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Asian Americans served at community mental health agencies for a diagnosis of schizophrenia

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Asian Americans served at community mental health agencies for a diagnosis of schizophrenia

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Content 1

Asian Americans Served at Community Mental Health Agencies for a Diagnosis of
Schizophrenia

Caroline Lim

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)

August 2017

2
Table of Contents

List of Tables .................................................................................................................................. 4
List of Figures ................................................................................................................................. 5
Acknowledgement .......................................................................................................................... 6
Abstract ........................................................................................................................................... 7
Chapter 1: Literature Review ........................................................................................................ 11
Schizophrenia............................................................................................................................ 12
Asian Population in the United States ...................................................................................... 13
Participation in Research among Asian Americans .................................................................. 14
Mental Health Needs of Asian Americans................................................................................ 15
Theories on Mental Health among Ethnic Minorities............................................................... 17
Mental Health Services Use by Asian Americans .................................................................... 18
Ethnicity-Specific Programs ................................................................................................. 19
Epidemiological Findings ..................................................................................................... 21
Mental Health Treatment Outcomes of Asian Americans ........................................................ 21
Limitations ............................................................................................................................ 22
Conceptual Framework for Examining Clinical Recovery from Schizophrenia ...................... 24
Chapter 2: Study Objectives ......................................................................................................... 27
Chapter 3: Methods ....................................................................................................................... 29
Study Design ............................................................................................................................. 29
Recruitment of Study Participants ............................................................................................ 30
Barriers to Research Participation......................................................................................... 31
Motivators of Research Participation.................................................................................... 36
Strategies Implemented......................................................................................................... 39
Nonviable Recruitment Strategies ........................................................................................ 46
Recruitment Outcome ........................................................................................................... 46
Summary ............................................................................................................................... 47
Study Procedure ........................................................................................................................ 47
Consent Process .................................................................................................................... 48
Research Interview................................................................................................................ 49
Measures ................................................................................................................................... 50
Demographic Variables......................................................................................................... 50
Clinical Variables.................................................................................................................. 51
Mental Health Service Access .............................................................................................. 53
Service Use and Quality of Care........................................................................................... 53
Psychosocial Stress ............................................................................................................... 54
Appraisal of Mental Health Need ......................................................................................... 58
Chapter 4: Sociodemographic Profile, Family Involvement, and Stress Experiences of Asian
Americans Served in Community Mental Health Agencies for a Diagnosis of Schizophrenia ... 60
Study Aims................................................................................................................................ 60
Methods..................................................................................................................................... 61
Measures ............................................................................................................................... 61
Statistical Analysis ................................................................................................................ 61
Results ....................................................................................................................................... 62
Clinical Profile ...................................................................................................................... 62
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Demographic Characteristics ................................................................................................ 62
Immigrant Histories .............................................................................................................. 63
Religious Affiliation ............................................................................................................. 64
Family Involvement .............................................................................................................. 65
Stress Experiences................................................................................................................. 68
Summary ............................................................................................................................... 75
Chapter 5: Treatment Outcomes of Asian Americans Diagnosed with Schizophrenia ................ 76
Study Aims................................................................................................................................ 76
Methods..................................................................................................................................... 77
Measures ............................................................................................................................... 77
Statistical Analyses ............................................................................................................... 80
Results ....................................................................................................................................... 82
Clinical Profile ...................................................................................................................... 82
Service Use ........................................................................................................................... 82
Treatment Outcomes ............................................................................................................. 83
Correlates of Treatment Outcomes ....................................................................................... 85
Summary ............................................................................................................................... 90
Chapter 6: Within-Group Differences in Treatment Outcomes of Asian Americans Diagnosed
with Schizophrenia........................................................................................................................ 91
Study Aims................................................................................................................................ 91
Methods..................................................................................................................................... 91
Measures ............................................................................................................................... 91
Statistical Analyses ............................................................................................................... 92
Results ....................................................................................................................................... 92
Chapter 7: Discussion ................................................................................................................... 93
Conclusions ......................................................................................................................... 106
References ................................................................................................................................... 108
Appendix ..................................................................................................................................... 143

4
List of Tables
Table 1. Demographic Profile of Study Sample (N = 75) .......................................................... 129
Table 2. Family Functioning of Study Sample Compared to First-Episode Psychosis Sample,
Chronic Schizophrenia Sample, and Healthy Controls............................................................... 131
Table 3. Prevalence of Major Traumatic Events and Level of Psychological Stress Compared to
Other Psychiatric Samples and the General Population ............................................................. 133
Table 4. Prevalence of Chronic Stressors in Study Sample ........................................................ 134
Table 5. PANSS Items Measuring the Five Syndromes of Schizophrenia ................................. 135
Table 6. Treatment Outcomes of Study Sample ......................................................................... 136
Table 7. Fitted Multivariate Linear Regression Models of Symptoms Severity of Schizophrenia
by Environmental Influences ...................................................................................................... 137
Table 8. Bivariate Analyses of Environmental Influences and Prognostic Indicators by
Functional Outcomes and Symptom Status ................................................................................ 138
Table 9. Bivariate Analyses of Environmental Influences and Prognostic Indicators by Recovery
Status ........................................................................................................................................... 139
Table 10. Comparison of Demographic Characteristics, Clinical Profile, and Treatment
Outcomes of East Asians and Southeast Asians Diagnosed with Schizophrenia ....................... 140

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List of Figures

Figure 1. A cultural model of the stress-diathesis framework of schizophrenia. ....................... 141
Figure 2. Recruitment flow diagram. .......................................................................................... 142

6
Acknowledgement
There are so many people that I want to thank, people without whom I would not be able
to complete my doctoral education. To my parents: thank you for being my prayer warriors; for
your love, unending faith, and support; and for teaching me the importance and value of being
diligent. To my siblings: thank you for making it so easy for me to be away from home, and for
your selfless love and support. Thank you to Dr. Barrio, my faculty mentor, for the opportunity
to work with you, for sharing your time with me, for your kindness and compassion, and for your
faith and support. Thank you to other faculty members, namely, Dr. Eric Rice, Dr. Dorian
Traube, Dr. John Brekke, and Dr. Yamada, for the opportunity to work with you on your projects
and to publish with you. Thank you for sharing your passion, which is so infectious, and for
showing me how research can be used to enhance the well being of vulnerable populations.
Thank you to all who advised me, mentored me, reached out to me, and encouraged me as I
undertook my dissertation research. A special thank you to the mental health providers for going
above and beyond their duty by taking the time to disseminate information on my dissertation
research to their clients, and to the master’s-level students for assisting me with my data
collection (Ashlie Chu, Cecilia Tran, Cenliu Zhu, Eve Zheng, Hei Man Fan, Siying Wang, and
Holly He). Importantly, thank you to the clients who participated in my dissertation research for
the privilege to hear about your recovery journey. Thank you to some of my dearest friends for
their friendship, love, and encouragement: Jen, Hui Ling, Suresh, and Yura. Lastly, to my God
and Savior, Jesus Christ, for the strength He gives me daily, and for the many wonderful people
He has placed in my life to encourage me, to love me, and to pray for me. I am grateful to Him
that I get to celebrate the end of this life chapter with my family.

7
Abstract
Introduction: Little is known about Asian Americans diagnosed with schizophrenia, a
low-prevalence but serious psychiatric disorder. A basic demographic characterization of this
population is lacking. Additionally, data on aspects of their psychological health, social
circumstances, lived experiences with mental illness, access to and use of services, and
importantly, treatment responsiveness that can provide clues to the existence of needs and
resources are scant. These gaps in knowledge are concerning because an increasing number of
users of mental health services in the Asian American community are expected to be individuals
with serious psychiatric disorders, yet little data exist to guide service delivery to this growing
group. Objectives: The goals of this study were related to Asian Americans diagnosed with
schizophrenia. The first study cataloged the socio-demographic characteristics of Asian
Americans served at community mental health agencies for a diagnosis of schizophrenia. The
second study assessed the treatment responsiveness of these users of mental health service and
identified the cultural promoters and barriers of the investigated outcomes (symptoms severity,
role functioning, symptomatic remission, and clinical recovery), with an emphasis on correlates
that are responsive to psychosocial interventions delivered by practitioners. The third study
investigated whether the treatment outcomes vary in Asian ethnic subgroups via comparison with
East Asian and Southeast Asian Americans diagnosed with schizophrenia. Methods:
Quantitative data for this cross-sectional study were gathered from interviews with 75 Asian
Americans diagnosed with schizophrenia who were served across four Los Angeles County
Department of Mental Health contracted and directly operated agencies and two board-and-care
facilities in Los Angeles. Demographics, clinical, and psychosocial data were collected using a
combination of in-person interviewing and participant completion of validated self-report
8
inventories. Univariable analyses were conducted to derive descriptive statistics for the study
sample – means and standard deviations were computed for continuous variable, and proportions
for categorical variables. Chi-square tests, with correction of unequal variances whenever
necessary, or Fisher’s exact tests for categorical variables with few observations were performed
to examine relationship between two categorical variables; two independent t tests or one-way
analyses of variance (ANOVA) were performed to compare means for two or more independent
groups, respectively; and bivariate correlations were performed to examine relationship between
two continuous variables. Multivariate ordinary least squares linear regression models and binary
logistic regression models were fitted to identify the correlates of continuous and categorical
outcome variables, respectively. Results: The study sample featured 51 participants diagnosed
with schizophrenia and 24 participants diagnosed with schizoaffective disorder. Importantly, this
study sample was composed of mostly individuals with established schizophrenia who have been
engaged in mental health treatment and services. The study sample was ethnically diverse, with
slightly more than three fourths of participants identifying as East Asian (Chinese, Japanese, and
Korean) and the remainder identified as Southeast Asian (Cambodian, Filipino, and Vietnamese).
Participants’ ages ranged from 19 to 66 years (M = 43.03; SD = 12.61). Men and women were of
comparable distribution. This study has demonstrated several points relevant to Asian Americans
treated in community mental health settings for a diagnosis of schizophrenia. The first study
found that participants were socially and economically more disadvantaged than the general
Asian American population, largely evidenced by their overall lower levels of educational
attainment, participation in labor force, and English proficiency. This study also provided
evidence of the centrality of Asian American parents as caregivers of adults with serious mental
illness. In general, the distributions of social adversities experienced by Asian Americans
9
diagnosed with schizophrenia were similar to other psychiatric samples, but higher than the
general population. Results also indicate that the minor events of daily life were a related form of
stressful experiences among participants, possibly more salient than other types of stressors
related to trauma or life events. Results from the second study indicate considerable
heterogeneity in treatment outcomes, with participants showing varying levels of symptoms
severity and functional outcomes. However, findings paint an overall picture of poor treatment
outcomes in this study sample, as evidenced by high proportion of participants who were at least
moderately symptomatic and showed poor functional outcomes. Furthermore, clinical recovery
from schizophrenia was not common in this sample (21.33%). Results from the second study
also suggest that specific prognostic indicators of schizophrenia typically correlate differentially
across treatment outcomes in that environmental conditions appear more relevant to symptoms
severity, whereas biological characteristics (age, gender, and age at onset of illness) were more
salient factors of global outcomes, namely, clinical recovery from schizophrenia. The third study
found that outcomes were comparable between East Asians and Southeast Asians participants.
Conclusion: This study is the first and largest study to provide empirical data that reflect the
resources, needs, and experiences of an ethnically diverse sample of Asian Americans treated for
a diagnosis of schizophrenia in community mental health settings. The impetus for this study
came from the hope that findings would challenge the prevalent notions about the unfavorable
outcome of schizophrenia, inform decisions about treatment and program development, and
shape policies for the delivery of services within mental health systems for a growing group of
Asian Americans with schizophrenia. Accordingly, the implications of this study’s findings
relate to ways to enhance the treatment outcomes and prevent further socioeconomic
disadvantages of Asian Americans with schizophrenia. Although findings from the proposed
10
study will not be generalizable to other Asian American subgroups and individuals belonging to
other racial and ethnic groups, it is envisaged that this study will serve as a springboard for future
research on Asian Americans with serious mental disorder.

11
Chapter 1: Literature Review
Little is known about Asian Americans diagnosed with schizophrenia, a low-prevalence
but serious psychiatric disorder. Much of what we know about this vulnerable population comes
primarily from participants enrolled in clinical drug trials, but even this information is limited to
their response to and tolerability of antipsychotic drugs. Although these data are no less
important, our understanding of a larger subset of Asian Americans with schizophrenia, namely
those receiving services in community mental health settings, is poor. We lack a basic
demographic characterization of this population. Additionally, data on aspects of their
psychological health, social circumstances, lived experiences with mental illness, access to and
use of services, and importantly, treatment responsiveness that can provide clues to the existence
of needs and resources are scant. These gaps in knowledge are concerning because an increasing
number of users of mental health services in the Asian American community are expected to be
individuals with serious psychiatric disorders (Kinzie & Tseng, 1978; Lau & Zane, 2000; Zane,
Hatanaka, Park, & Akutsu, 1994), yet little data exist to guide service delivery to this growing
group. It is reasonable to assume Asian Americans represent an increasing proportion of users of
mental health services given the substantial growth of this minority group in the United States
during the last decade. The U.S. Census Bureau (2016) estimated that the Asian population has
been and will continue to be the fastest-growing racial and ethnic group in the nation.
Accordingly, the need for mental health services in this minority group will continue to rise
significantly in the coming years. Research is needed to gather data on individuals treated for
schizophrenia to ensure acquisition of intervention development and skills by mental health
providers, generation of hypotheses by researchers, and importantly, planning of resource
allocation by health administrators.
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Schizophrenia
Schizophrenia is considered a serious psychiatric condition (National Institute of Mental
Health, 2009). The disorder is characterized by hallucinations and delusions that affect
individuals’ thinking, feelings, and behaviors. In some individuals, the disorder also involves
disorganization in thought processes and behavior. During periods of active psychosis,
individuals experience florid symptoms that interfere with their ability to differentiate between
what is real and what is imaginary and thus, may appear to have lost touch with reality. On this
basis, coupled with its longitudinal course and the extent and persistence of impairment in
functioning between episodes, schizophrenia is considered one of the most disabling and costly
psychiatric disorders to treat (McEvoy, 2007). Indeed, schizophrenia had been deemed a mental
disorder with no hope of recovery until recently (Tandon, Nasralla, & Keshavan, 2009).
Accumulating evidence from longitudinal studies of schizophrenia documenting a more
promising long-term course have challenged the conventional notion that schizophrenia is a
psychiatric disorder characterized by a uniformly poor outcome (Jääskeläinen et al., 2012; Lim,
Barrio, Hernandez, Barragán, & Brekke, 2015; McGlashan, 1988). These studies have found that
the long-term course of schizophrenia is highly heterogeneous, resulting in varying degrees of
recovery and disability. More importantly, evidence suggests that with the availability of more
tolerable antipsychotic medications and advances in psychosocial interventions, individuals
diagnosed with schizophrenia increasingly can achieve periods of clinical recovery. This
evidence, however, has been gathered primarily from nonminority individuals diagnosed with
schizophrenia. In response to a growing literature on ethnic disparities in mental health, research
is needed to gain knowledge of the occurrence of clinical recovery from schizophrenia across
various populations and cultures, especially racial and ethnic minority populations. The
13
following sections review important research to demonstrate that substantial progress has been
made toward furthering our understanding of Asian Americans’ mental health, but also highlight
existing gaps in knowledge, especially as it relates to schizophrenia in this ethnic minority
population, which this study strived to address.
Asian Population in the United States
Population estimates and projections indicate that the United States will become more
racially and ethnically diverse during the next few decades. Presently, the non-Hispanic White
population forms the majority group, constituting more than 50% of the nation’s total population.
The U.S. Census Bureau projected that this percentage will fall to below 50% by 2044, at which
point the country will become a majority–minority nation (Colby & Ortman, 2015). This
suggests that no racial and ethnic group will be the majority population in the coming decades,
because the growth of minorities is expected to exceed that of non-Hispanic Whites. Among all
the racial and ethnic groups represented in the country, the Asian population is projected to be
the fastest-growing population, with an expected increase of 143% by 2060 (Colby & Ortman,
2015). Indeed, the Asian population increased at a rate 4 times faster than the total population
between 2000 and 2010; whereas the nation’s population grew by close to 10%, the Asian
population grew by an astounding 46% during the same period (Hoeffel, Rastogi, Kim, &
Shahid, 2012). In 2010, 17.3 million people in the United States, or 5.6% of the nation’s
population, identified as Asian, with the majority living in the Western region of the country
(Hoeffel et al., 2012). Among various Asian groups in the United States, Chinese individuals
formed the largest group, followed by Filipino, Asian Indian, Vietnamese, Korean, and Japanese
populations (U.S. Census Bureau, 2016). Despite the growth of the Asian population in the
14
United States, knowledge of some of the most vulnerable subgroups in this population, such as
those with serious psychiatric disorders, is limited due to the dearth of empirical data.
Participation in Research among Asian Americans
The lack of empirical data on Asian Americans with serious psychiatric conditions such
as schizophrenia can be attributed to the underrepresentation of the general Asian population in
federally funded research (e.g., Lehman & Steinwachs, 1998; Lieberman et al., 2005) and those
with serious mental illness in national epidemiological surveys of the Asian population (e.g.,
Alegría et al., 2004). Despite the implementation of the National Institutes of Health
Revitalization Act, which stipulates the recruitment of women and minority groups for
participation in federally funded biomedical and behavioral studies, the enrollment rates of Asian
Americans into clinical research continue to be lower compared to other minority populations
and nonminority groups (Bistricky et al., 2010; Geller, Koch, Pellettieri, & Carnes, 2011;
UyBico, Pavel, & Gross, 2007; Wendler et al., 2006). A study of 86 federally funded randomized
controlled trials to determine the level of compliance with the act did not identify any studies that
included Asian participants (Geller et al., 2011). Additionally, a recent systematic review of
community-based participatory research clinical trials that recruited racial and ethnic minorities
found that only one of the 19 identified studies involved Asian Americans (Las Nueces, Hacker,
DiGirolamo, & Hicks, 2012). Specific to the recruitment of individuals with schizophrenia, the
largest randomized trial of antipsychotic drugs for the treatment of schizophrenia enrolled 1,493
patients with schizophrenia, but Asians comprised only 2% of the sample (Lieberman et al.,
2005). These findings, combined with the extensive publication of strategies to identify and
enroll Asian Americans in research, serve as a testament to the tangible obstacles to engaging
this minority population in the scientific inquiry process (e.g., Hinton, Guo, Hillygus, & Levkoff,
15
2000). However, the distinctive issues associated with being a minority with serious mental
illness pose additional impediments that further hinder recruitment of this subpopulation.
Perpetuating the low enrollment of Asian Americans with serious mental illness in research
violates the key ethical principle of justice for conducting research with human subjects, which
requires that the benefits and burden of research to be equally distributed across individuals and
groups. The present study represent initial efforts toward filling a lacuna in mental health
research of Asian Americans with serious mental illness by engaging and enrolling those treated
for schizophrenia in community mental health settings for participation in an observational
study.
Mental Health Needs of Asian Americans
Evidence gathered from epidemiological studies indicates that prevalence rates of various
psychiatric disorders in the Asian population are comparable to if not lower than those of other
racial and ethnic groups (Burnett-Zeigler, Bohnert, & Ilgen, 2013). These psychiatric conditions
include eating disorder (Nicdao, Hong, & Takeuchi, 2007), cannabis use disorder (Wu et al.,
2014), anxiety disorder (Asnaani, Richey, Dimaite, Hinton, & Hofmann, 2010), and major
depressive disorder (Gavin et al., 2010). However, these findings should not be construed as
indications of little need for mental health services among Asian Americans. On the contrary,
epidemiological studies have also provided some evidence demonstrating that the level of need,
measured by severity of symptomatology among those with a diagnosable psychiatric disorder, is
higher among Asian Americans than other racial and ethnic groups. For example, Wu and
colleagues (2014) reported that although Asian Americans have the lowest prevalence of
cannabis drug use, those who use cannabis have a significantly higher probability of meeting
criteria for cannabis use disorder than users belonging to other racial and ethnic groups. In the
16
same fashion, González and colleagues (2010) found that although Whites have the highest
prevalence of major depression compared to racial and ethnic minorities, African Americans and
Asian Americans tend to experience higher levels of chronicity and impairment.
This epidemiological evidence of higher illness severity among Asian Americans appears
to corroborate results from research on users of the public mental health system (Barreto &
Segal, 2005; Durvasula & Sue, 1996; Kinzie & Tseng, 1978; Lin, Tardiff, Donetz, & Goresky,
1978; Sue et al., 1991; Sue & Mckinney, 1975). Durvasula and Sue (1996) compared the severity
of disturbance between White and Asian clients served by the Los Angeles County Department
of Mental Health (LACDMH) between 1973 and 1988 and found higher levels of severity among
Asian clients. Specifically, a significantly higher proportion of Asian clients received severe
diagnoses (i.e., schizophrenia, brief reactive psychosis, delusional disorder, major depression,
bipolar disorder, and organic disorders) compared to their White counterparts. Asian clients were
also significantly more impaired in functioning compared to White clients, and this relationship
remained after controlling for important confounding variables that included age and gender.
These findings replicated those reported by Sue and colleagues (1991), who examined outpatient
service use in the Los Angeles County mental health system across major racial and ethnic
groups. Among Asian American clients, more than half (50.3%) were seen for a diagnosis of
psychosis. This proportion was significantly higher than those found among Mexican Americans
(35.6%) and Whites (42.8%) and comparable to that found among African Americans (50.2%).
Additionally, Asian American clients presented with significantly lower levels of functioning
than Mexican American clients (Sue et al., 1991). These findings—that Asian Americans who
use mental health services tend to have the most serious psychiatric conditions—have been
consistently reported since research on the mental health of Asian Americans first emerged
17
(Barreto & Segal, 2005; Sue & McKinney, 1975). Taken together, these results imply that the
levels of mental health need among Asian Americans are not inconsiderable, and by extension,
the use of intensive mental health services, which are more costly, may be higher in this minority
population than other racial and ethnic groups (Lau & Zane, 2000).
Theories on Mental Health among Ethnic Minorities
Given that the onset of psychiatric disorders is typically associated with exposure to
adversities stemming from the context of individuals’ lives (Sullivan, Neale, & Kendler, 2000),
stress theories have been put forward to explain the differences in risk across racial and ethnic
groups. Specifically, extant studies finding racial and ethnic differences in rates of mental
disorders have posited that either differential exposure or differential vulnerability to risk and
protective factors may account for higher rates of mental health needs in certain racial and ethnic
groups (e.g., Perilla, Norris, & Lavizzo, 2002; Schilling, Aseltine, & Gore, 2007). According to
the differential exposure hypothesis, inequality in mental health needs can be attributable to
between-group differences in distribution of risk and protective factors (Dohrenwend, 1973). For
instance, research has also found that the experience of racial prejudice and discrimination,
acculturative stress, trauma exposure, and chronic strains are salient risk factors that increases
the risk of mental health problems among Asian Americans (Chae, Lee, Lincoln, & Ihara, 2012;
Juang & Alvarez, 2010). This unequal distribution of risk and protective factors can occur
throughout development, prompting disparity in mental health outcomes over time (Gee,
Walsemann, & Brondolo, 2012). Differential susceptibility to the environment holds that
heterogeneity in individuals’ sensitivity to both adverse and supportive environmental conditions
prompts differential risk of mental disorder (Kessler, 1979). When applied to the investigation of
racial and ethnic differences in mental health needs, this theory contends that exposure to stress
18
differentially affects the psychological health of Whites compared to racial and ethnic minorities.
For example, Brown, Meadows, and Elder (2007) demonstrated that stressful life events exerted
greater impact on the trajectory of depressive symptoms among minorities (Black and Asian
females and Black males) than among non-minority adolescents. The present study did not test
these hypotheses, but described the risk and protective factors that presumably affect the
treatment outcomes of Asian Americans diagnosed with schizophrenia.
Mental Health Services Use by Asian Americans
Early research provided compelling evidence that Asian Americans are underrepresented
in mental health programs (Sue & McKinney, 1975). Sue and McKinney (1975) gathered data on
13,450 White and Asian patients served across 17 community mainstream mental health
facilities between 1970 and 1973 to examine patterns of mental health services use among Asian
Americans. The researchers found that significantly fewer Asian Americans sought out mental
health services (0.6%) than expected based on their representation in the facilities’ catchment
area (2.38%). This finding was further bolstered by results from a follow-up study (Sue, 1977).
Using the same data, Sue (1977) examined mental health services use across five racial and
ethnic groups (Whites, Blacks, Native Americans, Latinos, and Asians) and found that whereas
Blacks and Native Americans were overrepresented in the mental health system, Asians and
Latinos were severely underrepresented.
Other major findings that emerged from these seminal works include the following. First,
Asian Americans who used mental health services were overrepresented by individuals with the
most serious psychiatric disorders such as psychosis. Second, Asian Americans had significantly
poorer treatment engagement than their White counterparts, as indicated by higher rates of
treatment discontinuation after contact was made and fewer number of treatment sessions
19
completed (Sue & McKinney, 1975). More importantly, the finding of poorer treatment
engagement among Asian Americans was also apparent in other ethnic minority groups, such
that between 42% and 55% of ethnic minority clients failed to return after one contact with the
mental health system, compared to 30% of White clients (Sue, 1977). These high dropout rates
could not be attributed to ethnic minorities receiving different types of mental health services
(e.g., individual therapy). Accordingly, Sue (1977) contended that despite mainstream mental
health programs’ attempt to deliver equal services to clients of all races and ethnicities, these
treatments were unresponsive to the needs of not only Asian Americans, but also other ethnic
minorities.
Ethnicity-Specific Programs
On the basis of the abovementioned findings, Sue (1977) proposed several directions to
improve mental health care for ethnic minority clients. One of these recommendations involved
the establishment of ethnicity-specific mental health services that are separate from but parallel
to mainstream mental health programs. These programs are characterized by the availability of
bicultural and bilingual mental health providers to enhance therapist–client ethnic match and the
delivery of culturally congruent mental interventions to ethnic minority populations (e.g., Zane et
al., 1994).
Efforts to evaluate ethnicity-specific mental health programs have yielded robust
evidence attesting to the effectiveness of such programs in rectifying any disparities in mental
health care for ethnic minorities. Specifically, ethnic-specific programs were found to promote
significantly higher levels of service use and engagement among Asian Americans than did
mainstream programs (Snowden & Hu, 1997; Takeuchi, Sue, & Yeh, 1995), including levels of
use and engagement comparable to Whites (Zane et al., 1994). Whereas Sue (1977) reported that
20
more than half of Asian Americans served by mainstream mental health programs terminated
their treatment after one session, Zane and colleagues (1994) found that less than one quarter of
Asian clients served by an ethnicity-specific agency evinced this outcome. Importantly, this rate
was not significantly different from those found among White clients (Zane et al., 1994). Perhaps
the strongest line of evidence came from Takeuchi and colleagues (1995). Using LACDMH
service data, the researchers compared the treatment engagement of ethnic minorities served in
ethnicity-specific programs with those served in mainstream programs using several outcome
indexes. After controlling for relevant confounders including age and type of disorder, Takeuchi
and colleagues (1995) found that Asian Americans served in ethnicity-specific programs were
significantly more likely to continue in treatment (OR = 14.63) and received significantly more
treatment sessions (β = .29) than their counterparts served in mainstream programs. Not
surprisingly, when mental health services were delivered in mainstream mental health programs,
matching clients and therapists on ethnicity yielded similar positive effects on service use and
engagement (Sue et al., 1991; Takeuchi et al., 1995; Ying & Wu, 1994).
Results from a more recent investigation supported these earlier findings of increased
engagement in mental health services among Asian Americans. Barreto and Segal (2002)
analyzed data of clients (N = 10,262) served by the California Department of Mental Health
between 1998 and 2002 to examine racial and ethnic differences in mental health service use.
The researchers found that Asian Americans received the highest levels of services on all
measured indicators, i.e., number of outpatient services received, length of outpatient services,
and number of inpatient days. For example, Asian Americans averaged 331 minutes in outpatient
services, whereas Whites averaged 294, African Americans averaged 265, Latinos averaged 261,
and Native Americans averaged 319. Asian Americans and Native Americans received an
21
average of seven outpatient services during a 6-month period, whereas Whites received six and
African Americans and Latinos received five.
Epidemiological Findings
Subsequent research via community psychiatric epidemiological studies conducted with
Asian Americans has uncovered more nuances in mental health services use by this minority
population that are largely attributed to the influence of culture and immigration-related factors
(Alegría et al., 2004). Results from the National Latino and Asian American Study indicate that
U.S.-born and third-or-later-generation Asians have higher rates of mental health services use
than foreign-born and first- or second-generation Asians, respectively (Abe-Kim et al., 2007). In
fact, U.S.-born Asians with a demonstrated need used mental health services at a higher 12-
month rate than the general population—62.6% versus 41.1%, respectively (Wang et al., 2005).
Regarding English language proficiency, Asians with higher levels of proficiency are more likely
to use mental health services and antipsychotic medications (Gilmer et al., 2008; Ihara, Chae,
Cimmings, & Lee, 2014; Kang et al., 2010). Research has also found that stigma and use of
alternative treatments (e.g., traditional Chinese medicine) hinder the use of mental health
services among Asian Americans (Kim & Omizo, 2003; Okazaki, 2000; Yang, Corsini-Munt,
Llink, & Phelan, 2009).
Mental Health Treatment Outcomes of Asian Americans
Although significant progress has been made in understanding Asian Americans’ use of
mental health services, knowledge of this population’s response to mental health treatment
remains poor. Indeed, the supplement to Mental Health: A Report of the Surgeon General (U.S.
Department of Health and Human Services, 2001) echoed this gap in knowledge by noting that
research examining mental health treatment outcomes in this minority population has been
22
limited. Data on Asian Americans’ response to mental health treatment have hitherto come from
early research employing service data maintained by local mental health systems such as the
LACDMH (O’Sullivan, Peterson, Cox, & Kirkeby, 1989; Sue et al., 1991; Sue & McKinney,
1975; Takeuchi et al., 1995; Zane et al., 1994). Treatment outcome was defined as clients’ level
of overall functioning at discharge and measured with the Global Assessment Scale (GAS;
Endicott, Spitzer, Fleiss, & Cohen, 1976). These studies found that Asian American clients did
not demonstrate significantly better or worst treatment outcomes than clients belonging to other
racial and ethnic groups (Sue et al., 1991; Zane et al., 1994) and that Asian American clients
served in ethnicity-specific programs demonstrated better outcomes than their counterparts
served in mainstream programs (Lau & Zane, 2000).
Limitations
Several limitations of these studies are worth noting. First, these studies applied a narrow
measure of treatment outcomes, clients’ GAS scores at discharge. These data are necessary but
not a sufficient guide to treatment planning. More detailed data are needed to select the essential
services most critical for enhancing the treatment outcomes of Asian Americans with serious
psychiatric conditions. Second, previous studies have tended to focus on the treatment outcomes
of Asian Americans with a mix of psychiatric diagnoses. Given the enduring nature of
schizophrenia, which increases the likelihood of long-term treatment, combined with the sheer
number of Asian Americans expected to use mental health services for the treatment of this
disorder, it would be of interest to examine the treatment response of this subgroup of current
service recipients. This investigation would reveal whether mental health treatment has any
benefits for individuals with the most serious of psychiatric conditions. Third and perhaps most
concerning, previous studies did not apply specific criteria to evaluate response to treatment.
23
Asian Americans’ treatment outcomes have mostly been determined by comparison with other
racial and ethnic groups or with pretreatment characteristics. Results from these studies
demonstrating better outcomes among Asian Americans than other groups or higher level of
functioning at discharge than at admission should not be uncritically regarded as indicative of a
treatment response. Such comparative studies, although necessary to identify disparities in
mental health care, are not sufficient to determine whether a population is indeed responding to
treatment. For example, Takeuchi and colleagues (1995) reported that Asian Americans who
received mental health services at ethnicity-specific programs averaged a GAS score of 44 at
admission and 49 at discharge. Despite a higher rating at discharge, these GAS scores were not
clinically dissimilar in that they represent serious symptomatology or impairment in functioning.
Asian Americans, therefore, were as impaired in functioning at discharge as they were at
admission. Examining the occurrence of clinical recovery from various psychiatric disorders has
the potential to not only yield findings that allow for more meaningful evaluation of treatment
response, but also elevate expectations for treatment by setting a new clinical benchmark for
mental health providers. However, no studies have been published on clinical recovery from
schizophrenia in this racial and ethnic subpopulation. Clinical recovery is a fitting indicator of
treatment responsiveness because it represents a restoration of health and ability for individuals
whose lives have been affected by this disabling disorder. Moreover, seeking treatment for
schizophrenia, and other mental disorders, continues to carry a stigma among Asians in the
United States. Empirical evidence of clinical recovery among Asian Americans treated for
schizophrenia is needed to not only challenge this inaccurate notion, but also promote hope
among those individuals and families engaged in treatment. Importantly, empirical evidence of
24
such a favorable treatment outcome is also urgently needed to encourage timely help seeking
among nonusers of mental health services in the Asian community with a need for treatment.
Conceptual Framework for Examining Clinical Recovery from Schizophrenia
The stress-diathesis model has been the prevailing explanatory theory for understanding
the etiology and developmental trajectory of schizophrenia (Mueser & McGurk, 2004). The
model considers elevated levels of stress both a precipitating factor among individuals with
preexisting biological vulnerability and a risk factor that can impede the achievement of recovery
among individuals with manifested vulnerability by increasing the likelihood of psychotic
relapses. Nonetheless, the model also posits that personal capacities and the environment can
provide a buffer against the deleterious effects of stress. Accordingly, managing biological
vulnerability through pharmacotherapy while simultaneously alleviating stress by enhancing
adaptive coping skills and mitigating the effects of adverse environments has been the blueprint
for treatment of schizophrenia. The stress-diathesis model suggests that clinical recovery in
schizophrenia can be hastened by pharmacotherapy combined with psychosocial therapies that
equip individuals with internal resources to influence their environment and develop supportive
environmental resources.
Research has hitherto mostly examined the predictive relationships between clinical
recovery and biological functions, which are primary targets of pharmacotherapies (Albert et al.,
2011; Strauss, Harrow, Grossman, & Rosen, 2010; Verma, Subramaniam, Abdin, Poon, &
Chong, 2012). Further investigations are needed to determine whether intrapersonal
characteristics and environmental conditions, which are mostly amenable to psychosocial
therapies delivered by social workers, are vital to promoting periods of clinical recovery from
schizophrenia. Indeed, findings from qualitative studies of individuals considered to be in
25
recovery from severe mental illnesses that included schizophrenia suggest the importance of
personal attributes, environmental factors, and meaningful activities, hereafter referred to as
psychosocial factors, in facilitating recovery. Hope of recovery (Ridgway, 2001), self-
determination (Mancini, 2007; Ochocka, Nelson, & Janzen, 2005), spirituality and religion
(Barham & Hayward, 1998), presence of meaningful activities (Dunn, Wewiorski, & Rogers,
2008; Mancini, Hardiman, & Lawson, 2005), elimination of stigma (Jacobson & Greenley, 2001;
Ridgway, 2001), strong clinician–client relationship (Green et al., 2008), and social support
(Cohen, 2005; Jacobson & Greenley, 2001; Mancini et al., 2005; Schön, Denhov, & Topor,
2009) are among the important facilitative psychosocial factors of recovery identified in
qualitative studies. Although the contributions of these nonbiological characteristics have been
evaluated qualitatively, few empirical studies have quantitatively assessed the impact of these
factors on clinical recovery from schizophrenia; therefore, the extent to which these findings can
be generalized is unclear.
Drawing from the work of previous investigators (Knight, Silverstein, McCallum, & Fox,
2000), this study proposes an expanded stress-diathesis framework for conceptualizing racial and
ethnic differences in treatment outcomes of schizophrenia (see Figure 1). This expanded
framework recognizes that race and ethnicity implies differences in culture, which in turn
engender variation in risks and protective processes. These cultural differences are associated
with heterogeneity in appraisal of life events, coping strategies, magnitude and type of adversity
exposure, access to supportive resources, and use of mental health services across racial and
ethnic groups, which in turn influence the levels of experiential stress and engender differences
in treatment outcomes. This expanded framework, therefore, posits that these differential
mechanisms may contribute to disparities in treatment outcomes across racial and ethnic groups
26
via stress. This study contributes to the literature by empirically evaluating clinical recovery and
other dimensions of treatment outcomes among Asian Americans diagnosed with schizophrenia
and identifying its corresponding contributory psychosocial factors, with a focus on race and
ethnicity-related protective and risk factors unique to Asian Americans.

