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The U.S. Surgeon General's report Mental Health: Culture, Race, and Ethnicity-A Supplement to Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services, 2001) was arguably the best single scholarly contribution on the mental health of ethnic minority groups in the United States. Over 10 years have now elapsed since its publication in 2001. This article highlights advances and illuminates gaps in the knowledge gained about the mental health and psychotherapeutic treatment of Asian Americans in the past decade. Though larger epidemiological surveys point to lower prevalence rates of mental illness in Asian Americans, further advances are needed in culturally valid assessment and quantification of cultural biases in symptom reporting in order to draw definitive conclusions about the state of Asian American mental health. A focus on prevalence in Asian Americans as a whole also shrouds important subgroup elevations such as heightened suicide risk in Asian elderly women or greater posttraumatic stress disorder in Southeast Asian refugees. Despite important developments in our knowledge about mental health prevalence, help-seeking behaviors, and culturally competent treatments for Asian Americans, it appears that troublingly low rates of service utilization still remain even when one accounts for the seemingly low prevalence rates among Asian Americans. Some progress has been made in the cultural adaptations of psychotherapy treatments for Asian Americans. In order to reduce mental health care disparities, greater efforts are needed to provide outreach at the community level and to bridge the gap between mental health and other medical or alternative health facilities. We call for innovation and provide recommendations to address these issues in the next decade. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
Asian American Mental Health
A Call to Action
Stanley Sue Palo Alto University
Janice Ka Yan Cheng and Carmel S. Saad University of California, Davis
Joyce P. Chu Palo Alto University
The U.S. Surgeon General’s report Mental Health: Culture,
Race, and Ethnicity—A Supplement to Mental Health: A
Report of the Surgeon General (U.S. Department of Health
and Human Services, 2001) was arguably the best single
scholarly contribution on the mental health of ethnic mi-
nority groups in the United States. Over 10 years have now
elapsed since its publication in 2001. This article high-
lights advances and illuminates gaps in the knowledge
gained about the mental health and psychotherapeutic
treatment of Asian Americans in the past decade. Though
larger epidemiological surveys point to lower prevalence
rates of mental illness in Asian Americans, further ad-
vances are needed in culturally valid assessment and quan-
tification of cultural biases in symptom reporting in order
to draw definitive conclusions about the state of Asian
American mental health. A focus on prevalence in Asian
Americans as a whole also shrouds important subgroup
elevations such as heightened suicide risk in Asian elderly
women or greater posttraumatic stress disorder in South-
east Asian refugees. Despite important developments in our
knowledge about mental health prevalence, help-seeking
behaviors, and culturally competent treatments for Asian
Americans, it appears that troublingly low rates of service
utilization still remain even when one accounts for the
seemingly low prevalence rates among Asian Americans.
Some progress has been made in the cultural adaptations
of psychotherapy treatments for Asian Americans. In order
to reduce mental health care disparities, greater efforts are
needed to provide outreach at the community level and to
bridge the gap between mental health and other medical or
alternative health facilities. We call for innovation and
provide recommendations to address these issues in the
next decade.
Keywords: Asian Americans, mental health, prevalence,
utilization, appropriateness
The U.S. Surgeon General’s report Mental Health:
Culture, Race, and Ethnicity—A Supplement to Men-
tal Health: A Report of the Surgeon General (“the
Supplement”; U.S. Department of Health and Human Ser-
vices [DHHS], 2001), was based on the best available
scientific evidence concerning the mental health of ethnic
minorities in general and Asian Americans in particular.
The Supplement identified several important areas of need
that were necessary to confront in order to address the
mental health problems of Asian Americans in the United
States. In this article, we evaluate the progress achieved
over the past 10 years in three problem areas identified in
the Supplement—need for services, utilization of services,
and appropriateness and outcomes of these services.
The first problem area—need for services—addressed
the limited nature of knowledge about the prevalence of
mental health problems among Asian Americans and Pa-
cific Islanders (AA/PIs). The Supplement highlighted in-
formation about Asian subgroup differences in mental dis-
order prevalence (e.g., higher posttraumatic stress disorder,
or PTSD, in Southeast Asian refugees) but also showed
discrepancies between some studies that indicated greater
severity of mental health disorders and other studies that
showed lower prevalence and severity of mental health
disorders among Asian Americans. Overall, these incon-
sistencies in the research along with the insufficient amount
of research precluded definitive conclusions about the state
of Asian American mental health. Nevertheless, provi-
sional conclusions in the Supplement stated that “the over-
all prevalence of mental health problems and disorders
among AA/PIs does not significantly differ from preva-
lence rates for other Americans” (DHHS, 2001, Executive
Summary, p. 14). In this article, we revisit the knowledge
generated in the past 10 years to discern whether more
certainty can now be culled about Asian Americans’ need
for services. We show how developing but insufficient
advances in culturally valid assessment and quantification
Editor’s note. This article is one of three in a special section presented
in this issue of the American Psychologist (October 2012) as a 10-year
follow-up to the 2001 Surgeon General’s report Mental Health: Culture,
Race and Ethnicity—A Supplement to Mental Health: A Report of the
Surgeon General. The other articles in the special section address mental
health disparities among Latino Americans (Lopez, Barrio, Kopelowicz,
& Vega, 2012) and African Americans (Snowden, 2012).
Authors’ note. Stanley Sue, Department of Psychology, Palo Alto Uni-
versity; Janice Ka Yan Cheng and Carmel S. Saad, Department of Psy-
chology, University of California, Davis; Joyce P. Chu, Department of
Psychology, Palo Alto University.
This research was supported in part by the Asian American Center on
Disparities Research and National Institute of Mental Health Grant
Correspondence concerning this article should be addressed to Stan-
ley Sue, Department of Psychology, Palo Alto University, 1791 Aras-
tradero Road, Palo Alto, CA 94304. E-mail:
532 October 2012 American Psychologist
© 2012 American Psychological Association 0003-066X/12/$12.00
Vol. 67, No. 7, 532–544 DOI: 10.1037/a0028900
of cultural biases in symptom reporting make it difficult to
draw definitive conclusions about the state of Asian Amer-
ican mental health.
The second area of attention in the Supplement per-
tained to the unmet service needs of Asian American indi-
viduals. The Supplement concluded that
AA/PIs have lower rates of utilization compared to Whites. This
underrepresentation in care is characteristic of most AA/PI
groups, regardless of gender, age, and geographic location.
Among those who use services, the severity of their condition is
high, suggesting that they delay using services until problems
become very serious. Stigma and shame are major deterrents to
their utilization of services. (DHHS, 2001, Executive Summary,
p. 14)
Limited English proficiency and a lack of Asian-
language-proficient service providers were also identified
as major barriers to service use. We examine research
conducted in the past 10 years to determine whether suffi-
cient advances have been made to decrease these gaps in
mental health service use.
The third problem area identified in the Supplement
that we address concerns the appropriateness and outcomes
of mental health services. At the time of the Supplement’s
publication, there was “limited evidence regarding the re-
sponse of Asian Americans to mental health treatment”
(DHHS, 2001, p. 119). Factors that play a role in improved
outcomes and use of services were identified, such as
ethnic matching or provision of services in one’s preferred
language, especially for less acculturated Asian Americans.
However, the Supplement identified a need for more re-
search examining treatment outcomes and the appropriate-
ness of services. In this article, we investigate innovations
in mental health services in the past decade to determine
whether services have become more appropriate to the
needs of Asian Americans.
Need for Services: The State of Asian
American Mental Health
Since the writing of the Surgeon General’s Supplement
(DHHS, 2001), several large surveys have been completed
that provide important epidemiological information on the
state of mental health in Asian Americans.
New Knowledge About Prevalence Rates
Several groundbreaking epidemiological surveys have
been completed in the past decade that estimate the prev-
alence of mental health problems among Asian Americans.
We review findings from these and other studies and pro-
vide a critique of attempts to determine prevalence rates.
National Latino and Asian American
Study. The National Latino and Asian American Study
(NLAAS) was the first national epidemiological survey of
Asian Americans in the United States and represents a
significant advance over previous epidemiological studies
(Alegrı´a et al., 2004; Heeringa et al., 2004). For example,
previous major studies such as the Epidemiologic Catch-
ment Area study (Regier et al., 1993) and the National
Comorbidity Study (Kessler et al., 1994) included ex-
tremely small samples of English-speaking Asian Ameri-
cans. The Chinese American Psychiatric Epidemiological
Study was conducted in one geographic site among one
Asian subgroup only and focused mainly on mood disor-
ders (Takeuchi et al., 1998; Zheng et al., 1997).
The NLAAS used a stratified area probability sample
design to recruit 2,095 Asian Americans 18 years or older
who resided in any of the 50 states and Washington, DC,
between 2002 and 2003. The NLAAS sample comprised
predominantly three Asian ethnic subgroups— 600 Chi-
nese, 508 Filipinos, and 520 Vietnamese—and 467 other
Asians; about 75% of the sample was foreign born. House-
hold interviews were conducted in English, Mandarin, Can-
tonese, Tagalog, or Vietnamese by trained lay interviewers.
