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Detection of Depression in Chinese Americans
71
Hong Kong J Psychiatry 2005, Vol 15, No.3
Hong Kong J Psychiatry 2005;15:71-76 Original Article
© 2005 Hong Kong College of Psychiatrists
Detection of Major Depressive Disorder in
Chinese Americans in Primary Care
GLK Hsu, YM Wan, D Adler, W Rand, E Choi, BYP Tsang
Abstract
Objective: To assess the prevalence of major depressive disorder in Chinese Americans in the
greater Boston area.
Patients and Methods: Chinese American participants were recruited through 10 primary care
clinics in greater Boston. Depression was determined by assessment on 2 screening instruments,
the Mental Health Index-5 and Primary Care Screener for Affective Disorders for the first-stage
survey and by Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental
Disorders, 4th edition for the second-stage interview.
Results: The prevalence of major depressive disorder among Chinese Americans attending
primary care clinics (one-year prevalence of about 10%) appeared similar to the prevalence
reported in other ethnic groups. The brief survey (Mental Health Index-5) performed as well as
the lengthier one (Primary Care Screener for Affective Disorders). Few Chinese Americans with
identified major depressive disorder had received antidepressant treatment from their primary
care physician.
Conclusion: Cultural beliefs about mental health appeared as barriers to both detection and
treatment in this study.
Key words: Chinese Americans, Major depressive disorder, Prevalence, Primary health care, Questionnaires
First presented at the 2001 American Psychiatric Association Annual
Meeting, New Orleans, USA.
Dr George LK Hsu, MD, FRCPsych, Tufts-New England Medical
Center, Boston, Massachusetts, USA.
Dr Yu Mui Wan, EdD, Boston University Center for Psychiatric
Rehabilitation, Boston, Massachusetts, USA.
Dr David Adler, MD, Tufts-New England Medical Center, Boston,
Massachusetts, USA.
Dr William Rand, PhD, Tufts-New England Medical Center, Boston,
Massachusetts, USA.
Dr Elaine Choi, MD, Tufts-New England Medical Center, Boston,
Massachusetts, USA.
Dr Bill YP Tsang, EdD, Research Associate, Hong Kong Chinese
University Department of Social Work, Hong Kong, China.
Address for correspondence: Dr George LK Hsu, Professor of Psychiatry,
Tufts-New England Medical Center, Tufts University School of Medicine,
Tufts-NEMC, 750 Washington Street, Box, #1007, Boston, MA 02111, USA.
Tel: 617 636 7584; Fax: 617 636 4852;
E-mail: ghsu@tufts-nemc.org
Submitted: 11 April 2005; Accepted: 29 December 2005
Introduction
Depression is a common disorder in the USA. Between 5%
to 12% of men and 10% to 25% of women have an episode
of major depressive disorder (MDD) during their lifetime.1
Depression is also a serious illness, leading to functional
impairment, poor quality of life, loss of economic produc-
tivity, greater health care utilisation, and an increased risk
for suicide and increased mortality.2-9 It has been estimated
that MDD is associated with 20,000 suicides and $44
billion in health care costs in the USA annually.10,11 However,
little is known about the prevalence of MDD among Asian
Americans in the USA, despite the fact that they constitute
one of the fastest growing sectors of the population over the
last 30 years.12
It is widely acknowledged that Asian Americans shun
mental health services,13 as most ethnic minorities do.14
There is evidence to indicate that Asian Americans under-
utilise outpatient,15 inpatient16 and emergency17 psychiatric
services. Reasons for this may be complex but the stigma
of mental illness is thought to be a major factor.18-21 It is
possible that the use of alternative methods of treatment
(such as acupuncture) along with barriers to care (such as
language and cost issues) may also have reduced the use of
mainstream psychiatric services by Asian Americans.
Given the antipathy that Asian Americans appear to hold
for mental health services, it seemed reasonable to specu-
late that Asians who are depressed may be more likely to
seek treatment from primary care physicians (PCPs) than
from psychiatrists. This may be particularly the case for in-
dividuals who experience and present with somatoform
symptoms of MDD.22-24 Research in this area is lacking,
however. Despite the recent increase in research on MDD
in primary care,25-28 only one published study29 was identi-
fied that focused specifically on the issue of MDD among
Chinese Americans in primary care. A further study by Yeung
and colleagues noted that consulting a PCP for symptoms
GLK Hsu, YM Wan, D Adler, et al
72
Hong Kong J Psychiatry 2005, Vol 15, No.3
related to MDD was considered more acceptable to Chinese
Americans than consulting a psychiatrist.30
In a 14-nation survey conducted by the World Health
Organization, rates of depression reported were the lowest
in two Asian countries, China and Japan.31 This finding is
difficult to explain since China and Japan have suicide rates
that are among the highest in the world.32 It is possible that
there is under-reporting of depression in such surveys
because of the stigma attached.
