Lifetime and Twelve Month Prevalence Rates of Major Depressive Episodes and Dysthmia Among Chinese Americans in Los Angeles

Abstract

The authors' goal was to estimate the lifetime and 12-month rates of major depressive episodes and dysthymia for Chinese Americans who reside in Los Angeles. This effort, the Chinese American Psychiatric Epidemiological Study, is the first large-scale community psychiatric epidemiological study on an Asian American ethnic group that used DSM-III-R criteria for major depressive episodes and dysthymia.
A multi-stage sampling design was used to select respondents for participation in the survey. The sample included 1,747 adults, 18-65 years of age, who resided in Los Angeles County and who spoke English, Mandarin, or Cantonese.
Approximately 6.9% of the respondents had experienced an episode of major depression and 5.2% had had dysthymia in their lifetime. The 12-month rates of depressive episode and dysthymia were 3.4% and 0.9%, respectively. The most consistent correlate of lifetime and 12-month depressive episode and dysthymia was social stress, measured by past traumatic events and recent negative life events.
The Chinese American Psychiatric Epidemiological Study provides a rare opportunity to investigate the heterogeneity within a single Asian American ethnic group, Chinese Americans, and to identify the subgroups among Chinese Americans who may be most at risk for mental health problems.

Full text

Am J Psychiatry 155:10, October 1998
1407
Lifetime and Twelve-Month Prevalence Rates
of Major Depressive Episodes and Dysthymia
Among Chinese Americans in Los Angeles
David T. Takeuchi, Ph.D., Rita Chi-Ying Chung, Ph.D., Keh-Ming Lin, M.D., M.P.H.,
Haikang Shen, Ph.D., Karen Kurasaki, Ph.D., Chi-Ah Chun, M.A., and Stanley Sue, Ph.D.
Objective: The authors’ goal was to estimate the lifetime and 12-month rates of major
depressive episodes and dysthymia for Chinese Americans who reside in Los Angeles.
This effort, the Chinese American Psychiatric Epidemiological Study, is the first large-scale
community psychiatric epidemiological study on an Asian American ethnic group that used
DSM-III-R criteria for major depressive episodes and dysthymia. Method: A multi-stage
sampling design was used to select respondents for participation in the survey. The sample
included 1,747 adults, 18–65 years of age, who resided in Los Angeles County and who
spoke English, Mandarin, or Cantonese. Results: Approximately 6.9% of the respondents
had experienced an episode of major depression and 5.2% had had dysthymia in their life-
time. The 12-month rates of depressive episode and dysthymia were 3.4% and 0.9%, re-
spectively. The most consistent correlate of lifetime and 12-month depressive episode and
dysthymia was social stress, measured by past traumatic events and recent negative life
events. Conclusions: The Chinese American Psychiatric Epidemiological Study provides
a rare opportunity to investigate the heterogeneity within a single Asian American ethnic
group, Chinese Americans, and to identify the subgroups among Chinese Americans who
may be most at risk for mental health problems.
(Am J Psychiatry 1998; 155:1407–1414)
The Global Burden of Disease study conducted by
the World Health Organization (WHO) (1) recently
assessed the extent of disability (measured by number
of work days lost) and mortality associated with non-
communicable diseases in different countries. The
study concluded that depression is one of the most de-
bilitating health problems in the world. In 1990, de-
pression ranked fourth among all diseases (after lower
respiratory infections, diarrheal diseases, and condi-
tions arising during the perinatal period). The WHO
researchers predicted that, by the year 2020, depres-
sion will rank second (after heart disease), accounting
for 15% of the disease burden in the world (1). De-
pression is also a common illness in the United States:
the National Comorbidity Survey (2) estimated that
17% of all American adults have experienced a major
depressive episode in their lifetime. People who have a
depressive disorder experience severe limitations in
their physical and social functioning that are much
worse than those of patients who suffer from chronic
health conditions such as hypertension, advanced
coronary artery disease, lung problems, and back
problems (3).
Despite the large volume of studies that have docu-
mented the level of depressive symptoms and the rates
of depressive disorders in the past two decades, little
information is available about the rates and correlates
of depressive disorders among Asian Americans (4).
