A SYMPTOM PROFILE ANALYSIS OF DEPRESSION IN A NATIONAL REPRESENTATIVE SAMPLE OF ASIAN AMERICANS By Zornitsa Kalibatseva A THESIS Submitted to Michigan State University in partial fulfillment of the requirement for the degree of MASTER OF ARTS Psychology 2011 ABSTRACT A SYMPTOM PROFILE ANALYSIS OF DEPRESSION IN A NATIONAL REPRESENTATIVE SAMPLE OF ASIAN AMERICANS By Zornitsa Kalibatseva In the past decade, the influence of cultural factors has been examined in various forms of psychopathology. Previous research has suggested the existence of differences in depressive symptoms, diagnosis, and treatment of depression among ethnic and racial groups. In particular, Asian Americans have been found to report and experience depression differently than Caucasian Americans. Using a symptom profile approach, we explored the presentation of depressive symptoms in a national representative sample of Asian Americans and compared it to that of Caucasian Americans. This study used data from the National Latino and Asian American Study (NLAAS), a national epidemiological household study of Latinos and Asian Americans, and the National Comorbidity Survey-Replication (NCS-R), a nationally representative survey of English-speaking household residents. Depressive symptom profiles of Asian Americans and Caucasian Americans who reported depressive experiences (i.e., at-risk for depression) and who were diagnosed with Major Depressive Episode were compared in order to analyze the phenomenology of depression in these groups. Furthermore, possible factors that may impact the expression of depression, such as gender, acculturative stress, language choice, and English language proficiency were examined among Asian Americans. Findings suggested that Asian Americans reported somatic and affective depressive symptoms equally but endorsed a variety of symptoms less frequently than Caucasian Americans. Asian American men reported several symptoms more often than Asian American women. Finally, English proficient Asian Americans resembled Caucasian Americans in their manifestation of depression. ACKNOWLEDGEMENTS This research is based on data from the National Institute of Mental Health Collaborative Psychiatric Epidemiological Surveys (CPES), which provides data on the distributions, correlates, and risk factors of mental disorders among the general population, with special emphasis on minority groups. The current study utilized data from the National Comorbidity Survey Replication (NCS-R) and the National Latino and Asian American Study (NLAAS). Support for NCS-R is provided by the National Institute of Mental Health (NIMH) (U01-MH60220; R. Kessler and K. Merikangas, PIs) with supplemental support from the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute on Drug Abuse (NIDA; R01 DA 12058-05), the Robert Wood Johnson Foundation (RWJF; Grant #044708), and the John W. Alden Trust. The National Latino and Asian American Survey is supported by the National Institute of Mental Health (U01-MH06229; M. Alegria, PI), (U01-MH62207; D. Takeuchi, PI), Office of Behavior and Social Science Research, Substance Abuse and Mental Health Services Agency, and the Latino Research Program Project (PO1-MH059876). The CPES website provides information about the thousands of variables that users may access in the public use files for CPES and its constituent surveys. iii TABLE OF CONTENTS LIST OF TABLES....................................................................................................................... vi LIST OF FIGURES..................................................................................................................... viii INTRODUCTION....................................................................................................................... 1 Culture and Psychopathology.......................................................................................... 1 Culture and Psychiatric Diagnosis................................................................................... 3 Culture and Depression................................................................................................... 6 Depression among Asian Americans............................................................................... 10 Depression and Gender among Asian Americans........................................................... 15 Depression and Acculturation among Asian Americans................................................. 17 The Current Study........................................................................................................... 18 METHOD.................................................................................................................................... 21 Sampling Design..............................................................................................................22 Participants...................................................................................................................... 23 Measures.......................................................................................................................... 23 Ethnicity...............................................................................................................24 Gender................................................................................................................. 24 Depressive Symptoms......................................................................................... 25 Lifetime DSM-IV Major Depressive Episode..................................................... 25 Age of Onset of MDE.......................................................................................... 25 Duration of MDE................................................................................................. 25 Emotional Distress and Impairment.................................................................... 25 Acculturative Stress............................................................................................. 26 Language Choice................................................................................................. 26 Spoken English Proficiency.................................................................................27 Procedure......................................................................................................................... 27 Data Analyses.................................................................................................................. 27 Descriptives......................................................................................................... 28 Frequencies.......................................................................................................... 28 Chi-Square Analyses........................................................................................... 28 Independent t-test Analyses................................................................................. 28 RESULTS.................................................................................................................................... 29 Screening......................................................................................................................... 29 Descriptives..................................................................................................................... 29 Question Endorsement, Symptom Prevalence, and Symptom Profile............................ 30 Age of Onset and Duration............................................................................................. 30 Chi-Square Analyses: Race X Depressive Symptoms.................................................... 31 Emotional Distress and Impairment............................................................................... 31 iv Chi-Square Analyses: Gender X Depressive Symptoms for Asian Americans............. 32 Chi-Square Analyses: Acculturative Stress X Depressive Symptoms among Asian Americans........................................................................................................................ 33 Chi-Square Analyses: Language of Interview X Depressive Symptoms among Asian Americans........................................................................................................................ 34 Chi-Square Analyses: Spoken English Proficiency X Depressive Symptoms among Asian Americans..............................................................................................................34 DISCUSSION.............................................................................................................................. 35 APPENDIX A..............................................................................................................................50 APPENDIX B.............................................................................................................................. 53 APPENDIX C.............................................................................................................................. 84 REFERENCES............................................................................................................................ 89 v LIST OF TABLES Table 1. Descriptives for the At-Risk for Depression Sample..................................................... 54 Table 2. Descriptives for the MDE Sample................................................................................. 56 Table 3. Frequency of Depressive Symptoms among Asian Americans at Risk for Depression.................................................................................................................................... 58 Table 4. Frequency of Depressive Symptoms among Asian Americans with MDE................... 60 Table 5. Endorsement and Prevalence of Depressive Symptoms among Asian Americans and Caucasian Americans at Risk for Depression ...................................................................... 62 Table 6. Endorsement and Prevalence of Depressive Symptoms among Asian Americans and Caucasian Americans with MDE.......................................................................................... 64 Table 7. Frequency and Severity of Distress and Impairment among Asian Americans and Caucasian Americans at Risk for Depression.............................................................................. 66 Table 8. Frequency and Severity of Distress and Impairment among Asian Americans and Caucasian Americans with MDE................................................................................................. 67 Table 9. Endorsement and Prevalence of Depressive Symptoms among Asian American Men and Women at Risk for Depression..................................................................................... 68 Table 10. Endorsement and Prevalence of Depressive Symptoms among Asian American Men and Women with MDE........................................................................................................ 70 Table 11. Endorsement and Prevalence of Depressive Symptoms among Asian Americans at Risk for Depression with High and Low Levels of Acculturation Stress................................ 72 Table 12. Endorsement and Prevalence of Depressive Symptoms among Asian Americans with MDE with High and Low Levels of Acculturation Stress................................................... 74 Table 13. Endorsement and Prevalence of Depressive Symptoms among Asian Americans at Risk for Depression who Interviewed in English and in an Asian Language.......................... 76 Table 14. Endorsement and Prevalence of Depressive Symptoms among Asian Americans with MDE who Interviewed in English and in an Asian Language............................................. 78 Table 15. Endorsement and Prevalence of Depressive Symptoms among English Proficient vi and Non-proficient Asian Americans at Risk for Depression...................................................... 80 Table 16. Endorsement and Prevalence of Depressive Symptoms among English Proficient and Non-proficient Asian Americans with MDE......................................................................... 82 vii LIST OF FIGURES Figure 1. Frequency of Depressive Symptoms among Asian Americans with MDE Diagnosis and at Risk for Depression.......................................................................................... 85 Figure 2. Frequency of Depressive Symptoms among Asian Americans and Caucasian Americans at Risk for Depression............................................................................................... 86 Figure 3. Frequency of Depressive Symptoms among Asian Americans and Caucasian Americans with MDE.................................................................................................................. 87 Figure 4. Frequency of Depressive Symptoms among Asian Americans and Caucasian Americans at Risk for Depression (Significant Only) ................................................................ 88 viii A Symptom Profile Analysis of Depression in a National Representative Sample of Asian Americans Culture and Psychopathology Since the 1970’s, mental health professionals have shown an increasing interest in understanding the role of cultural factors in mental disorders. In recent decades, researchers have come to recognize that culture intervenes at various levels of psychopathology, ranging from etiology and symptom manifestation, to diagnosis and outcome (e.g., Mezzich, Kleinman, Fabrega, & Parron, 1996; Rogler et al., 1983). Culture is a multifaceted and complex concept and has been defined in numerous ways. This study will adopt a working definition by Marsella and Kaplan (2002) that captures the multiple layers and dynamics of the concept of culture: Shared learned meanings and behaviors that are transmitted within social activity contexts for purposes of promoting individual/societal adjustment, growth, and development. Culture has both external (i.e., artifacts, roles, activity contexts, institutions) and internal (i.e., values, beliefs, attitudes, activity contexts, patterns of consciousness, personality styles, epistemology) representations. The shared meanings and behaviors are subject to continuous change and modification in response to changing internal and external circumstances (p. 57). The relationship between culture and psychopathology is significant, yet often it is left unexplored or undetected in research because its complexity is difficult to operationalize. Some particular factors that may be impacted and shaped by culture are the types of physical and psychological stressors, coping mechanisms, basic personality patterns (e.g., self-concept, needs/motivations), language, standards of normalcy, deviance and health, classification of disorders, and experience and expression of psychopathology, including onset, manifestation, 1 course, and outcome (Marsella & Yamada, 2007). In addition, specific sociocultural and demographic variables have been explored in relation with mental illness, such as ethnicity, race, nationality, migration, urbanization, acculturation, individualism-collectivism, and poverty (Eshun & Gurung, 2009; Marsella & Yamada, 2007). As a result of the increased interest in the effects of culture on mental disorders, the field of cultural psychopathology emerged (Kleinman, 1988; Lopez & Guarnaccia, 2000). Most recently, Lopez and Guarnaccia evaluated the conceptualization and methodology employed in conducting cultural psychopathology research and concluded that culture interacts in all aspects of psychopathology research: measurement construction, choice of language, design of conceptual models, interaction between researchers and participants, understanding and definition of symptoms and disorders, and even the structure of the social world in which the participant lives. In 2001, the U.S. Department of Health and Human Services released the Surgeon General’s supplement report entitled Mental Health: Culture, Race and Ethnicity. The report highlighted that racial and ethnic minorities experienced “a disproportionately higher burden from unmet mental health needs” (p.3) and that there was an urgent need to understand and eliminate mental health disparities by studying the role of culture, improving access to services, and reducing barriers to treatment. At the same time, the report emphasized that “culture counts” and is applicable to all groups, not only minorities. This statement underlines the importance of “ethnocentricity”, which refers to the tendency to perceive reality from the perspective of our own cultural experience. Therefore, it is important to note that the contemporary comprehension of psychopathology as described in the current International Classification of Diseases (ICD-10; WHO, 1992) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA, 2 1994) reflects the views of health and disease that are predominantly held within Western culture (Eshun & Gurung, 2009; Kleinman, 1996; Marsella & Yamada, 2007). Thus, it is critical to recognize that current views of psychiatric nosology may be biased towards presenting the etiology, expression, diagnosis, and treatment of mental disorders in ways that are mostly congruent with Western culture. In previous research, the term Western has