Prevalence and predictors of depression in the older Asian Americans in Houston

Abstract

A study was conducted in the greater Houston area in the United States with 1840 Asian American participants where 413 (22.5%) were 55 years and older and 12.6 percent had depressive symptoms. Logistic regression analysis found that the likelihood of being depressed was significantly increased among individuals with anxiety symptoms (odds ratio (OR) = 769.36), at least a high school education (OR = 21.756), a greater number of generations living in the household (OR = 3.789), and chronic pain (OR = 2.604). Conversely, being married reduced the likelihood of being depressed by 89.5 percent (OR = .105). Implications focus on help-seeking behaviors of older Asian Americans in relation to their mental health needs.

Keywords

Anxiety symptoms depressive symptoms intergenerational households marital status older Asian Americans

Asian Americans comprise approximately 5.6 percent of the nation’s population with over 15 million Asian Americans living in the United States (US Census Bureau (USCB), 2011a, 2011b). The Asian American population is one of the fastest growing ethnic groups in the United States and is estimated to grow from 3.6 percent of the total population in 2000 to 9.3 percent (or 41 million) by the year 2050 (Centers for Disease Control and Prevention (CDC), 2010; USCB, 2012). In 2010, over 2.9 million (or 19.9%) of Asian Americans were 55 or older and another 39 percent of the population is projected to reach the age of 55 in the next 20 years (USCB, 2010). Older Asian Americans – a diverse, heterogeneous group with a wide range of cultural and socioeconomic backgrounds – have repeatedly been recognized as an understudied minority group with unique health and mental health concerns (Frisbie et al., 2001; Mui and Shibusawa, 2008; Tanjasiri et al., 1995).

Depression affects approximately 1 in 10 adults in the United States (CDC, 2012). However, statistics on older Asian Americans’ depression rates have ranged anywhere from 5 to 40 percent, a possible consequence of this population’s ethnic, cultural, and demographical diversity (Ina et al., 2011; Kuo et al., 2008; Li et al., 2004; Mui et al., 2003). Because Asian Americans are concentrated in specific geographic areas, some have argued that more localized studies are critical to better understand the Asian American population (Srinivasan and Guillermo, 2000). This community-based study uses data about the needs of Asian Americans aged 55 years and above in the greater Houston area to explore the potential role of culturally sensitive services for this population. After a literature review on depression affecting older Asian Americans, this article reports key survey findings on the mental health needs among this population with a focus on older adults representing the city’s two largest Asian ethnic communities, Vietnamese and Chinese.

Depression in older Asian Americans

Prevalence

To date, the prevalence of depression among older Asian Americans is still not entirely clear. One factor contributing to a lack of data is that Asian American older adults are tremendously diverse, encompassing individuals with cultural ties to as many as 48 different countries. Additionally, existing data on older Asian Americans suggest that depression might be more prevalent in this population than in younger Asian Americans and other ethnic groups. Most studies do not differentiate among the various Asian identities when gathering ethnic data. For example, in a study of 2240 elderly primary care patients with mental disorders, Bartels et al. (2002) found that Asian Americans (n = 111) had the highest proportion (57%) of suicidal or death ideations compared to African Americans, Hispanics, and Whites. Other studies provide evidence that depression has a disproportionate impact on different Asian ethnic groups. In another study of 552 Asian Americans aged 60 years and older, Kim and Choi (2010) found the prevalence rate of depression to be 7.4 percent for the Asian population, and they reported that Chinese older adults were more likely to be depressed compared to other Asian ethnic groups in the sample (including Vietnamese, Filipino, Japanese, Korean, and Asian Indian Americans). Challenges in differentiating the depression prevalence data based on each of these Asian ethnicities surfaced due to low response and participation rates among Asian older adults.

