Help-seeking behaviors among Chinese Americans with depressive symptoms.
Abstract: An exploratory survey indicated that the depression prevalence among Chinese Americans is 17.4 percent. Of 516 respondents, 34.9 percent preferred seeking advice from friends or relatives, followed by 30.2 percent not showing any preference when facing a mental health problem. Logistic regression results pointed to three contributing factors: anxiety problems, acculturation concerns, and domestic violence. Learning from these factors, the authors conducted additional analyses to connect depressive symptoms with demographics to explain the underutilization of mental health services. Significant results showed that male Chinese Americans were more likely than female Chinese Americans to seek help from physicians but less likely to seek help from friends. Those who were not employed were more likely than those who were employed to think that a family problem would take care of itself or to seek help from herbalists, from physicians, or from friends. implications for social work practice are discussed and address risk factors and multicultural considerations.

KEY WORDS: acculturation; anxiety disorder; Asian immigrants; domestic violence; help seeking
Article Type: Report
Subject: Asian Americans (Health aspects)
Asian Americans (Psychological aspects)
Help-seeking behavior (Analysis)
Family violence (Influence)
Anxiety
Authors: Leung, Patrick
Cheung, Monit
Tsui, Venus
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
Topic: Canadian Subject Form: Help seeking behaviour
Product: Product Code: 9101226 Domestic Violence (Families) NAICS Code: 92219 Other Justice, Public Order, and Safety Activities
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 294900195
Full Text: Depression is a serious mental health issue that occurs in people of all ages, genders, and socioeconomic backgrounds; however, not all cultures view depression as a mental illness. Chinese Americans seldom discuss their mental health problems (Hwang & Myers, 2007). Even if expressed, their "problems" are mainly tied to health care concerns, parental expectations, acculturation, or discrimination, as indicated in recent research (Grossman & Liang, 2008; Juang, Syed, & Takagi, 2007; S. Lee, Lee, Rankin, Weiss, & Alkon, 2007; Ying, 2007). In studies of Chinese Americans, help seeking has been found to be related to "environmental or hereditary causes" and has seldom been reported as personal or psychological problems (Chen & Mak, 2008).

Chinese Americans seldom seek mental health services. According to the U.S. Census Bureau (2008), Chinese Americans made up more than 20 percent of the 11.9 million Asians living in the United States, representing the largest Asian group in this country. Research has shown that Asian Pacific Americans, including Chinese Americans, tend to underutilize mental health services (Abe-Kim, Hwang, & Takeuchi, 2002; Matsuoka, Breaux, & Ryujin, 1997). A study conducted by Loo, Tong, and True (1989) showed that only 5 percent of the 108 Chinese Americans sought mental health services when needed. Data from the Chinese American Psychiatric Epidemiology Study (CAPES) revealed that only 17 percent of 1,747 Chinese Americans sought help when dealing with major depression and other psychiatric problems (Spencer & Chen, 2004). Among the help seekers in CAPES, only a small percentage had received services from professionals, such as mental health professionals (6 percent) and medical doctors (4 percent), in the previous six months, whereas the majority (90 percent) received informal support from religious leaders or friends (Spencer & Chen, 2004).

Although depression is widely underreported, research findings reveal that Chinese Americans are not free of mental health problems, and underutilization of mental health services is a great concern (Chen & Mak, 2008; S. Sue, Fujino, Hu, Takeuchi, & Zane, 1991). In addition, not all Chinese Americans are well-adjusted to their environment, and many do not feel comfortable communicating their problems to others (Grossman & Liang, 2008; J. Lee, Lei, & Sue, 2001; Yick, 2000). Spencer and Chen (2004) found that the main reason Chinese Americans did not seek help was related to language-based discrimination. The data from 1,747 CAPES respondents showed that "language-based discrimination was associated with higher levels of use of informal services and seeking help from friends and relatives for emotional problems" (Spencer & Chen, 2004, p. 809). As a result, many of these respondents showed negative attitudes toward professional mental health services and indicated preferences for informal and family support. Both Mui (1996) and Cheung (1989) shared the findings that depression can be prevented if Chinese immigrant clients receive help from their families and obtain external support to stay healthy. In this article, the literature is used to address help-seeking behaviors among Chinese Americans, and findings are reported from a research project conducted in a large city in the United States to illuminate factors contributing to Chinese Americans' depressive symptoms.

