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The cultural expression of depression in Asian Americans and European Americans

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The cultural expression of depression in Asian Americans and European Americans

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Content Running head: CULTURAL EXPRESSION OF DEPRESSION 1

The Cultural Expression of Depression in Asian Americans and European Americans

Jean M. Kim

University of Southern California

Faculty Advisor: Steven R. López, Ph.D.
Thesis Committee Members: Richard John, Ph.D.
David Schwartz, Ph.D.

Master’s Thesis
December 2012

CULTURAL EXPRESSION OF DEPRESSION 2
Table of Contents
Abstract……………………………………………………………………………………..……..3
The Cultural Expression of Depression………………………………………………………..….4
The Diagnositicity of Psychological and Somatic Symptoms………………………..…………...6
Overview and Hypotheses……...………………………………………………...……………….8
Method…………………………………………………………………………..……………….10
Participants…………………………………………………………....…..……………...10
Measures………………………………………………………………….………….......11
Results…………………………………………………………………………….……………...12
Overview……………………………………………………...………….………………12
Ethnicity and Degree of Depression………………………………..……………………12
Ethnicity and Symptom Endorsement…………………………………………………...13
Item Response Theory…………………………………………...………………………14
Discussion………………………………………………………………………………………..15
Limitations and Future Directions……………………………………………...………..18
Conclusions………………………………...…………………………………………….18
References………………………………………………………………………………………..20
Tables…………………………………………………………………………………………….24
Figures…………………………………..………………………………………………………..29

CULTURAL EXPRESSION OF DEPRESSION 3
Abstract
Despite the generally held notion that Asian Americans express depression differently than
European Americans, it is not clear if the differences observed in past studies are a reflection of
ethnic differences in the levels of depression or in the expression of depression. In the present
study, we examined the psychological and somatic symptoms of Major Depressive Disorder in a
nationally representative community sample of non-institutionalized Asian Americans (n =
2,095) and European Americans (n = 4,180). The samples were selected from the National
Latino and Asian American Survey and National Comorbidity Survey-Replication. We
consistently found that a smaller percentage of Asian Americans reported depressive disorders
and symptoms than European Americans. The ethnic differences in depressive symptoms were
greater for psychological symptoms than for somatic symptoms. Similar findings were found
using both Chi Square and IRT analyses. For the IRT analyses, differences in item parameters
were largely in the severity parameters for psychological symptoms, where Asian Americans had
a lower probability of endorsing psychological symptoms than European Americans, given
similar levels of the latent construct of depression. These findings suggest that the observed
ethnic differences are not an artifact of lower rates of depression among Asian Americans
compared to European Americans. Overall, this study found evidence to suggest less
psychologization in Asian Americans than in European Americans, and fewer differences in the
level of somatization between the two groups.
Keywords: somatization, psychological symptoms, depression, Asian Americans, item response
theory

CULTURAL EXPRESSION OF DEPRESSION 4
The Cultural Expression of Depression in Asian Americans and European Americans