This paper reports a two-stage survey to determine the
prevalence of MDD in Chinese Americans in primary care
conducted in metropolitan Boston. Chinese Americans were
the focus of the survey because they constitute the largest
group among Asians in Massachusetts.12 The study was ap-
proved by the Human Institutional Review Committee of
Tufts-New England Medical Center, and was designed to
answer the following questions:
1. Is a simple screening instrument, the Mental Health
Index-5 (MHI-5),33 better or worse at detecting depres-
sion in primary care in Chinese Americans than the
Primary Care Screener for Affective Disorders (PC-
SAD),34 a detailed screening instrument?
2. What is the estimated prevalence of depression in this
population?
3. Do Chinese Americans diagnosed with MDD under-
utilise mental health services? If so which of the 3
factors that Rogler and colleagues14 identified as rea-
sons for mental health service underutilisation (cultural
beliefs that impede use of services, use of alternative
pathways of care, and actual barriers to care) are
responsible for underutilisation in Chinese Americans?
4. What is the influence of the level of acculturation on the
performance of the screening instruments, the prevalence
of depression, and the pattern of service utilisation?
Patients and Methods
Participants and Procedure
The study was conducted at ten PCP offices in the metro-
politan Boston area. Five of the PCPs belonged to the Gen-
eral Medical Associates of Tufts-New England Medical
Center. The other 5 were private practitioners, 3 with of-
fices in the Chinatown area, and 2 with offices in nearby
towns (Quincy and Malden) with large Chinese immigrant
populations. The questionnaire phase of the study was con-
ducted between November 1999 and March 2000 and the
interview phase from February 2000 to July 2000.
Chinese patients attending one of the 10 above-mentioned
PCP clinics were approached for recruitment to the study.
During the first 4 weeks of the recruitment phase, a study
packet containing a one-page flyer describing the study, a
copy of the consent form, the MHI-5 and PC-SAD were
placed at the receptionist’s counter at each clinic. All Chi-
nese patients who came to register at the receptionist’s
counter were given the study packet by the receptionist.
Those who expressed an interest in participating in the study
were encouraged to call the research assistant (RA) at
Dr Hsu’s office regarding study participation. The initial
response was very poor and after 4 weeks, RAs trained
by one of the authors on how to approach a patient for
a research study, were stationed at each PCP clinic for 4
to 12 hours each week. The RA would approach each
Chinese patient at the clinic and describe the study.
The patient would complete the MHI-5 and PC-SAD after
they had signed the consent form. The RA was present to
answer any questions that the patient had regarding the
questionnaires, but the questionnaires were not administered
orally by the RA. Subjects were reimbursed $5 for comple-
tion of the questionnaires.
Instruments
The two questionnaires were: (1) MHI-5,33 a subscale of
the SF-36,35 a 5-item general mental health screening
instrument for psychiatric symptoms that have occurred in
the past 4 weeks. The MHI-5 took 2 to 3 minutes to complete;
and (2) PC-SAD, a 37-item self-administered questionnaire
consisting of a 3-item pre-screener, a 26-item MDD section,
and an 8-item dysthymia section. The pre-screener, designed
to reduce respondent burden by terminating the question-
naire when all responses to the 3 items are negative, con-
sists of 2 depression questions closely related to the World
Health Organization depression screening tool36 and one
dysthymia question. The PC-SAD provides a breakdown of
each of the Diagnostic and Statistical Manual of Mental
Disorders, 4th edition (DSM-IV) MDD/dysthymia symp-
toms for the diagnosis of current MDD (sensitivity 87.2%,
specificity 95%) and dysthymia according to DSM-IV
criteria.34 It takes 1 to 2 minutes to complete the PC-SAD pre-
screener, but about 30 minutes for the full questionnaire if the
individual answers “yes” to any of the pre-screening questions.