been used at the general and abstract level to refer to the United States, Canada, Western Europe, Australia, and New Zealand. It is important to note that when referring to Western culture, researchers concentrate mostly on the views of Caucasians or people of European descent and may not include racial and ethnic minorities’ views in the particular countries of interest (e.g., USA, Canada, etc.). Culture and Psychiatric Diagnosis One of the debates in the field of cultural psychopathology relates to the universality of normality and pathology (Canino & Alegría, 2008; Fabrega, 1996). Researchers reviewed empirical evidence on whether psychiatric disorders are etic (culture-universal phenomena) or emic (culture-specific phenomena).To illustrate this point with the case of depression, an etic view would assume that all people express depression similarly and universal diagnostic criteria can be applied without cultural biases. Conversely, an emic perspective of depression would claim that even if universal depressive symptoms existed, there is cultural variability in their expression (Fischer, Jome, & Atkinson, 1998; Hwang, Myers, Abe-Kim, &Ting, 2008). Moreover, cultural settings may define what is considered abnormal, the amount and the nature of the symptoms that are required for impairment, the course of the disorder, and the most appropriate treatment. The DSM and ICD classification systems adopt a relatively etic or universal view of mental disorders because they minimize the role of culture in the diagnostic 3 classification. At the same time, Fabrega (1996) insisted that Western European psychiatric nosology may be ethnocentric because it reflects specific histories and cultures. The conceptualization of psychiatric illness and diagnosis indicates conventions about normality and abnormality of behavior, personhood, social behavior, and nature of disease that emerged in a society. According to Fabrega (1996), the DSM-IV employed language categories and epistemologies of scientific objectivism, which suggests universality of psychiatric disorders. However, these diagnostic categories ignored the consideration of symbolic personal characteristics, such as motives, intentions, social standing, power, spiritualism, values, ethics, and life goals. The minimization of such personal characteristics automatically assumes emphasis on the conceptualization of personhood in Western societies, which accentuates autonomy, voluntarism, and individualism (Fabrega, 1996). Yet, there is evidence to suggest that other characteristics of the self may be more valued in Eastern cultures, such as interdependence, relatedness, and collectivism (Kitayama, Duffy, & Uchida, 2007; Markus & Kitayama, 1991). Therefore, clinicians need to be cognizant of, and attend to, to the inherent cultural biases in our current psychiatric nosology. Leong (2009) proposed that there may be certain threats to cultural validity in psychiatric assessment that may affect the diagnostic process. Leong argued that cultural validity is similar to the concept of population validity (Bracht & Glass, 1968) and is an important corollary of psychometric validities (e.g., face, construct, predictive, and concurrent). The concept of cultural validity refers to the effectiveness of a measure or the accuracy of a clinical diagnosis to address the existence and importance of essential cultural factors. Such cultural factors may include values, beliefs, experiences, communication patterns, and epistemologies inherent to the clients’ cultural backgrounds (Solano-Flores & Nelson-Barber, 2001). Threats to cultural validity in 4 assessment and diagnosis are due to a failure to recognize or a tendency to minimize cultural factors in clinical assessment and diagnosis. Leong suggested that there were several factors that may serve as sources of threats to cultural validity in the assessment of mental disorders: (1) pathoplasticity of psychological disorders, (2) cultural factors influencing symptom expression, (3) therapist bias in clinical judgment, (4) language capability of the client, and (5) inappropriate use of diagnostic and personality tests. The concept of pathoplasticity of psychological disorders refers to the variability in symptoms, course, outcome, and distribution of mental disorders among various cultural groups (Westermeyer, 1985). Some examples of pathoplasticity are the different prevalence rates of depression across countries and ethnic/racial groups in the same country (e.g., Kirmayer & Jarvis, 2005). The second threat to cultural validity is the influence of cultural background on symptom expression. For example, Ryder et al. (2008) found difference in symptom expression where depressed Canadian outpatients reported more psychological symptoms than depressed Chinese outpatients. The third threat to cultural validity is the therapist’s bias in clinical judgment. For instance, Li-Repac (1980) asked five White and five Chinese American therapists to rate the same Chinese and White patients. The White therapists rated the Chinese clients as more inhibited and depressed with less social poise/interpersonal capacity, while the Chinese therapists assessed the White clients as more severely disturbed than the White therapists did. The fourth threat to cultural validity is the language capability of the client since language may serve as a barrier to effective communication and may be used as a proxy of acculturation (Leong, 1986). Lastly, the inappropriate use of clinical and personality tests may also be a source of threat to cultural validity, since the majority of such tests were developed and tested with predominantly White participants. In order to solve the existing problem of threats to cultural validity, culture must be incorporated into the diagnostic process. 5 Kirmayer (2005) proposed a framework that integrated culture, context, and experience in diagnosis. Kirmayer emphasized the need to incorporate cultural diversity in diagnosis if psychiatry strived for a nosology that could be used across social and cultural contexts. The author argued that psychiatric diagnosis considered symptoms as a direct result of psychopathology. However, cognitive social psychology and clinical ethnography have provided evidence that symptom expression and experience are embedded in culturally based systems. In fact, there are many competing schemas that can define how physiological disturbances will be organized and expressed based on one’s knowledge about symptoms, explanatory models of illness and health, and societal norms. Therefore, psychiatric nosology and clinical assessment should consider the impact of society and culture (e.g., family, workplace, health care system, and global political and economic factors) on psychopathology and symptom expression. Research shows that society and culture may influence various mental disorders, but one of the most researched ones has been major depression. Culture and Depression According to the World Health Organization (WHO), major depression is reported as the leading cause of disability worldwide and the fourth largest contributor to the global burden of disease (WHO, 2005). Major depression is a chief public health problem and it is projected to be the second largest contributor to global disease burden by 2020 (Murray & Lopez, 1996). The lifetime prevalence rates of depression range from 10% to 25% for women and from 5% to 12% for men (APA, 1994). Depression has been identified in all countries and among all ethnic and racial groups that have been studied (Kessler et al., 2003; Miranda, Lawson, & Escobar, 2002; Weissman et al., 1996). 6 The ubiquity and the serious consequences of major depression call for prompt actions in increasing our understanding of its etiology, phenomenology, assessment, diagnosis, and treatment. It is believed that culture plays an important role in the aforementioned processes and affects the way depressive symptoms are experienced and expressed, as well as described and measured. Research on the subject of culture and depressive experience has lead to a wide array of theoretical and clinical publications (e.g., Kirmayer & Jarvis, 2006; Kleinman, 2004; Kleinman & Good, 1985; Marsella, 1987; Sartorius, 1973; Tanaka-Matsumi & Marsella, 1976). In their book Culture and Depression, Kleinman and Good (1985) bring together anthropologists, psychologists, and psychiatrists to present a unique perspective that challenges the purely biomedical conceptualization of depression. Cross-cultural studies of depression may provide evidence for its universality but they also offer data of cultural variations in depressive mood, symptoms, and illness. Therefore, the authors urge researchers to delve into the various aspects and nuances of depression that may have been left unexplored, such as expression of bodily complaints, meaning of variations of affect (e.g., dysphoria, sadness, emptiness, etc.), and particular cultural idioms describing mood and distress. The Western conceptualization of mental health relies on the notion of Cartesian dualism, considering the mind and the body as separate entities. The division of “psyche and soma” in Western medicine assumes that psychology and psychiatry deal with disorders of the mind and emotions, while somatic medicine treats the body and its disorders (Angel & Williams, 2000). However, this partition has proven to be quite controversial since all mental disorders according to the DSM and ICD classifications include somatic components. For instance, the current diagnosis of depression relies on both psychological and somatic symptoms. Interestingly, previous research implies that Westerners often describe depression in relation to concepts like 7 guilt, individualism, decision-making, and self-control (Marsella, 1987). In addition, the affective aspect of depression has been suggested to receive more emphasis in North American samples than in Asian samples (Ryder et al., 2008). In contrast, Eastern experience of depression may reflect the integration of body and mind, which would explain the widespread occurrence of somatic symptoms in place of affective ones or the lack of differentiation between the two realms (Kleinman, 2004; Ryder, Yang, & Heine, 2002). The chief symptom in major depression in the West is considered to be sadness or depressed mood. However, in many societies people who suffer from major depression do not complain primarily of sadness. The symptoms that stand out for those people may be changes in appetite, headaches, backaches, stomachaches, insomnia, or fatigue (Kleinman, 1996). Such symptoms and complaints would take people suffering from depression to their primary care doctor and they may be less likely to be diagnosed with a mental disorder. According to the DSM-IV (APA, 1994), the presence of sadness, or a lack of interest (anhedonia), is necessary for a major depressive episode diagnosis to be considered. Parallel with that, other current depressive symptoms in the DSM-IV are drastic changes in appetite or weight, sleep problems, psychomotor retardation or agitation, fatigue or low energy, difficulty concentrating or indecisiveness, worthlessness or inappropriate guilt, and suicidal ideation, plan, or attempt. In order to receive a Major Depressive Episode (MDE) DSM-IV diagnosis, at least five symptoms need to be endorsed for a period of two or more weeks most of the day, nearly every day. It is worth noting that some of the DSM-IV symptoms are directly related to Judeo-Christian religious concerns with guilt, sin, sloth, despair, and worthlessness (Marsella & Kaplan, 2002). However, these presentations may not be equally applicable in other cultures that embrace different religions and societal norms. 8 Marsella (1980, 2003) proposed that one of the main cultural influences of depressive experience and disorder is the concept of personhood held by a particular cultural tradition. On one end of the continuum, cultures are characterized by individuated self-structures, abstract languages, and a lexical mode of experiencing reality. In such cultures, individuals have “objective epistemic orientation,” express affective, existential, cognitive, and somatic symptoms, and experience an increased sense of isolation, detachment, and separation. In contrast, cultures at the other end of the continuum emphasize unindividuated self-structure, metaphorical language, and imagistic mode of experiencing reality. In these instances, individuals have “subjective epistemic orientation”, may express predominantly somatic symptoms and often experience depression in somatic and interpersonal domains encouraged by their society. To illustrate this, Western cultures value individuality and responsibility and often the associated depressive symptoms are related to the loss of personal control expressed in helplessness and powerlessness. On the other hand, in certain Eastern Asian (e.g., Chinese, Japanese, and Korean) societies, there is a strong emphasis on selfless subordination and the loss of control does not have such a negative connotation, which may lead to different manifestation of depression, in which helplessness is not expressed as a symptom. One of the major problems with ethnocultural variations of depressive disorders is evident in the measurement of depressive experiences. The existing assessments of depressive symptoms may have limited cultural validity and this may reduce their clinical utility in nonWestern populations (Marsella, Sartorius, Jablensky, & Fenton, 1985). The symptoms of major depression that are described by the DSM-IV and measured by clinicians may not be equally culturally sensitive to depressive experience (i.e., may be endorsed differently) in all populations. Therefore, Marsella (1980; 1987; 1993) proposed to measure depression based on five different 9 dimensions: affective, somatic, interpersonal, cognitive, and existential. According to Marsella, all of these components are present in the depression diagnosis. Yet, in Western culture more attention may be placed on affective and existential symptoms (e.g., depressed mood, discouragement, hopelessness), while non-Western populations may be more likely to experience dysfunction through somatic symptoms (e.g., loss of appetite, sleep problems). To illustrate this, Marsella, Kinzie and Gordon (1973) used factor analysis to explore the expression of depressive symptoms among Japanese, Chinese, and European Americans. The authors found different depressive symptom profiles among the three groups: the Chinese Americans were more likely to emphasize somatic complaints (e.g., headaches, insomnia, and indigestion), the Japanese Americans experienced more interpersonal problems (e.g., afraid to meet new people, does not feel like socializing, and feels ashamed), and the European Americans reported more affective and existential symptoms (e.g., loss of interest in life, hopelessness, depressed mood, suicidality, and memory problems). In addition, the authors found that Chinese and Japanese participants differed from Caucasian participants by reporting poor appetite more often, while Caucasian participants endorsed the urge to eat more frequently than the participants of Asian descent. The findings of this study suggested that various ethnic/racial groups may experience depression in different ways: Chinese Americans may have more somatic symptoms, Japanese Americans may endorse more interpersonal symptoms, and Caucasian Americans may concentrate more on affective and existential symptoms. A depressive symptom profile that allows us to map the endorsement of each symptom can reveal invaluable information about the phenomenology of the disorder in particular ethnocultural groups and may suggest important implications for diagnosis and treatment. Depression among Asian Americans 10 Asian Americans are one of the fastest growing and most diverse groups in the U.S. According to the U.S. Census Bureau (2004), by 2050 the Asian population in this country is projected to grow 213 percent, from 10.7 to 33.4 million people. This expected increase in the Asian population in the U.S. calls for a better understanding of this group’s mental health. Over 20 heterogeneous groups have been included under the label Asian Americans that may differ in their language, race, or religion. Although mental health researchers realize this grouping could be problematic, it is commonly used since researchers believe that it can help the overall understanding of mental health processes in this understudied group. Yet, analyses for each group should be performed when data are available. Among Asians and Asian Americans 1, reports about the lifetime prevalence of depression vary greatly. Some epidemiological studies indicated a relatively low lifetime prevalence rate of depressive disorders (6.9%) among Chinese Americans (Takeuchi et al., 1998) in comparison to Caucasian Americans (17.9%; Breslau, Aguilar-Gaxiola, Kendler, Su, Williams, & Kessler, 2006). Takeuchi, Hong, Gile, and Alegría (2007) reported that 9.1% of Asian Americans in the National Latino and Asian American Study endorsed any affective disorder. In addition, crossnational comparative community studies found that the prevalence of lifetime depression in Taiwan and Korea was 1.5% and 2.9%, respectively (Weissman et al., 1996), which is substantially lower than the rate of 17.9% indicated in the NCS-R (Breslau et al., 2006). However, other studies suggested that the prevalence of depression among Asian Americans is equivalent or greater than that among Caucasian Americans (Chang, 2002; Kuo, 1984). Regardless of the true prevalence of depression among Asian Americans, it has been established 1 When referring to Asian Americans, we include both immigrants from Asian countries to the U.S. (first generation) and Americans of Asian descent (second, third, or fourth generation). Studies of Asian populations will be discussed because they may be relevant to first generation Asian Americans. 