The relative absence of information about Asian
Americans is troubling because the empirical litera-
ture has not matched the growth of the population
from 1970 to 1990. There were about 7 million Asian
Americans in 1990, and the population is expected to
continue to increase (5). By the year 2025, demogra-
phers predict that the population will triple in size (6).
Despite the growth and the increased presence of
Asian American ethnic groups in cities across the
United States, we know very little about their health
and well-being.
Many of our estimates about psychiatric problems
Received July 7, 1997; revisions received Sept. 30 and Dec. 22,
1997, and March 9, 1998; accepted April 2, 1998. From the Neuro-
psychiatric Institute and the Department of Psychology, University
of California, Los Angeles. Address reprint requests to Dr. Takeu-
chi, 10920 Wilshire Blvd., Los Angeles, CA 90024-6505; dtake-
uch@ucla.edu (e-mail).
Supported by NIMH grants MH-47460, MH-47193, and MH-
44331.

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DEPRESSION AND DYSTHYMIA AMONG CHINESE AMERICANS
among Asian Americans come from treatment studies
or investigations that used symptom scales (7). Past
studies using treatment data showed that Asian Amer-
icans are underrepresented in mental hospitals and
outpatient clinics (8, 9). The use of treatment data has
been especially popular for estimating prevalence and
need among ethnic minority populations, where the
costs associated with sampling rare (or small) popula-
tions can be quite high. Data drawn from treatment fa-
cilities can provide an accumulation of large samples
of ethnic minority consumers (especially if the data are
amassed over time) and easily codified clinical data.
On the other hand, aside from issues pertinent to reli-
ability and validity of clinic record data, treatment sta-
tistics give a biased estimate when used to appraise the
prevalence of mental disorders in the community. This
appears to be especially true for ethnic minority
groups, many of whom experience barriers to service
access and use (10). As more community surveys have
been conducted to estimate the prevalence of psychiat-
ric disorders, the results indicate that treatment statis-
tics severely underestimate the level of need for mental
health services in the community (11, 12).
Despite the promise and appeal of survey research,
only limited numbers of community studies have been
conducted on Asian American ethnic groups. Some
critical methodological problems have hampered men-
tal health research in Asian American communities.
First, Asian Americans have often been considered a
homogenous category in large-scale studies, and this
assumption ignores the diversity of Asian American
groups. More than 20 Asian American ethnic groups
have been identified by the United States Bureau of the
Census (13). Failure to make distinctions among spe-
cific Asian American groups overlooks considerable
historical, social, and cultural differences among
groups and leads to faulty conclusions about the need
for mental health services (14–16). Second, when spe-
cific Asian American groups are differentiated, the
sample sizes for each group are often too small to
make accurate prevalence estimates or to conduct so-
phisticated analyses of the data (17). Third, Asian
American respondents in community surveys are often
chosen from a nonrandom sampling frame, such as
telephone directories, ethnic association lists, and
snowball samples (18). These sampling techniques are
understandable given the relatively small population
sizes and geographic dispersion of Asian American
groups. However, such sampling strategies detract
from a study’s findings because of the imprecise nature
of the respondent selection.
In this paper we report on a study that systematically
considered the cited methodological obstacles. We de-
scribe the prevalence and correlates of major depres-
sive episode and dysthymia among Chinese Americans
in Los Angeles. Although Chinese Americans are not
representative of all Asian Americans, they provide a
well-defined target group for generalizations that
emerge from the analyses. Our investigation also ap-
plied a sophisticated sampling design and set of proce-
dures to select respondents for the study. We used
DSM-III-R criteria to estimate the prevalence of de-
pression and dysthymia. Most studies on depression in
Asian Americans have used symptom scales. Although
the use of symptom scales provide useful data, they are
often general indicators of psychological distress or de-
moralization rather than a single diagnostic category.
Prevalence estimates of depression using standardized
criteria based on DSM-III-R for Asian Americans are
generally lacking. Therefore, in this paper we report on
the prevalence rates of major depressive episode and
dysthymia using DSM-III-R criteria among Chinese
Americans residing in Los Angeles.
