Depression and anxiety among Asian Americans: the effects of social support and strain.
Abstract: It is almost taken for granted that social relationships benefit mental health, yet these relationships may not always be protective. This study examines how the support and strains individuals derive from family and friends may be related to depression and anxiety among Asian Americans. Data come from the 2002-2003 National Latino and Asian American Study, the first nationally representative study of mental health outcomes among Asian Americans (n = 2,066). Results indicate that family support was associated with decreased odds of Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) criteria for both major depressive disorder (MDD) and generalized anxiety disorder (GAD) among men and women. In addition, family strain was associated with increased odds of GAD equally among men and women. However, friend strain was associated with increased odds of GAD among women but not men, and family strain was marginally associated with increased odds of MDD for women but was unrelated for men. The findings affirm the need to consider social strain along with social support, as well as their sources, with attention to the potentially stronger effects of strain for women. Implications for social work practice are discussed.

KEY WORDS: Asian Americans; mental health; social strain; social support; women
Article Type: Report
Subject: Social networks (Analysis)
Asian Americans (Psychological aspects)
Asian Americans (Health aspects)
Mental illness (Care and treatment)
Authors: Sangalang, Cindy C.
Gee, Gilbert C.
Pub Date: 01/01/2012
Publication: Name: Social Work Publisher: Oxford University Press Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 2012 Oxford University Press ISSN: 0037-8046
Issue: Date: Jan, 2012 Source Volume: 57 Source Issue: 1
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 294900194
Full Text: Conventional wisdom indicates that receipt of social support is universally beneficial. Social support from network ties is believed to be a fundamental aspect of psychological well-being and the therapeutic process (Kawachi & Berkman, 2001); however, social strain rooted in the same support networks may contribute to poorer mental health outcomes (Kook, 1992). Furthermore, research suggests support and strain may differentially affect men and women (Umberson, Chen, House, Hopkins, & Slaten, 1996). Recent research suggests that social networks and the ways individuals use these networks may also vary by culture, yet studies on minority communities, such as Asian Americans, are limited (H. S. Kim, Sherman, Ko, & Taylor, 2006).

Asian Americans are one of the fastest-growing minority groups in the United States (U.S. Census Bureau, 2011). Although prior research suggests that Asian Americans have lower rates of psychological disorder and use of mental health services than other racial and ethnic groups (Matsuoka, Breaux, & Kyujin, 1997), recent studies indicate a substantial need for mental health care among Asian Americans (Marshall, Schell, Elliott, Berthold, & Chun, 2005; Mui & Kang, 2006; Takeuchi et al., 2007). Shame and stigma associated with mental illness may discourage people from using formal mental health services. This may be particularly true among Asian Americans, who often rely on family and members of their informal networks for support of their mental health problems (Leong & Lau, 2001; Spencer & Chen, 2004).

The purpose of this study is to investigate the effect of social support and strain on mental health among Asian Americans. This study has several unique features. First, in contrast to prior studies that only focus on either support or strain, we examine both factors simultaneously while distinguishing between support and strain from friends and from family. Second, we investigate major depressive disorder (MDD) and generalized anxiety disorder (GAD) because these are clinical outcomes that contribute to considerable disability (World Health Organization, 2001). Third, we explore possible gender differences in these relations. Finally, we examine these issues among an understudied population and use a nationally representative sample.

BACKGROUND

Social Support, Social Strain, and Well-Being

A large body of literature has described the salubrious effects of social support (Berkman & Glass, 2000; House, Landis, & Umberson, 1988). Berkman and Glass described social support as emotional, instrumental, tangible, and informational resources that individuals obtain from their network ties. These resources are known to promote mental health by enhancing self-esteem, strengthening effective coping, and mitigating distress. In studies on Asian Americans, social support has been negatively associated with acculturative stress and depression (Mui, 2001; Yeh & Inose, 2003). Social support also buffered the effect of stressors on mental and physical health among diverse Asian American groups (Choi, 1997; Gee et al., 2006).