Contributing factors

A broad range of factors contributing to depression – including chronic conditions, self-perceived health, social support, acculturative stress, marital status, financial status, gender, and age – have been shown to be predictors of depression in older Asian Americans. Some studies have addressed factors contributing to depression by specific Asian ethnicities in the older population. For instance, studies by Leung et al. (2010) and Mui and Kang (2006) found that Vietnamese Americans (n = 572) and Asian American immigrants in general (n = 407), respectively, connected depression treatment to healthcare services. Specifically, the presence of chronic illnesses was positively correlated with depressive symptoms (Jang and Chiriboga, 2011; Jonnalagadda and Diwan, 2005; Niti et al., 2007). Other studies have found chronic pain to be a significant predictor of depression among older Chinese and Korean Americans (Ina et al., 2011; Wu et al., 2004). Poor self-perceived physical health status was also connected to depressive symptoms (Gautam et al., 2011; Ina et al., 2011; Jang et al., 2006; Leung et al., 2010; Mui and Kang, 2006). Sohn (2004) found that 69 percent of Korean Americans (aged 65 years and older) in Los Angeles had fair or poor self-rated health status compared to 27 percent of the American population aged 65 years and older. Ina et al. (2011) found that mobility was important among the respondents from Korea (n = 300), and self-care activities were correlated with reduction in depression among those from China (n = 336). Jang et al. (2006) studied 230 Korean Americans and found that their health perception was closely related to their mental health status.

Acculturative stress can be common among older Asian Americans, many of whom are immigrants to the United States and may have had difficulties adjusting to life in the United States (Segal, 2002). Several studies found that individuals with higher levels of acculturation were less likely to have depressive symptoms than those with lower levels of acculturation (Jang and Chiriboga, 2011; Jang et al., 2006; Kuo et al., 2008; Lai and Surood, 2008). Also, Jang and Chiriboga (2011) found that acculturation and social activity participation were protective factors against depression. However, social participation as a sole intervention might not provide positive outcomes for highly acculturated individuals. Similarly, in a sample of 489 Nepalese aged 60 years and older, Gautam et al. (2011) found that receiving emotional support was important in reducing depressive risk. Two other studies of the older Asian populations in Hong Kong (n = 554) and Canada (sample size not specified) identified cultural adjustments and appropriate health care as important factors in reducing depressive symptoms after controlling for respondents’ socio-demographics (Boey, 2001; Lai and Surood, 2008).

In terms of demographic characteristics, single older Asian Americans reportedly experienced greater depressive symptoms compared to their married counterparts (Boey, 2001; Gautam et al., 2011; Jang and Chiriboga, 2011; Jang et al., 2009; Wu et al., 2004). An elderly Chinese sample (n = 554, r = −.14, p < .01) found that education was negatively correlated with depressive symptoms (n = 554, r = −.14, p < .01) (Boey, 2001: 41). Research on the relationship between gender and depression prevalence is mixed and the age definition of ‘elderly’ varies. Specifically, a critical review of 24 studies found that depression was correlated with the female gender among older Asian Americans (Boey, 2001; Kuo et al., 2008; see also Leung et al., 2010), while other studies found no significant gender differences (Kim and Choi, 2010). Future studies should further investigate demographic determinants of depression.

Access to mental services and help-seeking behaviors

Evidence suggests that older Asian Americans continue to face tremendous challenges in accessing mental health and healthcare services. In a recent study, Sorkin et al. (2011) found that older Chinese, Filipino, Japanese, and Korean Americans were each less likely than their non-Hispanic White counterparts to use mental services and/or prescribed medication. For example, although the Filipino and Korean elderly were more likely to report mental distress symptoms, they were still less likely to utilize mental health services and medications.

Older Asian Americans also experience difficulties in accessing primary care services, which often serve as an important gateway to the mental health system. For example, in one study, only 42 percent of Korean Americans aged 65 years and older utilized a physician’s office compared to 86 percent of the overall US population (Sohn, 2004). Additional data show that 20 percent of the older Korean Americans studied relied on the emergency room compared to only 2.1 percent of all ethnicities nationwide. Potential barriers to health care include limited English proficiency, lack of knowledge about public health facilities, and a preference for informal and culturally based solutions to mental health problems (Chu and Sue, 2011; Sohn, 2004).