To obtain a valid Chinese version of both questionnaires,
the authors followed the guidelines for the cross-cultural
adaptation of health measures.37 The 2 questionnaires were
translated into Chinese and then translated back into English.
Equivalence in conceptual content for the Chinese and
English versions of the two questionnaires was achieved after
several revisions by discussion among the authors.
Second-stage Interview
All subjects who had a positive score on the MHI-5 or PC-
SAD were approached by telephone for an interview, as was
a randomly chosen group (20%) of subjects with a negative
score on both questionnaires. Every effort was made to con-
duct the interview as soon as possible after the questionnaire
screening. Subjects were reimbursed $50 for the interview.
A trained and experienced assessor administered the Struc-
tured Clinical Interview for the DSM-III-R (SCID),38 which
had been translated into Chinese, and an Acculturation
Questionnaire.39
Follow-up
All subjects who were diagnosed as having MDD on
interview were approached by telephone at 6 months for
a telephone interview by one of the authors. Questions
Detection of Depression in Chinese Americans
73
Hong Kong J Psychiatry 2005, Vol 15, No.3
on current mental status and service utilisation were admin-
istered over the telephone to those who consented to the
telephone interview.
Results
Number of Subjects
It was estimated that about 1000 patients were approached
for the Phase I Study. An exact count was not possible be-
cause it was unclear how many patients received the study
packet during the initial 4 weeks of the study. The number
of subjects who participated at each stage of the study is
summarized in Figures 1 and 2.
First Phase: Screening
A total of 560 questionnaires were returned. Among the
returned questionnaires, 500 MHI-5 (293 female, mean age
[± SD] 44.8 ± 10.4 years; 207 male, mean age 45.9 ± 10.7
years) and 476 PC-SAD (282 female, mean age 44.9 ± 10.5
years; 194 male, mean age 46.0 ± 10.8 years) were usable.
For the MHI-5, when a cut-off score of 52 was used (ie, a
score of less than 52 was considered “depressed”, a score of
52 or above was considered not depressed), 50 out of 500 sub-
jects (10%) had a positive score. For the PC-SAD, 45 of the
476 (9.5%) had a positive score. Therefore, both question-
naires identified about 10% of subjects as being depressed.
Second Phase: Interview
Interviews with the SCID were conducted in person by one
of the authors. Due to the one- to five-month gap between
the questionnaire survey and the interview, subjects were
asked specifically for: (1) the presence of depression
around the time of the questionnaire survey, defined for
the purpose of this study as current depression (CMDD)
and specifically about why they had visited their PCP at the
time; (2) presence of depression within the past 12 months
(one-year depression, OMDD); and (3) lifetime depression
(LMDD).
Thirty nine of the 50 MHI positive cases and 38 of the
45 PC-SAD positive cases were interviewed. Among the
MHI-5 and PC-SAD negative cases, 85 of 110 approached
were interviewed. The findings are summarised in Figures
1 and 2.
Estimated Prevalence of Depression
The prevalence of current depression, as indicated by
interview, was estimated as 6.5% of the 500 who provided
usable MHI-5 and 7.8% of 476 usable PC-SAD results
(Table 1). Since not all subjects were interviewed, these es-
timates are based on projecting the depression percentages
of those interviewed to the full sample. The estimated one-
year rate was 10.2% according to the MHI-5, and 10.7%
according to the PC-SAD. The estimated lifetime rate was
about 41% for both questionnaires.
Figure 1. Screening for depression with the Mental Health
Index-5 (MHI-5).
Abbreviations: SCID = Structured Clinical Interview for the
Diagnostic and Statistical Manual of Mental Disorders-IV;
LMDD = patients with lifetime major depression; OMDD =
one-year major depression; CMDD = current major depression;
DYS = dsythymia; OTH = other diagnosis; NOD = no diagnosis.
Figure 2. Screening for depression with the Primary Care
Screener for Affective Disorders (PC-SAD).
Abbreviations: LMDD = patients with lifetime major depression;
OMDD = one-year major depression; CMDD = current major
depression; DYS = dsythymia; OTH = other diagnosis;
NOD = no diagnosis.