Other research suggests that Asian cultural values related to collectivism can limit the healthful benefits of social support. In contrast to Western individualism, a collectivist orientation may hinder disclosure of personal problems for fear of burdening others, disrupting group harmony, or losing face (B.S.K. Kim, Atkinson, & Umemoto, 2001; H. S. Kim et al., 2006). Indeed, some studies have found that compared with white Americans, Asian Americans appear less likely to seek social support in response to stress (Taylor et al,, 2004) or after breast-cancer treatment (Wellisch et al., 1999). H. S. Kim et al. (2006) found that Asian American students sought less support from family and friends and, further, perceived support to be less helpful in dealing with stress than white students. Taken together, the conflicting findings regarding social support's effectiveness for Asian Americans demonstrate a need for further investigation.

An emerging body of research suggests that the very relationships that provide support can also engender strain. Social strain includes conflicts, feelings of undue obligation, and demands from one's friends and family (Lincoln et al., 2010; Lincoln, 2000; Mittelmark, 1999; Rook, 1992). Because greater attention is given to positive rather than negative components of social interactions, only a handful of studies have simultaneously examined both social support and social strain (Lincoln, 2000).

Some studies have found that strain and support are independently associated with well-being, such that strain is associated with diminished mental health while support is associated with improved mental health (Revenson, Schiaffino, Majerovitz, & Gibofsky, 1991; Stephens, Kinney, Norris, & Ritchie, 1987). Other studies have found that social strain exerts more robust effects on psychological well-being than social support (Fiore, Becker, & Coppel, 1983; Rook, 1984). Although promising, these studies have tended to focus on specific stressors (for example, caregiving to spouses with Alzheimer's disease), which can obscure the presence of multiple straining relationships and contexts (Fiore et al., 1983; Mittelmark, 1999). Moreover, these studies used specialized, nonrepresentative samples, raising questions about generalizability to other populations (Monette, Sullivan, & DeJong, 2005).

The collectivist orientation that characterizes many Asian cultures can also trigger social strain rooted in obligation, expectations, and norms of reciprocity (B.S.K. Kim et al., 2001). For example, Asian Americans who are family oriented may feel burdened with obligations that conflict with American norms of individualism (Yee, Huang, & Lew, 1998). Children and parents of Asian American families may have friction over parental expectations of educational and occupational achievement (Yee et al., 1998). Individuals may face pressure to fulfill unspoken expectations of reciprocity and indebtedness to friends and other network ties, such as the cultural value of utang na loob (feeling of mutual obligation) among Filipino Americans (Nadal, 2009). These aspects of cultural norms that can constrain social relations may not be captured in existing studies on social support for Asian Americans.

Social Support and Social Strain from Family versus Friends

Family members and friends may not present the same types of support and strain. Family relationships are often of longer duration and can include legal responsibilities and benefits. Studies have produced equivocal evidence for family versus friend support, with some studies showing that family support may buffer health more (Procidano & Heller, 1983; Wellisch et al,, 1999), whereas other studies have found the converse (Walen & Lachman, 2000), These mixed findings may be due, in part, to the sampling of different cultural populations, in which the bonds of family may be more or less salient than the bonds of friendship.

With regard to Asian Americans, scholars have noted that the family is often the central social unit, not the individual (H. K. Kim & McKenry, 1998). Indeed, research suggests that many Asians avoid bringing shame to their families (B. S. K. Kim et al., 2001) and have a strong sense of family obligation (Fuligni, 2001). Furthermore, family is often the first line in seeking help for mental health problems (Lin, Inui, Kleinman, & Womack, 1982). Hence, family members may be more aware of one's mental health needs, and their support may play a greater protective role than support from one's friends. Yet, for these same reasons, the strain from family may be even more salient than similar stressors coming from friends,

Social Support, Social Strain, and Gender

Gender may also influence how strain and support are related to mental health. Umberson et al. (1996) described the ways in which social relationships may have greater demands and responsibilities for women than for men. One factor relates to increased exposure to stress due to role strain. Compared with men, women tend to have additional demands from various relationships, particularly for those who have children, are married, or care for ill family members (Umberson et al., 1996). Another factor involves differential sensitivity to social strain. Several scholars have suggested that social relationships are more important for women than men and that disordered relationships may be particularly harmful for women (Belle, 1982; Miller, 1988). Accordingly, this suggests that social strains may place a greater psychological burden on women than men.