Cultural and social factors play critical roles in influencing older adults’ decisions to seek mental health services even as they experience health and cognitive declines (Laditka et al., 2011). Among the various Asian populations, cultural stigma surrounding mental health may act as a barrier to seeking services. For example, Jang et al. (2007) found that older Korean Americans tended to perceive mental health in either a ‘dismissive’ or ‘negative’ way (p. 4). Over half of their sample (240 out of 472) viewed depression as a normal aging process, but at the same time 71 percent of them also saw depression as a sign of individual weakness. The researchers found that perceptions of mental health were more positive among those who had lived in the United States for a longer period of time than those who had not. Similarly, in a study of 62 Chinese and Vietnamese Americans, Laditka et al. (2011) found that many considered their cognitive health ‘a burden’ (p. 1214).

Conversely, cultural traditions may also have a positive effect on mental health by promoting traditional coping strategies. In their exploratory study, Lee and Chan (2009) found that spirituality and religious traditions, for example, acceptance of one’s situation, were key coping strategies among older Chinese Americans. Alternative medicine, such as acupuncture, may garner less stigma or shame compared to formal mental health treatment (Yang et al., 2008). For many, the family and community tend to be key sources of support, while formal mental health services are typically used as a last resort (Lee and Chan, 2009; Pang et al., 2003).

The literature about the important factors associated with depression has formed a framework to design this study to focus on how depression is related to the help-seeking behaviors of older Asian Americans. Data from a convenience sample of Asian respondents in Houston, Texas, in the United States are analyzed to examine the connection that informal support can link older Asian Americans to formal services.

Method

With internal review board (IRB) approval from University of Houston, a survey was conducted as part of a needs assessment project in various Asian ethnic communities in Houston, Texas. In 2010, Asian Americans represented 7 percent of Houston’s total population with almost 400,000 residing in the city – making it the fourth largest concentration of Asian Americans in the United States (USCB, 2011b). This exploratory study was conducted in 2008 in Houston, Texas, using convenience sampling in community centers (cultural festivals, employment, and language classes), major shopping malls, churches, and temples. Subjects were recruited from various places and activities that specifically cater to the Asian American community such as community centers, religious gathering places, and language classes. Community leaders identified these settings and assisted in contacting potential respondents. Respondents were asked to complete an anonymous self-administered survey and could choose between English, Chinese, Korean, or Vietnamese versions of the survey.

The instrument

The survey contained 14 demographic items and 114 questions on needs and concerns. Leung and Cheung (2008) found the survey to have good face and content validity in a prevalence study of partner abuse among six Asian American ethnic groups. The needs assessment instrument was validated during a validity and translation checking process. First, prior to conducting the previous study (Leung and Cheung, 2008), we checked its face validity through input from community leaders. The researchers identified the top five Asian communities in Houston based on census data and found that the Vietnamese, Chinese, and Korean communities might require translated surveys. In our experience, Indian and Filipino Americans typically respond to English surveys. Next, three bilingual researchers further examined the face validity of the translated versions and then pilot tested them with at least 10 subjects in each of the respective ethnic groups. In addition to the three translated versions, bilingual research assistants were available at the research sites if respondents had questions or wanted someone to read the questions in order to help them fill out the survey; however, none of the respondents requested translation assistance.

For the purpose of this study, data were used from the following sections of the survey: demographics, family/relationship issues, types of hardship, help-seeking behavior, and depression measure. For this study, ‘elderly Asians’ were defined as those who provided demographic data indicating they were aged 55 years or older, which was considered a culturally significant transition point from ‘middle-aged’ to ‘elderly’. Respondents were further subdivided into four age categories: 55–64, 65–74, 75–84, and 85 and older. Although the broader community survey included information from all age groups, this analysis only focused on information related to those aged 55 years and older.

