Using data from a large, statewide survey, we found that LEP individuals in California were less likely to receive needed mental health services compared to those who spoke English when race/ethnicity and other associated factors, such as poverty, insurance status, U.S. nativity, and length of time in the United States were controlled. Because individuals who do not speak English well in California and elsewhere in the United States are largely concentrated in Asian/PI and Latino racial/ethnic groups, LEP may contribute to racial/ethnic disparities in mental health care.
Targeted examination of LEP within the Asian/PI and Latino subgroups revealed a dramatic difference in receipt of needed mental health care based on English language abilities. In the Asian/PI subgroup, for example, bivariate analyses revealed that 56% of Asian/PI respondents who spoke only English received needed mental health services, the highest rate of service observed in any subgroup studied. In contrast, only 11% of Asian/PI respondents who did not speak English received needed services. Similarly, multivariate analyses showed that Asian/PI respondents who did not speak English had 85% lower odds of receiving treatment compared to those who spoke only English, when other variables were controlled. These findings are consistent with a small, but important area of recent research indicating that studying access to care by race and ethnicity without considering English language proficiency among Latino10
and Asian/PI groups13
may provide a misleading portrait of access barriers to mental health care.
Our study had several limitations. We only addressed access to treatment. It is important to bear in mind that the receipt of mental health treatment does not guarantee quality of care, which is an important component in successful treatment outcomes. Previous studies have found that racial/ethnic minorities, and those who do not speak English well, generally receive poorer quality mental health care.2
However, for all racial/ethnic groups, receiving mental health treatment is associated with better outcomes than receiving no treatment at all.2
It is not clear from this study whether differences in service use are due solely to access barriers. Racial and ethnic groups differ in important ways in their desire for mental health services. Our analyses indicate that Asian/Pacific Islanders are less likely than members of other racial/ethnic groups to report a need for mental health services. These results suggest that cultural differences in definitions of mental illness or strategies for dealing with emotional distress may also affect utilization patterns. The lack of a robust measure of clinical need, as opposed to self-identified need, for mental health services may further obscure this issue in the analyses presented here. Further consideration of these factors may provide additional avenues for reducing disparities in mental health treatment.
Furthermore, LEP itself may not be the critical measure. Instead, it may be a marker for other variables that were unmeasured or not well measured in this study. Acculturation is of particular concern in relation to definitions of mental illness, stigma, and perceptions of mental health care. Without a broader range of specific acculturation measures, it was not possible to completely separate the role of language from other related factors. Interestingly, in multivariate analyses, both proxy measures of acculturation were statistically significant in all three study samples until LEP variables were added, suggesting that English language skills may be responsible for some variation in access to mental health care previously attributed to acculturation when English proficiency was not considered.
This study also confirms that English proficiency is certainly not the only factor leading to mental health disparities. In the analysis including all respondents, race/ethnicity variables were significant even when English language proficiency was included. Many access barriers have been identified as possible contributors to racial/ethnic disparities in receipt of mental health care, such as unequal access to insurance, stigma, racism, discrimination, differences in communication styles, and mistrust and fear of treatment.2
Of these variables, only insurance status was controlled in this study. Further study should consider the impact of these variables and how they are associated with LEP.
In the United States, the majority of individuals who do not speak English well are members of racial/ethnic minority groups. As LEP Americans make up a significant, and increasing, portion of the U.S. population, this creates a significant problem for our health system to address. The results of this study have implications for both practice and policy. In the practice setting, extra effort is warranted in primary care settings to explore the mental health needs of patients with limited English proficiency. These patients are particularly likely to seek assistance with mental health problems from primary care providers, yet language barriers may limit discussion of mental health and emotional issues. Furthermore, the limited availability of linguistically appropriate mental health services may make referrals particularly challenging.
In the policy arena, efforts to address health disparities, specifically, as well as more general efforts to increase access to mental health care, should address language barriers. Some policy instruments targeting language barriers are already in place, implemented at the clinic level and beyond. Recent state legislation, such as California’s “threshold language policy”,21
and existing federal laws, particularly Title VI of the Civil Rights Act of 1964,22
are relevant to this issue. However, the full implications of these laws are not always realized with respect to mental health care. Also, problems exist with the effective implementation of policies concerning language barriers, ranging from lack of awareness about patients’ rights to difficulty providing interpreters in all mandated situations for all possible languages. Despite these difficulties, the implementation of policies targeting language barriers to mental health treatment shows promising results.21
Such innovative efforts on state, local and clinic levels will hopefully be expanded with the goal of reducing racial/ethnic disparities in mental health care.