During the past two decades, numerous studies in cross-cultural anthropology, social sciences, and psychiatry with regard to Asian cultures have collectively provided a better understanding of how sociocultural influences and biological factors affect Asian-American mental health. Unfortunately, this body of new knowledge has not yet been fully incorporated into psychiatry residency training programs. Many graduating residents have not acquired adequate basic knowledge and skills to reliably diagnose and treat Asian-American patients. The recent advances in the areas of anthropology, social sciences, and ethnopsychopharmacology in the care of Asian-American patients have seldom been translated into systematic teaching of these subjects in psychiatric training curricula.

In this article we propose a biopsychosociocultural approach to understanding and caring for Asian-American patients. Consistent with the format of published residency curricula written by members of the American Psychiatric Association's committees on minority and underrepresented populations (1—4), we synthesize the information about mental health care for Asian-American patients and propose a curriculum that includes Asian-American demography, immigrant experience, and socioeconomic and cultural issues. In addition, we outline educational objectives and learning experiences and discuss special considerations in implementing such a curriculum in a general residency training program.

There are several reasons to include an Asian-American psychiatric curriculum in psychiatric residency training programs.

First, the Asian-American population is the fastest-growing minority group in the United States. The past two decades have seen the number of Asian Americans in the United States nearly double in each decade. This trend of population growth is likely to continue in the 21st century. Asian-American population in 2050 is projected to be approximately 37.6 million (5). Psychiatrists who are planning to practice in states along the West and East Coasts of the United States and in metropolitan areas where a substantial number of Asian Americans reside need to learn how to provide reliable assessments and treatments for this population.

Second, Asian Americans constitute one of the most diverse minority groups in the United States. There are at least 43 Asian American and Pacific Islander subgroups in the United States (6). Although many of these subgroups share an important cultural heritage, there are striking diversities among them. Cultural factors such as religions and cultural beliefs (7—9), degree of acculturation, socioeconomic adaptation, educational achievements (10—12), patterns of immigration (13), traumatic experiences (14,15), family dynamics (16,17), and help-seeking behaviors (18—20) strongly influence patterns of aberrant behaviors and psychopathology of each group. Biologically, Asian-American psychiatric patients have been found to respond to psychotropic medication in ways that differ from responses in Caucasian, Hispanic, and African-American groups as a result of their genetic enzymatic makeup (21—23). Knowledge about these issues will assist psychiatrists in providing culturally competent care.

Third, recent advances in communication technology, the expansion of the global economy, and ease of travel have drawn peoples from different continents closer. Future psychiatrists will be called upon for assessment and treatment of people of various cultural backgrounds in different geographic settings. Because Asians comprise more than 50% of the earth's population, knowledge of Asian-American issues becomes significantly more relevant for psychiatrists who may assume global practices (18).

Fourth, several public policy papers and educational reports have highlighted the importance of addressing sociocultural diversity in health care in the U.S. society. In 1978, the President's Commission on Mental Health, Subpanel on Asian and Pacific Islanders, urged the incorporation of Asian-American and Pacific Islander issues in the training curriculum of mental health professionals (24). In 1991, the Council on Medical Education and Career Development of the American Psychiatric Association emphasized the requirement that residency training in psychiatry ensure competency in the care of patients from diverse cultural backgrounds and to provide residents with knowledge of American culture and subcultures (25). In 1993, the American Medical Association's Directory of Graduate Medical Education Programs recommended integrating cultural issues into residency training programs and teaching residents how to conceptualize illnesses from biological, psychological, and sociocultural perspectives (26). Finally, the 2001 Accreditation Council for Graduate Medical Education (ACGME) Program Requirement for Psychiatric Residency Training required that didactic curriculum include topics such as ethnicity, especially when they are relevant to the programs' local communities.

Although Asian Americans and Pacific Islanders comprise more than 43 ethnic groups (6), limitation of space allows us to focus on only the largest Asian groups as categorized in the 1990 and 2000 U.S. Census (27). Yet we hope that an understanding of sociocultural factors in these groups can be extended to other Asian groups as well.