Many anthropologists and psychologists believe that the conceptualization of mood
disorders is rooted in Western culture and may not apply as well to other cultures. In support of
this, past research has demonstrated that Asian and Asian American patients are more likely than
European Americans to express depression somatically (Yen, Robins, & Lin, 2000; Yeung &
Chang, 2002). According to the American Psychiatric Association (DSM-IV-TR), “in some
cultures, depression may be experienced largely in somatic terms, rather than with sadness or
guilt” (2000, p. 353). The DSM-IV-TR lists imbalance, tiredness, and weakness as possible
expressions of depression in people of Asian background. Many refer to this as somatization, or
the presentation of physical symptoms as a manifestation of psychological distress (Kroenke et
al., 1997; Simon et al., 1999). Further examples of somatic symptoms include fatigue,
gastrointestinal problems, headache, and pain. There are many descriptions of somatization in
various East Asian countries, as well as a vast theoretical literature (Ryder et al., 2008).
A recent literature review, however, reveals only limited evidence that Asian Americans
are more likely than others to report somatic symptoms (Uebelacker, Strong, Weinstock, &
Miller, 2009). Although some clinical studies suggest that Asian American patients are more
likely to endorse somatic symptoms than European American patients (e.g., Huang et al., 2006),
the findings across studies have not been robust. Studies using community samples have also
failed to show consistent differences in the reports of somatic symptoms between depressed
Asian Americans and depressed European Americans (e.g., Yen, Robins, & Lin, 2000). Weiss
and colleagues (2009) also compared symptoms of depression in Thai and U.S. children and
adolescents from a community sample. The Thai and U.S. groups endorsed similar levels of
somatic (and psychological) symptoms (effect size of the mean contrasts = 0.00 (-.05 ~ .05) for
CULTURAL EXPRESSION OF DEPRESSION 5
children and adolescents). When Kadir and Bifulco (2010) examined a community sample, they
found that both somatic and psychological symptoms of depression are expressed in Malaysian
women in the community. The women described depression both psychologically and
somatically, giving “full and open” descriptions of psychological symptoms, while also often
endorsing somatic symptoms. Although this study was qualitative in nature, it is consistent with
other community-based studies (Cheng, 1988, 1989; Cheung, 1982) that suggest that the high
prevalence of somatization in people of Asian background is not likely observed in community
samples.
Like Yen and others, Ryder and his research team also suggest that there may be little
difference between Asian origin and European American adults in the presentation of somatic
symptoms. They argue that the actual difference is in people of Asian background endorsing
fewer psychological symptoms than people of European American background. In a recent study
of outpatients, they found that, using three different measures of depressive symptoms, the
Chinese sample endorsed a significantly lower level of psychological symptoms than the North
American sample on all three depression measures. Participants in the Chinese sample also
endorsed a significantly higher level of somatic symptoms than the North American sample on
two of the three depression measures. However, the effect sizes for psychological symptoms
were larger and more consistently significant than the effect sizes for somatic symptoms (Ryder
et al., 2008). Therefore, the authors argued that the true distinctive cross-cultural feature in the
expression of depression for Asian Americans may be their reporting of fewer psychological
symptoms than European Americans (Ryder et al., 2008). Psychologization can be defined as the
tendency to express distress in affective or cognitive terms (Kirmayer, 2001). Examples of
psychological symptoms include feelings of worthlessness, irritability, tearfulness, and depressed
CULTURAL EXPRESSION OF DEPRESSION 6
mood. Thus, based on Ryder and colleagues’ findings, it is important that the study of depression
among people of Asian background examines both somatic and psychological symptoms to
assess whether Asians and Asian Americans somaticize, European Americans psychologize, or
some combination of the two.
The Diagnosticity of Somatic and Psychological Symptoms
One problem with past studies that examine ethnic group differences in symptom
frequencies is that it is unclear whether a difference in frequency reflects an ethnic difference in
the expression of depression or simply a different level of disorder or symptom severity. For
example, in the Ryder et al. (2008) study, it may be that less psychologization among Asian
Americans may actually reflect that Asian Americans have lower levels of depression and not
simply lower levels of psychological symptoms. Thus, it is important that efforts be taken to
control for the severity of the mental disorder, in this case depression, when carrying out these
analyses.
Item Response Theory (IRT) provides a statistical approach to examine whether ethnic
group differences in depressive symptoms reflect differences in the expression of depression or
group differences in the severity of the disorder. IRT gives mathematical expressions of the
relationship between participants’ responses on an item (in this case, symptoms) and the
underlying construct (in this case, depression) thought to underlie the responses. The model
accounts for the potentially confounding effect of depression severity by assessing whether the
association between the item and the latent construct differs depending on racial/ethnic group
membership (i.e., Asian American or European American), when both groups are matched on the
level of depressive symptoms. Another advantage of the IRT approach is that it may be a more
precise manner of testing whether there are ethnic differences in symptom expression than the
CULTURAL EXPRESSION OF DEPRESSION 7
traditional frequency approach. For example, with the traditional approach, there may be
significant mean group differences in given symptom clusters suggesting that the two groups
express depression differently, yet the association between a given symptom and the latent
construct of depression may be no different for the two groups. Conversely, there may be no
difference in the frequency of psychological symptoms reported for the two groups, suggesting
no difference in the expression of the disorder, however, the relationship between the symptom
cluster and a diagnosis of depression may be much greater for one group than another.
In IRT, a mathematical function specifies an item characteristic curve (ICC), which
represents the probability of a response varying with the level of the underlying trait. The slope
and position are two important characteristics of this curve. First, the relative position of the ICC
indicates trait strength. This is called the severity or difficulty parameter. Second, the slope of the
ICC indicates the discriminability of that item between different levels of the trait. This is also
called the discrimination parameter. Differential item functioning (DIF) is a statistical approach
that is used to test the null hypothesis that these item parameters do not differ between two
groups.
Application of IRT methods to the evaluation of DSM-IV diagnostic criteria is an
emerging area of research. Uebelacker and colleagues (2009) tested the ‘somatic hypothesis’ of