STIGMA OF DEPRESSION

Most Chinese Americans define depression differently from the Western way of diagnosis and treatment. Such differences may be related to migration experiences; ethnic identity; and family structure, including parental roles and marital relationships (Juang et al., 2007; Takaki, 1989; Uba, 1994). Because of the diverse views on mental health that may have influenced clients' help-seeking behaviors, depression treatment should be mindfully planned with consideration of cultural factors (Hsu et al., 2008; E. Lee, 1997). The World Health Organization (WHO) (2008) incorporated mental health in its definition of health: "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." Within the Chinese community, the most common stereotype of mental health is that it is a Western problem of the mind and that a typical Chinese individual should not be affected by it. There is also a perception that if a Chinese person is diagnosed with depression, the illness is controlled by some unknown or spiritual forces (Cheung, 1989). It is essential to examine this perception as it relates to service needs and reluctance to seek help.

During the 1970s, an early community study of depression among Asian Americans showed that 40 percent of Chinese Americans reported a depressed feeling (Kuo, 1984). Another study reported that Chinese immigrants, on average, had a higher number of depressive symptoms than white Americans (Hurh & Kim, 1988). Hsu et al. (2008) found that Chinese Americans were affected by stigma associated with depression (much stronger than for white clients) and did not seek help for mental health symptoms, but instead sought treatment for "physical symptoms." Although the data did not separate the participants' ethnic origins, the National Asian Women's Health Organization (2001) found a lifetime prevalence rate of 6.9 percent and a 12-month rate of 3.4 percent for major depression among Asian Americans. With this and other evidence from the past two decades, helping professionals must attend to and assess the mental health needs of specific ethnic groups so that these underserved groups will not be neglected. To supplement past studies that lumped all Asian subgroups together (Durvasula & Mylvaganam, 1994) and take Fong and Mokuau's (1994) advice to study Asian populations by ethnicity, this study examined the unique needs of Chinese Americans.

CHINESE WAYS OF HELP SEEKING

Although not always open to seeking help, Chinese Americans are equally as susceptible to deleterious mental health problems as are non-Asian Americans (Chen & Mak, 2008; S. Sue, Nakamura, Chung, & Yee-Bradbury, 1994). Within the Chinese American community, six issues have been connected to their underutilization of mental health services: (1) lack of awareness or denial, (2) stigmatization, (3) misperceptions about Western medicine, (4) language barriers, (5) lack of culturally competent providers, and (6) adverse effects of the model minority image (Abe-Kim et al., 2002; Ho, Weitzman, Cui, & Levkoff, 2000; Qin, Way, & Rana, 2008; Spencer & Chen, 2004). Many Chinese people try to keep a positive health image and do not admit having been affected by mental health problems unless these problems can be framed as health care needs.

Implicit in the assumption of positive health is the popular notion that the close-knit family unit, with support from the ethnic community or extended family, can effectively deal with stressors that cause individual problems without the assistance of "outside" interventions (Dhooper & Tran, 1987; D. Sue, 1994; Yee, 1992). Many Chinese Americans view help seeking as "not necessary" or "not culturally acceptable" because emotional challenges are part of a normal life (Kung, 2003). Lou and Takeuchi (2001) found that most Chinese American parents in their study held a strong sense of shame when their children exhibited severe behavioral problems, and this "shameful" (or depressive) feeling reduced their motivation to seek help. In their clinical research, Fang and Wark (1998) demonstrated that Chinese American therapists were more effective in assisting Chinese Americans who held traditional values in disclosing emotional concerns at initial assessment. Help-seeking behaviors among Chinese Americans are connected to their attainment of personal and ethnically based support.