METHOD
Sample
Data are from the Chinese American Psychiatric Epidemiological
Study, a strata-cluster survey conducted in 1993–1994 in the greater
Los Angeles area. The survey’s three-stage probability sample of
1,747 Chinese American households generally represents the Chi-
nese American population residing in the area. The three-stage sam-
pling procedure was designed to 1) select tracts from the 1,652 cen-
sus tracts in Los Angeles County, which was cross-stratified by the
percent of Chinese American households in census tracts, by the me-
dian income for Asian Pacific households in tracts, and by the per-
cent of the race-ethnicity composition in the tracts, 2) randomly se-
lect 12 blocks within each of the tracts, and 3) randomly select four
households within each of the blocks. Selection in the first two stages
was designed with probabilities proportional to size, such that even
though selection probabilities varied within each stage, the ultimate
selection probabilities were the same for all Chinese households.
According to the 1990 census, Chinese Americans represented less
than 3% of the total population of Los Angeles County. To make the
survey cost-effective and increase the probability of locating a Chi-
nese American household, only the tracts where at least 6% of the
population was composed of Chinese Americans were sampled. As a
result, the Chinese American population in these selected tracts var-
ied from 6% to 72.3%. The percent of the foreign-born of all ethnic-
ities in the tracts varied from 14% to 82%. The average Asian Pa-
cific household income in these tracts varied from about $3,000 to
more than $108,000.
Data Collection
Bilingual interviewers, fluent in English and Mandarin or Can-
tonese, were recruited for this study. Whenever possible, interview-
ers were recruited from areas within the proximity of the sampled
census tract, which helped ensure familiarity with the neighbor-
hoods while gaining efficiency in travel time and mileage. All recruits
were screened for suitability for interviewing, reading and writing
ability in both languages, access to transportation, and style of pre-
sentation. In addition, the interviewers were lay interviewers, and
most of them had at least some college education.
The interviews were conducted in English, Mandarin, or Cantonese
depending on the respondent’s language preference. The interview
process lasted approximately 90 minutes. Data collection began in
April 1993 and was completed in August 1994. A total of 16,916
households were visited and screened to locate eligible respondents.
Eligible individuals included Chinese Americans, 18–65 years of age,
who resided in Los Angeles County. One eligible person within each
eligible household was randomly selected for the interview. Of the eli-
gible respondents, 1,747 interviews were completed, which resulted in
an 82% response rate. The sample size was based on an estimate of
the proportion of respondents who were likely to have experienced a
depressive episode in their lifetime. After complete description of the
study to respondents, written informed consent was obtained.

Am J Psychiatry 155:10, October 1998
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TAKEUCHI, CHUNG, LIN, ET AL.
Diagnostic Measure
The University of Michigan’s version of the Composite Interna-
tional Diagnostic Interview was used as the major diagnostic instru-
ment (2). The Composite International Diagnostic Interview is a
structured interview schedule based primarily on the National Insti-
tute of Mental Health Diagnostic Interview Schedule (DIS) and de-
signed to be used by trained interviewers who are nonclinicians.
Computer algorithms are used to construct clinical diagnoses based
on the responses to the Composite International Diagnostic Inter-
view. The Chinese American Psychiatric Epidemiological Study fo-
cused on a few major diagnoses, including affective disorders, anxi-
ety disorders, alcohol abuse or dependence, and smoking. This paper
reports only on affective disorders.
The substantive methodological work that has taken place on the
DIS in Hong Kong, Taiwan, and China suggests that when the DIS is
modified for a Chinese sample, the instrument has high reliability
and validity for most diagnoses, including mood disorders (19–21).
There is also some evidence that DSM-III-R diagnoses generated by
the DIS for schizophrenia, bipolar disorders, and depressive disor-
ders are compatible with the Chinese classification of major disor-
ders (22). The Composite International Diagnostic Interview was
originally designed to estimate the prevalence of specific disorders
across different countries or geographic regions, and it is particularly
useful in describing the co-occurrence of two or more disorders (23).
It has demonstrated good interrater reliability (24), test-retest reli-
ability (25), and validity for almost all diagnoses (25, 26). One no-
ticeable difference between the University of Michigan version and
the original Composite International Diagnostic Interview is the
placement of the lifetime review section at the beginning of the diag-
nostic section before any probing questions are asked. This modifi-
cation is in response to a common finding that respondents may
underreport stem questions when they recognize that positive re-
sponses lead to more detailed questions (2).