Studies indicate that social support for Asian American women is primarily family based (Meemeduma, 1992; Wellisch et al., 1999). Wellisch et al. found that Asian American women survivors of breast cancer relied less on social support compared to Anglo American women, in line with previous work that suggests Asian American women prefer to provide rather than receive care and are concerned with maintaining interpersonal harmony. Taken together, the aforementioned lines of research suggest that social support may be less protective of mental illness for women than men and, further, that social strain may be more strongly related to mental illness for women than for men. Moreover, the effects of family support and strain should be stronger among women for these same reasons.

Based on the literature, we examine the following four hypotheses:

1. Social support is related to lower risk of depressive disorder and generalized anxiety disorder.

2. Social strain is related to higher risk of depressive disorder and generalized anxiety disorder.

3. Support and strain from family will be more strongly related to these mental health problems than support and strain from friends.

4. Gender will moderate these associations, such that family or friend support will be more protective for women and strain will be a greater risk for women than men.

Because depressive disorder and generalized anxiety disorder (GAD) often co-occur (Bakish, 1999), we anticipate that the relationship between both social support and social strain will have parallel effects across both disorders.

METHOD

Data and Sampling

This study is based on data from the National Latino and Asian American Study (NLAAS), a psychiatric epidemiologic survey conducted between 2002 and 2003 across the United States (Alegria et al., 2004a, 2004b; Heerenga et al., 2004). Eligible respondents were age 18 years or older and were not in the military or institutionalized. The current analysis is restricted to Asian American respondents.

The NLAAS used a three-stage stratified probability sampling design. First, primary stage units of single counties or groupings of adjacent counties were devised into strata on the basis of size, location, and population characteristics. Second, within primary stage units, census blocks comprising area segments were stratified by geographic location and the race/ethnicity of household respondents. High-density supplemental samples were obtained from areas with five percent or greater of targeted ethnic groups. Sampling was performed within probabilities proportionate to census blocks for each area segment. Third, systematic random sampling was used to select housing units within area segments. Within consenting households, eligible main respondents were randomly selected, and then secondary respondents from the same household were also recruited. Interviews were conducted in the respondents' choice of Cantonese, English, Mandarin, Spanish, Tagalog, or Vietnamese using computer-assisted survey instruments. The response rate was 69.3 percent for main respondents and 73.7 percent for secondary respondents. Sample weights were developed to account for the complex sampling design and to allow estimates to be nationally representative (Heerenga et al., 2004).

The NLAAS is designed to be valid and reliable for diverse Asian and Latino communities. Briefly, this involved five steps: (1) identification of constructs that are relevant to the target population; (2) collaboration among a multicultural study team that included researchers with ethnic backgrounds similar to those of the target population; (3) translations and back-translations of research materials, and by extension, the availability of the study in six languages; (4) use of key-informant interviews with members of the target population across several states (and in Puerto Rico) to assess materials; and (5) pilot testing and revision of the materials as needed. Further details are available elsewhere (Alegria et al., 2004a, 2004b).

Participants

The Asian American subsample includes 2,095 respondents. The current analysis is restricted to individuals with no missing values for variables of interest (n = 2,066). Weighted sample characteristics are presented in Table 1.

Measures

MDD and GAD. The dependent variables were based on measures from the World Health Organization's expanded version of the Composite International Diagnostic Interview (WHO-CIDI) (World Mental Health Survey Consortium, 2004). Diagnostic outcomes were derived from algorithms of participant responses to the WHO-CIDI that were then used to classify an individual as meeting criteria for MDD or GAD, respectively, as defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) (DSM-IV-TR) (American Psychiatric Association [APA], 2000). These dichotomous variables indicated the presence or absence of the disorder within the past 12 months (0 = absent, 1 = present).