depression, namely that a particular racial/ethnic group (e.g., Asian Americans) would be more
likely to “somatize” than another racial/ethnic group (e.g., European Americans), given equal
levels of depression. This study utilized the National Epidemiologic Survey on Alcohol and
Related Conditions (NESARC) dataset, a large, nationally representative epidemiological sample
of adults in the United States. The Uebelacker et al. (2009) study examined symptoms of
depression, including analyses comparing non-Hispanic Whites to American Indians/Alaska
CULTURAL EXPRESSION OF DEPRESSION 8
Natives, Asians, African Americans, and Hispanics and also women to men. For the purpose of
this paper, we focus here on the Asian American to non-Hispanic Whites comparisons. For the
severity parameter, none of the symptoms met criteria for significant DIF, except for suicide. In
other words, given equivalent levels of depression severity, Asian Americans were more likely to
endorse suicidal ideation than White respondents. Also, for the discrimination parameter, only
one symptom met criteria for significant DIF. The symptom concentration was less
discriminating for Asian Americans than for European Americans for the diagnosis of
depression. Overall, Uebelacker et al. (2009) reported that the results failed to find support for
the notion that Asian Americans express depression differently than European Americans, even
when controlling for level of depression as carried out by IRT. The study was limited, however,
in that their community sample included a small Asian American group (n = 291) relative to
other groups examined in the study (ns ranged from 468 to 10,958). The study also excluded
those who were not fluent English speakers, thus the sample likely reflected a more acculturated
Asian American sample, thereby reducing the likelihood of finding ethnic differences. Finally,
the analyses focused only on seven MDD symptoms that were present in a two-week episode of
depressed mood or anhedonia. Only one other study to date has used IRT to examine DSM
symptoms of depression to determine whether symptoms function differently between groups (in
this case, those with and without a co-morbid medical condition; Simon & Von Korff, 2006).
However, these authors focused on depressed primary care participants with and without a co-
morbid medical condition and did not examine race/ethnicity differences.
Overview and Hypotheses
In the present study, we drew on the Collaborative Psychiatric Epidemiology Surveys, a
national psychiatric epidemiology database that includes both Asian Americans and European
Americans, to examine the variability in symptom expression of depression among Asian
CULTURAL EXPRESSION OF DEPRESSION 9
Americans and European Americans. The advantage of this database is that it is comprised of
nationally representative samples of persons residing in the community, while many past studies
have only used clinical samples. In addition, unlike the Uebelacker et al. (2009) study, non-
English speaking Asian American respondents were included.
We applied two statistical approaches. The first was to examine whether the two ethnic
groups differed in the types of symptoms endorsed, using Chi-square analyses. The second
approach applied Item Response Theory. Although we believe that the IRT approach is the more
precise way to test our hypotheses, by including the traditional approach, we were in a position
to assess how our findings map on to past research and how they compare to the IRT approach.
Accordingly, it allowed us to explore whether the statistical methods lead to similar or different
results.
Our first objective was to test whether Asian Americans and European Americans
differed with regard to both somatic and psychological symptoms. Consistent with Ryder and
associates’ (2008) previous findings, we expected Asian Americans would endorse lower levels
of psychological symptoms than European Americans. Additionally, while Ryder et al. (2008)
found smaller but significant differences in somatic symptoms between Asian and European
Americans on two out of three measures, other studies using community samples (e.g., Cheng,
1988, 1989; Cheung, 1982; Weiss et al. 2009) did not find a higher prevalence of somatization in
people of Asian descent. Therefore, we predicted that Asian Americans and European Americans
in this sample would not significantly differ in their levels of somatic symptom endorsement.
Next, we examined the relationship between the symptom and the latent structure of the
disorder using item response theory. For psychological symptoms, we expected that the severity
parameter would be higher for Asian Americans than European Americans. In other words,
CULTURAL EXPRESSION OF DEPRESSION 10
Asian Americans would have a lower probability of endorsing psychological symptoms than
European Americans with the same level of depression. For the discrimination parameter, we
explored whether psychologization is differentially related to the latent construct of depression
for Asian Americans or European Americans. For somatic symptoms, we expected that the
severity parameters would not be significantly different between the two racial/ethnic groups. In
other words, Asian Americans and European Americans would have similar probabilities of
endorsing somatic symptoms, given the same level of depression and thus similar severity
parameters. For the discrimination parameter, we again explored whether somatization is
differentially related to the latent construct of depression for Asian Americans or European
Americans.
Method
Participants
The participants were part of the Collaborative Psychiatric Epidemiology Surveys
(CPES), three studies that were conducted to collect epidemiological data on psychological
disorders in the general population, and in particular, people of minority groups. The CPES
included three surveys with nationally representative samples: the National Comorbidity Survey
Replication (NCS-R), the National Survey of American Life (NSAL), and the National Latino
and Asian American Study (NLAAS). These studies comprised the first national data set with
enough power to examine cultural or ethnic correlates of mental illness, and it allows researchers
to analyze the combined dataset as if it were one nationally representative study.
The Asian American data were selected from the National Latino and Asian American
Survey (NLAAS), which was a nationally representative household survey of respondents 18
years and older in the contiguous United States and Hawaii. The NLAAS Asian sample (N =
CULTURAL EXPRESSION OF DEPRESSION 11
2,095) included: Chinese (n = 600), Filipino (n = 508), Vietnamese (n = 520), and ‘other’ Asian
(n = 467) participants. Among the Asian Americans, 454 were U.S.-born, 1,639 were foreign-
born, and two did not identify a place of birth. Interviews were conducted in English, Mandarin,
Cantonese, Tagalog, and Vietnamese. Participants reported national origins in East Asia,
Southeast Asia, South Asia, and Central Asia. The mean age was 41.0 (SD = 14.7). Forty-seven
percent of the Asian Americans were male, and 53% were female. The response rate for Asian
Americans was 69.3%.
The European American data were selected from the National Comorbidity Survey-
Replication (NCS-R), which was a nationally representative household survey of respondents
aged 18 years and older in the contiguous United States. The non-Hispanic White sample was
comprised of 4,180 people. The mean age was 46.5 (SD = 17.8). Forty-six percent of the
