Sue, S. (2002). Asian American mental health: What we know and what we don't know. In W. J. Lonner, D. L. Dinnel, S. A. Hayes, & D. N. Sattler (Eds.), Online Readings in Psychology and Culture (Unit 3, Chapter 4), Center for Cross-Cultural Research, Western Washington University, Bellingham, Washington USA.

This material is copyrighted by the author(s), who have kindly extended to the Center the right to use the material as described in the Introduction to this collection and the form entitled "Agreement to Extend License to Use Work."

UNIT 3, CHAPTER 4

ASIAN AMERICAN MENTAL HEALTH: WHAT WE KNOW AND WHAT WE DON'T KNOW

Stanley Sue
Department of Psychology
University of California, Davis
U.S.A.

ABSTRACT

This chapter reviews and critically examines issues regarding the mental health of Asians in the United States. As a distinct ethnic group in the United States, Asian Americans have experienced value conflicts between their own ethnic culture and that of mainstream Americans, as well as instances of racial prejudice and discrimination. Given these experiences, it is important to examine the mental health status of Asian Americans. Several consistent research findings have emerged. First, few Asian Americans utilize the mental health system. Second, those who do use services are highly disturbed in terms of psychiatric disorders. Third, cultural factors appear to influence this pattern of low utilization but greater severity of disturbance. Fourth, epidemiological surveys show that the rates of mental disorders among Asian Americans are not extraordinarily low. Fifth, the relatively small population of Asian Americans, their heterogeneity, and the constantly changing demographic characteristics of the population have made it difficult to ascertain rates of mental disorders. More research is needed in order to gain insights into the within-group differences among Asian Americans, the role of acculturation in psychopathology and help-seeking behaviors, and cultural expressions of psychopathology.

INTRODUCTION

The Population of Asian Americans

Asians in the United States represent many subpopulations including Cambodians, Chinese, Japanese, Filipinos, Koreans, Laotians, Asian Indians, Vietnamese, etc. (Asian and Pacific Islanders are often considered among the many subpopulations). Asians comprise only 4% of the United States population but 60% of the world's population. Despite the fact that the groups are heterogeneous, researchers have often studied the subpopulations as an aggregate group because Asians often show similar cultural values that are in contrast to Westerners (e.g., Asian Americans are more likely to exhibit interdependence and family orientation than do White Americans).

In evaluating the mental health of Asian Americans, some inconsistencies are apparent. As an aggregate, Asian Americans appear to be relatively successful in terms of low rates of divorce, crime, and juvenile delinquency and high rates of educational attainments, family income, and socio-economic mobility. On the other hand, they have experienced racial prejudice and discrimination, stereotypic portrayals in the media, and English language and cultural adjustment difficulties. Given the inconsistent data on well being, how adjusted are Asian Americans?

Mental Health Services Studies

Early research on Asian Americans examined their use of treatment services. Research uniformly demonstrated that Asian Americans failed to use mental health facilities in the same proportion as their population (Sue, Sue, Sue, & Takeuchi, 1995). The "underutilization" was apparent regardless of the Asian American subgroup, age, gender, or geographic location. Is it possible that this population is relatively better adjusted than other populations, so that greater utilization of services is unnecessary? In general, every population underutilizes in the sense that not all individuals with psychological disturbance seek help from the mental health system. The important question is whether or not Asian Americans with psychiatric disorders have a greater propensity than other populations to avoid using available services. Considerable indirect evidence suggests that Asian Americans are less likely than the general population to use community resources. Research findings have revealed that few Asian Americans seek mental health treatment and those who do use them exhibit a greater level of disturbance within the client population. A parsimonious explanation is that only the most disturbed Asian Americans tend to seek such resources. Asian Americans who show a moderate degree of disturbance are thus more likely than are comparable White Americans to avoid using services.

A number of factors affect utilization and effectiveness of mental health options. Some of the factors involve accessibility (e.g., including ease of using what's available, financial costs involved, and their location and availability, cultural and linguistic appropriateness of what is offered, knowledge of what's available, willingness to use them, and existence of alternative and competing or alternative treatment possibilities. Obviously, the nature and severity of one's problems also influences utilization.

Culturally-based factors such as shame and stigma, conceptions of mental health, and alternative options are important factors that affect utilization and appropriateness of mainstream services (i.e., those that are available to the general population of Americans).

