Research roundup: Asian American mental health

This summary of articles looks at some of the latest research on Asian Americans’ participation in the mental health system.

The U.S. surgeon general’s report “Mental Health: Culture, Race and Ethnicity (2001)” and subsequent research have yielded diverse and inconclusive results regarding the rate of mental health problems and need for mental health services among Asian Americans. The heterogeneity of Asian Americans, who are comprised of numerous subgroups from many different countries, makes identifying needs difficult. There have also been challenges with developing culturally valid assessments, potential biases in data collection, and language barriers. 

The research is clear and consistent, however, that Asian Americans underutilize mental health services compared to other minorities and nonminorities. This lack of service use does not necessarily indicate a lack of need. Cultural values and stigma associated with mental health problems may keep Asian Americans from seeking help. When Asian Americans do seek services, they are more likely to see a general physician rather than a mental health professional.

The following research summaries examine factors that may affect Asian Americans’ use of mental health services and developmental influences that have shown to increase psychological well-being among Asian American adolescents. Psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice.

David, R.F., & Kiang, L. (2016). Religious identity, religious participation and psychological well-being in Asian American adolescents. Journal of Youth and Adolescence, 45, 532-546. doi:10.1007/s10964-015-0350-9.

Religiosity can have an important impact on adolescent identity development. The authors examined a sample of Asian American ninth and 10th graders (n=180) from six public high schools in North Carolina. Participants completed a battery of questionnaires for four consecutive years that included measures of religious identity (two dimensions: religious regard — positive feelings about one’s religious identity; and religious centrality — the extent to which religion or religious beliefs define oneself), religious participation (attendance at services or events) and psychological well-being, including self-esteem, depression, positive and negative affect, and meaning in life. This longitudinal study also examined these variables by gender and first- or second-generation American.

The religious identity of adolescents over the four-year period did not change over time, but religious participation significantly increased. Religious identity was positively and significantly predictive of self-esteem, positive affect and the presence of meaning in life. Religious identity was not significantly associated with depressive symptoms, negative affect or searching for meaning. Religious participation was significantly associated with positive affect and the presence of meaning in life.

Religion was especially salient in the lives of females, and females were more likely than males to use religion to mitigate depressive symptoms. In this study, U.S.-born Asian Americans demonstrated significantly fewer depressive symptoms and significantly lower negative affect than those born outside the U.S., suggesting that difficulties in trying to adapt to a new culture may contribute to depressive symptoms.

Brice, C., Warner, C.M., Okazaki, S., Ma, P.W.W., Sanchez, A., Esseling, P., & Lynch, C. (2015). Social anxiety and mental health service use among Asian American high school students, Child Psychiatry and Human Development, 46, 693-701. doi: 10.1007/s10578-014-0511-1.

Social anxiety often begins and its symptoms are most prevalent in adolescence. To examine social anxiety in a high school population, the authors screened 3,837 students (51 percent male, mean age 14.91, 209 Asian, 97 black, 274 Latino, 3,257 white). Students completed two self-report measures of social anxiety and a self-report question regarding mental health service use. A subsample (n=1,441) also completed a self-assessment of impairment and service use. Parents of students who scored above the clinical cut off for social anxiety were contacted and asked to be interviewed by phone about their perceptions of their adolescent’s impairment.

Analyses considered differences by gender and ethnic group. Females scored higher than males on both self-report measures of social anxiety. Asian females reported significantly more social anxiety than black and white females. Asian males reported significantly higher social anxiety than black and white males on one social anxiety measure, and Latino males scored significantly higher than black males on the same measure. On the other measure, Asian males reported more social anxiety than white males. Overall, Asian students scored positively for social anxiety at significantly greater rates than white and black students. Asian students also scored positive for social anxiety at greater rates than Latino students. Latino adolescents scored positive on one of the social anxiety measures at significantly greater rates than white and black students. White and black students did not differ from each other on the measures.

With regard to impairment, parental reports did not differ by gender or ethnicity. Interestingly, the parents of students who self-reported greater levels of social anxiety were more like to participate in the telephone interview than parents of students who met the cut off for social anxiety but had lower anxiety levels. Females endorsed being uncomfortable in social situations and reported greater school impairment than males. Asian and Latino students endorsed being uncomfortable at significantly higher rates than white students. They also reported more school impairment than white and black students.

Only 6.7 percent of students who screened positive for social anxiety sought services for their symptoms. There were no significant differences between ethnicities on service use.

Chang, J., Natsuaki, M.N., & Chen, C.N. (2013). The importance of family factors and generation status: Mental health service use among Latino and Asian Americans. Cultural Diversity and Ethnic Minority Psychology, 19, 236-247.  doi: 10.1037/a0032901.

Utilizing data from the 2004 National Latino and Asian American Study (n=4,649, 2,554 Latinos; 2,095 Asians), an epidemiological study of mental health among Latino and Asian Americans, the authors examined ethnic and generational differences between Latino and Asian Americans in measures of cultural conflict and family cohesion, and whether immigration and family-related factors (e.g., generation status, cultural conflict and family cohesion) impacted the use of mental health services.

A significant interaction between ethnicity and generational status emerged regarding family cultural conflict. First generation Asian Americans reported higher family cultural conflict than first generation Latinos but third generation Latino Americans experienced greater family cultural conflict than third generation Asian Americans. There were no significant differences between the two populations in the second generation.

With regard to family cohesion, both first generation Latino- and Asian Americans showed the highest level of family cohesion.  Cohesion patterns for the two ethnicities differed for later generations. Latino-Americans were found to have similar lower level of cohesion in both second and third generations with Asian Americans showing a consecutive decline in the second and third generations.

Family cultural conflict turned out to be a significant predictor of mental health service use among Asian Americans. Interestingly, second generation Asian Americans were more likely to access mental health services for family cultural conflict than either the first or third generation. Measures of family cohesion were not associated with use of mental health services. Latino Americans who experienced greater family cultural conflict regardless of generation status were more likely to use mental health services. Also, Latino Americans who reported greater family cohesion were less likely to use mental health services than those with weaker family cohesion regardless of generation status.

Clinical implications

While many are familiar with data suggesting that Asian Americans under report and underutilize mental health services, much less is known about why this might be the case and factors that might support well-being. As always, clinicians must be aware of issues such as generational status and distinct ethnic subgroup identification when working with Asian Americans in order to provide competent services. However, it is worth noting that measures of social anxiety suggested a higher prevalence among Asian American adolescents than other groups. Yet, it is possible that traditional “Asian” values such as interdependence and indirect expression may inaccurately elevate social anxiety scores. Screening for social anxiety may be particularly important with Asian American adolescents, particularly if the screen is culturally appropriate. Additionally, psychologists may particularly want to screen for factors that could contribute to psychological well-being, such as religious identity, and connect the patient with community partners (i.e. religious organizations) that could provide additional support. This might be a way to bring appropriate psychological concepts to populations that have typically underutilized mental health services. Lastly, exploring the role of potential family cultural conflict may be important when Asian Americans seek services. This is not to suggest that such conflict is the source of psychological problems, but it might be the impetus for individuals to seek care outside of family networks.

Additional resources 

Okazaki, S., Kassem, A.M., & Tu, M.C. (2014). Addressing Asian American mental health disparities: Putting community-based research principles to work. Asian American Journal of Psychology, 5, 4-12. doi: 10.1037/a0032675.

Sue, S., Cheng, J.K.Y, Saad, C.S., & Chu, J.P. (2012). Asian American mental health. American Psychologist, 67, 532-544. doi: 10.1037/a0028900.