Depression is the dependent variable measured by Part II of the Hopkins Symptoms Checklist-25 (HSCL-25). HSCL-25 has 15 questions measured by a 4-point response scale (1 = ‘Not at all’, 2 = ‘A little’, 3 = ‘Quite a bit’, and 4 = ‘Extremely’) to identify depressive symptoms (Parloff et al., 1954). According to a study by Lhewa et al. (2007) and Silove et al. (2007), HSCL-25 has been widely used and previously verified as reliable when used with Asian populations (such as Cambodian, Chinese, and Vietnamese), with a coefficient alpha of .89 for the Anxiety subscale and .92 for the Depression subscale. In Asian immigrant studies, HSCL-25 has consistently shown a high correlation between the total scores and severe emotional distress of unspecified diagnoses (Hinton et al., 2004; Pernice and Brook, 1996). The HSCL-25 depression scale is derived from the Diagnostic and Statistical Manual of Mental Disorders, Version IV-TR, of the American Psychiatric Association (APA) (2002) in which average depression score of 1.75 or higher is considered symptomatic. Since this study was a part of the Asian community survey, the 15 depression items in HSCL-25 were used instead of Geriatric Depression Screening Scale (GDS-15) designed for older adults, which might suggest instrumentation as a study limitation.

In terms of independent variables, data of mental health concerns and needs were first tested with bivariate analyses to examine whether each variable had a significant relationship with depression. Questions were answered with a 4-point scale to indicate the respondent’s perceived level of concern (0 = none, 1 = mild, 2 = moderate, 3 = serious) about each issue, and an average score was computed for the overall concern in each of these two categories:

Family/relationship issues: concerns toward issues with young children, problems with teenagers, problems with parents, problems with in-laws, problems with spouse or significant other, communication with family members, conflicting styles of parenting, children losing cultural roots, strict parents, financial management, child abuse, spousal abuse, elder abuse, isolation;

Hardships: concerns toward rape, robbery, murder, loss or separation of family, loss of income, serious illness, refugee camps, war trauma.

In addition, two questions were also asked to identify help-seeking channels and the respondents’ top preference: (1) Who would these respondents consult with when having family problems or related difficulties when they had many choices? and (2) Which helper would they prefer if they were given only one choice?

Data analysis procedures

The main research question focused on the relationship between having depressive symptoms (dependent variable) with independent variables such as physical and psychological symptoms (chronic pain, anxiety), access and barriers (medical care and language), and major demographics significantly related to depression in the bivariate analyses. Help-seeking preferences were qualitatively studied among those Asian Americans aged 55 years and older with depressive symptoms measured by HSCL-25.

First, chi-square tests were used to analyze the relationship between the variable ‘having depressive symptoms or not’ and the following categorical variables: gender (male and female), marital status (married and not married), employment (employed and unemployed), and educational level (high school or below, some college, Bachelor’s degree, Master’s degree, and PhD). Independent t-tests were used to address the relationship between having depressive symptoms (or not) and the following interval/ratio-level variables: age, years lived in the United States, number of generations living in the household, and levels of concern on four variables: access to medical care, language barriers, chronic pain, and anxiety symptoms. Significant variables were then entered into a logistic regression model to identify factors that might contribute to older Asian Americans’ depressive symptoms.

Results

This study sample came from a larger Asian community needs assessment study (N = 1840); among the respondents, only 413 (22.5%) respondents were aged 55 years and older. Of the older Asian respondents, 74.8 percent were married. Approximately 52.3 percent had obtained at least a bachelor’s degree. Over 39 percent of the respondents reported an annual household income of less than US$20,000, with about 41 percent being currently employed. While the entire sample had almost equal distributions between the two genders, the respondents in the ‘older Asians’ sample were represented by more females (53%) than males (47%). The overall depression prevalence among older Asians (those over 55 years) was 12.6 % the rate was higher within the female group (14.6%) than the male group (9.9%) but the different rates were not statistically significant.