FACTORS CONTRIBUTING TO DEPRESSION

Acculturation stress is a major factor contributing to depression among Chinese immigrants. Mental health studies specific to Chinese Americans show that major contributors to depression are life stressors such as stereotypes and the demands of work and family (Hsu et al., 2008; D. Sue, Sue, & Ino, 1990). A study in San Francisco's Chinatown found that depression among 108 Chinese Americans was connected to social isolation after migration and participants' lack of knowledge about service availability (Loo et al., 1989). Similar findings have revealed a connection between depression and specific life stressors such as domestic violence, pregnancy and child birth, and the "double burden" of maintaining balance between work and family (Hicks, 2006; National Asian Women's Health Organization, 2001). As reported previously, the CAPES study of 1,747 Chinese Americans also found high life stress (as measured by negative life events and other psychosocial risk factors due to immigration) among those who acculturated well but were reluctant to accept mental health services (Hwang & Myers, 2007). Patients' unwillingness to accept services can be related to their anxiety-related distress toward help seeking and a perception that helpers are judging them and applying a non-Asian model of assessment and treatment to them, and as a result, health care is sought instead of mental health services (Lubetkin, Jia, & Gold, 2003).

Another factor is related to self-image, as measured by health rating, bilingualism, and social support (Hwang, Myers, & Takeuchi, 2000). Based on the CAPES data, although acculturation was not found to be a significant predictor of depression or somatization, depression was connected to lack of cultural and family support (Hwang & Myers, 2007; Mak & Zane, 2004). As immigrants become more acculturated, they will become more distant from the culturally based services available to them at the time of their arrival in the United States (Hwang & Myers, 2007).

Because very little research has concentrated on how depression and underutilization of services have affected the mental health of Chinese Americans, it is essential to examine their help-seeking behaviors and identify what can help prevent depression. The present research on Chinese Americans focused on finding ways to facilitate culturally sensitive service planning and delivery to positively change service utilization.

RESEARCH METHOD

We conducted an exploratory survey in Houston, Texas, with convenience sampling data collected from Chinese community centers (cultural festivals, employment and language classes), major Chinese shopping malls, and Chinese churches and temples. Census 2000 data show that 24,001 Chinese people were residing in Houston, the fourth largest city in the United States (Area Connect, 2010). We contacted leaders in the Chinese community to endorse the study and to encourage and recruit participants. A booth was set up in each research site to publicize the research project, and researchers and volunteers simultaneously reached out to recruit participants for the stud. Community and religious leaders played an important role in this recruitment process as they announced their support of the study. Results were analyzed from respondents who self-identified as Chinese Americans who were age 18 or older and residing in the Houston metropolitan area.

The survey contained 14 demographic items and 114 questions on needs and concerns. It was previously found to have good face and content validity in a prevalence study of partner abuse among six Asian Americans ethnic groups conducted by Leung and Cheung (2008). The survey consists of nine sections: demographic information, basic needs, community/social issues, family/relationship issues, health issues, immigration issues, mental health issues, hardships, and domestic violence. The list of all of these issues and concerns can be found in the Appendix.

Except for the domestic violence section, where an eight-point scale Conflict Tactics Scale (Straus, 1979) was used, all other sections used a four-point scale to measure whether the stated issue or need was a concern, ranging from 0 = none to 3 = serious. The section on mental health issues used the Hopkins Symptoms Checklist (HSCL-25) (Parloff, Kelman, & Frank, 1954). The HSCL-25 comprises 25 questions (10 on anxiety, 15 on depression) with a four-point Likert-type response scale ranging from 1 = not at all to 4 = extremely; an average of 1.75 or higher is regarded as symptomatic. The HSCL-25 has been previously tested to be reliable when used with Asian populations, with coefficient alphas of .89 for the Anxiety subscale and .92 for the Depression subscale (Lhewa, Banu, Rosenfeld, & Keller, 2007).

Although originally listed in the instrument under immigration issues, acculturation concern was analyzed as a separate variable because the CAPES findings mentioned in Chen and Mak's (2008) study indicated that acculturation level is positively related to depression--that is, highly acculturated individuals show higher levels of depression. As a result, level of acculturation was not used as a measure in this study; instead, acculturation concern was measured. In addition, the survey included questions regarding help seeking related to mental health problems. The phase "family problems or difficulties" was used in the survey, on the basis of the literature that defines family problems or difficulties as worsening family relations and communication, unemployment, single parenting, and domestic violence, which are possible causes of subsequent mental health disturbances (Chiu & Ho, 2006; Substance Abuse and Mental Health Services Administration, 2008; WHO, 2008).