Before translating the Composite International Diagnostic Inter-
view into Chinese, we initiated a series of focus groups to determine
whether the idioms used for the expression of depressive symptoms
were meaningful to Chinese American respondents. Where potential
problem words and phrases were identified, additional probes were
developed to supplement the interview that assisted respondents in
understanding the meaning of key words or phrases. The final in-
strument was translated and back-translated several times to ensure
that the different language versions maintained consistency in mean-
ing for the questions and response categories within the Composite
International Diagnostic Interview.
Analysis Procedures
Weights were applied to the sample data to adjust for demo-
graphic variables, nonresponse rates, and the differential probabili-
ties of selection within the household. In the following analyses, only
weighted data are used. The weighted frequencies for the different
demographic variables are included in tables 1 and 2. To adjust for
the survey sample design, Taylor linearization (27) was imposed to
estimate the standard errors. Wald statistics based on these adjusted
standard errors were used for significance tests. Binomial logistic re-
gression was used to describe the differences among subgroups of
Chinese Americans who had a depressive episode or dysthymia. The
weighted maximum-likelihood method was used to estimate the pa-
rameters and standard errors from which the odds ratios, Wald F
statistic, and probability levels were calculated. In this paper, we
make assessments of statistical significance using a probability level
of 0.05. However, the tables in this paper display the Wald F statistic
and the actual probability levels for readers who wish to use other
statistical criteria to judge significance.
Limitations
The Chinese American Psychiatric Epidemiological Study has at
least two limitations common to cross-sectional psychiatric epidemi-
ological surveys. First, the diagnostic questions from the Composite
International Diagnostic Interview are based on retrospective ac-
counts of people’s experiences. Recall may be a problem for some re-
spondents, especially for older adults who try to remember the
symptoms that may have occurred quite early in their lives. Second,
while intensive training and supervision can assist lay interviewers to
administer the Composite International Diagnostic Interview prop-
erly, the diagnoses that result from this study may not have the same
level of accuracy as those reached by a trained clinician (2).
This study also has two additional limitations due to the unique
nature of the sample. Because of the complexities of sampling a rel-
atively rare population such as Chinese Americans in Los Angeles
County, some tradeoffs in the sampling design were made. If unlim-
ited resources were available for this study, it would be possible to
ensure that all Chinese Americans living in Los Angeles had an equal
probability of being selected for inclusion in the survey. However,
since the resources for the survey were limited, some decisions were
made to capture a sizable proportion of the Chinese American pop-
ulation in Los Angeles and still control the screening necessary to
find eligible respondents. Accordingly, we limited the study to geo-
graphic areas (census tracts) where Chinese Americans represented
at least 6% of the population. Going below this figure dramatically
increased the cost of screening. The 6% criterion still provided cov-
erage of approximately 60% of the Chinese American population in
Los Angeles. The sampling design constrains the extent that we can
draw conclusions regarding all Chinese Americans living in Los An-
geles. The sampling design excludes Chinese Americans who live in
low-density Chinese American geographic areas and, thus, tend to
be native-born. We examined whether density affected the lifetime
and current prevalence rates within our sample. No statistically sig-
nificant differences (p ≤0.05) were found in rates of depression and
dysthymia among different levels of density.
The final limitation is in the use of a diagnostic instrument using
DSM-III-R criteria for a sample, largely consisting of immigrants,
who come from a country that is culturally and linguistically differ-
ent from the United States. As stated earlier, previous work suggests
that standardized lay interviews have been quite effective in reaching
valid diagnoses of mood disorders. However, until more investiga-
tions are conducted on the validity of various diagnoses, the results
of Chinese American Psychiatric Epidemiological Study should be
interpreted with caution. In an attempt to understand cultural varia-
tions in the expression of distress, the Chinese American Psychiatric
Epidemiological Study also included neurasthenia, a mental health
problem that is common in Chinese-speaking countries. Some initial
results from the analyses of neurasthenia have been presented else-
where (28). In the current paper, we limit our analyses to the study
of depressive episodes and dysthymia. Despite the limitations cited,
the Chinese American Psychiatric Epidemiological Study used meth-
ods common to community psychiatric epidemiological surveys and
represents one of the most sophisticated epidemiological studies of
an Asian American ethnic group.
