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Depression in Chinese American Immigrant Adults: an Exploration of Culturally Based Manifestations, Structure, and Measurement

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Depression in Chinese American Immigrant Adults: an Exploration of Culturally Based Manifestations, Structure, and Measurement Depression in Chinese American Immigrant Adults: An Exploration of Culturally Based Manifestations, Structure, and Measurement by Rose Wong A dissertation submitted in partial satisfaction of the requirements for the degree of Doctor of Philosophy in Social Welfare in the Graduate Division of the University of California, Berkeley Committee in charge: Professor Lonnie R. Snowden, Chair Professor Julian C. Chow Professor Stephen P. Hinshaw Professor Mark R. Wilson Fall 2009 The dissertation of Rose Wong, titled Depression in Chinese American Immigrant Adults: An Exploration of Culturally Based Manifestations, Structure, and Measurement, is approved: Chair ___________________________________________ Date ____________________ ___________________________________________ Date ____________________ ___________________________________________ Date ____________________ ___________________________________________ Date ____________________ University of California, Berkeley Abstract Depression in Chinese American Immigrant Adults: An Exploration of Culturally Based Manifestations, Structure, and Measurement by Rose Wong Doctor of Philosophy in Social Welfare University of California, Berkeley Lonnie R. Snowden, Chair Chinese American immigrants have one of the lowest rates of mental health services utilization among minority populations in the United States. With regard to depression, this disparity is associated with stigma, insufficient knowledge of depression and its treatment, help seeking in medical and community settings, and misdiagnosis. From the viewpoint that the manifestation of depression varies culturally, this research, composed of three studies, uses an emic approach combined with item response analysis to explore cultural interpretations and expressions of distress, and their influence on assessment. The first study investigated manifestations of social self-construal in the illness narratives of eleven men and nine women diagnosed with major depression. These narratives revealed a range of emotional, cognitive, and behavioral experiences that contained a social interpretation of the self. Also, psychological concepts of anxiety, irritability, and emotional control referred directly to a social self. This study demonstrated the social content in lived experiences of illness. The second study examined the structure of depression. Depressed outpatients (n = 103) and community members (n = 124) completed a 47-item pilot scale containing Western and culture specific symptoms and a 21-item checklist of somatic symptoms. A multidimensional model of 59 items in three dimensions—psychological, somatic, and social—provided optimal fit of the data. Various patterns of dimensional expression within and across levels of overall distress were observed. Also, analysis of differential item functioning (DIF) showed significant influences of gender, age, education and acculturation on different areas of content. This study implicated a dimensional construct in illness presentation and progression. The third study developed a self-report measure for screening in primary care and community settings. Based on responses to the 47-item pilot scale, 42 items fit a unidimensional polytomous model. Analysis of DIF by gender, age, and acculturation variables revealed non- equivalent items. A 9-item instrument was composed of items unbiased by gender and with content validity for the purpose of screening. This measure showed excellent reliability coefficients, and similar predictive validity but higher convergent and content validity than a commonly used Western measure. This study highlighted a role for culturally sensitive content for effective outreach and assessment. 1 TABLE OF CONTENTS Introduction . 1 Study 1: Depression in Chinese American immigrants: Social self-construal in manifestations of distress . 5 Study 2: The structure of depression in Chinese American immigrants: An exploration of the psychological, somatic and social dimensions of distress with item response analysis. 52 Study 3: The Chinese American Depression Scale (CADS-9): Development of a culture-specific screening measure for immigrant adults using Rasch item response modeling . 117 Conclusion . 