For many Asian Americans, cultural attitudes and beliefs must be considered in the analysis of service utilization. Particularly important is the concept of "shame" or "face." "Haji" among the Japanese, "Hiya" among the Pilipinos, "Mentz" among the Chinese, and "Chaemyun" among the Koreans are terms that reveal concerns over the process of shame or the loss of face (Sue, 1994). Many Asian Americans tend to avoid the juvenile justice or legal system, mental health agencies, health services, and welfare agencies, because the utilization of services for certain problems is a tacit admission of the existence of these problems and may result in public knowledge of these familial difficulties. In particular, Asian Americans have been found to differ from White Americans in help-seeking behaviors for emotional difficulties. They are less likely to request outside help for these difficulties, turning first to their families for help and then to outside agencies or mainstream services as a last resort. Although most Americans are likely to turn to their families as the first resource, and to feel shame or stigma over certain problems, the avoidance of mainstream services is more pronounced among Asian Americans. That is, there is a differential effect caused by the strong concern over loss of face among Americans.

Because of shame and stigma, several consequences can be hypothesized. First, those behaviors that create shame and stigma are the ones that are most likely to be denied. Services for those behaviors tend to be underutilized. Second, Asian Americans may have needs for certain resources that are not reflected in utilization patterns. Third, if services are avoided and used as a last resort, then problems may be exacerbated, since there is a delay in finding assistance. It should be noted that the shame associated with having health and mental health problems may be more acutely experienced by Asian Americans who tend to reside in immigrant communities. In such communities, there are great expectations for doing well in America for the sake of the family members both in the United States and back in the country of origin. The personal networks in these communities are often extensive in which information about others is easily shared and disseminated. Within this context, the development of a mental health problem that may compromise a person's productivity or status can generate significant loss of face. Moreover, the need to seek outside help for such problems only exacerbates the shame.

Furthermore, cultural influences help to shape the symptoms exhibited when one is emotionally disturbed. Cultural factors also affect interpretations of the causes of disorders and interventions deemed appropriate to overcome health and mental health problems (Leong, 1986). In traditional Chinese culture, many diseases or physical afflictions are attributed to an imbalance of cosmic forces--yin and yang. The task is to restore imbalance through proper diet, exercise, and psychosocial relationships with others. Essentially, this is a holistic approach to health. Kinzie (1985) notes many Southeast Asians have a folk tradition in which illness is believed to be caused by physiological factors or supernatural forces (e.g., the consequence of offending a deity or spirit). Thus, they may have an unwillingness or inability to differentiate between psychological, physiological, and supernatural causes of illness.

Because of these cultural factors that influence symptom expressions and conceptions of illness, it is apparent that Asian Americans are likely to differ from mainstream Americans in the types of interventions used to prevent or treat emotional disturbances and illnesses. The interventions may involve restoration of balance and holistic approaches: Use of herbal medicine, consultations with folk healers or fortune tellers, acupuncture, certain forms of exercise, etc., that are consistent with their cultural beliefs. The extent of utilization of these alternatives among different Americans is unknown, although it is probably higher among recent immigrants or those who are relatively unacculturated to American society.

Asian and White Americans do have different conceptions of mental health and disturbance. Asian Americans tend to perceive more organic or somatic involvement in emotional disturbance. They also believe that the exercise of will power, the avoidance of morbid thoughts, and a focus on pleasant cognitions are means to enhance psychological well-being (Sue, 1994). Since professional mental health treatment often utilizes insight-oriented approaches that require self-disclosure of "morbid" (that is, disturbing and embarrassing) thoughts, Asian Americans may avoid Western forms of mental health treatment and seek medical treatment for emotional problems.

The research on utilization of mental health services and factors that inhibit utilization has been valuable in providing insights into mental health issues. However, to fully address the prevalence of mental disorders, epidemiological research is needed.

Epidemiological Studies

In studying the rates of mental health disturbances for Asian Americans, it is instructive to examine the rates of Asian who reside overseas (e.g., in Hong Kong, Japan, or Indonesia). As noted in Sue's review (1994), the evidence from epidemiological studies of overseas Asians does not support the notion that Asians are better adjusted than are Westerners. Several implications can therefore be drawn from this evidence. First, there is no reason to believe that being Asian is associated with significantly low rates of mental disorders and that Asians coming to the United States are less prone to developing these disorders. Second, Asian Americans are likely to be different from their overseas counterparts. Those who emigrate to the United States are not representative of those who remain (some come from educated, upper classes while others have led impoverished lives in their homelands and flee to the United States for better opportunities). Immigrants and refugees encounter unique experiences in this country such as exposure to different cultural values, English proficiency problems, minority status including racial/ethnic stereotypes, prejudice, discrimination, and a reduction in available social supports. In turn, these experiences can alter the stress-coping formulas for immigrants to the United States.