Overview of the Asian-American Population

In 1970, the Asian-American population was reported to be 1.5 million. By 1980, this population had exploded to 3.5 million. Between 1980 and 1990, it grew by 95% to 7.2 million. In Census 2000 this group reached 10.2 million (Asian alone) to 11.9 million (Asian alone or in combination with other races) (28). Most Asian Americans are concentrated in metropolitan areas and in populous states such as California, New York, Hawaii, Texas, New Jersey, Illinois, Washington, Florida, Virginia, and Massachusetts. Los Angeles County, California, and Honolulu County, Hawaii, are the U.S. counties with the largest numbers of Asian Americans. Some locales in Hawaii and California have shown a significant rise in Asian-American population. In Honolulu, Kauai, and Maui, for example, Asian Americans comprise more than 50% of the population. Thirty-six percent of San Francisco's population and 22% of the population of the "Silicon Valley" (vicinity of Santa Clara, CA) consist of Asian Americans (5).

Immigration Patterns

Asian Americans have come to the United States at different periods, by different routes, and under different circumstances. Furthermore, U.S. domestic and foreign policies and the global political and economic events have strongly influenced Asian-American immigration and population growth in the United States. Some came for economic reasons, others for freedom and safe haven. Many Asian Americans who fled their home countries suffered traumatic experiences caused by famine, war, political imprisonment, and persecution. In general, Asian-American immigration history can be roughly divided into three periods:

The Period of Pioneer Asian Immigrants (1849–1945):

The Chinese were the first Asians to immigrate to the United States, beginning in 1849. Next came large numbers of Japanese immigrants, beginning in 1880 (16,17,29). Waves of Filipinos began to come to Hawaii and the West Coast during the 1900s (13). These early Asian immigrants came to escape the economic hardships and political turmoil in their home countries and to seek better lives for themselves and their families. They were employed as hand laborers by sugar plantations in Hawaii; by farms in Oregon, Washington, California, and Hawaii; by gold mines during the Gold Rush; and by railroad companies during the construction of the U.S. transcontinental railway. Economic and political changes in the United States led to imposition of discriminatory laws and harassment of these first Asian Americans, a pattern that was to continue for nearly 100 years. Several Exclusion Acts and Immigration and Naturalization Acts from 1866 to 1945 forbade the Chinese and Japanese and other Asian immigrants to bring their wives and children, to possess land, or to become American citizens. These discriminatory policies resulted in a population decline among Asians in the United States, a shattering of their traditional family structures, and a disruption of the balance of genders in their communities. Many Asians were prevented from obtaining jobs commensurate with their skill levels. The most traumatic discriminatory event occurred with the implementation of Executive Order 9066 in 1942 that forced more than 100,000 Japanese Americans into internment camps during World War II. The traumatic concentration camp experiences have had a lasting emotional effect on the first (Issei), second (Nisei), and later generations of Japanese Americans (13,29,30).

The Period of Reunion and Reform (1945–1965):

World War II provided an opportunity for great numbers of Asian Americans to demonstrate their loyalty to the United States. Despite harsh treatment from the government, thousands of Chinese, Filipino, and especially Japanese Americans joined the military to fight (13). Asian Americans' participation in the Allied war campaign against Nazi Germany and Japan led to a more favorable attitude toward Asians in America. The U.S. Congress eventually repealed the Chinese Exclusion Acts in 1943. The subsequent enactment of the War Brides Act in 1945 allowed many Chinese and Japanese wives of Asian-American and American servicemen to come to the United States. These reunions resulted in the restoration of family units and relieved the disruption of family structure experienced by earlier Asian communities. The Refugee Relief Act in 1953 facilitated the acceptance of Chinese refugees who had escaped from Communist China. Many of these refugees were highly educated Chinese (13,17).

The Period of Economic Immigrants and Political Refugees (1965–present):

The civil rights movements of the 1960s had a significant beneficial influence on U.S. immigration policy (13). The Immigration and Naturalization Act Amendments of 1965 equalized immigration quotas between the Eastern and Western hemispheres, established a fair system for admission of immigrants, and allowed especially young, well-educated, professional worker immigrants from the Philippines, Korea, and India to come to the United States (13,31—33). These new skilled immigrants assisted in the expansion of the U.S. economy during the late 1960s and the 1970s. From 1980 to the present, the number of Asian Indians in the United States has increased by more than 100%. This new wave of South Asian immigrants comprises mostly family members of the Asian Indian professionals who came to the United States during the 1960s (33,34).

This period also witnessed the influx of war refugees and political refugees. At the end of the Vietnam war in 1975, hundred of thousands of Indochinese refugees fled the Communist forces. Indochinese refugees from Vietnam, Cambodia, and Laos experienced untold trauma both during the war and in being uprooted from their war-torn countries. They risked their lives on dangerous journeys to escape Communist regimes. After the massacre in Tiananmen Square in June 1989 and subsequent crackdown on democratic movements in China, many Chinese scholars and students sought political asylum in the United States. Recently, many Hong Kong immigrants chose to come to the U.S. for fear of living under the Chinese Communist regime when the British government returned Hong Kong to China in 1997 (35). Refugees who seek asylum in the United States face tremendous stress in adjusting and adapting to life in America (11,13,36—41).

