Asian Americans and Native Hawaiian Pacific Islanders Mental Health Issues

Introduction

Suicide is ranked ten on the top ten leading causes of death in the United States as well as in Asian Americans (AAs) and Native Hawaiian Pacific Islanders (NHPIs) (U.S. Department of Health and Human Services [HHS], Centers for Disease Control and Prevention [CDC], National Center for Health Statistics [NCHS], 2017). Suicide is the act or attempt in which an individual takes their own life voluntarily. According to the National Institutes of Mental Health, from 1999 to 2014, there has been a 24% increased rate of total suicide. Suicide rates between genders are significantly higher among males (20.7 per 100,000) compared to females (5.8 per 100,000) in 2014.Suicide is ranked eight on the top ten leading causes of death in AA and NHPI (Heron, 2011). There is little research on suicide intents disclosure among AA and NHPI.  It is unknown whether the individuals’ who committed suicide had disclosed having a mental illness to family, friends, or caregivers, but, based on the culture of AA and NHPI subgroups, it’s most common that the interpersonal aren’t aware of the individual’s mental illnesses (Kwan, Baig, & Lo, 2018).

In 2016, CDC noted there had been an increase of suicide in every state in the U.S. from 1999 through 2016 (CDC, 2015). Mental health problems are often a cause of death, but suicide is hardly a single factor. Mental health problems range from emotional, psychological, and social distraught affecting the individual is thinking, feelings, and behavior. Mental health illnesses, for example, depression and anxiety, are found as the best predictors of suicidal thought (Cheng, et al., 2010; Kuroki, & Tilley,2012; Wong, Browson, & Schwing, 2011; Wong, Koo, Tran, Chiu, &Mok, 2011). AA and NHPI encounter barriers in seeking support or professional help due to the stigmas associated with mental health in their culture (Han & Pong, 2015; Masuda & Boone, 2011; Shimotsu et al., 2014). According to the National Violent Death Reporting System, all death victims of suicide in 2016 who racially identify as Asian or Pacific Islander had an age-adjusted rate of 6.38 per 100,000 (CDC, 2016). Of the 693 deaths, 69.8% of the Asian/ Pacific Islander, non-Hispanic, victims’ deaths in 2016 were male, and 30.2% are female. There is also a difference between people with mental health problems/conditions and without. It was found, nationally, that people who didn’t identify having any mental health conditions “were more likely to be male and die by firearm” (CDC, 2015).  Often studies combine AA and NHPI subgroups into one large racial group due to underrepresentation. It’s noted the problem behind suicide in the U.S. is predominately due to relationship problems. Examples of relationship problems could mean conflict with a person’s family or community.

In AA and NHPI culture, discussion of mental health illnesses is considered taboo. It was noted that the influence of teachings and philosophies from Confucian discourages expressing emotion to maintain social and familial harmony as well as avoid exposing personal weakness (Kramer, Kwong, Lee, & Chung, 2002). Though not all AAs and NPHI practice Buddhism, similar experiences have encountered in different subgroups just as how health beliefs and behaviors vary in culture. Chinese and Japanese have identical views of mental illness been caused by evil spirits rather than identifying as a real illness; their coping behaviors is delaying or avoid seeking help which is common amongst most AAs (Kramer, Kwong, Lee, & Chung, 2002). Denial or discrimination once an individual identifies as having a mental illness restraint the individual from seeking help in fears of being labeled as being demonically possessed. Fear of shame among peers may have created a stigma of disclosing mental illness in today’s society. Also, societal pressures from other racial groups have created a perception that AA and NHPI have fewer health problems.

The “model minority myth” is a stereotype created on the perception that AA and NHPI “are academically, economically, and socially successful than any other racial minority group associated with their supposedly stronger values emphasizing hard work, perseverance, and belief in the American meritocracy” (Yoo, Burrola, &Steger, 2010). This has created a preconceived notion of AAs having any psychopathology resulting in underreported utilization of mental health services  (Han, Cha, Lee, & Lee, 2017). Such stigma can affect an individual’s decision to disclose their mental health condition.

An individual’s decision to disclose or expose private health information can be explained in a disclosure decision-making model (DD-MM) (Greene, 2009). The DD-MM is utilized for the general process of disclosure decision-making, but it was rarely tested on disclosing health information.  DD-MM consists of three factors: assessing the information, assessing the receiver, and disclosure efficacy (Greene, 2009).

