Depression and Asian American Women

Asian and Pacific Islander Americans represent one of the fastest growing segments of the population. Unfortunately, depression is the second leading cause of death in this group, with the highest rate of suicide among women between 15-24 years of age. While depression is a common and highly treatable disorder affecting over 17-20 million Americans annually, the pressures Asian American women sometimes feel compound and complicate their ability to get help-only 27 percent seek help and/or treatment.

Mental illness is an alarming problem in many Asian communities: It is not always recognized and treatment is not always sought. Many Asian Americans experienced severe psychological trauma before emigrating to the United States or during the process of fleeing their homes. In addition, social anxiety, social phobias, depression and trauma-related disorders occur at high rates within the Asian American community.

What is depression?

Clinical depression is a serious medical illness that is more persistent and intense than temporarily feeling sad or blue. It involves disturbances in mood, concentration, sleep, activity level, interests, appetite and social behavior. Although depression is highly treatable, for some it can be a life-long condition in which periods of wellness alternate with recurrences of illness.

What are the symptoms of major depression?

The onset of the first episode of major depression may not be obvious if it is gradual or mild. The symptoms of major depression characteristically represent a significant change from how a person functioned before the illness. The symptoms of depression include:

• persistently sad or irritable mood;
• pronounced changes in sleep, appetite and energy;
• difficulty thinking, concentrating and remembering;
• physical slowing or agitation;
• lack of interest in or pleasure from activities that were once enjoyed;
• feelings of guilt, worthlessness, hopelessness and helplessness
• recurrent thoughts of death or suicide; and
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders and chronic pain.

While no study has been conducted to determine the rate of mental disorders among Asian Americans and Pacific Islanders, there appears to be an increased risk of depression among this population: Chinese Americans report the highest lifetime prevalence rate. Anxiety, low self-esteem, social isolation, family pressure, problems with cultural adaptation, racism and discrimination as well as language barriers may also contribute to depression and make seeking help more challenging for these women.

What are the causes of major depression?

There is no single cause of major depression. Psychological, biological and environmental factors may all contribute to its development. Whatever the specific causes of depression, scientific research has firmly established that major depression is a biological, medical illness. There is also an increased risk for developing depression when there is a family history of the illness.

What are the risk factors for Asian American Women?

In many Asian cultures, the stigma surrounding mental illness is so extreme that it is thought to reflect poorly on family lineage. It limits the education, prevention and treatment within the community and is further exacerbated by the stereotype of the "model minority." The stereotype of the highly successful, well-educated and upwardly mobile person can sometimes make it difficult for Asian women to accept their "flaws." They feel they must live up to high standards and succeed in all areas (e.g., doing well in school, helping to support the family, taking care of elderly family members and maintaining a job).

In particular, women feel the pressure to succeed: In some traditional cultures, females are supposed to be perfect daughters, wives, mothers and nurturers, always putting others before themselves.

How is major depression treated?

The body and mind are more closely linked in many Asian cultures than in Western cultural philosophies. As such, the experience of mental illness and desired modes of treatment may differ with the Asian culture.

Asian Americans are more likely to be cognizant of physical symptoms associated with mental illness than with emotional symptoms. Because of this awareness, they may initially seek medical care for a mental illness.

Although major depression can be a devastating illness, it is highly treatable. Between 80-90 percent of persons diagnosed with major depression can be effectively treated and return to their usual daily activities and feelings. Many types of treatment are available, and the type chosen depends on the individual and the severity and patterns of her illness.

There are three well-established types of treatment for depression: medications, psychotherapy and electroconvulsive therapy (ECT). For some people who have a seasonal component to their depression, light therapy may be useful. Transcranial magnetic stimulation (TMS) maybe helpful for mild to moderate depression that has failed one medication trial. These treatments may be used alone or in combination. Additionally, peer education and support can promote recovery. Attention to lifestyle, including diet, exercise and smoking cessation, can result in better physical and mental health.

Medication. Research has shown that imbalances in neurotransmitters or chemicals in the brain, like serotonin, dopamine and norepinephrine, are likely the cause of depression. Antidepressants attempt to correct that imbalance and often take two to four weeks to start having an effect and six to 12 weeks for antidepressants to take full effect.