Data were collected by four researchers and ten volunteers recruited from the master's and doctoral social work programs at a major university in a southern U.S. state. Both English and Chinese (simplified and traditional) versions of the survey were provided, and participants were allowed to select their reading preference. The survey had an accompanying consent letter, approved by the institutional review board at the university, which explained the purpose of the study, anonymity, and voluntary participation. On completion of the survey, participants received small souvenirs for their participation.

RESULTS

Respondent Characteristics

A convenience sample of 516 Chinese Americans completed the survey, which represented 2.2 percent of the Chinese American population in Houston. Sociodemographic characteristics of these respondents are presented in Table 1.

Bivariate Analyses

In this self-reported study, the prevalence of having depressive symptoms among the 516 Chinese Americans was 17.4 percent, and the domestic violence prevalence was 14.7 percent. Results of the bivariate analyses showed that nine variables had significant relationships with depressive symptoms. The first five variables (categorical in scale) that were found, per chi-square statistics, to be significantly related to depressive symptoms were anxiety symptoms [[chi square](1, N = 402) = 144.35, p < .001], hardship issues [[chi square](1, N = 489) = 5.05, p=.025], immigration issues [[chi square](1, N = 489) = 4.58, p = .032], acculturation concern [[chi square](1, N = 416) = 8.91, p = .003], and domestic violence [[chi square](1, N = 379) = 10.18, p = .001] (see Table 2).

The next four variables (continuous in scale), assessed with Levene's test, were statistically significant, with unequal variances for basic needs [F(1, 459) = 4.22, p = .041], family/relationship issues [F(1, 423) = 10.09, p =.002], and health issues [F(1, 425) = 4.13, p = .043] and equal variances in community/social issues [F(1,458) = 3.19, p = .075]. Independent-samples t tests revealed four major significant findings: (1) Individuals with depressive symptoms differed from individuals without depressive symptoms in terms of having more basic needs, (2) individuals with depressive symptoms differed from individuals without depressive symptoms in terms of having more community/social issues, (3) individuals with depressive symptoms differed from individuals without depressive symptoms in terms of having more family/relationship issues, (4) individuals with depressive symptoms differed from individuals without depressive symptoms in terms of having more health issues (see Table 3).

Logistic Regression Model for Depressive Symptoms

As a means to report likelihood, a stepwise logistic regression showed that there was a significant relationship between the three (out of nine) variables and depressive symptoms. These three variables--anxiety symptoms, acculturation concern, and domestic violence--were significantly connected to depressive symptoms (see Table 4), To interpret these findings, three statements connecting these variables to depression can be provided: (1) Those with anxiety symptoms will be 24.8 times more likely to have depressive symptoms than those without anxiety symptoms. (2) Those who have acculturation concerns will be 1.71 times more likely to have depressive symptoms than those who do not have acculturation concerns. (3) Those who have experienced domestic violence will be 1.32 times more likely to have depressive symptoms than those who have never experienced domestic violence. This analysis indicates that these three variables account for 46.5 percent of the sample variability in their contribution to depressive symptoms.

PATTERNS OF HELP-SEEKING BEHAVIORS

Regarding help-seeking behaviors, 34.9 percent of the respondents preferred seeking advice from friends or relatives, followed by 30.2 percent not showing any preference. Some preferred consulting physicians (15.7 percent), whereas others assumed that the problem would take care of itself (7.6 percent). Some would consult religious leaders (5.0 percent), whereas others would seek assistance from mental health professionals (4.7 percent) or herbal doctors (1.9 percent). Overall, the Chinese Americans in this study were more inclined to seek advice from friends or relatives who spoke their language and less likely to consult with mental health professionals when facing family difficulties. The lack of bicultural and bilingual professionals in the mental health profession may have contributed to this reluctance.

