Following onset of a mental disorder, LEP Latino and Asian Americans are less likely to perceive a need for treatment or seek treatment, particularly specialty care, and experience longer duration of untreated disorder than their EP counterparts. Although LEP is associated with age, nativity, lack of insurance, and lower education, LEP remains associated with lower likelihood of lifetime treatment after adjustment for these and other variables, highlighting its importance as an independent contributor to disparities in care for mental disorders.
Interpretation of these findings is subject to several limitations. The community-based sample excludes institutionalized individuals who may be more likely to have severe disorders and to receive treatment. Likewise, some disorders including bipolar disorder and schizophrenia, which tend to be severe, were not assessed. Data on the onset of disorders and service use were based on self-report and collected retrospectively, potentially subject to limited recall and disclosure. Similarly, English language proficiency was based on self-report and not directly measured.
Examination of the impact of language proficiency on quality of care was limited by the small number of individuals with 12-month disorders accessing past-year treatment and the low overall rate of minimally adequate care. Fewer than 20% of Latino and Asian Americans with current mental disorders receive care that potentially meets minimally adequate standards, highlighting the overall lack of quality care for these individuals.
Several findings address potential explanations for the association between language proficiency and mental health treatment. Most Latino and Asian Americans with lifetime mental disorders did not identify a need for treatment. Consistent with prior research, 32, 33
perceived need for treatment was strongly related to service use. Lack of recognition was much more common among LEP than EP Asians with a less pronounced but similar pattern among Latinos. Low perceived need may arise from factors including tendency to somatize distress,34
cultural differences in explanatory models of illness that raise the threshold for identifying distress as a disorder,34
reliance on family or social networks for emotional problems rather than healthcare providers,35, 36
or limited mental health literacy (which may restrict understanding of what constitutes a mental disorder or the role of treatment).36
LEP individuals may reside in rural or poor areas with few mental health professionals,37
and thus have less access to information about mental health through patient education or public health campaigns.38
Whether and to what extent these factors contribute to low perceived need among ethnic minorities is important to determine, given that perceived need for care predicts eventual treatment.
Across all groups, more individuals accessed services (32.9% – 54.2%) than identified a need for such care (16.4% – 41.4%), suggesting that self-recognition of a mental health problem is only one pathway to care for Latino and Asian Americans. Social networks may play an important role in decisions to access care. Including problem recognition by family or peers with self-recognition, the combined rate of recognition (24.0% – 51.9%) approximated the rate of treatment, although there were still many individuals who accessed care without recognition by self or others. Individuals may have been brought to care as minors, received involuntary care, or sought care for other types of problems (e.g., somatic symptoms) and were referred by a professional to services. Further research of the process of help-seeking for mental disorders among LEP individuals would be warranted to investigate these possible explanations.
Results did not support the hypothesis that indicators of attitudinal barriers to treatment would be greater among LEP individuals. Contrary to expectations, the only significant association was among Latinos, for whom LEP is associated with less embarrassment about treatment. In multivariate analyses, embarrassment and discomfort were not significant predictors of lifetime treatment, suggesting that other factors such as low supply of mental health providers in their areas may be more critical in explaining the low rates of treatment among LEP individuals. Conversely, dimensions of stigma such as self-stigma and personal stigma were not measured in this study, although some evidence suggests the latter may be most relevant to perceived need and help-seeking for mental disorders.39
Analyses of barriers to treatment were limited by the small number of participants with 12-month disorders who accessed past-year treatment. Many more LEP than EP individuals delayed seeking treatment due to a language barrier even after recognizing a need, although this pattern was not statistically significant. In contrast, the majority of participants who received care were able to communicate with their providers in their own language. Because language concordance between participants and providers was not measured, we could not assess whether LEP participants were more likely to be treated by bilingual providers. Nationally, nearly 90% of LEP Latinos who have regular primary care use language services (interpreters or bilingual providers) to obtain care, suggesting that language services are of vital importance in facilitating access to medical care.5
It will be important to determine the extent of language barriers to treatment for mental disorders and examine how language services may impact help-seeking among LEP individuals.
Future studies of quality of care and language barriers within treatment utilizing clinical samples are warranted. Specifically, examination of the impact of patient-provider communication and language concordance in influencing the quality of care is an important direction for future research. Likewise, understanding whether mental health care quality differs between primary care and specialty settings for LEP patients would be valuable given that ethnic minorities are more likely to seek mental health care in primary care 7, 40
and evidence suggesting these settings provide lower quality of care for mental disorders.29, 41
Findings from this study indicate that limited English proficiency is an important factor in disparities in access to lifetime mental health care for Latino and Asian Americans with mental disorders. Moreover, results highlight that language proficiency is associated with perceived need for care, which in turn predicts lifetime treatment for mental disorders. Together, these findings raise the possibility that interventions that target access to care and mental health literacy among LEP communities may provide opportunities to reduce disparities in mental health care.