2. Introduction
Chinese Americans are the largest ethnic group among the Asian American
populations in the United States, with a population of 4.3 million (U.S. Census
Bureau, 2015).
Depression-related symptoms is reported in approximately 10% of Asian Americans.
15.9% of young Asian American women report suicidal thoughts (Kalibatseva &
Leong, 2011).
The purpose of this systemic review is to find the depression risk factors and the
effectiveness of culturally relevant interventions for reducing depression among
Chinese Americans.
3. Introduction
The Asian American Journal of
Psychology
The Journal is dedicated to research, practice,
advocacy, education, and policy within Asian
American psychology (APA, 2015).
Published: quarterly, beginning in March
4. Introduction
Database: CINAHL and PUBMED
Search Year and Language: 2010 – 2015, English
Keywords: Chinese Americans, Asian Americans, depression, behavioral
health, mental health, cultural barrier, immigration
Inclusion criteria: peer reviewed articles, primary quantitative and
qualitative research, health outcomes of interest, publication
language.
522 search articles yielded and 6 articles were selected for the review.
5. Methods
Yeung et al. (2010)
Included: a sufficient sample size and
randomized controlled trials (RCT).
Excluded: participants with a high risk of suicide,
substance use disorder, bipolar disorder and
unstable medical conditions.
Hwang et al. (2015)
Included: a small sample size and a RCT.
Excluded: reliable data and sufficient sample
size
Kwong, Chung, Cheal, Chou and Chen (2011)
Included: a RCT and a small sample size
Excluded: adequate and reliable samples due to
high refusal rate.
Chao et al. (2014)
Included: both participants and matching group
in the UCSF.
Excluded: diverse sample size.
Zhang, Fang, Wu and Wieczorek (2013)
Included: date from the National Latino and
Asian Study (NLAAS)
Excluded: the RCTs and controlled groups
Hsieh and Bean (2014)
Included: interpreting findings that understating
cultural factors in Chinese American families.
Excluded: a summary statistic
6. Author: Yeung et al. (2010)
Study Design
• Sample size: 4,228 Chinese American patients
• Participants: participants were randomized into culturally sensitive
collaborative treatment (CSCT) and compared group (Yeung et al.,
2010).
Study Results
• Results clearly showed that CSCT model achieved a nearly 7-fold
increase in treatment than the control care group (Yeung et al., 2010).
Study Conclusion
• CSCT is an effective model in improving the treatment among
depressed Chinese Americans, given patients the knowledge and
treatment based on culturally-based interventions (Yeung et al., 2010).
Evidence Rating
• This article was rated as a level 1 good quality study due to sufficient
sample size, randomized control group and reasonable consistent
results. However, there were some limitations, which included low
response rate and limited generalizability to other setting (John
Hopkins Hospital, 2012).
7. Author: Hwang et al. (2015)
Study Design
• Sample size: 50 Chinese Americans met criteria ( 145 Pre-Screening at
intake)
• Participants: 27 participants were randomized into culturally adapted
CBT (CA-CBT) and 23 participants were computer randomized into
cognitive behavioral health (CBT) (Hwang et al., 2015).
Study Results
• Results clearly presented that participants in both CBT and CA-CBT
significantly decreased in depressive symptoms (Hwang et al., 2015).
Study Conclusion
• Author suggested that more intensive and longer treatments may be
needed for severe depression and also cultural adaptations may
increase additional treatment benefits.
• It is unclear how the results might have been different if the sample
size was larger (Hwang et al., 2015).
Evidence Rating
• This article is a level 1 low quality study because of insufficient
sample (John Hopkins Hospital, 2012).
8. Author: Kwong et al. (2011)
Study Design
• Sample size: 6,065 Chinese Americans were screened for depression,
57 participated.
• Participants: participants were randomly assigned to receive either
enhanced physician care with care management or enhanced
physician care only (Kwong et al., 2011).
Study Results
• Result clearly states that both groups resulted in significant reduction
of depressive symptoms, so there was no difference between the two
groups (Kwong et al., 2011).
Study Conclusion
• Both physician care model and physician care with care management
models are not based on cultural interventions.
• The findings of the study may be related to high refusal rates and
small sample size (Kwong et al., 2011).
Evidence Rating
• This article is a level 1 low quality study due to some control - RCT
but insufficient sample size (John Hopkins Hospital, 2012).
9. Author: Chao et al. (2014)
Study Design
• The sample included 137 elderly, cognitively impaired and cognitively
normal Chinese Americans and 140 Caucasians with and without
cognitive impairment.
• Demographic variables and clinical variables were compared across
both groups (Chao et al., 2014).
Study Results
• The results clearly showed depression was more common in
cognitively impaired Chinese Americans (35%) versus cognitively
impaired Caucasians (15%); Chinese Americans were less likely to be
treated for depression (12%) than Caucasians (37%) (Chao et al.,
2014).
Study Conclusion
• Increased depression among cognitively impaired Chinese Americans,
but they are less likely to be treated (Chao et al., 2014).
Evidence Rating
• This article is a level 2 good quality study due to sufficient sample,
some control and reasonably consistent results, The limitation of the
article is a lack of randomized controlled group (John Hopkins
Hospital, 2012).