Patient approached
n≈1000
PC-SAD completed
n=500
CMDD
n=10
(26%)
CMDD
n=5
(0.6%)
OMDD
n=13
(34%)
OMDD
n=7
(0.8%)
LMDD
n=26
(68%)
DYS
n=3 OTH
n=5 NOD
n=4 LMDD
n=34
(40%)
DYS
n=2 OTH
n=13 NOD
n=36
SCID interview
n=35(78%) SCID interview
n=85(20%)
PD-SAD positive
n=45(9.5%*476) PD-SAD negative
n=431 (90.5%)
Patient approached
n≈1000
MHI-5 completed
n=500
NOD
n=2
LMDD
n=30
(77%)
OTH
n=6
DYS
n=1 LMDD
n=32
(38%)
DYS
n=3 OTH
n=12 NOD
n=38
SCID interview
n=39(78%*50) SCID interview
n=85(19%)
MHI-5 positive
(< 52)
n=50(10%*500)
MHI-5 negative
(≥52)
n=450 (90%)
OMDD
n=15
(38%)
OMDD
n=6
(0.7%)
CMDD
n=13
(33%)
CMDD
n=3
(0.4%)
GLK Hsu, YM Wan, D Adler, et al
74
Hong Kong J Psychiatry 2005, Vol 15, No.3
Performance of Each Questionnaire for Detecting
Current Depression
The sensitivity, specificity, positive predictive value (PPV),
and negative predictive value (NPV) of the MHI-5 and PC-
SAD are presented in Table 1, as determined by the “gold
standard” of interview with the SCID.
Level of Acculturation
Of 126 subjects interviewed, 20 were at Level 1 (Very
Chinese), 100 at Level 2 (Mostly Chinese), and only 4 at
Level 3 (Bicultural). A further 2 subjects did not complete
the acculturation scale.
Subsequent Treatment
Eleven of the 16 CMDD patients identified by MHI-5 and
SCID were interviewed by telephone at 6 months. Two pa-
tients returned to consult their PCP for their MDD, with
neither receiving antidepressant medication. Two were
treated at a mental health clinic with antidepressant medi-
cation. Two sought alternative treatment (Qigong, traditional
Chinese medicine). All still had some residual symptoms
at follow-up. The 5 patients who declined follow-up had
received no treatment from their PCP. Therefore, most pa-
tients received no antidepressant treatment for their MDD.
Reasons for Mediocre Performance of Screening
Questionnaires
The authors were interested in identifying why both ques-
tionnaires had a relatively high false-negative rate and, par-
ticularly for the PC-SAD, a relatively higher false-positive
rate.
The high false-negative rate was related to 2 issues. Many
subjects reported a reluctance to endorse the presence of
depressive symptoms on a self-report questionnaire. They
expressed a fear that if they did they might be perceived to
be abnormal or mentally ill. A second reason was a different
conceptualisation of depression. Many would not accept that
they were “depressed” (ie, that they had a depressive or
mental disorder) as they believed their symptoms were
explained by their personal circumstances. Therefore,
depressive symptoms occurring in the context of a stressful
or traumatic life event such as immigration, the cultural
revolution, or unemployment, they argued, were “natural”
and not abnormal (“everyone gets depressed at such times”).
The high false-positive rate occurred primarily because
our subjects failed to distinguish between current and past
depression (ie, presence of lifetime depression but not within
the past 4 weeks) on both screening questionnaires, and for
the PC-SAD, to distinguish between current major depres-
sion and dysthymia. It appeared that subjects either did not
understand the questions that specified a time-frame (eg,
“In the past 4 weeks…”), or else did not consider the finer
distinctions of symptoms occurring in different contexts to
be important.
Finally, many complained predominantly of somatoform
symptoms such as dizziness, palpitations, tinnitus, anorexia,
insomnia and lack of strength. They believed that subjec-
tive dysphoria was a natural reaction to the somatoform
symptoms (“Wouldn’t you be depressed if you had these
symptoms?”). This interpretation precluded them from en-
dorsing the presence of depression on the questionnaire.