Socioeconomic, Educational, and Cultural Variables

Asian Americans are a large, heterogeneous group whose subgroups differ in socioeconomic status, educational achievements, and cultural characteristics. Other important cultural identity variables include age, gender, sexual orientation, and religious/spiritual beliefs. These variables have influenced Asian Americans' acculturation processes, development of mental health problems, help-seeking behaviors, access to health care, and compliance with treatment.

In terms of socioeconomic status, Asian-American families, as a whole, have higher median family income ($51,205) than all other U.S. ethnic groups ($40,816), primarily as a result of higher educational achievement and having more family members in the labor force (5,28). However, as individuals, the average per capita income of Asians is lower than national per capita income. Recently the poverty rate of Asian Americans decreased to 10.2% in 1999 from 12.5% in 1998 (28). In 1990, information on poverty rates showed variation among specific groups. The poverty rates were 6% for Filipino, 7% for Japanese, 10% for Asian Indian, and 14% for Chinese and Korean Americans. The Southeast Asian Americans were the poorest, with 64% among Hmong, 43% among Cambodian, 35% among Laotian, and 26% among Vietnamese individuals (27).

Although Asian-American cultures highly value educational achievement, its attainment differs widely among different Asian groups. The percentage of completion of high school or higher is 88% for Japanese, compared with 31% for Hmong. At the college level, 38% of Asian Americans receive a bachelor's degree or higher, compared with 20% of the total population. Asian Indians have the highest achievement rates, and Cambodians, Laotians, and Hmong have the lowest (27).

Asian-American subgroups share many characteristics but also have great diversity. They speak different languages and follow various religious beliefs. The majority of Asian-American subgroups are influenced by two distinct civilizations: Chinese and Indian cultures. Chinese Confucian, Buddhist, and Taoist philosophies exert a strong influence on social, family, and individual values, literature, art, and languages among Japanese, Korean, Vietnamese, Mien (Laotian), and Hmong traditional societies. The Japanese, Korean, and old Vietnamese (chu nom) scripts were derived from Chinese ideographs. The current Vietnamese romanized written language was not developed until the 17th century, when French and Portuguese missionaries introduced it for use in evangelism (36). The Mien and Hmong have no indigenous written script. They rely on oral history and tradition to transmit their culture from one generation to another. Their shamans keep their intellectual and cultural records in written Chinese characters (38). Cambodian and Laotian cultures are deeply rooted in Asian Indian civilization. The Cambodian written language is derived from Sanskrit script, and the Laotians use Pali script (37,38).

In terms of religion, many Chinese, Japanese, Koreans, and Vietnamese worship their ancestors and believe in Mahayana Buddhism. Many Japanese Americans follow Shintoism and Zen Buddhism. Filipino Americans are mostly Catholic. More than 70% of Koreans in the United States are Protestant Christians. The Hmong and Mien mostly believe in animistic and supernatural causes. The Cambodians and Laotians are followers of Brahmanism of the Hindus and Theravada Buddhism (37,38). Among Asian Indians, Hinduism is the major religion (33,42). The Pakistanis are mostly followers of Islam.

In summary, Asian-American groups have many common socioeconomic, educational, and cultural characteristics, but they also show distinctive differences. Understanding Asian-American diversities will help to dispel stereotypes about Asian Americans as a homogeneous group. Each Asian-American ethnic group has its own unique characteristics, and each person must be assessed individually.

By the end of their residency training, all residents should successfully acquire the following essential knowledge, skills, and attitudes concerning the psychiatric care of Asian-American patients and their families. (For suggested core readings for use in teaching, see t1.)

Knowledge

The resident should be able to demonstrate an adequate understanding of the following:

Skills

Psychiatric residents should demonstrate competence in the following skills in working with Asian-American patients:

Attitudes

The residents should demonstrate the following through their behavior and demeanor:

Didactic Experiences

Didactic courses are essential in introducing Asian-American issues to residents. These courses can be implemented either through a separate cross-cultural track (in a series of seminars on cultural psychiatry that includes Asian-American cultures along with issues of other minority groups) or by the incorporation of Asian-American content materials into existing core curricular topics. Both approaches will be expedient ways of teaching Asian-American issues as well as other cross-cultural psychiatry issues.