European Americans were male, and 54% were female. The response rate for European
Americans was 70.9%.
Measures
Composite International Diagnostic Interview (CIDI; World Health Organization).
The CIDI is the most widely used structured diagnostic interview. It is fully structured, lay-
administered, and generates ICD-10 and DSM-IV diagnoses. It was designed to be used across
cultural and ethnic groups. Specially trained, non-clinical interviewers administered the CIDI
face-to-face with computer-assisted technology. This study primarily focused on the following
sections of the CIDI.
Screening section. In this section, participants were asked three questions specific
to depression. These items consisted of questions asking about times when most of the day, one
felt “sad, empty or depressed”, “very discouraged about how things were going”, or when one
CULTURAL EXPRESSION OF DEPRESSION 12
“lost interest in most things [he/she] usually [enjoys]”. If the participant endorsed at least one of
the screening items, they went on to answer questions in the depression module.
Depression module. This module consisted of symptoms that mapped on to the
DSM-IV-TR criteria for Major Depressive Disorder. It included 23 psychological symptoms
(e.g., “Did you feel hopeless about the future nearly every day?”) and 11 somatic symptoms
(e.g., “Did you have a much larger appetite than usual nearly every day?”).
Results
Overview
We first examined the entire sample to see whether there were ethnic group differences in
the level of depression using the depression screening items. We then carried out two distinct
sets of analyses with those who screened positive for possible depression to examine the specific
symptom expressions for the two ethnic groups. The analysis of symptom expression between
ethnic groups was carried out with this subsample because all the depressive symptoms were
assessed with this group. The first symptom analysis examined the rate of endorsement of
psychological and somatic symptoms by Asian and European Americans. This was done using
Chi Square analyses. Because of the potentially confounding effect of depression severity in
evaluating group differences in the expression of depression, our second set of analyses used IRT
to examine any potential DIFs in psychological and somatic symptoms.
Ethnicity and Degree of Depression
Across all assessments of depression, Asian Americans reported significantly less
depression. First, when the overall sample is considered, a smaller percentage of Asian
Americans than European Americans reported depression screening items. For example, 31.8%
of Asian American endorsed the item “sad/empty/depressed”, whereas half of European
CULTURAL EXPRESSION OF DEPRESSION 13
Americans (49.9%) endorsed this item (p < .001, see Table 1). Spearman’s rho for these three
screening items was perfect at 1.00, p < .01. Asian Americans (AAs) also reported lower rates of
Major Depressive Disorder (MDD) than European Americans (EAs; Pearson Chi-Square, two-
sided, p’s < .001); this was the case for lifetime (AAs: 9.2%; EAs: 18.0%) and twelve-month
MDD (AAs: 4.5%; EAs: 7.2%).
Ethnicity and Symptom Endorsement
An examination of ethnic group differences for specific symptom endorsement reveals a
pattern similar to the overall lower rate of depression for Asian Americans than European
Americans. For those who received the depression module by endorsing at least one of the
depression screening items mentioned previously, a smaller percentage of Asian Americans than
European Americans reported psychological symptoms on 9 of the 23 psychological symptoms
(39%) that were assessed. For example, only 41.9% of the Asian Americans reported guilt
whereas 50.9% of the European Americans reported this symptom (p = .004, see Table 2).
Spearman’s rho for the psychological symptoms was 0.975 (p < .001). With regard to the 11
somatic symptoms, Asian Americans were significantly lower in their endorsement rate than
European Americans for just two of the symptoms (18%). For example, 26.7% of the Asian
Americans reported larger appetite, whereas 39.5% of the European Americans reported larger
appetite (p = .019, see Table 3). Spearman’s rho for the somatic symptoms was 0.855 (p = .001).
Asian Americans were indeed lower than European Americans in their endorsement for
psychological and somatic symptoms, however fewer differences were observed regarding
somatic symptoms. Even when there were differences in somatization, the opposite of the
“somatization hypothesis” occurred, with smaller percentages of Asian Americans endorsing
somatic symptoms than European Americans.
CULTURAL EXPRESSION OF DEPRESSION 14
Item Response Theory (IRT)
Results from the IRT analyses are shown in Tables 4 and 5, which list the severity and
discrimination parameters for each psychological and somatic depressive symptom across the
racial/ethnic group comparisons. For the psychological symptoms, an examination of DIF
showed that these items had more differences across racial/ethnic groups in terms of
severity/difficulty and few differences in terms of discrimination. Eleven out of twenty three
psychological symptoms exceeded criteria for statistical significance in DIF for the severity
parameter (see Table 4). For example, the ICCs for the item “guilt” are plotted in Figure 1. This
shows that given equivalent levels of depression severity, Asian Americans are less likely to
endorse guilt than European American respondents. Regarding the discrimination parameters,
there was one statistically significant difference: thoughts about death were more discriminating
for Asian Americans than for European Americans. The ICCs for this item are plotted in Figure
2.
For somatic symptoms, there were few statistically significant DIFs in either severity or
discrimination. Two out of eleven somatic symptoms exceeded criteria for statistical significance
in DIF for the severity parameter (see Table 5). For these two, Asian Americans were less likely
to endorse somatic symptoms than European Americans, given similar levels of depression.
There were also two statistically significant differences in discrimination parameters (see Table
5). For these two symptoms, the items were more discriminating for Asian Americans than
European Americans. Interestingly, the item “fatigue/loss of energy” showed statistically
significant differences in both severity and discrimination parameters, and the item’s ICCs are
plotted in Figure 3. Given equivalent levels of depression severity, Asian Americans tended to be
CULTURAL EXPRESSION OF DEPRESSION 15
less likely to endorse “fatigue/loss of energy” than European Americans, and this item was more
discriminating for Asian Americans than European Americans.
Discussion
We found that Asian Americans within a national sample present with significantly fewer
depressive disorders and symptoms than do European Americans. Moreover, there are more
ethnic differences for psychological symptoms than for somatic symptoms. For nine of the
twenty-three psychological symptoms, a smaller percentage of Asian Americans than European
Americans reported these symptoms, whereas for two of the eleven somatic symptoms, a smaller
percentage of Asian Americans than European Americans reported these symptoms. The
frequency analysis supports our hypothesis that Asian Americans endorse fewer psychological
symptoms. We did not find full support for our hypothesis that Asian Americans would endorse
similar levels of somatic symptoms compared to European Americans. In fact, on two of the