Assessing the information is how the individual assess the health information they had received (Greene, 2009). An example would be an AA high school or college student being diagnosed with mild depression and anxiety by their school psychiatrist. Once diagnosed, the student would begin assessing whether the diagnosis needs to be disclosed to family or friends. Before disclosing, there are five potentially overlapping factors that may affect their decision: “stigma, prognosis, symptoms, preparation, and relevance” (Greene et al., 2012). The perception of stigma is likely to reduce the chances of disclosing medical diagnosis. An example of stigma would be the culture stigma among AA and NHPI when disclosing having a mental health problem. The prognosis, or outcome of the disease, is it treatable, terminal, or chronic can influence the decision to disclose as well. If symptoms are identifiable, visually or emotionally, it would impact the individual’s choice of disclosure to others. An example would be a NHPI college student having visual self-inflicted scars on their wrists. If someone recognized the scars, they would question the individual, thus, possibly disclosing they are suffering a mental illness. Another consideration would be the individual’s need for preparation after diagnosis. If the individual is diagnosed with major depression, a psychiatrist would recommend taking anti-depressants to prepare and protect the person. The last consideration is whether the diagnoses are relevant to others. For example, if a child is suffering from anxiety and depression due to family problems, it is relevant for the parents to be notifying their child is suffering due to their marital issues.

Assessing the receiver is “analyzing the potential receiver” (Greene et al, 2012). It is the process of evaluating the association between the individual and the receiver. There are multiple considerations to take when assessing the receiver. First consideration would be the quality of the relationship, which depends on how close one feels and how much they trust others with private health information. Second consideration would be the anticipated reaction after disclosure, which can result in a positive or negative response. Last consideration that is closely related to anticipate reaction would be confidence in response. Confident in response “reflect the degree to which the discloser is certain that the intended target (receiver) will respond to the disclosed information in the way the discloser anticipated” (Greene et al., 2012). When confident, the individual will become more efficacious about disclosing.

Disclosure efficacy is the third assessment of DD-MM. Efficacy is commonly defined as confidence and skills when disclosing the health information. An example would be a male AA college student disclosing to his immigrant parents that he is suffering from major depression and has been secretly plotting his death. By feeling confident about their diagnosis, the individual is more likely to disclose that information. Ultimately, the result of whether the individual discloses their health information or not it up to the individual.

Methods

This review is being conducted in partial fulfillment of requirements for the Masters of Public Health (MPH) graduate degree at the CSU Fullerton Department of Health Science. A systematic review is helpful in enhance future studies by learning from previous studies. Systematic reviews are beneficial in limiting bias, increasing reliability, reducing delay during the implementation of discoveries, improving generalizability, initiating more research about subgroups of the study population, and increase the validity of the results (Gopalakrishnana&Ganeshkumar, 2013). Serving as a map of results to expose evidence on the effectiveness of mental health services subgroups as well as provide further recommendations based on original studies offered to Asian American (AA) and Native Hawaiian Pacific Islander (NHPI) who disclose having a mental illness to any individual. A relevant question associated with this systematic review is what do we know about disclosure of a mental illness in different AA and NHPI subgroups.

The author will screen titles, abstracts and references list for potential inclusion. A minimum of fifteen publications is selected for full-text review for inclusion eligibility assessment. A standardized form for data extraction will be created to capture essential study characteristic by depression and anxiety, and include relevant research objective, participants, geographical location, Asian American and Pacific Islander subgroups, and study design and analysis. Data is synthesized by categorizing geographic location, study methodology, and AA and NHPI groups. There is currently no reporting protocols available for this systematic review. This systematic review will follow the guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to aid in the structure of this approach (Moher, et al., 2009).

Eligibility criteria and rationale

The author will screen titles, abstracts and references list for potential inclusion. A hand full of publications is selected for full-text review for inclusion eligibility assessment. A standardized form for data extraction will be created to capture essential study characteristic by disclosure of mental illness, and include relevant research objectives, participants, geographical location, Asian American and Pacific Islander subgroups, and study design and analysis. Data is synthesized by categorizing geographic location, study methodology, and AA and NHPI groups. The following are necessary criteria eligible for inclusion: 1) All articles are required to have been peer-reviewed; 2) AA and NHPIs are the target population of the study, as a group or separately to minimize racial bias; 3) research must be conducted within the U.S.; 5) outcomes of disclosure of mental health problem; and 6) article must be published in 2000 or later. Exclusion criteria include the following: 1) literature reviews or discussion papers.

