoms are not recognized or

individuals intentionally choose not to seek treatment due to such reasons as stigma or

embarrassment (APA, 2016b). Researchers have identified several explanations as to why the

number of Asians experiencing mental health issues continues to grow consistently. For

example, according to a 2007 U.S. study looking at the mental health of 1.5 to 2.0 generation

Asian-American young adults from Asian Indian, Cambodian, Chinese, Indonesian, Korean,

Taiwanese, and Vietnamese descent, it revealed common stressors they experienced. These

stressors include parental pressure to succeed in academia, pressure to keep the “model minority”

stereotype, challenges living two different cultures, being afraid to discuss symptoms of mental

health issues as it is seen as taboo within their culture, and experiencing discrimination of their

cultural and racial background (APA, 2016a, para. 5). Unfortunately, data gathered from a

number of studies have aggregated all Asian subgroups into one collective group. Consequently,

this does not accurately reflect how each individual population suffers from mental illness and

identify which specific barriers are hindering their ability to seek treatment (Herrick & Brown,

1998). Therefore, public health professionals are not able to implement effective mental health

interventions to each individual Asian group.

Treatment of Mental Health Issues

Fortunately, there are several evidence-based approaches for mental health treatment,

including: (a) psychotherapy, which explores feeling, thoughts, and behaviors in aiming to

improve a person’s well-being; (b) medications, which are not used to cure, rather to assist with

managing symptoms; (c) case management, in which a case manager assists with the

coordination of necessary services for treatment and recovery; (d) hospitalization, which is used

for close observation of the person in order to correctly diagnose and prescribe appropriate

medications with their effective dosage; (e) peer support groups, where a group meeting

consisting of peers who are affected by similar disorders and experiences sharing the same goal

of recovery; and (f) complementary and alternative medicine (CAM), which includes treatment

and practices usually not related to standard care (MentalHealthAmerica, 2016). Although

treatments exist and have been proven to work effectively, many individuals who suffer from

mental illness go without help, thereby creating an epidemic of mental health issues all over the

world. One location in particular which many residents of the country experience mental illness

is the United States.

Common Barriers to Effective Mental Health Treatment in Developed Countries

There is a gap in mental health treatment seen among people living within developed

countries. Studies show a range of 44% to 70% of individuals who need care but do not receive it

(Unite for Sight, 2015). Often, stigma and discrimination have been the primary barriers

discouraging many individuals from seeking care for their mental health issues (U.S. Department

of Health and Human Services [HHS], 1999). Others include people having the fear of being

hospitalized, fragmentation of services (e.g., long wait times), the lack of mental health

professionals, having no health insurance, and overall lack of awareness about the availability of

professional help (Bernstein, 2014; Lee, Lytle, Yang, & Lum, 2010).

Many individuals underreport their mental illness or do not seek health care services due

to lack of knowledge and poor understanding about mental illness which, in turn, gives them an

inability to recognize the need for help (Unite for Sight, 2015). Barriers to treatment for

individuals that are brought on by health care providers, consist of under detection, mistreatment

(e.g., discrimination), undertreatment (e.g., not providing adequate care), lack of confidentiality,

lack of cultural understanding, language and system barriers (e.g., incongruity with cultural

needs and available services (Alegria et al., 2008; Aratini & Liu, 2015; Augsberger, Yeung,

Dougher, & Hahm, 2015; Givens & Tjia, 2002). Many studies indicated the most prevalent

impediment in the developed world was the low perceived need for treatment (Bruwer et al.,

2011).

Research on Barriers to Mental Health Service among Asians

As mentioned previously, much of the research examining the lack of utilization of

mental health services among different Asian populations have highlighted various barriers. For

instance, a study examining a large sample of 296 Asian American college students coming from

nine Asian ethnic backgrounds – Asian Indian, Bangladeshi, Burmese, Cambodian, Chinese,

Filipino, Japanese, Korean, Laotian, Nepali, Pacific Islander, Pakistani, Sri Lankan, Taiwanese,

Thai, and Vietnamese – noted a lack of acculturation was an influence on the attitudes towards

seeking professional psychological assistance (Miller et al., 2011). Another study using a student

sample of 87 Asian American high school participants revealed that youth tend to avoid seeking

help for mental health issues due to potential embarrassment (Thapa et al., 2015). Peer pressure,

family influences, and face loss concerns proved to be significant barriers among a study

population consisting of Filipino Americans, Chinese Americans, Korean Americans, Japanese

American, Native Hawaiian and other Asian American Pacific Islander groups (Masson,

Shopshire, Sen, & Iguchi, 2012).