In terms of age, 50.6 percent of the respondents were 55–64 years old, 32.5 percent were 65–74 years old, 14.2 percent were 75–84 years old, and 2.7 percent were 85 years and older. On average, our typical respondent in the sample was 66 years old (median = 64; mode = 57), living in the United States for 24 years in a three-member, two-generation household. No significant difference in depression prevalence was found between the 55–64 years old group and those above 65 years old.

In terms of ethnicity, the majority of the subjects aged 55 years and older were represented by Chinese (41.9%), Vietnamese (24.2%), and Taiwanese (10.7%). Within these three ethnic groups, depression prevalence rates were as follows: Chinese (18.5%), Vietnamese (14%), and Taiwanese (6.8%). Prevalence rates for other ethnic groups based on a small sample must be assessed with caution. For example, although the prevalence rate seems to be high among the Filipino respondents (50%), only four subjects in this ethnic group responded to the questions for the depression scale (Table 1).

Table 1.

Characteristics of respondents (N = 413)^a.

Variable	n	%
Gender
Male	192	46.5
Female	219	53.0
Ethnicity
Chinese	173	41.9
Vietnamese	100	24.2
Taiwanese	44	10.7
Korean	31	7.5
Indian	27	6.5
Pakistani	25	6.1
Others (Filipino, Japanese, Cambodian, Nepalese, unknown)	13	3.1
Years lived in the United States (mean: 23.73, SD: 12.21)
Less than 1 year	4	1.0
1–5 years	16	3.9
5–10 years	26	6.3
More than 10 years	190	46.0
Age, years (mean: 65.67, SD: 8.50)
55–64	209	50.6
65–74	134	32.5
75–84	59	14.2
85 and older	11	2.7
Marital status
Married	309	74.8
Not married	104	25.0
Employment status
Employed	169	40.9
Unemployed	221	53.5
Educational level
High school or below	103	24.9
Some college	73	17.7
Bachelor’s degree	136	32.9
Master’s degree or above	51	12.4
PhD	29	7.0
Income (annual household)
Less than US$20,000	162	39.2
US$20,000–US$59,999	97	23.5
US$60,000 and over	109	26.4
Generations live in household (mean: 1.52, SD: .83)
1	162	39.2
2	100	24.2
3	34	8.2
4 and more	2	.5
Depressive symptoms
Without symptoms	361	87.4
With symptoms	52	12.6

SD: standard deviation.

Some categories of data contain missing data and the total percentage may not add to 100 percent.

In the bivariate findings, neither family relationship concerns nor hardship concerns were significantly connected to the respondents’ report of depressive symptoms. Since logistic regression could predict factors contributing to the dependent variable, we could only enter significant bivariate findings to the analysis in terms of levels of agreement toward having access to medical care, having language barriers, having chronic pain, and having anxiety symptoms. These significant variables, along with a set of demographic variables based on support from the previous literature, were then included in a logistic regression analysis to identify the effect of these factors on depressive symptoms among 413 older Asian Americans in this sample (see Table 2). In consideration of maintaining a sufficient sample size for the analysis, this logistic model was used for all respondents as a group, not by Asian ethnicity. Ethnic differences must be addressed in future research of a larger sampling frame.

Table 2.

A logistic regression analysis of factors predicting depressive symptoms.

Contributing factors	B	SE	Significance	Odds ratio
Anxiety symptom	6.646	1.402	.000**	769.360
Educational level	3.080	1.387	.026*	21.756
Generations in household	1.332	.674	.048*	3.789
Chronic pain	.957	.469	.041*	2.604
Language barriers	.478	.468	.308	1.613
Employed	.165	1.158	.887	1.179
Years lived in the United States	−.035	.037	.341	.965
Income level	−.176	1.134	.876	.838
Gender	−.401	.876	.647	.669
Access to medical care	−.698	.470	.138	.498
Marital status	−2.255	.938	.016*	.105
Constant	−6.036	2.557	.018*	.002

SE: standard error.