27
Chapter 2: Study Objectives
To address the outlined gaps in research, this study proposed the following goals related
to Asian Americans served at community mental health agencies for a diagnosis of schizophrenia
and tested the following hypotheses, where appropriate:
1. To detail the strategies implemented to engage and enroll Asian Americans diagnosed with
schizophrenia, a traditionally isolated and difficult-to-reach population, for research
participation;
2. To catalog the socio-demographic characteristics of Asian Americans served at community
mental health agencies for a diagnosis of schizophrenia;
3. To assess the treatment responsiveness of this ethnic minority population treated for
schizophrenia in community mental health agencies by examining symptoms severity, role
functioning, symptomatic remission, and overall treatment responsiveness indicated by the
achievement of clinical recovery;
4. To identify the cultural promoters and barriers of the investigated treatment outcomes among
Asian Americans diagnosed with schizophrenia with an emphasis on correlates that are
responsive to psychosocial interventions delivered by social work practitioners; and
Hypothesis 1: Based on the stress-diathesis framework, we expected that favorable treatment
outcomes (lower symptoms severity, adequate role functioning, achievement of symptomatic
remission and clinical recovery from schizophrenia) would be positively associated with
exposure to more favorable environmental conditions (healthy family functioning) after
controlling for the influence of known prognostic indicators of schizophrenia (age, gender,
age at onset of illness, and history of child adversity).
28
Hypothesis 2: Higher levels of exposure to adverse environments (comprising recent traumas
and life events, and chronic strains) would be negatively associated with favorable treatment
outcomes after controlling for the influence of examined prognostic indicators of
schizophrenia.
5. To assess whether the treatment outcomes vary in Asian ethnic subgroups via comparison
with East Asian and Southeast Asian Americans diagnosed with schizophrenia.
Hypothesis 3: Based on differences in immigration histories between East Asians and
Southeast Asians, e.g., the latter group has been found to have higher levels of exposure to
traumatic events, we expected that occurrence of clinical recovery among Southeast Asians
diagnosed with schizophrenia would be comparatively lesser than that among East Asians.

