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We don’t talk about these things in our family.

I wanted to see someone, but my mom doesn’t believe in therapy.

It is all in his head.

Dr. Punit Mahendru frequently hears such statements from her South Asian patients. She is a Clinical Psychologist at Kaiser Permanente in Fremont, CA.

“Unfortunately, many of my patients reach out only as a last resort,” Dr. Mahendru laments. “They keep things under wraps until they are no longer able to, by which time it’s invariably too late to provide effective help.”

According to the Mayo Clinic, the term mental illness encompasses a wide range of mental health disorders that affects mood, thoughts, emotions, and behavior. This includes depression, anxiety disorders, schizophrenia, eating disorders, and addictive behaviors.

Everyone feels stressed, anxious or depressed from time to time, but when symptoms are frequent and begin to affect our ability to function normally, it should be considered an illness that requires care and treatment, like any physical ailment.

The signs and symptoms of mental illness are wide-ranging; they include sadness, excessive fear, worry, guilt, large mood swings, excessive anger, tiredness, sleep issues, confused thinking, withdrawal from friends and activities, the inability to deal with people, daily problems and stress, change in eating habits, alcohol or drug use, paranoia, hallucinations, hostility or violence, and suicidal thinking. Specialists offer treatment that is usually a combination of psychotherapy and medications.

Americans these days have a better understanding, and are more accepting, of mental health issues. However, South-Asian culture, background, and upbringing play an important role in shaping beliefs and attitudes toward mental health. They affect how we think of emotional difficulties, how we cope, and our willingness to seek help.

As the South-Asian population in the US grows, so do the stressors of life in this population. Depression and anxiety are common in the community, and addiction to alcohol and drugs is a growing issue. Bipolar and other mood disorders are also prevalent.

“Any gathering of 20 South Asians is highly likely to have at least a couple of people impacted by one of these issues,” says Dr. Mahendru, “but our families do not have a model for how to deal with them. Seeking professional help for mental health is the last resort; they try all sorts of other things first. Parents want to protect the child and the family image at all costs. By ruling out professional help, by hiding, accepting, and tolerating these issues, they unwittingly become enablers, allowing the problem to become acute.”

A root cause of anxiety among children and young adults is the conflict between the need to conform to their peer group on the outside, and the family traditions and values at home, leading to a buildup of stress and depression.

For seniors in the community, Dr. Mahendru says, “the key mental-health issue is depression due to loneliness, especially when physical limitations restrict abilities and movement.” Seniors then lack both the physical and psychological energy to reach out to the community. They often do not seek help for it. Friends or family need to be watchful to compensate, assist, and enable them to fulfill their interests and needs.

Dr. Jyothsna Bhat, another clinical psychologist, agrees there’s a stigma associated with mental illness in the South-Asian community. While some have integrated and assimilated into society and follow Western-oriented health beliefs and practices, many are guided by traditional beliefs, biases, and fears. They believe mental conditions are not “real” illnesses, attributing them to overactive imaginations or hysteria. Depression, anxiety or stress are written off as problems for the weak-minded, or as ways to seek sympathy or attention.

US-born children of immigrants are frequently influenced or affected by their parents’ views. Some neurobiological studies also suggest that cultural differences result in different basic mental processes that drive different responses to mental illness. A cross-cultural understanding of mental illness is needed, with nuanced interpretations of how people perceive their illnesses.

The National Alliance on Mental Illness (NAMI) reports that “second-generation children of immigrants can face challenges in cultural identity, struggling to balance their familial ties to traditional cultural values, with the pressure to assimilate to mainstream American society. Additionally, an emphasis on community identity can create a strong burden of expectations, which may increase stigma and shame if a person doesn’t meet those expectations.”

According to the AAPI American Health Forum, young South Asians, and women, in particular, have higher suicide rates relative to the general US population, with family conflict, depression, anxiety, and domestic violence as contributing factors.

A higher percentage of South-Asian youth between 15 and 24 exhibit symptoms of depression compared to the national average. Their report cites several cultural roadblocks to recognition of, and treatment for, depression and other mental illnesses, including religious belief in suffering as a punishment for past deeds; cultural stigma associated with mental illness; family hierarchy, relationships, gender roles, and expectations that create barriers and hamper open communication.

Language differences further hamper communication, pointing to the need for mental health practitioners of the same ethnic origin who might be accepted and trusted more readily, because of their familiarity with the culture and social norms.

With recent advances in genetics and neuroimaging, scientists are just beginning to understand the underlying biology of mental disorders. Genes linked to schizophrenia have been identified; abnormalities in growth and under-connectivity among brain regions have been tied to autism. Researchers have connected physiological processes in one specific area of the brain with severe depression and have demonstrated that deep-brain stimulation of the area can alleviate symptoms in some individuals. It is, however, accepted that personality traits and environmental, behavioral, and social factors are very important factors contributing to mental illness.

We as a community need to get rid of this stigma, eliminate the taboo and normalize acceptance of mental illness for what it is—an illness, just like heart trouble or diabetes. We need to build awareness, educate people on the issues, and provide support and understanding to those in need.

Dr. Mahendru urges initiating conversations at different levels within the community to meet these objectives. She also has this parenting advice: “When your children are young, it is essential to balance discussions about achievement and productivity with the importance of emotional wellbeing and balanced life for the child. Fostering and maintaining good, open communication with [your] children is crucial. The moment your child receives the message that he or she is not good enough for you, and does not meet your expectations, he or she will withdraw and shut down communication.”

Dr. Mahendru urges the medical community to collaborate for integrating care and treatment of mental and physical illnesses, and for primary-care physicians to routinely have a conversation about mental health with their patients. To the rest of us, she says, “encourage people to share stories of how they overcame issues of mental health. More openness is a key to getting rid of this stigma in our society.”