somatic symptoms, Asian Americans were lower than European Americans in the endorsement
of these symptoms, which is opposite to what Ryder et al. (2009) found using their clinical
sample. Nevertheless, the overall findings are consistent with Ryder’s main conclusion that the
difference between Asian Americans and European Americans is greater for psychological
symptoms than for somatic symptoms.
To rule out the possibility of an artifact of lower rates of depression among Asian
Americans compared to European Americans, we carried out Item Response Theory (IRT)
analyses. As mentioned, an advantage of the IRT approach over the typical frequency approach
is that it accounts for the potentially confounding effect of depression severity in evaluating
group differences, and it may be a more precise manner of testing whether there are ethnic
differences in symptom expression. With the IRT analyses, we found very similar results to the
CULTURAL EXPRESSION OF DEPRESSION 16
frequency analyses; the most distinguishing differences were found with psychological as
opposed to somatic symptoms. Relative to European Americans, Asian Americans were less
likely to endorse psychological symptoms, given similar levels of depression.
There was also quite a bit of overlap with the given symptoms using both Chi Square and
IRT analyses. For example, feeling discouraged, feeling hopeless, feeling guilty, being
indecisive, thinking a lot about death, not being able to cope with responsibilities, and feeling
like you wanted to be alone all showed significantly different endorsements rates across
racial/ethnic groups using Chi Square and significantly different severity parameters across
groups using IRT. Specifically, Asian Americans were less likely to endorse these psychological
symptoms than European Americans. On the other hand, of the somatic symptoms, the item “lost
weight” was the only item that was significant using both Chi Square and IRT analyses. Overall,
there were few differences in severity for somatic symptoms, as hypothesized. In particular, the
items lost weight and fatigue/loss of energy showed significantly different severity parameters,
with Asian Americans again being more likely to endorse the item than European Americans
with similar levels of depression.
Past literature has focused mostly on this severity parameter, and not as much on the
discrimination parameter, so we had no a priori hypotheses on the discrimination parameter. We
found that there were few differences in the discrimination parameter for both psychological and
somatic symptoms, although the two differences were noted above.
Overall, it can be seen that the ethnic differences are largely the same using both the
frequency and IRT approaches. The Chi-Square and IRT analyses yielded significant differences
across racial/ethnic groups for the symptoms of feeling discouraged, hopelessness, guilt,
indecisiveness, thinking about death, not being able to cope, and wanting to be alone. The
CULTURAL EXPRESSION OF DEPRESSION 17
methods revealed a similar pattern, and thus the findings are not simply an artifact of a lower
level or severity of depression among Asian Americans compared to European Americans.
We believe these findings add to the literature in important ways. First, the IRT analyses
suggest that there truly are some differences, but only in the severity parameter for psychological
symptoms. Compared to European Americans, Asian Americans are less likely to report
psychological symptoms, and they require higher levels of depression to report psychological
symptoms. Second, these findings differ from the IRT analysis of Uebelacker and colleagues
(2009) who found only one ethnic difference for the severity parameter and one ethnic difference
for the discrimination parameter. We place more confidence in the findings of the current study
given the large sample size and given that the sample likely represents more sociocultural
variability in the expression of depression, since those who did not speak English well were
included in the present study but not in the Uebelacker et al. (2009) study. A third contribution of
this study is that prior research indicating less psychologization was based largely on clinical
populations. The current study provides complementary evidence using a nationally
representative, community sample of non-institutionalized populations. This is one of a few
studies using a nationally representative community sample of Asian and European Americans
that examines both psychological and somatic symptoms. Moreover, the prior clinical and
community studies (e.g., Weiss et al., 2009) only carried out frequency (i.e., classical test theory)
analyses and did not include IRT analyses, which take into account depression severity.
The findings also have potential clinical implications. Keeping in mind this pattern of less
psychologization in Asian Americans may assist clinicians in the detection and assessment of
depression. Although the DSM is heavily weighted towards psychological symptoms (i.e., more
than 50% of the DSM criteria are psychologically minded), it may be important to consider that
CULTURAL EXPRESSION OF DEPRESSION 18
it may take an Asian American who is more depressed to endorse the psychological symptoms
than a European American client. Keeping this pattern in mind has the potential to assist
clinicians in better detecting depression in Asian Americans who are experiencing the disorder.
Limitations and Future Directions
Because of the nature of the survey, this dataset did not allow us to examine depressive
symptoms in the entire sample, as only those who passed the screening items received the
depression module. Thus, it will be important to replicate these findings in future studies, using
both an entire community and clinical sample.
Second, there may be important subgroup differences, within the broad racial/ethnic
categories. For example, some research suggests that Korean women have a significantly higher
somatic symptom mean than Japanese women, but that somatic concerns account for less
variance in Beck Depression Inventory scores in Koreans than for Japanese (Arnault & Kim,
2008). Because the current project was an initial study on race/ethnicity differences, we did not
examine subgroup differences within Asian and European Americans. There might be variability
within these two groups, due to nationality, language, country of birth, etc. This would be an
interesting and important area of future research.
Finally, this study does not explain why Asian Americans psychologize less than
European Americans. Future studies might look at the role of stigma, help-seeking, and other key
variables to help explain this difference.
Conclusions
Although the somatization hypothesis has been popular in past theory and research of
symptom expression in racial and ethnic minority groups, more recent studies, particularly those
using community samples, do not fully support this hypothesis. Similar to Ryder et al. (2009),
CULTURAL EXPRESSION OF DEPRESSION 19
we found less psychologization in Asian Americans than in European Americans, and fewer
differences in the level of somatization among the two groups. Furthermore, we found that the
observed ethnic differences are not likely to be an artifact of lower rates of depression among
Asian Americans compared to European Americans. By using a large, nationally representative
sample and multiple methods of analyses, this has helped to better clarify the aforementioned
discrepancy in past cross-cultural research.