Social Support among Family and Friends. Soda] support was measured with a brief six-item scale previously examined in the NLAAS with Latinos by Mulvaney-Day, Alegria, and Sribney (2006). Three questions asked about the frequency of support (1 = none to 4 = a lot) by three specific means: (1) talking on the phone or getting together with relatives, (2) relying on relatives for help with a serious problem, and (3) relying on relatives to talk about worries. Family support was assessed by averaging across these three items (Cronbach's alpha = 0.71); higher values indicated greater social support. The same three questions were repeated, but with regard to friends, to create an analogous measure of friend support (Cronbach's alpha = 0.77).

Social Strain among Family and Friends. Two items measured family strain, or the frequency of respondents' conflicts and demands with family members. Respondents were asked two questions: (1) how often their relatives and children make too many demands, and (2) how often they argue with family. Responses ranged from 1 = not at all to 4 = often. Items were averaged to create an index in which higher scores reflected greater strain (Cronbach's alpha = 0.59). Friend strain was measured with two similar items (Cronbach's alpha = 0.60).

Control Variables. The multivariate analyses control for the following sociodemographic characteristics: gender, age, education, work status, marital status, ethnicity, and nativity (immigrant versus nonimmigrant). These characteristics have all been previously related to psychological well-being and disorder (Aneshensel, Rutter, & Lachenbruch, 1991; Dohrenwend et al., 1992; Mirowsky & Ross, 1992; Pearlin & Johnson, 1977; Stronks, Van De Mheen, Van Den Bos, & Mackenbach, 1997; Takeuchi et al., 2007).

Analysis

We first examined bivariate relations between variables and then proceeded with multivariate models using logistic regression for each dependent variable. First, we examined the associations between family support and the dependent variable (MDD or GAD within the past 12 months) and between friend support and the dependent variable, controlling for covariates. Second, we examined the associations between family strain and the dependent variable and between friend strain and the dependent variable, controlling for covariates. The final model included family support, friend support, family strain, friend strain, and covariates simultaneously. We then examined the effect of gender on the associations between support and strain and dependent variables with interaction terms. These analyses centered continuous variables at their mean to reduce multicollinearity and to facilitate interpretation (Aiken & West, 1991). Finally, significant interactions were graphed to aid interpretation. All analyses were weighted to account for complex sampling design and to make the estimates nationally representative. We used the Stata software program, version 10.0 (StataCorp, 2007).

RESULTS

Of the respondents, 4.6 percent could be classified as having MDD and 1.4 percent as having GAD within the past 12 months (see Table 1). Respondents as a whole reported moderate levels of social support; a mean of 2.73 from family and 2.66 from friends suggests that respondents relied on these people "sometimes." A relatively lower level of social strain was reported; a mean of 1.96 from family and 1.68 from friends indicates that conflicts and demands from these people occurred "rarely."

The bivariate associations between measures of social support and strain from family and friends and the odds of meeting criteria for MDD and GAD within the last year are presented in Table 2. Unadjusted bivariate analyses showed that family strain was positively associated with higher odds of MDD. Specifically, a one-unit increase in family strain resulted in 1.83 greater odds of MDD (95 percent confidence interval [CI] [1.42, 2.37]). Unadjusted bivariate analyses also showed that family support was negatively associated with the odds of meeting criteria of GAD (odds ratio [OR] = 0.55; 95 percent CI [0.32, 0.94]) and family strain was positively associated with the odds of meeting criteria of GAD (OR. = 1.90; 95 percent CI [1.10, 3.28]).