Our result showing no significant relationship between depression and help-seeking behavior suggests that Chinese Americans tend not to seek help when facing depression. We conducted further analyses to examine the help-seeking patterns by demographic data to explain why Chinese Americans underutilized mental health services. Chi-square results revealed the following:. Male Chinese Americans were more likely (53.3 percent) than female Chinese Americans (39.1 percent) to seek help from physicians [[chi square](1, N = 339) = 4.272, p =.039]. Female Chinese Americans were more likely (84.2 percent) than male Chinese Americans (72.4 percent) to seek help from friends [[chi square](1, N = 409) = 8.511, p = .004]. Those who were not employed were more likely than those who were employed to think that their family problem would take care of itself [[chi square](1, N = 319) = 9.291, p = .002] or to seek help from herbalists [[chi square](1, N = 282) = 10.718, p = .01], physicians [[chi square](1, N = 331) = 6.446, p = .011], or friends [[chi square](1, N = 398) = 5.621, p = .018]. Those with annual incomes lower than $20,001 were more likely (29.3 percent) than those with higher incomes (8.3 percent) to seek help from herbalists [[chi square](1, N = 270) = 15.048, p < .001]. Other demographic data--such as with versus without college education and living with someone in the household versus living alone--did not seem to be correlated with significant differences in help-seeking behaviors. Overall, mental health services were not perceived as a helping source.

DISCUSSION

The results of this study reveal that anxiety, domestic violence, and acculturation concerns were significantly related to the development of depressive symptoms among Chinese Americans. Unsurprisingly, the results on anxiety and domestic violence were consistent with those of other studies (Mak & Zane, 2004; Yick, Shibusawa, & Agbayani-Siewert, 2003). Mak and Zane used the CAPES data to show a significant connection between anxiety, depression, support, and somatization. Yick and associates, in their study of 262 Chinese Americans, found a statistically significant relationship between domestic violence and depression, particularly in cases of verbal aggression. Acculturation concern was also found to be connected to depression in the present study, which supports Yick's (2000) finding that acculturation concern was significantly connected to severe physical violence experienced during one's lifetime. Attention to the issue of acculturation concern is required, because research has documented that abuse and violence are associated with increased risk for developing a range of psychiatric conditions (Warshaw & Barnes, 2003). When acculturation was measured in the CAPES study, it was defined as "levels of acculturation," not "acculturation concern" (Hwang & Myers, 2007; Mak & Zane, 2004). The present study identifies acculturation as a concern that positively and significantly connects with depressive symptoms. Learning from this result, practitioners will be able to identify how this concern affects Chinese American clients' emotional responses to planned interventions focused on cultural adjustment. In Hwang et al.'s (2000) analysis of the CAPES data, even if acculturation level was high, those Chinese Americans who experienced greater stress exposure and reduced social supports were likely to be depressed. Additional qualitative analysis regarding the content of acculturation concerns would help researchers and practitioners understand how acculturation may contribute to the mental health of Chinese immigrants.

Although gender was entered in the analysis as a variable, we did not find any significant relationship between gender and depressive symptoms, even though male participants tended to seek help from physicians when they experienced family problems. According to the American Psychiatric Association (2000), women are at greater risk for depressive disorders than are men due to genetic factors, sex hormones, life stress and trauma, interpersonal relationships, and cognitive styles. Chinese culture has socialized women to be subservient to a patriarchal society. Determining whether this gender role expectation applies to Chinese American women may require additional evidence-based research. Nevertheless, recent studies have consistently shown that Chinese and Chinese American women are more willing than their male counterparts to seek help for emotional problems and stressful life events (Camras, Kolmodin, & Chen, 2008; Hicks, 2002). However, whether service utilization or help-seeking patterns are different between male and female Chinese Americans needs to be investigated further. Future research needs to include a larger sample and to investigate generational status and gender differences in relation to mental health needs and service utilization in this population.

In this study, none of the demographic factors showed any significant relationship to depressive symptoms. A study reported in Pittsburgh Business Times ("Low Income, More Stress," 2006) indicated that lower income and lower education were related to higher levels of stress. However, the study only found that lower income has a relationship with seeking help from herbalists, not that it was significantly related to depressive symptoms. This contrasting result may require more attention and further research to inspect how Chinese Americans deal with unfavorable situations in their lives.