 Search strategy

 The following are search engines to be utilized for this study: PubMed, CINAHL Plus with Full-text (EBSCO), Google Scholar, Science Direct, PsychINFO (EBSCO), Academic Search Premier (EBSCO), Mental Measurements Yearbook with Tests in Print (EBSCO), and JSTOR.  The following are search terms to be utilized in all databases mentioned:

1. (Afghanis OR Bangladeshis OR Bhutanese OR Burmese OR Cambodian OR Chinese OR Filipino OR Korean OR Hmong OR Japanese OR Nepalese OR Pakistanis OR Singaporeans OR Sir Lankans OR Taiwanese OR Thai OR Vietnamese OR South Asians OR Carolinians OR Chuukese OR Guamanians OR Ikiribati OR Kosraean OR Maldivians OR Marshallese OR Mariana Islanders OR Melanesians OR Micronesians OR ni-Vanuatu OR Okinawans OR Palauan OR Papua New Guineans OR Pohnpeians OR Polynesians OR Saipanese OR Samoans OR Solomon Islanders OR Tahitians OR Tongans OR Yapese)
2. (mental health problem or mental illness or mental problems or depression or anxiety or suicide or attempted suicide or suicidal intention)
3. (disclosure or disclose or identified or identify or disclos*)
4. (america OR us OR usa OR united states)
5. 1 and 2 and 3 and 4
6. 2 and 3 and 4

Study selection and data extraction

The author will screen titles, abstracts and references list for potential inclusion. Selected articles will be selected for full-text review for inclusion eligibility assessment. A standardized form for data extraction will capture essential study characteristics relevant to research objective, participants, geographical location, and AA and NPHI subgroups. Data is synthesized and the qualities of the articles are assessed. By determining the quality of the article would benefit in reducing or elimination errors that may bias data when analyzed. To determine the quality of the article, it must include the key concepts associated with disclosure of mental health and positive or negative effects in result of the behavior or diagnosis. After filtering out quality data, the data analysis process begins.

 For this systematic review, the outcomes of the articles will be inputted in a table that includes the title of the article, author, population, study design, type of data collected, outcome, and limitations. By creating the chart, it analyzes whether the studies have a similar procedures and outcomes.

Summary of key constructs/concepts

Mental illness is a broad term used interchangeably with mental health problems or mental disorder. Mental illnesses range from anxiety and panic attacks to Post Traumatic Stress Disorder (PTSD). Mental health problems can develop at any age but previous research has found biological factors, life experiences, and family history of mental health problems are contributing factors to developing a problem. Psychological imbalances are why one in ten young people may have experienced major depression, often after they have reached adolescence (U.S. Department of Health and Human Services [HHS], Centers for Disease Control and Prevention [CDC], National Center for Health Statistics [NCHS], 2017).

Depression is a mood disorder (U.S. Department of Health and Human Services, 2018).  When someone is going through depression, it can cause symptoms that affect how you feel, think and do daily activities (U.S. Department of Health and Human Services, 2018). Daily activities that become difficult for someone diagnosed with depression could be getting out of bed, clean after themselves, or work. Depression is also commonly known as major depression, major depressive disorder, or clinical depression. Anxiety is also a mood disorder, similar to depression.

Anxiety disorder is the feeling of worry, nervousness, or uneasiness that affects an individual’s life (U.S. Department of Health and Human Services, 2018). When someone diagnosed with anxiety, it does not just go away and may even worsen over time if left untreated (U.S. Department of Health and Human Services, 2018). Anxiety is very broad; one facet of anxiety this study will focus are the comorbidities such as physical and emotional symptoms that impair the individual of their daily activities. Depression and anxiety can affect many people, but there is limited research on AA and PI.

Study participants will include overall AAs and PIs individuals from different subgroup that represent other cultures and ethnicities. Asian subgroups include Afghanis, Bangladeshis, Bhutanese, Burmese, Cambodian, Chinese, Filipino, Korean, Hmong, Japanese, Nepalese, Pakistanis, Singaporeans, Sir Lankans, Taiwanese, Thai, Vietnamese, and South Asians. Pacific Islander subgroups include Carolinians, Chuukese, Guamanians, Ikiribati, Kosraean, Maldivians, Marshallese, Mariana Islanders, Melanesians, Micronesians, ni-Vanuatu, Okinawans, Palauan, Papua New Guineans, Pohnpeians, Polynesians, Saipanese, Samoans, Solomon Islanders, Tahitians, Tongans, and Yapese.

 Disclosure of mental health is when an individual openly shares that they are currently going through that is effecting their mental well-being. When an individual reveal their vulnerabilities, there are many possible outcomes. For example, if a war veteran returned home and suffered signs and symptoms of PTSD, the individual may divulge their concerns to a near friend or relative. The positives of disclosure related to better quality of social support, increase self-esteem, and lower levels of depression. If the individual has a traumatic experience, like child abuse, they won’t be as reluctant to discuss their experience and receive the needed mental health services ( O’Leary, P. Coohey, C., & Easton, S. D., 2010). When the individual vouchsafes their self-diagnoses or diagnoses, it’s important to disclose it to someone who is closely related to the individual like a mother (Ruggiero, 2000). Response is also something to take within consideration when disclosing a mental illness.