RESULTS
This paper reports the prevalence rates for major de-
pressive episode and dysthymia. The occurrence of at
least one major depressive episode is an essential fea-
ture for a diagnosis for major depressive disorder. Life-
time rates refer to the proportion of respondents who
reported having experienced the problem ever in their
lifetime, and 12-month prevalence rates are the pro-
portion of respondents who experienced the problem
sometime during the 12 months before the interview.
The lifetime rate of major depression episode was
6.9%; 3.4% of the respondents had an episode in the
past 12 months. Approximately 5.2% of the respon-
dents experienced dysthymia in their lifetime; 0.9%
had experienced it within 12 months of the interview.
The National Comorbidity Survey (2), using the Com-
posite International Diagnostic Interview, reported
much higher rates of depressive episodes: a lifetime

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DEPRESSION AND DYSTHYMIA AMONG CHINESE AMERICANS
rate of 17.1% and a 12-month rate of 10.3%. How-
ever, the National Comorbidity Survey rates for life-
time (6.4%) and current (2.5%) dysthymia were rela-
tively closer to the estimates found in this study, which
suggests that the experience of sadness may be more
chronic than episodic for Chinese Americans, many of
whom are immigrants.
Table 1 displays the odds ratios for the lifetime oc-
currence of a depressive episode and dysthymia.
Among the sociodemographic variables, marital status
has the strongest and most consistent association with
the lifetime occurrence of a major depressive episode.
Age shows some association with depression and dys-
thymia in that respondents in the younger age groups
(ages 18–29 and 30–49) are less likely to have experi-
enced mood disorders than the oldest age group in our
sample (ages 50–65). Since many of the respondents
were immigrants, the age variable is confounded with
age at immigration. Table 1 shows that age at immigra-
tion is associated with depressive episodes and dysthy-
mia. Accordingly, there may be strong cohort differ-
ences based on the timing of immigration rather than
simply an age effect.
TABLE 1. Odds Ratios for Correlates of Lifetime Depressive Episode and Dysthymia Among Chinese Americans in Los Angeles
Area (N=1,747)
Variable Weighted
Percentagea
Depressive Episode Dysthymia Depressive Episode/
Dysthymia
Odds
Ratio FbpOdds
Ratio FbpOdds
Ratio Fbp
Sociodemographic variables
Age (years)
18–29 30 0.36 6.68 0.01 0.18 13.40 <0.01 0.29 12.30 <0.01
30–49 50 0.45 5.50 0.02 0.50 4.78 0.03 0.48 6.42 0.01
50–65 20
Age at immigration (years)
21–40 51 1.59 2.07 0.15 3.50 8.89 <0.01 2.13 6.09 0.01
41–65 17 3.29 7.94 0.01 6.62 18.40 <0.01 3.89 13.10 <0.01
0–20 32
Marital status
Single 30 0.73 1.14 0.29 0.31 8.70 <0.01 0.55 4.61 0.03
Separated, divorced, or widowed 5 2.02 4.24 0.04 2.18 5.13 0.02 1.81 3.77 0.05
Married 66
Sex
Female 50 1.07 0.06 0.80 0.97 0.01 0.91 1.00 0.00 0.99
Male 50
Socioeconomic status
Education
Grades 0–11 21 1.72 2.57 0.11 2.09 5.83 0.02 2.09 6.95 0.01
High school 20 1.21 0.34 0.56 1.10 0.07 0.79 1.35 1.05 0.30
Some college 59
Household income (thousands of
dollars)
0.0–11.9 27 0.84 0.17 0.68 2.50 4.19 0.04 1.15 0.12 0.72
12.0–24.9 26 0.96 0.01 0.93 3.00 5.69 0.02 1.56 1.22 0.27
25.0–49.9 28 0.61 1.19 0.28 1.61 0.96 0.33 0.74 0.47 0.49
≥50.0 19
Employment status
Unemployed 8 3.17 15.10 <0.01 2.20 3.98 0.05 3.04 16.10 <0.01
Other 37 1.04 0.02 0.90 1.13 0.15 0.70 1.23 0.66 0.42
Employed 56
Home ownership
Own 49 0.61 3.25 0.07 0.52 6.72 0.01 0.49 9.25 <0.01
Rent 51
Acculturation
Language usage
English 9 0.31 5.20 0.02 0.16 5.23 0.02 0.24 9.28 <0.01
Both English and Chinese 24 1.09 0.08 0.77 0.86 0.29 0.59 0.87 0.30 0.58
Chinese 68
Length of residence in the United
States (years)
0–4 25 1.18 0.20 0.65 1.00 0.00 0.99 1.16 0.20 0.66
5–9 24 0.83 0.49 0.48 0.90 0.12 0.73 0.83 0.58 0.45
≥10 51
Negative life events
At least one event 36 2.41 8.93 <0.01 3.82 25.60 <0.01 2.48 14.30 <0.01
None 64
aBecause of rounding, weighted percentages may not add up to 100 exactly.