Associations between Support and Strain and MDD

Models 1a to 5a in Table 3 show the associations between support and strain from family and friends and MDD, controlling for covariates (tables omit the covariates for parsimony, but they are available from the authors). These models indicated that both family support and family strain were associated with MDD within the last year. In model la, family support was associated with decreased odds of MDD (OR = 0.63; 95 percent CI [0.48, 0.83]), whereas in model 3a, family strain was associated with increased odds of MDD (OR= 1.63; 95 percent CI [1.28, 2.07]). We found no significant associations between friend support and MDD or friend strain and MDD (models 2a and 4a). With the inclusion of all of the support and strain variables, model 5a shows a similar pattern of relations, in which greater family support was associated with reduced odds of MDD (OR = 0.63; 95 percent CI [0.48, 0.82]) and greater family strain was associated with greater odds of MDD (OR = 1.15; 95 percent CI [0.64, 2.05]).

Associations between Support and Strain and GAD

Models 1b to 5b in Table 3 show the associations between support and strain from family and friends and GAD, controlling for covariates. Model 1b indicated that increased family support was protective against GAD (OR=0.44; 95 percent CI [0.26, 0.74]). In model 3b, a one-unit increase in family strain was associated with 1.78 higher odds of meeting criteria for GAD (95 percent CI [1.04, 3.05]). Models 2a and 4a show that neither friend support nor friend strain was associated with GAD. In model 5b, family support and strain variables exerted similar effects on GAD with the inclusion of all independent variables. Specifically, family support was negatively associated with meeting criteria for GAD (OR = 0.42; 95 percent CI [0.27, 0.65]). Further, in the presence of family support, family strain continued to be related to higher odds of meeting criteria for GAD (OR = 1.69; 95 percent CI [1.13, 2.511).

The Moderating Effect of Gender

Our analyses suggested that gender moderated strain. Specifically, we found a significant interaction between gender and friend strain with GAD (p < .05) and a marginally significant interaction between gender and family strain with MDD (p = .06). The interaction between friend strain and gender with GAD, wherein friend strain was associated with increased log odds of GAD among women but not among men is illustrated in Figure 1. Among men, friend strain was associated with decreased log odds of GAD. In a similar manner, Figure 2 presents the interaction between family strain and gender with MDD. For both genders, family strain was associated with increased log odds of MDD, but this association appears attenuated among men compared with women. Finally, gender did not moderate the effect of support from family or friends on MDD or GAD.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

DISCUSSION

The aims of this study were to examine the main effects of social support and social strain from family and friends on mental health variables (MDD and GAD) and to investigate possible gender differences in these relationships among a nationally representative sample of Asian Americans.

Our data showed that support from family, but not friends, was associated with decreased odds of MDD and GAD, after controlling for sociodemographic characteristics. Many studies combine support from family and friends (for example, Noh & Kaspar, 2003; Taylor et al., 2004; Yang & Clum, 1995). Our study indicates that it is important to consider who is providing this support.

Furthermore, strain from family, but not friends, was related to increased odds of MDD and GAD. These results are aligned with other studies that demonstrate greater levels of social strain are linked to psychological distress and disorder (Revenson et al., 1991; Walen & Lachman, 2000). In particular, measures of familial strain related to conflicts and demands such as those reported presently have also been captured in earlier studies on Asian Americans that examined issues such as intergenerational conflict and caregiver burden (Adams, Aranda, Kemp, & Takagi, 2002; Ying & Han, 2007).

Moreover, this finding demonstrates the continued influence of family strain after controlling for receipt of support variables and other demographic characteristics. This suggests that family support and strain are independent constructs that are not necessarily inversely related (Lincoln et al., 2010; Rook, 1984). Hence, future studies should not merely infer strain based on low social support but rather measure strain and support as distinct concepts.

Although strain and support from family were associated with GAD and MDD, there were no such associations for support from friends. The prominence of family network factors compared with friendship network factors is consistent with other research suggesting that for Asian populations the major social unit is the family (B. S. K. Kim et al., 2001). Although prior research indicates that social support may be less effective for mitigating distress among Asian Americans compared with European Americans (H. S. Kim et al., 2006; Taylor et al., 2004), our findings provide another interpretation of these weaker associations: Perhaps the effects were attenuated because past studies did not distinguish between family and friends. We do not have non-Asian populations represented in our study, although future research should examine whether some of the population differences in support could be explained by the source of support (that is, from friends versus family).