11 that once they have a mental disorder, it tends to be very persistent and they are less likely to seek treatment for psychological problems than Caucasian Americans (Leong, 1986; Meyer, Zane, Cho, & Takeuchi, 2009; Sue, Zane, & Young 1994). Moreover, Alegría et al. (2008) found that Asian Americans with a past-year depressive disorder were significantly less likely to access any depression treatment and to receive adequate care compared to non-Latino Whites. Thus, if Asian Americans suffer from depression, they may be less likely to have the disorder detected and treated, which may result in a worse prognosis (Marin & Escobar, 2008). The observed health disparities in depression treatment call for a closer examination of the manifestation and experience of depression among Asian Americans. Research on depressive symptoms and psychological distress among Asians and Asian Americans has found higher endorsement rates of somatic symptoms (e.g., Kleinman, 1977; Lu, Bond, Friedman, & Chan, 2010; Marsella et al., 1973; Parker et al., 2001; Rao, Young, & Raguram, 2007). As a result, it has been concluded that somatization, or somatic expression of distress, is common among Asian cultures, while in Western cultures there is more emphasis on verbal and emotional expression and reporting of psychological distress, such as sadness or hopelessness (Chun, Enomoto, & Sue, 1996; Hwang et al., 2008). One of the proposed explanations for the emphasis on somatic symptoms among Asian Americans has been the holistic representation of mind and body. Support for this proposition has been found in previous research on depressive symptoms among Asian Americans that examined the factor structure of the CES-D (Center for Epidemiological Studies Depression Scale). The CES-D assesses four domains of depression: negative/depressed affect, positive affect, interpersonal problems, and somatic symptoms (Radloff, 1977). However, these dimensions do not always hold and fewer factors often emerge among ethnic/racial minority 12 populations (Cheung & Bagley, 1998; Chung & Singer, 1995; Edman et al., 1999). For example, Edman et al. found that in a sample of Filipino American adolescents, only two factors provided a reasonably good fit: the first one included depressed affect, somatic complaints, and interpersonal problems and the second one consisted of the positive affect items. This finding implies that depressive symptoms may cluster in a different way among Asian Americans. In addition, Kanazawa, White, and Hampson (2007) investigated cultural variations in depressive symptoms among Native Hawaiians, Japanese Americans, and European Americans using the CES-D and found that Japanese Americans reported lower levels of positive affect compared to European Americans. This discrepancy was attributed to the differences in emotion regulation rather than in levels of depression. Additionally, Lu et al. (2010) examined the CES-D in a sample of Hong Kong Chinese and Anglo American students. While the authors found support for four factors in both samples, they observed a tendency among the Chinese participants to report somatic symptoms and a tendency among Anglo Americans to report both somatic and affective symptoms. Furthermore, Lu and colleagues concluded that Americans participants considered somatic and affective experiences as two different dimensions that comprise depression equally and Chinese individuals were more likely to report their somatic symptoms, as opposed to their depressed feelings, despite their awareness of the psychological problem. The observed tendency among the Chinese participants to concentrate on somatic symptoms is arguably more socially acceptable and may be related to the assumption that a cure can be found more easily for such complaints (Lu et al., 2010). Despite the various explanations that have been proposed to explain somatization, researchers recently have offered an alternative explanation (Parker et al., 2001; Ryder et al., 2008). A recent study by Ryder and colleagues explored depressive symptom presentations 13 among Chinese and Euro-Canadian outpatients and concluded that the type of assessment (spontaneous problem report, symptom self-report questionnaire, or structured clinical interview) influenced the type and frequency of the symptoms that the patient reported. In this study, Chinese outpatients were found to report more depressive somatic symptoms in spontaneous report and structured interviews, while Euro-Canadian outpatients reported significantly more depressive affective symptoms (e.g., depressed mood, anhedonia, worthlessness, guilt) in all three assessment modalities. Based on their findings, Ryder and colleagues suggested that researchers may have spent too much time on discussing Chinese somatization of depression. Instead, they argue that it is more likely that Westerners overemphasize the affective or psychological aspects of depression compared to other cultures. This phenomenon is referred to as the “psychologization” of depression (Ryder et al., 2008). Similarly, Kirmayer and Young (1998) argued that somatization is ubiquitous, although its features and prevalence may vary across cultures and somatic symptoms are “the most common clinical expression of emotional distress worldwide” (p.420). The affective/somatic dichotomy in depression among Asians has been examined in multiple studies. However, very few studies have explored the endorsement of specific depressive symptoms among Asian Americans. Most of the existing studies that investigated racial and ethnic differences in the expression of DSM depressive symptoms included African Americans, Hispanics, and Caucasian Americans (Breslau, Javaras, Blacker, Murphy, & Normand, 2008; Iwata, Turner, & Loyd, 2002; Roberts, Chen, & Solovitz, 1995). Only one such comparative study of depressive symptoms that included an Asian American group was located (Uebelacker, Strong, Weinstock, & Miller, 2009). Uebelacker et al. (2009) examined differences in DSM-IV major depression symptoms among English-speaking African Americans, Hispanics, 14 non-Hispanic Whites, Asian Americans, and American Indians. The authors used differential item functioning to detect whether certain depressive symptoms were easier to endorse for one racial/ethnic group when the level of depression severity was equal between groups. The results indicated that in comparison to Caucasian Americans, Asian Americans were more likely to endorse suicidal ideation given equal levels of depression severity. In addition, poor concentration discriminated Caucasian Americans more than Asian Americans. However, Uebelacker and colleagues did not find any evidence to support their hypothesis that somatic symptoms would be endorsed more often among all racial/ethnic minorities, including Asian Americans. This study did not examine the two affective depressive symptoms in the DSM-IV, namely depressed mood and anhedonia, because their sample consisted of individuals who received an MDD diagnosis and the endorsement rates of these two symptoms were too high. Therefore, analyses for differences in the endorsement of affective symptoms between Caucasian Americans and Asian Americans were not conducted. While there may be racial/ethnic variations in symptom expression of depression, we need not neglect other factors that may also be important in depression expression, such as gender (e.g., Smith et al., 2008) and acculturation (e.g., Chung et al., 2003). The possible influences of gender and acculturation on depressive symptoms among Asian Americans have not been vastly explored and the reviews that we continue to provide of each topic are relatively scant and inconclusive. Depression and Gender among Asian Americans In Western countries, it has been found that women suffer from major depression up to twice as often as men (e.g., Weissman et al., 1993). Depressive symptomatology has also been found to vary with gender (e.g., Smith et al., 2008). In a symptom profile study, Smith and 15 colleagues found that Caucasian American women reported higher rates of diminished libido, hypersomnia, excessive self-reproach, and diurnal variation, and lower levels of initial insomnia compared to Caucasian American men. In addition, Caucasian American women report higher rates of atypical or somatic depression, which includes endorsement of sleep disturbance, appetite/weight changes, and fatigue (Silverstein, 2002). While researchers acknowledge the importance of gender in prevalence rates and symptom expression among Caucasian Americans, little is known about gender’s role in depression manifestation among other racial/ethnic groups and, in particular, among Asian Americans. A few studies concentrated on Asian American women’s experience of depression. In a qualitative study of symptom manifestation among Korean immigrant women in the U.S., Bernstein, Lee, Park, and Jyoung (2007) found that report of depressive symptoms was complex and in all domains of the person’s existence. Some of the topics discussed were “emotional entrapment, shame and failure as women, disappointment at not being able to live a normal life, and emotional restraint” (p.393). Women were observed to express emotions more often somatically, bodily, and metaphorically than verbally (e.g., reports of aches and pains and weakness). In addition, women described their experience using the term “suffering” rather than “depression”. The authors explained these patterns with an emphasis on society (collectivism) in Korean culture, where the expression of negative affect may be socially unacceptable. Another study examined the relationship among cultural group, depressive symptoms, and somatic symptoms among Japanese and Korean women (San Arnault & Kim, 2008). The authors found a significant positive correlation between somatic symptoms and high depression scores on the Beck Depression Inventory (BDI) for both cultural groups. The most common endorsed somatic symptoms for both Japanese and Korean women with high BDI scores were 16 abdominal upset, weakness, dizziness, aches and pains, and palpitations. The results of this study suggest that Asian women often tend to express depression in somatic symptoms. In general, there is a paucity of research to support or refute gender differences in depressive symptoms among Asian Americans. The two studies described here concentrated on the depressive experiences of Asian women but little is known about depression among Asian men and Asian Americans. Therefore, it is important to investigate more thoroughly whether Asian American women and men endorse depressive symptoms differently. Depression and Acculturation among Asian Americans Other important factors that may be associated with the expression of depressive symptoms among Asian Americans are acculturation and language. For instance, Chung et al. (2003) found that in a primary care setting, 41.3% of Asian patients had depressive symptoms but physicians identified only 23.6% of them as psychiatrically distressed. The authors concluded that it may be difficult for primary care physicians to recognize depressive symptoms and to give an accurate diagnosis to patients who have low acculturation levels and/or are of Asian ancestry (Chung et al., 2003). Similarly, acculturative stress has been positively related to higher rates of depressive symptoms among six groups of Asian immigrant elders (Chinese, Korean, Indian, Filipino, Vietnamese, and Japanese; Mui & Kang, 2006), although this study did not elaborate on the particular expression of symptoms. In addition, English language proficiency plays an important role in communicating one’s symptoms and is an integral part of acculturation (Lam, Pacala, & Smith, 1997). Kim, Wang, Deng, Alvarez, and Li (2011) examined the relationship of English proficiency and depressive symptoms in a sample of Chinese American adolescents. The authors found that self-reported low English proficiency in middle school was related to later reporting of accented English in high school, which, in turn, 17 related to their perception of being labeled as perpetual foreigners. Both boys and girls who internalized the perpetual foreigner stereotype experienced more discrimination and reported more depressive symptoms than the adolescents who did not identify as perpetual foreigners. While this study provided insight into the relationship between English proficiency and depression, the role that English proficiency might play in the expression of depressive symptoms among Asian Americans needs to be examined. Based on the reviewed research, there is strong evidence to support that depressive symptoms and experience are shaped by culture. Previous research studies that investigated depressive symptoms among Asians and Asian Americans looked at outpatient and community samples (e.g., Kanazawa et al., 2007; Ryder et al., 2008), explored depression predominantly among one Asian ethnic subgroup (e.g., Chinese, Korean, or Japanese), employed qualitative methods that may make it difficult to replicate results (Bernstein et al., 2007), and used assessment instruments (e.g., BDI or CES-D) that did not allow a DSM-IV diagnosis of major depression to be made. Therefore, it is important to investigate depressive symptomatology among Asian Americans in more depth by addressing these limitations. Thus, the main focus of this study was to obtain and analyze a detailed depressive symptom profile of Asian Americans in a nationally representative U.S. sample using a diagnostic interview (WMH CIDI; World Mental Health Composite International Diagnostic Interview) that allowed the examination of DSM-IV Major Depressive Episode (MDE) criteria. In addition, this study explored how gender, acculturative stress, and language proficiency may impact depressive symptom manifestation. The Current Study Relatively few studies have examined particular symptoms of depression among Asian Americans and none of these studies employed a large U.S. national sample of Asian Americans. 18 In this largely exploratory study, systematic analyses were performed to examine the frequencies of discrete depressive symptoms in order to form a symptom profile of depression among Asian Americans. The symptom profile of depressed Asian Americans was compared to that of depressed Caucasian Americans in order to detect possible similarities and differences in the manifestation of depression between the two racial groups. Based on the existing literature, differences in affective and somatic symptoms were expected. In addition, the age of onset and duration of the most severe major depressive episode was compared among Asian Americans and Caucasian Americans. The study also examined reports of distress and impairment associated with the depressive episode among Asian Americans and Caucasian Americans. Moreover, depressive symptoms were examined in relation to gender, since it is possible that Asian American women endorse different symptoms in comparison to Asian American men. The occurrence of depressive symptoms was analyzed in relation to acculturative stress, language preference, and language proficiency as a proxy for acculturation among Asian immigrants. The primary goal of the study was to answer the following questions and test the hypotheses specified below: 1) What depressive symptoms have the highest endorsement rate among Asian Americans (e.g., depressed mood, anhedonia, appetite/weight changes, or loss of energy)? Hypothesis: Based on previous research, it was expected that Asian Americans would be more likely to have the highest endorsement rates for somatic depressive symptoms (e.g., appetite/weight changes, sleep disturbance, psychomotor retardation/agitation, and loss of energy). 19 2) What is the age of onset and duration of the worst major depressive episode among Asian Americans? (exploratory question) 3) Which depressive symptoms are endorsed more often by Asian Americans than by Caucasian Americans or vice versa? Hypothesis: It was expected that Asian Americans would endorse somatic depressive symptoms more (e.g., appetite/weight changes, sleep disturbance, psychomotor retardation/agitation, and loss of energy) than Caucasian Americans. It was also hypothesized that Caucasian Americans would endorse affective depressive symptoms more (e.g., depressed mood, discouragement, anhedonia, and self-reproach) than Asian Americans. 