CULTURAL EXPRESSION OF DEPRESSION 20
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CULTURAL EXPRESSION OF DEPRESSION 24
Table 1

Rates of Depression Screening Item Endorsement by Race/Ethnicity (%)

Depression Screening Item

Asian
American
(n = 2284)
European
American
(n = 6696)

Sad/empty/depressed

31.8

49.9*

Discouraged about life 32.4 52.6*

Lost interest in enjoyable things 24.7 36.9*

Note. For Asian Americans, the number of “refused” responses
ranged from 1-2, and the number of “don’t know” responses
ranged from 0-1. For European Americans, there were no
“refused” responses, and the number of “don’t know” responses
ranged from 1-5.
* p < .001.

CULTURAL EXPRESSION OF DEPRESSION 25
Table 2

Rates of Depressive Psychological Symptom Endorsement for those who “Screened In” to the
Depression Module by Race/Ethnicity

Asian American

European American

Depressive Psychological
Symptom of CIDI
% Endorsement n % Endorsement n

Psychological Symptoms

Felt depressed 89.0 310 92.9* 1763
Nothing could cheer 60.4 275 64.2 1636
Discouraged 79.7 310 86.7** 1762
Hopelessness 61.5 247 68.6* 1521
Loss of interest 69.0 310 74.1 1760
Nothing was fun 62.3 308 67.2 1755
Worthlessness 62.8 180 68.8 1021
Loss of confidence 73.6 295 77.9 1717
Not as good as others 61.1 296 59.5 1718
Guilt 41.9 296 50.9** 1719
Trouble concentrating 73.8 294 78.0 1716
Indecisiveness 54.9 295 62.7* 1701
Thoughts come slowly 57.6 295 55.4 1700
Thought about death 51.0 296 57.6* 1726
Better if dead 41.6 296 42.6 1720
Thought about suicide 27.5 295 32.0 1727
Made suicide plan 42.0 81 33.0 551
Made suicide attempt 30.9 81 25.0 552
Irritability 60.9 294 58.0 1723
Couldn’t cope w/ responsibility 45.4 295 56.3** 1726
Wanted to be alone 69.9 296 76.8* 1721
Less talkative 80.4 296 81.5 1719
Tearfulness 61.1 296 67.6* 1727

Note. The number of respondents per item varies given the computer algorithm of the CIDI and its “skip function”.
The maximum subsamples by ethnicity are Asian American n = 310 and European American n = 1763.
* p < .05. * p < .01. *** p < 0.001.