The data provided partial support for the hypothesis that the effects of support and strain varied by gender. There were no gender differences for support, but there were for strain. Strain from relatives was related to increased risk of MDD for women but not for men.

Several interpretations of these findings are possible. The salience of social relationships in women's lives may contribute to a greater impact of social strain for women. If women's psychological development is rooted in the quality of their social relationships, as Miller (1988) suggested, social strain may be more toxic for women than it is for men.

In addition the findings may be related to one's ability to control his or her strains. Low control has been linked to the development of depression and anxiety (APA, 2000; Seligman, 1975). Women may be more likely to encounter social strains that are less controllable in nature due to gendered expectations about women's social roles. For example, women are often expected to be caregivers and may feel unable to avoid a caregiving role (Adams et al., 2002). Men, on the other hand, may not face this type of role strain and may feel more able to escape from obligations and responsibilities tied to their social networks.

Finally, studies have described gendered expressions of distress, in which men and women may equally experience distress but express it differently. For example, women are more likely to be diagnosed with mood disorders, whereas men are more likely to be diagnosed with alcohol or substance abuse (Aneshensel et al., 1991). The low prevalence of alcohol and drug abuse in our sample did not allow for comparison across clinical outcomes. Future research should determine whether our results are replicable and investigate the potential mechanisms that may underlie these potential gender differences.

A caveat, however, is that the interaction of gender and family strain for MDD was only marginally statistically significant. One interpretation is that this particular result was an artifact of the data because the interaction was significant at p < .06. That is, on the basis of a very strict criterion of alpha, it would be reasonable to argue that men and women showed similar associations between family strain and MDD. However, interactions are often statistically underpowered and the line between .05 and .06 arbitrary (Abraham & Russell, 2008; Aiken & West, 1991; Greenland, 1983). Hence, it would be prudent to consider these potential gender differences with the understanding that future research is required to verify them.

There was also a statistically significant interaction between strain from friends and gender with regard to GAD. Strain from friends was related to increased risk of GAD for women, but unexpectedly, this strain was related to decreased risk for men. Hence, the null association between friend strain and GAD seen in the aggregated analysis resulted from the trends from women and men cancelling each other.

It is unclear why men seemed to have lower risk of GAD with increasing strain. We speculate that there may be an omitted variable related to how men process questions related to strain. GAD is often characterized by excessive worry (Borkovec & Costello, 1993). Perhaps men who report strain are simultaneously dismissive of these demands (for example, "my friends make too many demands on me, but that's them and I don't worry about it"). Future research is required to clarify the veracity of these ideas and mechanisms that may underlie our anomalous finding.

In addition to the caveats already mentioned, several others should be acknowledged. First, the low prevalence of MDD, GAD, and strain may contribute to type II errors--that is, diminished ability to detect potential relations, such as the association between friend support and MDD and GAD. Furthermore, these low rates may be reflective of Western diagnostic criteria based on the DSM-IV-TR, which may have underestimated the actual prevalence of depression and anxiety due to cultural bias in instrumentation (Ying, 2002). This may be particularly relevant to the data in the sample as three-quarters of respondents are foreign born.

Second, our measures collapse across various types of social support and strain. For example, we were unable to distinguish between emotional and instrumental support. An important next step is to make these finer distinctions in the types of support and strain Asian Americans encounter. Indeed, one prior study found that instrumental, but not emotional, support was related to chronic physical illness among Filipino Americans (Gee et al., 2006).

Third, cross-sectional data cannot confirm the causal direction of the hypothesized relationships. For example, the reverse may be true, with individuals with depression and anxiety encountering greater strain from their social ties. Longitudinal data is needed to enhance our understanding of these relationships.