For example, a seminar on the impact of immigration and acculturation on mental health could highlight the unique aspects of the experience of Asian Americans. Asian-American cultural beliefs could be introduced in the psychiatric assessment and evaluation seminars. These incorporations help the residents understand how Asian-American patients use cultural beliefs to explain their psychiatric symptoms, help-seeking behaviors, and compliance with treatment. A course on psychopathology could include frequently encountered culture-bound syndromes in Asians.

Asian-American women's issues can be a part of seminars on gender and topics affecting women. The cultural aspects of the roles of Asian-American women, Asian-American relationships in domestic violence, and various psychosocial adaptation stresses of Asian-American women should be given particular consideration in discussions of women's issues.

Asian-American gay and lesbian issues can be incorporated in seminars on concerns for minority groups or sexuality.

Psychotherapy seminars should include the topic of Asian-American individual and family life cycles in Asian cultural contexts, as well as Asian alternative therapies and healing systems. Issues of transference and countertransference with Asians in individual and group therapies should be discussed (68,92).

Special consideration should be given to Asian-American survival of mass violence and its unique features in seminars about PTSD. Many psychiatric patients of this group have developed severe PTSD symptoms with psychotic features that are resistant to treatment (43,93,94).

In seminars on biological treatments, discussions should include alternative treatments in Asian-American communities, especially herbal medicines and the interaction of herbal medicines with psychotropic medications. Asian-American genetic differences as related to pharmacogenetics, pharmacokinetics, and pharmacodynamics can be incorporated in a course on psychopharmacology. Special emphasis should be placed on the sensitivity of Asian-American patients to psychotropic medications and their vulnerability to severe side effects.

Courses on substance abuse can incorporate Asian-American concerns. The rise of alcohol and drug use among Asian-American youth is an alarming, emerging issue in Asian-American communities and should be addressed within the topic of substance abuse.

Aside from seminars, other educational formats can be useful didactically. Videotapes and films on Asian-American cultures are powerful teaching tools to explore sensitive issues. When feasible, field trips to Asian-American community clinics are good ways to enhance learning and exposure to Asian-American cultures. Journal clubs can provide up-to-date literature reviews of Asian-American mental health problems. Grand Rounds are excellent opportunities to invite local and national speakers to present challenging and innovative materials on Asian-American patient issues.

Clinical Experiences

Clinical components of training should integrate knowledge of Asian-American cultures with practical, hands-on experiences.

As pointed out in the demographic data, the majority of Asian Americans are clustered on the West and East Coasts and in metropolitan areas in the United States. Thus, many psychiatric residents from other parts of the country may not have opportunities to work with Asian-American patients during training. In situations where the Asian-American population is small, consideration should be given to the use of elective training in locations where Asian-American patients can be seen. Some residencies and programs with a specific Asian-American focus are the psychiatric residency programs at the University of California, San Francisco (95); the University of California, Davis, in Sacramento; UCLA-Harbor in Los Angeles; the University of Hawaii in Honolulu; the Elmhurst Hospital Center at the Mt. Sinai Medical Center in New York City; and the Intercultural Psychiatric Program at the Oregon Health Sciences University in Portland (96).

Faculty Supervision

Asian and non-Asian faculty members who are knowledgeable in cross-cultural psychiatry and experienced in working with Asian-American patients should be recruited to supervise residents on Asian-American mental health issues. Qualified faculty members can serve as role models or mentors for residents. They can also function as sources of information and expertise for consultations or case discussions on Asian-American psychiatric patients. Asian-American residents and non—Asian-American residents should have equal opportunities to work with Asian-American patients. Faculty supervisors should be culturally sensitive to residents' cultural backgrounds to help them overcome their biases regarding Asian-American patients, if present, and to address transference and countertransference issues (97,98).

Resident and Program Evaluation

Residents' input into program evaluation is essential to ensure that educational goals are achieved.

Several special considerations need to be addressed to facilitate the implementation of this curriculum.

We have proposed a model curriculum that provides the residents with basic knowledge, clinical skills, and behavioral parameters for working with Asian-American patients. Support from program directors and departmental leadership is essential to ensure success in implementation.

This work was adapted from A Psychiatric Residency Curriculum for Learning About Asian-American Issues, prepared by F. Lu, N. Du, A.C. Gaw, and K. Lin for the Committee of Asian-American Psychiatrists, American Psychiatric Association, 2000.