Other studies have also made efforts to recognize barriers among Asians who have

immigrated to a developed country and show that suppression of emotions, cultural stigma,

competing cultural practices, lack of knowledge, language barriers, and cost have served as

obstacles to receive care (Kim-Goh, Choi, & Sook Yoon, 2015; Saechao, Sharrock, Reicherter,

& Kohli, 2011). One study in particular identified barriers to treatment showed that unsuccessful

referrals for Asian refugees were often due to cultural and religious beliefs, lack of coordination

from providers, lack of transportation, and language (Shannon, Vinson, Cook, & Lennon, 2015).

Benefits to Culturally Competent Health Care

Gaining a better understanding of the Asian populations, and taking into consideration

individual group’s unique set of barriers to receiving mental health services, suitable

interventions will be created to effectively treat them. This is a form of cultural competency,

which “respects the diversity in the population and cultural factors that can affect health and

healthcare, such as language, communication styles, beliefs, and attitudes, and behaviors”

(AHRQ, 2016, para. 1). In the 1970s and 1980s, counselors and psychologists were among the

first in the mental health field to bring light to cultural competency issues in organizations such

as the Association for Non-White Concerns in Personnel and Guidance and the Association for

Multicultural Counseling and Development (Sue, Zane, Hall, & Berger, 2009). It has been noted

that when healthcare providers and organizations implement culturally competent practices,

improved health outcomes are produced, including social benefits, health benefits, and business

benefits (Health Research & Educational Trust, 2013, June).

Social benefits consist of patients and healthcare providers having mutual respect and

trust between each other, promotes involvement and participation of the community in health

issues, and encourages the responsibilities of the patient and family members for good health.

Health benefits encompass improved preventive care by patients; progress with better data

collection; increase in cost savings from a reduction in the number of treatments, decrease in

medical errors, as well as a reduction in legal costs; less missed medical visits; and a drop in

health care disparities among the patient population will occur. Lastly, business benefits consist

of improvements in the efficiency of care services; a decrease in the number of barriers that slow

progress; and various perspectives, strategies and ideas are included in the decision-making

progress (Health Research & Educational Trust, 2013, June).

To reduce mental health disparities, cultural competency training has been mandated for

many agencies/ organizations in the past couple decades, including governmental sectors,

professional organizations, and various other institutions (Sue, Zane, Hall, & Berger, 2009).

Producing more research to collect useful data regarding barriers to mental health services

among Asian subgroups will contribute to the progress of knowledge to cultural competency

allowing practitioners to know what works and how strategies will work for each population.

REFERENCES

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?pageaction=displayproduct&productid=1934

AIDS.gov. (2014). What is mental health? Retrieved from https://www.aids.gov/hiv-aids-basics/

staying-healthy-with-hiv-aids/taking-care-of-yourself/mental-health/

Alegria, M., Chatterji, P., Wells, K., Coa, Z., Chen, C., Takeuchi, D., Jackson, J., & Meng, X.

(2008). Disparity in depression treatment among racial and ethnic minority populations in

the United States. Psychiatric Services, 59(11), 1264-1272.

American Psychological Association. (2016a). Data on behavioral health in the United States.

Retrieved from http://www.apa.org/helpcenter/data-behavioral-health.aspx

American Psychological Association. (2016b). Mental health among Asian-Americans.

Retrieved from http://www.apa.org/pi/oema/resources/ethnicity-health/asian-american/

article-mental-health.aspx

Aratini, Y., & Liu, C. (2015). English proficiency, threshold language policy and mental health

service utilization among Asian American children. Archives of Psychiatric Nursing,

29(5), 326-332.

Augsberger, A., Yeung, A., Dougher, M., & Hahm, H. (2015). Factors influencing the

underutilization of mental health services among Asian American women with a history

of depression and suicide. BMC Health Services Research, 8(15), 542.