Fourth, we did not examine additional stressors, such as caregiving responsibilities, physical health, or trauma exposure (Adams et al., 2002; Leong & Lau, 2001; Patterson & Gatwick, 1994). It is important to note that such variables can mutually affect and be influenced by social relationships as well as conditions like depression and anxiety. For instance, caregiving responsibilities may moderate family strain (that is, people who must care for family members may have more depression for a given level of family strain than people without such responsibilities). Future studies should include these and similar factors.

Fifth, although the internal consistency reliability of our social support measures are considered acceptable, the Cronbach's alpha for the strain measures could be improved. This is not surprising given that our strain measures consisted of only two items, and it is well known that alpha increases with the number of items in the scale. To check our findings, we performed additional analyses that used the individual items in lieu of the scales (not shown). These analyses are consistent with those reported here, suggesting that our findings are robust to the specification of the strain measures. Nonetheless, future studies should develop more comprehensive measures of strain.

Finally, due to the low prevalence of MDD and GAD, we did not disaggregate among Asian ethnic groups. However, a key step for future research would be to examine the diversity within Asian Americans. For example, the types of social strains experienced by Vietnamese Americans, who tend to have low rates of out-marriage and larger families, may differ from those of Japanese Americans, who tend to have higher rates of out-marriage and smaller families (Huang, Saenz, & Aguirre, 1997).

With these caveats recognized, several strengths of our study deserve mention. First, we analyzed the contributions of social support and strain simultaneously. Second, we investigated important and clinically relevant mental disorders using a highly structured and previously validated instrument. The WHO-CIDI was developed by groups of experts from across the world, including Asian and Asian American collaborators, who sought to develop a valid and reliable measure of mental disorders applicable across diverse cultures (Kessler & Ustun, 2006). Third, we examined an understudied but rapidly growing population. Finally, our data are nationally representative of Asian Americans living in the United States.

Social Work Implications

Although social workers have generally recognized the positive sides of social relationships, our study serves as an important reminder not to assume that individuals always enjoy benefits from their networks. Mental health interventions aimed at enhancing social support among individuals with depression and anxiety may be more effective by understanding the quality of a client's social relationships. Our findings are consistent with what practitioners already understand--that individuals can have both positive and negative interactions with members of their social network. This notion can be commonly taken for granted, and social workers must be cognizant of the ways in which clients' relationships can both alleviate and cause psychological distress. Furthermore, greater specificity in our understanding and assessment of the positive and negative aspects of social relationships need to be developed for both research and practice (Lincoln, 2000).

With regard to cultural considerations for Asian American clients, a key finding is that social workers should pay close attention to strain and support from family members in particular. Indeed, social workers should consider how Asian American families could be a primary source of their clients' troubles. Accordingly, culturally sensitive practice could include interventions that focus not only on individuals, but also on their families.

Potential differences between men and women should also be considered. Women may be particularly vulnerable to social strain, possibly due to greater exposure or sensitivity to distress. An important implication is that social workers should be attuned to gender differences when identifying therapeutic approaches. For Asian American women, understanding their role in relation to others in the family may be particularly important.

In conclusion, social workers must be attuned to the quality of their client's social relationships and interactions as well as the various functions of their social networks. Although our study focused on Asian Americans in the United States, future studies should investigate these same issues of support and strain among other racial and ethnic groups. Our findings further support the need to acknowledge the benefits and costs associated with social networks, particularly for Asian Americans.

doi: 10.1093/sw/swr005

The authors thank Todd Franke and the anonymous reviewers for their comments on the manuscript. This study was supported by the Council on Social Work Education Minority Fellowship Program. An earlier version of this article was presented at a meeting of the Society for Social Work and Research, January 16, 2010, San Francisco.