To assess lifetime and 12-month prevalence of psychiatric
disorders, the NLAAS used the World Health Organization
Composite International Diagnostic Interview (WMH-CIDI;
Kessler & U
¨stu¨n, 2004), a diagnostic interview based on
criteria from the fourth edition of the Diagnostic and Statis-
tical Manual of Mental Disorders (DSM–IV; American Psy-
chiatric Association, 1994). The NLAAS is considered one of
the major, pioneering research projects in Asian American
mental health.
The NLAAS results indicated that the overall lifetime
prevalence of any psychiatric disorder among Asian Amer-
icans was 17.3%, and the 12-month prevalence was 9.19%
(Takeuchi et al., 2007). While the NLAAS focused on
Asian Americans and Latinos, their rates can be compared
with those of other ethnic groups from previous studies.
These Asian American prevalence rates were lower than
those reported for non-Hispanic Whites, African Ameri-
cans, and Hispanics in the National Comorbidity Study
(Breslau, Kendler, Su, Gaxiola-Aguilar, & Kessler, 2005),
Stanley Sue
533October 2012 American Psychologist
lower than the 28.1%–30.2% lifetime prevalence rate of
any psychiatric disorder reported by Latinos in the same
NLAAS sample (Alegrı´a et al., 2007), and lower than the
30.5% lifetime prevalence rate among African Americans
in a study of comparable methodologies, the National Sur-
vey of American Life (Williams, Haile, Gonzalez, Neigh-
bors, & Baser, 2007). Comparisons of rates across different
studies are hazardous because of variations in methodol-
ogy, assumptions, disorders examined, and sampling. Nev-
ertheless, Asian Americans have consistently reported
lower rates of mental disorders.
The NLAAS also revealed that immigration-related
factors were related to the presence of disorders but that the
patterns differed for Asian men and women. Nativity was
strongly associated with the presence of disorders for Asian
women, whereas English proficiency was associated with
disorders for Asian men. Asian women who were born
outside the United States were less likely to have any
lifetime depressive, anxiety, substance, or psychiatric dis-
order than were those who were U.S. born. Nativity was
associated with anxiety disorders only for 12-month prev-
alence. In addition, second-generation women were at high
risk for lifetime and 12-month prevalence of disorders. For
Asian men, those who had higher levels of English profi-
ciency generally had lower rates of lifetime and 12-month
depressive, anxiety, and psychiatric disorders (Takeuchi et
al., 2007). This study indicates that gender is an important
factor to consider when assessing specific prevalence rates
for mental problems in the Asian American population.
A number of investigators analyzed NLAAS data per-
tinent to other mental disorders and correlates of these
disorders. For example, one study examined rates of eating
disorders (Nicdao, Hong, & Takeuchi, 2007), and the re-
sults indicated that the lifetime and 12-month prevalence
rates of eating disorders were low among Asian Americans.
The lifetime prevalence of eating disorders ranged from
0.08% for anorexia nervosa to 4.35% for any binge eating.
Lifetime binge eating disorder was more prevalent among
Asian women than Asian men.
It should be noted that the NLAAS sample included a
somewhat higher proportion of foreign-born Asians than
represented in the national population. The effect of this is
unclear because immigrants may have a lower prevalence
of mental disorders (Takeuchi et al., 2007). Nevertheless, a
number of other studies using other sampling techniques
also reveal a lower prevalence rate of mental disorders
among Asian Americans.
The 2010 National Survey on Drug Use
and Health (2012). The National Survey on Drug
Use and Health (NSDUH), an annual survey sponsored by
the Substance Abuse and Mental Health Services Admin-
istration (SAMHSA), examines the mental health status
and use of illicit drugs, alcohol, and tobacco products for
various groups (e.g., African Americans, Hispanics, and
non-Hispanic Whites) in the U.S. population. Using an
independent, multistage, area probability sampling design,
the 2010 NSDUH (SAMHSA, 2012) interviewed a total of
68,487 respondents 12 years of age or older. Most of the
questions were administered via audio computer-assisted
self-interviewing to provide the respondent with a maxi-
mum amount of privacy. The 2010 NSDUH noted that the
interview was available in English or Spanish only. No
interviews were conducted with those who did not speak
English or Spanish.
Overall, findings from the 2010 NSDUH (SAM-
HSA, 2012) and previous NSDUH reports revealed that
Asian Americans had the lowest rates of illicit drug use,
alcohol use, tobacco use, substance dependence/abuse,
and serious/overall mental health problems when com-
pared with African Americans, American Indians/Alaska
Natives, Hispanics, and non-Hispanic Whites. For ex-
ample, among respondents age 18 or older, Asian Amer-
icans (15.8%) reported the lowest prevalence of past-
year mental disorders when compared with Hispanics
(18.3%), American Indians/Alaska Natives (18.7%), Af-
rican Americans (19.7%), and non-Hispanic Whites
(20.6%). Results from the annual surveys conducted
over the past decade have revealed convergent results:
Asian Americans, adults as well as youths, appear to
have low rates of mental disorders and substance use.
These findings are also consistent with those of Price,
Risk, Wong, and Klingle (2002), who examined rates of
substance use and abuse by Asian Americans derived from
four national epidemiologic studies: the 1999 National
Household Survey on Drug Abuse, the 1992 National Lon-
gitudinal Alcohol Epidemiologic Survey, and the 1995
National Longitudinal Study of Adolescent Health In-
School (Add Health S) and In-Home (Add Health H)
Surveys. Results revealed that while different Asian sub-
groups varied in substance use, Asian Americans largely
showed lower rates of substance use and abuse than non-
Hispanic Whites and other ethnic minority groups.
Janice Ka
Yan Cheng
534 October 2012 American Psychologist
Studies on specific Asian American sub-
groups or specific mental disorders. Other
studies do not focus on representative samples of the U.S.
Asian American population, but rather sample specific
Asian American subgroups with specific mental disorders.
These studies also provide valuable information about the
state of Asian American mental health.
Studies on major depressive disorder have found ele-
vated rates in some settings and that factors such as accul-
turation and immigration affect the prevalence of depres-
sion. For example, Yeung et al. (2004) studied the
prevalence of major depressive disorder among Chinese
Americans in a primary care setting in Boston, Massachu-
setts. Overall, the prevalence of major depression was
found to be 19.6%, which was comparable to or higher than
prevalence rates among predominantly White samples ex-
amined in previous studies in primary care settings. Yang
and WonPat-Borja (2006) reviewed the Asian American
mental health literature and found that studies on gender
differences in rates of depressive disorders had mixed
findings; some studies showed that Asian American women
had higher levels of depression than Asian American men,
while others did not. Studies on the association between
immigration and depression also had mixed findings. Uti-
lizing the Chinese American Psychiatric Epidemiological
Study, Hwang, Chun, Takeuchi, Myers, and Siddarth
(2005) showed that the risk for developing a depressive
disorder decreased as length of residence in the United
States increased. In addition, although Chinese immigrants
were at highest risk for depression at or soon after their
arrival in the United States, these immigrants had de-
creased risk as acculturation increased.
Other research has highlighted the fact that Southeast
Asian refugees continue to suffer from high rates of psy-
chiatric disorders, decades after resettlement in the United
States. Marshall, Schell, Elliott, Berthold, and Chun (2005)
assessed the prevalence, comorbidity, and correlates of
psychiatric disorders in Cambodian refugees two decades
after resettlement in the United States. The vast majority of
the respondents had been exposed to trauma and violence
before immigration (e.g., 99% experienced near-death
states due to starvation, 96% reported forced labor, 90%
reported having a family member or friend murdered, and
54% reported having been tortured). About 70% of the
respondents reported exposure to violence after resettle-
ment in the United States. In terms of mental health status,
62% of the respondents had PTSD and 51% had major
depression in the past 12 months. However, low rates of
alcohol use disorder (4%) were found. Both premigration
and postmigration trauma exposure were positively associ-
ated with 12-month PTSD and major depression.
As a whole, Asian Americans have been shown to
have lower overall rates of completed suicide than non-
Hispanic Whites, with 6.24 completed suicides per 100,000
AA/PI individuals compared with 14.31 completed sui-
cides per 100,000 non-Hispanic Whites (Centers for Dis-
ease Control and Prevention, 2009). Similarly, Asian
Americans as a group tend to have rates of nonfatal out-
comes (e.g., suicidal thoughts and attempts) lower than or
similar to those of non-Hispanic Whites. Among adults age
18 or older, the 2010 NSDUH found that the rates of
having serious suicidal thoughts during the past year were
3.2% for Asian Americans, 4.6% for Native Hawaiians/
Pacific Islanders, 4.0% for non-Hispanic Whites, 4.1% for
African Americans, 2.4% for Hispanics, and 7.5% for
American Indians/Alaska Natives (SAMHSA, 2012). Dul-
dulao, Takeuchi, and Hong (2009) studied lifetime suicidal
ideation, plans, and attempts in Asian Americans using the
NLAAS data and found an estimated lifetime prevalence of
8.6% for suicidal ideation and 2.5% for attempts. The
National Comorbidity Survey, an epidemiological survey
that employed a similar methodology, found a 13.5% life-
time prevalence of suicidal ideation and a 4.6% lifetime
prevalence of suicide attempts in the general U.S. popula-
tion (Kessler, Borges, & Walters, 1999).