Findings on help-seeking behaviors indicate that most Chinese Americans do not recognize the importance of mental health and counseling services or use such services even if they are aware of their depressive symptoms; depression is widely underreported. Mental health service organizations have received little attention from this ethnic group. As indicated in previous research, underutilization of mental health services is attributed to fear of bringing shame or stigma to the family. Chinese Americans who have strong adherence to traditional Chinese and family values may wish to avoid conflicts, thus influencing their preference for seeking support and advice from relatives or friends. Inclination to seek help from physicians indicates that Chinese Americans may have a different understanding of mental health than do members of many other groups, viewing it as part of overall health concerns. Tung (1994) discussed the symbolic meaning of the body within Chinese culture and used the term "somatization" to discuss how Chinese people relate mental or psychological problems to physical problems and express concerns in concrete terms that are connected to their physical body. Tung also stated that, in traditional Chinese medicine, illnesses can primarily be attributed to internal causes, namely "seven emotions": joy, anger, worry, si (sentiment), sadness, fear, and shock. Another study of somatization in a Chinese American community showed, however, that the diagnosed physical illnesses that are connected to increased distress may not be cultural responses to express psychological problems in somatic terms (Mak & Zane, 2004). Despite the varied discussions on somatization related to mental health and psychological well-being, further investigation of how Chinese Americans deal with stress is required. The use of qualitative research may allow respondents to address their views and perceptions of mental health and its related services and their help-seeking preferences. In addition, an inclination to seek assistance from physicians for mental health problems indicates that social workers need to work collaborately with physicians to promote mental health, especially among new immigrants.

This study was subject to some limitations. This was a self-administrated survey covering a number of issues related to mental health needs that could have been viewed as personal by the participants and, thus, increased their reluctance to participate. Random selection of participants was not possible in the research sites because the participants attended an activity while the research was conducted at the same time, and it would have been unwise to use a selection method that would make them feel left out from or targeted for the study. As a result of including sensitive topics about individual's hardships, some surveys were not included in the analysis due to large amounts of missing data. Although there is limited generalizability, this study reached a sample size that was large enough to identify connections between depressive symptoms and project contributing factors.

Another limitation was the use of a standardized instrument as part of the survey that contained both measures of depressive symptoms (the dependent variable) and anxiety (one of the independent variables). It is important to note that the constructs of both variables have been separately measured. Nevertheless, researchers must be cautious when interpreting the connection between anxiety and depression. The coexistence of these two variables can be used as a logical explanation for this connection, rather than treating anxiety variable separately when depression is of concern. Although this connection is not new information, this result shows that culturally sensitive services accepting anxiety as a first complaint should be planned with the evidence that anxiety and depression can coexist, but Chinese people tend to seek help to treat their anxiety first.

PRACTICE AND RESEARCH IMPLICATIONS

As indicated, in the present study, facing aversive situations (such as anxiety, domestic violence, or acculturation concerns) increased Chinese Americans' risk of developing mental disorders. This study has identified the urgent need for advocacy and educational programs to promote an understanding of mental health in the Chinese American community. Community education on dispelling the model minority myth, removing stigma facing mental health patients and their families, and promoting healthy and positive mental health must be a high priority. This study has revealed that about one-third of Chinese Americans would consult physicians for mental health problems, demonstrating that it is vital to engage physicians and to connect mental health professionals with health care professionals in collaborative projects for mental health promotion and mental illness prevention.

Although the attitude of the second- and third-generation Chinese Americans toward the use of mental health services is changing, sociocultural factors may continue to affect their willingness to talk about their private lives (Weaver & Kim, 2008). An understanding of traditional Chinese family and cultural values, belief systems, and attitudes toward mental illness is essential for mental health professionals working with Chinese immigrants. As Hwang and Wood (2007) observed, cultural competence has become part of the fabric of clinical competence in work with Chinese Americans. Bilingual and bicultural service providers who focus on the body-mind connection in mental health may better serve the specific mental health needs of Chinese Americans. Dennis (2004) remarked that there is a need to improve diagnostic tools to be sensitive to the needs of different cultures. As a result, culturally sensitive practice in multicultural communities should expand not only to encompass counseling and treatment, but also to include assessment tools and evaluation systems. Awareness and improvements in cultural sensitivity are crucial in helping ethnic minorities find the most culturally relevant support while encouraging utilization of mainstream services.