bdf=1, 401.

Am J Psychiatry 155:10, October 1998
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TAKEUCHI, CHUNG, LIN, ET AL.
The most perplexing of the results in table 1 is the
absence of an association between sex and depressive
episodes and dysthymia. In most community studies,
women have consistently higher rates of mood disor-
ders than men. In the National Comorbidity Survey
(2), for example, women were 1.8 times more likely to
have a lifetime mood disorder than men. To explore
this anomaly further, we examined sex differences
among respondents at different acculturation levels.
We used an acculturation scale that included items on
language use, ethnicity of the workplace, and types of
foods eaten (29). A high score indicated a greater ex-
posure to American life styles and a low score indi-
cated a greater exposure to Chinese culture. To explore
how acculturation and sex intersect to explain the
rates of mood disorders among Chinese men and
women, we divided the sample into two groups based
on a midpoint on the acculturation scale score. Al-
though the selection of the midpoint is somewhat arbi-
trary, it did create two groups that differed in accultur-
ation levels. The mean score of the group on the top
half of the scale (mean=3.00, SD=0.42) was signifi-
cantly higher than the mean score of the group on the
bottom half (mean=1.76, SD=0.30) (F=1735.36, df=1,
1642, p=0.0001). We examined the association be-
tween sex and depression and dysthymia in these two
groups. Since women are expected to have a higher
rate of depression, we used a one-tailed test of the odds
ratios. Within the high-acculturation-score group,
women were 3.1 times more likely than men to have
dysthymia in their lifetime (Wald F=1.76, df=1, 401,
p=0.10) and 2.16 times more likely than men to have
a lifetime depressive episode (Wald F=1.15, df=1,
401, p=0.14). In the low-acculturation-score group,
women did not differ significantly from men in life-
time depressive episodes (odds ratio=0.99, Wald F=
0.00, df=1, 401, p=0.97) and dysthymia (odds ratio=
0.91, Wald F=0.09, df=1, 401, p=0.76). Two explana-
tions are plausible. First, it is possible that women who
have low acculturation levels may be protected
against the onset of depressive episodes. Second, it is
also likely that sex differences may become pro-
nounced as Chinese immigrants become accultur-
ated. Although these explanations are not mutually
exclusive, our data do not allow us to examine this
issue extensively.
The socioeconomic status variables are associated
with either lifetime depression or dysthymia. Between
the two immigration variables, only language use is as-
sociated with depressive episodes and dysthymia.
Among all correlates listed in table 1, negative life
events has one of the strongest and most consistent as-
sociations with the lifetime occurrence of major de-
pressive episode and dysthymia. The life events mea-
sure is an inventory of 10 traumatic events (combat
experience; life-threatening accident; involvement in a
natural disaster; witnessing someone being badly in-
jured or killed, raped, sexually molested, physically at-
tacked, or assaulted; physical abuse as a child; neglect
as a child; and threat with a weapon). The experience
of at least one negative life event is associated with an
elevated risk for depressive episode and dysthymia.
Table 2 displays the association of the sociodemo-
graphic, socioeconomic status, immigration, and life
event variables with 12-month major depressive epi-
sode and dysthymia. Age and sex do not show an asso-
ciation with 12-month depressive episode and dysthy-
mia. Marital status is associated with dysthymia but
not with depressive episode.
Among the socioeconomic status variables, income
and employment status are associated with current de-
pressive episode and dysthymia. Language and length
of time in the United States are not associated with ei-
ther disorder. Recent negative life events (e.g., breakup
of a close friendship, separation from a loved one, hav-
ing been robbed or burglarized, having one’s driver’s li-
cense suspended, suing someone, being sued by some-
one, experiencing serious trouble with police or law,
death of close friends or relatives) has a strong associ-
ation with both disorders.