4) Do Asian Americans differ from Caucasian Americans in their emotional distress and impairment? Hypothesis: It was expected that Asian Americans would report higher impairment but lower emotional distress in comparison to Caucasian Americans. The secondary goal of this study was to answer the following questions: 5) Which depressive symptoms are endorsed more often by Asian American men than by Asian American women and vice versa? (exploratory question) 6) Which depressive symptoms are endorsed more often among Asian immigrants with high acculturative stress compared to Asian immigrants with low acculturative stress? (exploratory question) 7) Which depressive symptoms are endorsed more often among Asian American participants who did the interview in English compared to Asian Americans who did the interview in Mandarin, Cantonese, Tagalog, or Vietnamese? (exploratory question) 20 8) Which depressive symptoms are endorsed more often among Asian American participants who speak English proficiently as opposed to non-proficiently? (exploratory question) The ultimate goal of this study was to provide important information about the nature and expression of depression among Asian Americans. A more nuanced understanding of these factors will allow for better recognition, assessment, and diagnosis of depression in this population in both primary care and mental health settings. In addition, this study’s findings will be relevant to creating, adapting, and applying the most suitable treatments for depression based on the particular depressive symptoms and the client’s treatment goals. Method To address the research questions, secondary data analysis was conducted using data drawn from two of the three nationally representative epidemiological surveys that are part of the Collaborative Psychiatric Epidemiology Surveys (CPES; Pennell et al., 2004). The CPES includes the National Comorbidity Survey-Replication (NCS-R), the National Latino and Asian American Study (NLAAS), and the National Survey of American Life (NSAL; Heeringa et al., 2004). These surveys collected comprehensive epidemiological data on lifetime and 12-month prevalence of psychiatric disorders and rates of mental health use among the U.S. population and included a large number of racial and ethnic minority groups. In order to examine the proposed research questions, data for Asian Americans were drawn from the NLAAS and data for Caucasian Americans and Asian Americans were drawn from the NCS-R. The NLAAS is the first national representative community household epidemiological survey of Latinos and Asian Americans in the U.S. The rationale, overview, and procedures for the development of the NLAAS are described in detail in Alegría, Takeuchi, et al. (2004). The NCS-R is a nationally 21 representative survey of English-speaking household residents aged 18 or older who live in the coterminous United States (Kessler & Meikangas, 2004). The CPES studies are compatible in the sampling methods and measures they used and allow comparisons of psychiatric disorder characteristics, prevalence, service utilization, and associated environmental, social, and psychosocial factors between Caucasian, Hispanic, African American, and Asian American adults. The CPES dataset was selected for the current study because it is the largest available epidemiological dataset that included a nationally representative sample of Asian Americans and Caucasian Americans. Sampling Design The NLAAS and the NCS-R used a four-stage stratified probability sampling procedure to recruit and survey adult non-institutionalized Asian Americans and Caucasian Americans. The core sampling process started with sampling in Metropolitan Statistical Areas (MSA) and single counties. The second stage involved area segments sampling and the third stage comprised of housing units sampling. In the final stage, eligible respondents in each household were randomly selected. For the NLAAS, since the core sampling would have not provided sufficient number of participants of certain ethnic backgrounds, the sampling was augmented by adding five supplemental area probability samples at stage two with high residential densities (with 5% or higher) of the groups of interest. The sampling procedures have been described in more detail in Heeringa et al. (2004). Participants Participants in this study were 2095 Asian Americans drawn from the NLAAS, 189 Asian Americans from the NCS-R, and 6696 non-Latino Whites from the NCS-R. All participants were 18 years or older living in the coterminous United States. Among the NLAAS 22 respondents there were 600 Chinese, 508 Filipino, 520 Vietnamese, and 467 Other Asians (for all other groups). The Asian American participants from the NCS-R (n = 189) were part of the Other Asian category in the CPES dataset. Measures The NLAAS measures were translated in four Asian languages: Cantonese, Mandarin, Tagalog, and Vietnamese. The NLAAS consists of the NLAAS Core, the NLAAS Non-Core, and the NLAAS Study Specific section. The NLAAS Core battery compares to the NCS-R and NSAL instruments with identical measures of psychiatric illness, service use, and impairment. The NLAAS Non-Core measures are shared either with the NSAL or the NCS-R but not with both, and the Study Specific section was limited to the NLAAS (Alegría, Villa, et al., 2004). The NLAAS and the NCS-R used the core CPES questionnaire, which was based on the World Health Organization's (WHO) version of the Composite International Diagnostic Interview (CIDI 3.0). The CIDI was developed for the World Mental Health (WMH) Survey Initiative (WMH-CIDI) and is described in detail in Kessler and Üstün (2004). The WMH-CIDI is a fully standardized diagnostic interview and includes a screening section and 40 sections that focus on diagnoses (22), functioning (4), treatment (2), risk factors (4), socio-demographic correlates (7), and methodological factors (2). Previous studies of the validity of CIDI diagnostic assessments show that CIDI diagnoses are significantly related to independent clinical diagnoses, although concordance is not perfect (Haro et al., 2006; Wittchen, 1994). The first section of the WMH-CIDI was a screening questionnaire, which included core questions about particular disorders. If the participant endorsed at least one of the questions for a particular disorder, s/he was asked to complete the module associated with the disorder later. 23 Thus, participants who completed the Depression Module had to endorse one or more of the following three questions: 1) “Have you ever in your life had a period of time lasting several days or longer when most of the day you felt sad, empty or depressed?” 2) “Have you ever had a period of time lasting several days or longer when most of the day you were very discouraged about how things were going in your life?” 3) “Have you ever had a period of time lasting several days or longer when you lost interest in most things you usually enjoy like work, hobbies, and personal relationships?” This study aimed to explore depressive symptoms among two populations: all participants who completed the Depression Module and all participants who received a lifetime DSM-IV Major Depressive Episode (MDE) diagnosis. The first sample was called the “at-risk” for depression sample and the second one was referred to as the “MDE sample”. The second sample was embedded within the first sample. The rationale for examining the “at-risk” sample was that it would provide us with more variation within the sample and allow us to examine participants with subthreshold levels of depression who may be otherwise ignored. Depressive symptoms were assessed for the most severe depressive episode in the participant’s life. Ethnicity. The NLAAS targeted Asian American participants of Vietnamese, Filipino, and Chinese background. There was a fourth category of “Other Asian” that included participants of all other Asian ethnicities in the NLAAS and all Asian participants from the NCSR. The four categories were combined to create one category of Asian Americans. Caucasian Americans were drawn from the NCS-R study. Gender. Participants reported their gender as male or female. 24 Depressive symptoms. The Depression section of the WMH-CIDI included questions about depressive symptoms during the most severe major depressive episode experienced by the participant. Most of the questions were relevant to a DSM-IV MDE symptom (e.g., depressed mood, psychomotor retardation/agitation) and were rated as present (1) or absent (0). Based on DSM-IV MDE diagnostic rules, the endorsement or denial of a symptom (e.g., worthlessness) defined further inquiry about other related symptoms (e.g., guilt). Appendix A includes a list of the 28 assessed depressive symptoms. Lifetime DSM-IV Major Depressive Episode. Lifetime DSM-IV Major Depressive Episode diagnosis was coded as present or absent (0 = none, 1 = any). This variable was provided based on a SAS algorithm that considered the number of symptoms and rule outs. Age of Onset of MDE. The age of onset of the most severe major depressive episode was assessed. Duration of MDE. The duration (in days) of the most severe major depressive episode was assessed. Emotional Distress and Impairment. Five indicators were used to assess emotional distress and impairment associated with the most severe major depressive episode: severity and frequency of emotional distress, number of hours feeling sad per day, interference of sadness with work/relations/social life, and inability to perform daily activities. The severity of emotional distress was assessed on a 4-point scale ranging from mild (1) to very severe (4). Participants reported the number of hours feeling sad every day during the depressive episode on a 4-point scale ranging from less than 1 hour (1) to more than 5 hours (4). Next, the interference of sadness with work/relation/social life was assessed on a 5-point Likert scale ranging from not at all (1) to extremely (5). Lastly, participants reported the frequency of their emotional distress and 25 the inability to perform daily activities related to the most severe major depressive episode on a 4-point scale ranging from often (1) to never (4). These variables were recoded, so that higher scores would indicate higher frequency. Acculturative Stress. This scale used nine items from the Hispanic Stress Inventory (Cervantes, Padilla, and Salgado de Snyder (1991), as cited in Alegría, Takeuchi et al., 2004). The items were administered only to immigrants and measured the stress resulting from immigration to the U.S. The items focused on the following aspects of acculturative stress among immigrants: felt guilty about leaving family/friends in country of origin, same respect in U.S. as in country of origin (reverse-coded), limited contact with family and friends, interaction hard due to difficulty with English language, treated badly due to poor/accented English, difficult to find work due to Latino/Asian descent, questioned about legal status, thinking might be deported if s/he went to social/government agency, and avoid health service due to INS. Participants answered whether they had experienced any of the listed problems with yes, no, or N/A. The sum of the nine items was computed and used as a scaled score with higher values indicating higher level of acculturative stress. The scale’s Cronbach’s α for Asian American immigrants was .63. The scale score of acculturative stress (AS) was recoded into a dichotomous variable that included a low AS and a high AS group. Asian American participants who reported two or more experiences (50.2%) of acculturative stress were placed in the high AS group, and those who reported none or one AS experiences (49.8%) were in the low AS group. Language choice. Participants reported their language of preference for the interview. Respondents chose between English, Cantonese, Mandarin, Tagalog, and Vietnamese. Interviews in the four Asian languages were coded as “Asian language” interviews and the remaining interviews were coded as “English language” interviews. 26 Spoken English proficiency. Asian American participants assessed how well they speak English on a 4-point ordinal scale ranging from poor (1) to excellent (4). In order to conduct chisquare analyses, responses were recoded into a dichotomous variable, where poor and fair were coded as “non-proficient” and good and excellent were coded as “proficient”. Procedure Data collection for NCS-R and NLAAS took place between February 2001 and December 2003. Initially, households and respondents were selected based on the probability sampling described earlier. NCS-R surveys were conducted by 342 certified English interviewers, while NLAAS data were collected by 275 trained bilingual and bicultural interviewers. The interviewers obtained informed consent and conducted interviews by phone or in person with the help of computer-based software. Later, a random sample of respondents was re-contacted to validate the data for quality control purposes. All instruments were translated and back translated in Cantonese, Mandarin, Tagalog and Vietnamese according to standard techniques (Alegria, Vila et al., 2004). Participants received monetary compensation for their participation. The development and implementation of all CPES studies is described in more detail in Pennell et al. (2004). Data Analyses Of the combined NCS-R and NLAAS sample, only participants who endorsed depressive experiences in the screening questions and continued to answer questions about symptoms of their most severe depressive episode were included in the analyses. The study used both withingroup (among Asian Americans) and between-group (between Asian Americans and Caucasian Americans) comparisons. All analyses were conducted using the Complex Samples Module in IBM SPSS version 19.0 in order to conduct weighted analyses and to control for sample design 27 effects due to sample stratification and clustering. Specific CPES sample weights for NCS-R and NLAAS were utilized for all analyses. An alpha of .05 was used to evaluate the significance of all analyses. Descriptives. Demographics and clinical characteristics were reported for Asian Americans and Caucasian Americans. Frequencies. Frequencies of depressive symptom question endorsement for Asian Americans were run and compared to identify which depressive symptoms are most often endorsed. Chi-Square Analyses. To examine the rates of endorsement of depressive symptoms between Asian Americans and Caucasian Americans, a series of Pearson chi-square analyses were conducted. Significant results, as indicated by p-values of less than .05, suggest that significant differences exist in endorsement rates of depressive symptoms between the two racial groups. Pearson chi-square analyses were also used to compare endorsement rates of depressive symptoms between Asian American men and women, Asian American immigrants with low and high acculturative stress level, Asian Americans who did the interview in English or in an Asian language (Cantonese, Mandarin, Tagalog, or Vietnamese), and Asian Americans who were proficient or non-proficient in English. Independent t-test Analyses. To examine mean differences related to the age of onset and duration of the most severe depressive episode among Asian Americans and Caucasian Americans, independent t-tests were conducted. In addition, variables related to severity and frequency of emotional distress and impairment among Asian Americans and Caucasian Americans were compared using independent t-tests. 28 Results Screening Twenty-three percent (n = 2073; 310 Asian Americans and 1763 Caucasian Americans) of the pooled NLAAS and NCS-R samples (n = 8980) endorsed depressed mood, lack of interest, or discouragement for a period of two weeks or longer during their lifetime and answered the questions about depressive symptoms. This extended sample was referred to as “at-risk” for depression sample. One fifth (n = 1598; 19.7%) of the pooled NLAAS and NCS-R samples screened positive for suspected lifetime history of depression. The proportion of Asian Americans with Major Depressive Episode (9.1%, SE = 0.8%; unweighted n = 221) was significantly lower than that of Caucasian Americans (20.3%, SE = 0.5%; unweighted n = 1377), 2  (1, N = 88) = 38.660, p < 0.001. This sample was referred to as “MDE sample” and it was yielded from the at-risk sample. Because of the exploratory nature of this study, all analyses were conducted for both the at-risk and MDE samples. Descriptives Descriptive statistics for the at-risk sample (n = 2073) are presented in Table 1 and descriptive statistics for the MDE sample (n = 1598) are presented in Table 2. The age range for participants was 18-91 in both samples. The mean age in the at-risk sample was 39.22 (SE = 0.88) for Asian Americans and 44.15 (SE = 0.65) for Caucasian Americans. Similarly, the mean age in the MDE sample was 38.44 (SE = 1.05) for Asian Americans and 43.45 (SE = 0.62) for Caucasian Americans. Both racial groups had more females than males (61.3% vs. 38.7% for both groups) in the at-risk sample as well as in the MDE sample (58.9% vs. 41.1% for Asian Americans and 62.6% vs. 37.4% for Caucasian Americans). Within the Asian American at-risk sample there were 9.6% Vietnamese, 16.3% Filipino, 31.1% Chinese, and 42.9% Other Asian. 