Focusing the examination of suicide on Asian Amer-
icans as a whole shrouds the fact that certain subgroups of
Asian Americans may be at higher risk for suicide. Re-
search has demonstrated that elderly AA/PI women are at
higher risk for suicide relative to other racial groups within
the same gender and age category. According to the Cen-
ters for Disease Control and Prevention (2009), among
women between the ages of 75 and 79, the rates of com-
pleted suicide were 7.34 per 100,000 for AA/PIs, 4.21 per
100,000 for non-Hispanic Whites, 0.77 per 100,000 for
African Americans, 1.03 per 100,000 for Hispanics, and
0.00 per 100,000 for American Indians/Alaska Natives.
Among women between the ages of 80 and 84, the rates of
completed suicide were 3.68 per 100,000 for AA/PIs, 3.63
per 100,000 for non-Hispanic Whites, 1.37 per 100,000 for
African Americans, 1.86 per 100,000 for Hispanics, and
0.00 per 100,000 for American Indians/Alaska Natives.
Among women over 85 years old, the rates of completed
Carmel S.
Photo by Yasmine
535October 2012 American Psychologist
suicide were 9.78 per 100,000 for AA/PIs, 3.16 per
100,000 for non-Hispanic Whites, 0.39 per 100,000 for
African Americans, 0.48 per 100,000 for Hispanics, and
0.00 per 100,000 for American Indians/Alaska Natives.
Yang and WonPat-Borja (2006) performed a thorough lit-
erature review and concluded that elderly Asian women
were at higher risk for suicidethan elderly women in other
racial groups. Finally, Bartels et al. (2002) examined sui-
cidal and death ideation among older primary care patients
with depression, anxiety, and at-risk drinking. Similar to
the previously cited trends of elevated risk in elderly Asian
Americans, elderly Asian primary care patients reported
the highest prevalence of suicidal or death ideation (56.8%)
and elderly African American primary care patients re-
ported the lowest (27.0%). Duldulao et al. (2009) further
found that U.S.-born Asian women reported higher rates of
suicidal ideation and suicide plans than U.S.-born Asian
men and foreign-born Asian men and women. Weighted
lifetime prevalence rates of suicidal ideation were 15.93%
for U.S.-born women, 8.53% for U.S.-born men, 7.92% for
foreign-born women, and 7.05% for foreign-born men.
Weighted lifetime prevalence rates of suicide plans were
7.14% for U.S-born women, 2.13% for U.S.-born men,
2.45% for foreign-born women, and 3.49% for foreign-
born men. These findings point to the role of nativity and
gender in predicting suicide risk. Duldulao et al. (2009)
speculated that Asians who voluntarily immigrated to the
United States might be healthier than their U.S.-born coun-
terparts. The authors also speculated that U.S.-born and
immigrant Asian women might experience sociopolitical
risk factors for suicide (e.g., sexism and racism) differently
or to different degrees. Nevertheless, it remains unclear
what proximal factors might account for these differences.
In summary, while the Supplement report (DHHS,
2001) provided the provisional conclusion that rates of
mental disorders in Asian Americans were no different than
those in the general population, more recent research dem-
onstrates (a) lower overall prevalence rates for mental
disorders among Asian Americans (Nicdao et al., 2007;
Takeuchi et al., 2007) and (b) higher rates of specific
disorders in certain Asian subgroups. Yet, these conclu-
sions must be interpreted cautiously with careful consider-
ation of research-related methodological and conceptual
Methodological and Conceptual
Considerations in Prevalence Studies
Questions about true prevalence rates and the accuracy of
these methodologies that query for the presence of mental
disorders have bedeviled researchers and service providers.
On the one hand, if Asian Americans are less likely to
suffer from mental disorders, reasons for this lower prev-
alence must be deduced in order to draw implications for
the effective prevention and alleviation of mental distress.
On the other hand, if prevalence rates have been consis-
tently underestimated in research studies, the validity of
research methods, measures, and conceptual schemes
should be carefully scrutinized. In addition, stereotyping
Asian Americans as a model minority group is harmful
because an underestimation of their rates of mental disor-
ders may result in need-based reduction of societal atten-
tion, goods, and services.
Two unresolved issues continue to prevent definitive
conclusions about rates of mental disorders among Asian
Americans. First, culturally based reporting biases among
Asian Americans present problems for the cross-cultural
reliability and validity of measures. These cultural report-
ing biases have not been quantified and integrated into
recommendations for interpreting self-report measurement
of psychopathology. Second, cultural bias in conceptual-
izations of mental disorders may influence the validity of
prevalence studies.
Questionable reliability and validity due
to culturally based reporting biases. Reporting
biases, such as a tendency to underreport, overreport, or
report certain mental health issues more than others, affect
the reliability and accuracy of a particular measure’s ability
to represent the true state of mental health among Asian
Americans. A handful of studies indicate the presence of
culturally pertinent reporting biases.
For example, a study by Lam, Pepper, and Ryab-
chenko (2004) compared depressive symptoms among
Asian and Caucasian Americans and found that self-report
measures of depression may represent an overestimation of
this clinical problem compared with interview-derived as-
sessments. Participants were 238 Asian American and 556
Caucasian American college students who completed the
self-report Beck Depression Inventory (BDI) and the Mood
and Behavior Questionnaire (MBQ; unpublished measure).
In addition, a subsample of participants (n118; 75
screened positive for depression according to the BDI or
MBQ, and 43 screened negative for depression) was inter-
viewed using the Structured Clinical Interview for DSM-IV
(SCID). Results indicated that Asian American students
Joyce P. Chu
536 October 2012 American Psychologist
had significantly higher BDI scores than Caucasian Amer-
ican students. About 21% of Asian American students
reported a BDI score of 16 or higher, compared with 11%
of Caucasian American students. Of the 118 participants
who screened positive for depression and were interviewed
using the SCID, 5.1% of Asian Americans and 7.6% of
Caucasian Americans were diagnosed with current major
depressive disorder; 17.9% of Asian Americans and 17.7%
of Caucasian Americans were diagnosed with any current
mood disorder (i.e., major depressive disorder, depressive
disorder not otherwise specified, and dysthymia). Finally,
among the 118 participants who were interviewed using the
SCID, 33% of Asian Americans and 43% of Caucasian
Americans were diagnosed with any current or lifetime
mood disorder.
In contrast to findings from the self-report BDI, the
SCID interview revealed no ethnic differences in rates of
current major depressive disorder or any current or lifetime
mood disorder between Asian American and Caucasian
college students. Lam et al. (2004) suggested that the use of
self-report measures such as the BDI as an indicator of
depression may overestimate rates of depression, particu-
larly among Asian Americans.
Okazaki (2002) examined discrepancies between a
target person’s self-rating of depression and social anxiety
and ratings of the target provided by others. In general, the
ratings of informants, compared with the self-rating of the
target, underestimated the emotional distress. Importantly,
the underestimation was greater for Asian American targets
than for non-Hispanic White targets. Thus, whereas Lam et
al.’s (2004) study showed cultural reporting bias depending
on the administration style of the assessment (self-report
versus in-person interview), Okazaki’s (2002) study pro-
vided evidence of cultural reporting bias depending on the
perspective of the respondent (self vs. other). Other studies
have found that Asians in general have a middle response
style in which there is a tendency to avoid the use of
extremes on rating scales (Harzing, 2006). It is notable that
these cultural variations in reporting tendencies were cap-
tured in studies prior to the Supplement’s (DHHS, 2001)
release (e.g., Morrison & Downey, 2000); little progress
has been made over the last decade to synthesize these
findings into concrete conclusions. As such, innovative
efforts are needed to synthesize the extant knowledge about
reporting biases into recommendations for cultural modi-
fications to the content, scoring, and interpretation of meth-
odologies utilized for assessment of mental disorders. Rec-
ommendations are discussed at the conclusion of this
Cultural bias in the conceptualizations of
mental disorders. The accuracy of research on men-
tal health prevalence among Asian Americans is also af-
fected when the definition of a mental disorder applies
unequally across ethnic boundaries. The Supplement report
(DHHS, 2001) confirmed that different cultural groups
vary in the distribution of disorders, symptom expressions,
and culture-bound syndromes.
Since the writing of the Supplement, Hinton and col-
leagues (Hinton, Chhean, Pich, Hofmann, & Barlow, 2006;
Hinton, Pich, Marques, Nickerson, & Pollack, 2010) dis-
covered a series of culturally specific idioms of distress—
variations in symptom expression—among Southeast
Asian refugees experiencing PTSD symptoms. In Cambo-
dian refugees, somatic symptoms such as tinnitus (a buzz-
ing in the ear) are likely to be associated with traumatic
stress (Hinton, Chhean, et al., 2006). PTSD in Cambodian
refugees also commonly co-occurs with the cultural phe-
nomenon of khyaˆl attacks, which in addition to meeting
diagnostic criteria for panic attacks also have characteris-
tics unique to Cambodian individuals such as being accom-
panied by a fear of death from dysfunction of the body and
being triggered by the transition from sitting to standing
(Hinton et al., 2010). These cultural variations in symptom
expression would not typically be captured by measures
constructed around classic DSM-IV-TR (American Psychi-
atric Association, 2000) anxiety disorder criteria and would
therefore be misdetected or underdetected by Western-
based assessments.