 Response from disclosing a mental health is important of disclosing the event. If the response is incorrect, it may create adverse effect in the individual. Adverse effects may be falling in to depression, self-harm, suicide contemplation, seeking assistant or even suicide completion.  If the incorrect response, such as becoming hostile, nonproductive response, or disbelieving, may create traumatic and “lead to long-term mental health symptoms (Feiring, Taska, & Lewis, 2002). When assessing risk of bias across studies, this study will use the Cochrane Database of Systematic Reviews (CDSR).

Results

 A total of 373 citations were identified through various search engines. After 19 duplicate articles were removed, 354 remaining titles and abstracts were screened according to the inclusion and exclusion criteria. Twenty-four articles were potentially relevant and applicable to this systematic review. After reading the full-text articles to assess for eligibility, there was a remainder of nine articles that may be included. Fifteen full-text articles were excluded because six were dissertation, three didn’t focus on AA and NHPIs, two did not mental anything about disclosing a mental disorder, two were literature reviews or meta-analysis, and two were conducted outside of the U.S. A total of 6 publications were included for this review. A flowchart of the studies showing studies included and excluded at each stage is shown following the PRISMA 2009 flow diagram (See Figure 1).

Publications were categorized by relevant research objectives, number of participants and geographical location, AA and NHPI subgroup, study design and analysis, results, and limitations of the study (Table 1). All studies are about mental health or psychological disorders. 67% of the articles are cross-sectional studies and 50% use logistic regression for the data analysis. 50% of the studies did not distinguish the specific subgroups of AA and NHPI. Aside from that most study participants reflected more Koreans than Chinese.

Discussion

The publications had provided an insight of the available literature on disclosing mental health problems. During my search for articles, it was difficult to identity sufficient articles for AA and NHPIs. Most articles are done on Caucasian, African American, and Hispanic groups. In some studies, AA and NHPIs categorized as other. To prevent risk of misinterpretation, studies that did not identify what the ‘other’ group is composed of were not included.  There is a common theme throughout all the study results which is shame. The influence of teachings and philosophies from Confucian discourages expressing emotion to maintain social and familial harmony as well as avoid exposing personal weakness (Karmer, Kwong, Lee, & Chung, 2002). Though not all AAs and PIs practice Buddhism, similar experiences are encountered in different ethnicities just as how health beliefs and behaviors vary among Chinese, Japanese, Korean, and Vietnamese cultures. Chinese and Japanese have similar views of mental illness being caused by evil spirits rather than identifying as a real illness; their coping behaviors is delaying or avoid seeking help which is common amongst most AAs (Karmer, Kwong, Lee, & Chung, 2002). Denial or discrimination once an individual identifies as having a mental illness restraint the individual from seeking help in fears of being labeled as being demonically possessed. Stigmas of mental health in this community create barriers for those who want to find support or professional advice (Han & Pong, 2015; Masuda & Boone, 2011; Shimotsu et al., 2014). All articles discussed a form of support would come from family yet it was

Among the limitations of all studies, generalizability was coherent. Since all the studies focus on a specific racial group, it is recognizable cultures differ from person to person. An interesting limitation was small sample sizes. It was noted that one publication’s limitation was their sample size being too small (Barry, D. T., & Mizrahi, T. C., 2005). It was reported AA and NHPIs were less likely to participate in studies. It was also noted throughout all the publications that men were least likely to response in the interviews (Berkman, C. S., & Ko., E., 2009; Chen, F., Lai, G. Y.-C., & Yang, L., 2013).

A future direction of this systematic review is to create a study among AA and NHPIs about disclosure of mental illnesses. There are studies about disclosure of mental illness among the racial group, but majority of those studies are based outside of the U.S. Currently, there is a limitation of what can be utilized due to the stigma behind discussion of mental illness.

• Ruggiero, K. J., McLeer, S. V., & Dixon, J. F. (2000). Sexual abuse characteristics associated with survivor psychopathology. Child Abuse & Neglect, 24(7), 951–964
• Feiring, C., Taska, L., & Lewis, M. (2002). Adjustment following sexual abuse discovery: The role of shame and attributional style. Developmental Psychology, 38(1), 79–92.
• O’Leary, P. Coohey, C., & Easton, S. D. (2010). The effect of severe child sexual abuse and disclosure on mental health during adulthood. Journal of Child Sexual Abuse, 19,275-289.