CULTURAL EXPRESSION OF DEPRESSION 26
Table 3

Rates of Depressive Somatic Symptom Endorsement for those who “Screened In” to the
Depression Module by Race/Ethnicity

Asian American

European American

Depressive Somatic Symptom of
CIDI
% Endorsement n % Endorsement n
Lost weight 61.7 149 81.3*** 846
Gained weight 57.7 26 60.0 230
Smaller appetite 69.0 294 64.2 1699
Larger appetite 26.7 90 39.5* 618
Insomnia 76.5 294 72.9 1702
Hypersomnia 51.4 70 59.9 484
Psychomotor agitation 19.7 147 27.1 852
Others noticed agitation 67.9 28 78.7 225
Psychomotor retardation 50.9 293 51.8 1679
Others noticed retardation 73.1 145 72.5 846
Fatigue/loss of energy 82.8 296 83.3 1715

Note. The number of respondents per item varies given the computer algorithm of the CIDI and its “skip function”.
The maximum subsamples by ethnicity are Asian American n = 310 and European American n = 1763.
* p < .05. * p < .01. *** p < 0.001.

CULTURAL EXPRESSION OF DEPRESSION 27
Table 4
Differential item functioning of DSM-IV psychological symptoms of Major Depressive Disorder
for Asian and European Americans

Severity/Difficulty Parameter Discrimination Parameter
Psychological
Symptoms

Asian
American

European
American

Sig.

Asian
American

European
American

Sig.
Felt depressed -2.031 (0.317) -2.157 (0.138) 0.358 0.772 (0.160) 0.948 (0.092) 0.830
Nothing could cheer -0.245 (0.107) -0.475 (0.053) 0.027 1.025 (0.170) 0.841 (0.060) 0.154
Discouraged -1.215 (0.169) -1.561 (0.085) 0.034 0.926 (0.157) 1.017 (0.081) 0.697
Hopelessness -0.163 (0.110) -0.524 (0.053) 0.002 1.046 (0.186) 0.963 (0.071) 0.338
Loss of interest -0.703 (0.123) -0.906 (0.054) 0.065 0.969 (0.152) 1.033 (0.070) 0.649
Nothing was fun -0.444 (0.109) -0.675 (0.052) 0.028 0.991 (0.151) 0.891 (0.060) 0.269
Worthlessness 0.068 (0.104) -0.232 (0.059) 0.006 1.486 (0.308) 1.056 (0.095) 0.091
Loss of confidence -0.806 (0.143) -1.128 (0.073) 0.022 0.942 (0.164) 0.863 (0.066) 0.327
Not as good as others -0.343 (0.117) -0.355 (0.050) 0.462 0.866 (0.144) 0.816 (0.056) 0.373
Guilt 0.426 (0.136) -0.022 (0.058) 0.001 0.670 (0.118) 0.590 (0.044) 0.263
Trouble concentrating -0.943 (0.180) -1.164 (0.077) 0.129 0.753 (0.140) 0.818 (0.063) 0.664
Indecisiveness -0.157 (0.141) -0.483 (0.053) 0.015 0.597 (0.111) 0.804 (0.056) 0.952
Thoughts come slowly -0.223 (0.116) -0.186 (0.047) 0.616 0.816 (0.137) 0.827 (0.056) 0.530
Thought about death 0.032 (0.108) -0.354 (0.064) 0.001 0.866 (0.140) 0.562 (0.044) 0.019
Better if dead 0.348 (0.103) 0.290 (0.047) 0.304 1.038 (0.166) 0.885 (0.059) 0.193
Thought about suicide 0.945 (0.150) 0.785 (0.063) 0.163 0.883 (0.151) 0.754 (0.054) 0.211
Made suicide plan 1.271 (0.356) 1.623 (0.169) 0.814 0.462 (0.203) 0.503 (0.083) 0.574
Made suicide attempt 2.165 (0.744) 2.869 (0.528) 0.780 0.377 (0.200) 0.314 (0.078) 0.385
Irritability -0.465 (0.166) -0.455 (0.081) 0.522 0.564 (0.110) 0.436 (0.040) 0.137
Couldn’t cope w/
responsibility
0.201 (0.092) -0.197 (0.041) 0.000 1.265 (0.193) 1.099 (0.070) 0.209
Wanted to be alone -0.911 (0.209) -1.324 (0.103) 0.038 0.589 (0.118) 0.626 (0.053) 0.613
Less talkative -1.527 (0.312) -1.606 (0.124) 0.407 0.604 (0.134) 0.638 (0.057) 0.592
Tearfulness -0.836 (0.344) -1.456 (0.196) 0.059 0.306 (0.091) 0.306 (0.038) 0.500