Mental disorders in their entirety can also be ex-
pressed and experienced differently by Asian American
subgroups—an example of a phenomenon called culture-
bound disorders. Neurasthenia, for example, is a culture-
bound syndrome especially common among Chinese indi-
viduals and is defined as a mental and physical exhaustion
marked by chronic fatigue, weakness, aches, and pains.
Neurasthenia had been listed in previous versions of the
DSM but was removed in part because of its lower preva-
lence in the United States and because of the belief that the
disorder was actually a masked version of depression. In a
study of Chinese Americans in Los Angeles, Zheng et al.
(1997) found that nearly 7% of a random sample of re-
spondents reported they had experienced neurasthenia. The
neurasthenic symptoms often occurred in the absence of
symptoms of other disorders, raising doubt that neurasthe-
nia is simply another disorder (e.g., depression) in disguise.
Furthermore, more than half of those with this syndrome
did not have a concomitant Western psychiatric diagnosis
from the DSM-III-R(American Psychiatric Association,
1987). Thus, although Chinese Americans are likely to
experience neurasthenia, mental health professionals using
the standard U.S. diagnostic system may fail to identify this
disorder and the need for mental health care.
Recently, Watters (2010) presented a more insidious
perspective on Western influences on the process of defin-
ing and conceptualizing mental disorders. Watters argued
that American domination of the mental health field has
provided Americans with leverage in setting the definitions
of mental disorders and culture-bound syndromes, which
are then exported to other cultures. Watters (2010) stated
that in the process of teaching the rest of the world to think
like us, we have been exporting our Western “symptom
repertoire.” Such a process can alter the expression of
mental illness in other cultures. Indeed, a handful of mental
health disorders (e.g., depression, PTSD, and anorexia)
now appear to be spreading rapidly across non-Western
Obviously, the “exporting” of definitions or concep-
tual schemes from one culture to another is appropriate if
537October 2012 American Psychologist
their superior validity or usefulness can be demonstrated.
However, the very basis for our knowledge in psychology
has been challenged as being WEIRD (i.e., based on West-
ern, educated, industrialized, rich, and democratic samples
of human beings). Henrich, Heine, and Norenzayan (2010)
contended that psychology has typically used these circum-
scribed samples to generate knowledge and theories when
such samples are actually atypical of human beings
throughout the world. Thus the accumulated knowledge
gained from doing so, as well as the theoretical and con-
ceptual schemes advanced, may be quite local and biased in
favor of people fitting the profile of the WEIRD acronym.
Such bias along with its exportation can lead to fundamen-
tal errors in the understandings and cross-cultural applica-
bility of psychopathology.
Clearly, cultural bias in the conceptualization of men-
tal disorders can influence not only an Asian American
individual’s reporting of symptoms but also clinicians’
interpretation and classification of psychological symp-
toms. Future research is needed to modify assessment
procedures to account for cultural variation in symptom
expression, and to determine how to account for culture-
bound disorders, when approximating the mental health
needs of the Asian American population. In this regard,
while large-scale and sophisticated survey research meth-
ods have been extremely helpful in epidemiology, qualita-
tive studies within ethnic communities can provide valu-
able information on cultural and local conceptions of
mental disorders.
Many scholars have pointed to the need for improve-
ments in the upcoming release of the DSM-5 (the new fifth
edition of the DSM anticipated in 2013) to address cultural
bias in the diagnosis of mental disorders (e.g., Alarco´n,
2009; Alarco´n et al., 2009; Lewis-Ferna´ ndez et al., 2010).
Identified needs have included an updated definition of a
mental disorder that recognizes the importance of socio-
cultural etiologies, revision of criteria sets or descriptive
text to address cross-cultural limitations in diagnostic cri-
teria, inclusion of cultural symptom variations in the defi-
nition of individual diagnostic categories, increased atten-
tion to the categorization of culture-bound syndromes, and
an updated cultural formulation. The DSM-5 is currently in
development, with work groups developing proposed
changes for cultural variations in mental disorders.
Summary: What Is the State of Asian
American Mental Health?
The consistency of findings on the low prevalence rates of
mental disorders in Asian Americans is striking. Given the
concerns over the validity of assessment of Asian Ameri-
cans, the first step in developing our knowledge is to search
for any systematic methodological or conceptual confounds
that may explain the findings. Furthermore, the state of
Asian American mental health cannot be summarized by
any single statement about prevalence of mental disorders
being higher, lower, or similar to those of other groups.
Instead, there is tremendous variance based not only on the
type of clinical problem but also on the Asian American
subgroup considered and on other variables such as accul-
turation, gender, and age.
Substance use disorders and eating disorders appear to
occur at lower rates among Asian Americans as a whole.
Findings for depression and anxiety have been mixed, with
factors such as acculturation and immigration playing an
important role differently for men and women. PTSD is
elevated only among Southeast Asian refugee groups such
as Cambodians, and elevated rates of suicide have been
found only in Asian American elderly women.
Several issues pose additional challenges for the study
of the state of Asian American mental health. It has been
difficult to draw conclusions about the mental health of
Asian Americans because of the lack of studies and the use
of research designs or methods that do not provide direct or
unequivocal evidence. In addition, certain subgroups of
Asian Americans (e.g., Hmong, Iu Mien, and Pacific Is-
landers), who may have relatively high prevalence rates,
have been inadequately sampled. While Asians constitute
about 60% of the world’s population, they represent only
about 5% of the U.S. population (U.S. Census Bureau,
2010). Therefore, Asian American researchers have a dif-
ficult time finding adequate or representative samples of
Asian Americans. The heterogeneity of the Asian Ameri-
can population further complicates attempts to find ade-
quate samples (e.g., selective attrition from research par-
ticipation, immigrant vs. native-born status, English
language proficiency, different levels of acculturation).
While some researchers have argued that prevalence
rates among Asian Americans are low (because of child-
rearing practices, cultural resources, spirituality, etc.), oth-
ers believe that the rates are high because of cultural
conflicts and experiences with microaggression. Particu-
larly for mental disorders such as depression and anxiety
for which there is conflicting evidence in the literature,
perhaps the largest barriers to definitive conclusions about
prevalence rates lie within several methodological and con-
ceptual limitations. The unknown quantity of culturally
based reporting biases and of cultural biases in conceptu-
alizations of mental disorders makes it difficult to deter-
mine the accuracy of the prevalence data reported in this
article. A quantification of such reporting tendencies and
biases in symptom expression or psychopathology concep-
tualization is needed in order to develop recommendations
for future interpretation of prevalence research.
Utilization of Mental Health Services
The Supplement (DHHS, 2001) to the Surgeon General’s
report concluded that Asian Americans have the lowest
rates of service utilization and help-seeking behaviors
among ethnic minority groups and Whites. These low
utilization rates are characteristic of most Asian American
groups regardless of gender, age, and geographic location
and are not due to lower rates of mental disturbance. Part of
the service use problem is also represented by delays in
help seeking until the severity of a mental health problem
is high and by a greater likelihood of choosing informal,
alternative, or medical service providers rather than mental
health professionals. The Supplement also identified im-
538 October 2012 American Psychologist
portant cultural factors that act as deterrents to service use,
such as stigma, shame, and a lack of service providers who
speak Asian languages.
Data from the past decade of research are similar to
the findings reported in the Supplement and show that
mental health service underutilization remains a problem
across Asian American groups. Le Meyer, Zane, Cho, and
Takeuchi (2009) examined utilization rates among the
NLAAS sample, focusing on Asian Americans with a
probable diagnosable disorder on the basis of DSM-IV
criteria. Among this sample, Le Meyer et al. found that
only 28% used specialty mental health services (in contrast
to 54% in the general population), 16% used primary care
services, and 11% used alternative services to address their
mental health concerns. Also similar to findings from pre-
vious research, Asian Americans still seek services from
general medical service providers or nonprofessional
sources more than from mental health professionals to
address their mental health concerns. For example, Chu,
Hsieh, and Tokars (2011) found that Asian Americans with
suicidal ideation or attempts seek help from nonprofes-
sional sources or medical professionals rather than mental
health professionals. In addition, Abe-Kim et al. (2007)
examined utilization rates among the NLAAS sample and
found that among all 2,095 Asian American respondents,
8.6% sought help from “any” service (both general medical
services and specialty mental health services), 4.3% sought
help from general medical providers, and 3.1% sought help
from mental health providers. For those who needed ser-
vices (those diagnosed with a probable mental disorder
within the past 12 months), Abe-Kim et al. found that only
34.1% utilized services, compared with 41.1% in the gen-
eral population (Wang et al., 2005). Moreover, generational
status was positively associated with service utilization and
perceived helpfulness of treatment. For example, among
those with a probable disorder diagnosis, third-generation
or later Asian American respondents sought help from any
services at significantly higher rates (62.6%) than did first-
generation (30.4%) or second-generation (28.8%) Asian
American respondents (Abe-Kim et al., 2007, p. 93). These
results indicate that although nativity and later generational
status may be positively associated with mental disorder
among Asian Americans, these individuals may also be
more willing to seek treatment when they experience symp-
toms of mental disorder.
According to the 2010 NSDUH, rates of past-year
utilization of mental health services for adults 18 and older
were as follows: Asian Americans, 5.3%; Hispanics, 7.9%;
African Americans, 8.8%; and non-Hispanic Whites,
16.2% (SAMHSA, 2012). The significantly lower rates for
Asian Americans were consistently demonstrated each year
for the past decade. Because the 2010 NSDUH also esti-
mated the prevalence of mental disorders among various
ethnic minority groups, it was possible to test an alternative
explanation for the rates of utilization—namely, that Asian
Americans show low utilization of services because they
have low rates of mental disorders. To calculate utilization
rates after controlling for rates of disorders, we divided the
utilization rate by the disorder rate for various groups.
Results indicated that Asian Americans (34%) were still
more likely to underutilize services given their respective
prevalence rate for disorders than were Hispanics (43%),
African Americans (45%), and non-Hispanic Whites
(79%). Calculations were not possible for American Indi-
ans/Alaska Natives because of missing data.
Findings from research in the past 10 years have also
replicated previous knowledge concerning factors that pre-
dict service use. A delay in recognizing symptoms and in
seeking help, stigma and shame over using services, lack of
financial resources, conceptions of health and treatment
that differ from those underlying Western beliefs, cultural
inappropriateness of services (e.g., lack of providers who
speak the same languages as clients with limited English
proficiency), and the use of alternative resources within the
AA/PI communities have repeatedly been found to serve as
barriers to help-seeking behavior (e.g., Le Meyer et al.,
2009). Ting and Hwang (2009), for example, found that an
inability to tolerate stigma was negatively associated with
help-seeking attitudes, even after controlling for other vari-
ables often associated with help seeking. Moreover, Kim
and Omizo’s (2003) study of college students revealed an
inverse relationship between adherence to Asian cultural
values (which emphasize concern with saving face, Zane &
Yeh, 2002) and willingness to see a counselor. These
results were observed even after controlling for the effects
of gender, age, generational status, and previous counseling
Complementing existing knowledge is new informa-
tion about the complex role played by immigration and
acculturation-related factors in choosing service providers.
Abe-Kim et al. (2007) compared service utilization rates
among immigrant and U.S.-born Asian Americans to ex-
amine how immigration-related factors (e.g., nativity sta-
tus, years in the United States., English proficiency, age at
time of immigration, and generational status) were associ-
ated with service utilization among the NLAAS sample.
Interestingly, number of years spent in the United States
(among immigrant Asian Americans) and level of English
proficiency were not associated with service use. However,
Le Meyer et al. (2009) found that among both the U.S.-
born and immigrant Asian American samples, an interac-
tion emerged such that the use of alternative services either
facilitated or inhibited specialty mental health service use,
depending on the individual’s English proficiency. Specif-
ically, for those with poor or fair English language profi-
ciency, alternative services seemed to compete with spe-
cialty mental health care. That is, individuals who used
alternative services were less likely to use specialty mental
health services. However, for those with good or excellent
English proficiency, the use of alternative services in-
creased the likelihood of utilizing specialty mental health
services a great deal.
New knowledge also addresses the types of problems
that initiate the decision to seek help. At one Asian-ori-
ented mental health services center, depression was the
primary reason for seeking mental health services among
Asian Americans (Akutsu & Chu, 2006). Those groups
with high proportions of refugees (e.g., Cambodians) were
539October 2012 American Psychologist
especially likely to seek help for depression and somatic
problems. Abe-Kim, Takeuchi, and Hwang (2002) used a
prospective design to examine 56 Chinese Americans who
sought help for emotional problems. Individuals experienc-
ing high levels of family conflict had a higher likelihood of
seeking both medical and mental health services, even after
the authors controlled for the influence of traditional help-
seeking factors. The results indicated that the presence of
conflictual family ties led to help-seeking behaviors more
than did the absence of supportive linkages between family
Summary: Do Asian Americans Seek Help?
New research from the past decade shows that Asian Amer-
icans with mental health problems still do not seek out or
receive the services they need. Unfortunately, despite the
Supplement report’s (DHHS, 2001) stated priority of elim-
inating mental health care disparities, reducing barriers,
and improving access to mental health treatment, little
progress has been made to eliminate the disparities in
mental health service access for Asian American popula-
tions. Advances in knowledge from the past decade instead
address new understandings about the conditions that
prompt help seeking (e.g., depression and family conflict)
and the role of acculturation-related factors in the likeli-
hood of seeking help from different types of providers. We
now turn to the issue of culturally competent services to
examine whether service innovations in the past 10 years
have provided the tools needed to reach Asian Americans
who are reluctant to seek help. These innovations will be
crucial to the goal of eliminating mental health care dis-
parities among Asian Americans.
Promising Models for Cultural
Decades of research noting mental health care disparities
for Asian Americans have pointed to inadequacies in the
existing landscape of mental health services. Clearly, at the
time of the Supplement report (DHHS, 2001), the mental
health system and its approaches were not effectively
reaching an adequate proportion of Asian Americans in
need of mental health assistance. As of 2001, several so-
lutions had been pursued to address the problem of low
service access. Some mental health service organizations
targeted community education and outreach efforts to in-
crease the acceptability of utilizing services, developed
ethnic-specific programs, or increased the availability of
bilingual staff (Chin, 1998; Chun & Akutsu, 1999).
Other solutions to the problem of service underutili-
zation have since been explored. One particular limitation
highlighted in the Supplement report pertained to limited
evidence regarding treatment outcomes for Asian Ameri-
cans. In response, since 2001, many investigators have
directed attention to developing and increasing the avail-
ability of culturally competent treatments. Adaptations to
evidence-based treatments have comprised the major inno-
vation in culturally competent practice of the past decade.
In the zeitgeist of evidence-based practice, cultural
psychologists recognized that treatments proven to work
with Caucasian populations may not be similarly portable
or efficacious in ethnic minority populations such as Asian
Americans. As a result, clinical scientists recognized the
need to culturally adapt these treatments to make them
understandable and effective for Asian American popula-
tions (e.g., Hall, 2001; Hinton, Pich, Chhean, Safren, &
Pollack, 2006). Several promising efforts of cultural adap-
tation have emerged in recent years. For example, Hinton,
Pich, et al. (2006) introduced a culturally sensitive cogni-
tive-behavioral therapy (CBT) intervention to treat the so-
matic symptoms that often accompany PTSD among trau-
matized Cambodian refugees. Specifically, the authors
described how several refugees experienced neck-focused
panic attacks, a culture-bound syndrome in which trauma-
tized individuals experience recurrent episodes of neck
soreness, head symptoms (e.g., headache, tinnitus, blurry
vision, and dizziness), and general symptoms of autonomic
arousal (e.g., cold extremities, palpitations, and shortness
of breath). The authors utilized a multiple-baseline, across-
subjects design in which the three patients started therapy
in subsequent intervals. The treatment consisted of 11
sessions of individual CBT administered by a bicultural
worker blind to the patient’s treatment status. The treat-
ment provided information about the nature of PTSD and
panic disorder, introduced muscle relaxation, guided cog-
nitive restructuring of fear networks (especially trauma
memory associations to catastrophic misinterpretations of
somatic sensations), introduced interoceptive exposure to
anxiety-related sensations, provided an emotional process-
ing protocol to utilize during times of trauma recall, ex-
plored the physiological nature of neck panic, included
exposure to and verbal recounting of trauma-related mem-
ories, and taught cognitive flexibility.
The treatment was culturally adapted in that it in-
corporated culturally appropriate visualization (e.g., vi-
sualizing a lotus bloom that spins in the wind at the end
of a stem), which helped in encoding events within the
Asian cultural value of flexibility. Similarly, it included
framing relaxation techniques as a form of mindfulness,
a key Asian cultural virtue. Results revealed that for all
three patients, neck-focused panic and associated flash-
backs decreased, as did other measures of psychopathol-
ogy (e.g., depression and anxiety). Results also showed
that improvement was related to the particular time of
treatment implementation. All three patients displayed at
least a 36% improvement in various forms of psychopa-
thology (as measured by the Harvard Trauma Question-
naire) and a 37%–50% decrease in depression and anx-
iety scores.
Shen, Alden, Söchting, and Tsang (2006) described
their clinical observations and experiences in imple-
menting a Cantonese-language cognitive-behavioral
treatment program to treat depressed Hong Kong immi-
grants in Vancouver, Canada. Like Hinton, Pich, et al.
(2006), the authors chose to adapt a CBT intervention
because CBT techniques have been suggested to be more
compatible with Chinese values and preferences than
have other Western psychotherapies. Patients were di-
vided into groups: One group received treatment as usual
540 October 2012 American Psychologist
(TAU), which consisted of their established regimen of
sessions with their family physicians or psychiatrists and
often included antidepressant medication. The experi-
mental group participated in the 10-week CBT program
in addition to TAU. Results revealed that the CBT group
displayed significantly more reduction of depressive
symptoms than the TAU group on both self-report mea-
sures and on interview symptom severity indices. In fact,
the effect size of the CBT group was about twice that of
the TAU group.
Attempts have been made to guide the implementation
of culturally competent services by developing models for
such services. Leong and Lee (2006) formulated the cul-
tural accommodation model (CAM). The purpose of this
model was to provide an enhanced theoretical understand-
ing of how to adapt treatments to serve the needs of
culturally diverse clientele. CAM emphasizes the impor-
tance of (a) identifying cultural gaps in traditional Western
psychotherapy’s treatment of ethnically diverse clients, (b)
accommodating for these “blind spots” by identifying cul-
tural concepts that can make the theory or model more
culturally valid, and (c) testing the revised model’s incre-
mental effectiveness above and beyond the original “non-
accommodated” model.
The formative method for adapting psychotherapy
(FMAP; Hwang, 2009) presents an alternative model to
guide the cultural modification process. The FMAP is a
community collaborative approach that incorporates in-
put from mental health providers and consumers in a
bottom-up philosophy. The FMAP consists of five phas-
es: (a) generating knowledge and collaborating with
stakeholders, (b) integrating generated information with
theory and empirical and clinical knowledge, (c) review-
ing the initial culturally adapted intervention with stake-
holders and revising the intervention, (d) testing the
intervention, and (e) finalizing the culturally adapted
intervention. Hwang (2009) successfully utilized the
FMAP procedure to create a culturally adapted CBT
manual for Chinese Americans. Chu, Huynh, and Area´n
(2011) also utilized the FMAP procedure to adapt an
evidence-based treatment, problem solving therapy, for
depression in Chinese older adults.
There is emerging evidence that cultural adapta-
tions to treatments are beneficial. In a meta-analysis of
over 70 research studies that have examined ethnic or
culture-specific forms of intervention, Griner and Smith
(2006) found a moderate effect for treatments that were
adapted to better serve the needs of specific ethnic
groups (the average effect was d.45). Interventions
that were adapted toward a specific ethnicity were four
times as effective as those that were not. Linguistic
match was found to be twice as effective as treatment
conducted in English for clients whose English language
abilities were poor. In addition, in a review of research
studies on cultural competency, Sue, Zane, Hall, and
Berger (2009) concluded that culturally adapted inter-
ventions provided beneficial effects that extended above
and beyond those produced by TAU.
Summary: Are Mental Health Services
Appropriate to the Needs of Asian
What is clear from the extensive evidence pointing to the
underserved needs of Asian Americans is that new inno-
vations are needed to reach a greater proportion of Asian
Americans with mental disorders. Improving the appropri-
ateness of services for Asian Americans will likely involve
a multipronged effort. Language-matched providers, eth-
nic-specific programs, and general training on how to be
culturally competent during psychotherapy were predomi-
nant efforts to increase service access and use prior to the
writing of the Supplement (DHHS, 2001). In the past
decade, new innovations in developing appropriate services
have resulted in culturally adapted treatments or psycho-
therapy options tailored to the specific needs of particular
ethnic minority groups. Progress in the cultural adaptations
of psychotherapy treatments for Asian Americans has
proved promising. Yet research on cultural adaptations is
still in a nascent stage, and further innovations are needed
to address the problem of service underutilization that
persists. One important area for future investigation is to
specify what needs to be customized in culturally compe-
tent treatments. To gain insights in how to identify needed
cultural adaptations, Cardemil (2010) suggested that differ-
ent cultural groups be compared not only on the efficacy of
treatment but also on the acceptability of treatment (e.g.,
acceptance of treatment rationale, therapeutic alliance, and
general satisfaction with treatment). Failure to demonstrate
equivalent efficacy and acceptability would suggest that
adaptation is needed and the type of modification that
would be beneficial.
One may be tempted to raise the question of whether
services should be the focus of attention, if indeed, Asian
Americans have low rates of mental disorders and low
service utilization rates. Our position is that because of
methodological and conceptual issues, the prevalence of
mental disorders among Asian Americans is still an open
question that must be further examined. Furthermore, low
service utilization, whether attributable to personal reluc-
tance, misunderstanding of its value, or cultural inappro-
priateness of services, is unfortunate. It means that a major
resource is limited in its effectiveness in treating mental
disorders and promoting emotional well-being. As services
become more culturally sensitive, effectiveness and utili-
zation tend to increase (Sue et al., 2009).
This article highlighted advances and illuminated gaps in
the knowledge gained about the mental health of Asian
Americans in the past decade with regard to need for
services, utilization of services, and appropriateness and
outcomes of these services. We found that there are now
important new epidemiological data, enhanced understand-
ing of predictors of help seeking, and promising data on
culturally adapted psychotherapy treatments. Mental health
services still largely fail to reach Asian Americans in need
of assistance. However, some innovations have been de-
541October 2012 American Psychologist
veloped to reach out to Asian Americans and have yielded
promising results. In addition, further research is needed
that focuses on the establishment of valid measures for
Asian Americans and that addresses cultural considerations
in symptom reporting bias and conceptualization of mental
We call for innovation over the next decade to ad-
vance our knowledge about the state of Asian American
mental health, to decrease mental health care disparities,
and to create services appropriate to the mental health
needs of Asian American communities. Several recommen-
dations will facilitate achievement of these goals:
1. Increased resources and efforts should target the
epidemiological study of mental disorders in subgroups of
Asian Americans that have been inadequately sampled
(e.g., Hmong, Iu Mien, and Pacific Islanders).
2. Special attention is needed to understand and man-
age clinical problems known to be more prevalent in cer-
tain Asian American subgroups: suicide among Asian
American older women and PTSD in Southeast Asian
3. To increase our ability to make definitive conclu-
sions about the state of Asian American mental health,
future research should:
a. Modify assessment procedures to account for cul-
tural variations in symptom expression and to determine
how to account for culture-bound disorders, when approx-
imating the mental health needs of the Asian American
b. Identify and quantify the underlying moderating
factors (e.g., stigma, shame, emotion inhibition) that affect
Asian Americans’ tendency to disclose more, to disclose
less, or to disclose in a certain reporting pattern, in order to
better predict the accuracy of self-report.
c. Examine possible systematic errors or biases that
may account for convergent findings of low prevalence
rates among Asian Americans. For example, reporting ten-
dencies for Asian Americans should be analyzed using
different assessment methodologies to yield insights about
the underestimation, accurate estimation, or overestimation
of psychopathology among existing epidemiological sur-
vey studies. Quantitative and qualitative research ap-
proaches should both be used.
4. Scientists and clinicians should focus on innovative
solutions to decreasing mental health care disparities in
Asian American communities. Strategies that increase ser-
vice use among Asian Americans will need to address
barriers to help seeking (e.g., delay in recognizing symp-
toms and seeking help, stigma and shame over using ser-
vices, lack of financial resources, non-Western conceptions
of health and treatment, use of alternative resources, and
lack of language-proficient providers). Community-level or
cross-disciplinary collaborations may be necessary to ef-
fectively reach Asian Americans who are reluctant to seek
specialty mental health care.
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... Unlike many other places in the U.S., Asian Americans are a racial and ethnic majority in Hawaiʻi (U.S. Census Bureau, 2010Bureau, , 2019) and yet they were found to be the least likely to have direct and indirect experiences of seeking professional psychological services among the three racial and ethnic groups of interest in the present study. As such, our findings suggest that mental health service underutilization in Asian Americans may be independent of their social status as a racial and ethnic majority or minority, and instead perhaps rooted in, or shaped by, their Asian American cultural norms/practices, such as saving face and the integrity of conserving interpersonal expression (Sue et al., 2012). ...
... They also found that integrated care-based interventions, which allowed individuals to access mental health services through primary care settings, reduced racial and ethnic disparities in the initiation of mental health services. The integrated care model may be particularly suitable to many Asian American emerging adults, as it offers mental health services with more convenience and privacy and with less stigma (e.g., Masuda et al., 2021;Sue et al., 2012). On college campuses, offering outreach and informal consultation services, such as walk-in counseling sites situated in students' dormitories, may promote mental health service utilization among Asian American and multiracial American emerging adults because of its greater accessibility (Boone et al., 2011). ...
... The university culture, the availability and promotion of psychological services, and university counseling center outreach activities might have been confounding factors. Relatedly, Asian American, multiracial American, and White American emerging adults, the target populations of interest in the present study, are all heterogeneous groups (e.g., Miller et al., 2019;Sue et al., 2012), representing people from diverse sociocultural backgrounds. As such, a second major limitation is the lack of investigation of within-group differences, and future studies should investigate mental health service utilization among various subgroups of Asian American, multiracial American, and White American groups, as well as the potential sociocultural variables which may account for mental health service utilization and mental health help-seeking attitudes. ...
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In this cross-sectional survey, we examined the direct and indirect mental health help-seeking experiences and relevant psychological factors in Asian American, multiracial American, and White American emerging adults aged 18–25 years old. The study sample consisted of 384 Asian American (249 women, 135 men), 244 multiracial American (172 women, 72 men), and 245 White American (190 women, 55 men) emerging adults, who were recruited from a four-year public university in the state of Hawaiʻi of the United States (U.S.). Results revealed that Asian American and multiracial American emerging adults were less likely to: (a) have previous experience of seeking professional psychological services: (b) have been prescribed, or are currently taking, a psychotropic medication; (c) know someone close to them who had sought psychological services; or (d) know someone close to them who was diagnosed with a psychological disorder, compared to their White American peers. We also discuss implications of the present findings, limitations of the study, and future directions in this line of research.
... 18 Even before the pandemic, Asian Americans had poor mental health status. 10,11,[18][19][20] The current climate of racial discrimination and social isolation has further worsened the condition. 2,4,6 Our result of South Asians and Southeast Asians being more likely to experience psychological distress during the COVID-19 pandemic was consistent with the study by Woo and Jun,7 which found a sevenfold increase in the prevalence of depression and anxiety symptoms among Asian Americans. ...
... 22 These increases in mental health impacts can be attributed to stress due to migration and acculturation, somatization, stigmas surrounding mental health and use of mental health services, underrepresentation among the mental health care providers, lack of culturally informed interventions and social isolation, and increased racial discrimination amid the COVID-19 pandemic. 2,[18][19][20] The study has several imitations. Due to the selfreported responses from the participants, the study was subject to recall bias and measurement errors. ...
Purpose: This study aims to explore the differences in mental health status among Asian Americans during the COVID-19 pandemic. Methods: Data from the 2020 Health, Ethnicity, and Pandemic (HEAP) Study were used to explore the psychological distress of 2672 adults, using the Standard Kessler Psychological Distress Scale. Results: We observed that among Asian American subgroups, South Asian Americans had significantly higher odds of experiencing psychological distress than non-Hispanic White Americans (odds ratio = 1.82, 95% confidence interval = 1.00-3.31), after controlling for covariates. Conclusion: The study identified differences in mental health status among Asian American subgroups. We recommend the implementation of culturally appropriate interventions to help Asian Americans cope with mental health challenges.
... Results of the current study revealed that students' depressive symptoms were not associated with an increase in negative coping skills. Although somewhat unexpected, previous findings for depression among Asian Americans have been mixed with some studies showing that sociocultural factors can play important protective roles against negative mood states (Sue et al., 2012;Leong et al., 2013). However, anxiety symptoms were positively associated with an increase in negative coping skills. ...
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PurposeAsian Americans comprise 21% of matriculating medical students in the United States but little is known about their mental health. With the growing focus on addressing the mental health of medical students, this systematic, nationwide survey assesses the relationship between anxiety and depression symptoms and coping skills among Asian American medical students.Materials and methodsA survey tool comprised of Patient Health Questionnaire-9, General Anxiety Disorder-7, and questions related to coping were emailed to members of the Asian Pacific American Medical Students Association enrolled in a United States medical school during the 2016–2017 academic year. We evaluated associations between anxiety and coping as well as depression and coping.ResultsA total of 511 Asian American medical students completed the survey. Anxiety symptoms were positively correlated with an increase in negative coping skills. Depressive symptoms were not correlated with an increase in negative coping skills.Conclusion Professionals and medical schools that aim to improve the mental health of medical students should be aware of the needs of specific populations. Asian American students who experience anxiety were more likely to utilize avoidant or negative coping strategies. In addition, Asian American students who experience depressive symptoms were not more likely to utilize these negative coping strategies. Further research must be done to evaluate the factors that influence the use of negative coping strategies to better address anxiety within the Asian American medical student population.
... Asian Americans are viewed as a "model minority" who are better off than other racial and ethnic groups in terms of various health outcomes, including mental disorders. This entrenched stereotype contributes to the underestimated rates of depression and anxiety in this community, which may develop or be exacerbated through migration and acculturation [5] and, in turn, depression and anxiety can negatively impact their lives. Moreover, the existing literature has documented various methodological issues in collecting and analyzing data about Asian Americans. ...
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Asians are one of the fastest-growing racial groups in the United States. The mental health of Asian Americans, particularly regarding depression and anxiety, needs significant attention. Various biopsychosocial factors interact to influence the risks of depression, anxiety, and sleep quality among Asian Americans. Currently, multiple methodological issues exist in the research of Asian Americans, such as limited data collection using Asian languages and inconsistent reporting of race and ethnicity data, which may be lacking entirely. All these methodological issues in research may account for the seemingly low prevalence rates of mental health problems among Asian Americans. In our study on mental health and sleep quality among Chinese and Korean Americans, we adopted multiple data collection strategies during the COVID-19 pandemic, including using culturally adaptive and validated measures as well as operating culture-sensitive procedures in the recruitment and data collection. The successful use of these strategies could promote early detection and personalized treatment of depression, anxiety, and sleep disturbance among Asian Americans. These strategies would further improve health care service use in this population. International Registered Report Identifier (IRRID) RR2-10.1136/bmjopen-2020-047281
... Various research has emphasized the importance of a measurement invariance that yields comparable information regardless of race or ethnicity, which could be affected by the respondents' attitudes, values, or language (Drasgow & Kanfer, 1985;Leong & Gupta, 2008;Okazaki & Sue, 2016). It is meaningful that these race/ethnic groups were equally included in this study, considering the underrepresentation of those individuals as research participants other than the White/non-Hispanic group, especially in the mental health field including assessment and measurement (Alegria et al., 2002;Snowden, 2001;Sue et al., 2012). The statistical methods used for the first objective were applied to the data of each race/ethnic group. ...
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The Brief Adjustment Scale–6 (BASE-6) was recently developed for measuring general psychological functioning within measurement-based care (MBC). The present study further evaluated psychometric properties, generalizability to race/ethnic populations, and clinical utility of the BASE-6. Three adult samples, Sample 1: online community participants ( n = 394); Sample 2: college students ( n = 249); Sample 3: outpatient clinic clients ( n = 80), were included. The results demonstrated a high level of internal consistency, good test–retest reliability, and convergent validity in all samples. The unidimensional structure of BASE-6 was confirmed and factorial invariance was established across groups. Finally, the BASE-6 captured change over time by demonstrating a large effect size of pre–post treatment changes and significant linear change in multilevel growth modeling. These results support the BASE-6 as a reliable and valid measure regardless of race/ethnicity and can sensitively detect clinical change over the course of the treatment. Thus, the BASE-6 appears to accurately monitor overall psychological adjustment.
... Finally, advancing psychosocial interventions and services to address anti-Asian racial trauma and its intergenerational, psychiatric, and socioeconomic sequelae is crucial (Asian American Psychological Association, 2021; Liu & Modir, 2020). As a chronically underserved group in behavioral health services (Ihara et al., 2014;Sue et al., 2012)-including substance abuse treatment (Sakai et al., 2005)-and because perceived discrimination deters helpseeking (Burgess et al., 2008), Asian American emerging adults are an exceptionally vulnerable population at the present time, indicating proactive clinical practice efforts. ...
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The COVID-19 pandemic has incited widespread anti-Asian racism, which is linked to numerous behavioral health consequences including depressive symptoms. As racism-induced depressive symptoms are linked to coping-related alcohol use and because alcohol-related problems represent a significant public health concern in this population, we investigated whether COVID-19 racism predicted alcohol use severity through depressive symptoms and drinking to cope motives among Asian American emerging adults (N = 139; M age = 23.04; 50% women, 50% men). We conducted a serial mediation wherein COVID-19 racism predicted alcohol use severity sequentially through depressive symptoms and drinking to cope motives. COVID-19 racism directly and significantly predicted alcohol use severity. The indirect effect via depressive symptoms and drinking to cope motives was also significant, suggesting that COVID-19 racism is likely a risk factor for alcohol-related problems. Results inform intervention science and highlight the need for policy and behavioral health services to curb COVID-19 racism.
... 3 There is evidence suggesting under-utilisation of mental health services among ethnic Chinese relative to the non-Chinese population in Aotearoa, 4 which aligns with findings from ethnic Chinese migrants internationally. 5,6 In addition, recent reviews into Aotearoa's mental health system have found that it does not provide enough culturally-specific, holistic options for treatment. 7,8 More recently, challenges have been presented by the COVID-19 pandemic, which has further negatively impacted ethnic Chinese mental health. ...
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Aim: Little is known about the experiences of ethnic Chinese accessing mental health services in Aotearoa New Zealand, resulting in uncertainty around their service preferences, and facilitators or barriers to their mental health help-seeking. This paper investigated the experiences of providers of specific mental health services for ethnic Chinese in Aotearoa, their opinions regarding their patients' experience, and their suggestions to improve the system. Method: Sixteen health professionals with experience and expertise delivering mental health services for ethnic Chinese were interviewed at 12 organisations across Aotearoa. Interviews were recorded, transcribed and analysed using general inductive methods and thematic analysis. Results: Practitioners' experiences revolved heavily around cultural brokerage, which is vital for culturally appropriate care, but this is time-consuming and receives little formal support. Practitioners thought the patient experience was inadequate, with a lack of language- and culturally appropriate services leading to delays in help-seeking. Practitioners' suggestions for system improvement included increasing resourcing for research, and for expanding the availability of language and culturally appropriate services. Conclusion: Current mental health service provision is inadequate for ethnic Chinese seeking help in Aotearoa, and is causing harm by delaying mental health help-seeking. Decisive Government leadership and deeper collaboration between non-Government organisations (NGOs) will be key to improving mental health service accessibility and outcomes.