DISCUSSION
Two divergent hypotheses are presented when pre-
dictions are made about the prevalence of psychiatric
problems among Asian Americans. The first hypothe-
sis suggests that rates will be high because a large pro-
portion of Asian Americans are immigrants who will
undergo difficult transitions in their adjustment to
American society. Indeed, studies have found that
some Asian American ethnic groups have higher symp-
tom scores than whites (4). The second hypothesis ar-
gues that the rates of mood disorders will be low be-
cause Asian Americans, like their counterparts in other
countries, are likely to express their problems in be-
havioral or somatic terms rather than as emotional
ones. Available evidence suggests that the rates of
mood disorders are quite low in Taiwan, Hong Kong,
and China (30).
Findings from the Chinese American Psychiatric Ep-
idemiological Study suggest that, when DSM-III-R cri-
teria are used, the prevalence estimates of depressive
episodes and dysthymia are more complex than the hy-
potheses that have been advanced. When compared
with a national estimate, the National Comorbidity
Survey (2), which used the same diagnostic measure
(the Composite International Diagnostic Interview),
Chinese Americans have a much lower rate of major
depressive episode. However, it is equally evident that
Chinese Americans are not adverse to expressing
problems in emotional idioms. This is supported by
the finding of similar rates of lifetime and current
dysthymia in our study and the National Comorbidity
Survey.
Except for marital status and employement status,
none of the sociodemographic and socioeconomic
variables shows a strong and consistent association
with both lifetime and current major depressive epi-
sode and dysthymia. The lack of an association with

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DEPRESSION AND DYSTHYMIA AMONG CHINESE AMERICANS
sex, household income, and education warrants some
comment. Education and income may not be consis-
tently associated with depression and dysthymia in our
sample for two reasons. First, past empirical studies do
not actually show a stable association between socio-
economic status and depression. Although the inverse
association between socioeconomic status and mental
illness is widely known, socioeconomic status has
unique associations with discrete disorders. The Epide-
miologic Catchment Area (ECA) study (31), for exam-
ple, found that socioeconomic status was not associ-
ated with depression but had an inverse association
with lifetime rates of alcohol abuse. The National Co-
morbidity Survey (2) demonstrated that people in the
lowest income levels (compared with those in the high-
est) were most at risk for affective disorders and that
socioeconomic status was more strongly linked to anx-
iety disorders than to affective disorders. The inverse
association between socioeconomic status and depres-
sion has not been found consistently for all ethnic
TABLE 2. Odds Ratios for Correlates of 12-Month Depressive Episode and Dysthymia Among Chinese Americans in Los Angeles
Area (N=1,747)
Variable Weighted
Percentagea
Depressive Episode Dysthymia Depressive Episode/
Dysthymia
Odds
Ratio Wald
FbpOdds
Ratio Wald
FbpOdds
Ratio Wald
Fbp
Sociodemographic variables
Age (years)
18–29 30 0.69 0.48 0.49 0.24 2.39 0.12 0.74 0.37 0.54
30–49 50 0.76 0.38 0.54 0.35 2.72 0.10 0.73 0.58 0.45
50–65 20
Age at immigration (years)
21–40 51 1.01 0.00 0.98 —c1.08 0.03 0.86
41–65 17 1.52 0.75 0.39 —c1.68 1.25 0.26
0–20 32
Marital status
Single 30 1.19 0.23 0.63 0.37 0.84 0.36 1.24 0.37 0.54
Separated, divorced, or wid-
owed 5 2.32 3.70 0.06 4.86 5.96 0.02 2.76 6.05 0.01
Married 66
Sex
Female 50 0.67 1.72 0.19 1.12 0.03 0.85 0.66 2.01 0.16
Male 50
Socioeconomic status
Education
Grades 0–11 21 1.91 3.01 0.08 3.21 3.56 0.06 1.71 2.37 0.12
High school 20 1.64 1.28 0.26 1.08 0.01 0.93 1.41 0.66 0.42
Some college 59
Household income (thousands
of dollars)
0–11.9 27 2.17 2.66 0.10 8.66 3.82 0.05 2.37 3.33 0.07
12–24.9 26 2.30 2.94 0.09 5.33 2.10 0.15 2.63 4.18 0.04
25–49.9 28 1.04 0.00 0.95 2.35 0.50 0.48 1.04 0.00 0.95
≥50 19
Employment status