Continuous research on this understudied population is important. Future research can expand to include large sample sizes in quantitative studies to have a better representativeness of the Chinese American population. In addition, in-depth interviews and focus groups should be conducted with Chinese Americans to understand their views and definitions of mental health and their perceptions of service utilization. Such further study would be especially valuable given the present dearth of qualitative data. Moreover, the literature shows that such areas as acculturative stress and family violence, sociocultural factors (including cultural and familial conflicts), demographics (such as gender and education), and the support network substantially affecting the psychological well-being of Chinese immigrants (Huntsinger & Jose, 2006; Mak & Zane, 2004; Yick, 2000) all deserve more research.

To conclude, the social and economic costs of mental health problems can be long-lasting and tremendous; therefore, efforts should be directed toward preventive services that will reduce social stigma and discrimination against those who suffer these problems. Such direction is similar to the suggestions offered by the WHO (2008) with a research focus on the causes, treatment, and evaluation of mental health problems. The present study has marked a crucial step to show that Chinese Americans experiencing unfavorable situations--such as anxiety, acculturation concern, and domestic violence--will have a higher risk of developing depressive symptoms. Further investigation and empirical study is required to expand our knowledge on practical ways to treat and prevent depression among Chinese immigrants given their unique cultural expectations.

doi: 10.1093/sw/swr009

APPENDIX

Survey Items: Concerns and Needs Basic Needs: food, housing, clothing, adequate income, access to medical care, others

Community/Social Issues: crimes against people, crimes against property, unemployment, underutilized skills, transportation, adequate education/ job training, day care for children, 24-hour care for children, day care for dependent adults, 24-hour care for adults, lack of recreational activities, poor performance in job/school, language barriers, financial assistance, discrimination, religious support, ethnic group support, lack of child mentoring programs, lack of Asian volunteers in the community, others

Family/Relationship Issues: problems with young children, problems with teenagers, problems with parents, problems with in-laws, problems with spouse or significant others, communication with family members, conflicting styles of parenting, children losing cultural roots, strict parents, financial management, child abuse, spouse abuse, elder abuse, isolation, others

Health Issues: chronic pain/illness, disabling/terminal illness, alcohol/drug problems, pregnancy-related concerns, abortion, eating disorders, sexual dysfunction, physical problems without medical cause, developmental disabilities, others

Mental Health Issues: Hopkins Symptoms Checklist (Parloff, Kelman, & Frank, 1954)

Types of Hardship: rape, robbery, murder, loss/ separation of family, dramatic loss of income, serious illness, refugee camps, war trauma, others

Immigration Issues: uncertainty of sponsorship, uncertainty of employment, waiting for legal status, mode of transportation, political freedom, religious freedom, political asylum, family reunion, public financial assistance, discrimination, adequate legal assistance, others Acculturation Concern

Family Violence: Conflict Tactics Scale (Straus, 1979)

Original manuscript received February 19, 2009

Final revision received April 8, 2010

Accepted July 29, 2010

Advance Access Publication May 22, 2012

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Patrick Leung, PhD, is professor and director, Office for International Social Work Education, Graduate College of Social Work, University of Houston. Monit Cheung, PhD, LCSW, is professor and principal investigator, Child Welfare Education Project, Graduate College of Social Work, University of Houston. Venus Tsui, PhD, is assistant professor, Worden School of Social Service, Our Lady of the Lake University. This article is based on a juried paper presented at the 54th Annual Program Meeting of the Council on Social Work Education in Philadelphia, November 2008. Address correspondence to pleung@uh.edu.
Table 1: Sociodemographic Characteristics
of Respondents (N= 516)