CULTURAL EXPRESSION OF DEPRESSION 28
Table 5
Differential item functioning of DSM-IV somatic symptoms of Major Depressive Disorder for
Asian and European Americans

Severity/Difficulty Parameter Discrimination Parameter
Somatic
Symptoms
Asian
American
European
American
Sig. Asian
American
European
American
Sig.
Lost weight -1.088 (0.773) -3.982 (1.106) 0.016 0.237 (0.123) 0.225 (0.062) 0.465
Gained weight -0.919 (1.649) 26.274
(240.687)
0.545 0.254 (0.326) -0.010 (0.094) 0.218
Smaller appetite -2.133 (0.949) -1.920 (0.405) 0.582 0.219 (0.092) 0.179 (0.035) 0.342
Larger appetite 1.009 (0.425) 0.403 (0.119) 0.085 0.601 (0.229) 0.524 (0.071) 0.374
Insomnia -2.714 (1.077) -2.721 (0.489) 0.498 0.257 (0.101) 0.217 (0.039) 0.356
Hypersomnia -0.292 (0.427) -0.611 (0.091) 0.232 0.346 (0.214) 0.760 (0.102) 0.960
Psychomotor
agitation
0.688 (0.288) 1.276 (0.265) 0.934 1.036 (0.287) 0.383 (0.062) 0.013
Others noticed agit. -1.222 (3.080) -2.882 (1.298) 0.310 0.294 (0.593) 0.276 (0.128) 0.488
Psychomotor
retardation
0.046 (0.113) -0.069 (0.056) 0.181 0.812 (0.134) 0.626 (0.047) 0.095
Others noticed
retar.
-1.502 (1.055) -2.112 (0.651) 0.311 0.300 (0.157) 0.230 (0.060) 0.339
Fatigue/loss of
energy
-1.215 (0.185) -1.704 (0.130) 0.015 0.986 (0.185) 0.656 (0.060) 0.045

CULTURAL EXPRESSION OF DEPRESSION 29
Figure 1. Illustrative Item Characteristic Curves for the “Guilt” Psychological Depressive
Symptom Item Derived From Asian and European Americans

0
0.5
1
-6 -4 -2 0 2 4 6
P(endorsing)
Theta
Asian Americans
European Americans
CULTURAL EXPRESSION OF DEPRESSION 30
Figure 2. Illustrative Item Characteristic Curves for the “Thought About Death” Psychological
Depressive Symptom Item Derived From Asian and European Americans

0
0.5
1
-6 -4 -2 0 2 4 6
P(endorsing)
Theta
Asian Americans
European Americans
CULTURAL EXPRESSION OF DEPRESSION 31
Figure 3. Illustrative Item Characteristic Curves for the “Fatigue/Loss of Energy” Somatic
Depressive Symptom Item Derived From Asian and European Americans

0
0.5
1
-6 -4 -2 0 2 4 6
P(endorsing)
Theta
Asian Americans
European Americans

Abstract (if available)

Abstract Despite the generally held notion that Asian Americans express depression differently than European Americans, it is not clear if the differences observed in past studies are a reflection of ethnic differences in the levels of depression or in the expression of depression. In the present study, we examined the psychological and somatic symptoms of Major Depressive Disorder in a nationally representative community sample of non-institutionalized Asian Americans (n = 2,095) and European Americans (n = 4,180). The samples were selected from the National Latino and Asian American Survey and National Comorbidity Survey-Replication. We consistently found that a smaller percentage of Asian Americans reported depressive disorders and symptoms than European Americans. The ethnic differences in depressive symptoms were greater for psychological symptoms than for somatic symptoms. Similar findings were found using both Chi Square and IRT analyses. For the IRT analyses, differences in item parameters were largely in the severity parameters for psychological symptoms, where Asian Americans had a lower probability of endorsing psychological symptoms than European Americans, given similar levels of the latent construct of depression. These findings suggest that the observed ethnic differences are not an artifact of lower rates of depression among Asian Americans compared to European Americans. Overall, this study found evidence to suggest less psychologization in Asian Americans than in European Americans, and fewer differences in the level of somatization between the two groups.

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Creator Kim, Jean M. (author)

Core Title The cultural expression of depression in Asian Americans and European Americans

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Publication Date 11/21/2014

Defense Date 08/29/2012

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

Tag Asian Americans,Depression,item response theory,OAI-PMH Harvest,psychological symptoms,somatization

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