... In recent years, a growing number of studies have documented the relatively low rates of mental health utilization among Asian Americans (Abe-Kim et al., 2007;Nguyen & Anderson, 2005). Stigma and shame attached to mental illness have been identified as two of the factors accounting for this low utilization (Sue et al., 2012). It might be assumed that if young Indian Americans experience mental health problems, they would seek mental health treatment or some type of supportive service that could provide relief for their symptoms. ...
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Indian Americans now constitute the nation's second largest foreign-born population group in the United States (U.S.). Concerning Indian American youth, there is a paucity of information about their experiences in the U.S., particularly with respect to cultural stress and model minority stress, and whether these stressors have an impact on their mental health. This article describes the dual experiences of Indian American youth in the Indian and American cultures and discusses two theoretical frameworks (cultural stress and model minority stress) that illuminate dynamics influencing the lives of these youth. We illustrate three core pathways (independent, synergistic and indirect) by which cultural stress and model minority stress can influence the mental health of Indian American youth. Social workers and other behavioral health providers can assist Indian American youth by examining their own biases related to the model minority stereotype, helping school personnel assess the impact of this stereotype, and remembering that Indian American youth are not a monolith. Researchers need to disaggregate data on Asian Americans to gather accurate statistics on the Indian American population and refine model-minority-stereotype assessment instruments.
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Alzheimer’s dementia (AD) is a currently incurable neurodegenerative disease that is disproportionately prevalent in racially marginalized populations. However, due to underrepresentation in AD research, the full spectrum of AD-associated comorbidities that increase AD risk or suggest potential AD treatment disparities in these populations is not completely understood. Here, we perform low-dimensional embedding, enrichment analysis, and disease network-based analyses of 5,664 patients with AD and demographically matched controls across two electronic medical record (EMR) systems and five medical centers, with equal representation of Asian-, Non-Hispanic Black-, Latine-, and Non-Hispanic White-identified individuals. Our results suggest that while AD-associated comorbidities may be generally similar across racialized populations, some comorbidities may be enriched in subsets of racialized populations. Our approach could be a starting point for hypothesis-driven studies that can further explore the relationship between these comorbidities and AD in racialized populations, potentially identifying interventions that can reduce AD health disparities.
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The purpose of this study was to examine the relationships among Asian American adherence to Asian cultural values, attitudes toward seeking professional psychological help, and willingness to see a counselor. Based on the data from 242 Asian American college students, the results revealed that adherence to Asian cultural values inversely predicted both attitudes toward seeking professional psychological help and general willingness to see a counselor, above and beyond the effects of related demographic variables. The results also indicated that attitudes toward seeking professional psychological help were a perfect mediator on the relationship between adherence to Asian cultural values and willingness to see a counselor in general and between adherence to Asian values and willingness to see a counselor for personal and health problems in particular.
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Studies of attitudes across countries generally rely on a comparison of aggregated mean scores to Likert-scale questions. This presupposes that when people complete a questionnaire, their answers are based on the substantive meaning of the items to which they respond. However, people's responses are also influenced by their response style. Hence, the studies we conduct might simply reflect differences in the way people respond to surveys, rather than picking up real differences in management phenomena across countries. Our 26-country study shows that there are major differences in response styles between countries that both confirm and extend earlier research. Country-level characteristics such as power distance, collectivism, uncertainty avoidance and extraversion all significantly influence response styles such as acquiescence and extreme response styles. Further, English-language questionnaires are shown to elicit a higher level of middle responses, while questionnaires in a respondent's native language result in more extreme response styles. Finally, English-language competence is positively related to extreme response styles and negatively related to middle response styles. We close by discussing implications for cross-national research.
Background: General population survey data are presented on the lifetime prevalence of suicide attempts as well as transition probabilities to onset of ideation, plans among ideators, and attempts among ideators either with or without a plan. Risk factors for these transitions are also studied. Methods: Data are from part II of the National Comorbidity Survey, a nationally representative survey carried out from 1990 to 1992 in a sample of 5877 respondents aged 15 to 54 years to study prevalences and correlates of DSM-III-R disorders. Transitions are estimated using life-table analysis. Risk factors are examined using survival analysis. Results: Of the respondents, 13.5% reported lifetime ideation, 3.9% a plan, and 4.6% an attempt. Cumulative probabilities were 34% for the transition from ideation to a plan, 72% from a plan to an attempt, and 26% from ideation to an unplanned attempt. About 90% of unplanned and 60% of planned first attempts occurred within 1 year of the onset of ideation. All significant risk factors (female, previously married, age less than 25 years, in a recent cohort, poorly educated, and having 1 or more of the DSM-III-R disorders assessed in the survey) were more strongly related to ideation than to progression from ideation to a plan or an attempt. Conclusions: Prevention efforts should focus on planned attempts because of the rapid onset and unpredictability of unplanned attempts. More research is needed on the determinants of unplanned attempts.
• After initial interviews with 20 291 adults in the National Institute of Mental Health Epidemiologic Catchment Area Program, we estimated prospective 1-year prevalence and service use rates of mental and addictive disorders in the US population. An annual prevalence rate of 28.1% was found for these disorders, composed of a 1-month point prevalence of 15.7% (at wave 1) and a 1-year incidence of new or recurrent disorders identified in 12.3% of the population at wave 2. During the 1-year follow-up period, 6.6% of the total sample developed one or more new disorders after being assessed as having no previous lifetime diagnosis at wave 1. An additional 5.7% of the population, with a history of some previous disorder at wave 1, had an acute relapse or suffered from a new disorder in 1 year. Irrespective of diagnosis, 14.7% of the US population in 1 year reported use of services in one or more component sectors of the de facto US mental and ad- dictive service system. With some overlap between sectors, specialists in mental and addictive disorders provided treatment to 5.9% of the US population, 6.4% sought such services from general medical physicians, 3.0% sought these services from other human service professionals, and 4.1% turned to the voluntary support sector for such care. Of those persons with any disorder, only 28.5% (8.0 per 100 population) sought mental health/addictive services. Persons with specific disorders varied in the proportion who used services, from a high of more than 60% for somatization, schizophrenia, and bipolar disorders to a low of less than 25% for addictive disorders and severe cognitive impairment. Applications of these descriptive data to US health care system reform options are considered in the context of other variables that will determine national health policy.
The present study examined the degree of agreement between self-rated and peer-rated depression and social anxiety in White American and Asian American college students. A total of 160 Asian American and 177 White American target participants completed self-report measures of depression and social anxiety, and 1 peer informant completed the ratings for each target on the same measures. Results indicated that Asian American targets' levels of self-reported social anxiety and depression were underestimated by their peer informants to a greater extent than those of White American targets. The self-other discrepancy of distress was greatest for Asian American targets rated by White American informants. Degree of acquaintanceship and level of emotional expressivity did not moderate these findings. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
In this chapter, the authors seek to address these critical questions by first describing how cultural processes shape psychopathology by infusing experiences of distress with meaning and organizing distress in ways coherent with the social context. The authors examine how Asians, in particular, may employ somatic metaphors as a culturally mediated form of distress that conveys communal bodily, emotional, and social meanings, and the authors evaluate to what extent Asian Americans consequently somatize mental illness symptoms. In the next major section, the authors evaluate evidence relevant to the prevalence and manifestation of psychopathology among Asian Americans. They begin by reviewing how prevalent mental disorders are within Asian countries and how the experience of psychopathology may change among Asian Americans due to processes linked with immigration to the United States. The authors then briefly review the major principles of constructing cross-cultural assessments of psychiatric disorders before evaluating psychopathology research on Asian Americans, specifically focusing on mental health utilization studies and research on neurasthenia, anxiety, schizophrenia-spectrum, and major depressive disorders. The authors conclude by returning to our original questions regarding prevalence and manifestation of psychopathology among Asian Americans and identifying areas that need further study. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Among rising concerns surrounding heightened suicide in certain subgroups of Asian Americans, it is important to understand the help-seeking rates and pathways among Asian Americans experiencing suicidality. This study examined perceived need for care, help-seeking behavior, and chosen sources of care among Asian Americans compared with Latinos in the National Latino and Asian American Study who reported a history of lifetime suicidal ideation, suicide attempts, or mental disorders without history of suicide. Consistent with existing literature in Caucasians, suicide attempts in Asian Americans and Latinos were related to greater help seeking and perceived need beyond that of mental disorders only. However, Asian Americans with suicide attempts still reported lower perceived need and help-seeking behaviors compared with Latinos. In contrast to both the existing literature and Latinos in this study, Asian Americans with suicidal ideation were no more likely to perceive a need for help or seek help than Asian Americans with a mental disorder without history of suicide and were less likely to seek and perceive a need for help than Latinos with suicidal ideation. These findings point to the idea that Asian Americans who have serious suicidal ideation or attempts may underestimate the importance of their condition and do not receive the level of attention and support needed. Findings also show that Asian Americans with suicidal ideation and attempts prefer seeking help from nonprofessional rather than professional sources of help, other than medical professionals. Clinical implications for outreach, assessment, and management of suicide are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)