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Time after time, Joy Luangphaxay would see Asian-American seniors come to the nonprofit Hamilton-Madison House accompanied by their adult children and complain to therapists about their difficulty falling sleeping. That they’d had many a restless night.

But Luangphaxay, of the social services group based in New York City, said there would be more meaning behind their words. Often, she told HuffPost, the seniors were going through anxiety and depression but just weren’t sure how to vocalize it.

Mental health is a touchy subject in the Asian-American community, especially for the senior population. But experts say it’s time to start talking about it. Asian-American senior women have the highest suicide rate of any racial group, according to the American Psychological Association. Yet Asian Americans are almost three times less likely than their white counterparts to seek mental health services.

The subject has remained out of the spotlight in part because Asian-Americans hesitate to speak about their mental health issues from fear of being shameful, experts say. They’re calling for more culturally understanding mental health strategies available in more languages to help the community, as well as a better understanding within the community that mental health problems are normal.

“These elders are dealing with trauma as a result of living in war-torn countries, witnessing political upheaval or adapting to life in a foreign land.”

Immigrants and refugees suffering in silence

“Our elders are often forgotten,” Dr. Dj Ida, executive director of the National Asian American Pacific Islander Mental Health Association, told HuffPost. “And after what many of them have been through, they deserve to lead a life with respect and dignity ― particularly those who have experienced trauma. They’ve been through a lot ― they’ve been through hell and back.”

A large number of senior Asian Americans deal with mental health issues, with more than 50 percent in New York City alone expressing symptoms of loneliness or depression, according to a 2016 report. Many of those at risk for depression and suicide are immigrants and refugees, Ida explained. These elders are dealing with trauma as a result of living in war-torn countries, witnessing political upheaval or adapting to life in a foreign land.

Among them are refugees who survived Cambodia’s Khmer Rouge regime that left more than 1.5 million people dead, many buried in mass graves. There are also those who struggle to deal with memories of communist “re-education” and the Vietnam War. And some senior immigrants still have trauma from adjusting to the U.S. Even if they’ve lived in the country for a while, they can still feel separated by language and culture, Ida said.

“They generally don’t say ‘I’m depressed.’”

Seniors who are isolated are also at risk for depression and suicide. When elderly Asian Americans lose their support systems, like a spouse, or don’t have adult children to care for them, they often find it tough to grapple with their situation, experts say.

“This can be particularly difficult for elders who were raised with the cultural expectation that their children would take care of them in their old age,” Ida said.

For senior women, Ida suspects, the suicide rate is particularly high partly because they tend to outlive men. And if they depended on their husbands for support, but no longer have it, they become especially vulnerable.

Admitting you need help isn’t part of Asian culture

But getting help for mental health issues isn’t so simple for these seniors. Sometimes the problem is cultural: Many feel afraid their illnesses will cause them to “lose face” or bring shame to their families, according to a mental health report by Joyce P. Chu and Stanley Sue of Palo Alto University.

“Many Asian Americans tend to avoid the juvenile justice or legal system, mental health agencies, health services, and welfare agencies, because the utilization of services for certain problems is a tacit admission of the existence of these problems and may result in public knowledge of these familial difficulties,” the report notes.

Both Ida and Luangphaxay also said elders fear becoming a burden to their families, and will hide feelings of sadness and loneliness to avoid it.

Those who do hint at having mental health issues often explain their symptoms in physical terms rather than psychological ones due to the stigma around getting help, Luangphaxay said.

“They generally don’t say ‘I’m depressed,’” she explained, adding that many will go to a primary care doctor to explain these ailments. “They’ll address [mental health issues] in more physical ways like, ‘My stomach hurts,’ ‘I can’t sleep.’”

“The least we can do is make sure that in their senior years, they can lead a decent life.”

Finding solutions

However, even if these seniors with mental health issues want to seek help, they aren’t all able to get it. More than half of Asian Americans over 55 have limited English language proficiency, according to a report by the National Asian Pacific Center on Aging, and that language barrier becomes a barrier to accessing services.

Many also face financial obstacles to mental health care. One in four Asian-American seniors in New York City, for example, is living in poverty. The high rates of uninsured among some groups of seniors also affects their access to help, Luangphaxay said.

But more can be done to make mental health care a priority in the community. It starts with redefining what mental health issues are, Ida says: a normal response to stressful situations rather than a weakness. And as also stressed in Chu and Sue’s report, culturally competent help is crucial. The report explains there’s a dire need for professionals who not only can understand the world views of Asian-American seniors, but also are able to deliver mental health strategies that comply.

“Asian Americans who make the difficult decision to initiate contact with mental health providers may be more likely to stay in treatment if they encounter these culturally-congruent aspects of the care process,” the report said.

Assistance doesn’t just come in the form of a mental health specialist, Ida said. It can also mean helping individuals participate in activities they enjoy, which can reduce isolation and make them feel valuable in a way that’s culturally familiar to them.

There’s still a long way to go, and Ida says what we know about Asian-American seniors’ mental health is just the tip of the iceberg. So far, much of the available data is aggregated and doesn’t go into the unique mental health challenges among Asian subgroups. But as Asian-American mental health professionals continue to advocate for better data, Ida says, it’s important for the public to understand the situation many seniors are facing.