Original manuscript received December 2, 2008

Final revision received July 8, 2010

Accepted July 9, 2010

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Cindy C. Sangalang, MSW, is a PhD candidate, Department of Social Welfare, School of Public Affairs, and Gilbert C, Gee, PhD, is associate professor, Department of Community Health Sciences, School of Public Health, University of California, Los Angeles. Address correspondence to Cindy C. Sangalang, 3250 School of Public Affairs, Los Angeles, CA 90095; e-mail: sangalan@ucla.edu.
Table 1: Sample Characteristics of Asian
Americans in the National Latino and
Asian American Study, 2002-2003
(n = 2.066)

Characteristic                     %    M       SE

DSM-I1=772 major depressive       4.6
disoider (patst 12 months)
DSM-IV-TR generalized anxiety     1.4
disorder (past 12 months)
Family support (range: 1-4)             2.73    0.03
Friend support (range: 1-4)             2.66    0.03
Family strain (range: 1-4)              1.96    0.02
Friend strain (range: 1-4)              1.68    0.02

Gender
  Male                          47.41
  Female                        52.59
Age (range: 18-95 years)                41.27   0.70
Ethnicity
  Chinese                       28.51
  Filipino                      21.58
  Vietnamese                    12.87
  Other Asian                   37.04
Education
  Less than high school         14.29
  High school graduate          17.77
  Some college                  25.07
  College graduate              42.87
Work status
  Employed                      63.82
  Unemployed                     6.40
  Not in the labor force        29.78
Marital status
  Married                       68.66
  Divorced/separated/widowed     8.31
  Never married                 23.03
Nativity status
  U.S. born                      23.7
  Foreign born                  76.30
Region
  West                          68.01
  Northeast                     15.53
  Midwest                        8.56
  South                             8

Notes: Data are weighted to reflect population percentages.
DSM-IV-TR=Diagnostic and Statistical Manual of Mental Disorders
(4th ed., text rev.) (American Psychiatric Association, 2000).

Table 2: Bivariate Odds Ratios (ORs) of
72-Month Major Depressive Disorder
(MDD) and Generalized Anxiety Disorder
(GAD) (n = 2,066)

                 MOD                     GAD
Variable         OR         95% CI       OR       95% CI

Family support   0.%5       0.5, 1.00    0.55 *   0.32, 0.94
Friend support   1.35       0.91, 2.00   1.06     0.59, 1.89
Family strain    1.83 ***   1.42, 2.37   1.90 *   1.10, 3.28
Friend strain    1.64       0.94, 2.88   1.76     0.94, 3.28

Note: CI=confidence interval.
* p<.05. *** p-001.

Table 3: Odds Ratios (ORs) of 12-Month Major Depressive Disorder (MDD)
and Generalized Anxiety Disorder (GAD) in Relation to Social Support
and Strain from Family and Friends (n=2,066)

                                   MOD
                 Model 1a          Model 2a        Model 3a

Variable         OR       95% CI   OR     95% Cl   OR         95% CI

Family support   0.63 *   0.48,
                          0.83
Friend support                     0.81   0.49,
                                          1.34
Family strain                                      1.63 ***   1.28,
                                                              2.07
Friend strain

                        MOD                            GAD
                 Model 4a          Model 5a            Model 1b

Variable         OR     95%u CI    OR         95% Cl   OR

Family support                     .63 ***    0.48,    0.48 **
                                              0.82
Friend support                     0.85       0.51,
                                              1.42
Family strain                      1.65 ***   1.26,
                                              2.15
Friend strain    1.31   0.78,      1.15       0.64,
                        2.20                  2.05

                                   GAD
                 Model 1b   Model 2b        Model 3b

Variable         95% CI     OR     95% CI   OR       95% Cl

Family support   0.26,
                 0.74
Friend support              0.70   0.35,
                                   1.41
Family strain                               1.78 *   1,04,
                                                     3.05
Friend strain

                              GAD
                 Model 4b        Model 5b
Variable                95% CI   OR         95% CI
                 OR
Family support                   0.42 ***   0.27,
                                            0.65
Friend support                   0.77       0.40,
                                            1.47
Family strain                    1.69 *     1.13,
                                            2.51
Friend strain           0.92,    1.81       1.00,
                 1.91   3.96                3.30

Notes: Multivariate models are controlled for gender, age, ethnicity,
education level, employment status, nativity, marital status, and
region. CI=confidence interval.

* p < 05, ** p < .01, *** p < .001.
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