10. Author: Zhang et al. (2013)
Study Design
• Sample size: 600 participants
• The study analyzed the immigration related depression among
Chinese Americans and used Stata Software 10.0 to analyze data for
controlling age, education level or marital status, and other related
factors (Zhang et al., 2013).
Study Results
• The depression rates were 23.20% (vs. 8.25% for China born),
compared with those who immigrated to the United States at different
ages (<18 vs. Q18 years), the lifetime prevalence rates of depressive
disorder (17.95% vs. 7.14%) (Zhang et al., 2013).
Study Conclusion
• The conclusion stated the study found United States–born immigrants
at young age (<18 years old) had higher depression rates than
Chinese-born immigrates (Zhang et al., 2013).
Evidence Rating
• This article is a level 3 good quality study based on some control and
reasonably consistent results (John Hopkins Hospital, 2012).
11. Author: Hsieh and Bean (2014)
Study Design
• The article by Hsieh and Bean (2014) discussed a culturally-
competent treatment for working with Chinese American Families.
• This is a qualitative study
Study Results
• The article explained and analyzed the effect of cultural factors,
collectivism, gender factors, family hierarchy, acculturation and sexual
development on Chinese adolescent depression (Hsieh & Bean, 2014).
Study Conclusion
• The conclusion clearly states that be aware of these factors benefits
doctors and clinicians to treat this problem in a systemic perspective
(Hsieh & Bean, 2014).
Evidence Rating
• This article is a level 3 good quality study that identifies key concepts
and fairly definitive conclusions, the limitation of article is lacking of
data and compared group (John Hopkins Hospital, 2012).
12. Conclusion
Depression among Chinese Americans continues to be a constant issue. The findings of this
literature review support prior findings indicating high rates of depression among Chinese
Americans.
All selected articles found that the cultural barrier and culture-related factors may cause under-
recognition and under-utilization of the mental health services.
The research findings support that the effectiveness of utilizing culturally collaborative treatment
and overcoming the language and cultural barrier for depression among Chinese Americans.
13. Discussion
Cross-cultural barriers are often blocked the road to the treatment of mental health illness.
A culturally-based care model plays an important role in screening, treatment and intervention of
depression among Chinese population.
Also high refusal rate leaded to a smaller sample size which increased the difficulty for this issue
related research.
Future research is needed to focus on how to utilize the cultural-based model to make depression
screening, interventions and treatment more accessible for Chinese Americans.
14. Nursing Implications
• Utilize culturally collaborative model for
depression screening and intervention
• Overcome the language and cultural barrier
• Improve the patient-provider relationship
• Use risk factors to implement treatment
• Discuss concerns with patients
• Education
15. References
Chao, S. Z., Matthews, B. R., Yokoyama, J. S., Lai, N. B., Ong, H., Tse, M., & ... Rosen, H. J. (2014). Depressive symptoms in
Chinese-American subjects with cognitive impairment. American Journal of Geriatric Psychiatry, 22(7), 642-652.
doi:10.1016/j.jagp.2012.10.029
Hsieh, A. L., & Bean, R. A. (2014). Understanding familial/cultural factors in adolescent depression: A culturally-competent
treatment for working with Chinese American families. American Journal of Family Therapy, 42(5), 398-412.
doi:10.1080/01926187.2014.884414
Hwang, W., & Fujimoto, K. (2015). Culturally adapted cognitive-behavioral therapy for Chinese Americans with depression: A
randomized controlled trial. Psychiatric Services, 66(10), 1035-1042. doi:10.1176/appi.ps.201400358
Johns Hopkins Hospital/The Johns Hopkins University (2012). Research evidence appraisal tool. Johns Hopkins nursing
evidence-based practice: Model and guidelines (2nd ed., pp. 237-240). Indianapolis, IN: Sigma Theta Tau International Honor
Society of Nursing.
Kwong, K., Chung, H., Cheal, K., Chou, J., & Chen, T. (2013). Depression care management for Chinese Americans in primary care:
A feasibility pilot study. Community Mental Health Journal, 49(2), 157-165. doi:10.1007/s10597-011-9459-9
16. References
United States Census Bureau. (2015). Chinese American population. Retrieved from https://www.census.gov/newsroom/facts-for-
features/2015/cb15-ff07.html
Yeung, A., Shyu, I., Fisher, L., Wu, S., Yang, H., & Fava, M. (2010). Culturally sensitive collaborative treatment for depressed Chinese
Americans in primary care. American Journal of Public Health, 100(12), 2397–2402. http://doi.org/10.2105/AJPH.2009.184911
Zhang, J., Fang, L., Wu, Y.-W. B., & Wieczorek, W. F. (2013). Depression, anxiety, and suicidal ideation among Chinese Americans: A
study of immigration-related factors. The Journal of Nervous and Mental Disease, 201(1), 17–22.
http://doi.org/10.1097/NMD.0b013e31827ab2e2
Zornitsa Kalibatseva and Frederick T. L. Leong, “Depression among Asian Americans: Review and Recommendations,” Depression
Research and Treatment, vol. 2011, Article ID 320902, 9 pages, 2011. doi:10.1155/2011/320902