Indeed, one might speculate that Asian Americans might be under considerable stress because of these experiences. What do the empirical findings reveal? Large-scale and rigorous epidemiological studies have not been conducted on Asian Americans. Under such circumstances, one must form conclusions based on the preponderance of evidence. Until recently, the findings seemed to converge. They revealed that the prevalence of disorders among Asian Americans was as high as or even higher than those of other Americans--findings that were inconsistent with the general stereotypes concerning Asian well-adjustment. The studies of Asian Americans cover broad periods of time, starting from the 1970s to the present.
Many of the available surveys appear to indicate that significant numbers of Asian Americans are experiencing mental and emotional problems. Several studies have examined the rates of depression among Asian Americans using the Center for Epidemiology Studies of Depression (CES-D). Interviewing Asian Americans located through directories, organizations, and snowballing techniques in Seattle, Kuo (1984) found that Chinese, Japanese, Filipino, and Korean Americans on average reported slightly more depressive symptoms than did Caucasian respondents in other studies. Using the CES-D, similar findings of prevalence rates were reported by Hurh and Kim (1990). Korean immigrants residing in Chicago had higher scores for depression than did the Chinese, Japanese and Filipinos in Kuo's study. High rates of depression were also revealed in a telephone survey of Chinese Americans located in the telephone directory in San Francisco. Using the CES-D, Ying (1988) found the Chinese Americans to be significantly more depressed than the Chinese Americans in Kuo's study.

Certain groups such as Southeast Asian refugees and immigrants have extremely high levels of depression and other disorders (Westermeyer, 1988). Studies have also consistently shown that Southeast Asian refugees constitute a high risk group for mental disorders including depression and Post-Traumatic Stress Disorder (Kinzie et al., 1990). The elevated prevalence rates of psychopathology in the Southeast Asian refugee community are attributable to repeated exposure to catastrophic environmental stressors such as torture, combat, witnessing the death of family and relatives, and forcible detainment in harsh refugee camp conditions.

As noted by Leong (1986), studies of college students also suggest that Asian Americans experience major adjustment problems. For example, Okazaki (1997) compared the responses of Asian and White American college students on various measures of depression and anxiety. Results revealed that the Asian American students reported higher levels of depression and social anxiety.

All of these various studies (on students, refugees and immigrants, etc.) go beyond suggesting that, contrary to some stereotypes, Asian Americans are not an extraordinarily well-adjusted minority group. They support a more drastic conclusion--namely, that Asian Americans have lower mental health than do Whites. Before considering this statement, it should be noted that some more recent studies suggest that Asian Americans may indeed be better adjusted.

The Chinese American Psychiatric Epidemiological Study (CAPES) was undoubtedly the most rigorous and large-scale investigation of any Asian group in the United States (see Takeuchi et al., 1998). The project was a five-year community epidemiological study investigating the mental health problems and needs for mental health services among Chinese Americans. The study had two specific aims: (a) to estimate the prevalence rates of selected mental disorders among Chinese Americans, and (2) to identify the factors associated with mental health problems among Chinese Americans. This study obtained 1,700 completed household interviews with Chinese-Americans residing in Los Angeles County. Followup interviews with the same respondents were conducted one-and-one-half years later which allowed the unprecedented opportunity to note changes in mental health and the factors associated with changes. The target population for the study includes Chinese immigrants and native-born residents of the United States.

The results were contrary to the findings of the studies reviewed earlier. Chinese Americans in the CAPES project did not have higher rates of mental disorders than Whites. While it can be argued that the rates of mood disorders among Chinese Americans were within the bounds of other Americans, the rates for anxiety were somewhat low. Why have the findings been so discrepant? Perhaps the conflicting findings with respect to the mental health of Asian Americans are attributable to the nature of the population.

Research Problems

What is the nature of the Asian American population? It is small, diverse, and ever-changing. Asian Americans represent only about 4% of the U.S. population. Consequently, researchers have had a difficult time finding adequate sample sizes and representative samples of Asian Americans. In many studies, samples of convenience were frequently used, often from quite different sources. Estimates of the prevalence of psychopathology may conflict because they are based on different kinds of samples.