Discussion
This study found that the prevalence of 7% for current MDD
among Chinese Americans in primary care was similar to
that of other ethnic groups in a similar setting,40,41 although
lower than the 14.6% reported by Yeung et al.30 About 10%
of subjects had had an episode of MDD in the last 12 months,
a rate that was comparable to that found in the National
Comorbidity Survey,42 but about 3 times higher than the 12-
month rate of the respondents in the Chinese American Psy-
chiatric Epidemiology Study conducted in Los Angeles.43
Differences between samples and study methodology could
have accounted for the disparate results across studies, but
it seems unlikely that the prevalence of MDD among Chi-
nese Americans is very different from that in the other eth-
nic groups. It may also be possible that Chinese Americans
are more likely to experience depression in terms of somatic
or somatoform symptoms.23,44,45
There were 3 methodological limitations with this
study. The first was the fact that the questionnaire survey
and the SCID interview were not conducted at the same
time. The SCID interview, conducted on average 3 months
after the screening questionnaire survey, could have yielded
biased data because of problems of recall. The second
problem was the non-random selection of subjects. Many
factors might have determined who in the end chose to
complete and return the questionnaire, or to participate
in the interview. The third problem was that our subjects
were Cantonese or Mandarin speaking. Chinese subjects
that did not speak either of these languages were excluded.
These findings therefore may not be applicable to the
overall population of Chinese Americans attending primary
care.
Taking into account these limitations, the study high-
lighted the difficulties encountered in the detection of depres-
sion in Chinese Americans in primary care. A review by
Table 1. Performance of the Mental Health Index-5 (MHI-5)
and Primary Care Screener for Affective Disorders (PC-SAD).
MHI-5 PC-SAD
Sensitivity 51.20 31.80
Specificity 92.90 92.40
Positive predictive value 33.30 26.30
Negative predictive value 96.50 94.10
Estimated prevalence of 6.51% 7.81%
current depression
Estimated prevalence of 10.20% 10.69%
one-year depression
Estimated prevalence of 41.57% 42.69%
lifetime depression
Detection of Depression in Chinese Americans
75
Hong Kong J Psychiatry 2005, Vol 15, No.3
Mulrow and colleagues found that nine widely used depres-
sion screening instruments had an average sensitivity of 84%
(range, 67% to 99%) and an average specificity of 72%
(range, 40% to 95%).46 The sensitivity data for the 2 screen-
ing questionnaires in this study were at the lower end of this
range, although in terms of specificity they performed well.
The mediocre performance of the questionnaires in this study
seemed to be related to cultural factors: a fear of disclosure,
a different conceptualisation of depression, unfamiliarity
with screening instruments, and a somatoform symptom
profile. Our findings therefore were in accord with those of
Yeung and colleagues.30 They reported that a brief face-to-
face screening conducted by an experienced researcher was
likely to be more effective than a paper-and-pencil screen-
ing procedure for the detection of MDD in Chinese Ameri-
cans in primary care. It would be important to study the
effectiveness of a two-question face-to-face case-finding
interview in this population.47
That Chinese Americans would conceptualise major
depression differently than current psychiatric thinking was
not surprising,45 and raised ontological issues regarding the
nature of MDD which are beyond the scope of this study.
From a pragmatic standpoint, the conceptualisation of de-
pression resulted in a passive acceptance of the symptoms
that remained largely untreated during the subsequent
6 months. Untreated depression has been identified as a
major burden to the individual and to society,48 leading to
impaired physical, mental and social well-being, decreased
productivity, and increased mortality.2-4,9,10 Our findings
highlight the need for vigorous detection and treatment of
MDD in Chinese Americans.
Finally, cultural beliefs about mental illness appear to
be the main impediment to mental health service utilisation
among the Chinese Americans in this study. There was little
evidence that alternative treatments or actual barriers to care
prohibit the use of mainstream mental heath services. As
the majority of study subjects were traditionally Chinese in
their cultural orientation, it could not be determined whether
acculturation to Western beliefs about mental illness would
improve the detection and treatment of MDD. This is an
issue that future studies must explore. Unfortunately, many
Chinese immigrants to the USA may still find the diagnosis
of depression “morally unacceptable and experientially
meaningless”.44
Acknowledgements
This research was supported by a grant from the New
England Medical Center Research Foundation and the
General Clinical Research Center at Tufts-New England
Medical Center under NIH grant M01 RR00054.
The authors would like to thank the following primary
care physicians for their collaboration in the study and the
support and assistance of their office staff: Dr Wing Ar Moy,
Dr Stephen Louie, Dr Matthew Siu, Dr Lei Wang, Dr Yun
Lam, Dr Robert Wu, Dr Barbara Edwards, Dr Joseph Lau,
and Dr Eileen Hession.
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