29 The ethnic composition of the Asian American MDE sample was 11.8% Vietnamese, 16.5% Filipino, 30.7% Chinese, and 40.9% Other Asian. Three quarters (77%) of the participants at risk for depression met criteria for DSM-IV Major Depressive Episode (MDE). However, Caucasian Americans (78.3%) in the at-risk sample were more likely to be diagnosed with MDE than Asian 2 Americans in the at-risk sample (69%), ( (1, N = 71) = 3.037, p = .001). Question Endorsement, Symptom Prevalence, and Symptom Profile The endorsement rates of depressive symptoms according to DSM-IV MDE criteria for each racial group in each of the samples (at-risk and MDE) are presented in Table 3 and Table 4, respectively. Among the most frequently endorsed symptoms (>70%) for Asian Americans at risk for depression were feeling depressed, feeling discouraged, trouble sleeping, low energy, trouble concentrating, loss of self-confidence, and feeling less talkative. The items that were most often (>70%) endorsed by Asian Americans diagnosed with MDE were feeling depressed, feeling discouraged, loss of interest, smaller appetite, trouble sleeping, low energy, trouble concentrating, loss of self-confidence, feeling less worthy than other people, desire to be alone, and feeling less talkative. Figure 1 presents a symptom profile of Asian Americans from the atrisk and MDE sample. Age of Onset and Duration The age of onset and length of the most severe depressive episode was compared between Asian Americans and Caucasian Americans with MDE (see Table 2 for detailed results). Asian Americans (M = 29.97, SE = 1.29) were significantly younger than Caucasian Americans (M = 33.32, SE = 0.57) when they experienced their most severe depressive episode (t(56) = -2.371, p = .021). However, the Asian American sample (M = 38.44, SE = 1.05) was significantly younger than the Caucasian American sample (M = 43.45, SE = 0.62), t(62) = -4.322, p < .001. Therefore, 30 the comparison of age of onset was conducted again with age as a covariate. No significant differences were found after controlling for age (t(56) = -.739, p = .463). Chi-Square Analyses: Race X Depressive Symptoms The endorsement rates of depressive symptoms among Asian and Caucasian participants were compared and results are presented in Table 5 for the at-risk sample and Table 6 for the MDE sample. Significant differences in endorsement rates were found in the at-risk sample between Asian Americans and Caucasian Americans for 9 of the 28 questions, with Asian Americans endorsing less frequently than Caucasian Americans all 9 questions (see Figure 4). In particular, Caucasians were significantly more likely than Asians to report feeling 2 2 sad/empty/depressed ( (1, N = 71) = 1.346, p = .030), feeling discouraged about life ( (1, N = 2 2 71) = 2.288, p = .006), loss of interest ( (1, N = 71) = 1.223, p = .021), larger appetite ( (1, N 2 = 71) = 1.549, p = .044), weight gain ( (1, N = 71) = 1.307, p = .028), loss of self-confidence 2 2 ( (1, N = 71) = 1.442, p = .019), feeling guilty ( (1, N = 71) = 1.820, p = .010), desire to be 2 2 alone rather than with friends ( (1, N = 71) = 3.191, p = .001), and crying often ( (1, N = 71) = 1.079, p = .019). Chi-square analyses in the MDE sample revealed twо depressive symptoms that 2 were endorsed more frequently by Caucasians than Asians: weight gain ( (1, N = 62) = 1.410, p 2 = 0.037) and desire to be alone ( (1, N = 62) = 1.561, p = 0.006). Figure 2 and Figure 3 present the data graphically for the at-risk and the MDE sample, respectively. Figure 4 shows data only for the symptoms that were endorsed differently in the at-risk sample. Emotional Distress and Impairment 31 In order to examine the severity and frequency and emotional distress and impairment during the most severe major depressive episode, independent t-tests were conducted. Means and standard deviations of the five indicators of emotional distress and impairment are reported in Table 7 (for at-risk sample) and Table 8 (for MDE sample). In the at-risk sample, Asian Americans reported significantly lower severity of emotional distress than Caucasian Americans (t(71) = -2.27, p = .026) and fewer hours of sadness per day (t(66) = -5.65, p = .001). Asian Americans reported that sadness interfered significantly less with their work, relations, and social life compared to Caucasian Americans (t(69) = -4.78, p = .001). However, Asian Americans were unable to perform their daily activities more frequently than Caucasian Americans (t(67) = 2.51, p = .015) as a result of their depressive experiences. In the MDE sample, Asian Americans experienced significantly fewer hours of sadness per day (t(60) = -4.01, p = .001) and reported that sadness interfered significantly less with their work, relations, and social life than Caucasian Americans did (t(61) = -4.11, p = .001). However, Asian Americans still reported inability to perform daily activities more frequently than Caucasian Americans (t(62) = 2.61, p = .011). Chi-Square Analyses: Gender X Depressive Symptoms for Asian Americans The endorsement rates of depressive symptoms among Asian American men and women in both samples were compared. Results are presented in Table 9 (at-risk) and Table 10 (MDE). The lifetime prevalence rate of MDE was 7.9% for Asian American men and 10.2% for Asian American women and the difference was not statistically significant (2(1, N = 65) = 3.642, p = .111). However, significant differences in symptom expression were found for 6 of the 28 questions in the at-risk sample. In comparison with Asian American women, Asian American 2 men were more likely to report that they felt discouraged about things in life ( (1, N = 28) = 2 8.331, p = .002), had low energy ( (1, N = 28) = 6.063, p = .008), had had thoughts that they 32 2 would be better off dead ( (1, N = 28) = 10.043, p = .008), preferred to be alone rather than with 2 2 friends ( (1, N = 28) = 5.942, p = .018), and were less talkative ( (1, N = 28) = 7.597, p 2 = .004). Asian American women were more likely to endorse crying often ( (1, N = 28) = 29.287, p < .001) than Asian American men. For the MDE sample, significant differences in endorsement rates were found between Asian American men and women for 5 of the 28 questions, with men endorsing more frequently four of the five questions. Men were significantly 2 more likely than women to report feeling discouraged about life ( (1, N = 23) = 8.052, p = .004), 2 2 would be better off dead ( (1, N = 23) = 4.886, p = .045), feeling nervous or anxious ( (1, N = 2 23) = 1.813, p = .040), and talking less ( (1, N = 23) = 4.977, p = .016). On the contrary, Asian 2 women reported crying more frequently than Asian men ( (1, N = 23) = 27.651, p < .001). Chi-Square Analyses: Acculturative Stress X Depressive Symptoms among Asian Americans Depressive symptoms among Asian Americans with low and high levels of acculturative stress (AS) were compared using chi-square analyses. The analyses conducted with the at-risk sample revealed that Asian Americans endorsed five questions differently depending on their acculturative stress level (see Table 11). In particular, Asian Americans who experienced more 2 acculturative stress were more likely to report feeling sad, empty, or depressed ( (1, N = 28) = 2 3.483, p =.002), losing interest in almost all things ( (1, N = 28) = 7.776, p = .013), having 2 2 smaller appetite ( (1, N = 28) = 15.62, p = .001), losing weight ( (1, N = 28) = 12.99, p = .006), 2 and talking or moving more slowly ( (1, N = 28) = 5.274, p = .020) than Asian Americans who reported less acculturative stress. For the MDE sample, we found that Asians who experienced 33 2 high levels of AS were more likely to report having less appetite ( (1, N = 23) = 13.06, p 2 = .001) and losing weight ( (1, N = 23) = 8.874, p = .024) than those with low levels of AS. On the other hand, Asian participants who experienced low levels of AS endorsed more often feeling 2 2 restless and jittery ( (1, N = 23) = 4.381, p = .032), having made a suicide plan ( (1, N = 23) = 2 3.688, p = .002), and wanting to be alone rather than with friends ( (1, N = 23) = 8.597, p = .007) than Asian participants with high levels of AS. Table 12 provides details of the results from the conducted analyses in the MDE sample. Chi-Square Analyses: Language of Interview X Depressive Symptoms among Asian Americans In order to compare whether the language of interview (English vs. Asian language) was related to the endorsement rates of depressive symptoms among Asian Americans, chi-square analyses were conducted. Table 13 (at-risk sample) and Table 14 (MDE sample) present frequencies and Pearson chi-square values. Among the participants who were at risk for depression, those who did the interview in an Asian language endorsed more often insomnia 2 ( (1, N = 28) = 7.157, p = .037) than those who did the interview in English. On the other hand, participants who did the interview in English were more likely to report past thoughts of 2 2 committing suicide ( (1, N = 28) = 6.063, p = .042), past suicide plan ( (1, N = 28) = 6.665, p 2 = .005), and desire to be alone rather than with friends ( (1, N = 28) = 24.213, p < .001) in comparison to those who interviewed in an Asian language. In the MDE sample, participants 2 who did the interview in an Asian language were more likely to report loss of weight ( (1, N = 2 23) = 4.862, p = .039) and insomnia ( (1, N = 23) = 9.605, p = .009). Asian Americans who did 34 2 the interview in English were more likely to endorse having thought of committing suicide ( (1, 2 N = 23) = 7.702, p = .036), having made a suicide plan ( = 5.692, p = .001), and preferring to 2 be alone rather than with friends ( (1, N = 23) = 23.59, p < .001). Chi-Square Analyses: Spoken English Proficiency X Depressive Symptoms among Asian Americans To determine the relationship between depressive symptoms and self-reported proficiency to speak English among Asian Americans, chi-square analyses were conducted. Table 15 (at-risk) and Table 16 (MDE) present the results of the performed analyses. Out of the 28 questions, eight questions were endorsed differently among participants at risk for depression. In particular, English proficient participants were more likely to report having gained weight 2 2 ( (1, N = 28) = 6.576, p = .01), hypersomnia ( (1, N = 28) = 6.225, p = .01), and wanting to be 2 alone rather than with friends ( (1, N = 28) = 4.965, p = .001) than non-proficient participants. At the same time, non-proficient participants were more likely than proficient participants to 2 2 endorse discouragement about things in life ( (1, N = 28) = 5.168, p = .043), insomnia ( (1, N 2 = 28) = 9.864, p = .005), psychomotor retardation ( (1, N = 28) = 6.554, p = .03), slow thinking 2 2 ( (1, N = 28) = 8.736, p = .034), and being less talkative ( (1, N = 28) = 2.574, p = .04). In the MDE sample, English proficient participants endorsed more often than non-proficient 2 participants feeling restless and jittery ( (1, N = 23) = 4.20, p = .016), losing self-confidence 2 2 ( (1, N = 23) = 6.635, p = .019), and wanting to be alone rather than with friends ( (1, N = 23) 2 = 7.375, p = .001). Non-proficient participants were more likely to report smaller appetite ( (1, 35 2 2 N = 23) = 5.575, p = .036), loss of weight ( (1, N = 23) = 8.936, p = .007), insomnia ( (1, N = 2 2 23) = 8.101, p = .02), psychomotor retardation ( = 5.222, p = .045), slow thinking ( = 8.085, 2 p = .012), and irritable mood ( (1, N = 23) = 5.63, p = .023) than English proficient participants. Discussion This study examined a symptom profile of depression among a nationally representative sample of Asian Americans and compared it to that of Caucasian Americans. Overall, Asian Americans at risk for depression had high endorsement rates (> 70%) for a variety of depressive symptoms, including depressed mood, discouragement, insomnia, loss of energy, trouble concentrating, loss of self-confidence, and decreased talkativeness. This pattern is relatively consistent with our hypothesis stating that somatic symptoms will be most prevalent among depressed Asian Americans. Indeed, trouble sleeping and low energy are somatic in nature and the endorsement rate of appetite/weight changes was above 70% when endorsement rates of decreased (64.9%) and increased (8.3%) appetite were jointly considered. However, high endorsement rates of affective symptoms were also observed among Asian Americans. In particular, feeling sad, feeling discouraged about things in life, and losing self-confidence were most often endorsed. The high endorsement rates of affective symptoms could be explained in three different ways. First, the results are consistent with findings that Asian Americans experience depressive affective symptoms and are aware of the underlying psychological problems in depression (Lu et al., 2010). Second, the high endorsement rates of affective symptoms among Asian Americans might be related to their acculturation level as more acculturated Asian Americans may be more likely to manifest depression similarly to Caucasian Americans (Lee, 2002). Third, the diagnostic measure (WMH-CIDI) that was used in the CPES 36 used a screening process that emphasized affective symptoms of depression (i.e., felt sad, empty, or depressed; felt discouraged; lost interest in almost all things). Therefore, it is possible that the participants who completed the Depression Module were already primed to report their affective symptoms. Similarly, Asian Americans who were diagnosed with MDE reported most often (>70%) depressed mood, discouragement, anhedonia, smaller appetite, insomnia, low energy, poor concentration, loss of self-confidence, worthlessness, desire to be alone, and decreased talkativeness. The reported symptoms covered seven of the nine DSM-IV categories and seemed congruent with the presentation of depression seen in Western cultures. While these results suggest that the core features of depression may be present in different racial/ethnic groups, it is important to consider this finding in the context of the methodology that was used as noted in the following classic example from cross-cultural psychology. The International Pilot Study of Schizophrenia (IPSS) conducted by the World Health Organization in the 1970s provided the first data for cross-cultural comparisons of schizophrenia and concluded that psychoses present similarly across cultures. However, Kleinman (1988) later criticized the IPSS’ methodology for using stringent inclusion and exclusion criteria, which yielded an “artificially homogenous sample” (Thakker & Ward, 1998, p.516). Kleinman suggested that the observed “similarity was an artifact of methodology” (p.19). In the present study, a similar phenomenon may have been observed, as the screening questions for depression were based on DSM-IV MDE criteria and the participants included in the MDE sample were selected based on these possibly rigid criteria. However, having strict exclusion/inclusion criteria in cross-cultural studies may result in the exclusion of those participants who showed the greatest diversity of symptoms which might not 37 fit with the DSM-IV diagnostic approach (Thakker & Ward, 1998). In our case, less stringent criteria were applied for the at-risk sample, while the MDE sample was more strictly defined. To examine similarities and differences in depressive symptoms among Asian Americans and Caucasian Americans, the frequencies of endorsement were compared. Nine differences were found in the at-risk sample and, for all of them, Caucasian Americans endorsed the symptom significantly more often than Asian Americans. In particular, Caucasian Americans endorsed feeling sad, empty, or depressed, feeling discouraged about things in life, losing interest in almost all things, having a larger appetite, gaining weight, losing self-confidence, feeling extreme guilt, wanting to be alone rather than with friends, and crying often. These findings were only partially consistent with our hypothesis, which predicted that Asian Americans would endorse somatic symptoms more often and Caucasian Americans would be more likely to endorse affective symptoms. We observed that while the first part of this hypothesis was not supported, the second one was confirmed. Caucasian Americans were more likely to endorse depressed mood, anhedonia, and self-reproach symptoms. This finding is consistent with the recent propositions that Westerners are more likely to “psychologize” depression than Asians and that somatic complaints are ubiquitous, while the emphasis on affective symptoms may be a Western phenomenon (Kirmayer & Young, 1998; Ryder et al., 2008). We can speculate that the expression of negative emotions is more socially acceptable among Caucasian Americans than Asian Americans due to possible differences in the interaction between self-construal and emotional regulation. Independent self-construal involves construing the self as an individual, whose behavior is organized and meaningful based on the person’s own feelings, thoughts, and actions. Interdependent self-construal entails perceiving oneself as part of 38 social relationships and realizing that one’s behavior is contingent on and organized by the person’s perception of others’ thoughts, feelings, and behaviors (Markus & Kitayama, 1991). Markus and Kitayama suggested that independent self-construal is observed in Western cultures and interdependent self-construal is more common in Asian cultures, although variations within cultures are possible. In terms of emotional regulation, the authors implied that a person’s selfconstrual can affect the expression, intensity, and