29
Chapter 3: Methods
Study Design
Data for this cross-sectional study came from 75 Asian Americans seen at urban
community mental health agencies as outpatients for a diagnosis of schizophrenia. Consequently,
nearly all of participants were receiving public assistance (e.g., Social Security income). Using
purposive sampling methods, participants were recruited from four mental health agencies
directly operated or contracted by the LACDMH and two board-and-care facilities in Los
Angeles where they received services. These agencies were identified for study involvement
because they either served a large number of clients of Asian descent or were determined by the
LACDMH as ethnicity-specific mental health agencies (Lau & Zane, 2000). Los Angeles has
one of the heaviest concentrations of Asians in the United States, thus providing researchers with
unique opportunities to collect relevant data on Asian Americans treated for schizophrenia that
can be used to transform the delivery of mental health services to this population. Furthermore,
the tremendous diversity of the Asian population in Los Angeles gives researchers the means to
gather disaggregated data on Asian Americans for the investigation of important within-group
differences. Eligible clients were aged 18 or older; received a chart diagnosis of schizophrenia
spectrum disorder; self-identified as a person of Asian descent or Asian American; could speak
and read English, Chinese (simplified or traditional), Vietnamese, or Khmer; agreed to a face-to-
face interview; and demonstrated competence to consent to participate in research. This study
followed the federal government’s definition of Asian American, comprising individuals with
origins in the Far East, Southeast Asian, or Indian subcontinents. To yield a sufficient number of
participants who were representative of the target population, the study applied few exclusion
criteria. Nonetheless, individuals who were under conservatorship or receiving acute inpatient
30
services or step-down mental health services at locked facilities during the recruitment period
were excluded. Reasons for this exclusion are detailed subsequently. Prior to any data collection,
the study was explained to and written informed consent was obtained from all eligible clients in
their preferred language. The study protocol and interview schedule were reviewed and approved
by institutional review boards at the University of Southern California, Pacific Clinics, and
LACDMH.
Recruitment of Study Participants
As previously described, the underrepresentation of Asian Americans with schizophrenia
in the research literature may be attributable to several factors that include the linguistic and
cultural diversity of the Asian American community acting as a deterrent to researchers,
difficulties in reaching this subgroup that is traditionally hidden away in its community, the
Asian community’s mistrust of research that has discouraged their participation, and importantly,
the erroneous but pervasive belief in this community that individuals with schizophrenia are not
suitable for research participation. Collectively, these barriers have created a dearth of empirical
data from this socially disadvantaged subgroup with which to determine their treatment
responsiveness. The following sections describe the barriers to and facilitators of research
participation among Asian Americans with schizophrenia, which informed the strategies used to
enhance outreach to and enrollment of this hard-to-engage population. Whereas some of the
listed barriers and facilitators are applicable to the general Asian American population, others are
unique to Asian Americans with schizophrenia. The goal was to focus attention on the latter.
These strategies are described in hopes of contributing to a body of research that has tended to
report the barriers to and facilitators of research participation among Asian Americans, rather
than the implementation of culturally sensitive recruitment strategies to enhance representation
31
of this minority group in research. Moreover, previous research has not addressed strategies for
recruiting participants who may have decisional impairment resulting from a serious psychiatric
condition. Following this description, strategies to tailor recruitment efforts to overcome these
barriers to research participation are discussed.
Barriers to Research Participation
The challenges of engaging and recruiting Asian Americans diagnosed with
schizophrenia into mental health research are more complex than those associated with the
recruitment of the general Asian population. These barriers—at the agency, researcher, and
participant levels—collectively impinged on the enrollment of a sufficient number of participants
and a sample representative of the target population.
Agency level. Difficulty reaching Asian Americans with schizophrenia, who are
traditionally hidden away in their communities, has prompted mental health researchers to either
exclude this subpopulation from the sampling frame or enroll a comparatively smaller sample
than other racial and ethnic groups (e.g., Alegría et al., 2004; Rosenberg, Lu, Mueser, Jankowski,
& Cournos, 2007). Exceptions were found in studies that used service data maintained by public
mental health systems, thus precluding the recruitment of study participants (e.g., Takeuchi et al.,
1995; Ying & Hu, 1994). As a first step toward involving Asian Americans diagnosed with
schizophrenia in research, it is necessary to establish a strong and positive relationship with
community mental health agencies where these individuals are traditionally served.
Collaborating with the community has been found to be more effective in recruiting ethnic
minorities for research participation than traditional methods of recruitment (Areán et al., 1993;
Han, Kang, Kim, Rhy, & Kim, 2011). However, attempts to engage such agencies in the research
process are not without their challenges.
32
At the agency level, mental health providers’ mistrust of researchers’ agenda or the
research process is among the foremost barriers to reaching this subpopulation in the Asian
community for research participation. This barrier has been widely documented in studies
involving minority populations or socially disadvantaged groups (Bonevski et al., 2014; George,
Duran, & Norris, 2014; Sinclair et al., 2000; Yancey, Ortega, & Kumanyika, 2006). Related to
the present study, mistrust of the researchers was palpable among program directors, who were
understandably concerned that the data may yield findings that reflect unfavorably on the agency
or would be used for the sole purpose of advancing the researchers’ careers.
Not surprisingly, mistrust was most evident among program directors of ethnicity-
specific programs. Among the mental health agencies invited to serve as recruitment sites for the
present study (N = 11), those that declined were ethnicity-specific mental health programs (n =
4), of which three cited the abovementioned concern as a reason for declining to participate. The
fourth ethnicity-specific mental health program that declined to be involved as a recruitment site
expressed the view that research involving Asian Americans with serious mental illness,
especially those diagnosed with schizophrenia, was impractical. The program directors at this
agency expressed the opinion that Asian Americans with schizophrenia generally are too
cognitively impaired to participate in research studies that involve participant completion of self-
report questionnaires. This sentiment demonstrates that unfavorable views of individuals with
schizophrenia are widespread and held by not only laypersons but also mental health
professionals.
Mistrust of research was also evident at the provider level. This manifested in some
providers’ views about research participation—that it offers no direct benefits to clients or the
community, may be demanding for clients, and has the potential to exacerbate clients’
33
symptoms. Research has unequivocally found that providers serve as key gatekeepers to the
Asian population with mental health needs (Bistricky et al., 2010; Han et al., 2007) and that
engaging the help of these gatekeepers enhances recruitment (e.g., Lau & Gallagher-Thompson,
2002). Accordingly, the unfavorable perception of or indifference toward research deterred some
providers from disseminating information on research opportunities to eligible clients. An
additional and more daunting issue encountered by the majority of providers related to their
availability. Providers who had expressed an interest in assisting with recruitment were often
constrained by time due to competing service demands, which conflicted with their ability to
disseminate information on research opportunities to their clients. The reliance on providers as
the primary source of referral meant that the extent of outreach to the target population was
dependent on the availability and willingness of providers to assist with recruitment.
In addition to barriers stemming from mistrust toward research, an additional barrier
related to the conflict between the goals of community mental health agencies and those of
researchers. One of the agencies shared the concern that mental health providers may be
burdened with an activity that does not necessarily meet the agencies’ priority of service
delivery. Research, therefore, was perceived as interfering with providers’ primary
responsibility.
Researcher level. The Asian population in the United States is highly diverse and
features more than 11 ethnic groups. These ethnic groups differ in important ways such as
demographics, country of birth, reason for emigration, nativity status, language spoken, and
English proficiency, among other things (Reeves & Bennett, 2004). For example, although the
majority of Asian Americans are foreign born, approximately 60% of Japanese are U.S. born,
compared to only 20% of Koreans and 30% of Chinese. Similarly, although more than 60% of
34
Asians report speaking English very well, this percentage varies across ethnic groups, with the
highest proportion among Filipinos and Asian Indians (more than 75%), followed by Chinese
and Koreans (approximately 50%), and finally Vietnamese (less than 40%).
Unfortunately, implementation of research with Asian Americans, including individuals
with serious psychiatric conditions, can be complicated by these heterogeneities, especially
language differences (Lee, Lei, & Sue, 2008). The linguistic diversity of Asian Americans makes
not only recruitment of a representative sample for research participation challenging, but also
implementation impractical and unfeasible, especially for studies with limited resources. Indeed,
a widely cited barrier to recruiting a representative sample of Asian Americans for research
participation is the daunting and costly task of meeting the diverse linguistic needs of this
minority population by providing study materials in various Asian languages and building and
training an ethnically diverse team of interviewers that is culturally and linguistically compatible
with the target population (Giarelli et al., 2011; Hussain-Gambles, Atkin, & Leese, 2006; Sheikh
et al., 2009). In some cases, the logistics and costs of overcoming these challenges have resulted
in routine exclusion of Asian Americans with limited English proficiency or systematic inclusion
of only certain ethnic groups such as Chinese Americans or Filipino Americans. These cultural
adaptations, however, are critical to promoting access to research among individuals with limited
English proficiency (e.g., Giarelli et al., 2011; Han et al., 2007; Hinton et al., 2000), who
comprise close to 40% of the U.S. Asian population (Gryn & Gambino, 2012). For example,
research involving different subgroups of Asian Americans has found that the absence of
recruiters and interviewers who were matched with clients’ ethnicity was a barrier to research
participation among those with limited English proficiency (George, Duran, & Norris, 2014).
Addressing the language barriers to Asian Americans’ participation in mental health research is
35
of particular importance because such studies typically rely on direct communication with
participants as the primary mode of data collection. Relevant to the purposes of the present
study, data were collected using a combination of in-person interviewing and participants’
completion of self-report inventories. Accordingly, the availability of easy-to-read translated
study materials and culturally competent interviewers was essential for increasing the target
population’s access to research participation, especially those with limited English proficiency.
Additional barriers at the researcher level that interfere with the recruitment of Asian
Americans with schizophrenia relate to concerns about unintended effects (e.g., symptoms
exacerbation) of the research interview with this vulnerable population and that schizophrenia is
a low-prevalence disorder. On the basis of these concerns, individuals with psychotic disorders
have typically been excluded from the sampling frame of mental health research (e.g., Alegría et
al., 2004).
Participant level. At the client level, several barriers related to illness, personal
characteristics, and perceptions about research were apparent. Analogs from mental health
providers suggest that clients’ illness severity had a strong influence on their interest in research
participation. Specifically, individuals with more severe symptomatology unique to
schizophrenia—namely, higher severity of negative symptoms, poor insight into their mental
health condition, prominent paranoid delusions, severe conceptual disorganization, and
significant cognitive impairments—were less likely to be approached by providers with
opportunities for research participation. When approached, these individuals were more likely to
decline participation. Among clients who expressed an interest in learning more about the
research study, literacy level, English proficiency, confidence about completing self-report
questionnaires, the need to reveal personal and confidential information for research purposes,
36
length of the research interview, and the inconvenience of research participation (e.g., limited
availability, trouble with transportation to and from the research interview site) were frequently
reported concerns.
Other barriers were related to clients’ attitudes toward research. These included
unfamiliarity with research, individual and cultural stigma of participating in mental health
research, general mistrust engendered by the belief that participants would be treated as “lab
rats” or that researchers would push their agenda without regard for participants’ well-being,
issues of confidentiality, prior negative experiences, misconceptions about how the research data
would be used, the need to sign an informed consent document, the possibility of losing Social
Security income due to research participation, and that research participation may be stressful.
Such barriers have been widely reported by other studies involving Asian Americans and thus,
are not unique to those with serious psychiatric conditions (e.g., Giarelli et al., 2011; Maxwell,
Bastani, Vida, & Warda, 2005).
Motivators of Research Participation
Feedback from mental health providers and research participants revealed important
sociocultural motivators to research participation among Asian Americans with schizophrenia.
One key motivator was the provision of monetary compensation for participants’ time. The
monetary incentive offered in the present study, although nominal relative to other studies with
larger budgets, was considerable for some participants who did not have any sources of earned or
unearned income (e.g., immigrants without any family support) or who were receiving a stipend
through the Supplemental Security Income program. This was most perceptible when
participants described with evident enthusiasm their plans for spending the monetary
compensation on items that most would take for granted. In one case, a participant shared that
37
the compensation enabled him to get a long-overdue haircut and buy a bowl of pho for dinner.
The benefits of providing monetary compensation on enrollment of ethnic minorities have been
widely reported (e.g., Areán & Gallagher-Thompson, 1996).
Receiving a personalized invitation from their mental health provider followed by a brief
in-person meeting or phone conversation with the principal investigator (whenever possible, or
with a member of the research team who was linguistically matched with the client) was another
important facilitator of research participation in this population. This method of recruitment
involving direct contact with prospective participants offered several benefits over passive
recruitment strategies such as dissemination of research opportunities through advertisements
and flyers. First, prospective clients’ concerns about the study’s credibility and mistrust of the
researchers’ agenda or the research process were generally allayed when the invitation came
from a mental health professional personally known to them. Second, personalized invitations
enabled providers and the principal investigator to highlight the potential personal and
community gains of research participation. Third, investigator-initiated outreach following the
receipt of a research invitation allowed prospective participants to gather more information on
the study and become acquainted with the research team. Whenever possible, the principal
investigator, rather than a member of the research team, conducted the follow-up outreach to
establish professional legitimacy. Importantly, such follow-up meetings presented the principal
investigator (or the research staff) with the opportunity to show sensitivity in explaining the
study and handling of participants’ questions, thereby further diffusing clients’ anxiety about the
research process and being interviewed by a nonprovider who was unfamiliar to them. Yancey
and colleagues (2006) found that although broadcast media yielded more prospective ethnic
minority participants than face-to-face recruitment, the former method of recruitment resulted in
38
higher rates of ineligibility and decline to participate. Experiences in the current study are in
agreement with this finding in that the use of English and translated flyers as an initial
recruitment effort at an agency did not yield any inquiries about the study or enrollment of
participants, thereby demonstrating the ineffectiveness of passive strategies with Asian
Americans with serious psychiatric conditions. This method of recruitment, however, has been
found to be effective with other Asian American subgroups (e.g., Maxwell et al., 2005).
Endorsement from significant others was another key facilitator of research participation.
According to mental health providers, several eligible clients wanted to participate but were
prevented from doing so by their family members. Conversely, a number of clients who were
initially less enthusiastic about the research opportunity ultimately agreed to participate after the
encouragement of their family members, who either viewed research as important or believed it
would benefit their loved ones. For example, a Chinese American client was encouraged by her
mother and husband to participate in the present study because they were of the opinion that the
client could be drawn away, albeit briefly, from her hallucinatory experiences. Researchers who
have enrolled other subgroups of Asian Americans for research participation have similarly
noted the influential role of family members in the consent process (Giarelli et al., 2011; Levkoff
& Sanchez, 2003). Although the decision to participate rests on the individual, observations from
across research with Asian Americans, including the present study, suggest the potential benefits
of involving family members in clients’ decision to participate. Efforts to enhance involvement
of Asian Americans in research could include increasing awareness of research opportunities
among family members. This can be achieved by expanding outreach efforts to ensure that
information on research opportunities are disseminated not only to prospective participants but
also their family members.
39
Altruism as engendered by the perceived benefits of participation to other Asians whose
lives have been affected by serious mental illness or to the wider Asian community was another
salient facilitator of research participation. Some notable examples of participants’ altruistic
motives that influenced their decision to participate included the desire to share their recovery
journey in hopes that their narrative would benefit others, the hope that their responses would
help improve mental health services to the Asian community, and the desire to assist the
principal investigator in her goal of completing her dissertation research. Not surprisingly, this
facilitator of research participation has been reported in studies involving other Asian subgroups
such as women enrolled in cervical cancer research or specific ethnic groups such as Filipino
American immigrants enrolled in cancer screening research (Maxwell et al., 2005).
Strategies Implemented
This study featured culturally sensitive recruitment strategies aimed at promoting
outreach and access to research participation among Asian Americans with schizophrenia. These
strategies and the outcome of yearlong recruitment efforts are detailed here.
Agency level. To overcome the distrust of community mental health agencies in research,
this study involved establishing a partnership marked by reciprocity of gains and respect for and
sensitivity to their priorities of service delivery. After relevant community mental health
agencies were identified as possible recruitment sites, emails were sent to the program directors
of these agencies. The advantages of this method of outreach included the possibility of sharing a
research brief on the proposed study (as an attachment) with the program directors for their
perusal and consideration prior to a face-to-face meeting. This method of outreach also gives
program directors the flexibility to respond at a time that was most convenient for them. When
response didn’t occur, follow-up emails tended to elicit a response. This was followed by a face-
40
to-face meeting with program directors to introduce the study and respond to questions and
concerns about the study. The goals and significance of the study were highlighted during these
meetings. Additionally, benefits of the research study for Asian Americans with schizophrenia
and their family members, along with the clinical utility of the study findings, were stressed.
These meetings also provided the opportunity to invite the program directors to consider how the
research project could be fine-tuned to better capture the experiences of their Asian clients.
After addressing the program directors’ questions and concerns, the principal investigator
sought their permission to give presentations on the study to their team of mental health
providers. Oftentimes, these providers serve as gatekeepers to the Asian population with mental
health needs and hence play a critical role in connecting research teams to the target population
(Bistricky et al., 2010; Han et al., 2007; Hinton et al., 2000). Research studies involving the
Asian population have found that engaging the help of these gatekeepers enhanced recruitment
(Lau & Gallagher-Thompson, 2002). Additionally, research has found that Asian Americans are
more likely to consider participating if the credibility of the study is established (Bistricky et al.,
2010). These presentations thus provided a platform to simultaneously establish the legitimacy of
the proposed study and build relationships with providers. These presentations involved
responding to providers’ questions and concerns and distributing handouts prepared especially
for providers on the study that delineated the study aims, procedure, and referral procedure.
Additionally, the appropriate safeguards built into the study to ensure that the risk of harm to
participants was minimized were also highlighted during these presentations. This included
assurances that all interviewers were at least master’s-level clinicians trained to ask questions
respectfully and respond to participants sensitively and appropriately. To facilitate referral,
providers received one-page handouts for distribution to their clients who were eligible for
41
research participation. The handout was developed specifically for prospective participants and
described frequently asked questions related to research participation (e.g., research procedures
to be followed, expected duration of participation, possible venues for participation, risk and
benefits of study participation, etc.). This handout was available in English, Chinese (traditional
and simplified), and Vietnamese.
In addition to making an introductory presentation on the study, the principal investigator
met with the involved agencies periodically during the data collection period to apprise them of
the study progress and share preliminary results. These presentations were essential to reminding
providers about the study and maintaining the flow of referrals, in addition to introducing the
study to providers who may be new to the clinical team (e.g., Areán & Gallagher-Thompson,
1996). These periodic presentations also provided opportunities to remain in contact with the
providers, which was essential for building rapport and trust (Han et al., 2007). More
importantly, providing feedback about preliminary findings was critical for demonstrating to
community partners a commitment to using research to complement their work rather than the
pursuit of a research agenda. In addition to such presentations, the principal investigator
requested for permission from the respective program directors to circulate emails with
information on the study to serve as reminders to providers that recruitment was ongoing.
This experience suggests that presentations on the study to mental health providers are
critical for engaging the help of gatekeepers with reaching the target population for research
participation. Among the four mental health agencies directly operated and contracted by the
LACDMH that served as recruitment sites, the principal investigator met with three teams of
mental health providers to apprise them of the study. All agencies, however, received handouts
prepared for providers and eligible clients on the study. At the conclusion of data collection, the
42
principal investigator received five referrals from the agency at which the study was not
introduced in person. On the other hand, an agency that permitted several opportunities to engage
with mental health providers offered 25 referrals. It is important to highlight that these two
agencies served a comparable number of Asian Americans diagnosed with schizophrenia. In
addition, referrals from providers tended to occur shortly after each presentation. Collectively,
these findings attest to the benefits of face-to-face meetings and outreach to potential referral
sources.
To further mitigate mental health providers’ mistrust of research while strengthening the
partnership, the principal investigator strived to complement the service priorities of providers by
apprising referring clinicians of their clients’ mental state during the research interview. This
information included the extent to which their clients tolerated the study procedure, observed
difficulties with completing the research interview (if any), whether their clients revealed any
suicidal or homicidal thoughts, and issues that their clients had raised during the research
interview that they asked to be conveyed to their treating clinicians. Providing such feedback has
been found to facilitate rapport building with the community (Areán & Gallagher-Thompson,
1996; Hans et al., 2007). Moreover, every effort was made to ensure that activities related to the
research study had minimal impacts on providers’ and agencies’ priorities and daily routine. This
included a straightforward referral procedure, involving providers in the data collection only
when necessary (e.g., verification of clinical history data from clients with poorer recollection),
scheduling of research appointments directly with clients, liaising with the administrative team
rather than providers about the logistics of the research study, avoiding scheduling research
interviews on days that were the busiest for the agency, and not flooding providers with
43
unnecessary emails or phone calls. These gestures demonstrated respect for providers’ full
schedule.
Researcher level. Previous studies have consistently noted language barriers to be a
reason for Asian Americans’ resistance to research participation (Giarelli et al., 2011; Gollin,
Harrigan, Perez, Easa, & Calderón, 2005). The same barrier applies to the recruitment of Asian
Americans with serious psychiatric conditions. To meet the language needs of Asian Americans
with schizophrenia, all research documents—the recruitment material, informed consent form,
and interview schedule—were translated into several Asian languages, namely, Chinese
(simplified and traditional), Vietnamese, and Khmer. These translations were undertaken to
address the language preferences of clients served at the community mental health agencies
where recruitment occurred. As previously described, such an accommodation, however, was
extremely costly. In fact, the considerable cost of translation services deterred translation of the
research documents into other Asian languages such as Tagalog or Korean.
To further accommodate the language preferences of participants with limited English
proficiency, the principal investigator assembled a team of seven bilingual and bicultural
interviewers who were master’s-level students in social work, marriage and family therapy, or
occupational therapy. These student interviewers spoke and read an Asian language, which
enabled them to read the research questions and their respective response options to all
participants who wished to be interviewed in their native language. All student interviewers were
of similar ethnicities as the target population, which facilitated rapport building and trust. Indeed,
the use of bicultural and bilingual interviewers has been noted to be critical for research that
involves ethnic minority populations (Areán & Gallagher-Thompson, 1996). Moreover, all
44
student interviewers received 2 hours of training weekly for 8 weeks on topics related to human
subjects research, schizophrenia, and interviewing techniques.
Recognizing the vulnerability of this population associated with possible decisional
impairment, the principal investigator implemented protections to minimize the possibility of
coercion or undue influence, specifically, by ensuring that enrollees had consent capacity.
Participants’ capacity to consent to research was assessed using the University of California, San
Diego Brief Assessment of Capacity to Consent (Jeste et al., 2007). For participants who
completed the research interview over two or more sessions, this assessment was repeated at the
start of each session. Clients with the most serious psychiatric symptoms were excluded, namely,
individuals receiving treatment in inpatient settings, not engaged in mental health treatment or
services, or with a conservator.
Participant level. The principal investigator employed a client-centered approach to
involving Asian Americans with schizophrenia in research. This approach is characterized by
proactive interpersonal contact with prospective participants, beginning with mental health
providers and followed by a member of the research team. Feedback from mental health
providers, coupled with the research team’s experiences, suggests that a substantial number of
clients preferred to be initially approached by their mental health providers rather than by the
principal investigator (or a research staff member). Clients who had not heard about the research
study were extremely wary of the investigator’s motives when individually approached about
research participation. It was reasonable to assume that these clients were concerned that they
would be coerced into participation, and hence they tended to terminate the conversation shortly
after contact was made. Concerns of being coerced into research participation have been reported
in previous studies with Asian American participants (Maxwell et al., 2005). Consequently,
45
mental health providers served as the first line of outreach. Whenever possible, mental health
providers also facilitated face-to-face meetings between the research staff and prospective
participants prior to enrollment, which appeared to further alleviate participants’ anxiety or
concerns about the research process.
In an effort to overcome the aforementioned recruitment barriers related to clients’
attitude toward research, careful consideration was given during the consent process. This
included conducting the informed consent process in the clients’ preferred language; ensuring
that the consent process occurred in the absence of clients’ mental health providers to minimize
undue influence; emphasizing to eligible clients that their participation was voluntary in that
their decision to participate only related to their agreement to be enrolled in the study, that they
may discontinue participation at any time without penalty or loss of benefits to which they are
otherwise entitled, and that they have the right to decline to answer any questions; assuring
participants of confidentiality while highlighting potential situations that would limit the
promises of confidentiality; emphasizing the distinction between their participation in research
and treatment such that their decision whether to participate in the former had no impact on the
latter; and avoiding using the term schizophrenia during the informed consent process,
recognizing that prospective participants varied significantly in their level of awareness and
understanding of their psychiatric condition.
The researchers implemented several other accommodations to diffuse prospective
participants’ anxiety about the research process. For example, the research interviews occurred at
the agency where clients were receiving services. An added benefit of conducting the research
interview in a familiar setting was the availability of providers on-site to respond to any
unintended effects of the research interview. However, it was not feasible to meet with every
46
participant at the agency because some clients’ routine appointments were spaced up to 3 months
apart. Additionally, a substantial number of clients had limited means of transportatio n to the
agency and relied exclusively on their family members to drive them to the mental health center
on days of their routine appointment. These clients cited that family members were often
reluctant to drive them to the center for non-treatment-related activities. Consequently, the
interview location was expanded to include participants’ home. To further minimize unnecessary
travel time, research appointments were scheduled to coincide with clients’ routine appointments
with their mental health providers whenever possible. The research team also strived to be
flexible in scheduling appointments with participants by inviting them to identify a day and time
that worked best for them. This meant that certain interviews had to be conducted during the
weekends for clients who had commitments during the week.
Nonviable Recruitment Strategies
Thus far, considerable effort has been made to delineate strategies that facilitated efforts
to involve Asian Americans with serious mental illness in research. This section briefly describes
strategies found to be feasible regarding the recruitment of the general Asian population, but not
with subpopulations with schizophrenia, for participation in clinical research. These strategies
include snowball sampling, use of trained peers, and recruitment of individuals from the
community or interest groups (e.g., National Alliance on Mental Illness). The main issue
associated with these traditional methods of recruitment is that participants’ diagnosis cannot be
verified via a valid source.
Recruitment Outcome
During the enrollment period between February 2016 and February 2017, 93 Asian
American clients were referred for study participation and 75 (80.65%) were enrolled (see Figure
47
2). Of the 18 clients not enrolled, 10 (55.56%) declined to participate after they were contacted,
five (27.78%) did not meet the diagnostic criterion, and three (16.67%) were judged to not have
the capacity to consent to research due to severe disorganization in thought processes. This
appears to be the largest sample of Asian Americans with schizophrenia enrolled in a nonclinical
trial study.
Summary
The barriers to recruiting Asian Americans are complex and often associated with being a
member of a racial and ethnic group and having a serious psychiatric condition. According to
Levkoff and colleagues (2000), enrollment of ethnic minorities in research is enhanced when
researchers acknowledge and respond to perceptions of the research process at the macro
(community agencies), mediator (gatekeepers), and individual (participants and caregivers)
levels. The research team strived to implement this matching model of recruitment by addressing
barriers to research participation among Asian Americans with schizophrenia at the institution,
researcher, and individual levels. This experience suggests that the implementation of targeted
and culturally sensitive recruitment strategies is critical and that most of these barriers to
research participation are modifiable. When properly addressed, recruitment of Asian Americans
with schizophrenia can be enhanced. This experience demonstrates that a subgroup of ethnic
minority individuals with serious psychiatric disorder is willing to participate in research and can
be enrolled.
Study Procedure
The primary source of recruitment was referrals by mental health providers (e.g., case
managers, social workers, or therapists). On this basis, mental health providers identified clients
who met the study inclusion criteria and presented the study to these prospective participants. To
48
facilitate the referral process, the researchers prepared a recruitment script that providers had the
option of to introduce the study to their clients. This script was approved by the requisite
institutional review boards. In addition, providers received an information sheet they could share
with their clients after introducing the study. This one-page information sheet explained the
objective of the study, its procedure, the risk and benefits of participation, duration and possible
venues of participation, incentives for participation, and contact information of the principal
investigator. Those interested in participating were invited to sign a patient health information
form that permitted their providers to release their identifying information, namely, their name
and contact information, to the principal investigator. No data were gathered from individuals
who met the study inclusion criteria but declined to participate.
Consent Process
Clients who expressed interest to participate after being apprised of the study and
reviewing the consent document were assessed regarding their comprehension of the research
protocol before being invited to sign the informed consent documents. This assessment was
completed using the University of California, San Diego Brief Assessment of Capacity to
Consent, which has evidence of reliability and validity (Jeste et al., 2007). Prospective
participants were deemed to have consent capacity for research if they were able to communicate
a choice, understand the relevant information presented, appreciate the nature and potential risk
of their participation, and understand that participation was voluntary. This evaluative method is
commonly used to determine the capacity of participants with cognitive impairments to make
informed decisions. For non-English-speaking clients, the consent process was administered in
their language of preference. Additionally, the informed consent documents were translated.
49
Research Interview
The research interview was composed of semistructured interviews and participant
completion of self-report questionnaires to yield demographics, clinical, and psychosocial data.
Interviews lasted 2 hours on average. Given the considerable administration time, participants
had the option of completing it during two or more sessions. Participants received light
refreshments and given as many breaks as they needed. It is noteworthy that participants
tolerated this process, as evidenced by the fact that all 75 participants enrolled in the study
completed the research interview. This outcome was observed despite participants being assured
that they may discontinue participation at any time without penalty or loss of benefits to which
they are otherwise entitled, including monetary compensation. Consultation meetings with
several mental health providers indicated that a considerable number of clients might have
impairment of cognitive functions, although to varying degrees. Consequently, the research
questions and response choices were read to all participants. Participants completed the
interviews either at the community mental health agency where they were receiving services or
at their homes. For participants who preferred to be interviewed in their native language, the
research interview was conduct with the help of a bilingual interviewer of similar linguistic and
cultural background as that of participants. Due to the limited resources available in the
community, the interviews were completed in English, Mandarin, Cantonese, or Vietnamese
only. Locating student interviewers who could speak and read in Khmer proved to be a
formidable obstacle. Some of the gathered data were based on retrospective construction
(subsequently described), increasing the possibility of recall bias inherent in such an approach.
To minimize this bias, the recall period was limited to the prior 180 days, objective outcomes
were use when possible, structured questionnaires were administered, and information were
50
verified against a reliable source such as participants’ mental health provider when consent had
been granted. All other data featuring uncertainty or missingness were validated with referring
mental health providers. Participants received $30 as compensation for their time.
Measures
Selection of variables for measurement was guided by the expanded stress-diathesis
framework (described in Chapter 1) for conceptualizing racial and ethnic differences in treatment
outcomes of schizophrenia. Given that the overarching aim of this study was to investigate the
cultural contributory factors of clinical recovery and other relevant outcomes among Asian
Americans treated for schizophrenia, the relevant constructs were assessed using validated
questionnaires. Abridged versions of selected questionnaires were identified, if possible, to keep
interviews at an acceptable duration. The research questionnaires were available in English (see
Appendix), simplified and traditional Chinese, Vietnamese, and Khmer. The research documents
were translated using the forward–backward translation method. Importantly, forward translation
was completed independently from backward translation and performed by different translators.
This was followed by expert review by the team of bilingual master’s-level student interviewers
to ensure content validity. Prior to any data collection with eligible clients, the English research
questionnaires was pilot-tested with 15 Asian Americans from the community, some of whom
had an undisclosed mental health need, to approximate the research interview length and
determine the appropriateness and relevance of the research instrument items for the Asian
American population. The research interview was completed in English by 75% of participants.
Demographic Variables
Data on participants’ age at the time of research participation, gender, ethnicity (Chinese,
Cambodian, Filipino, Japanese, Korean, Vietnamese, other), living arrangement, marital status
51
(married or in a relationship, previously married or single), family size, primary language,
English proficiency, educational level, employment status, and religious affiliation were
gathered. A set of immigration-related variables was composed of nativity status, country of
birth, years lived in the United States, age at time of immigration, and generational status.
Generational status featured six categories: 1.00 generation (immigrants who arrived in the
United States at age 18 or older), 1.25 generation (immigrants who arrived in the country
between the ages of 13 and 17), 1.50 generation (immigrants who arrived between the ages of 6
and 12), 1.75 generation (immigrants who arrived before the age of 6), 2.00 generation (U.S.-
born individuals with foreign-born parents), and 3.00 generation (U.S.-born individuals with
U.S.-born parents).
Clinical Variables
Data on participants’ psychiatric diagnosis, presence and severity of psychiatric
symptoms, length of illness, functional outcomes, and independent living skills were gathered.
Psychiatric diagnosis. Psychiatric diagnosis was ascertained by participants’ self-report
and verified with the referring mental health provider.
Symptomatology. Presence and severity of psychiatric symptoms during the previous 2
weeks and 6 months were assessed using the 30-item Positive and Negative Syndrome Scale
(PANSS; Kay, Fiszbein, & Ohier, 1987). This instrument assesses the syndromes distinct in
schizophrenia, namely, positive symptoms, negative symptoms, and general psychopathology.
Each item was rated on a Likert scale ranging from 1 (absent) to 7 (extreme) on the basis of each
participant’s self-report during a semistructured clinical interview, behavior during the interview,
and report from the referring mental health provider. The principal investigator conducted the
assessment with all participants and therefore scored all ratings. She received training in
52
interview and ratings methods similar to a protocol developed by Ventura and colleagues (1993)
prior to the initiation of data collection. Importantly, she achieved satisfactory concordance in
ratings with an expert consensus (intraclass correlation = .72). Items chosen a priori were
grouped and summed to form five syndrome subscales, namely, Positive, Negative, Activation,
Dysphoric Mood, and Autistic Preoccupation, for typological assessment of participants’
psychopathology and predominant syndromes. This measure is widely used in clinical studies of
individuals with schizophrenia from various racial and ethnic groups and has been shown to have
very good psychometric properties (Kay et al., 1987).
Length of illness. For each participant, length of illness was computed by subtracting age
at onset of florid psychotic symptoms from age at study entry.
Functional outcomes. Participants’ functional outcomes were assessed using the 3-item
Strauss and Carpenter Outcome Scale (Strauss & Carpenter, 1972). Specifically, data were
gathered on participants’ functional outcomes at study entry and during the previous 6 months in
the domains of duration of hospitalization for psychiatric treatment, frequency of social contacts,
and engagement in various meaningful activities that comprised formal employment, irregular or
supported employment, work as a caregiver or homemaker, volunteer work, and provision of
informal social assistance. Each item was rated on a 5-point Likert scale, with higher scores
indicating better outcomes.
Independent living skills. Participants’ independent living skills in eight domains were
evaluated using the Lawton Instrumental Activities of Daily Living Scale (Lawton & Brody,
1969). These areas of functioning were operating the telephone, shopping, food preparation,
housekeeping, laundry, mode of transportation, responsibility for medications, and managing
finances. Participants were rated regarding their competence to perform these activities of daily
53
living on the basis of their self-report. A score of 0 was assigned to participants with the lowest
level of competence to perform the assessed task (e.g., completely unable to shop), whereas a
score of 1 was reserved for participants who reported some level of adequacy (e.g., shops
independently for small purchases). The eight items were summed such that higher scores
indicated higher levels of competence in independent living. Although this scale was developed
for use among older adults, it nevertheless captures the functional skills needed for independent
living among individuals with serious psychiatric conditions. This assessment, however, could
not be completed for participants living in board-and-care facilities.
Mental Health Service Access
Assessment of treatment history included age at onset of florid psychotic symptoms, age
at first prescription of antipsychotic medication, age when participants first sought inpatient
psychiatric hospitalization, and age when participants first sought services from the community
mental health agency from which they were recruited for study participation. These data were
based mostly on self-report from participants. Data with uncertainty or missingness were
validated by the referring mental health provider.
Service Use and Quality of Care
Mental health service use was assessed as participants’ level of medication use, treatment
engagement, and perceived therapeutic alliance with their primary mental health provider.
Medication use. Assessment of medication use was based on participants’ self-report of
days of use of any antipsychotic medications during the previous 180 days. Participants’ level of
medication adherence was recorded as continuous use, regular use, low use, or nonuse. In
accordance with the criterion proposed by Kane and colleagues (2003), participants who reported
being on any antipsychotic medication continuously during the previous 6 months were coded as
54
continuous use; participants who reported being on any antipsychotics more than 50% of the
time but less than continuously in the previous 6 months were coded as regular use; participants
who reported being on any antipsychotic medication for less than 50% of the time during the
previous 6 months were coded as low use; and participants who reported not being on any
antipsychotics during the assessed period were coded as nonuse. Data on the number and types
of antipsychotic medication prescribed were also gathered to serve as indicators of the quality of
care received.
Treatment engagement. Participants’ treatment engagement was determined by
subtracting the age when participants first sought community mental health services from their
age at study entry.
Therapeutic relationship. Therapeutic relationship was measured with the Health Care
Climate Questionnaire (Williams, Grow, Freedman, Ryan, & Deci, 1996). This 6-item self-report
scale assesses the extent to which participants perceive their mental health care providers as
supportive and encouraging autonomy versus controlling. Participants indicate their responses on
a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Scores were
summed, with higher scores indicating higher levels of perceived autonomous and supportive
care. This scale has been shown to have good reliability (Williams et al., 1996). In this study
sample, the scale had a Cronbach’s alpha of .84, indicating excellent internal consistency.
Psychosocial Stress
Much of stress research has focused on the effects of specific categories of stressors on
the trajectory of schizophrenia. This study featured a more comprehensive assessment of various
experiences to disaggregate the effects of acute stressors stemming from recent life events,
chronic strains, and major traumatic events, and importantly, to determine whether these
55
disaggregated effects were significant for understanding variability in treatment outcomes of
schizophrenia. In addition to assessing types of environmental stressors salient in the lives of
Asian Americans living with schizophrenia, this study measured psychological stress as
indicated by participants’ appraisal of life stress.
Acculturative stress. Acculturative stress was measured as a count of nine dichotomous
items adapted from the Mexican American Prevalence and Services Survey (Vega et al., 1998).
Immigrant participants who arrived in the country at age 13 or older (i.e., 1.25 and 1.00
generation) were asked to report whether they related to the following experiences: (a) feel guilty
for leaving behind family and friends; (b) feel that in the United States they have the respect they
had in their country of origin; (c) feel that living out of their country of origin has limited their
contact with family or friends; (d) find it hard to interact with others because of difficulties they
have with the English language; (e) feel that people treat them badly because of their language
skills; (f) find it difficult to find a job they want because of they are of Asian descent; (g) have
been questions about their legal status; (h) have concern that they will be deported if they go to a
social or government agency; and (i) avoid seeking health services due to fear of immigration
officials. This set of items was used to measure acculturative stress in the National Latino and
Asian American Study (Alegría et al., 2004), suggesting its suitability for use with Asian
Americans.
Major traumatic events. Exposure to major traumas was determined with a 20-item
checklist developed by Turner and Lloyd (1995) that asked participants whether they had
experienced any of eight identified traumatic events before the age of 18 years (e.g., ever had a
major illness or accident that required hospitalization for a week or longer; parents getting a
divorce; repeated a grade at school; sent away from home because of a wrong committed; and
56
experienced physical or sexual abuse) and any of 12 identified traumatic events in their
adulthood, lifetime, and prior 6 months (e.g., seeing something violent happen to someone or
seeing someone killed; experienced a major fire, flood, earthquake, or other natural disaster;
being involved in a serious accident, injury, or illness that was life threatening or caused long-
term disability; experienced physical abuse by a partner). Level of retrospectively reported
exposure was derived from counts of the number of items reported to have ever occurred and to
have occurred in the prior 6 months.
Recent life events. The Life Event List (Cohen, Tyrrell, & Smith, 1993) was used to
assess the occurrence of recent life events bearing on living situations, relationships, health,
employment and finances, and safety. Participants were asked whether they had experienced any
of the listed life events during the last 6 months. This scale was chosen because it captures events
experienced with high frequency by the general population.
Chronic strains. Enduring stressors were measured with a 51-item inventory developed
by Wheaton (1994). This self-report inventory assesses chronic stress experienced in the
domains of financial issues, general or ambient problems, work, marriage and relationship,
parental, family, social life, residence, and health. Participants were asked to indicate which of
the events they had experienced during the last 6 months. Each item has a 3-level categorical
response ranging from 1 (true) to 3 (very true). Responses were summed and converted to z-
scores. Although this inventory has not been used with Asian Americans with schizophrenia, it
has been used in studies designed to investigate the impact of social stress on psychological
distress (Turner, Wheaton, & Lloyd, 1995).
Family functioning. Participants’ perception of their family’s functioning was assessed
with the Family Adaptability and Cohesion Evaluation Scale IV (Olson, 2011). Participants were
57
encouraged to consider the functioning of their immediate family members or family of origin.
According to the circumplex model of marital and family systems (Olson, 2000), balanced levels
of cohesion and flexibility characterize healthy family systems, whereas unbalanced levels of
these traits are associated with problematic families. Too much cohesion and flexibility result in
an enmeshed and rigid family system. Conversely, extremely low levels of cohesion and
flexibility prompt disengagement and chaos. The 42-item self-report instrument has two
balanced subscales that measure healthy levels of cohesion and flexibility and four unbalanced
subscales that measure the extreme ends of these two dimensions, namely, disengagement,
enmeshment, chaos, and rigidity. Each subscale features seven items, and response options were
on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Ratings across
the seven items were summed to produce a raw score for each subscale, with higher scores on the
balanced scales indicating healthier family functioning and the converse applying to the
unbalanced subscales, i.e., higher scores indicate greater family dysfunction. These raw scores
were converted into percentile scores using the Percentile Conversion Chart to enable
comparison across groups (Olson, 2010). Using percentile scores, three ratio scores—cohesion,
flexibility, and total circumplex—were computed to determine the extent of balanced and
unbalanced traits in a family system. Cohesion ratio measures the level of balance between
cohesion, disengagement, and enmeshment in a family system; flexibility ratio measures the
level of balance between flexibility, rigidity, and chaos in a system; and total circumplex ratio
measures the overall level of balanced and unbalanced traits in a system. A ratio score of 1 is
indicative of an equal amount of balanced and unbalanced traits in a family system and a ratio
score greater than 1 is indicative of a more balanced family system, with higher scores indicating
healthier family system (i.e., balanced traits outweigh unbalanced traits). It is important to note
58
here that items related to family flexibility, chaos, rigidity could not be reliably assessed among
some participants (up to 17.33%) who had no contact with their families or had been living away
from their family members for an extended period. Consequently, the flexibility and total
circumplex ratio scores—which were computed using the flexibility, chaos, and rigidity subscale
scores (Olson, 2010)—reflect the level of functioning among participants who had ongoing
contact with their family members. This instrument has demonstrated good levels of reliability
and validity (Olson, 2011). Alpha reliabilities for the subscales are as follows: cohesion (.91),
flexibility (.66), disengagement (.87), enmeshment (.73), rigidity (.71), and chaos (.73). The
lower coefficient for the subscale measuring flexibility can be attributed to the higher number of
missing responses, as previously detailed.
Perceived stress. Participants’ appraisal of life stress was measured using the Perceived
Stress Scale (Cohen & Williamson, 1988). This 10-item self-report scale assessed the extent to
which participants considered their lives to be uncontrollable, unpredictable, and overloaded. On
this basis, each item was rated on a 5-point Likert scale ranging from 0 (never) to 4 (very often),
reflecting the frequency with which participants perceived their lives as stressful during the prior
6 months. Ratings were summed to yield a composite score that ranged from 0 to 40, with higher
scores indicating more perceived stress. This scale has been shown to have good internal
consistency and predictive validity in a sample of individuals with various psychiatric conditions
(Hewitt, Flett, & Mosher, 1992). The scale also had good internal consistency with this study
sample, as evidenced by an alpha coefficient of .85.
Appraisal of Mental Health Need
Levels of internalized stigma and hope were used as proxy measures of participants’
appraisal of their mental health needs.
59
Internalized stigma. Internalized stigma of mental illness was measured using the brief
version of the Internalized Stigma of Mental Illness Scale (Ritsher, Otilingam, & Grajales,
2003). The self-report scale contains 10 items measuring experiences related to alienation,
discrimination, social withdrawal, stereotype endorsement, and stigma resistance. Each item was
rated on a 4-point Likert scale ranging from 1 (disagree) to 4 (strongly agree). The mean of the
items were computed, and a score greater than 2.5 represented high levels of internalized stigma.
The scale has been found to have adequate internal consistency and predictive validity among
individuals with mental illness (Boyd, Otilingam, & DeForge, 2014). The scale’s high internal
consistency in this study sample (Cronbach’s alpha = .83) supports the scale’s reliability.
Hope. Level of hope was measured using the Herth Hope Index (Herth, 2006). This self-
report scale contains 12 items that reflect the multidimensionality of hope in clinical populations
represented by the following three subscales: temporality and future (e.g., “I believe that each
day has potential”), positive readiness and expectancy (e.g., “I have a sense of direction”), and
interconnectedness (e.g., “I have a faith that gives me comfort”). Each item is rated on a 4-point
Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). The index, which was
generated by summing scores across the 12 items, has demonstrated good internal consistency,
construct validity, and criterion-related validity (Herth, 2006). Additionally, it has been used in a
variety of research studies involving individuals with schizophrenia (Corrigan, Salzer, Ralph,
Sangster, & Keck, 2004), suggesting it is appropriate for use with this population.