Unemployed 8 4.34 14.30 <0.01 6.09 6.91 0.01 4.63 17.20 <0.01
Other 37 0.48 4.07 0.04 0.41 1.66 0.20 0.48 4.52 0.03
Employed 56
Home ownership
Own 49 0.57 2.34 0.13 1.14 0.05 0.83 0.57 2.44 0.12
Rent 51
Acculturation
Language usage
English 9 0.60 0.82 0.37 —c0.56 1.07 0.30
Both English and Chinese 24 1.00 0.00 1.00 0.22 3.09 0.08 0.95 0.02 0.90
Chinese 68
Length of residence in the
United States (years)
0–4 25 0.90 0.08 0.78 1.35 0.18 0.67 0.87 0.14 0.71
5–9 24 0.83 0.25 0.62 0.67 0.22 0.64 0.77 0.54 0.46
≥10 51
Recent negative life events
At least one 36 2.50 7.61 0.01 8.83 12.00 <0.01 2.63 9.12 <0.01
None 64
aBecause of rounding, weighted percentages may not add up to 100 exactly.
bdf=1, 401.
cOdds ratio estimates were not reliable because of a zero cell.

Am J Psychiatry 155:10, October 1998
1413
TAKEUCHI, CHUNG, LIN, ET AL.
groups (32). Second, commonly used measures of so-
cioeconomic status, such as income and education,
may not fully capture the important dimensions of sta-
tus among immigrant groups. Although some Chinese
immigrants may have high levels of education when
they arrive in the United States, it may not lead to high-
paying jobs because employers may not value educa-
tion gained in another country as much as education
gained in the United States. Moreover, language diffi-
culties and discrimination against immigrants may pre-
vent them from accruing the benefits of higher educa-
tion. Finally, although income typically measures the
annual resources available to a person, it does not fully
capture other economic resources that people can rely
on (e.g., savings, home ownership) (33). Some immi-
grants in low-income brackets may be quite wealthy,
and some who have high annual incomes may use most
of their resources to accommodate their entry into the
United States.
The absence of an association between sex and de-
pressive episodes and dysthymia is striking. Most stud-
ies tend to show that women have significantly higher
rates of depression than men. Although the precise rea-
son for sex differences is open for debate, women tend
to show a 2-to-1 margin in depression across a number
of countries and studies. However, some exceptions to
this pattern can be found. Brown and associates (34)
found no association between sex and 12-month rates
of depression among African Americans in Maryland.
No sex association was found among Southeast Asian
refugees in Canada (35) and among Korean Americans
living in Chicago (36). The Taiwan study (30) found
that women had slightly elevated rates of depression
and dysthymia but that the rates for both men and
women were low and that the differences did not ap-
pear statistically significant. In a reanalysis of the ECA
data (37), Jewish men had a similar rate of major de-
pression as Jewish women, although other religious
groups (e.g., Catholics, Protestants, and non-Jews)
had the expected 2:1 female-male ratio for depres-
sion. Some of our preliminary analyses suggest that
acculturation may partly explain the absence of an
overall sex difference. Sex differences seem to appear
as Chinese immigrants acculturate to life in the
United States. Another explanation is that when the
rate of alcohol consumption is low, as it is among
Chinese Americans (38), sex differences in mood dis-
orders may be diminished (37).
There are some similarities and differences between
our findings and those of previous studies regarding
the rates and correlates of major depressive episode
and dysthymia. Although the Chinese American Psy-
chiatric Epidemiological Study focuses exclusively on
Chinese Americans, much diversity exists within this
ethnic category. For example, Chinese Americans who
immigrate to the United States come from countries
that are different in their sociopolitical environment—
such as China, Taiwan, and Hong Kong. Moreover,
large numbers of Chinese sought refuge from Vietnam
during and after the Vietnam conflict. The Chinese
American Psychiatric Epidemiological Study provides
a rare opportunity to investigate the heterogeneity
among Chinese Americans and to identify subgroups
who may be most at risk for mental health problems.
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