frequency of emotions. Specifically, those with independent selves learn how to communicate very effectively their “ego-focused” emotions, such as sadness or frustration. In contrast, people with interdependent self-construal need to control and de-emphasize their private feelings in order to fit into the interpersonal context. Therefore, Caucasian Americans may put more weight on expressing negative affect (e.g., depressed mood, discouragement, crying often) than Asian Americans when they suffer from depression. Using the self-construal framework, we can also discuss Caucasian Americans’ higher endorsement of wanting to be alone rather than with friends. The desire to be on one’s own when one is depressed may be related to the concept of independence and individualism seen more often among Western cultures. Conversely, Asian Americans may either seek help from their social network or they may simply not have the choice to be on their own because isolation and avoidance are not socially appropriate. In addition, Caucasian Americans’ tendency to endorse self-reproach symptoms more often than Asian Americans is consistent with Marsella’s suggestion that guilt and worthlessness may be more salient to Westerners because they are related to the Judeo-Christian religion and individualism (Marsella, 1987; Marsella & Kaplan, 2002). A possible equivalent of guilt and worthlessness in Asian cultures could be shame or loss of face. In contrast to the ego-centered feelings, emotions, such as shame and loss of face may be considered feelings of interpersonal 39 communion (Markus & Kitayama, 1991). Unfortunately, we did not have data to draw conclusions about these constructs. Another important finding was the higher endorsement rates of increased appetite and weight gain among Caucasian Americans and not Asian Americans. Although we did not have a hypothesis for this particular symptom, it is important to note that Marsella et al. (1973) reported a similar pattern, with Japanese and Chinese Americans endorsing a lack of appetite and Caucasian Americans endorsing an urge to eat. This finding also emphasizes the importance of keeping the appetite and weight change symptoms separate when examining cultural variations in depressive symptoms. That is, if we collapse all appetite/weight change symptoms together, we may not be able to detect meaningful differences. Only two differences were detected in the MDE sample with Caucasian Americans reporting more frequently than Asian Americans weight gain and desire to be alone. The homogeneity of presented symptoms between Asian Americans and Caucasian Americans suggests that when using the strict MDE category as opposed to the less strict at-risk category, we observe fewer differences in symptom endorsement. Next, age of onset, duration, distress, and impairment were examined between Asian and Caucasian Americans. There were no differences in the age of onset and duration of the most severe depressive episode between the two groups. However, as hypothesized, differences in distress and frequency of impairment were detected, with Caucasian Americans reporting more emotional distress and more hours of sadness than Asian Americans. At the same time, Asian Americans reported higher frequency of their inability to perform daily activities than Caucasian Americans. One potential explanation for the found differences may be the wording of the questions. The two questions that inquired about emotional distress and sadness were less likely 40 to be endorsed by depressed Asian Americans. Nevertheless, when the participants were asked how often they were unable to perform everyday tasks, Asian Americans readily reported they were impaired more often than Caucasian Americans did. Consequently, future studies may need to phrase questions regarding impairment and distress without over-emphasizing the emotional or affective component of distress. The secondary goal of this study was to examine the role of gender, acculturative stress, language of interview, and spoken English proficiency on depressive symptoms among Asian Americans. The considerable scarcity of research on these topics prevented us from formulating hypotheses and the questions we posed were exploratory. First, we examined gender differences in the expression of depression among Asian Americans. The lifetime prevalence rate of MDE did not differ between Asian American men and women. This finding is inconsistent with gender differences in lifetime prevalence of depression among Caucasian Americans because women have been consistently reported to suffer from depression twice as much as men. Whereas no gender differences were found in the prevalence of depression, several gender differences were detected in symptom endorsement in the at-risk sample. The overall tendency for Asian American men was to endorse all but one of the symptoms more often than Asian American women. Specifically, men reported more discouragement, low energy, thoughts of being better off dead, desire to be alone rather than with friends, and decreased talkativeness in comparison to women. A possible explanation for the observed symptom patterns may be that Asian Americans are endorsing these specific symptoms more often in order to communicate their distress. Traditional gender roles in Asian cultures designate men as the breadwinners and women as the caretakers. Men are often seen as tough, agentic, and strong, while women are perceived as communal and adaptive (Okazaki, 1998). 41 Suffering from depression may be a particularly debilitating and contradictory experience for Asian American men. Therefore, reporting symptoms, such as discouragement, low energy, and desire to be dead (e.g., as opposed to sadness, self-reproach, or poor concentration) may have the function of explaining their inability to provide for their family. While some of these symptoms may be explained with gender roles in Asian cultures, others such as crying often, being less talkative, and wanting to be alone may be explained with gender differences in emotion socialization, especially for negative emotions. Research shows that parental emotion socialization may differ for boys and girls. For example, fathers reported that they rewarded girls and punished boys for expressing sadness (Garside & Klimes-Dougan, 2002). If similar emotion socialization gender differences are present among Asian Americans, we can assume that Asian American women will be more likely to exhibit their sadness more openly than Asian American men. The pattern of findings was similar in the MDE sample, although fewer symptoms differed significantly between men and women. This could be due to the smaller sample and the decreased variance of depressive symptoms among participants diagnosed with MDE. The second factor that we examined in relation to depressive symptoms was acculturative stress (AS). Asian American immigrants at risk for depression who experienced higher acculturative stress reported higher frequency of five symptoms, including depressed mood, anhedonia, smaller appetite, weight loss, and psychomotor retardation. Since this pattern presents a mixture of somatic and affective symptoms we may conclude that immigrants under high acculturative stress are more likely to endorse both types of symptoms. Previous research with Asian American immigrants examined the relationship of nativity, English proficiency, age at time of immigration, generational status and their association with lifetime and 12-month 42 prevalence of depressive, anxiety, and substance abuse disorders (Takeuchi, Zane et al., 2007). The findings from this study confirmed the “immigrant paradox”, which states that immigrants were less likely than U.S. born Asian Americans to suffer from any mental disorder in their lifetime. However, our findings suggest that examining a psychological variable such as acculturative stress may offer a unique perspective of looking within the variation of the immigrant group. In other words, although Asian American immigrants may appear healthier overall, there is variation within this group and immigrants who experience higher acculturative stress are likely to report both affective and somatic depressive symptoms more often. This finding is consistent with the proposition that acculturative stress, or the stress that occurs during the acculturation process, is associated with heightened level of psychosomatic symptoms and lowered mental health status (Berry, Kim, Minde, & Mok, 1987). In addition, these results fit with findings from previous studies that tried to disentangle the effects of acculturation and acculturative stress among Asian immigrants (Ayers, Hofstetter, Usita, Irvin, Kang, & Hovell, 2009). Ayers and colleagues examined the effects of acculturation, acculturative stress, and social support on depression among female Korean immigrants. The researchers found that acculturation did not have a direct impact on depression; however, acculturative stress and social support predicted depression. This study concluded that stressful experiences related to acculturation and immigration may lead to depressive feelings. Our study builds upon this finding to point to the specific symptoms that may be more prevalent among Asian immigrants with low and high levels of acculturative stress. Participants with high levels of acculturative stress who were diagnosed with MDE reported smaller appetite and loss of weight more often than participants with low levels of acculturative stress. Interestingly, the low AS group endorsed psychomotor agitation more 43 frequently, having made a suicide plan, and desire to be alone than the high AS group. Overall, Asian Americans who reported high acculturative stress were less likely to be proficient in English. Thus, variations in endorsement of depressive symptoms and acculturative stress may be related to fluctuations in levels of English proficiency and acculturation. The role of language in depressive symptomatology was examined in two different ways: by comparing Asian Americans who interviewed in English versus their native Asian language and by comparing Asian Americans who reported they were English proficient versus nonproficient. Based on previous research, if we assume that language is a proxy of acculturation, we would expect that English proficient Asian Americans are more acculturated than those who are non-proficient (Lee, Nguyen, & Tsui, 2009). The comparisons by choice of language yielded almost identical results in the at-risk and MDE sample. Participants who did the interview in English as opposed to an Asian language were more likely to endorse suicidality (both having thoughts and having a plan) as well as desire to be alone. Those who conducted the interview in an Asian language endorsed insomnia and loss of weight more frequently. The pattern of these results suggests that less acculturated individuals may be reporting somatic symptoms when depressed, while more acculturated individuals may be socially avoidant and desperate. These findings are consistent with Marsella’s (1980, 2003) proposed model of “objective” and “subjective” epistemic orientations for Western and Eastern cultures, respectively. Marsella suggested that people from Western and individualist cultures may be more likely to express depressive symptoms in affective, existential, cognitive, and somatic terms and to report feelings of isolation, separation, and detachment from others. Alternatively, people from Eastern and collectivist cultures may be more likely to express symptoms in somatic and interpersonal terms 44 and discouraged to report negative affect verbally in front of group members in their social networks. Lastly, English proficiency (proficient versus non-proficient) was also significantly associated with endorsement rates of depressive symptoms among Asian Americans. A pattern similar to the observed Caucasian American-Asian American differences was noticed: English proficient Asian Americans were more likely than non-proficient speakers to report reverse somatic symptoms, such as weight gain and hypersomnia. It is possible that if English proficient speakers are more acculturated, the manifestation of their depression is starting to resemble that among Caucasian Americans (Lee, 2002). In addition, non-proficient (and less acculturated) Asian Americans were more likely than English proficient Asian Americans to endorse somatic symptoms, such as insomnia and psychomotor agitation, which would be consistent with a more somatic presentation of depression among Asians (e.g., Parker et al., 2001). Another parallel that can be drawn between the Caucasian-Asian American comparison and the English proficientnon-proficient comparison is that Caucasian and English proficient participants reported their desire to be alone rather than with friends when depressed more often than Asians and nonproficient participants. Again, the difference in the endorsement of this symptom may be best explained within the framework of individual versus collectivist societies (Markus & Kitayama, 1991), as the former may be more prone and tolerant to isolation and avoidance when one is depressed, while the latter may encourage and expect social interactions regardless of one’s affect. Clinical Implications The reported findings have important implications for mental health professionals and primary care physicians who work with Asian Americans. A culturally informed assessment of 45 depressive symptoms among Asian Americans may not emphasize affective symptoms, such as feeling sad, empty, or depressed or losing interest in things that were previously enjoyed. While these symptoms may be present among depressed Asian Americans, they may not be the most salient ones or the reason why the clients sought help in the first place. When assessing distress and impairment, it may be helpful to ask questions related to physical distress (e.g., bodily pains) and different areas of impairment (e.g., work, social interactions) instead of assuming a focus entirely on emotions. In addition, taking into consideration the effect of gender, acculturation, and acculturative stress of the client may be essential for the assessment, diagnosis, and treatment of depression among Asian Americans. Since men may be more likely to report symptoms that interfere with their ability to provide, those may be the symptoms that they readily describe and seek treatment for (e.g., feeling discouraged or tired). English proficiency and high levels of acculturation among Asian Americans may change the presentation of symptoms in ways that are more similar to Caucasian Americans’ expression of depression. Therefore, mental health professionals and physicians may need to be particularly attuned to clients with low English proficiency and low levels of acculturation. Such clients may report primarily somatic symptoms and may have difficulty discussing emotions, such as sadness, irritability, and frustration. In addition, it is important to consider the effects of acculturative stress that new immigrants deal with during the process of acculturation. High levels of acculturative stress may be likely to result in a high prevalence of both somatic and affective symptoms among Asian immigrants, which may indicate their high level of distress. Limitations This study had several limitations that need to be addressed in future research. First, the screening process that was used in the WMH-CIDI limited our sample to Asian American 46 participants who reported past experiences of sad, empty, or depressed mood, discouragement, and lack of interest. While this screening process is consistent with the current DSM-IV diagnosis, it might have eliminated Asian American participants who experienced depression in strictly somatic terms. However, we believe that the sample that we examined still presented with reasonable cultural variations in depression and provided valid data to answer our research questions. Another limitation of the current study was the small cell counts to examine differences in depressive symptoms based on ethnicity. While one of the strengths that the CPES dataset has is the oversampling of Chinese, Filipino, and Vietnamese participants, we could not take advantage of this feature because the number of individuals in each ethnic group who were at risk for depression or diagnosed with MDE was already substantially reduced. Thus, any analyses that compared individuals across ethnic groups would have provided results of questionable validity. A limitation of this study that is associated with secondary data analysis is the restriction of variables that could be explored. Since acculturation was not measured in the NLAAS, we used spoken English proficiency as a proxy for acculturation. However, we realize that language represents only one facet of the complex process of acculturation. In addition, the acculturative stress measure was administered to Asian immigrants only, which suggests that it is more likely that it captured issues related to immigration stress rather than acculturative stress. Directions for Future Research The systematic examination of symptom profiles of mental disorders among ethnic and racial minorities and cross-culturally can provide valuable information that will help in improving assessment, diagnosis, and