60
Chapter 4: Sociodemographic Profile, Family Involvement, and Stress Experiences of
Asian Americans Served in Community Mental Health Agencies for a Diagnosis of
Schizophrenia
Study Aims
Research has found that although Asian Americans are more resistant to interfacing with
the mental health system, those who do tend to be individuals with the most serious psychiatric
disorders such as schizophrenia. Efforts to provide culturally responsive mental health treatments
to these recipients of services should be informed by descriptive statistics about their
characteristics, needs, and resources. To this end, the primary aim of the first study was to
catalog the socio-demographic characteristics of Asian Americans served at community mental
health agencies for a diagnosis of schizophrenia. Additionally, the social and stress experiences
of this subpopulation were described. Whenever possible, these descriptive statistics were
compared to the general population, the national Asian American sample, and other community
samples of individuals with schizophrenia and other serious mental illnesses. This study appears
to be the first to detail the psychosocial profile of Asian Americans diagnosed with
schizophrenia. It is anticipated that this initial effort to characterize this growing subgroup of
recipients of mental health services will not only facilitate hypothesis generation and prompt
more vigorous future studies, but also generate data that can be utilized by mental health
providers to optimize treatments.
61
Methods
Measures
The measures used were described elsewhere (see Chapter 3). Briefly, data were
collected via in-person interviewing and participant completion of validated self-report
inventories. Collectively, these methods yielded demographic, clinical, and psychosocial data.
Statistical Analysis
Univariable analyses were conducted to derive descriptive statistics for the study sample
– means and standard deviations were computed for continuous variable, and proportions for
categorical variables. On the basis of research findings of the effects of immigration-related
factors on the mental health needs and service use of Asian Americans, relevant analyses were
stratified by nativity (U.S. born versus foreign born) and generational status to identify
differences among subgroups. Generational status was collapsed into 1.00-generation
immigrants, 1.25- and 1.50-generation immigrants, and 1.75-or-later-generation immigrants.
Certain analyses were also stratified by demographic characteristics—namely, age, gender, and
living arrangement. Chi-square tests, with correction of unequal variances whenever necessary,
or Fisher’s exact tests for categorical variables with few observations were performed to examine
relationship between two categorical variables; two independent t tests or one-way analyses of
variance (ANOVA) were performed to compare means for two or more independent groups,
respectively; and bivariate correlations were performed to examine relationship between two
continuous variables. Preselect two-tailed directional tests and statistical significance was
determined at  = .05. Analyses were performed with STATA 13.0.
62
Results
Clinical Profile
The study sample featured 51 participants diagnosed with schizophrenia (68.00%) and 24
participants diagnosed with schizoaffective disorder (32.00%). Most participants (88.00%)
reported taking antipsychotic medication continuously during the last 6 months. The average age
at onset of illness was 22.62 years (SD = 8.38; range = 11–51), and close to two fifths of
participants (37.84%) reported experiencing their first symptom of psychosis before 18 years old.
On average, participants had been diagnosed with schizophrenia for 14.41 years (SD = 12.32;
range = 0–51), with the majority (90.54%) having a length of illness of 5 years or longer. This
study sample reflects clinical characteristics common to individuals with schizophrenia. One
notable exception relates to participants’ age at onset of illness, in that the proportion of
participants with early-onset psychosis (≤ 18 years old) is considerably higher (37.84%) than in
previous studies involving individuals with first-episode schizophrenia (11%–21%; Amminger et
al., 2011; Häfner & Nowotny, 1995).
Demographic Characteristics
Table 1 displays the sample’s demographic characteristics. The study sample was
ethnically diverse, with slightly more than three fourths of participants identifying as East Asian
(i.e., Chinese, Korean, or Japanese). Participants’ ages ranged from 19 to 66 years (M = 43.03;
SD = 12.61). Men (56.00%) and women (44.00%) were of comparable distribution. More than
three quarters of participants (79.45%) completed at least a high school education (including
equivalency) and slightly more than one third (39.73%) had some college education; however,
less than one fifth of participants (15.07%) had obtained a college degree. This is compared to
87.1%, 19.8%, and 51.50% of the Asian American population with at least a high school
63
diploma, some college education, and a bachelor’s degree or higher, respectively (U.S. Census
Bureau, 2015). Most participants were unemployed at study entry (76.00%) and were not
married (74.67%), compared to 35.00% and 33.60% of the Asian American population not in the
labor force and never married, respectively. Among participants who had ever been married (n =
19), 61.16% had children, but only 30.77% of those who are parents had ongoing contact with
their children. Relatedly, the divorce rate among study participants was high, with 21.33% of
participants who had ever been married being divorced or separated, compared to 5.1% of the
general Asian American population (U.S. Census Bureau, 2015). The large majority of
participants reported their English proficiency to be at least fair (88.00%), but less than half
(44.00%) reported English to be their primary language. Among participants whose primary
language was not English (n = 42), more than half (57.14%) reported speaking English less than
good, compared to less than one third of the Asian American population (30.40%).
Immigrant Histories
The majority of study participants were foreign born (70.67%), which is similar to the
proportion of the Asian American population (68.9%; U.S. Census Bureau, 2000). Slightly more
than half of these participants (54.72%) were born in East Asia, namely, China (18.87%),
Taiwan (13.21%), South Korea (11.32%), Hong Kong (7.55%), or Japan (3.77%). The remaining
participants were born in Southeast Asian countries such as Vietnam (22.64%), Philippines
(9.43%), Cambodia (5.66%), Thailand (2.67%), Laos (1.33%), and Myanmar (1.33%). Close to
two thirds of foreign-born participants emigrated to the United States at age 13 or older, with an
average age at emigration of 16.23 years (SD = 11.17, range = 2–50). Among foreign-born
participants, approximately 37.74% were first-generation immigrants and the remaining
participants were 1.25-generation (18.87%), 1.50-generation (20.75%), or 1.75-generation
64
(22.64%) immigrants. The average length of stay in the United States among foreign-born
participants was 30.49 years (SD = 9.73, range = 6–59). About two thirds of foreign-born
participants (67.92%) completed the research interview in English, compared to the
overwhelming majority of native-born participants (95.45%). Relatedly, almost half of foreign-
born participants (47.17%) reported speaking English less than good.
Religious Affiliation
More than 7 in 10 participants (72.00%) reported having a religious identity, whereas
slightly more than a quarter (28.00%) had no religious affiliation. These rates of religious
identity are comparable to proportions in the general population and the Asian American
population (Newport 2016; Pew Research, 2012). In this study, more than half of affiliated
participants (62.96%) identified with a Christian religion, about a quarter identified with
Buddhism or Taoism (27.78%), and the remainder either identified with other religions or
reported having affinity to more than one religion (9.26%). Despite the high rate of religious
identity, a smaller percentage of participants (56.00%) attended public religious activities during
the previous year. Of note, a third of affiliated participants (33.33%) did not attend any formal
religious meetings at a church, synagogue, mosque, or temple during the prior 12 months. A
similar pattern emerged for time spent in private religious activities; nearly half of participants
(48.00%) and one third of affiliated participants (33.33%) reported rarely or never performing
any private activities such as praying, meditation, or scripture study during the prior 12 months.
These lower levels of religious involvement in this sample are inconsistent with those reported in
previous research on the use of religious and spiritual coping strategies among individuals with
serious mental illness (Mohr et al., 2012; Tepper, Rogers, Coleman, & Malony, 2001). Extant
research has found that a large number of individuals with serious mental illness rely on religious
65
activities such as prayer and attending religious services as a coping strategy. For instance, Mohr
and colleagues (2012) found that 80% of participants in a study sample composed of outpatients
with schizophrenia reported performing private religious activities regularly (i.e., every day or
every week), compared to 25.33% of participants in the present study.
Family Involvement
Living arrangement. Participants reported varied living arrangements. More than half
(56.00%) were living with their immediate family members (29.33% with parents only, 10.66%
with siblings or a spouse, and 17.33% with parents and other family members); slightly more
than one third were residing in board-and-care facilities (34.67%); and the rest were living
independently (9.33%). Interestingly, women were more likely to live independently than did
men, 18.18% and 2.38%, respectively, with this difference showing marginal statistical
significance, p = .06. The large majority of participants living at home (n = 43) resided in a
household that included a parent (81.39%). The proportion of participants living with parents
(46.66%) is considerably higher than the rate reported in previous studies involving mostly
participants belonging to other racial and ethnic groups, whereas the proportion of participants in
independently living was significantly lower (Stueve, Vine, & Struening, 1997; Tsai, Stroup, &
Rosenheck, 2011). Tsai and colleagues (2100) found that among participants enrolled in the
Clinical Antipsychotic Trials of Intervention Effectiveness study (Lieberman et al., 2005), an
overwhelmingly White and Black sample (96.1%), 15.6% were living with parents and 18.0%
were living independently.
Findings from this study also revealed that more than half of participants (51.52%) living
independently or in board-and-care facilities reported either having lost both parents, being
estranged from the surviving parent, or that the surviving parent had a disability, compared to
66
14.29% of those living at home, χ
2
(1, 75) = 12.05, p < .01. Relatedly, almost twice as many
participants residing with their immediate family members (64.29%) reported that both parents
were healthy compared to participants living independently or in supervised settings (33.33%).
Although living with family offers many benefits to individuals with a serious psychiatric illness,
findings from the present study suggest that the family can also be a source of stress, as
evidenced by the finding that 30.95% of participants living with their family reported that the
behavior of a relative had been a significant problem for them during the previous 6 months,
compared to only 6.06% of participants living independently or in supervised settings (p < .05).
Family contact. Most participants (90.54%) reported having contact with their family
members regardless of their living situation, which is considerably higher than the proportion
among individuals belonging to other racial and ethnic groups (Lehman & Steinwachs, 1998). In
a sample composed mostly of nonminority Whites and minority African Americans who were
diagnosed with schizophrenia (N = 440), 77.20% of respondents reported having some ongoing
contact with their families, compared to 90.54% of participants in the present study. Importantly,
more than three quarters of participants (78.79%) living independently or in supervised settings
had ongoing contact with an immediate or extended family member. Among these individuals,
close to half (46.88%) had at least monthly contact. Participants living independently or in
supervised settings who had at least one parent capable of caregiving were more likely to report
ongoing contact with their family members (93.33%) than their counterparts with unavailable
parents (64.70%), but this difference was not statistically significant, p = .09.
Family functioning. As evidenced by the mean ratio scores displayed in Table 2,
participants on average perceived their families to have healthy functioning. Based on these ratio
scores, slightly more than three quarters of participants (75.68%) reported healthy levels of
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cohesion in that the level of balanced cohesion in the family system was perceived to be higher
than the levels of disengagement and enmeshment (i.e., unbalanced cohesion). Similarly, a great
majority of participants (87.10%) indicated healthy levels of flexibility in their family system.
Overall, most participants reported higher levels of balanced rather than unbalanced traits in their
family systems, as evidenced by the finding that 83.87% of participants had a total circumplex
ratio score of 1 or higher.
Although the majority of participants perceived their families to display higher levels of
functional rather than dysfunctional behavior, these systems may be less balanced and healthy
than those not affected by mental illness. Table 2 displays the average raw scores of the various
subscales from the present study compared to those from a previous study by Koutra and
colleagues (2014), which examined family functioning in three Greek samples: patients with
first-episode psychosis, patients with chronic schizophrenia, and healthy individuals with no
history of psychiatric conditions in their family. This is one of a handful of studies that examined
family functioning of individuals with schizophrenia, and thus formed this study’s comparative
sample. Levels of cohesion and flexibility were lowest in this study sample and the comparative
sample of patients with chronic schizophrenia, intermediate among patients with first-episode
psychosis, and highest among healthy controls. A similar pattern emerged in relation to the other
assessed dimensions of family functioning; levels of disengagement and rigidity were lowest
among healthy controls, intermediate among patients with first-episode psychosis, and highest
among study participants and patients with chronic schizophrenia. Given that this study featured
mostly participants with subsequent-episode schizophrenia, the relatively comparable levels of
family functioning between study participants and the comparative sample of patients with
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chronic schizophrenia from the foregoing study by Koutra and colleagues (2014) appear
reasonable.
Another noteworthy finding is the association between family functioning and
participants’ living arrangements, as demonstrated by the comparison between the raw and ratio
scores of participants living with their families and those living independently or in board-and-
care facilities (see Table 2). Participants living independently or in supervised settings reported
significantly lower levels of cohesion, t(73) = -3.93, p < .001, and enmeshment, t(73) = -3.37, p
< .01, but significantly higher levels of disengagement, t(72) = 3.93, p < .001, in their families
than participants living with family members. A similar trend emerged regarding levels of family
functioning, in that a significantly higher percentage of participants living in independent or
supervised settings perceived their families to be somewhat connected (versus higher levels of
connectedness), χ
2
(2, 75) = 10.84, p < .01, and high in disengagement, χ
2
(4, 75) = 13.26, p < .01,
than participants living with their family members.
Stress Experiences
Table 3 and 4 detail the stressful events and social circumstances unique to Asian
Americans with schizophrenia due to their status as immigrants or lived experiences with the
disorder.
Acculturative stress. About half of foreign-born participants (52.83%) experienced
acculturative stress in the previous 6 months, with an average of 0.98 (SD = 1.09; range = 0–4)
stressors. The mean acculturative stress level found in this study sample is lower than that
reported by previous studies using data from the National Latino and Asian American Study.
These studies have found that the majority of Asian immigrants (70.00%) experienced
69
acculturative stress and reported an average of 2.01 (SD = 1.87) stressors (Lueck & Wilson,
2010; Gong, Xu, Fujishiro, & Takeuchi, 2011).
There were important subgroup differences in acculturative stress among participants.
For instance, women on average reported more acculturative stress than men, t(50) = -2.89, p <
.01. Levels of acculturative stress also varied significantly by generation status, F(3, 49) = 9.26,
p < .001, so that it was highest among first generation immigrants (M = 1.68, SD = 1.16),
intermediate among 1.25-generation immigrants (M = 1.30, SD = 0.95), and lowest among 1.50-
or earlier-generation immigrants (M = 0.29, SD = 0.75). Furthermore, generational status was
also significantly linked to the type of stressor experienced. Almost one third of 1.00-generation
immigrants (31.58%) felt that living out of their country of origin had limited their contact with
family and friends, compared to 20.00% of 1.25-generation immigrants, and none of 1.50-or-
earlier generation immigrants (p < .01). Likewise, more than half of 1.00-generation immigrants
(57.89%) found it hard interacting with others because of difficulties they had with the English
language compared to slightly over one third of 1.25-generation immigrants (40.00%) and less
than one tenth of 1.50-or-earlier generation immigrants (8.33%; p < .01). A comparable number
of 1.00-generation and 1.25-generation immigrants reported having difficulties finding the work
they want because they are of Asian descent – 38.46% and 37.50%, respectively, compared to
4.17% of 1.50-or-earlier generation immigrants (p < .05). East Asians and Southeast Asians did
not differ significantly in levels of acculturative stress—1.11 versus 0.88, respectively; t(50) =
0.73, p = .47.
Major traumatic event. On average, participants reported 2.26 childhood traumas (SD =
2.16) and 6.03 lifetime traumas (SD = 3.90), with 8.33% of participants reported having been
exposed to at least one of the assessed traumas in the last 6 months. The following discussion
70
focused on childhood adversities identified in the Adverse Childhood Experiences Study (e.g.,
Felitti et al., 1998) and the National Comorbidity Study (e.g., Green et al., 2010) to have
enduring consequences on mental health outcomes. Additionally, given the inevitability of
certain traumatic event such as parental loss coupled with the relatively infrequent occurrence of
other events, the discussion focused on preventable adult traumas that were experienced by a
sizable number of participants. Table 3 displays the prevalence of retrospectively reported
traumatic events in this study sample compared to community samples of individuals with
schizophrenia and other serious mental illnesses and the general population.
Adverse childhood events. Prevalence rates of individual childhood events ranged from a
high of 39.44% for direct exposure to an event that resulted in trauma-related thoughts to a low
of 12.33% for parental substance use. The rates of individual childhood adversities among
participants are mostly comparable to if not lower than those of other samples of adults with
schizophrenia (Rubino, Nanni, Pozzi, & Siracusano, 2009), but generally higher than that of the
general population for most events except for parental substance use (Felitti et al., 1998; Green et
al., 2010). More specifically, the occurrence of some adverse childhood events such as childhood
maltreatment were between two to four times higher than the prevalence in the general
population. The report of childhood physical abuse did not differ significantly by gender, χ
2
(1,
73) = 0.18, p = .67, as was true of neglect, χ
2
(1, 73) = 0.66, p = .42. However, more than twice as
many women (28.12%) reported childhood emotional abuse as men (12.20%), with the
difference showing marginal statistical significance, χ
2
(1, 73) = 2.94, p = .09. Of note is the
considerably higher prevalence of parental divorce or separation in this sample compared to the
national rate among Asian Americans – 22.97% and 5.1%, respectively. Another noteworthy
finding is that 25% of participants reported being separated from their parents before the age of
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18 years, a rate that is also four times higher compared to the general population. Parental mental
illness was not systematically measured, which may explain its lower prevalence in this study
sample (14.67%) compared to another diagnostically similar sample (21.4%). Overall, 58.33% of
participants reported at least one adverse childhood event related to maltreatment, parental
maladjustment (mental illness or substance use), and interpersonal loss (parental divorce or
separation, or separation from parents). This is comparable to the prevalence of 53.4% in the
general population (Green et al., 2010). When all assessed adverse childhood events were
considered, findings revealed that the majority of participants (83.10%) reported at least one
childhood adversity.
Lifetime. Close to half of participants said that they have experienced physical assault,
parental loss, and arrest. These traumatic experiences merit attention by sheer weight of numbers
and thus, form the focus of the discussion that follows.
Regarding victimization, 46.97% of participants reported having been a victim of
physical assault in adulthood by an intimate partner, strangers, or acquaintances. The proportion
of participants who have ever experienced physical assault in adulthood corresponds to those
found in other community samples of persons with serious mental illness. For instance, Chuang
and colleagues (1987) noted that 47.62% of outpatients with schizophrenia reported they had at
one time been victimized, and Brekke and colleagues (2001) found that 38% of their study
sample, which was comprised mostly of nonminority Whites and minority African Americans
with schizophrenia, reported having been victimized during the 3-year long study period. On the
other hand, the rate of recent victimization is substantially lower among participants than other
community samples. Specifically, 2.67% of participants reported having been victimized during
the prior 6 months, compared to the 6-month and 4-month rate of 25.6% and 8.2%, respectively,
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in samples that comprised mostly of nonminority Whites and minority African Americans with
serious mental illness (Hiday, Swartz, Swanson, Borum, & Wagner, 1999; White, Chafetz,
Collins-Bride, & Nickens, 2006). Of note, a significantly higher percentage of men than women
in this study reported having been a victim of physical assaulted in adulthood, 58.33% compared
to 33.33%, χ
2
(1, 66) = 4.11, p < .05, which is inconsistent with earlier studies that found either
no significant differences in prevalence by gender (Brekke et al., 2001; Goodman et al., 2001), or
women being more likely to report victimization (White et al., 2006). A history of assault in
adulthood was not significantly associated with age, t(64) = 0.15, p = .89.
Thirty-two participants (43.84%) reported having at least one previous arrest in their
lifetime, and two participants (2.67%) had been arrested during the prior 6 months. Arrest rates
have been found to be higher among individuals with schizophrenia than in community samples
without a history of psychiatric condition (Harry & Steadman, 1989), hence the finding that more
than 4 in 10 participants reported a history of arrest is not surprising. However, the lifetime arrest
rate in this study sample is lower than those found in other community samples of adults treated
for schizophrenia – these earlier studies have reported rates between 49% and 71% in samples
composed mostly of White and Black male participants with schizophrenia (Brekke et al., 2001;
Lafayette, Frankie, Pollock, Dyer, & Goff, 2003; White et al., 2006). Findings also revealed that
more male participants (53.66%) than female participants (31.25%) reported a history of arrest,
but this difference was marginally statistically significant, p = .06. History of arrest, however,
was not significantly associated with age, t(71) = 0.34, p = .73.
Overall, 20.55% of participants reported having ever been sexually assaulted or abused.
This is compared to a lifetime rate of about 50% found in previous studies of diagnostically
mixed samples of mostly nonminority White and minority Africa American adults with serious
73
mental illness, of which the majorities were diagnosed with schizophrenia spectrum disorder
(Goodman et al., 2001; Mueser et al., 2004). Lifetime prevalence of sexual assault or abuse in
this study did not differ significantly by gender in that, 25.00% of women compared to 17.07%
of men reported experiencing this event, χ
2
(1, 73) = 0.69, p = .41.
Recent life events. More than half of participants (56.76%) did not experience any of the
assessed life event. Participants who experienced a negative life event during the previous 6
months reported an average of 1.09 event (SD = 0.39; range = 1–3). The most common negative
life event concerned the behavior of a family member, followed by involuntary unemployment.
The occurrence of other life events was relatively infrequent, as reported by less than 10% of
participants. Findings revealed an association between the report of a problematic family
member and living arrangement and gender. Almost 5 times as many participants living with
family (30.95%) as participants living independently or in supervised settings (6.06%) reported
that the behavior of a family member had been problematic in the previous 6 months, p < .01.
Additionally, almost twice as many female participants living with family members (43.75%)
than male participants (23.08%) reported this stressor, although the association did not reach
statistical significance, χ
2
(1, 42) = 1.98, p = .16.
As previously described, another common life event relates to involuntary unemployment
in that 31.25% of participants who experienced an acute stressor during the last 6 months
reported that they were involuntarily unemployed. This stressor was significantly associated with
age—35.29% of participants in their 30s reported that they had been concerned about being
unemployed compared to 15.00% of participants in their 40s, 8.70% of participants in their 50s
or older, and 0% of participants in their 20s, p < .05. There was no association with gender in
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that women (12.50%) and men (16.67%) were equally likely to report that being involuntarily
unemployed had been a concern for them, p = .75.
Chronic strains. The overwhelming majority of participants (97.30%) reported
experiencing at least one chronic life event in the previous 6 months. The rates of the assessed
stressors are listed in Table 4. The most common chronic stressors experienced by participants
were difficulties finding a romantic partner (54.79%), having a long-term health problem that
prevented them from doing the things they like to do (54.05%), being alone too much (54.05%),
not having enough money to meet their daily needs (48.65%), wondering if they would ever get
married (46.58%), and not having enough friends (47.30%). Levels of chronic stress did not
differ significantly by gender, t(72) = -1.02, p = .31; however, there was a weak but insignificant
association with age, b = 0.01, t(72) 1.62, p = .10.
Psychological stress. Participants’ average level of perceived stress as measured by the
Perceived Stress Scale (Cohen et al., 1983) was 18.34 (SD = 7.85; range = 0–36). Table 3
displays the mean stress level in this study sample and in a probability sample of respondents
who completed a national survey that was administered in 2009 (N = 2000; Cohen & Janicki-
Deverts, 2012). Comparison of mean stress levels revealed some trends in this study sample that
were similar to those found in the general population, but also highlighted important differences.
For instance, the distribution of stress between the genders was comparable to those in the
general population in that, women on average reported higher levels of stress than men, but the
difference was not statistically significant, t(72) = -1.22, p = .23. Similarly, stress level decreased
with increasing age, albeit less consistently compared to the general population, F(4, 66) = 1.62,
p = .18. In contrast to the general population, this study sample reported an inversed relationship
between psychological stress and educational attainment in that stress was highest among
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participants who completed college and lowest among those with less than high school
education, F(3, 66) = 0.97, p = .41. This relationship, however, was not statistically significant.
Importantly, findings also revealed that higher mean stress levels was significantly associated
with the following environmental stressor: poorer family functioning, b = -0.58, t(61) = -3.27, p
< .01; the experience of a life event during the previous 6 months, t(71) = -2.-02, p < .05; and
higher levels of chronic stress, b = 0.60, t(71) = 6.27, p < .001).
Summary
The outlined demographic characteristics suggest that this sample is socially and
economically more disadvantaged than the general Asian American population. Findings also
suggests that parents, rather than significant others or siblings, are more likely to be the primary
caregivers of Asian Americans with schizophrenia. In general, the distributions of social
adversities experienced by participants were similar to other psychiatric samples, but higher than
the general population.