166 i ACKNOWLEDGMENTS I thank my dissertation committee members, Lonnie R. Snowden, Mark R. Wilson, Stephen P. Hinshaw, and Julian C. Chow for supporting my development as a researcher, and my efforts to contribute to the welfare of the Chinese immigrant community. With Professor Snowden, I had the pleasure of witnessing his passion for intellectual understanding directed toward the resolution of social problems, and a notable compassion that motivated his work. From Professor Wilson and his colleague, Karen Draney, I gained an invaluable appreciation of item response analysis as a tool for understanding psychological and intellectual functioning. I also learned how to base my research foremost on substantive rationale and logical steps to achieve thorough and useful results. I am grateful to Professor Hinshaw for the exposure I had to the execution of a large-scale psychological investigation through my participation in his laboratory. I am also indebted for his timely moral and practical support associated with my research and career development. Finally, I thank Professor Chow for teaching me how to integrate diverse viewpoints to probe practical research questions. I recognize members of the School of Social Welfare for the roles they played in my education. I thank Professor Yu-Wen Ying for inspiring me to think creatively and broadly, and to learn to communicate my ideas clearly. I owe to her my appreciation of research as a means of teaching students and practitioners how to more deeply engage with the individuals who come into their lives. I thank Dean Lorraine Midanik, Associate Dean Andrew Scharlach, and Doctoral Program Chair, Jill Duerr Berrick, for their moral and instrumental support, which allowed me to obtain a National Institute of Mental Health dissertation grant and complete an ambitious study. I am grateful to Claudia Waters, Lecturer and Computing Manager, for her timely assistance with many statistical and practical questions. Finally, I am grateful to Barbara Haden, Graduate Assistant, for her kindness, guidance, and hard work for me throughout my years as a master’s and doctoral student. I benefited from the assistance of a group of bi-cultural and bilingual graduate and undergraduate students who contributed integrally to the execution of my research. These students were Rufina Wu, Cindy Lee Sung, Carmen Guo, Julia Kim Lam, Tak Lok Joyce Lam, Chih-Tao Tu, Shu Kau Andy Wong, and Bing Zhang. A handful of other students also participated by conducting interviews with clinical and community participants. I had the pleasure of sharing with all of them an empathy with Chinese immigrants due to the life difficulties these immigrants encountered, a desire to hear and understand them, and a motivation to support their well-being. I acknowledge Rufina Wu especially for the superb quality of her interviews with clinical participants in the qualitative phase of research. I also benefited intellectually from the expert instruction of Leah Lyn Walker, doctoral candidate in the School of Education, on conducting item response analysis. I am grateful to professionals and organizations in the community for their contributions to this research. I thank Dr. George Lee and Flora Chu of Asian Health Services, Joyce Lim of Asian Community Mental Health Services, Doreen Der-McLeod and Yulanda Kwong of Cameron House, Nancy Lim Yee of Chinatown Child Development Center, Wilma Louie of Chinatown/North Beach Community Mental Health Services, William Kwok of Hire-Ability Employment Services, and Kavoos G. Bassiri and Angela Tang of Richmond Area Multi- Services, Inc. for the participation of their organizations as study sites. I also thank Dr. Frances He, Dr. Gordon Juan, Rudy Kao, Edward Ka Ting Koo, Chang Yeong Lun, Tina T. Shum, and Dr. Aiqun Wang for their participation as clinical experts in various phases of research. I regard ii all of these professionals very highly for their dedication to the health of Asian Americans. Finally, I acknowledge the Chinese Community Health Care Association, the National Institute of Mental Health (Grant no. 5R36MH080607), and the Fahs-Beck Fund for Research and Experimentation for funding my research. iii INTRODUCTION This dissertation research aimed to contribute to the effective detection and treatment of depression for Chinese immigrants to the United States. Chinese Americans have one of the lowest rates of mental health services utilization among all minority ethnic groups in the U.S. (Bui & Takeuchi, 1992; Herrick & Brown, 1998; Snowden & Cheung, 1990; Sue & McKinney, 1975; Zhang, Snowden, & Sue, 1998). Such disparity in the treatment of depression, specifically, has been attributed to cultural barriers that hinder the individual’s decision to use mental health services. These barriers include problems of language; limited knowledge of mental illness and Western treatments (Yeung et al., 2004; Lin, 1985; Tseng, 1975); low direct access to mental health consultation (Hong, Lee, & Lorenzo, 1995); cultural beliefs such as stigma, fate, and self- blame (Abe-Kim, Takeuchi, & Hwang, 2002; Kung, 2004; Yeung & Kam, 2008); and a view of medical care as the appropriate intervention for depression (Ying, 1990). Associated with these barriers, illness-related behaviors among Chinese Americans include seeking help in primary care and community
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