treatment. In the case of depression, it may be particularly 47 important to examine symptoms of depression among individual ethnic groups of Asian Americans and other racial minorities. In addition, while we found cross-racial and cross-gender differences, testing the mechanisms behind these differences in the expression of depressive symptoms among Asian Americans will be an important next step. Another topic that deserves more attention is the effects of acculturation and acculturative stress on the overall prevalence of depression and depressive symptoms in particular. While there is some evidence to suggest that low acculturation may be linked to high acculturative stress for new immigrants, we know little about the impact of acculturative stress (i.e., the psychological, somatic, and social difficulties during the process of acculturation) on the manifestation of depression. Researchers may need to examine particular psychological variables that are related to acculturation and immigration in order to understand their effects on mental health and mental disorders. Lastly, future research of depressive symptoms endorsed by both depressed and non-depressed Asian Americans may shed some light in elucidating the diagnostic validity of the DSM-IV MDE diagnosis. In general, having a more loosely defined sample as opposed to a strictly defined sample will allow us to examine cultural variations of depression and other disorders more thoroughly. To our knowledge, this is the first study that examined a symptom profile of depression among Asian Americans and compared it to Caucasian Americans in a nationally representative sample. Overall, the findings suggested that Asian Americans express depression through both somatic and affective symptoms. However, Asian Americans are less likely to report a variety of symptoms, including affective ones, in comparison to Caucasian Americans. This finding may confirm the tendency of Westerners to “psychologize” depression and weaken the claim that Asians tend to “somaticize” depression. However, the current finding that the Asian Americans did not somaticize depression as much as would be expected according to the literature on 48 Asians (e.g., Kleinman, 1977; Parker et al., 2001) may be moderated by the acculturation level of the sample which was not assessed directly in this study. Additional research will be needed to tease out whether acculturation moderates the somatization tendency or if the “somatization” tendency does not apply to Asian Americans. It is important to note that the high endorsement rates of depressive symptoms among Caucasian Americans in comparison to Asian Americans may reflect differences in emotional restraint and self-construal. At the same time, differences were observed within Asian Americans in relation to gender, language, and acculturative stress. Variations in gender were marked by higher endorsement of discouragement, fatigue, and suicidality among men than women and were hypothesized to be related to gender roles among Asian Americans. Lastly, differences in symptom expression among English proficient and non-proficient Asian Americans resembled differences among Caucasian and Asian Americans. It was suggested that more acculturated Asian Americans may manifest depression similarly to Caucasian Americans. 49 Appendix A 50 Appendix A In answering the next questions, think about the period of (several days/two weeks) or longer during that episode when your (sadness/and/discouragement/and/loss of interest) and other problems were most severe and frequent. During that period, which of the following problems did you have most of the day nearly every day: 1. Did you feel sad, empty, or depressed most of the day nearly every day during that period of (several days/ two weeks) or longer? 2. During that period of (several days/ two weeks) or longer, did you feel discouraged about how things were going in your life most of the day nearly every day? 3. During that period of (several days/ two weeks) or longer, did you lose interest in almost all things like work and hobbies and things you like to do for fun? 4. Did you have a much smaller appetite than usual nearly every day during that period of (several days/ two weeks)? 5. Did you have a much larger appetite than usual nearly every day? 6. Did you gain weight without trying to during that period of (several days/ two weeks)? 7. Did you lose weight without trying to? 8. Did you have a lot more trouble than usual either falling asleep, staying asleep, or waking too early nearly every night during that period of (several days/ two weeks)? 9. Did you sleep a lot more than usual nearly every night during that period of (several days/ two weeks)? 51 10. Did you feel tired or low in energy nearly every day during that period of (several days/ two weeks) even when you had not been working very hard? 11. Did you talk or move more slowly than is normal for you nearly every day? 12. Were you so restless or jittery nearly every day that you paced up and down or couldn't sit still? 13. Did your thoughts come much more slowly than usual or seem mixed up nearly every day during that period of (several days/ two weeks)? 14. Did you have a lot more trouble concentrating than is normal for you nearly every day? 15. Were you unable to make up your mind about things you ordinarily have no trouble deciding about? 16. Did you lose your self-confidence? 17. Did you feel that you were not as good as other people nearly every day? 18. Did you have feelings of extreme guilt nearly every day? 19. Did you feel irritable, grouchy, or in a bad mood nearly every day? 20. Did you feel nervous or anxious most days? 21. Did you often think a lot about death, either your own, someone else’s, or death in general? 22. During that period, did you ever think that it would be better if you were dead? 23. Did you think about committing suicide? 24. Did you make a suicide plan? 25. Did you make a suicide attempt? 26. Did you feel like you wanted to be alone rather than spend time with friends or relatives? 27. Did you feel less talkative than usual? 28. Were you often in tears? 52 Appendix B 53 Table 1 Descriptives for the At-Risk for Depression Sample (n = 2073) Asian Caucasian (n = 310) (n = 1763) M(%) (SE) M(%) (SE) Vietnamese 9.6% (1.8) NA Filipino 16.3% (1.5) NA Chinese 31.1% (3.3) NA Other Asian 42.9% (2.9) NA Male 38.7% (2.7) 38.7% (1.4) Female 61.3% (2.7) 61.3% (1.4) 39.22 (.88) 44.15 (.65) 0-11 years 9.7 (2.2) 12.8 (1.0) 12 years 15.3 (1.9) 30.3 (1.2) 13-15 years 25.8 (2.5) 30.2 (0.9) ≥ 16 years 49.2 (2.4) 26.7 (1.3) Married/Cohabiting 53.7 (2.5) 54.5 (1.6) Divorced/Separated 14.2 (1.7) 24.8 (1.1) Never Married 32.2 (1.9) 20.6 (1.7) Endorsed 69.0% (2.2) 78.3% (1.0) Variables Ethnicity Gender Age Education Marital Status MDE Dx 54 Table 1 (cont’d) Not Endorsed 31.0% (2.2) 21.7% (1.0) Frequency of emotional distress 2.60 (0.06) 2.55 (0.03) Sadness interfering with work/relations 3.23 (0.06) 3.55 (0.03) Frequency of inability to perform daily activities 2.85 (0.06) 2.67 (0.03) Severity of emotional distress 2.50 (0.07) 2.66 (0.03) # hours sadness/day 3.22 (0.06) 3.59 (0.02) 2.38 (0.21) NA English 74.6% (3.3) NA Asian Language 25.4% (3.3) NA n = 278 2.92 (0.11) NA Acculturative Stress n = 136 Language Choice n = 279 English Language Proficiency 55 Table 2 Descriptives for the MDE Sample (n = 1598) Asian Caucasian (n = 221) (n = 1375) M (%) (SE) M (%) (SE) Vietnamese 11.8% (2.6) NA Filipino 16.5% (1.9) NA Chinese 30.7% (4.0) NA Other Asian 40.9% (3.6) NA Male 41.1% (3.4) 37.4% (1.4) Female 58.9% (3.4) 62.6% (1.4) 38.44 (1.05) 43.45 (0.62) 0-11 years 9.4 (2.8) 13.3 (1.1) 12 years 16.5 (2.6) 30.6 (1.3) 13-15 years 30.7 (3.6) 30.5 (1.2) ≥ 16 years 43.4 (3.5) 25.6 (1.3) Married/Cohabiting 49.6 (2.8) 53.4 (1.5) Divorced/Separated 15.3 (2.0) 25.9 (1.2) Never Married 35.1 (1.9) 20.6 (1.6) Onset of MDE 29.97 (1.29) 33.32 (0.57) Duration of MDE 420.27 (116.90) 331.09 (33.94) Variables Ethnicity Gender Age Education Marital Status 56 Table 2 (cont’d) Frequency of emotional distress 2.77 (0.06) 2.69 (0.03) Sadness interfering with work/relations 3.42 (0.06) 3.69 (0.03) Frequency of inability to perform daily activities 2.99 (0.07) 2.79 (0.03) Severity of emotional distress 2.65 (0.07) 2.75 (0.03) # hours sadness/day 3.33 (0.07) 3.64 (0.02) 2.75 (0.26) NA English 74.6% (4.1) NA Asian Language 25.4% (4.1) NA n = 196 2.90 (0.15) NA Acculturative Stress n = 96 Language Choice n = 198 English Language Proficiency 57 Table 3 Frequency of Depressive Symptoms among Asian Americans at Risk for Depression (n = 310) Symptom Item Frequency SE Unweighted n Depressed Mood Felt sad, empty or depressed 89.0 0.9 276 Discouraged about things in your life 80.1 1.8 247 68.3 2.0 214 Smaller appetite 64.9 2.7 203 Larger appetite 8.3 2.0 24 Gain weight 9.7 1.7 28 Lose weight 53.1 3.1 171 Insomnia 74.1 2.0 225 Sleep a lot more than usual 13.7 1.4 36 83.3 2.5 245 Talk/move more slowly 52.5 2.7 149 Restless and jittery 10.7 1.9 29 72.9 3.5 217 Anhedonia Lose interest in almost all things Appetite/Weight change Sleep disturbance Loss of energy Low energy Psychomotor retardation/agitation Cognitive difficulties Trouble concentrating 58 Table 3 (cont’d) Slow thought 55.3 3.3 170 Indecisive 56.6 2.8 162 Lost self-confidence 71.5 2.3 217 Feel not as good as other people 61.5 3.3 181 Feelings of extreme guilt 59.9 2.7 179 Thought of death 51.0 3.7 151 Would be better off dead 43.1 3.1 123 Thought of committing suicide 26.4 3.0 81 Made a suicide plan 11.8 1.7 34 8.9 1.4 25 Irritable, grouchy, or in a bad mood 59.9 2.7 179 Nervous or anxious 59.3 2.7 169 Wanted to be alone rather than with friends 67.0 2.1 207 Less talkative 80.8 2.7 238 Often in tears 60.4 2.4 181 Self-reproach Suicidality Made a suicide attempt Other psychological problems Note: Symptoms in bold indicate high frequency of endorsement (over 70%). 59 Table 4 Frequency of Depressive Symptoms among Asian Americans with MDE (n = 221) Symptom Item Frequency SE Unweighted n Depressed Mood Felt sad, empty or depressed 95.9 0.4 212 Discouraged about things in your life 90.2 1.8 196 84.1 1.9 183 Smaller appetite 72.7 3.0 163 Larger appetite 9.4 3.0 18 Gain weight 9.6 2.4 20 Lose weight 60.7 3.8 142 Insomnia 77.3 2.0 178 Sleep a lot more than usual 14.6 1.6 26 90.1 1.7 196 Talk/move more slowly 56.1 3.0 120 Restless and jittery 13.5 2.3 27 80.8 3.7 181 Anhedonia Lose interest in almost all things Appetite/Weight change Sleep disturbance Loss of energy Low energy Psychomotor retardation/agitation Cognitive difficulties Trouble concentrating 60 Table 4 (cont’d) Slow thought 59.8 4.1 140 Indecisive 65.6 2.7 137 Lost self-confidence 78.7 3.3 173 Feel not as good as other people 70.1 4.1 151 Feelings of extreme guilt 51.8 2.9 109 Thought of death 60.0 4.5 128 Would be better off dead 47.0 3.9 100 Thought of committing suicide 31.0 3.5 68 Made a suicide plan 14.2 1.9 29 Made a suicide attempt 9.8 1.7 20 Irritable, grouchy, or in a bad mood 63.8 3.1 140 Nervous or anxious 64.2 3.5 137 Wanted to be alone rather than with friends 73.0 2.4 164 Less talkative 85.1 2.9 187 Often in tears 68.8 2.5 149 Self-reproach Suicidality Other psychological problems Note: Symptoms in bold indicate high frequency of endorsement (over 70%). 61 Table 5 Endorsement and Prevalence of Depressive Symptoms among Asian Americans (n = 310) and Caucasian Americans (n = 1763) at Risk for Depression Symptom Item Asian SE Caucasian SE Total χ² p Depressed Mood Felt sad, empty or depressed 89.0 1.7 92.8 0.7 92.7 1.346 .030 Discouraged about things in your life 80.2 2.4 86.8 0.8 86.6 2.288 .006 68.3 2.4 74.5 1.1 74.3 1.223 .021 Smaller appetite 64.9 3.6 63.9 1.4 63.9 .023 .807 Larger appetite 8.3 2.1 13.9 0.9 13.8 1.549 .044 Gain weight 9.7 2.0 15.1 0.8 14.9 1.307 .028 Lose weight 53.1 3.6 53.6 1.6 53.6 .006 .892 Insomnia 74.1 2.3 73.7 1.3 73.7 .005 .873 Sleep a lot more than usual 13.7 2.0 16.2 1.0 16.1 .261 .318 83.3 2.7 83.4 1.1 83.4 .000 .982 Talk/move more slowly 52.5 3.1 52.0 1.1 52.0 .006 .883 Restless and jittery 10.7 2.3 13.4 1.0 13.3 .353 .317 Anhedonia Lose interest in almost all things Appetite/Weight change Sleep disturbance Loss of energy Low energy Psychomotor retardation/agitation Cognitive difficulties 62 Table 5 (cont’d) Trouble concentrating 72.9 3.8 77.8 0.7 77.7 .791 .171 Slow thought 55.3 3.5 55.9 1.2 55.9 .010 .862 Indecisive 56.6 3.3 62.4 1.2 62.3 .832 .102 Lost self-confidence 71.5 2.7 78.2 1.0 78.0 1.442 .019 Feel not as good as other people 61.5 3.5 59.4 1.3 59.5 .109 .563 Feelings of extreme guilt 42.5 3.3 51.4 1.3 51.2 1.820 .010 Thought of death 51.0 4.0 58.3 1.3 58.0 1.226 .095 Would be better off dead 43.1 3.3 42.9 1.4 42.9 .001 .952 Thought of committing suicide 26.4 3.2 33.0 1.2 32.8 1.131 .075 Made a suicide plan 11.8 2.1 11.0 0.9 11.0 .033 .746 Made a suicide attempt 8.9 1.5 8.5 0.6 8.5 .013 .788 Irritable, grouchy, or in a bad mood 59.9 3.4 58.0 1.0 58.0 .082 .593 Nervous or anxious 59.3 3.2 64.3 1.4 64.2 .635 .148 Alone rather than with friends 67.0 2.4 77.0 0.9 76.7 3.191 .001 Less talkative 80.8 3.0 81.2 0.8 81.2 .005 .911 Often in tears 60.4 2.6 66.9 0.9 66.7 1.079 .019 Self-reproach Suicidality Other psychological problems Note: Percents are weighted. Statistical tests are design adjusted. Boldface type indicates a significant chi-square test for difference at the p = 0.05 level. 63 Table 6 Endorsement and Prevalence of Depressive Symptoms among Asian Americans (n = 221) and Caucasian Americans (n = 1375) with MDE Symptom Item Asian SE Caucasian SE Total χ² p Felt sad, empty or depressed 95.9 0.8 95.9 0.5 95.9 0.001 1.000 Discouraged about things in your life 90.2 1.9 91.4 0.7 91.3 0.069 0.562 84.1 2.4 82.7 1.3 82.8 0.055 0.632 Smaller appetite 72.7 3.5 68.4 1.4 68.5 0.370 0.281 Larger appetite 9.4 3.1 15.2 0.9 15.1 1.102 0.135 Gain weight 9.6 2.5 16.4 1.0 16.3 1.410 0.037 Lose weight 60.7 4.1 57.2 1.7 57.3 0.197 0.465 Insomnia 77.3 2.8 77.1 1.0 77.1 0.001 0.959 Sleep a lot more than usual 14.6 2.5 17.1 0.9 17.0 0.184 0.406 90.1 1.8 89.0 1.1 89.0 0.055 0.609 Talk/move more slowly 56.1 3.7 56.9 1.3 56.8 0.009 0.857 Restless and jittery 13.5 3.1 13.9 1.0 13.9 0.005 0.903 Depressed Mood Anhedonia Lose interest in almost all things Appetite/Weight change Sleep disturbance Loss of energy Low energy Psychomotor retardation/agitation Cognitive difficulties 64 Table 6 (cont’d) Trouble concentrating 80.8 4.1 84.5 0.6 84.4 0.428 0.336 Slow thought 59.8 4.4 62.3 1.3 62.2 0.113 0.582 Indecisive 65.6 3.1 68.7 1.7 68.7 0.175 0.397 Lost self-confidence 78.7 3.5 80.7 1.1 80.7 0.112 0.582 Feel not as good as other people 70.1 4.4 63.1 1.4 63.3 0.874 0.144 Feelings of extreme guilt 51.8 3.5 55.6 1.6 55.5 0.236 0.325 Thought of death 60.0 4.7 63.2 1.4 63.1 0.176 0.528 Would be better off dead 47.0 4.1 46.8 1.6 46.8 0.001 0.974 Thought of committing suicide 31.0 3.7 37.3 1.4 37.2 0.699 0.138 Made a suicide plan 14.2 2.3 12.7 1.1 12.8 0.075 0.576 Made a suicide attempt 9.8 1.8 9.3 0.8 9.4 0.012 0.801 Irritable, grouchy, or in a bad mood 63.8 3.7 61.0 1.3 61.1 0.129 0.482 Nervous or anxious 64.2 3.9 67.8 1.2 67.7 0.244 0.383 Alone rather than with friends 73.0 2.7 80.7 1.2 80.5 1.561 0.006 Less talkative 85.1 3.2 84.8 0.9 84.8 0.003 0.931 Often in tears 68.8 2.8 69.5 1.1 69.5 0.011 0.803 Self-reproach Suicidality Other psychological problems Note: Percents are weighted. Statistical tests are design adjusted. Boldface type indicates a significant chi-square test for difference at the p = 0.05 level. 65 Table 7 Frequency and Severity of Distress and Impairment among Asian Americans (n = 310) and Caucasian Americans (n = 1763) at Risk for Depression Variable Asian Caucasian t-test p Frequency of emotional distress interfering 2.60 (0.06) 2.55 (0.03) 0.737 0.463 3.23 (0.06) 3.55 (0.03) -4.779 0.001* 2.85 (0.06) 2.67 (0.03) 2.510 0.015* Severity of emotional distress 2.50 (0.07) 2.66 (0.03) -2.271 0.026* # hours sadness/day** 3.22 (0.06) 3.59 (0.02) -5.650 0.001* with daily activities Sadness interfered with work/relations/social life Frequency of inability to perform daily activities *Statistically significant at p < .05 **Higher values show more hours of sadness on an ordinal scale of less than 1 hour/day (1) to more than 5 hours/day (4) 66 Table 8 Frequency and Severity of Distress and Impairment among Asian Americans (n = 221) and Caucasian Americans (n = 1377) with MDE Variable Asian Caucasian t-test p Frequency of emotional distress interfering 2.77 (0.06) 2.69 (0.03) 1.248 0.217 3.42 (0.06) 3.69 (0.03) -4.107 0.001* 2.99 (0.07) 2.79 (0.03) 2.613 0.011* Severity of emotional distress 2.65 (0.07) 2.75 (0.03) -1.367 0.177 # hours sadness/day** 3.33 (0.07) 3.64 (0.02) -4.006 0.001* with daily activities Sadness interfered with work/relations/social life Frequency of inability to perform daily activities *Statistically significant at p < .05 **Higher values show more hours of sadness on an ordinal scale of less than 1 hour/day (1) to more than 5 hours/day (4) 67 Table 9 Endorsement and Prevalence of Depressive Symptoms among Asian American Men (n = 121) and Women (n = 189) at Risk for Depression Symptom Item Men SE Women SE Total χ² p Felt sad, empty or depressed 90.2 1.4 88.2 1.4 89.0 .317 .336 Discouraged about things in life 88.4 1.9 74.9 3.0 80.1 8.331 .002 74.6 3.2 64.3 3.4 68.3 3.626 .075 Smaller appetite 61.2 4.2 67.2 4.0 64.9 1.105 .344 Larger appetite 7.0 3.0 9.1 2.1 8.3 .403 .518 Gain weight 7.0 2.8 11.4 2.2 9.7 1.522 .296 Lose weight 51.6 4.4 54.1 4.5 53.1 .170 .703 Insomnia 73.2 3.4 74.7 2.6 74.1 .086 .728 Sleep a lot more than usual 15.3 3.3 12.7 2.0 13.7 .416 .549 90.0 3.0 79.1 2.7 83.3 6.063 .008 Talk/move more slowly 55.4 4.5 50.7 3.8 52.5 .619 .461 Restless and jittery 13.3 3.2 9.1 2.0 10.7 1.242 .245 Depressed Mood Anhedonia Lose interest in almost all things Appetite/Weight change Sleep disturbance Loss of energy Low energy Psychomotor retardation/agitation Cognitive difficulties 68 Table 9 (cont’d) Trouble concentrating 75.8 4.6 71.0 4.5 72.9 .803 .425 Slow thought 60.4 4.4 52.0 4.6 55.3 1.992 .197 Indecisive 61.4 4.0 53.5 4.0 56.6 1.762 .204 Lost self-confidence 67.5 5.6 74.1 3.0 71.5 1.494 .356 Feel not as good as other people 67.3 4.5 57.9 4.1 61.5 2.656 .104 Feelings of extreme guilt 47.4 3.7 39.4 3.1 42.5 1.810 .119 Thought of death 56.2 6.3 47.7 5.0 51.0 1.993 .337 Would be better off dead 54.5 5.3 35.8 3.8 43.1 .008 Thought of committing suicide 28.5 6.1 25.0 3.5 26.4 10.04 3 .446 .636 Made a suicide plan 12.2 4.0 11.5 2.0 11.8 .040 .873 Made a suicide attempt 6.8 3.3 10.2 1.8 8.9 .966 .472 Irritable, grouchy, or in a bad mood 59.8 4.0 59.9 3.2 59.9 .001 .970 Nervous or anxious 61.2 4.1 58.1 2.7 59.3 .292 .430 Alone rather than with friends 75.4 3.3 61.7 3.3 67.0 5.942 .018 Less talkative 88.7 2.7 75.8 3.5 80.8 7.597 .004 Often in tears 41.2 3.4 72.7 3.0 60.4 Self-reproach Suicidality Other psychological problems 29.28 .001 7 Note: Percents are weighted. Statistical tests are design adjusted. Boldface type indicates a significant chi-square test for difference at the p = 0.05 level. 69 Table 10 Endorsement and Prevalence of Depressive Symptoms among Asian American Men (n = 91) and Women (n = 130) with MDE Symptom Item Men SE Women SE Total χ² Felt sad, empty or depressed 96.8 0.8 95.2 0.4 95.9 0.314 0.120 Discouraged about things in life 97.0 1.6 85.5 2.7 90.2 8.052 0.004 88.9 3.1 80.8 2.7 84.1 2.640 0.112 Smaller appetite 67.5 4.5 76.4 4.0 72.7 2.123 0.126 Larger appetite 7.4 3.8 10.8 3.4 9.4 0.694 0.461 Gain weight 7.5 3.6 11.1 3.3 9.6 0.799 0.505 Lose weight 58.5 5.0 62.3 5.3 60.7 0.323 0.590 Insomnia 79.1 2.9 76.0 3.2 77.3 0.280 0.536 Sleep a lot more than usual 13.9 3.5 15.1 2.4 14.6 0.065 0.807 92.2 3.1 88.7 1.9 90.1 0.751 0.385 Talk/move more slowly 54.3 4.4 57.4 4.1 56.1 0.210 0.615 Restless and jittery 15.5 3.7 12.0 2.5 13.5 0.551 0.408 p Depressed Mood Anhedonia Lose interest in almost all things Appetite/Weight change Sleep disturbance Loss of energy Low energy Psychomotor retardation/agitation Cognitive difficulties 70 Table 10 (cont’d) Trouble concentrating 80.0 5.0 81.3 4.3 80.8 0.056 0.817 Slow thought 62.7 4.9 57.7 6.2 59.8 0.550 0.543 Indecisive 66.9 4.2 64.7 4.0 65.6 0.112 0.732 Lost self-confidence 78.7 7.3 78.7 3.7 78.7 .001 1.000 Feel not as good as other people 75.3 5.1 66.5 4.8 70.1 1.962 0.112 Feelings of extreme guilt 57.1 4.1 48.1 3.9 51.8 1.746 0.123 Thought of death 61.5 6.9 59.0 5.3 60.0 0.146 0.758 Would be better off dead 55.9 5.8 40.8 4.8 47.0 4.886 0.045 Thought of committing suicide 33.8 7.8 29.1 4.6 31.0 0.549 0.644 Made a suicide plan 15.9 5.1 13.0 2.2 14.2 0.383 0.630 Made a suicide attempt 8.9 4.0 10.5 2.3 9.8 0.154 0.774 Irritable, grouchy, or in a bad mood 67.3 4.4 61.2 3.8 63.8 0.860 0.236 Nervous or anxious 69.4 4.7 60.6 3.5 64.2 1.813 0.040 Alone rather than with friends 79.9 3.6 68.1 3.8 73.0 3.761 0.067 Less talkative 91.5 2.1 80.7 4.3 85.1 4.977 0.016 Often in tears 49.2 4.0 82.5 2.9 68.8 27.65 0.001 Self-reproach Suicidality Other psychological problems Note: Percents are weighted. Statistical tests are design adjusted. Boldface type indicates a significant chi-square test for difference at the p = 0.05 level. 71 Table 11 Endorsement and Prevalence of Depressive Symptoms among Asian Americans at Risk for Depression with High (n = 57) and Low (n = 79) Levels of Acculturative Stress Symptom Item Low АS SE High AS SE Total χ² p Depressed Mood Felt sad, empty or depressed 86.3 2.5 96.0 1.1 90.2 3.483 .002 Discouraged about things in life 81.8 3.8 91.6 3.1 85.7 2.542 .076 61.7 4.1 83.9 4.9 70.6 7.776 .013 52.2 5.6 85.3 4.2 66.2 15.62 .001 Larger appetite - - - - - - Gain weight - - - - - - - Lose weight 41.7 6.9 73.9 8.3 54.7 12.99 .006 72.8 4.3 84.5 3.6 77.8 2.553 .082 - - - - - - - 81.4 7.2 86.0 3.8 83.4 .487 .462 Talk/move more slowly 51.7 5.1 71.5 7.7 60.1 5.274 .020 Restless and jittery 12.4 2.9 7.5 3.7 10.3 .812 .361 Anhedonia Lose interest in almost all things Appetite/Weight change Smaller appetite - Sleep disturbance Insomnia Sleep a lot more than usual Loss of energy Low energy Psychomotor retardation/agitation Cognitive difficulties 72 Table 11 (cont’d) Trouble concentrating 71.8 4.5 84.1 4.7 77.0 2.710 .085 Slow thought 56.0 6.0 66.3 10.7 60.4 1.416 .449 Indecisive 52.9 7.2 64.4 5.7 57.8 1.733 .151 Lost self-confidence 70.6 4.7 68.1 9.7 69.6 .092 .815 Feel not as good as other people 65.0 6.1 59.5 11.3 62.7 .415 .673 Feelings of extreme guilt 34.6 5.4 34.0 6.6 34.3 .006 .927 Thought of death 46.6 5.6 50.4 13.3 48.2 .188 .758 Would be better off dead 45.1 5.9 49.9 7.0 47.1 .300 .500 Thought of committing suicide 26.1 5.8 25.5 6.7 25.8 .006 .937 Made a suicide plan 16.4 3.9 8.5 4.5 13.2 1.696 .098 Made a suicide attempt 15.8 4.1 12.3 5.6 14.4 .311 .506 Irritable, grouchy, or in a bad mood 59.6 4.3 59.1 7.2 59.4 .003 .959 Nervous or anxious 59.8 4.4 65.4 7.3 62.2 .429 .424 Alone rather than with friends 64.4 5.7 56.4 5.0 61.0 .859 .253 Less talkative 87.8 4.0 82.7 4.9 85.6 .688 .403 Often in tears 56.7 6.4 70.8 7.6 62.6 2.697 .244 Self-reproach Suicidality Other psychological problems Note: Percents are weighted. Statistical tests are design adjusted. Boldface type indicates a significant chi-square test for difference at the p = 0.05 level. Missing values indicate insufficient cells counts (expected count for unweighted values was < 5). 73 Table 12 Endorsement and Prevalence of Depressive Symptoms among Asian Americanс with MDE with High (n = 51) and Low (n = 45) Levels of Acculturative Stress Symptom Item Low АS SE High AS SE Total χ² p Depressed Mood Felt sad, empty or depressed - - - - - - - Discouraged about things in life - - - - - - - 86.3 2.9 90.9 5.1 88.6 .498 .524 63.9 7.5 94.0 3.1 79.0 13.06 .001 Larger appetite - - - - - - Gain weight - - - - - - - Lose weight 54.2 8.5 82.8 8.8 68.0 8.874 .024 73.2 6.1 85.0 3.0 79.1 2.021 .142 - - - - - - - - - - - - - - Talk/move more slowly 60.2 6.8 73.3 8.3 66.8 1.873 .123 Restless and jittery 20.0 4.6 5.7 3.0 12.8 4.381 .032 Anhedonia Lose interest in almost all things Appetite/Weight change Smaller appetite - Sleep disturbance Insomnia Sleep a lot more than usual Loss of energy Low energy Psychomotor retardation/agitation Cognitive difficulties 74 Table 12 (cont’d) Trouble concentrating 85.8 3.3 88.7 5.2 87.2 .178 .685 Slow thought 65.3 8.2 64.0 12.6 64.7 .017 .933 Indecisive 62.9 7.5 72.3 5.8 67.6 .970 .179 Lost self-confidence 87.5 4.5 68.5 10.7 78.3 5.064 .054 Feel not as good as other people 74.1 5.1 66.4 12.3 70.2 .672 .558 Feelings of extreme guilt 46.6 6.0 37.2 7.0 41.9 .867 .186 Thought of death 62.6 6.6 54.4 15.7 58.5 .656 .597 Would be better off dead 52.5 8.2 46.8 7.8 49.6 .309 .553 Thought of committing suicide 34.2 6.9 22.4 7.5 28.4 1.639 .231 Made a suicide plan 22.8 5.7 8.4 4.2 15.8 3.688 .002 Made a suicide attempt 20.5 5.6 12.5 5.9 16.6 1.082 .175 Irritable, grouchy, or in a bad mood 70.1 5.2 63.3 7.0 66.8 .498 .388 Nervous or anxious 70.4 5.8 64.8 8.1 67.6 .337 .487 Alone rather than with friends 83.5 5.5 56.0 5.8 69.7 8.597 .007 Less talkative - - - - - - - Often in tears 72.2 7.9 73.0 7.8 72.6 .008 .948 Self-reproach Suicidality Other psychological problems Note: Percents are weighted. Statistical tests are design adjusted. Boldface type indicates a significant chi-square test for difference at the p = 0.05 level. Missing values indicate insufficient cells counts (expected count for unweighted values was < 5). 75 Table 13 Endorsement and Prevalence of Depressive Symptoms among Asian Americans at Risk for Depression who Interviewed in English (n =199) and in an Asian Language (n = 80) Symptom Item English SE Asian SE Total χ² p Depressed Mood Felt sad, empty or depressed 89.4 1.3 91.1 1.8 89.9 .153 .379 Discouraged about things in life 80.0 2.8 85.3 4.3 81.3 .978 .374 67.2 3.0 78.1 4.3 70.0 3.021 .087 Smaller appetite 65.9 2.3 65.9 7.3 65.9 .001 .993 Larger appetite - - - - - - - Gain weight - - - - - - - Lose weight 52.2 3.2 59.7 9.0 54.1 1.103 .419 72.2 2.4 88.1 5.0 76.3 7.157 .037 - - - - - - - 86.2 1.9 76.3 6.9 83.6 3.696 .062 Talk/move more slowly 52.4 3.0 53.8 9.8 52.8 .041 .897 Restless and jittery 10.7 1.8 14.8 5.0 11.8 .840 .363 Anhedonia Lose interest in almost all things Appetite/Weight change Sleep disturbance Insomnia Sleep a lot more than usual Loss of energy Low energy Psychomotor retardation/agitation Cognitive difficulties 76 Table 13 (cont’d) Trouble concentrating 73.0 4.0 69.8 7.2 72.2 .252 .654 Slow thought 54.3 3.8 61.0 8.0 56.0 .949 .443 Indecisive 58.0 4.2 46.7 10.1 55.1 2.602 .381 Lost self-confidence 73.8 3.0 66.6 7.4 71.9 1.304 .404 Feel not as good as other people 62.3 2.9 55.2 10.0 60.5 1.091 .466 Feelings of extreme guilt 43.4 2.4 32.8 6.9 40.6 2.361 .211 Think about death 52.5 4.7 49.6 8.6 51.8 .177 .776 Would be better off dead 43.6 3.5 44.1 8.2 43.8 .005 .957 Thought of committing suicide 30.6 3.6 15.4 5.1 26.7 6.063 .042 Made a suicide plan 15.6 2.1 3.7 2.1 12.5 6.665 .005 Made a suicide attempt 10.7 1.7 6.9 3.2 9.7 .823 .352 Irritable, grouchy, or in a bad mood 59.1 3.0 57.8 7.7 58.7 .036 .871 Nervous or anxious 54.9 2.9 65.8 6.9 57.7 2.485 .162 Alone rather than with friends 75.5 2.5 43.2 6.2 67.2 24.213 .001 Less talkative 79.6 2.8 85.5 5.1 81.1 1.196 .250 Often in tears 62.9 3.0 57.8 8.0 61.6 .568 .310 Self-reproach Suicidality Other psychological problems Note: Percents are weighted. Statistical tests are design adjusted. Boldface type indicates a significant chi-square test for difference at the p = 0.05 level. Missing values indicate insufficient cells counts (expected count for unweighted values was < 5). 77 Table 14 Endorsement and Prevalence of Depressive Symptoms among Asian American with MDE who Interviewed in English (n =141) and in an Asian Language (n = 57) Symptom Item English SE Asian SE Total χ² p Depressed Mood Felt sad, empty or depressed - - - - - - - 90.7 2.3 89.8 4.1 90.5 .035 .851 84.8 2.9 92.1 2.7 86.8 1.764 .121 Smaller appetite 73.1 2.9 77.9 5.4 74.3 .444 .305 Larger appetite - - - - - - - Gain weight - - - - - - - Lose weight 58.7 4.7 76.5 6.9 63.0 4.862 .039 Insomnia 75.3 2.7 95.4 3.0 80.4 9.605 .009 Sleep a lot more than usual 13.5 2.3 2.9 2.9 10.8 4.377 .121 90.4 2.2 92.4 2.8 90.9 .182 .538 Talk/move more slowly 54.2 3.6 62.0 9.9 56.2 .935 .486 Restless and jittery 13.8 2.4 17.6 5.2 14.7 .444 .414 Discouraged about things in life Anhedonia Lose interest in almost all things Appetite/Weight change Sleep disturbance Loss of energy Low energy Psychomotor retardation/agitation Cognitive difficulties 78 Table 14 (cont’d) Trouble concentrating 80.3 4.2 82.6 5.8 80.9 .127 .685 Slow thought 57.5 4.8 66.9 9.0 59.9 1.398 .355 Indecisive 66.2 4.4 56.6 9.6 63.8 1.511 .434 Lost self-confidence 81.6 3.7 74.0 7.6 79.7 1.377 .345 Feel not as good as other people 69.8 3.7 67.2 9.1 69.1 .112 .745 Feelings of extreme guilt 52.4 3.2 39.6 7.3 49.1 2.436 .146 Thought of death 60.3 5.9 60.8 6.9 60.4 .003 .956 Would be better off dead 46.1 4.4 49.5 9.2 47.0 .177 .730 Thought of committing suicide 36.9 3.9 15.9 6.7 31.4 7.702 .036 Made a suicide plan 19.3 2.4 5.2 1.4 15.6 5.692 .001 Made a suicide attempt 12.5 2.1 7.7 3.3 11.3 .857 .250 Irritable, grouchy, or in a bad mood 60.9 3.3 68.3 8.0 62.8 .893 .378 Nervous or anxious 60.1 3.5 70.7 8.4 62.8 1.810 .245 Alone rather than with friends 82.0 3.5 46.8 5.0 73.0 23.59 .001 Less talkative 84.1 3.5 91.6 4.3 86.0 1.767 .181 Often in tears 71.6 3.4 65.8 8.1 70.2 .611 .539 Self-reproach Suicidality Other psychological problems Note: Percents are weighted. Statistical tests are design adjusted. Boldface type indicates a significant chi-square test for difference at the p = 0.05 level. Missing values indicate insufficient cells counts (expected count for unweighted values was < 5). 79 Table 15 Endorsement and Prevalence of Depressive Symptoms among English Proficient (n = 125) and Non-proficient (n = 71) Asian Americans at Risk for Depression Symptom Item Non-prof SE Prof SE Total χ² p Depressed Mood Felt sad, empty or depressed 92.4 2.0 87.9 1.6 89.5 1.357 .098 Discouraged about things in life 88.3 3.0 77.0 3.5 80.9 5.168 .043 78.2 4.2 65.0 3.5 69.6 5.220 .054 Smaller appetite 72.0 5.8 62.3 2.7 65.7 2.536 .166 Larger appetite 4.4 2.2 10.4 2.4 8.3 2.902 .058 Gain weight 3.0 2.0 12.6 1.7 9.3 6.576 .010 Lose weight 62.4 6.2 49.4 4.0 53.9 4.053 .086 Insomnia 87.5 3.5 70.2 2.9 76.2 9.864 .005 Sleep a lot more than usual 3.9 1.8 13.7 1.7 10.2 6.225 .010 80.2 5.2 85.4 2.7 83.6 1.214 .303 Talk/move more slowly 63.5 4.9 47.0 4.5 52.8 6.554 .030 Restless and jittery 7.2 2.5 13.9 2.8 11.5 2.655 .061 Anhedonia Lose interest in almost all things Appetite/Weight change Sleep disturbance Loss of energy Low energy Psychomotor retardation/agitation Cognitive difficulties 80 Table 15 (cont’d) Trouble concentrating 71.7 7.7 72.2 4.0 72.0 .010 .946 Slow thought 68.0 7.2 49.1 3.4 55.8 8.736 .034 Indecisive 56.0 5.4 54.2 4.5 54.8 .079 .819 Lost self-confidence 66.5 6.0 75.1 2.3 72.1 2.236 .163 Feel not as good as other people 63.7 8.1 58.4 2.3 60.3 .725 .519 Feelings of extreme guilt 34.7 4.9 43.9 2.9 40.6 2.120 .165 Thought of death 50.9 7.9 52.2 3.5 51.7 .042 .871 Would be better off dead 51.1 6.7 40.1 3.0 44.0 2.987 .109 Thought of committing suicide 21.3 4.8 29.3 3.5 26.5 1.970 .182 Made a suicide plan 10.2 3.0 13.9 1.8 12.6 .751 .218 Made a suicide attempt 11.2 2.6 8.9 1.7 9.7 .355 .357 Irritable, grouchy, or in a bad mood 64.0 6.1 55.5 3.2 58.5 1.785 .260 Nervous or anxious 62.0 5.8 55.4 3.0 57.7 1.093 .323 Alone rather than with friends 58.3 4.0 71.8 2.2 67.0 4.965 .001 Less talkative 86.2 3.5 78.1 3.3 81.0 2.574 .040 Often in tears 59.2 6.5 62.9 4.1 61.6 .347 .683 Self-reproach Suicidality Other psychological problems Note: Percents are weighted. Statistical tests are design adjusted. Boldface type indicates a significant chi-square test for difference at the p = 0.05 level. 81 Table 16 Endorsement and Prevalence of Depressive Symptoms among English Proficient (n = 125) and Non-proficient (n = 71) Asian Americans with MDE Symptom Item Non-prof SE Prof SE Total χ² p Depressed Mood Felt sad, empty or depressed - - - - - - - 93.3 2.9 88.8 2.8 90.4 1.051 .336 88.9 3.1 85.2 3.2 86.5 .53 .457 83.8 4.8 68.5 3.6 74.1 5.575 .036 Larger appetite - - - - - - - Gain weight - - - - - - - Lose weight 76.7 5.3 55.0 5.1 62.7 8.936 .007 90.9 3.2 74.1 3.4 80.3 8.101 .020 - - - - - - - 91.4 2.7 90.5 2.6 90.8 .049 .804 Talk/move more slowly 66.9 4.1 50.0 5.9 56.2 5.222 .045 Restless and jittery 7.7 3.1 18.4 3.9 14.4 4.20 .016 Discouraged about things in life Anhedonia Lose interest in almost all things Appetite/Weight change Smaller appetite Sleep disturbance Insomnia Sleep a lot more than usual Loss of energy Low energy Psychomotor retardation/agitation Cognitive difficulties 82 Table 16 (cont’d) Trouble concentrating 83.6 6.9 79.1 3.9 80.7 .593 .563 Slow thought 72.6 6.9 51.9 3.7 59.6 8.085 .012 Indecisive 61.0 5.2 65.0 4.5 63.5 .304 .608 Lost self-confidence 70.4 7.0 85.6 3.2 79.9 6.635 .019 Feel not as good as other people 74.5 8.1 65.6 3.0 68.9 1.704 .301 Feelings of extreme guilt 41.2 5.4 53.8 4.2 49.2 2.872 .122 Thought of death 57.8 8.5 62.0 4.6 60.5 .332 .627 Would be better off dead 54.7 7.6 42.9 4.1 47.3 2.551 .141 Thought of committing suicide 26.3 6.5 34.1 3.9 31.3 1.268 .331 Made a suicide plan 13.4 3.6 17.0 2.2 15.7 .437 .362 Made a suicide attempt 13.5 3.4 10.1 2.2 11.3 .504 .317 Irritable, grouchy, or in a bad mood 73.1 5.5 56.1 3.6 62.5 5.63 .023 Nervous or anxious 67.1 7.1 60.3 4.1 62.8 .918 .421 Alone rather than with friends 61.6 3.1 79.4 3.6 72.8 7.375 .001 Less talkative 91.1 3.0 82.9 4.1 85.9 2.587 .069 Often in tears 65.0 7.1 73.3 4.4 70.3 1.522 .396 Self-reproach Suicidality Other psychological problems Note: Percents are weighted. Statistical tests are design adjusted. Boldface type indicates a significant chi-square test for difference at the p = 0.05 level. Missing values indicate insufficient cells counts (expected count for unweighted values was < 5). 83 Appendix C 84 Figure 1. Frequency of Depressive Symptoms among Asian Americans with MDE Diagnosis and at Risk for Depression. 85 Figure 2. Frequency of Depressive Symptoms among Asian Americans and Caucasian Americans at Risk for Depression. 86 Figure 3. Frequency of Depressive Symptoms among Asian Americans and Caucasian Americans with MDE. 87 Figure 4. Frequency of Depressive Symptoms among Asian Americans and Caucasian Americans at Risk for Depression (Significant Only). 88 References 89 References Alegría, M., Chatterji, P., Wells, K., Cao, Z., Chen, C., Takeuchi, D., et al. (2008). Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatric Services, 59, 1264-1272. Alegría, M., Takeuchi, D. 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