76
Chapter 5: Treatment Outcomes of Asian Americans Diagnosed with Schizophrenia
Study Aims
Users of mental health services in the Asian American community tend to be individuals
with serious psychiatric disorders, yet little is known about the treatment responsiveness of those
diagnosed with schizophrenia. This gap in knowledge is concerning because users of mental
health services in the Asian American community tend to be individuals with serious psychiatric
disorders. Given that the Asian population in the United States grew by 46% during the last
decade, it is reasonable to speculate that the demand for mental health services by the Asian
community has significantly increased and will continue to rise, particularly among those with
the highest level of mental health need. Initial efforts are needed to gather outcome data on those
treated for schizophrenia, one of the most disabling conditions, for health-care planning.
This second study strived to fill this research gap by assessing the treatment
responsiveness of 75 Asian Americans seen at community mental health agencies for a diagnosis
of schizophrenia. Specifically, this study examined symptoms severity, role functioning,
symptomatic remission, and overall treatment responsiveness indicated by the achievement of
clinical recovery. A second aim of this study was to identify the cultural promoters and barriers
of the aforementioned treatment outcomes. An emphasis was placed on identifying
environmental correlates that are most responsive to psychosocial interventions delivered by
social work practitioners. This study tested the stress-diathesis hypothesis that higher levels of
exposure to adverse environments would be negatively associated with treatment responsiveness
over and above the influence of prognostic indicators found to be associated with schizophrenia
in the literature. Additionally, it was hypothesized, per the stress-diathesis model, that good
treatment outcomes indicated by lower symptoms severity, adequate role functioning, sustained
77
symptomatic remission, and evidence of clinical recovery would be positively associated with
exposure to more favorable environmental conditions (healthier family functioning) keeping
constant the influence of salient prognostic indicators of schizophrenia and exposure to
environmental stress. Confirmation of the latter two hypotheses would lend further support to the
influence of environmental conditions on not only the onset but also the outcomes of
schizophrenia.
Methods
Measures
Independent variables. This study’s independent variables related to exposure to
various environmental influences during the previous 6 months. Specifically, the variables
considered were whether or not the participant was exposed to a stressor, levels of chronic
strains, and levels of balanced cohesion in the family system as self-reported by participants.
Given the low occurrence of major traumatic event during the previous 6 months in this study
sample, this exposure was combined with the experience of acute stressors stemming from recent
life events to produce fewer but larger groups. As such, participants who reported experiencing
either a major traumatic event or acute stressor during the preceding 6 months were grouped and
coded with a 1, and the rest of participants formed the reference group. Chronic strains and levels
of balanced cohesion in the family system were treated as interval variables.
Covariates. To ensure that participants being compared were similar in the prognostic
indicators that have been found to be associated with course of illness in schizophrenia, the
covariates of age at study entry, gender, age at onset of illness, and history of childhood
adversity, hereafter referred to as prognostic indicators of schizophrenia, were included in the
estimated models. Including these covariates allowed the investigation of whether the
78
environment has any additional association with outcomes after allowing for the effects of
known prognostic indicators of schizophrenia. Research has noted an inverse relationship
between age and severity of psychotic symptoms among individuals with schizophrenia in that
symptoms tended to attenuate with increasing age (Carone, Harrow, & Westermeyer, 1991). On
this basis, a nonlinear relationship between age and symptoms severity were modeled by
including the square of age in the estimated models. Gender was measured as a nominal variable
(male or female). Age and age at onset of illness were treated as ratio-level measurement
variables. Previous studies have found that abuse or neglect in childhood can affect severity of
symptoms among adults with schizophrenia (e,g., Schenkel, Spaulding, DiLillo, & Silverstein,
2005). Accordingly, history of childhood adversity was included as a covariate and treated as a
categorical variable measured at two levels to represent whether or not the participant reported
experiencing at least one adverse childhood event related to maltreatment (physical abuse,
emotional abuse, or neglect), parental maladjustment (mental illness or substance use), and
interpersonal loss (parental divorce or separation, or separation from parents). Given the
collinearity between length of illness, age, and age at onset, length of illness was not included as
a covariate.
Dependent variables. The outcomes examined were symptoms severity, role
functioning, symptomatic remission, and overall treatment responsiveness indicated by the
achievement of clinical recovery.
As previously described, the Positive and Negative Syndrome Scale (PANSS; Kay,
Fiszbein, & Ohier, 1987) was used to assess the presence and severity of symptoms. This study
considered the severity of the following syndromes of schizophrenia occurring during the 2
weeks before the research interview: Positive, Negative, Activation, Dysphoric Mood, and
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Autistic Preoccupation (White, Harvey, Opler, & Lindenmayer, 1997). The PANSS items
measuring these syndromes are displayed in Table 5. Syndrome scores were computed by
summing the constituent PANSS items, with higher scores indicating more severe
symptomatology.
Participants’ functional outcomes were assessed using the 3-item Strauss and Carpenter
Outcome Scale (Strauss & Carpenter, 1972). Specifically, data were gathered on participants’
functioning at study entry and during the previous 6 months in terms of duration of
hospitalization for psychiatric treatment, frequency of social contacts, and engagement in various
meaningful activities that comprised formal employment (including work as a student), irregular
or supported employment, work as a caregiver or homemaker, volunteer work, or provision of
informal social assistance. Each item was rated on a 5-point Likert scale, with higher scores
indicating better outcomes. Adequate role functioning was defined as being engaged in any of
the assessed meaningful activities at least part-time or full-time half the time during the previous
6 months (i.e., a score of ≥ 2).
The Remission in Schizophrenia Working Group proposed that symptomatic remission is
achieved if the symptomatology characteristic of schizophrenia, namely delusions,
hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative
symptoms, are of minimal intensity for at least 6 months (Andreasen et al., 2005). To this end,
selected PANSS items that correspond to key features of schizophrenia were used to determine
whether participants achieved symptomatic remission: delusions, conceptual disorganization,
hallucinatory behavior, blunted affect, passive or apathetic social withdrawal, lack of spontaneity
and conversation flow, mannerisms or posturing, and unusual thought content. Participants who
received PANSS ratings of mild or less (≤ 3) for these items, with the exception of blunted
80
affect, during the previous 6 months were classified as in remission. As previously described,
this study featured mostly participants who have an average length of illness of about 14 years. It
is reasonable to assume that the majority of participants have been on maintenance antipsychotic
medications, which are known to cause the side effect of flattened affect. Accordingly,
participants who received a rating of moderate of less (≤ 4) for blunted affect but mild of less (≤
3) for all other items were nonetheless considered to be in remission.
Most definitions of clinical recovery stipulate concurrent absence of psychotic
symptomatology and a normative level of functioning sustained over a specified period
(Liberman, Kopelowicz, Ventura, & Gutkind, 2002). This study relied on extant definitions of
recovery, which stipulate the fulfillment of the following set of criteria for at least 6 months: (1)
be in symptomatic remission per the operational definition proposed by the Remission in
Schizophrenia Working Group (Andreasen et al., 2005); (2) demonstrate adequate role
functioning defined by a score of 2 or greater on the Strauss and Carpenter Outcome Scale (S-
CS; Strauss & Carpenter, 1972) item measuring meaningful activities, (3) demonstrate adequate
social functioning defined by a score of 2 or greater on the S-CS item measuring social contacts,
which corresponded to having had some social contact once a month or more during the
preceding 6 months; and (4) experience no psychiatric hospitalization.
Statistical Analyses
Univariate analyses were conducted with the observed data to determine the levels of
symptoms severity and derive the prevalence of different categorical treatment outcomes.
Multivariate ordinary least squares (OLS) linear regression models were fitted to estimate
the effects of the investigated environmental influences on symptoms severity after controlling
for relevant prognostic indicators. Diagnostic statistics were calculated before estimation of the
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regression models to determine whether the data met the assumptions of multiple regression
analysis. Variables were transformed, whenever necessary, to meet the major assumptions of
linear regression. Both measures of tolerance and variance inflation factor confirmed the absence
of multicollinearity. Normality of residuals was examined using kernel density plots and tested
using the Shapiro–Wilk W test. Diagnosis of heteroscedasticity was performed using the
Breusch–Pagan test and by examining the residual versus fitted plot. These diagnostic statistics
revealed that the estimated models did not meet the assumptions of normality of residuals and
homogeneity of variance of the residuals. Accordingly, robust standard estimators were applied
to the fitted models to yield robust standard errors.
To identify correlates of the investigated categorical outcome variables (adequate role
functioning, symptomatic remission, and clinical recovery from schizophrenia), direct
multivariable binary logistic regression analyses were performed. Because of the study’s modest
sample size, which precluded the inclusion of all proposed independent variables in a
multivariate model, the selection of potential correlates was guided by the purposeful selection of
covariates method proposed by Hosmer, Lemeshow, and Sturdivant (2013a), which involves
several stages of analyses. First, Pearson chi-square tests for categorical explanatory variables or
two-sample t-tests for continuous explanatory variables were performed to investigate the
association between each independent variable and dependent variable. For categorical variable
with few observations, Fisher’s exact test was performed instead of the regular chi-square test.
Independent variables that were statistically significantly associated with the dependent variable
at p < .10 (two-tailed) in the bivariate analyses were candidates for entry in the multivariate
model. Second, direct binary logistic regression analyses were performed to identify statistically
significant correlates after adjusting for the set of covariates. Independent variables that were not
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statistically significant in the multivariable model were removed. Third, independent variables
that were not statistically significant at the bivariate level were added to the multivariate model
separately to identify variables that were statistically significantly related to the dependent
variable in the presence of other variables. Variables that were statistically significant were
removed, resulting in the final model. Steps 1 through 3 were performed for all categorical
treatment outcomes examined. The purposeful selection method has been shown to be superior to
stepwise selection in retaining statistically significant explanatory variables and confounders
(Hosmer et al., 2013b). Two-tailed directional tests were reported, hence statistical significance
was determined at  = .05. Analyses were performed with STATA 13.0 using data from
participants with complete information for all variables included in the analytic models.
Results
Clinical Profile
The study sample featured 51 participants diagnosed with schizophrenia (68.00%) and 24
participants diagnosed with schizoaffective disorder (32.00%). The average age at onset of
illness was 22.62 years (SD = 8.38; range = 11–51), and close to two fifths of participants
(37.84%) reported experiencing their first symptom of psychosis before 18 years old. On
average, participants had been diagnosed with schizophrenia for 14.41 years (SD = 12.32; range
= 0–51), with the majority (90.54%) having a length of illness of 5 years or longer. Accordingly,
this study sample was composed of mostly individuals with established schizophrenia who were
not experiencing their first episode of psychosis, with a handful of early schizophrenia.
Service Use
The average duration of service use was 10.29 years (SD = 9.28; range = 0.08—30), with
61.54% of participants having a length of service use of more than 5 years and 21.54% having a
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length of service use of less than 2 years. The majority of participants were on maintenance
antipsychotic medication, as evidenced by the finding that 90.67% reported continuous or regular
use of antipsychotic medication during the previous 6 months. The majority of participants
(83.33%) who were on maintenance treatment were prescribed one antipsychotic medication, the
most common being an atypical antipsychotic. Those who were prescribed two antipsychotics
were generally given a combination of atypical antipsychotics. This study, therefore, featured
participants who had high levels of treatment and service engagement.
Treatment Outcomes
Table 6 displays the descriptive statistics for the various treatment outcomes examined in
this study.
Symptoms severity. A few inferences can be drawn from the descriptive statistics.
Participants experienced a spectrum of symptomatology beyond the core syndromes of
schizophrenia. The standard deviations suggest some heterogeneity in symptoms severity among
participants, but the variations were not dramatic. The mean scores, compared to the possible
range of values on the various subscales, indicate that participants, on average, were not acutely
ill at study entry. Although participants’ symptomatology, on average, was considerably reduced
in severity, less than half (40.00%) had psychotic symptoms that were sufficiently mild to meet
the cross-sectional criteria for symptomatic remission. Participants with unremitted psychosis
(60.00%) had at least moderate levels of positive or negative symptoms at study entry.
Role functioning. Work functioning was overall poor for the study sample. At study
entry, the overwhelming majority of participants were unemployed (73.33%). Notably, only
10.67% participants were gainfully employed, including supported employment, 9.33% were
students, and 2.67% were homemakers or caregivers. This occupational data suggests that the
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majority of participants had difficulties achieving adequate level of role functioning. Data on
participants’ functioning in the previous 6 months revealed more heterogeneity in that there was
an even split in participants with adequate functioning, intermediate levels of functioning, and
poor functioning. One-third of participants (34.67%) reported that they were engaged in gainful
employment or other activities (e.g., being a homemaker, student, caregiver, volunteer) about
half the time, another one-third (33.33%) were engaged in some meaningful activities but at a
lower frequency (i.e., less than half the time during the same time period), and the rest reported
not being engaged in any of the assessed activities. Accordingly, these findings revealed that 1 in
3 participants had significant functional impairments.
Symptomatic remission. Among participants who reported continuous or regular use of
antipsychotic medication during the previous 6 months (n = 68), 46.15% were responsiveness to
treatments as indicated by the remission of symptoms that was sustained for a period for 6
months. Nonetheless, 53.85% of participants experienced either episodic or persisting residual
symptoms that were at least moderate in intensity despite continuous use of antipsychotic
medication. These findings suggest that about 1 in 2 participants showed only partial response to
neuroleptic treatment.
Clinical recovery. Overall, about 2 in 10 participants (n = 16; 21.33%) displayed good
global outcome during the previous 6 months as indicated by the achievement of clinical
recovery. These participants were able to simultaneously sustain remission of psychotic
symptoms and maintain adequate levels of social and vocational activities that persisted during
the previous 6-month period. Nonetheless, the overwhelming majority of participants (78.67%)
were either symptomatic at some point during the previous 6-months period (17.33%), showed
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an unchanging state of poor functioning (18.64%), or had difficulties with both domains of
sustained symptomatic remission and adequate functioning (46.67%).
Correlates of Treatment Outcomes
Symptoms severity. Table 7 displays the results of the fitted multivariate regression
models. Controlling for the influence of the examined prognostic indicators, exposure to adverse
environmental conditions was significantly associated with severity of activation symptoms and
dysphoric mood. The coefficients were positive, indicating that exposures were associated with
more severe symptoms. More specifically, exposure to either a major traumatic event or acute
stressor during the preceding 6 months compared to no exposure was associated with higher
levels of activation symptoms, b = 1.66, t[63] = 1.93, p = .06, and higher levels of dysphoric
mood, b = 2.09, t[63] = 1.93, p < .01. More severe dysphoric mood was also significantly
associated with higher levels of chronic stress in the previous 6 months, b = 0.99, t[63] = 1.93, p
< .01.
A more consistent pattern emerged in relation to exposure to favorable environmental
conditions and symptoms severity. After partialling out the effects of the various prognostic
variables and keeping constant levels of exposure to adverse environments, family functioning,
indicated by balanced cohesion in the family system, was significantly associated with severity
of all assessed syndromes with the exception of activation symptoms. The coefficients were
negative, indicating that higher levels of balanced cohesion in the family system were associated
lower severity across most syndromes of schizophrenia. The examined associations were at most
moderately inter-correlated, with the majority having standardized beta coefficients of less than
0.30, which is indicative of a weak association.
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Past research has noted an inverse relationship between age and severity of psychotic
symptoms (e.g., Carone et al., 1991) Similarly, this pattern was observed in this present study,
especially as it relates to positive symptoms and autistic preoccupation. As age increased,
positive symptoms decreased in severity, b = -0.01, t[63] = -3.43, p < .01, as was true of
symptoms of autistic preoccupation, b = -0.01, t[63] = -3.17, p < .01. The significant quadratic
term indicates that the decrease in severity accelerated as participants got older. All of the
estimated models were significant. Notably, the variance in symptoms severity that was
explained by the covariates and independent variables ranged from 16.55% for negative
symptoms to 32.14% for dysphoric mood.
Role functioning. Bivariate comparisons between participants who showed and did not
show adequate role functioning revealed few statistically significant differences but several
substantive differences (see Table 8). Participants with better role adjustment were significantly
less likely to be exposed to either a major traumatic event or acute stressor during the preceding
6 months compared to participants with functional impairments, 30.77% vs. 55.32%, χ
2
(1, 73) =
4.05, p < .05. Concerning the prognostic indicators, women were more likely to show adequate
role functioning compared to men, 42.42% vs. 28.57%, χ
2
(1, 75) = 1.57, p = .21; participants
who did not experience any childhood adversities were more likely to have adequate role
adjustment compared to their counterparts who experienced maltreatment, parental
maladjustment, or interpersonal loss during their childhood, 43.33% vs. 30.95%, χ
2
(1, 72) =
1.16, p = .28; participants with adequate role functioning, on average, were older than
participants with poor role functioning, 46.58 vs. 41.14, respectively, t(73) = -1.80, p = .08; and
lastly, participants with adequate role functioning had a later age at onset of illness compared to
participants with poor role functioning, 24.81 vs. 21.50, t(72) = -1.64, p = .11. Notably, these
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differences were mostly marginally statistically significant. Consequently, these variables lost
statistical significance in the multivariate model, yielding no significant correlates from the set of
covariates and environmental variables.
On the basis of prior research, further analyses were conducted to examine the correlation
between symptoms severity, educational attainment as a proxy for premorbid functioning, and
functional outcomes. Keeping constant the examined prognostic indicators (age, age at onset of
illness, and premorbid functioning), the odds of a remitted participant maintaining adequate role
functioning was significantly higher than the odds of an unremitted participant evidencing
adequate role functioning, OR = 6.18, 95% CI = 1.82, 21.01. Notably, for a given symptom
status, age, and age at onset of illness, participants with higher levels of premorbid functioning
(i.e., had some college education or completed a bachelor’s degree or higher) had significantly
greater odds of showing adequate role adjustment than participants with lower levels of
premorbid functioning (i.e., high school diploma or lower).
Concerning other critical areas of functioning, about one-quarter of participants living
with family members (22.50%) were found to not have adequate level of everyday living skills
necessary for independent residential functioning, with the overwhelming majority of
participants having intermediate levels of living skills. Perhaps the most noteworthy set of
findings relate to the everyday functioning of participants with an early onset of illness. Keeping
constant age and levels of symptoms, participants who reported an onset of psychotic symptoms
before the age of 18 years old had significantly lower levels of independent living skills than
participants who had an onset of illness after the age of 18.
Symptomatic remission. Comparing remitted and unremitted participants on the
investigated independent variables revealed few differences (see Table 8). At the bivariate level,
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remitted participants, on average, were significantly older than their unremitted counterpart,
48.07 vs. 40.19, t(73) = -2.71, p < .01. Remitted participants, on average, showed a non-
significant trend for having a later age at onset of illness compared to unremitted participants,
23.89 vs. 21.96, t(72) = -0.95, p = .34. Additionally, more women achieved symptomatic
remission than men – 39.39% vs. 33.33%, respectively – but this difference was not statistically
significant, χ
2
(1, 75) = 0.29, p = .59. Results of the multivariate analysis identified age to be the
only statistically significant correlate of symptom status, OR = 1.06, 95% CI = 1.01 – 1.10, so
that the odds of achieving a 6-month period of symptomatic remission increased by 5.54% each
year older a participant gets.
Clinical recovery. Comparisons of the prognostic variables and stress experiences
between participants who achieved clinical recovery and participants who did not revealed
differences bearing on certain demographic and illness-related characteristics (see Table 9).
Participants who evidenced a 6-month period of clinical recovery differed from those who did
not in the following ways: they were significantly older, 51.63 vs. 40.69, respectively, t(73) = -
3.27, p < .01; they had a later age at onset of illness, 26.69 vs. 21.55, respectively, t(72) = -2.22,
p < .05; and they were more likely to be women, χ2(1, 75) = 2.83, p < . 10. The differences
between the two groups on the examined environmental variables were substantively significant,
but marginally statistically significant. Due to the low occurrence of clinical recovery in this
study sample (n = 16; 21.33%), its corresponding correlates could not be reliably estimated.
Indeed, the examined environmental variables and most of the prognostic indicators, with the
exception of age, did not emerge as significant correlates in the multivariate model. Concerning
age, older participants, on average, were significantly more likely to show clinical recovery for a
given gender and age at onset, OR = 1.07, 95% CI = 1.01, 1.14. More specifically, the odds of
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achieving a 6-month period of clinical recovery from schizophrenia increase by 7.30% each year
older a participant gets.
Several factors may explain the insignificant findings, but the main issue appears to be
that there was considerable variability in clinical and psychosocial profile of participants who did
not meet the clinical recovery criteria, thus obscuring the relationships between their
psychosocial profile and treatment outcomes. To gain a better picture of the factors that
differentiate between participants who evidenced clinical recovery from those who did not, the
comparison group was limited to those who were considered treatment resistant per the
consensus established by the Treatment Response and Resistant in Psychosis (TRIPP) Working
Group (Howes et al., 2016). Comparisons with participants who experienced persistence of
significant symptoms despite continuous use of antipsychotic medication or adequate treatment
revealed similar trends (see Table 9). On average, participants who were in clinical recovery
were significantly older than those with treatment resistant schizophrenia, 51.63 vs. 40.47, t(29)
= -2.51, p < .05, and had a later age at onset of illness, 26.69 vs. 18.71, t(29) = -3.26, p < .01.
The proportion of women who showed clinical recovery was greater than the percentage of men
who showed the similar outcome, 66.67% vs. 37.50%; in contrast, almost twice as many men as
women experienced persistence of significant symptoms, 62.60% vs. 33.33%, χ
2
(1, 31) = 2.63, p
= .10. Additionally, participants who did not experience any childhood adversities were more
likely to show clinical recovery compared to their counterparts who experienced childhood
maltreatment, parental maladjustment, or interpersonal loss, 66.67% vs. 47.05%, although this
difference was not statistically significant, χ
2
(1, 29) = 1.09, p = .30.

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Summary
Results indicate considerable heterogeneity in outcomes, with participants showing
varying levels of symptom severity and functional impairments. However, findings paint an
overall picture of poor treatment outcomes in this study sample, as evidenced by high proportion
of participants who were at least moderately symptomatic and showed poor functional outcomes.
Furthermore, clinical recovery from schizophrenia was not common in this sample. Results also
suggest that specific prognostic indicators of schizophrenia typically correlate differentially
across treatment outcomes: environmental conditions appear more relevant to symptoms
severity, whereas biological characteristics (age, gender, and age at onset of illness) were more
salient factors of global outcome.

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Chapter 6: Within-Group Differences in Treatment Outcomes of Asian Americans
Diagnosed with Schizophrenia
Study Aims
On the basis of research finding the effects of immigration-related factors on the mental
health needs and service use of Asian Americans, the outlined findings related to participants’
treatment outcomes were further stratified by ethnicity to identify differences between East
Asians and Southeast Asians. The aim of this third study was to answer the following research
questions: Is there a relationship between participants’ ethnicity and treatment outcomes?
Methods
Measures
Independent variables. Participants’ ethnicity groups were collapsed into East Asian
and Southeast Asian for analysis. Participants who identified as ethnically East Asian, but were
born and raised in Southeast Asia were classified as Southeast Asian. This group of participants
comprised largely of Vietnamese Americans who are ethnically Chinese.
Covariates. Similar to Study 2, the prognostic indicators of schizophrenia, namely, age at
study entry, gender, age at onset of illness, and history of childhood adversity were considered as
covariates where there were statistically significant differences between the ethnic groups being
compared.
Dependent variables. The outcomes examined were symptoms severity, role
functioning, symptomatic remission, and overall treatment responsiveness indicated by the
achievement of clinical recovery.
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Statistical Analyses
Univariable analyses were conducted to derive descriptive statistics for the study sample
– means and standard deviations were computed for continuous variable, and proportions for
categorical variables. Chi-square tests, with correction of unequal variances, whenever
necessary, or Fisher’s exact tests were performed to examine relationship between two
categorical variables, and two independent t tests were performed to compare means between the
ethnic groups. Multivariate ordinary least squares linear regression models were fitted to
estimate the effect of ethnicity on symptoms severity after controlling for relevant prognostic
indicators. Binary logistic regression analyses were performed to estimate the effect of ethnicity
on three categorical outcome variables, adequate role functioning, symptomatic remission, and
clinical recovery. Preselect two-tailed directional tests and statistical significance was
determined at  = .05.
Results
Overall, Southeast Asian participants and East Asian participants did not differ
significantly in the examined treatment outcomes of schizophrenia. Comparing the symptoms
severity of Southeast Asians with those of East Asians revealed no statistically significant
differences, with the exception of autistic preoccupation. Further examination of the data
revealed that the differences were small and thus, were not substantial enough to be clinically
significant. Southeast Asians were as likely as East Asians to achieve adequate role functioning,
experienced sustain remission of psychotic symptoms, and evidenced a 6-month period of
clinical recovery. Similar trends emerged in the multivariate analyses that included the set of
covariate variables in that participants’ ethnicity was not associated with outcomes over and
above the influence of the examined prognostic indicators of schizophrenia (results not shown).
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Chapter 7: Discussion
Despite the country’s growing diversity, racial and ethnic minorities continue to be
underrepresented in research, especially clinical research. Among the many implications of the
“majority-minority” nation projection for social work researchers include the need to increase
representation of racial and ethnic minorities in research. The increased representation of
minorities in research is needed not only to broaden the generalizability of research findings but
also to yield pertinent data on race- and ethnicity-related mechanisms for human diseases and
disorders. Importantly, enrolling racial and ethnic minorities in research will enable the
investigation of any disparities in status, service access and use, health care quality, and
treatment outcomes. This study is a reflection of a collective effort toward filling this research
gap by recruiting Asian Americans with schizophrenia into research. The overarching goals of
this study were to characterize Asian Americans who are treated for schizophrenia in community
mental health agencies and examine their responsiveness to treatment. This is one of few studies
to provide information on schizophrenia among different detail Asian groups including Chinese,
Filipino, Vietnamese, Koreans, Japanese, and Cambodian. To the best of our knowledge, this is
the first and largest study to provide a comprehensive data that reflects the resources, needs, and
experiences of an ethnically diverse sample of Asian Americans diagnosed with schizophrenia.
Data for this cross-sectional study came from interviews conducted between February
2016 and 2017 with 75 Asian Americans seen at community mental health agencies for a
diagnosis of schizophrenia. Using convenient sampling methods, participants were recruited
from four mental health agencies directly operated or contracted by the LACDMH and two
board-and-care facilities in Los Angeles where they were receiving services. Data collection
efforts yielded a sample composed of mostly individuals with established schizophrenia who
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have been engaged in mental health treatment and services. Participants have an average duration
of service use of 10.29 years. The higher levels of engagement in mental health treatment and
services in this study sample may be due in large part to the availability of ethnic-specific
programs. Takeuchi and colleagues (1995) have found that Asian Americans in Los Angeles who
received services from ethnic-specific mental health programs were significantly more likely
than their counterparts who received services from mainstream programs to continue in
treatment. Indeed, the availability of bicultural and bilingual mental health providers who were
matched to clients of similar ethnicity appeared to be a salient facilitator of service engagement
in this study sample, especially among foreign-born participants given their lower levels of
English proficiency and varied levels of acculturation.
The outlined demographic characteristics suggest that participants were socially and
economically more disadvantaged than the general Asian American population, largely
evidenced by their overall lower levels of educational attainment, participation in labor force,
and English proficiency. Some socioeconomic disadvantages such as those stemming from their
lower educational attainment appear to have occurred prior to the onset of the disorder and
amplified with the onset of schizophrenia. Consistent with findings from extant research
involving other racial and ethnic groups with serious mental illness (Mohr et al., 2011), religion
appeared to be an integral part of most participants’ lives on the basis of the finding that the
majority of participants (72.00%) reported having a religious identity. However, a relatively
smaller proportion of participants (56.00%) attended public religious activities or participated in
private religious activities (48.00%) during the previous year. These lower levels of religious
involvement in this sample are inconsistent with those reported in previous research on the use of
religious and spiritual coping strategies among individuals with serious mental illness (Mohr et
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al., 2012; Tepper et al., 2001). This finding suggests that religion may be less influential in the
lives of Asian American participants with schizophrenia, although a larger number reported
having a religious affiliation.
The emphasis on family is strong among Asian Americans. Clinical observations of
mental health care providers suggest that a considerable number of Asian Americans diagnosed
with schizophrenia and other serious psychiatric conditions are cared for by or have ongoing
contact with their immediate family members. This indicates the importance of learning about
the extent of family involvement and the functioning of Asian American families whose lives
have been affected by schizophrenia, which could help identify familial patterns that are
consequential for poor treatment outcomes. The majority of existing research on family factors
that influence the course of schizophrenia has focused on caregivers’ expressed emotions and
burden. Expressed emotions refer to the affective attitudes and behavior of relatives toward a
family member with schizophrenia, whereas family burden relates to the disruptions in daily
activities and psychological consequences for relatives related to caring for a family member
with schizophrenia. To contribute to the knowledge base of the influence of family factors on the
outcomes of schizophrenia among Asian Americans, this study examined participants’ living
arrangement, frequency of family contact, and family functioning from the perspective of
individuals with the disorder.
Results revealed that the proportion of participants living with parents is considerably
higher than the rate reported in previous studies involving mostly participants belonging to other
racial and ethnic groups, whereas the proportion of participants in independently living was
significantly lower (Stueve, Vine, & Struening, 1997; Tsai, Stroup, & Rosenheck, 2011). This
finding suggests that parents, rather than significant others or siblings, are more likely to be the
96
primary caregivers of Asian Americans with schizophrenia. This is a reasonable speculation
given that most participants had never been married and that secondary family members (e.g.,
adult siblings) tended to be married with familial responsibilities. Research has provided some
empirical evidence of this finding (Kung, 2003; Okazaki, 2000). In a study that examined the
burden of caring for a family member with schizophrenia among Chinese Americans, Kung
(2003) found that the majority of respondents were parents (60%). Similarly, Okazaki (2000)
found that the majority of Asian American clients with severe mental illness (58.1%) were living
with one or both parents. Further evidence of the centrality of Asian American parents as
caregivers of adults with serious mental illness came from the finding that parents’ inability to be
involved in caregiving appeared to be a precipitating factor for independent or supervised living
among participants in this study. Findings also indicate that most participants (90.54%) reported
having contact with their family members regardless of their living situation, which is
considerably higher than the proportion among individuals belonging to other racial and ethnic
groups (Lehman & Steinwachs, 1998). The presence of a surviving parent appeared to influence
not only participants’ living arrangements but also the frequency of family contact. This further
highlights that in the Asian community, parents are integral to the caregiving of a relative with
mental illness.
There has been little research on the types and distribution of social adversities
experienced by Asian Americans with mental health needs, much less, those with the most
serious psychiatric conditions. This study featured a comprehensive assessment of various
experiences to disaggregate the effects of acute stressors stemming from recent life events,
chronic strains, and major traumatic events, and importantly, to determine whether these
97
disaggregated effects were significant for understanding variability in treatment outcomes of
schizophrenia.
Related to acculturative stress, the mean level found in this study sample is lower than
that reported by previous studies using data from the National Latino and Asian American Study
(Lueck & Wilson, 2010; Gong et al., 2011). It is important to consider the context from which
the study sample was drawn from in interpreting this finding. The lower mean acculturative
stress level may be partly due to the majority of participants living in residential ethnic enclaves
where ethnicity-specific mental health programs operated. The diverse racial and ethnic
composition of Los Angeles may have also protected immigrants from experiencing more
acculturative stress than their counterparts living in less diverse cities. Importantly, the lower
level of acculturative stress in this study sample may also be explained by measurement
differences between studies. Specifically, acculturative stress was measured as lifetime
experience in the National Latino and Asian American Study, whereas this study limited the
assessment to the preceding six months. Findings of higher levels of acculturative stress among
first generation immigrants compared to 1.50-or-earlier generation immigrants suggest that
acculturative stress may not be as consequential in the treatment outcomes of more naturalized
Asian Americans with schizophrenia than their counterparts who immigrated to the country as
adults.
Findings on the prevalence rates of individual adverse childhood events are consistent
with previous studies that have found high prevalence of childhood trauma in clinical
populations (Read et al., 2005; Morgan & Fisher, 2007). Indeed, previous studies of early
adverse experiences have consistently found higher prevalence of abuse or neglect among
respondents with psychiatric conditions, especially serious mental illness, compared to the
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general population (Read et al., 2005; Morgan & Fisher, 2007). Overall, 58.33% of participants
reported at least one adverse childhood event related to maltreatment, parental maladjustment
(mental illness or substance use), and interpersonal loss (parental divorce or separation, or
separation from parents). Although comparable to the prevalence of 53.4% in the general
population (Green et al., 2010), the prevalence rate may be underestimated in this study sample
given that data on other adverse childhood events related to kinship care or out-of-home
placement, parental criminality, and domestic violence were not gathered. When all assessed
adverse childhood events were considered, findings revealed that the majority of participants
(83.10%) reported at least one childhood adversity.
Concerning participants’ lifetime exposure to major traumatic events, findings highlight
that Asian Americans with schizophrenia are as vulnerable as individuals belonging to other race
and ethnicity with similar diagnosis to experiences of arrest and victimization. Close to half of
participants reported having been a victim of physical assault in adulthood by an intimate
partner, strangers, or acquaintances. This rate is not unexpected given that research has
consistently found victimization among individuals with serious mental illness to be significantly
higher than in the general population (Choe, Teplin, & Abram, 2008; Chuang et al., 1987;
Teplin, McClelland, & Abram, 2005). The proportion of participants who have ever experienced
physical assault in adulthood is comparable to those found in other community samples of
persons with serious mental illness (Brekke et al., 2001; Chuang et al., 1987). These comparable
rates suggest that Asian Americans with schizophrenia are as vulnerable as individuals with
schizophrenia who belong to other racial and ethnic groups to being victims of violent crimes in
adulthood. On the contrary, the lower rate of recent victimization in this sample may be
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attributable to the higher occurrence of important risk factors of victimization among participants
enrolled in previous studies, namely, homelessness and substance use.
Similarly, the finding that more than 4 in 10 participants reported a history of arrest is not
surprising given that arrest rates have been found to be higher among individuals with
schizophrenia than in community samples without a history of psychiatric condition (Harry &
Steadman, 1989). However, the lifetime arrest rate in this study sample is lower than those found
in other community samples of adults treated for schizophrenia. Because being male has been
found to be a risk factor for arrest among individuals with serious mental illness (White et al.,
2006), the higher arrest rates described in previous studies may be due in part to the larger
number of men in these samples, which ranged from 68% to 75% (Brekke et al., Lafayette et al.,
2003; White et al., 2006), compared to 56% in the present study. Research has also found that
people with serious psychiatric disorders were more likely to be arrested during periods
decompensated mental states, generally triggered by non-adherence to antipsychotic medications
(Robertson, Pearson, & Gibb, 1996), and when homeless (White et al., 2006). Accordingly, the
low rate of arrest in the prior 6 months in this study sample may be explained by the findings that
all participants were housed and engaged in services, and most reported high levels of
medication use.
Compared to previous studies, the occurrence of sexual assault or abuse in this study
sample is lower. The lower rate may be partly attributed to underreporting by participants and
previous studies using samples with a mix of psychiatric diagnoses. Indeed, Spence and
colleagues (2006) found that 32.50% of respondents in a sample of adults with schizophrenia
reported having ever been sexually assaulted or abused, a rate that is comparable to the present
study (20.55%). However, the finding that occurrence of sexual assault or abuse did not differ by
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gender was unexpected, as previous studies of individuals with serious mental illness tended to
have found higher lifetime rates of sexual assault and abuse among women than men (Goodman
et al., 2001; Mueser et al., 2004). On the other hand, this finding reveals that Asian American
men with schizophrenia may be equally vulnerable to sexual assault as women with serious
mental illness. However, findings related to other traumatic events indicate that men may be
more vulnerable to being a victim of physical assault and being arrested compared to women.
Interestingly, more than half of participants did not experience a recent life event. Among
those who did, the most common negative life event concerned the behavior of a family member,
followed by involuntary unemployment. However, the overwhelming majority of participants
reported experiencing at least one chronic life event in the previous 6 months. This set of
stressors appears to be attributed to the lack of or failed efforts to engage with one’s
surroundings, which is counter-intuitive given the widespread perception that stress among
individuals with schizophrenia is generally triggered by surplus exposure to life events rather
than the lack thereof. This finding may suggest that withdrawing from one’s surrounding can
engender low-grade but long-lasting stress among individuals with schizophrenia. Additional
multivariate analyses were performed to examine the relationship between the experience of
chronic strain indexed by engagement with one’s surroundings and psychological stress. Keeping
constant gender, severity of major symptoms of schizophrenia, and exposure to other
environmental stressors, participants who reported higher levels of chronic strains were found to
have significantly higher levels of psychological stress. Further support for the disadvantages of
not being engaged with one’s surroundings comes from findings of a significant positive
association with levels of depression even after partialling out the effects of core symptoms of
schizophrenia. These results suggest that among individuals who are in the stable phase of
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schizophrenia, the minor events of life were a related form of stressful experiences. Furthermore,
it was not the exposure to negative life events, but the lack of opportunities to be engaged with
one’s surroundings that seemed to engender stress in the majority of participants.
In addition to describing the demographic characteristics of Asian Americans with
schizophrenia, this study also focused on the treatment outcomes of this population on average
10.29 years (Median = 7.67; range = 0.08–30) after their index admission to the community
mental health agency where they were recruited for study participation. Several dimensions of
outcomes were examined in this study, namely, symptoms severity, role functioning,
symptomatic remission, and clinical recovery. Results indicate considerable heterogeneity in
outcomes, with participants showing varying levels of symptoms severity and functional
impairments. Some participants had no more than mild symptoms of schizophrenia, but were not
engaged in any meaningful activities (14.67%). A handful of participants were able to show
remittance of functional deterioration despite having delusions or hallucinations of at least
moderate intensity (13.33%). However, most participants were found to have intermediate levels
of functioning and symptoms severity (50.66%), with a handful of participants (21.33%)
evidencing good global outcome indicated by a 6-month period of clinical recovery. Treatment
outcomes were comparable between Southeast Asians and East Asians, which failed to support
the hypothesis that the former would show poorer outcomes on the basis of different
premigration stressors and migratory motivations.
Findings related to the low occurrence of symptomatic remission in this study sample
(36.00%) demonstrate that there were a sizable number of participants who were vulnerable to
persisting psychotic symptoms despite receiving maintenance antipsychotic medication. Perhaps
of greater importance is the finding that a very large percentage of participants (65.33%) showed
102
poor role or vocational adjustment. This finding is notable given the risk of long-term
socioeconomic disadvantage among individuals who are not gainfully employed. Another
noteworthy finding concerns the association between symptoms severity and functional
outcomes. Results from this study revealed that participants who achieved sustained remission of
psychotic remission had significantly higher likelihood of engaging in meaningful activities at
least half the time in the preceding 6-months period compared to participants with unremitted
psychosis. This finding of an association between symptom status and functional outcome is
consistent with previous studies (Brier, Schreiber, Dyer, & Pickar, 1991; Harding, Brooks,
Ashikaga, Strauss, & Breier, 1987; Haro, J. M., Novick, D., Suarez, D., Ochoa, S., & Roca, M.,
2008). Findings also revealed that after partially out the effects of age, age at onset of illness, and
exposure to environmental stressors, participants who continued to experienced chronic residual
symptoms reported significantly higher levels of psychological stress than participants who were
in remission. This indicates that residual psychotic symptoms are associated with higher levels of
perceived stress. Of note is the finding that symptomatic remission was as common as the
achievement of adequate role adjustment is inconsistent with earlier studies that have tended to
find higher rates of symptomatic remission (e.g., Haro et al., 2011; Lim et al., 2015).
Collectively, these findings demonstrate the need for interventions aimed at improving
symptoms control among participants.
In this study, recovery was defined as the alleviation of core symptoms of schizophrenia
to a degree that had minimal interference with daily functioning. Findings from this study
indicate an overall picture of poor treatment outcomes in this study sample, as evidenced by high
proportion of participants who were at least moderately symptomatic and showed poor functional
outcomes. Furthermore, clinical recovery from schizophrenia was not common in this sample.
103
However, the rate of recovery in this study is consistent with earlier studies of recovery from
schizophrenia and comparable to those reported in other diagnostically similar samples
comprising of other race and ethnicities (Lim et al., 2015; Breier, Schreiber, Dyer, & Pickar,
1991). Nonetheless, the finding that about 20% of participants achieved good global outcome
suggests that clinical recovery, as indicated by the simultaneous achievement of low-grade
psychotic symptoms and adequate role functioning, is achievable among some individuals with
schizophrenia. This finding is in contrast to the prevailing perception that schizophrenia is
characterized by uniformly poor outcomes and lends support to the growing notion that
schizophrenia is a highly heterogeneous disorder.
Research on the influence of environmental conditions on outcomes of schizophrenia has
been scant given the focus on clinical and treatment characteristics of the majority of studies.
This study contributes to a growing body of research on recovery from schizophrenia by
investigating the contribution of exposure to favorable and adverse environments on treatment
outcomes. Specifically, this study examined exposure to two dimensions of stress, acute stressor
stemming from a recent life or traumatic event and chronic strains. Additionally, this study
examined the impact of exposure to supportive environments controlling for exposure to
stressors. According to the vulnerability stress model of schizophrenia, the interaction of
psychosocial stressor with a biological vulnerability for schizophrenia results in symptom
exacerbation. Although the experience of stressful life events has the potential to exacerbate
psychotic symptoms in schizophrenia, results from this study suggest otherwise. Higher levels of
exposure were not significantly associated with the syndromes characteristic of schizophrenia
(i.e., positive and negative symptoms), but with other general psychopathology, namely,
dysphoric mood and activation symptoms. However, healthier family functioning was mostly
104
consistently associated less severe symptoms across the examined syndromes of schizophrenia.
Although the effect sizes of these environmental correlates were no more than moderate in
strength, these findings suggest that severity of symptoms in schizophrenia are not independent
from environmental conditions in that it appears responsive to supportive environments.
Importantly, levels of exposure were comparable between participants with poor outcomes and
those who showed good treatment outcomes, as evidenced by sustained remission of psychotic
symptoms, maintenance of adequate role functioning, and overall clinical recovery for a period
of 6 months. Although these results were not in the direction predicted, the null findings
demonstrate that the absence of stress is not necessary to prompt more favorable outcomes in
schizophrenia.
The wider range in age found in this study sample allowed for the investigation of the
effects of age on treatment outcomes in schizophrenia. Results revealed that more positive global
outcome was significantly associated with age in that clinical recovery was more common
among older participants – 45.83% of participants aged 50 and older showed clinical recovery
compared to 7.84% of participants below 50 years old. Similar findings were noted in relation to
age and symptoms severity and role functioning. This finding upholds the observations of prior
long-term follow-up studies that schizophrenia reaches a plateau in terms of severity during the
early phase and tends to improve over time (Carpenter & Strauss, 1991). There were several
noteworthy trends that did not reach statistical significance, likely because of the study’s small
sample size and low occurrence of good outcomes (i.e., adequate role functioning, symptomatic
remission, and clinical recovery). These include the associations between positive treatment
outcomes and being female, having an earlier age at onset of illness, and the absence of
childhood adversities. Overall, results from this study suggest that specific prognostic indicators
105
of schizophrenia typically correlate differentially across different treatment outcomes. Indeed,
environmental conditions appear more relevant to symptoms severity, whereas biological
characteristics such as age, gender, and age at onset of illness were more salient factors of global
outcome.
Limitations
Findings from this study must be interpreted in light of the characteristics of this sample.
Participants in this study were not randomly selected, thus were not representative of all Asian
Americans with schizophrenia. The use of a non-probability method of sampling yielded a
sample that is unbalanced in demographic and clinical characteristics. Specifically, the study
failed to reach clients who were not engaged in treatment, have severe negative symptoms, or
highly symptomatic. In other words, participants were selectively healthier than non-participants.
Accordingly, this study sample is not representative of the intended study sample and of the most
severely ill. On this basis, the occurrence of clinical recovery and other favorable treatment
outcomes are likely inflated in this sample. Results from this study indicate an association
between the environment and treatment outcome, with the strongest association found with
severity of symptoms. Given the cross-sectional nature of this study, results cannot be inferred as
causation. Accordingly, it is possible that participants with more severe symptoms had higher
probability of reporting more negative ratings. Despite our concerted efforts to measure the
environmental stressors salient in the lives of Asian Americans with schizophrenia, some of the
administered measures may have lacked appropriate sample-specific content. This may explain
the insignificant findings related to the association between recent life events and the various
dimensions of outcomes.
106
Conclusions
This study is the first to date to examine the treatment outcomes of an ethnically diverse
sample of Asian Americans served in community mental health agencies for a diagnosis of
schizophrenia. The impetus for this study came from the hope that findings would challenge the
prevalent notions about the unfavorable outcome of schizophrenia, inform decisions about
treatment and program development, and shape policies for the delivery of services within
mental health systems for a growing group of Asian Americans with schizophrenia.
The implications of this study’s findings relate to ways to enhance the treatment
outcomes and prevent further socioeconomic disadvantages of Asian Americans with
schizophrenia. First, the availability of culturally relevant supported employment programs for
Asian Americans with schizophrenia has the potential to increase this population’s participation
in the labor force, thereby decreasing their risk of a life of socioeconomic disadvantages. Second,
on the basis of research establishing the efficacy of family interventions for the treatment of
schizophrenia, results from this study of the influence of balanced cohesion in the family system
on symptoms severity suggest that this psychosocial intervention could be open to all relevant
family members, whenever possible, to foster cohesion in the family unit. Treatment of
schizophrenia has hitherto focused on stress reduction and management. This may have partly
resulted in individuals with schizophrenia not fully engaging in a productive life, fearing that any
involvement may potentially trigger a relapse. However, results from this study showed that
stress was associated with the lack of engagement with one’s surroundings. It is also noteworthy
that these lower-intensity daily stressors were reported at a considerably higher frequency than
other types of stressors related to trauma or life events. One inference that can be drawn from the
preceding findings is that chronic strains stemming from the lack of or failed efforts to engage
107
with one’s surroundings should be a target of intervention. Opportunities for engagement in
meaningful activities characterized by opportunities to contribute, to meet potential life partners,
and to be socially connected has the potential to alleviate depression and enhance quality of life
among Asian Americans with schizophrenia. Lastly, the availability of atypical pharmacological
treatments and empirically verified psychosocial interventions make clinical recovery from
schizophrenia a viable treatment goal. Findings from this study support the need for increased
treatment expectations beyond mere symptoms control and service engagement to include
sustained periods of clinical recovery among Asian Americans with serious psychiatric disorders.
In conclusion, this study serves as a first step for future research on Asian Americans
with schizophrenia and serious psychiatric disorders. Given the smaller sample size, we contend
the several differences found between subgroups, although not statistically significant, were
substantively significant in that the differences were large enough to be important in the context
of mental health service delivery. However, findings would benefit from replication from future
studies with larger sample size.