Access to medical care, language barriers, and chronic pain: 0 = no concern, 1 = mild, 2 = moderate, and 3 = serious concern.

Gender: 1 = male; 2 = female.

Employed: 1 = employed; 0 = not employed.

Marital status: 1 = married; 0 = not married.

Income level: 0 = household income below US$20,000; 1 = US$20,000 or above.

Educational level: 0 = high school or below; 1 = above high school.

p < .001; *p < .05; χ² = 86.864, df = 11, p < .001; Nagelkerke R² = .765.

Results showed that five factors significantly contributed to having depressive symptoms, while holding all other variables constant, including having anxiety symptoms, number of generations living in the household, educational level, concerns about chronic pain, and marital status (χ² = 86.86, df = 11, p < .001 with Nagelkerke R² = .765). In terms of the effect of each contributing variable, those with anxiety symptoms were about 768 times more likely to have depressive symptoms than those without anxiety symptoms. Those with high school education or above had an increased likelihood of having symptoms by almost 21 times as compared to those with less than high school education. Each unit increase in the number of generations living in the household multiplied the likelihood of having depressive symptoms by 2.789 times. Respondents with chronic pain were 1.6 times more likely to have depressive symptoms than those without chronic pain. Conversely, being married reduced the likelihood of having depressive symptoms by 89.5 percent.

There were no statistically significant differences in help-seeking behaviors and preferences between those with depressive symptoms and those without. In terms of help-seeking preferences among those with depressive symptoms, 42.4 percent of the respondents indicated ‘no preference’, 25 percent preferred medical doctors, 9.6 percent preferred mental health professionals, 7.7 percent said that their problem would ‘heal by itself’, and 3.8 percent preferred herbalists. Findings related to self-healing or herbalist consultation could be connected to the concept of ‘self-care’ within the natural healing process. In terms of actual help-seeking practice, many of these respondents with depressive symptoms had sought help from medical doctors (42.4%) and families/friends (40.4%). While some of them had sought help from mental health professionals (21.2%), many ignored their problems by doing nothing (17.3%) (see Table 3). There were no significant differences between those with and those without depressive symptoms in seeking help from herbalists or medical doctors. As a follow-up to these findings, when comparing those with depression to those without, a chi-square test showed that more depressive respondents would seek help (20.4%) than not seek help (11.4%) from mental health professionals (χ² = 3.416, df = 1, p = .0325).

Table 3.

Preferred versus actual help-seeking channels among the respondents with depressive symptoms.

Help-seeking Channel (n = 52)	Help preferred		Help actually acquired^a
Help-seeking Channel (n = 52)	n	%	n	%
Medical doctors	13	25.0	22	42.4
Friends/family	5	9.6	21	40.4
Mental health professionals	5	9.6	11	21.2
Do nothing	4	7.7	9	17.3
Herbalists	2	3.8	4	7.7
Religious leaders	1	1.9	7	13.5
No preference	22	42.4	NA	NA

NA: not applicable.

Some respondents answered more than one source of assistance.

Discussions and implications

Houston is a culturally diverse city with a population of 2 million, in which 7 percent are Asian (USCB, 2011b). Although ethnic breakdowns could be found only in the 2000 Census showing that Chinese represented 23 percent and Vietnamese represented 31 percent of the Houston Asian population (Infoplease, 2014), we found in another source that 49 percent of the non-English speakers in Houston could speak Chinese and 32 percent could speak Vietnamese (Rodriguez, 2006). Similar to this study, the study by Rodriguez (2006) used statistics based on a community sample willing to fill out a survey. The 12.6 percent prevalence rate for depression among the Asian older adults in this study falls within the ranges reported in the cited literature. This finding demonstrates that Houston, the fourth largest city in the United States, has a strong need for mental health services for older Asian Americans.

Using the results from the logistic model, we found that five variables contributed to depressive symptoms among these respondents. The anxiety symptom variable used in this study validated the HSCL-25 as the self-reported anxiety score corresponded highly with the Hopkins 15-item depression symptom scale. The anxiety symptom variable also demonstrated the importance of measuring both anxiety and depression symptoms simultaneously although older adults may only seek help for their anxiety. In primary care settings, evidence has shown that patients with chronic illnesses tend to feel better when they are able to manage both their depression and anxiety (Pommer et al., 2012).

The researchers cannot locate prior research that addresses the impact of number of generations living in the household on depressive symptoms. However, research has shown that an overcrowded or high-density environment can adversely affect mental health (Regoeczi, 2008). Regoeczi (2008) found that women tended to have a higher likelihood of depression when living in a crowded place, which may help to explain the higher depression rates among the women in our study. Additionally, intergenerational expectations and value systems could influence negative attitudes in interpersonal relationships.

The current literature suggests that both age and education levels may contribute to depression. In a neuroscience study comparing patients in six Asian countries, Sulaiman et al. (2014) found that when compounded by physical concerns such as chronic pain, age and education level may contribute to symptoms of distress and depression. Our finding that education level contributes to depression among older Asian Americans adds to the literature on the connection between age, education, and depression.

Finally, we found that being married was an influenced symptom reduction. Current research has focused on how depression could negatively affect marital quality (Najman et al., 2014); however, when marriage is perceived as a social support, it can contribute to depressive symptom reduction (Qadir et al., 2013). Marriage as a contributor to depression may be particularly the case among women, so gender differences need to be further explored.

The data in this study indicated an apparent mental shift from problem-solving to help-seeking. Social workers may need to encourage older Asian American clients to seek help for solving personal problems. This study suggested that when a professional can help an older person to value self-healing and self-care and can praise his or her efforts to locate family resources, then this person’s help-seeking outside of the family can be viewed as an acceptable way to find health solutions. This reframing strategy may lead respondents with depressive symptoms to use mental health services to access early intervention or prevention services. Knowing that they can seek assistance for receiving preventive assessment, older Asian Americans may recognize help-seeking as part of the process of maintaining better health and mental health status.

Another interesting finding was the significant impact that the number of generations within the household had on the probability of depression among older Asian Americans. Although Asian culture, collectively, seems to promote the idea of ‘respecting elders’, the presence of multiple generations in a household may contribute to increased generational conflict or tension that may negatively impact the older generations, that is, the grandparents (Hofstetter et al., 2009; Segal, 2002; Thang, 2010). By working with the entire household, social workers can help to mediate these generational tensions and, in doing so, may help to address the potential risk of depression among the older members of the household.

Since this study was part of a needs assessment community survey, the respondents were recruited in the community, not from clinical settings. In clinical settings, the depression prevalence rate among the Asian elderly population was reported between 17 and 31 percent, using the GDS-15 (Nyunt et al., 2009: 380). Comparatively, this community-based study reported a lower rate of 12.86 percent using the 15 items in HSCL-25. Differences in the rates may reflect an important distinction between assessing depression in community versus clinical settings. Both differences in measurement tools and the recruitment strategy, which resulted in a relatively small number of ‘old-old’ Asian Americans (85 years or older; n = 11) responding to the survey, may be considered limitations of the study. Although individuals aged 55–64 years old are defined as ‘seniors’ based on many Asian cultures, these respondents may represent only the young-old if they have retired or may consider themselves as middle-aged if they are still employed. Findings of this study show that the young-old are more willing or able than the old-old to participate in community projects, which may have contributed to slightly more than half (50.6%) of this study’s respondents being younger individuals within the range of 55–64 years. The 55–64 and the 65+ respondents did not differ significantly along the major variables measured in this study. Possible interventions to facilitate senior citizens’ utilization of social services may include encouraging the community-oriented younger old to attend self-care training where they can teach both the younger and older generations about various mental health maintenance methods and self-care strategies.

A question generated from this study is, How do social workers help those who indicate that they have ‘no preference’ in choice of assistance but are in need of care from mental health professionals? This question links to the cultural competency that social workers must develop and practice with appropriate needs assessment skills. In this study, cultural competency involves using research knowledge to involve the young-old Asian Americans in community projects that demonstrate how self-care methods can be useful. Self-help, self-care, and solution-focused projects can become outreach efforts to help Asian older adults and their families connect with social and mental health services.

This is a community study that took place in locations where neighborhood activities were held for subject recruitment. Its original intent was to study perceived and actual needs in Asian families and within their communities. Although this report focuses on depression and its correlates, other neighborhood characteristics (such as crime, poverty, proximity of healthcare support, and social ties) which may also affect depression (as suggested by Kim and Ross, 2009; Mair et al., 2008) were not significantly connected to having depressive symptoms. Further investigations that remove clinical variables such as anxiety may bring other neighborhood factors into the statistical equation so that macro-factors can be analyzed. With more data support, future studies could focus on analyzing how neighborhood factors may affect a person’s ability to connect with family and create community ties.

Conclusion

This study examined the depression prevalence and help-seeking behaviors of older Asian Americans in relation to their mental health issues. Anxiety was found to be the strongest predictor of depression, which is consistent with studies correlating depression with different types of anxiety among Asians (Nguyen et al., 2011; Kim and Choi, 2010; Takeuchi et al., 2007). Although the overall prevalence rate of this sample was reported at the 12.6 percent, ethnic variations are important to consider. Many of the research sites were organized by cultural or immigration service agencies in the Chinese community, which typically attract many Chinese, Vietnamese, and Taiwanese people. The overall prevalence rate is lower than the national average, such as 20–55 percent among Vietnamese immigrants reported by Stutters and Ligon (2001). The low overall prevalence rate compared to the national average (such as 20%–55% among Vietnamese immigrants reported by Stutters and Ligon (2001)) may be connected to the fact that more than half respondents in the sample were represented by the young-old, and many of the Asian elderly who were depressed might be housebound and therefore unable to take part in the survey. As a result, the depression prevalence presented in this article might have underestimated the overall prevalence among the Asian elderly.

Researchers have criticized studies on depression among Asian Americans for not specifically addressing service utilization or ethnic heterogeneity (Kalibatseva and Leong, 2011). Our study focused on the two of the largest Asian groups in Houston: Vietnamese and Chinese. Analyzing the results related to demographics in this study, we found that having a higher level of education, living with more generations in the household, and having chronic pain were significant contributing factors to the presence of depressive symptoms among older Asian Americans, mostly represented by Chinese and Vietnamese respondents. Since finding a sufficient number of respondents to confirm these findings for ethnic comparisons is difficult, a qualitative study could be conducted in each ethnic group. These studies could focus only on one ethnicity at a time to find out more about the subjects’ perceptions of their cultural differences and how those differences might contribute to depression severity, differential views on service utilization.

Finally, findings of this study show that being married can significantly reduce the likelihood of depression. It is unclear whether marriage itself is a protective factor or whether companionship or socialization is the most important resilience factor in reducing depressive symptoms. Social workers can identify social and community-based strategies to prevent depression among various older Asian Americans since this study did not find a significant difference in marital status between the 55- and 64-year-old and the 65+ groups. The young-old population can use their learned strategies to engage others in community services and be more active in looking for resources and social services for self-help. Their participation in community services can guide their families to work through mental health issues while addressing healthcare concerns through social enquiries. These young-old individuals can be ambassadors to help those in the older group accept the importance of family and community support in symptom reduction.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author biographies

Patrick Leung, PhD, is Professor of Social Work and Director of the Office for International Social Work Education, Graduate College of Social Work, University of Houston.

Monit Cheung, PhD, LCSW, is Professor of Social Work and Principal Investigator of Child Welfare Education Project, Graduate College of Social Work, University of Houston.

Dennis Kao, PhD, is Assistant Professor, Department of Social Work, California State University, Fullerton.

Amy Carvalho Gulati, LSW, MSW, MPH, is a social worker at PEER Services in Evanston, Illinois.

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