Individuals and their families must be cautious during the early stages of medication treatment because normal energy levels and the ability to take action often return before mood improves. At this time-when decisions are easier to make, but depression is still severe-the risk of suicide may temporarily increase. This is also true for individuals under 25 years old-the FDA issued a black box warning outlining a small increased risk of suicidal thinking and actions. This risk is most worrisome during the first months of treatment.

• Asian Americans require sensitivity when being prescribed medications as they may react differently to the medications than other cultures, in terms of side effects and toxicity.
• The majority of Asian Americans seek alternative modes of treatment for illnesses. Some alternative modes of care, such as herbal treatments, may interfere with prescription medications.
• Genetic variations may cause differences in the metabolization of some prescription drugs. Specifically, many Asian Americans have a genetic alteration that decreases the metabolic rate of the IID6 isoenzyme-which is responsible for metabolizing tricyclic antidepressants and many antipsychotics.
• Differences in body fat and diet may result in fluctuating responses to prescription medications.

Psychotherapy. There are several types of psychotherapy that are effective for depression including cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). CBT concentrates on changing the negative attributional bias (seeing every cup as half-empty) associated with major depression. The focus in IPT is on a patient's relationships with peers and family members and the way they see themselves. Research has shown that mild to moderate depression can often be treated successfully with either of these therapies used alone. However, severe depression appears more likely to respond to a combination of psychotherapy and medication.

Asian American women tend to seek treatment less often than Caucasian women. Focus groups sponsored by the National Asian Women's Health Organization (NAWHO) found that Asian American women of all ages felt isolated. They talked of seeing other family and friends going through depression, but doing so while remaining silent. This cycle of silence is a major concern.

What are some barriers to treatment for Asian American women?

• The stigma associated with mental illness is of particular concern in Asian communities due to cultural perception.
• Health care is family-based in many Asian cultures and mental health care, when sought, may be approached with a similar expectation.
• High rates of Asian Americans lack health insurance.
• Asian American women are known to seek help only when there is a major crisis. Services available are often underutilized because they are ashamed to discuss personal problems: in many Asian cultures, expression of one's feelings is an admission of weakness.
• Communication is challenging in that few mental health care providers are conversant in Asian languages. Additionally, many Asian languages do not contain distinct words to describe feelings linked with mental illness. For example, anxiety, insomnia and pain are all expressed with only one word in several Asian languages.
• Due to the lack of reports of depression and Asian American women, there is very little comprehensive data available: it is known, however, that Asian American women ages 15-24 are second only to Native Americans in the rate of death by suicide.

Receiving treatment for a mental illness as an Asian American is challenging, but there are programs to help. New programs, like the Bridge Program in New York, aim to overcome these barriers. The Bridge Program has been successful in educating Asian communities about mental health care and offering communication tools to providers. Seventy-five physicians have been trained, and mental health encounters by Asian American clinic patients has increased 300 percent since the program's inception.

Many other cities are starting to replicate this program and create new ones in order to reach out to the Asian American community.

Asian American women can begin to seek help by calling local clinics asking about their services (i.e., services provided in their native language). A special point should be made to give their health care provider feedback for future improvements and remember:

• Mental health is important.
• One does not have to deal with stress and isolation on your own.
• Consider the services provided by a counselor to help deal with stress.
• Do not wait for a crisis! Be proactive.
• Encourage local organizations and churches to address the issue in workshops and regularly scheduled events.

There is always hope

Those who do seek help often find barriers in receiving adequate services due to ethnic diversity among Asian communities. Still, reaching out and taking charge of one's mental health will make the individual and the family stronger and will serve as a positive example for future generations.

For more information about this topic and to find support, visit:

• American Psychiatric Association at http://healthyminds.org
• The National Asian American Women's Health Organization, NAWHO at www.nawho.org
• Pick Your Path to Health, a national public health education campaign sponsored by the Office on Women's Health within the U.S. Department of Health and Human Services. For more information call 1 (800) 994-WOMAN or visit www.4woman.gov or www.womenshealth.gov/minority
• Mental Health Services Locator at http://mentalhealth.samhsa.gov/databases/default.asp

Reviewed by Ken Duckworth, M.D.
October 2009