108
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129
Table 1. Demographic Profile of Study Sample (N = 75)

Variable M (SD) n (%)
Ethnicity
a

Chinese

40 (53.33)
Korean

10 (13.33)
Cambodian

8 (10.67)
Japanese

7 (9.33)
Vietnamese

5 (6.67)
Filipino

4 (5.33)
Thai

1 (1.33)
Age 43.03 (12.61)

Gender

Men

42 (56.00)
Women

33 (44.00)
Nativity

Foreign-born

53 (70.67)
US-born

22 (29.33)
Primary language

English

33 (44.00)
Asian language

41 (54.67)
English proficiency

Excellent or good

48 (64.00)
Fair

18 (24.00)
Poor or does not speak English

9 (12.00)
Marital status

Not married

56 (74.67)
Currently married

3 (4.00)
Previously married
b

16 (21.33)
Educational attainment

< High school

10 (13.70)
High school graduate

18 (24.00)
Some college education
c

29 (38.67)
Completed college

11 (14.67)
Employment status

Unemployed

57 (76.00)
Some employment

8 (10.67)
Student

7 (9.33)
Supported employment

2 (2.67)
Living situation

With family

42 (56.00)
Parent(s) only

21 (50.00)
Parent(s) and sibling(s)

13 (30.95)
Sibling(s) only

7 (16.67)
Board-and-care facility

26 (34.67)
Independent

7 (9.33)
Religious affiliation

Christianity

34 (45.33)
130
No religious affiliation

21 (28.00)
Buddhism

14 (18.67)
Other affiliation
d
6 (8.00)
a
The majority of participants identified with only one detailed Asian group, such as “Chinese” or “Vietnamese,”
with only one participant reporting more than one race (Vietnamese and White).
b
Comprised participants who were separated, divorced, and widowed.
c
Includes trade school, community college, and college.
d
Comprised of multifaith, Judaism, Latter Day Saints, and Taoism.

131
Table 2. Family Functioning of Study Sample Compared to First-Episode Psychosis Sample, Chronic Schizophrenia Sample,
and Healthy Controls
Variable
Living with
Family
Living
Independe
ntly
a

Study
Sample
First-
Episode
Chronic
Schizophre
nia
b

Healthy
Controls
b

p
c

(n = 42) (n = 33) (N = 75) (n = 50) (n = 50) (n = 50)
Ratio scores, M (SD)

Cohesion 1.81 (0.80) 1.29 (0.78) 1.59
(0.83)

1.63 (0.75) 2.76
(0.58)
<
.01 Balanced, n (%) 38 (90.48) 18 (56.25) 56 (75.68)

Flexibility 1.70 (0.70) 1.49 (0.64) 1.63
(0.69)

0.96 (0.45) 2.40
(0.59)
0.26
Balanced, n (%) 39 (92.86) 15 (75.00) 54 (87.10)

Total Circumplex 1.76 (0.69) 1.40 (0.64) 1.64
(0.69)

1.29 (0.57) 2.58
(0.53)
0.06
Balanced, n (%) 38 (90.48) 14 (70.00) 52 (83.87)

Raw scores, M (SD)

Cohesion 26.83 (5.72) 20. 30
(1.50)
23.96
(7.81)
29.58
(5.65)
24.92
(6.61)
32.06
(2.99)
<
.001 Flexibility 24.45 (5.33) 22.75
(5.23)
23.90
(5.32)
22.14
(5.19)
16.18
(5.14)
27.10
(3.78)
0.19
Disengage 18.64 (6.35) 24.72
(7.27)
21.27
(7.37)
13.76
(5.33)
17.06
(6.61)
11.32
(2.71)
<
.001 Enmeshed 14.07 (4.42) 10.76
(3.95)
12.61
(4.51)
15.04
(4.09)
17.12
(6.16)
12.70
(2.82)
<
.01 Rigid 18.50 (5.82) 19.64
(5.06)
18.89
(5.55)
16.84
(4.22)
19.40
(5.59)
13.36
(3.44)
0.63
Chaos 12.93 (4.61) 13.52
(4.81)
13.12
(4.65)
12.76
(5.42)
17.08
(7.07)
10.16
(3.01)
0.66
Levels, n (%)

Cohesion

Somewhat
connected
5 (11.90) 15 (45.45) 20 (26.67)

<
.01 Connected 18 (42.86) 10 (30.30) 28 (37.33)

Very connected 19 (45.24) 8 (24.24) 27 (36.00)

Flexibility

Somewhat flexible 6 (14.29) 3 (14.29) 9 (14.29)
0.64
Flexible—very
flexible
36 (85.71) 18 (85.71) 54 (85.71)

Disengagement

Low—very low 40 (53.34) 11 (33.33) 40 (53.33)
<
.01
Moderate 8 (19.05) 6 (18.18) 14 (18.67)

High—very high 35 (46.67) 16 (48.48) 21 (28.00)

Enmeshment

Low—very low 32 (96.97) 39 (92.86) 71 (94.67)

0.63
132
Moderate 3 (7.14) 1 (3.03) 4 (5.33)

Rigidity

Low—very low 27 (64.29) 17 (77.27) 44 (68.75)
0.29
Moderate—very
high
15 (35.71) 5 (22.73) 20 (31.25)

Chaos

Low—very low 39 (92.86) 20 (95.24) 59 (93.65)
0.59
Moderate—high 3 (7.14) 1 (4.76) 4 (6.35)

Note. Family functioning was assessed with the Family Adaptability and Cohesion Evaluation Scale IV.

a
Comprised participants who were living independently or in board-and-care facilities.
b
Participants comes from a research study by Kourtra and colleagues (2014).
c
Test statistic represents comparison between participants who were living with their family members and participants who were living independently or in
Board-and-care facilities.
133
Table 3. Prevalence of Major Traumatic Events and Level of Psychological Stress
Compared to Other Psychiatric Samples and the General Population
Variable Study Sample
Psychiatric
Sample
General
Population
N (%) % %
Adverse Childhood Events, M (SD) 2.26 (2.16)

Scared 28 (39.44)

Major illness that required hospitalization 21 (28.38)

5.8
Separation from parents 18 (25.00) 9.6–41.3 6.7
Repeating a grade 18 (24.32)

Neglect 17 (23.29) 17.7 5.6
Parental divorce or separation 17 (22.97) 28.3–35.9 17.5
Emotional abuse 14 (19.18) 13.2–17.2 11.1
Parental unemployment 11 (15.07)

Parental mental illness 11 (14.67) 21.4 10.3–17.5
Physical abuse 10 (13.70) 13.5–56.4 8.4–10.8
Parental substance use 9 (12.33) 35.0 8.5–25.6
Any adversities 59 (83.10)

Lifetime Trauma

Parental loss 34 (45.33)

Arrested 32 (43.84) 49–71
Assaulted 25 (38.46) 27.5–84.4
Sexually abused or assaulted 15 (20.55) 32.5–51.5
Psychological Stress, M (SD) 18.34 (7.85)
Gender
Men 17.33 (8.00) 15.52 (7.44)
Women 19.65 (7.57) 16.14 (7.56)
Age
Less than 25 17.00 (9.57) 16.78 (6.86)
25—34 15.77 (8.33) 17.46 (7.31)
35—44 22.05 (8.88) 16.38 (7.07)
45—54 17.31 (6.61) 16.94 (7.83)
55—64 17.63 (5.61) 14.50 (7.20)
Race and ethnicity
White 15.70 (7.51)
Black 15.68 (7.51)
Latino 17 (7.45)
Other 17.44 (7.67)
Asian 18.34 (7.85)
Educational attainment
< High school 16.40 (6.88) 19.11 (7.92)
High school graduate 18.57 (8.28) 16.59 (7.76)
Some college education 17.79 (7.73) 16.00 (7.54)
Completed college 21.82 (8.07) 15.17 (7.22)
Note. Values represent n (%) unless otherwise noted.

Table 4
134
Table 4. Prevalence of Chronic Stressors in Study Sample
Difficulty finding someone compatible 40 (54.79)
Long-term health problem 40 (54.05)
Alone too much 40 (54.05)
Don't have enough money 36 (48.65)
Wonder whether one will ever get married 34 (46.58)
Don't have enough friends 35 (47.30)
Taking on too many things at once 32 (43.24)
Too much pressure to be like others 32 (43.24)
Having to attend social events alone 30 (40.54)
Too much is expected by others 28 (37.84)
Want to live father away from family 22 (29.73)
Long-term illness or disability in a family member 22 (29.73)
Family lives too far away 19 (25.68)
Wish to have children 18 (24.32)
Long-term debt or loan 14 (18.92)
Family member is in bad health and may die 11 (14.86)
Substance use in a family member 10 (13.51)
Caring for an aging parent almost daily 7 (9.46)
Note. Values represent n (%).

135
Table 5. PANSS Items Measuring the Five Syndromes of Schizophrenia
Positive
Delusions
Hallucinatory behavior
Grandiosity
Somatic concerns
Unusual thought content
Negative
Blunted affect
Emotional withdrawal
Poor rapport
Passive or apathetic social withdrawal
Lack of spontaneity and flow of conversation
Mannerisms and posturing
Motor retardation
Uncooperativeness
Disturbance of volition
Poor impulse control
Activation
Excitement
Hostility
Poor rapport
Tension
Uncooperativeness
Poor impulse control
Dysphoric Mood
Somatic concerns
Anxiety
Guilt feelings
Tension
Depression
Autistic Preoccupation
Hallucinatory behavior
Difficulty in abstract thinking
Stereotyped thinking
Poor attention
Disturbance of volition
Preoccupation
Note. All items were measured with the Positive and Negative Syndrome Scale (PANSS).

136
Table 6. Treatment Outcomes of Study Sample

M (SD) n (%)
Symptoms severity
a

Positive syndrome
b
10.55 (4.33)

Negative syndrome
c
19.53 (6.19)

Activation
d
9.72 (3.57)

Dysphoric Mood
e
9.95 (3.12)

Autistic Preoccupation
f
11.85 (4.62)

Adequate role functioning

26 (34.67)
Symptomatic remission

27 (36.00)
Clinical recovery

16 (21.33)
Note. Adequate role functioning was defined as being engaged in age appropriate roles (gainful
employment, student, homemaker, volunteer, or caregiver) at least half the time during the previous 6
months.
a
Measured with the Positive and Negative Syndrome Scale; higher scores indicate more severe
symptoms; scores were reflective of levels of psychopathology in the previous 2 weeks.
b
Scores were the summed of 5 items from the PANSS and possible values ranged from 5 to 35.
c
Scores were the summed of 10 items from the PANSS and possible values ranged from 10 to 70.
d
Scores were the summed of 6 items from the PANSS and possible values ranged from 6 to 42.
e
Scores were the summed of 5 items from the PANSS and possible values ranged from 5 to 35.
f
Scores were the summed of 6 items from the PANSS and possible valules ranged from 6 to 42.

137
Table 7. Fitted Multivariate Linear Regression Models of Symptoms Severity of Schizophrenia by Environmental Influences

Positive Negative Activation Dysphoric Mood Autistic Preoccupation
b SE β b SE β b SE β b SE β b SE β
Environmental influences

Recent stressor 0.10 0.97 .01 -1.36 1.45 -.11 1.66 0.86 .23
†
2.09 0.36 .31
**
1.41 1.06 .15
Chronic strains 0.37 0.46 .09 -0.05 0.72 .00 0.09 0.42 .03 0.99 0.36 .31
**
0.12 0.59 .03
Balanced cohesion
c
-2.87 1.63 -.23
†
-4.26 2.33 .22
†
-1.72 1.43 -.17 -2.18 0.80 -.23
**
-3.36 1.73 -.24
†

Covariates

Age
b
-0.08 0.04 -.25
†
-0.09 0.07 -.17 -0.05 0.04 -.16 -0.01 0.04 -.06 -0.14 0.04 -.38
**

Quadratic term: age
2
-0.01 0.00 -.35
**
0.00 0.00 .11 0.00 0.00 .07 0.00 0.00 .13 -0.01 0.00 -.36
**

Female -0.28 0.94 '-.03 -0.65 1.38 -.05 0.45 0.86 -.06 -0.18 0.65 -.03 -0.12 0.90 -.01
Age at onset
c
11.47 13.98 .10 37.32 21.97 .21
†
12.82 11.20 .13 -1.89 6.87 -.02 8.90 16.32 .07
Childhood adversity -0.36 1.06 -.04 1.30 1.45 .10 0.87 0.99 .12 -0.67 0.69 -.10 -0.64 0.99 -.07
R
2
21.62 16.55 20.52 32.14 31.32
df 63 63 63 63 63
F 3.63
**
1.59 3.11
**
5.18
***
5.84
***

Note. b, unstandardized regression coefficient; β, standardized regression coefficient; SE, unstandardized coefficient standard erro r, calculated using robust estimator; df,
degrees of freedom. Analyses were conducted using data from participants who had completed information for all variables included in the analytic model (n = 63);
accordingly, the df reflects number of cases with complete data used in the analyses, less number of parameters estimated.
†p < .10. *p < .05. **p < .01. ***p < .001.
a
Variable received a transformation by dividing its square root by 1.
b
Variable was centered.
c
A square root transformation was applied to the variable.
138

Table 8. Bivariate Analyses of Environmental Influences and Prognostic Indicators by Functional Outcomes and Symptom
Status

Poor Functioning
Adequate
Functioning
Test Statistic Unremitted In Remission Test Statistic
(n = 49) (n = 26) (n = 48) (n = 27)
Environmental Influences

Recent stressor

No 21 (53.85) 18 (46.15)
χ
2
(1, 73) = 4.05
*

25 (64.10) 14 (35.90)
χ
2
(1, 73) = 0.04
Yes 26 (76.47) 8 (23.53) 21 (61.76) 13 (38.24)
Chronic strains -0.02 (0.94) 0.11 (1.07) t(72) = -0.53 0.05 (0.97) -0.03 (1.03) t(73) = 0.34
Balanced cohesion 1.59 (0.86) 1.58 (0.79) t(72) = 0.02 1.57 (0.83) 1.61 (0.83) t(72) = -0.19
Covariates

Age 41.14 (11.25) 46.58 (14.41) t(73) = -1.80
†
40.19 (11.77) 48.07 (12.69) t(73) = -2.71
**

Gender

Female 19 (57.58) 14 (42.42)
χ
2
(1, 75) = 1.57
20 (60.61) 13 (39.39)
χ
2
(1, 75) = 0.29
Male 30 (71.43) 12 (28.57) 28 (66.67) 14 (33.33)
Age at onset 21.50 (8.78) 24.81 (7.26) t(72) = -1.64 21.96 (8.71) 23.89 (7.78) t(72) = -0.95
Childhood adversity

No 17 (56.67) 13 (43.33)
χ
2
(1, 72) = 1.16
18 (60.00) 12 (40.00)
χ
2
(1, 72) = 0.14
Yes 29 (69.05) 13 (30.95) 27 (64.29) 15 (35.71)
Note. Values represent n (%) unless otherwise noted. Values represent row percentages for categorical explanatory variables.
†p < .10. *p < .05. **p < .01. ***p < .001.

c
Indicated by the experience of maltreatment (physical abuse, emotional abuse, or neglect), parental maladjustment (mental illness or substance use), or
interpersonal loss (parental divorce or separation, or separation from parents) before 18 years old. b
Indicated by exposure to a major traumatic event or acute stressor during the previous 6 months.
c
Values represent M (SD).
d
Assessed with an inventory developed by Wheaton (1994); scores were standardized and higher scores reflect higher levels of c hronic stressors.
e
Assessed with the Family Adaptability and Cohesion Evaluation Scale IV; higher scores reflect healthier family functioning.

139
Table 9. Bivariate Analyses of Environmental Influences and Prognostic Indicators by Recovery Status
Not in Recovery In Recovery Test Statistic
Treatment
Resistant
In Recovery Test Statistic
(n = 59) (n = 16) (n = 15) (n = 16)
Environmental Influences

Recent stressor

No 29 (74.36) 10 (25.64)
χ
2
(1, 73) = 0.68
8 (44.44) 10 (55.56)
χ
2
(1, 29) = 0.00
Yes 28 (82.35) 6 (17.65) 5 (45.45) 6 (54.55)
Chronic strains -0.00 (0.97) 0.13 (1.08) t(72) = -0.47 -0.25 (0.94) 0.13 (1.07) t(72) = -1.01
Balanced cohesion 1.65 (0.71) 1.62 (0.62) t(72) = 0.85 1.37 (0.66) 1.43 (0.70) t(28) = -0.23
Covariates

Age 40.69 (11.52) 51.63 (13.08) t(73) = -3.27** 40.47 (11.59) 51.63 (13.08) t(29) = -2.51*
Gender

Female 23 (69.70) 10 (30.30)
χ2(1, 75) = 2.83†
5 (33.33) 10 (66.67)
χ2(1, 31) = 2.63†
Male 36 (85.71) 6 (14.29) 10 (62.50) 6 (37.50)
Age at onset 21.55 (8.31) 26.69 (7.57) t(72) = -2.22* 18.71 (5.51) 26.69 (7.59) t(28) = -3.26**
Childhood adversity

No 22 (73.33) 8 (26.67)
χ
2
(1, 72) = 0.59
4 (33.33) 8 (66.67)
χ
2
(1,29) = 1.09
Yes 34 (80.95) 8 (19.05) 9 (52.94) 8 (47.06)
Note. Values represent n (%) unless otherwise noted. Values represent row percentages for categorical explanatory variables.
†p < .10. *p < .05. **p < .01. ***p < .001.

c
Indicated by the experience of maltreatment (physical abuse, emotional abuse, or neglect), parental maladjustment (mental illness or substance use), or
interpersonal loss (parental divorce or separation, or separation from parents) before 18 years old. b
Indicated by exposure to a major traumatic event or acute stressor during the preceding 6 months.
c
Values represent M (SD).
d
Assessed with an inventory developed by Wheaton (1994); scores were standardized and higher scores reflect higher levels of c hronic stressors.
e
Assessed with the Family Adaptability and Cohesion Evaluation Scale IV; higher scores reflect healthier family functioning.