Bayer, R. (2005). The hidden costs of mental illness. Retrieved from http://upperbay.org/DO%

20NOT%20TOUCH%20-%20WEBSITE/ articles/costs%20of%20 mental%20

illness.pdf

Bernstein, K. S., Cho, S. R., Nguyen, M. H. T., Chen, D., Chiu, Y., & Bang, H. (2014).

Development and psychometric testing of the mental health service barrier assessment

instrument. Journal of Theory Construction & Testing, 18(2), 40-49.

Bruwer, M. B., Sorsdalh, K., Harrison, M. B., Stein, M. D., Williams, D., & Seedat, S. (2011).

Barriers to mental health care and predictors of treatment dropout in the South African

stress and health study. Psychiatric Services, 62(7), 774-781.

George Washington University. (2016). Asian American mental health disparities & cultural

psychiatry. Retrieved from https://smhs.gwu.edu/psychiatry/sites/psychiatry/files/Sally

%20He.pdf

Givens, J. L., & Tjia, J. (2002). Depressed medical students’ use of mental health services and

barriers to use. Academic Medicine, 77(9), 918-921.

Health Research & Educational Trust. (2013, June). Becoming a culturally competent health care

organization. U.S. Department of Health and Human Services, Office of Minority Health.

Retrieved from http://www.hpoe.org/Reports-HPOE/becoming_ culturally_competent_

health_care_organization.PDF

Herrick, C. A. & Brown, H. N. (1998). Underutilization of mental health services by Asian-

Americans residing in the United States. Issues Mental Health Nursing, 19(3), 225-240.

Hong, S., Walton, E., Tamaki, E., & Sabin, J. (2014). Lifetime prevalence of mental disorders

among Asian Americans: Nativity, gender, and sociodemographic correlates. Asian

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Insel, T. R. (2008). Assessing the economic costs of serious mental illness. American Journal of

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Kim-Goh, M., Choi, H., & Yoon, M. S. (2014). Culturally responsive counseling for Asian

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Lee, H. Y., Lytle, K., Yang, P. N., & Lum, T. (2010). Mental health literacy among Hmong and

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Masson, C., Shopshire, M., Sen, S., Hoffman, K., Hengl, N., Bartolome, J., McCarty, D.,

Sorensen, J.L., & Iguchi, M. (2013). Possible barriers to enrollment in substance abuse

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Masuda, A., Anderson, P., Twohig, M., Feinstein, A., Chou, Y., Wendell, J. W., & Stormo, A. R.

(2009). Help-seeking experiences and attitudes among African American, Asian

American, and European American college students. International Journal for the

Advancement of Counseling, 31(3), 168-180.

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Miller, M. J., Yang, H. K., Choi, N. Y., & Lim, R. H. (2011). Acculturation, enculturation, and

Asian American college students’ mental health and attitudes toward seeking profession

psychological help. Journal of Counseling Psychology, 58(3), 346-357.

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CHAPTER 2. LITERATURE REVIEW

Treatments for Infertility

There are many treatments available that will help infertile couples achieve the goal of

being able to conceive a child. Intrauterine insemination (IUI) is the first step of treatment

recommended for couples who have infertility issues. Some of these issues are due to male

factors such as low sperm count, while others are cervical conditions in females, such as scar

tissue or cervical mucus problems. IUI is considered to be a less invasive and less expensive

procedure as compared to in vitro-fertilization (IVF). In most cases, IUI is done in conjunction

with ovulation stimulating medications such as Clomid (Clomiphene Citrate) or Gonadotropins

(e.g., follicle-stimulating hormone [FSH], luteinizing hormone [LH], and human chorionic

gonadotropin [HCG]) (American Pregnancy Association, 2017, February 4).

The procedure for IUI consists of essentially injecting the male sperm into the woman’s

uterus to assist the sperm in reaching the fallopian tubes. This process still requires the sperm to

fertilize an egg on its own. Before the injection, the sperm sample is washed so that the semen is

seperated from the seminal fluid. Once the wash is completed, the actual insemination is

performed approximately at the time of ovulation, which is closely monitored by a infertility

specialist. This procedure can usually be done in minutes and provides minimal discomfort for

the patient. The next step is to watch for signs of pregnancy. This is usually determined by a

simple blood test. Some of the risks of IUI include becoming pregnant with multiples by

hyperstimulation of the ovaries from the medications mentioned above. In addition, there is a

small risk of infe

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