Variable                              M      SD      n     %

Age (years)                           48.3   18.1   477   92.4
  Missing                                            39    7.6
Years in United States                17.4   12.2   497   96.3
  Missing                                            19    3.7
Gender
  Male                                              219   42.4
  Female                                            293   56.8
  Missing                                             4    0.8
Marital status
  Single                                            120   23.3
  Married                                           337   65.3
  Divorced/separated                                 19    3.7
  Widowed                                            29    5.6
Living with significant other                         9    1.7
  Missing                                             2    0.4
Currently employed
  Yes                                               307   59.5
  No                                                182   35.3
  Missing                                            27    5.2
Education
  High school                                        89   17.2
  Some college                        -             102   19.8
  Bachelor or above                                 294   57.0
  Other                                               9    4.3
Annual household income
  Less than $19,999                                 139     27
  $20,000 to $39,999                                 74   14.4
  $40;000 to $59,999                                 59   11.4
  $60,000 to $79,999                                 52   10.1
  $80,000 and over                                  147   28.5
  Missing                                            45    8.7
People living in household,           3.05   3.49
  including sell
  1-2                                               218   42.2
  3-4                                               215   41.7
  5 and over                                         50   -9.7
  Missing                                            33    6.4
Number of generations                 1.60   0.85
  1                                                 159   30.8
  2                                                 171   33.1

  3 and over                                         44    8.6
  Missing                                           142   27.5
People in household under age 18      0.9    1.0
  0                                                 132   25.6
  1-2                                               157   30.5
  3 and above                                        14    2.7
  Missing                                           213   41.3
People in household age 60 and over   0.8    0.9
  0                                                 165   32.0
  1                                                  60   11.6
  2                                                  83   16.1
  3-4                                                 5    1.0
  Missing                                           203   39.3

Table 2: Depressive Symptoms
Table Mental Health Issue

                             % with DS   % without DS
Issue                           (n)          (n)

VVithanxietys mptoms         71.4 (60)     9.7 (31)
Without anxiety symptoms     28.6 (24)    90.3 (287)
With hardship                62.2 (56)    49.1 (196)
Without hardship             37.7 (34)    50.9 (203)
Witit immigration issues     61.1 (55)    48.6(194)
Without immigration          38.9 (35)    51.4 (205)
issues
With acculturation concern   33.3 (24)     17.7(61)
Without acculturation        66.7 (48)    82.3 (283)
Concern
With domestic violence       32.4 (23)    14.3 (44)
Without domestic violence    67.6 (48)    85.7 (264)

Table 3: Independent Samples t Tests
Showing Differences between individuals
with and without Depressive Symptoms
(DS)

Variable and DS Status     n    M       5D      T           p

Basic needs                                     3.014 (a)   0.003

  With DS                  84   1.692   0.956
  Without DS              377   1.339   1.035
Community/social issues                         3.255 (b)   0.001
  With DS                  86   1.768   0.785
  Withour DS              374   1.435   0.872
Family/relationship                             3.830 (c)   0.000
issues
  With DS                  78   1.626   0.859
  Without DS              347   1.199   1.018
Health issues                                   5.318 (d)   0.000
  With DS                  85   1.572   0.859
  Without DS              342   1.002   0.979

(a) df=129.98, Cohen's d=0.36.

(b) df=458, Cohen's d=0.40.

(c) df=730.43, Cohen's d=0.46.

(d) df=143.35, Cohen's d=0.62.

Table 4: Logistic Regression Model for Depressive Symptoms

Variable                  B      SE      OR (exp B)   p

Constant                -2.955             0.052
Anxiety sympro ns        3.250   0.349    25.797      0.000
Acculturation concern    0.996   0.389     2.708      0.010
Dom?estic violence       0.892   0.401     2.317      0.036

                        95% Cl for exp B

Variable                Lower    Upper

Constant
Anxiety sympro ns       13.027   51.085
Acculturation concern    1.263    5.806
Dom?estic violence       1.055    5.088

Notes: OR=odds ratio; Cl=confidence interval. [chi square]
(3, N=360)=124.656, p < .007, Negelkerke [R.sup.2] =.465.
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