140
Table 10. Comparison of Demographic Characteristics, Clinical Profile, and Treatment
Outcomes of East Asians and Southeast Asians Diagnosed with Schizophrenia
East Asians Southeast Asians Test statistic p
(n = 45) (n = 30)
Demographic characteristics

Age
a
43.44 (13.42) 42.40 (11.48) t(73) = 0.36 .73
Gender

Female 25 (75.76) 8 (24.24)
χ
2
(1, 75) = 6.10 < .05
Male 20 (47.62) 22 (52.38)
Clinical profile

Diagnosis

Schizophrenia 30 (58.82) 21 (41.18)
χ
2
(1, 75) = 0.09 .76
Schizoaffective 15 (62.50) 9 (37.50)
Age at onset 22.32 (7.54) 23.17 (9.59) t(72) = -0.41 .67
Treatment outcomes

Symptoms severity
b

Positive symptoms
a
10.60 (4.13) 10.47 (4.67) t(73) = 0.13 .90
Negative symptoms
a
19.00 (5.85) 20.33 (6.70) t(73) = -0.91 .36
Activation
a
9.87 (3.77) 9.50 (3.30) t(73) = 0.43 .66
Dysphoric mood
a
10.24 (3.24) 9.50 (2.92) t(73) = 1.01 .31
Autistic preoccupation
a
10.89 (4.04) 13.30 (5.08) t(73) = -2.28* < .05
Adequate role functioning 16 (35.56) 10 (33.33) χ
2
(1, 75) = 0.04 .84
Symptomatic remission 14 (31.11) 13 (43.33) χ
2
(1, 75) = 1.17 .28
Clinical recovery 10 (22.22) 6 (20.00) χ
2
(1, 75) = 0.05 .82
Note. Values represent n (%) unless otherwise noted. Values represent column percentages for categorical explanatory
variables.
†p < .10. *p < .05. **p < .01. ***p < .001.
a
Values represent M (SD).

b
Measured with the Positive and Negative Syndrome Scale; higher scores indicate more severe symptoms; scores were
reflective of levels of psychopathology in the previous 2 weeks. b
Scores were the summed of 5 items from the PANSS and possible values ranged from 5 to 35.

c
Scores were the summed of 10 items from the PANSS and possible values ranged from 10 to 70.

d
Scores were the summed of 6 items from the PANSS and possible values ranged from 6 to 42.

e
Scores were the summed of 5 items from the PANSS and possible values ranged from 5 to 35.

f
Scores were the summed of 6 items from the PANSS and possible values ranged from 6 to 42.

141

Figure 1. A cultural model of the stress-diathesis framework of schizophrenia.
Stress
Biological
Vulnerability

Recovery Outcomes
Environment
Race and
Ethnicity
Mental Health
Services Use

Antipsychotic
Medications
Psychosocial
Interventions
Coping
Strategies
Appraisal
Substance Use
142

Figure 2. Recruitment flow diagram.

Assessed for eligibility (n = 93)
Excluded (n = 18)
 Declined to participate (n = 10)
 Did not meet diagnostic criterion (n = 5)
 Decisional impairment (n = 3)
Enrolled (N = 75)
143
Appendix
A. Sociodemographic

What is your age? _______________

What is your gender?
☐ 1. Female
☐ 2. Male
☐ 3. Transgender
How would you classify your ethnicity?
☐ 1. Chinese
☐ 2. Vietnamese
☐ 3. Other (please specify: _______________________)

Were you born in the United States?
☐ 1. No
☐ 2. Yes

If participant is foreign-born:

Where were you born?
☐ 1. China
☐ 2. Taiwan
☐ 3. Hong Kong
☐ 4. Vietnam
☐ 5. Other (please specify: _________________________________________________________________)

How old were you when you immigrated to/arrived in the United States? ______________________________

How long have you been living in the United States? ______________________________________________
☐ 1. Less than a year (please specify length: ____________________________________________ months)
☐ 2. More than a year (please specify length: ____________________________________________ months)

Indicate participants’ generational status.
☐ 1.00 generation (immigrants who arrived in the United States at 18 years or older)
☐ 1.25 generation (immigrants who arrived in the United States between 13 and 17 years of age)
☐ 1.50 generation (immigrants who arrived in the United States at 12 years of age or younger)
☐ 2.00 generation (born in the United States and at least 1 foreign-born parent)
☐ 3.00 generation or later (born in the United States and at least both parents born in the United States)

What is your primary language
☐ 1. English
☐ 2. Other (please specify: ____________________)
What is your second language?
☐ 1. English
☐ 2. Other (please specify: ____________________)
☐ 3. None

How well do you speak English?
☐ 1. Excellent
☐ 2. Good
☐ 3. Fair
☐ 4. Poor
☐ 5. Participant does not speak English
How well do you read and write English?
☐ 1. Excellent
☐ 2. Good
☐ 3. Fair
☐ 4. Poor
☐ 5. Participant does not read/write English

What is your current marital status?
☐ 1. Single
☐ 2. Married
☐ 3. Divorced/ Separated
☐ 4. Living with another
☐ 5. Widowed

Do you have any children (i.e., biological children)?
☐ 1. No
144
☐ 2. Yes (number of children: __________________)

For participants with children (18 years old and below):

What are your children’s ages?
☐ ☐ ☐ ☐ ☐ ☐☐ ☐☐☐
Do you have custody of your children?
☐ 1. Yes
☐ 2. No (please specify who has custody: _____________________________________________________)

Who is the primary caregiver to your children (i.e., responsible for children’s daily needs)?
☐ 1. Participant
☐ 2. Participant’s spouse/partner
☐ 3. Participant’s parents-in-law
☐ 4. Participant’s parents
☐ 5. Other relatives
☐ 6. Other (please specify: ____________________)

Do you have any help with child rearing?
☐ 1. No
☐ 2. Participant’s spouse/partner
☐ 3. Participant’s parents
☐ 4. Participant’s parents-in-law
☐ 5. Other relatives
☐ 6. Other (please specify: ____________________)

What is your current living situation?
☐ 1. Supervised/semi-supervised (e.g., board & care)
☐ 2. Family home
☐ 3. Independent (i.e., own apartment or room)
☐ 4. Friend’s home
☐ 5. Relative’s home
☐ 6. Shelter (temporary or emergency)
☐ 7. Homeless
☐ 8. Other (please specify: ____________________)

For participants who are living with family members:

Number of family members in the household (excluding the participant): ______________________________

Relationships:
☐ 1. Parents
☐ 2. Children
☐ 3. Spouse
☐ 4. Siblings
☐ 5. Grandparents
☐ 6. Extended family (e.g., uncles, aunts)

Do you have any pets?
☐ 1. No
☐ 2. Yes

For participants who do not have any pets: Would you like to have a pet? ☐ 1. No ☐ 2. Yes

For participants with pets: How important is your pet to you?
☐ 1. Extremely important to you
☐ 2. Very important to you
☐ 3. Fairly important to you

☐ 4. Not too important to you
☐ 5. Not at all important to you

145
What is your occupational status? (Check all that applies)
☐ 1. Employed, full time
☐ 2. Employed, part-time
☐ 3. Supported employment/vocational training
☐ 4. Student, full time
☐ 5. Student, part-time
☐ 6. Homemaker
☐ 7. Unemployed
☐ 8. Other (please specify: ____________________)

What is the highest level of education you have completed?
☐ 1. Elementary school (Grade 1 – 6)
☐ 2. Junior high school (Grade 7 – 8)
☐ 3. High school or equivalent (Grade 9 – 12)
☐ 4. Vocational/technical school
☐ 5. Some college
☐ 6. Bachelor’s degree
☐ 7. Master’s degree
☐ 8. Doctoral degree
☐ 9. Professional degree (MD, JD, etc.)
☐ 10. Other (please specify: ___________________)

Do you have a mobile device?
☐ 1. No ☐ 2. Cell phone ☐ 3. Smart phone

B. Strauss and Carpenter Outcome Scale

Did you have any hospitalization for psychiatric treatment during the past 6 months?
How many times were you hospitalized? How long were your stays?
☐ 4. Not in hospital in last 6 months
☐ 3. Hospitalized less than 1.5 months
☐ 2. Hospitalized 1.5 to 3 months
☐ 1. Hospitalized over 3 months, up to 4.5 months
☐ 0. Hospitalized more than 4.5 months

How often did you meet with friends in the last 6 months, not including meetings with friends at work/school
or “over the back fence” meetings?
☐ 4. On average at least once a week
☐ 3. Two to three times a month
☐ 2. About once a month
☐ 1. Does not meet with friends except "over the back fence,"
at work, or at school
☐ 0. Does not meet with friends at all under any conditions

Have you been working (paid formal position) in the past 6 months?
☐ 4. Employed continuously in last 6 months
☐ 3. Employed more than 3 months but less than continuously
☐ 2. Employed part-time or full-time about half of the time
☐ 1. Employed less than half of the time
☐ 0. No useful work
Hours of engagement per week: _____

Have you been receiving pay to do work or chores for someone else (irregular work) in the past 6 months?
☐ 4. Continuously in last 6 months
☐ 3. More than 3 months but less than continuously
☐ 2. Part-time or full-time about half of the time
☐ 1. Less than half of the time
☐ 0. None
Hours of engagement per week: _____

Have you been engaged in volunteer work?
Such as unpaid services for a church, educational organization, and etc.
☐ 4. Continuously in last 6 months
☐ 3. More than 3 months but less than continuously
☐ 2. Part-time or full-time about half of the time
☐ 1. Less than half of the time
☐ 0. None
Hours of engagement per week: _____

Have you been a caregiver to a friend or relative who has trouble taking care of himself/herself because of
physical or mental illness, disability, or for some other reason?
☐ 4. Continuously in last 6 months
☐ 3. More than 3 months but less than continuously
☐ 2. Part-time or full-time about half of the time
☐ 1. Less than half of the time
☐ 0. None
Hours of engagement per week: _____

146
Have you been providing informal social assistance?
For example, providing transportation to, shop for, or run errands for others? Helping with housework or with
the upkeep of others’ homes? Providing childcare without pay? Or doing any other things to help?
☐ 4. Continuously in last 6 months
☐ 3. More than 3 months but less than continuously
☐ 2. Part-time or full-time about half of the time
☐ 1. Less than half of the time
☐ 0. None
Hours of engagement per week: _____

C. Duke University Religion Index (DUREL)

What is your religious preference?
☐ 1. Christian
☐ 2. Buddhist
☐ 3. Taoist
☐ 4. Folk religions
☐ 5. No religious affiliation/ Do not believe in any religion
☐ 6. Other affiliation (please specific: _______________)

How often do you attend church or other religious meetings, such as prayer groups or scripture study groups?
☐ 1. Never
☐ 2. Once a year or less
☐ 3. A few times a year
☐ 4. A few times a month
☐ 5. Once a week
☐ 6. More than once per week

How often do you spend time in private religious activities, such as prayer, meditation, or bible study?
☐ 1. Rarely or never
☐ 2. A few times a month
☐ 3. Once a week
☐ 4. Two or more times per week
☐ 5. Daily
☐ 6. More than once a day

The following statements are about religious belief or experience. Please tell me the extent to which each
statement is true or not true for you.

In my life, I experience the presence of the Divine (i.e., God)
☐ 1. Definitely not true
☐ 2. Tends not to be true
☐ 3. Unsure
☐ 4. Tends to be true
☐ 5. Definitely true of me

My religious beliefs are what really lie behind my whole approach to life.
☐ 1. Definitely not true
☐ 2. Tends not to be true
☐ 3. Unsure
☐ 4. Tends to be true
☐ 5. Definitely true of me

I try hard to carry my religion over into all other dealings in life.
☐ 1. Definitely not true
☐ 2. Tends not to be true
☐ 3. Unsure
☐ 4. Tends to be true
☐ 5. Definitely true of me

D. Smoking

During the previous 6 months, about how often did you smoke?
☐ 1. Not at all
☐ 3. Occasionally
☐ 2. Almost never
☐ 4. More than half the time
☐ 5. Nearly every day
☐ 6. Every day

If participant has been smoking during the previous 6 months:

When you did smoke, how many sticks do you consume per day, on average:
__________________________

147
E. FACES IV: Questionnaire

The following set of questions relates to your views on the relationships among your family members. Read
each statement and circle the option that describes how much you agree with that statement.

Strongly
disagree
Generally
disagree
Undecided
Generally
agree
Strongly
agree
1.
Family members are involved in each other’s
lives. (Category: cohesion)
1 2 3 4 5
2.
Our family tries new ways of dealing with
problems. (Category: flexibility)
1 2 3 4 5
3.
We get along better with people outside our family
than inside. (Category: disengaged)*
1 2 3 4 5
4.
We spend too much time together.
(Category: enmeshed)*
1 2 3 4 5
5.
There are strict consequences for breaking the
rules in our family. (Category: rigid)*
1 2 3 4 5
6.
We never seem to get organized in our family.
(Category: chaotic)*
1 2 3 4 5
7.
Family members feel very close to each other.
(Category: cohesion)
1 2 3 4 5
8.
Parents equally share leadership in our family.
(Category: flexibility)
1 2 3 4 5
9.
Family members seem to avoid contact with each
other when at home. (Category: disengage)*
1 2 3 4 5
10.
Family members feel pressured to spend most
free time together. (Category: enmeshed) *
1 2 3 4 5
11.
There are clear consequences when a family
member does something wrong. (Category: rigid)*
1 2 3 4 5
12.
It is hard to know who the leader is in our family.
(Category: chaotic) *
1 2 3 4 5
13.
Family members are supportive of each other
during difficult times. (Category: cohesion)
1 2 3 4 5
14. Discipline is fair in our family. (Category: flexibility) 1 2 3 4 5
15.
Family members know very little about the friends
of other family members. (Category: disengaged)*
1 2 3 4 5
16.
Family members are too dependent on each
other. (Category: enmeshed)*
1 2 3 4 5
17.
Our family has a rule for almost every possible
situation. (Category: rigid)*
1 2 3 4 5
18.
Things do not get done in our family.
(Category: chaotic)*
1 2 3 4 5
19.
Family members consult other family members on
important decisions. (Category: cohesion)
1 2 3 4 5
20.
My family is able to adjust to change when
necessary. (Category: flexibility)
1 2 3 4 5
148

Strongly
disagree
Generally
disagree
Undecided
Generally
agree
Strongly
agree
21.
Family members are on their own when there is a
problem to be solved. (Category: disengaged)*
1 2 3 4 5
22.
Family members have little need for friends
outside the family. (Category: enmeshed)*
1 2 3 4 5
23. Our family is highly organized. (Category: rigid)* 1 2 3 4 5
24.
It is unclear who is responsible for things (chores,
activities) in our family. (Category: chaotic)*
1 2 3 4 5
25.
Family members like to spend some of their free
time with each other. (Category: cohesion)
1 2 3 4 5
26.
We shift household responsibilities from person to
person. (Category: flexibility)
1 2 3 4 5
27.
Our family seldom does things together.
(Category: disengaged)*
1 2 3 4 5
28.
We feel too connected to each other.
(Category: enmeshed)*
1 2 3 4 5
29.
Our family becomes frustrated when there is a
change in our plans or routines. (Category: rigid)*
1 2 3 4 5
30.
There is no leadership in our family.
(Category: chaotic) *
1 2 3 4 5
31.
Although family members have individual
interests, they still participate in family activities.
(Category: cohesion)
1 2 3 4 5
32.
We have clear rules and roles in our family.
(Category: flexibility)
1 2 3 4 5
33.
Family members seldom depend on each other.
(Category: disengaged)*
1 2 3 4 5
34.
We resent family members doing things outside
the family. (Category: enmeshed)*
1 2 3 4 5
35.
It is important to follow the rules in our family.
(Category: rigid)*
1 2 3 4 5
36.
Our family has a hard time keeping track of who
does various household tasks. (Category: chaotic)*
1 2 3 4 5
37.
Our family has a good balance of separateness
and closeness. (Category: cohesion)
1 2 3 4 5
38.
When problems arise, we compromise.
(Category: flexibility)
1 2 3 4 5
39.
Family members mainly operate independently.
(Category: disengaged)*
1 2 3 4 5
40.
Family members feel guilty if they want to spend
time away from the family. (Category: enmeshed)*
1 2 3 4 5
41.
Once a decision is made, it is very difficult to
modify that decision. (Category: rigid)*
1 2 3 4 5
42.
Our family feels hectic and disorganized.
(Category: chaotic)*
1 2 3 4 5

149
F. Cohen Perceived Stress Scale

The following questions ask about your level of stress DURING THE PAST MONTH. In each question, you will
be asked how often you felt or thought a certain way.

Never
Almost
never
Someti
mes
Fairly
often
Very
often
1.
In the past month, how often have you been
upset because of something that happened
unexpectedly?
0 1 2 3 4
2.
In the past month, how often have you felt
unable to control the important things in your
life?
0 1 2 3 4
3.
In the past month, how often have you felt
nervous or stressed?
0 1 2 3 4
4.
In the past month, how often have you felt
confident about your ability to handle personal
problems?
0 1 2 3 4
5.
In the past month, how often have you felt that
things were going your way?
0 1 2 3 4
6.
In the past month, how often have you found
that you could not cope with all the things you
had to do?
0 1 2 3 4
7.
In the past month, how often have you been
able to control irritation in your life?
0 1 2 3 4
8.
In the past month, how often have you felt that
you were on top of things?
0 1 2 3 4
9.
In the past month, how often have you been
angry because of things that happened that
were outside of your control?
0 1 2 3 4
10.
In the past month, how often have you felt that
difficulties were piling up so high that you could
not overcome them?
0 1 2 3 4

150
G. Herth Hope Index

Listed below are a number of statements. Read each statement and circle the option that describes how much
you agree with that statement DURING THE PREVIOUS 6 MONTHS.

Strongly
Disagree
Disagree Agree
Strongly
Agree
1. I have a positive outlook toward life. 1 2 3 4
2. I have short and/or long range goals 1 2 3 4
3. I feel all alone. 1 2 3 4
4. I can see possibilities in the midst of difficulties. 1 2 3 4
5. I have a faith that gives me comfort. 1 2 3 4
6. I feel scared about my future. 1 2 3 4
7. I can recall happy/joyful times. 1 2 3 4
8. I have deep inner strength. 1 2 3 4
9. I am able to give and receive caring/love. 1 2 3 4
10. I have a sense of direction. 1 2 3 4
11. I believe that each day has potential. 1 2 3 4
12. I feel my life has value and worth. 1 2 3 4

151
H. Brief Internalized Stigma of Mental illness Scale

The following statements relate to your views on mental illness. I am going to use the term "mental illness", but
please think of it as whatever you feel is the best term for it. For each statement, please tell me how much you
agree with it.

Strongly
Disagree
Disagree Agree
Strongly
Agree
1. People with mental illness tend to be violent. 1 2 3 4
2.
People with mental illness make important
contributions to society.
1 2 3 4
3.
I don't socialize as much as I used to because my
mental illness might make me look or behave
"weird"
1 2 3 4
4. Having a mental illness has spoiled my life. 1 2 3 4
5.
I stay away from social situations in order to
protect my family or friends from embarrassment.
1 2 3 4
6.
People without mental illness could not possibly
understand me.
1 2 3 4
7.
People ignore me or take me less seriously just
because I have a mental illness.
1 2 3 4
8.
I can't contribute anything to society because I
have a mental illness.
1 2 3 4
9.
I can have a good, fulfilling life, despite my mental
illness.
1 2 3 4
10.
Others think that I can't achieve much in life
because I have a mental illness.
1 2 3 4
11.
My family thinks that I can't achieve much in life
because I have a mental illness.
1 2 3 4
12.
My clinicians think that I can't achieve much in life
because I have a mental illness.
1 2 3 4

152
I. Instrumental Activities of Daily Living Scale

Ability to use telephone
☐ 1. Operates telephone on own initiative; looks up and dials numbers, etc. (1)
☐ 2. Dials a few well-known numbers (1)
☐ 3. Answers telephone but does not dial (1)
☐ 4. Does not use telephone at all (0)

Shopping
☐ 1. Takes care of all shopping needs independently (1)
☐ 2. Shops independently for small purchases (0)
☐ 3. Needs to be accompanied on all shopping trip (0)
☐ 4. Completely unable to shop (0)

Food preparation
☐ 1. Plans, prepare and serve adequate meals independently (1)
☐ 2. Prepares adequate meals if supplied with ingredients (0)
☐ 3. Heats, serves and prepares meals, or prepares meals but does not maintain adequate diet (0)
☐ 4. Needs to have meals prepared and served (0)

Housekeeping
☐ 1. Maintains house alone with occasional assistance (1)
☐ 2. Performs light daily tasks such as dishwashing, bed making (1)
☐ 3. Performs light daily tasks, but cannot maintain acceptable level of cleanliness (1)
☐ 4. Needs help with all home maintenance tasks (1)
☐ 5. Does not participate in any housekeeping tasks (0)

Laundry
☐ 1. Does personal laundry completely (1)
☐ 2. Launders small items (1)
☐ 3. All laundry must be done by others (0)

Mode of transportation
☐ 1. Travels independently on public transportation or drives own car (1)
☐ 2. Arranges own travel via taxi, but does not otherwise use public transportation (1)
☐ 3. Travels on public transportation when accompanied by another (1)
☐ 4. Travel limited to taxi or automobile with assistance of another (0)
☐ 5. Does not travel at all (0)

Responsibility for own medications
☐ 1. Is responsible for taking medication in correct dosages at correct time (1)
☐ 2. Takes responsibility if medication is prepared in advance in separate dosage (0)
☐ 3. Is not capable of dispending own medication (0)

Ability to handle finances
☐
1. Manages financial matters independently (budgets, writes checks, pays rent, bills goes to bank), collects
and keeps track of income (1)
☐ 2. Manages day-to-day purchases, but needs help with banking, major purchases, etc (1)
☐ 3. Incapable of handling money (0)

153
J. Medication Use
Please check the antipsychotic medications prescribed and taken in the LAST 6 MONTHS (to be gathered
from medical records):
Name Type Code Medication Compliance*
1
ST
Generation Antipsychotics
Haldol (Haloperidol) ☐ Oral ☐ Depot ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Clopixol (Zuclopenthixol) ☐ Oral ☐ Depot ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Loxitane (Loxapine) ☐ Oral ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Mellaril (Thioridazine) ☐ Oral ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Modecate (Fluphenazine) ☐ Oral ☐ Depot ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Piportil (Pipothiazine Palmitate) ☐ Oral ☐ Depot ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Stelazine (Trifluoperazine) ☐ Oral ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Thorazine (Chlorpromazine) ☐ Oral ☐ Depot ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
2
ND
Generation Antipsychotics
Aripiprazole (Abilify) ☐ Oral ☐ Depot ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Clozapine (Clozaril) ☐ Oral ☐ Depot ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Olanzapine (Zyprexa) ☐ Oral ☐ Depot ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Paliperidone (Invega) ☐ Oral ☐ Depot ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Quetiapine (Seroquel) ☐ Oral ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Risperidone (Risperdal) ☐ Oral ☐ Depot ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
Ziprasidone (Geodon) ☐ Oral ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
☐ Oral ☐ Depot ☐ Off ☐ On
☐ Nonuse ☐ Low
☐ Regular ☐Continuous
*Nonuse = Not on antipsychotic medication during the previous 6 months Low use = On antipsychotics less than 50% of the time; Regular = On
antipsychotics more than 50% of the time but less than continuously; Continuous = On antipsychotics continuously during the previous 6 months (can
include occasional nonuse)

In addition to the medication that you have been prescribed by your psychiatrist, how often did you used
complementary or alternative medicine during the previous 6 months?
☐ 1. Not at all
☐ 2. Almost never (e.g., as and when needed)
☐ 3. Occasionally
☐ 4. More than half the time
☐ 5. Nearly every day
☐ 6. Every day

154
K. Diagnosis

Participants’ chart diagnosis (to be gathered from medical records)
☐ 1. Schizophrenia
☐ 2. Schizoaffective disorder
☐ 3. Schizophreniform disorder
☐ 4. Substance use disorder
☐ 5. Other disorders (please specify: ________________________________________________________)

155
L. PANSS Interview

The next series of questions are focused on understanding your thoughts and feelings in the PREVIOUS 2
WEEKS. Some questions may sound strange so please bear with me. Please feel free to let me know if you
like the questions repeated or if you like me to clarify the questions.
Note: Be sure to assess for whether the starred symptoms were presence in the previous 6 months. If present,
proceed to establish the severity of the symptoms.

P1. DELUSIONS*
Delusional Mood*
1. During the past 2 weeks, have you been feeling that something odd is going on that you can’t explain?
2. Do things around you feel strange?
3. Have you been feeling that something unpleasant might happen?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?

Intensity
How convinced are you that this
happened?

Response
How did you respond?
How has this affected you?

Delusion of Reference*
1. During the past 2 weeks, have you been feeling that things that were happening around you had a special meaning?
2. Have you been feeling that people were trying to give you messages through the TV? Radio? Newspaper? FB?
3. OR, have you been getting messages through the TV that you feel is meant specifically for you?
4. Have you been feeling that certain body gestures (from strangers, friends, or family members) are directed at you?
5. Have you been feeling that certain colors have special meaning to you?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?

Intensity
How convinced are you that this
happened?

Response
How did you respond?
How has this affected you?

156
Thought Insertion / Thought Withdrawal*
1. During the past 2 weeks, have you been feeling that ideas or thoughts that are not your own have been inserted into
your mind by other persons or forces?
2. During the past 2 weeks, have you been feeling that other persons or forces are removing ideas or thoughts from your
mind?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?

Intensity
How convinced are you that this
happened?

Response
How did you respond?
How has this affected you?

Thought Broadcasting / Thoughts being Read*
1. During the past 2 weeks, have you been feeling that others can hear your thoughts as though they were being
broadcasted over the air like a radio?
2. During the past 2 weeks, have you been feeling that others can read your mind?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?

Intensity
How convinced are you that this
happened?

Response
How did you respond?
How has this affected you?

Delusion of Control / Somatic Passivity*
1. During the past 2 weeks, have you been feeling that someone, or something, outside yourself has been controlling
your thoughts? Feelings? Actions? Urges?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?

157
Previous 2 weeks Previous 6 months
Intensity
How convinced are you that this
happened?

Response
How did you respond?
How has this affected you?

Nihilistic Delusion*
1. During the past 2 weeks, have you been feeling that you (or a part of you) did not exist, or was dead?
2. How about feelings that the world does not exist?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?

Intensity
How convinced are you that this
happened?

Response
How did you respond?
How has this affected you?

Jealous Delusion* (access if the participant has been in a romantic relationship)
During the past 2 weeks, have you been worried about relationships that your partner has with other people?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?

Intensity
How convinced are you that this
happened?

Response
How did you respond?
How has this affected you?

158
Erotomanic Delusion*
1. Besides your partner, have you been feeling that someone else is in love with you?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?

Intensity
How convinced are you that this
happened?

Response
How did you respond?
How has this affected you?

P6. SUSPICIOUSNESS*
1. During the past 2 weeks, have you been feeling that others talk about you behind your back? Laugh at you?
2. Have you been feeling that people are watching or spying on you?
3. Have you been feeling that you are in danger? Has anyone been trying to hurt you?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?

Intensity
How convinced are you that this
happened?

Response
How did you respond?
How has this affected you?

159
G1. SOMATIC CONCERNS*
1. During the past 2 weeks, how have you been feeling about your health?

If participant complains of ill health, ask the following:
2. Do you feel that you have a medical illness?
3. Has any part of your body been troubling you?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?

Intensity
How convinced are you that this
happened?

Response
How did you respond?
How has this affected you?

P5. GRANDIOSITY*
1. If you compare yourself to the average person, do you consider yourself superior to, on par with, or inferior to others?

In response is superior, ask the following questions:
2. During the past 2 weeks, do you have talents that most people don’t have? Special powers? ESP or the ability to read
other people’s minds?
3. Do you consider yourself to be very wealthy?
4. Would you describe yourself as famous? Would people recognize you from TV or newspaper?
5. Are you a religious person? Are you close to God? Did God assign you some special role or purpose? Can you be
one of God’s messengers or angels?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?

Intensity
How convinced are you that you
(have this ability)?

Response
How did you respond?
How have you used this special
power or your status?

160
G3. GUILT FEELINGS*
1. During the past 2 weeks, have you been feeling bad or guilty about something that you have done and you feel you
deserve punishment?
2. For example, do you feel that you deserve life imprisonment, torture, or death?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?

Intensity
How much has it bother you?
How convinced are you that you
deserved to be punished?
What kind of punishment?

Response
Have you done anything to
punish yourself?