The Asian American population is also extremely diverse and heterogeneous. More than 50 distinct ethnic groups (including Pacific Islander Americans), that may primarily speak one of more than 30 different languages, are included in the Asian American category. Even if we focus on one particular group, the heterogeneity is problematic and not encountered to the same extent by Asians in their homeland. For example, the Chinese American population is far more diverse than the Chinese population in overseas parts of the world. Chinese in the U.S. are composed of both native and foreign born, individuals who come from mainland China, Taiwan, Hong Kong, Singapore, Vietnam, and elsewhere.. Chinese Americans speak many dialects and languages, are exposed to American values, and are members of a minority group. All of these produce a very heterogeneous population. The same is true of nearly all Asian American groups--greater heterogeneity exists for their group in the U.S. than in their homeland. This is an important point to understand. It means that measures (such as the MMPI-2) which have been validated with Chinese in China may not have good validity for Chinese in the U.S. The problem confronting Asian American researchers is that the heterogeneity exists within a relatively small population. Outcomes from research investigations are then highly dependent on the particular samples drawn, and findings may fluctuate widely.

Finally, the Asian American population is undergoing rapid change relative to other populations. The Asian American population has doubled in size each decade for about the last three decades. The composition has changed, too. Whereas Japanese Americans were the largest group of Asian Americans a couple of decades ago, they are now outnumbered by Chinese and Filipino Americans. Today the Asian American population is predominantly overseas born, in contrast to the situation three decades ago. These demographic changes are likely to produce different prevalence rates. Because of the traumas faced by Southeast Asian refugees and their relatively recent entry into the U.S., prevalence rates for mental disorders among Asian Americans have dramatically changed.

In sum, there are some very good reasons why researchers have a difficult time ascertaining the prevalence of mental disorders among Asian Americans and why findings may be inconsistent. The relatively small size, heterogeneity, and changing demographic characteristics of the population pose more basic difficulties in research than do problems of measurement.

The specific prevalence rates of mental disorders among Asian Americans have been difficult to determine. Sufficient evidence does exist to show that Asian Americans are not significantly less prone to mental disorders than other ethnic groups. The relatively small population, heterogeneity, and changing demographic characteristics have hindered a more precise determination of prevalence rates within the Asian American population. Research concerning mental health issues should continue to be based on both the aggregate group (all Asian Americans) and particular Asian ethnicities (e.g., Chinese Americans).

References

Hurh, W. M., & Kim, K. C. (1990). Correlates of Korean immigrants' mental health. Journal of Nervous and Mental Disease, 178, 703-711.

Kinzie, J.D. (1985). Overview of clinical issues in the treatment of Southeast Asian refugees. In T.C. Owan (Ed.), Southeast Asian mental health: Treatment, prevention, services, training, and research (pp. 113-136). Washington, DC: U.S. Government Printing Office.

Kinzie, J., Boehnlein, J.K., Leung, P.K., Moore, L.J., Riley, C., & Smith, D. (1990). The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees. American Journal of Psychiatry, 147,913-917.

Kuo, W. H. (1984). Prevalence of depression among Asian-Americans. Journal of Nervous and Mental Disease, 172, 449-457.

Leong, F. T. (1986). Counseling and psychotherapy with Asian-Americans: Review of the literature. Journal of Counseling Psychology, 33, 196-206.

Okazaki, S. (1997). Sources of ethnic differences between Asian American and White American college students on measures of depression and social anxiety. Journal of Abnormal Psychology, 106, 52-60.

Sue, S. (1994). Mental health. In N. Zane, D.T. Takeuchi, & K. Young (Eds.), Confronting critical health issues of Asian and Pacific Islander Americans (pp. 266-288). Newbury Park, CA: Sage.

Sue, S., Sue, D.W., Sue, L., & Takeuchi, D.T. (1995). Psychopathology among Asian Americans. Cultural Diversity and Mental Health, 1, 39-54.

Takeuchi, D.T., Chung, R.C., Lin, K.M., Shen, H., Kurasaki, K., Chun, C., & Sue, S. (1998). Lifetime and twelve-month prevalence rates of major depressive episodes and dysthymia among Chinese Americans in Los Angeles. American Journal of Psychiatry, 155, 1407-1414.

Westermeyer, J. (1988). DSM-III psychiatric disorders among Hmong refugees in the United States: A point prevalence study. American Journal of Psychiatry, 145, 197-202.

Ying, Y. (1988). Depressive symptomatology among Chinese-Americans as measured by the CES-D. Journal of Clinical Psychology, 44, 739-746.

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