P3. HALLUCINATORY BEHAVIOR*
Auditory Hallucination*
1. Sometimes people tell me that they can hear noises or voices. During the past 2 weeks, have you heard noises or
voices that only you can hear?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?
What do you hear?
When do these experiences
occur?
Where do they really come
from?

Intensity
Are the voices as clear and loud
as my voice?

Frequency
How often have you been
hearing these voices?
How long do the voices last for?

Insight
Why do you have these
experiences?

Response
Why do you have these
experiences?
How have you responded to
these (voices)?

161
Visual Hallucination*
1. During the past 2 weeks, have you been seeing things that others can't see? For example, figures, objects, or
shadows?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?
What do you see?
When do these experiences
occur?
Where do they really come
from?

Intensity
Are the images clear?

Frequency
How often have you been
seeing these images?
How long do the images last
for?

Insight
Why do you have these
experiences?

Response
How have you responded to
these images that you see?

Olfactory Hallucination*
1. During the past 2 weeks, have you smelled things that others can’t?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?
What do you smell?
When do these unusual
experiences occur?

Intensity
How strong are these scents?

Frequency
How often have you been
having these experiences?
How long do the scents last for?

Insight
Why do you have these
experiences?

162
Response
Why do you have these
experiences?
How have you responded to
these experiences?

Tactile / Gustatory Hallucinations*
1. During the past 2 weeks, have you been getting any strange or usual sensation from your body? Do you ever get
strange feelings on or just beneath your skin?
2. During the past 2 weeks, have you been getting odd taste in your mouth?
Previous 2 weeks Previous 6 months
Content
Can you tell me more?
What do you feel (or taste)?
When do these unusual
experiences occur?

Intensity
How strong are these
sensations?

Frequency
How often have you been
having these experiences?
How long do they last for?

Insight
Why do you have these
experiences? Are these normal
experiences?

Response
Why do you have these
experiences?
How have you responded to
these experiences?

N4. PASSIVE SOCIAL WITHDRAWAL / G16. A CTIVE SOCIAL A VOIDANCE*
1. During the past 2 weeks, how have you been spending your time?
2. Do you join in activities with others? Or do you prefer to be alone?
3. Do you have many friends? How about close friends?
4. How often have you been out with friends during the past 2 weeks?
5. Do you usually initiate outings with friends?
Previous 2 weeks Previous 6 months
Content
If participant does not join in
activities, determine if the social
withdrawal is due to negative or
negative symptoms: Why not?

163
G14. POOR IMPULSE CONTROL
1. During the past 2 weeks, have you been getting along with others?
2. How would you describe your temper?
3. Have you been getting into fights?
4. Have you been losing control of your temper or behavior?
Content
G2. A NXIETY
1. Have you been feeling worried or nervous in the past 2 weeks?
2. What’s been making you feel nervous or worried?
3. Just how nervous have you been feeling?
4. Have you been shaking at times or has your heart been racing?
5. Has your sleep, eating, or participation in activities been affected?
6. Do you get into a state of panic?
Content
Sxs: shortness of breath,
hyperventilation, heart
palpitations, sweating, nausea,
fear of losing control

G2. DEPRESSION
1. How has your mood been in the past 2 weeks?

If participant’s response suggest possible low mood, continue with the following questions:
2. Have there been times in the past 2 weeks when you were feeling sad or unhappy?
3. How often do you feel sad?
4. Just how sad have you been feeling?
5. Have you been crying lately?
6. Has your mood in any way affected your sleep?
7. Has it affected your appetite?
8. Do you participate less because of your mood?
Content
Sxs: Low mood, lost of interest,
poor sleep and appetite,
decreased energy, feelings of
hopelessness, irritability,
thoughts of suicide

G10. DISORIENTATION
1. Can you tell me today’s date?
2. Can you tell me what day of the week it is?
3. What is the name of the place that you are in now?
4. What is the name of the doctor (or social worker) who is treating you?
5. Do you know who the president is?
Content
Assess for orientation to time,
place, and persons

164
N5. DIFFICULTY IN A BSTRACT THINKING (PART 1)
I am going to now say a pair of words, and I would like you to tell me in what important ways they are alike. For example,
with the words “apples” and “banana,” how are they alike? What do they have in common?

If the response is that “they are both fruit,” then say: Good. Now what about…?
1. Ball and orange
2. Table and chair
3. Arm and leg
4. Painting and poem
N5. DIFFICULTY IN A BSTRACT THINKING (PART 2)
You have probably heard the expression, “Don’t judge a book by its cover.” What is the deeper meaning of this proverb?

If the response is that “you don’t judge a person before getting to know him/her,” then say: Good. Now what about…?
1. Plain as the nose on your face (to be very obvious)
2. Don't cross the bridge until you come to it (don’t w orry about a possible future problem but w ill deal w ith it if it happens)
3. The grass always looks greener on the other side (other people alw ays seem to be in a better situation than you, although
they may not be)

4. People who live in glass houses should not throw stones at others (you should not criticize other people for bad qualities
in their character that you have yourself)

G12. LACK OF JUDGMENT AND INSIGHT
1. How long have you been receiving services at the APFC?
2. Why did you come to this mental health center?
3. Do you need to be at APFC for treatment?
4. Would you say that you have a mental health need or a mental illness?
5. Why are you taking medicine?
6. In your opinion, do you need to be taking medication?
7. Does the medicine help you in any way?
8. What are your plans?
9. What about your longer-range goals?
Content

165
M. Clinical History

The next series of questions are related to the time when you first noticed that your mental health was
declining and when you sought professional help.

How old were you when you first noticed that your mental health was declining?
Some people have told me that it started with them experiencing anxiety; restlessness; trouble with sleep,
appetite, mood, concentration; difficulties at work or school; and feeling more withdrawn from family and
friends.
Age at onset of unspecified
psychiatric symptoms

You have shared about (participants’ symptoms, e.g., hearing voices, or feeling that people are monitoring your movements).
How old were you when these experiences started?
Age at onset of psychotic
symptoms

Who did you (or your family) first approach for help with your mental health?
First contact
How old were you when saw a mental health professional (e.g., psychiatrist, psychologists, social worker) for
help with your mental health?
Age first saw a mental
health worker for help

How old were you when received your first hospitalization for mental health treatment?
Age at first psychiatric
hospitalization

How old were you were first prescribed medication by a psychiatrist?
Age first prescribed
medication

How long have you been receiving services at this center?
Years

166
N. Health Care Climate Questionnaire

This questionnaire contains questions related to your visits with your mental health providers. We would like to
know more about how you have felt about your encounters with them DURING THE PREVIOUS 6 MONTHS.

Strongly
Disagree
Disagree Neutral Agree
Strongly
Agree
1.
I feel that my providers have provided
me choices and options.
1 2 3 4 5
2. I feel understood by my providers. 1 2 3 4 5
3.
My providers convey confidence in my
ability to make changes.
1 2 3 4 5
4.
My providers encourage me to ask
questions.
1 2 3 4 5
5.
My providers listen to how I would like to
do things.
1 2 3 4 5
6.
My providers try to understand how I
see things before suggesting a new way
to do things.
1 2 3 4 5

167
O. Acculturative Stress Scale

Note: Complete this scale if participant is foreign born or grew up in a foreign country, that is, if participant is
generation 1.5 and below.

Please tell me if you have felt this way in the following situations IN THE PAST 6 MONTHS

No Yes
1. Have you felt guilty for leaving family or friends in your country of origin? 0 1
2.
Have you felt that in the United States you have the respect you had in your
country of origin?
1 0
3.
Have you felt that living out of your country of origin has limited your contact
with family or friends?
0 1
4.
Have you found it hard interacting with others because of difficulties you
have with the English language?
0 1
5.
Have people been treating you badly because they think you do not speak
English well or speak with an accent?
0 1
6.
Have you found it difficult to find the work you want because you are of
Asian descent?
0 1
7. Have you been questioned about your legal status? 0 1
8.
Have you thought that you will be deported if you go to a social or
government agency?
0 1
9.
Have you avoided seeking health services due to fear of immigration
officials?
0 1

168
P. Major Traumas

I will be reading some potentially serious events that could have happened at any time in your life. Please tell me
if any of these things have happened to you.

Note: If any of the listed traumas do not apply to the participant, circle “No”

Childhood Traumas (< 18 years) No/ NA Yes Age
1.
Did you ever have a major illness or accident that required you to
spend a week or more in hospital?
0 1
2. Did your parents get a divorce/separate? 0 1
3. Did you have to do a year of school over again? 0 1
4.
Did your father or mother not have a job for a long time when they
wanted to be working?
0 1
5.
Did something happen that scared you so much you thought about it
for years after?
0 1
6.
Were you ever sent away from home or kicked out of the house
because you did something wrong?
0 1
7.
Did either of your parents drink or use drugs so often or so regularly
that it caused problems for the family?
0 1
8.
Were you regularly physically abused by one of your parents or a
caregiver(s)?
0 1
9.
Were you regularly emotionally abused by one of your parents or a
caregiver(s)?
0 1
10.
Were you regularly neglected by one of your parents or a
caregiver(s)?
0 1
Adult Traumas No/ NA Yes Time
11.
Have you ever been divorced or ended a relationship with someone
you were still in love with?
0 1
☐ Past 6 mths
☐ > 6 mths
12. Has one of your parents died? 0 1
☐ Past 6 mths
☐ > 6 mths
13. Has a spouse, child, or other loved one died? 0 1
☐ Past 6 mths
☐ > 6 mths
14.
Have you ever seen something violent happen to someone or seen
someone killed?
0 1
☐ Past 6 mths
☐ > 6 mths
15.
Have you ever been in a major fire, flood, earthquake, or other
natural disasters?
0 1
☐ Past 6 mths
☐ > 6 mths

169
Adult Traumas No/ NA Yes Age
16.
Have you ever had a serious accident, injury, or illness that was life
threatening or caused long-term disability?
0 1
☐ Past 6 mths
☐ > 6 mths
17.
Has one of your children ever had a near-fatal accident or life-
threatening illness?
0 1
☐ Past 6 mths
☐ > 6 mths
18.
Have you ever been in combat in a war, lived neared a war zone, or
been present during a political uprising?
0 1
☐ Past 6 mths
☐ > 6 mths
19.
Have you ever discovered that your spouse or partner in a close
relationship was unfaithful?
0 1
☐ Past 6 mths
☐ > 6 mths
20.
Have you ever been physically abused by your current or a previous
spouse or partner?
0 1
☐ Past 6 mths
☐ > 6 mths
21.
Has your spouse, partner, child, or a close family member been
addicted to alcohol or drugs?
0 1
☐ Past 6 mths
☐ > 6 mths
22. Have you ever been either sexually abused or sexually assaulted? 0 1
☐ Past 6 mths
☐ > 6 mths
23. Have you ever been arrested? 0 1
☐ Past 6 mths
☐ > 6 mths

170
Q. Chronic Stressors
The following questions describe some situations that sometimes come up in people’s lives. As I read each
item, please tell me whether these things are not true, somewhat true, or very true for you DURING THE
PREVIOUS 6 MONTHS.

General stressors Not True
Somewhat
true
Very true NA
1. You're trying to take on too many things at once. 0 1 2 NA
2.
There is too much pressure put on you to be like other
people.
0 1 2 NA
3. Too much is expected of you by others. 0 1 2 NA
4. You have a long-term debt or loan. 0 1 2 NA
5.
You don’t have enough money to meet your daily
needs.
0 1 2 NA
6. You wish you could have children but you cannot. 0 1 2 NA
7.
A long-term health problem prevents you from doing the
things you like to do.
0 1 2 NA
8. You are alone too much. 0 1 2 NA
9.
You have to go to social events alone and you don’t
want to.
0 1 2 NA
10. You don’t have enough friends. 0 1 2 NA
11. You want to live farther away from your family. 0 1 2 NA
12. Your family lives too far away. 0 1 2 NA
13.
Someone in your family or a close friend has a long-
term illness or handicap.
0 1 2 NA
14.
You have a parent, a child, or a spouse or partner who
is in very bad health and may die.
0 1 2 NA
15.
Someone in your family has an alcohol or drug
problem.
0 1 2 NA
16. You take care of an aging parent almost every day. 0 1 2 NA
If participant was/has been employed (including
homemakers) during the previous 6 months:
Not True
Somewhat
true
Very true NA
17.
Your supervisor is always watching what you do at
work.
0 1 2 NA
18. You want to change jobs but don't feel you can. 0 1 2 NA
19.
Your job often leaves you feeling both mentally and
physically tired.
0 1 2 NA
171
20. You are worried that you may lose your benefits 0 1 2 NA
21. You don't get paid enough for the job you have. 0 1 2 NA
22. Your work is boring and repetitive. 0 1 2 NA
23.
You are looking for a job and can't find the one you
want.
0 1 2 NA
If participant was a student during the previous 6
months:
Not True
Somewhat
true
Very true NA
24.
You are not sure that you will be able to complete your
education.
0 1 2 NA
25.
You find it difficult to balance your school demands with
your social life and/or work.
0 1 2 NA
26.
You are concerned with your ability to keep up your
grades.
0 1 2 NA
27.
You want to go to college (or enter an educational
program) but you don't have the money to pay for it.
0 1 2 NA
28.
You want to go to college (or enter an educational
program) but you don't have the grades to get in.
0 1 2 NA
If participant was/ has been in a relationship in the
previous 6 months:
Not True
Somewhat
true
Very true NA
29. You have a lot of conflict with your partner. 0 1 2 NA
30. Your partner doesn't understand you. 0 1 2 NA
31. You don't get what you deserve out of your relationship. 0 1 2 NA
32. Your partner doesn't show enough affection. 0 1 2 NA
33.
Your partner is not committed enough to your
relationship.
0 1 2 NA
34. Your sexual needs are not fulfilled by this relationship. 0 1 2 NA
35.
Your partner is always threatening to leave or end the
relationship.
0 1 2 NA
If participant was divorced or separated in the previous 6
months:
Not True
Somewhat
true
Very true NA
36. You have a lot of conflict with your ex-spouse. 0 1 2 NA
37.
You don’t see your children from a former marriage as
much as you would like.
0 1 2 NA

172
If participant is a parent: Not True
Somewhat
true
Very true NA
38. One of your children seems very unhappy. 0 1 2 NA
39. You feel your children don't listen to you. 0 1 2 NA
40. A child's behavior is a source of serious concern to you. 0 1 2 NA
41.
One or more children do not do well enough at school
or work.
0 1 2 NA
42. Your children don’t help around the house. 0 1 2 NA
43.
One of your children spends too much time away form
the house.
0 1 2 NA
If participant was/has been single in the previous 6
months:
Not True
Somewhat
true
Very true NA
44. You wonder whether you will ever get married. 0 1 2 NA
45.
You find it is too difficult to find someone compatible
with you.
0 1 2 NA
Following questions assess participant’s neighborhood: Not True
Somewhat
true
Very true NA
46. The place that you live is too noisy or too polluted. 0 1 2 NA
47.
When coming or going from your neighborhood, you
have to plan carefully to avoid being a victim of violence
or crime.
0 1 2 NA
48.
There are some places in your neighborhood where
you never feel safe.
0 1 2 NA
49. You often hear gunshots in your neighborhood. 0 1 2 NA
50.
Gang-related crime or violence is a problem in your
neighborhood.
0 1 2 NA
51.
There is a lot of drug use and drug sales in your
neighborhood.
0 1 2 NA
52. You would like to move but you cannot. 0 1 2 NA

173
R. Life Events

Below are questions about a number of events that commonly happen in people’s lives. Each question is
concerned with whether an event has happened to you (and in some cases your family member) during the
last 6 months.

1. Have you moved during the
last 6 months?
☐ 1. No
☐ 2. Yes

If yes:
Would you say that you moved to a neighborhood that is better, worse, or
about the same as where you were living?
☐ 1. Same
☐ 2. Better
☐ 3. Worse

Overall, would you say that your moving was a good or bad experience?
☐ 1. Very good
☐ 2. Moderately good
☐ 3. Slightly good
☐ 4. Slightly bad
☐ 5. Moderately bad
☐ 6. Very bad
2. Have you broken off an
engagement to be married or
ended an intimate
relationship during the last 6
months?
☐ 1. No
☐ 2. Yes
If yes:
How would you rate your feelings about breaking up?
☐ 1. Very good
☐ 2. Moderately good
☐ 3. Slightly good
☐ 4. Slightly bad
☐ 5. Moderately bad
☐ 6. Very bad

3. Did you get married during
the last 6 months?
☐ 1. No
☐ 2. Yes
If yes:
Did you want to get married?
☐ 1. No
☐ 2. Yes

Overall, would you rate getting married as a good or bad experience?
☐ 1. Very good
☐ 2. Moderately good
☐ 3. Slightly good
☐ 4.Slightly bad
☐ 5.Moderately bad
☐ 6. Very bad
4. Were you separated or
divorced during the last 6
months?
☐ 1. No
☐ 2. Yes
If yes:
Did you want to get separated or divorced?
☐1. No ☐ 2. Yes

Overall, would you rate your separation or divorce as a good or bad
experience?
☐ 1. Very good
☐ 2. Moderately good
☐ 3. Slightly good
☐ 4.Slightly bad
☐ 5.Moderately bad
☐ 6. Very bad
5. Did you break up with a
close friend during the last 6
months?
☐ 1. No
☐ 2. Yes
If yes:
Did you want to break up with this friend?
☐1. No ☐ 2. Yes

Overall, would you rate you're your breaking up as a god or bad
experience?
☐ 1. Very good
☐ 2. Moderately good
☐ 3. Slightly good
☐ 4.Slightly bad
☐ 5.Moderately bad
☐ 6. Very bad
174
6. Have you had any important relationship, for example, with your spouse, a close friend, your boss, or a
family member become significant worse during the last 6 months (this should not include the relationship
referred to in item 5 above)?
☐ 1. No ☐ 2. Yes
If yes:

☐ 1. Boss
☐ 2. Spouse
☐ 3. Friend
☐ 4. Child
☐ 5. Parent
☐ 6. Other family member
7. Did you have a child or
adopt a child during the last
6 months?
☐ 1. No
☐ 2. Yes
If yes:
Is this a first child?
☐ 1. No ☐ 2. Yes

Did you plan to have this child?
☐ 1. No ☐ 2. Yes

Would you rate having a child and adjusting to having a child as a good or
bad experience?
☐ 1. Very good
☐ 2. Moderately good
☐ 3. Slightly good
☐ 4.Slightly bad
☐ 5.Moderately bad
☐ 6. Very bad
8. Have you, a very close friend, or close family member had an accident that required emergency medical
treatment during the last 6 months?
☐ 1. No ☐ 2. Yes
If yes:

☐ 1. You
☐ 2. Spouse/partner
☐ 3. Child
☐ 4. Spouse/s parent
☐ 5. Sibling
☐ 6. Friend
☐ 7. Other
9. Have you, a very close friend, or close family member been hospitalized for a serious (life threatening)
illness during the last 6 months?
☐ 1. No ☐ 2. Yes
If yes:

☐ 1. You
☐ 2. Spouse/partner
☐ 3. Child
☐ 4. Spouse/s parent
☐ 5. Sibling
☐ 6. Friend
☐ 7. Other
10. (Women) Have you been
pregnant during the last 6
months?
(Men) Has your wife,
partner, or girlfriend been
pregnant during the last 6
months?
☐ 1. No
☐ 2. Yes
If yes:
Was the pregnancy planned or unplanned?
☐ 1. Planned ☐ 2. Unplanned

How would you rate being pregnant?
☐ 1. Very good
☐ 2. Moderately good
☐ 3. Slightly good
☐ 4.Slightly bad
☐ 5.Moderately bad
☐ 6. Very bad
11. (Women) Have you had an abortion during the last 6 months?
(Men) Has your wife, partner, or girlfriend had an abortion during the last 6 months? (Tick no if you do not
have a wife, partner, or girlfriend)

☐ 1. No ☐ 2. Yes

12. (Women) Have you had a miscarriage or stillbirth during the last 6 months?
(Men) Has your wife, partner, or girlfriend had a miscarriage or stillbirth during the last 6 months? (Tick no
if you do not have a wife, partner, or girlfriend)

☐ 1. No ☐ 2. Yes

175
13. Have you, your
spouse/partner, or other
member of your immediate
family lost or changed jobs
or been involuntarily
unemployed during the last
6 months?
☐ 1. No
☐ 2. Yes

If yes:
Who?
☐ 1. You ☐ 2. Spouse/partner ☐ 3. Family member

Why did you (or spouse or family member) leave?
(Answer only for you if all lost or changed jobs)
☐ 1. On strike
☐ 2. Temporarily laid off
☐ 3. Fired
☐ 4. Found better job
☐ 5. Business closing
☐ 6. Retired
☐ 7. Other

Could you (or spouse or family member) have stayed in your old job if you
wanted?
☐1. No ☐ 2. Yes

How would you rate your feelings about leaving your job (or your spouse
or family member leaving his/her job)?
☐ 1. Very good
☐ 2. Moderately good
☐ 3. Slightly good
☐ 4. Slightly bad
☐ 5. Moderately bad
☐ 6. Very bad
14. During the last 6 months, have you, your spouse/partner, or other member of your immediate family
suffered a significant business or investment loss or has a business you owned failed?
☐ 1. No ☐ 2. Yes If yes:
☐ 1. You ☐ 2. Spouse/partner ☐ 3. Family member
15. During the last 6 months,
have you, your
spouse/partner, or other
member of your immediate
family (e.g., child) had any
serious problems or
disappointment at school or
in an educational course
(university, training
program)?
☐ 1. No ☐ 2. Yes
If yes:
Who?
☐ 1. You ☐ 2. Spouse/partner ☐ 3. Family member

What was the disappointment?
☐ 1. Demoted
☐ 2. Failed to be promoted
☐ 3. Failed a course
☐ 4. Trouble with boss or coworkers
☐ 5. Put on academic probation
☐ 6. Failed to get an educational
course (college, etc.)
☐ 7. Other
16. Have you, your spouse/partner, or other member of your immediate family had significant success at
work or in an educational course during the last 6 months?
☐ 1. No ☐ 2. Yes
If yes:
☐ 1. You ☐ 2. Spouse/partner ☐ 3. Family member
17. Has there been a significant
change in your personal
finances during the last 6
months?
☐ 1. No ☐ 2. Yes
If yes:
Has the change been for the better or worse?
☐ 1. Better ☐ 2. Worse
18. Has your house been broken into and/or burgled during the last 6 months?

☐ 1. No ☐ 2. Yes

176
19. Have you, your
spouse/partner, or other
member of your immediate
family been assaulted or
mugged during the last 6
months?
☐ 1. No ☐ 2. Yes
If yes:
Who?
☐ 1. You
☐ 2. Spouse/partner
☐ 3. Child
☐ 4. Parent
☐ 5. Sibling
☐ 6. Other
20. Has the behavior of any
member of your family been
a significant problem for you
during the last 6 months?
☐ 1. No ☐ 2. Yes
If yes:
Who?
☐ 1. You
☐ 2. Spouse/partner
☐ 3. Child
☐ 4. Parent
☐ 5. Sibling
☐ 6. Other
21. Have you, your
spouse/partner, or other
member of your immediate
family had to appear in
court during the last 6
months as a defendant, a
witness in a criminal case,
or as party to a suit?
☐ 1. No
☐ 2. Yes
If yes:
Who?
☐ 1. You
☐ 2. Spouse/partner
☐ 3. Child
☐ 4. Parent
☐ 5. Sibling
☐ 6. Other

How would you rate the court experience?

☐ 1. Very good
☐ 2. Moderately good
☐ 3. Slightly good
☐ 4.Slightly bad
☐ 5.Moderately bad
☐ 6. Very bad

22. Have you had a pet (animal) to whom you were attached die, or get lost, became very ill, or did you have
to give it away during the last 6 months?
☐ 1. No
☐ 2. Yes

177
S. PANSS Observation

Note down your OBSERVATIONS of the participant’s behavior during the interview.
Gather feedback from primary care worker (e.g., referring clinician) for a subset of items, marked with *.

P2. CONCEPTUAL DISORGANIZATION*: Participant manifested disorganization in thinking process.
Previous 2 weeks Previous 6 months
Content

P4. EXCITEMENT: Participant was hyperactive as reflected in accelerated motor behavior, heightened responsivity to
stimuli, hypervigilance, or excessive mood lability
Content

P7. HOSTILITY: Participant was manifesting verbal and nonverbal expression of anger and resentment, including
sarcasm, passive-aggressive behavior, verbal abuse, and assaultiveness.
Content

N1. BLUNTED AFFECT*: Participant showed reduction in facial expression, modulation of feelings, and communicative
gestures.
Previous 2 weeks Previous 6 months
Content

N2. EMOTIONAL WITHDRAWAL: Participant showed lack of interest in, involvement with, and affective commitment to life
events and his/her surroundings.
Content

N3. POOR RAPPORT: Participant showed a lack of interpersonal empathy and openness in conversation, and also a
minimal sense of closeness, interest, or involvement with the interviewer.
Content

N6. LACK OF SPONTANEITY AND CONVERSATION FLOW*: Participant showed a reduction in the normal flow of
communication associated with apathy, avolition, defensiveness, or cognitive deficit.
Previous 2 weeks Previous 6 months
Content

178
N7. STEREOTYPED THINKING: Participant showed decreased fluidity, spontaneity, and flexibility of thinking, as evidenced
in rigid, repetitious, or barren thought content.
Content

G4. TENSION: Participant showed overt physical manifestation of fear, anxiety, and agitation, such as stiffness, tremors,
profuse sweating, and restlessness.
Content

G5. MANNERISM AND POSTURING*: Participant showed unnatural movements or posture as characterized by an
awkward, stilted, disorganized, or bizarre appearance
Previous 2 weeks Previous 6 months
Content

G7. MOTOR RETARDATION: Participant showed a reduction in motor activity reflected by the slowing or lessening of
movements and speech, diminished responsiveness to stimuli, and reduced body tone.
Content

G8. UNCOOPERATIVENESS: Participant actively refused to comply with the will of significant others, including the
interviewer, perhaps associated with distrust, defensiveness, stubbornness, hostility, and etc.
Content

G11. POOR A TTENTION: Participant showed poor concentration, distractibility from internal and external stimuli, and
difficulty in harnessing, sustaining, or shifting focus to new stimuli.
Content

G15. PREOCCUPATION: Participant was absorbed with internally generated thoughts and feelings or with autistic
experiences to the detriment of reality orientation and adaptive behavior.
Content

END

Abstract (if available)

Abstract Introduction: Little is known about Asian Americans diagnosed with schizophrenia, a low-prevalence but serious psychiatric disorder. A basic demographic characterization of this population is lacking. Additionally, data on aspects of their psychological health, social circumstances, lived experiences with mental illness, access to and use of services, and importantly, treatment responsiveness that can provide clues to the existence of needs and resources are scant. These gaps in knowledge are concerning because an increasing number of users of mental health services in the Asian American community are expected to be individuals with serious psychiatric disorders, yet little data exist to guide service delivery to this growing group. Objectives: The goals of this study were related to Asian Americans diagnosed with schizophrenia. The first study cataloged the socio-demographic characteristics of Asian Americans served at community mental health agencies for a diagnosis of schizophrenia. The second study assessed the treatment responsiveness of these users of mental health service and identified the cultural promoters and barriers of the investigated outcomes (symptoms severity, role functioning, symptomatic remission, and clinical recovery), with an emphasis on correlates that are responsive to psychosocial interventions delivered by practitioners. The third study investigated whether the treatment outcomes vary in Asian ethnic subgroups via comparison with East Asian and Southeast Asian Americans diagnosed with schizophrenia. Methods: Quantitative data for this cross-sectional study were gathered from interviews with 75 Asian Americans diagnosed with schizophrenia who were served across four Los Angeles County Department of Mental Health contracted and directly operated agencies and two board-and-care facilities in Los Angeles. Demographics, clinical, and psychosocial data were collected using a combination of in-person interviewing and participant completion of validated self-report inventories. Univariable analyses were conducted to derive descriptive statistics for the study sample—means and standard deviations were computed for continuous variable, and proportions for categorical variables. Chi-square tests, with correction of unequal variances whenever necessary, or Fisher’s exact tests for categorical variables with few observations were performed to examine relationship between two categorical variables

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Asset Metadata

Creator Lim, Caroline Sheng Foong (author)

Core Title Asian Americans served at community mental health agencies for a diagnosis of schizophrenia

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 07/22/2017

Defense Date 06/19/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Asian Americans,demographics,OAI-PMH Harvest,schizophrenia,treatment outcomes

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Barrio, Concepcion (committee chair), Ailshire, Jennifer (committee member), Brekke, John (committee member)

Creator Email carolisl@usc.edu,csflim80@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-409625

Unique identifier UC11264482

Identifier etd-LimCarolin-5588.pdf (filename),usctheses-c40-409625 (legacy record id)

Legacy Identifier etd-LimCarolin-5588.pdf

Dmrecord 409625

Document Type Dissertation

Rights Lim, Caroline Sheng Foong

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA