Вы находитесь на странице: 1из 12

Japanese Americans' Health Concerns

and Depressive Symptoms: Implications


for Disaster Counseling
Monit Cheung, Patrick Leung, and Venus Tsui

This study examined factors contributing to depressive symptoms among Japanese


Americans. Data were collected in Houston, Texas, in 2008, before the March 2011 Japan
earthquake, through a community survey including demographic and mental health questions and the Hopkins Symptoms Checklist. Among 43 Japanese American respondents in
this convenience sample, the depression prevalence was 11.6 percent. Chi-square results
found i:hat having anxiety symptoms and holding a master's degree had statistically significant relationships with depressive symptoms. An independent sample t test found that those
having depressive symptoms experienced significantly more health issues than those without
depressive symptoms. When these statistically significant variables were entered into a logistic regression model, the overall effect of having health issues, anxiety symptoms, and a master's degree collectively predicted depressive symptoms. It was also found that Japanese
Americans rarely consult mental health professionals; in particular, female Japanese American respondents tend to seek help from religious leaders. As implied by these findings, the
reluctance of Japanese Americans to seek formal help can be explained by social stigma, a
health-oriented approach to treatment, and other cultural considerations. Practice implications focus on disaster counseling with a connection between mental health needs and
health care support.
KEYWORDS: depression prevalence; disaster training; health issues; help-seeking behavior; Japanese mental health

n 2010, Asians (alone, not in combination


with other races) represented 4.8 percent of
the U.S. population, a 43.3 percent increase
from the 2000 Census data (U.S. Census Bureau
[USCB], 2010aj. Among them, Japanese Americans have rarely been selected as a single study target because, as of 2010, they represented only 5.6
percent of the country's Asian population and less
than 1 percent (approximately 0.4 percent including combined races) of the entire U.S. population
(USCB, 2010a).
Census 2010 also revealed that among the
total Japanese population in the United States
(1,304,286), 763,325 reported their ethnicity as
Japanese alone without hsting other ethnicities,
and 540,961 listed at least one other ethnicity, of
the same or a different race. These figures reflect a
41 percent interethnic representation rate, the
highest among all Asian American groups (see
Table 1). Even though Japan was ranked sixth as
country of origin among the Asians residing in the

doi: 10.1093/sw/swt0-.6 2013 National Association of Social Workers

United States, only 3.4 percent within the foreignbom Asian population (343,746) were of Japanese
descent (USCB, 2010b). Over two-thirds of all
Japanese Americans were bom in the United States,
the highest proportion among all Asian Americans.
However, approximately half of all Japan-bom
immigrants in the United States are wives of American citizens (Toji, 2003), and many Japanese American families represent the third or higher generation
in the United States (Machizawa &c Lau, 2010).
Thus, children of these famihes are less likely to
identify themselves as Japanese than as American or
Japanese American (Toji, 2003). These statistics
demonstrate that members of this culturally diverse
population have divergent and unique needs.
Many studies about Japanese Americans have
focused on their long immigration history and cultural changes, but it is of equal importance to identify their needs and concerns, like those in the
community-based study reported here. The hterature review focuses on the mental health needs and

201

Table 1: Interethnic Representation Rates 2010 U.S. Census Data


(A)
One Ethnicity
Alone

(B)
Alone or in Any
Combination^

interethnic Representation
Rate''

2,843,391
128,792
15,290
91,085
231,616
3,137,061
2,555,923
247,593
63,383
763,325
1,423,784
191,200
16,138
51,907
363,699
38,596
196,691
166,620
1,548,449

3,183,063
147,300
19,439
100,200
276,667
3,794,673
3,416,840
260,073
95,270
1,304,286
1,706,822
232,130
26,179
59,490
409,163
45,381
230,382
237,583
1,737,433

11
13
21
9
16
17
25
5
33
41
17
18
38
13
11
15
15
30
11

Asian American Ethnic


Group
Asian Indian
Bangladeshi
Bhutanese
Burmese
Cambodian
Chinese (except Taiwanese)
Filipino
Hmong
Indonesian
Japanese
Korean
Laotian
Malaysian
Nepalese
Pakistani
Sri Lankan
Taiwanese
Thai
Vietnamese

iOurce: U. S. Census Bureau. (2010a). 2010 Census data. RetrievetJ from http:Jf^Aww.census.gov/2010census/data/
"Combination within the same ethnicity or in any other race group.
*The Interethnic representation rate is calculated by KB).(A)l/(B)x100%.

depression prevalence of Japanese Americans in


order to support our research study. As a result of
scant research about Japanese Americans' depression, our review also extends to studies of Japanese
nationals.
FACTORS CONTRIBUTING TO DEPRESSION
Professional Help and Informal Support
Japanese culture places strong emphases on family
bonds, social harmony, emotional restraint, and
avoidance of stigma or shame (haji), all of which
may result in preferring alternative health care to
treat psychological distress. For instance, Narikiyo
and Kameoka (1992) reported that Japanese Americans rated informal support (family, friends, selfhelp or support groups) and the ability to "endure
and adjust to [a] situation" (p. 365) as more helpful
and beneficial in treating problems. Their findings
revealed a greater tendency for Japanese Americans
to resolve problems with informal support rather
than with professional help because of shame and
social stigma. Unexpectedly, the study also found
that Japanese Americans and white Americans did
not differ significantly in their perceptions of the

202

helpfulness of psychotherapy and mental health


professionals. The authors explained that those who
sought professional help might have a higher level
of acculturation, which could mediate the influence
of stigma associated with professional help seeking.
Acculturation may also affect the adherence to traditional gender roles that can explain certain helpseeking behaviors. Yamawaki and Tschanz (2005)
found that their subjects firom Japan were more likely
than their subjects firom the United States to adhere
to traditional gender role expectations. Japanese culture stresses a hierarchical family structure in which
men are discouraged firom seeking help, whereas
women may disclose their problems to professionals
to seek a harmonious Ufe (Yamawaki, 2010). In
Chan and Hayashi's (2010) study about traditional
masculine identity and help-seeking behaviors in
Japan, 265 Japanese male participants were skeptical
about the effectiveness of professional help because
of their inclination toward success and restrictive
emotionality. Even when some of these men experienced depressive symptoms, their cultural alignment
negatively impacted their willingness to seek professional help.

Social Work

VOLUME 58, NUMBER 3

JULY 2013

Japanese Americans have underutilized mental


health services because of a denial of mental illness
Pennis, 2004; French, 2002). With help-seeking
data, Narikiyo ind Kameoka (1992) found that
Japanese Americ:an undergraduate students (5.6
percent) were significantly less likely than their
white American counterparts (25 percent) to
receive mental health services when needed. The
Japanese American students (13.2 percent) were
also less likely than their white American counterparts (34 percent) to know whether family members or friends hsd used mental health services. In a
community study in Hawaii, depressed Japanese
Americans' mental health service utilization was
lower than that of Native Hawaiians (Kanazawa,
White, & Hampson, 2007). In terms of emotional
regulation, Kanazawa et al. (2007) found that more
Japanese Americans ( = 357) yielded low scores
for positive affect than European Americans
(n = 176) when faced with a problem. Ono et al.
(2000) found that many people in Japan with
somatic depressive symptoms choose to see physicians and disclose only physical symptoms. Similarly, another study showed that depressed patients
in Japan presented more somatic complaints, such
as abdominal disrress, headaches, and neck pain, to
their physicians than did American patients (Waza,
Graham, Zyzanscd, & Inoue, 1999). Aragona et al.
(2005) identifie these physical symptoms as having strong cultural significance for Japanese people
with depression. All of these studies indicated that
the help-seeking behaviors of Japanese Americans
need further attention.
Depression Prevalence and Symptom
Disclosure
In Japanese culture, depression is perceived as a
consequence of interpersonal disturbances, and its
treatment emphasizes the creation of positive
aspects of Ufe and the promotion of group harmony (Kanazav/a et al., 2007). Individuals are
expected to achieve mind-body connections to
promote self, family, or group well-being (Young,
2003). Because mental illnesses are typically
thought to represent shame and penonal weaknesses, Japanese people in general are inclined to
regard depression as a somatic problem with physical symptoms while simultaneously avoiding the
label of a mental disorder (Young, 2003).
Despite knowledge regarding symptomology,
there is a lack of published depression prevalence

rates to inform mental health services for Japanese


Americans. Because Japanese Americans represent
only a small percentage in most Asian American
Studies, we found that the depression prevalence
among Asian Americans (such as 19.6 percent in
our recent study in Leung, Cheung, & Tsui, 2012)
is often used to estimate the problems among the
various Asian subgroups. Other research reports
have addressed specific populations, such as the
depression rates for older Japanese Americans,
which range between three and 20 percent
(Shibusawa & Mui, 2001; Yamamoto et al., 1985;
Yeung et al., 2004), or use general data to compare
Japanese Americans and white Americans in a specific city (Kuo, 1984). Specifically, a Honolulu
study found that the depression prevalence rate
among 3,139 Japanese American men age 71 to 93
yean was 8.5 percent; the rate among those who
adhered to the traditional Japanese culture was 28
percent lower than those assimilated to American
culture (Harada et al., 2011). Tang (2007) states
that the model minority image (that Asian people
are high achievers) has masked Asians' ethnic
diversity, and the inconsistent figures reported in
the literature may have underestimated Japanese
Americans' mental health needs.
Predictors of Depression among Japanese
Americans
Cultural expectations and sociodemographic variables can serve as predictors of help-seeking preferences. In a longitudinal study of 9,201 adult
respondents in Japan, health status was identified as
a predictor of depression, with a 4.2 percent prevalence rate among those who expressed poor health
versus 1.5 percent among all respondents (Tanaka,
Sasazawa, Suzuki, Nakazawa, & Koyama, 2011).
Although most of the cited depression studies
focused on Japanese adolescents or college students, older adults, and women, Tanaka et al.'s
(2011) study reported findings from the 40- to
69-year-old age group and identified a prevalence
difference between genders: 5.3 percent among
women and 4.6 percent among men.
Studies have found a number of other contributing factors to depression and other mental health
disorders in the Japanese and Japanese American
communities, including gender, language proficiency, acculturation, generational status, anxiety,
domestic violence, interpersonal relationships, personality, support network, scarcity of resources, Lving

CHEUNG ET AL. I Japanese Americans' Health Concerns and Depressive Symptoms: Implications for Disaster Counseling

203

arrangements, and life Stressors (GeUis & Taguchi,


2004; Kamo & Zhou, 1994; Laser, Luster, &
Oshio, 2007; Narikiyo & Kameoka, 1992; Padilla,
Wagatsuma, & Lindholm, 1985; Takeuchi et al.,
2007; Williams et al., 2002, 2005; Yoshihama,
2001). In a study of 97 Japanese American elderly
age 65 years or older in community-based geriatric
settings, findings revealed that health status, social
support, negative life events, and family history of
depression were associated with higher depression
scores (GeUis 6c Taguchi, 2004). Another study
that focused on Japanese youth age 18 to 22 yean
found five significant predictors of depression: a
history of firequent physical illness, parental favoritism of a sibling, maternal depression, being bullied,
and the lack of an easy temperament (Laser et al.,
2007). Narikiyo and Kameoka (1992) found that
Japanese-American students were more likely than
white American students to attribute mental lness
to social causes such as "problems with other people," which is consistent with the Japanese value of
preserving interpersonal hamiony. In a confirmatory model integrating Japanese ethnicity, cultural
identity, and depression, Williams et al. (2005)
found that being Japanese American (versus partJapanese American), female gender, and cultural
events that required intensive time commitment
were predictive of depression.
The literature has yielded useful information
about Japanese Americans' mental health needs
and the correlates to depression. These correlates
were grouped into demographic characteristics,
mental health needs, and six other areas of needs
(basic needs, community and social issues, family
relationships, health concerns, hardships, and
immigration issues). In this article, we report the
findings of a community survey that focused on
Japanese Americans' depressive symptoms as they
relate to these needs and concerns.
METHOD

This study identifies predictors of depressive symptoms among Japanese Americans and explores their
help-seeking preferences. A community survey
was conducted in Houston, Texas, the fourth largest city in the United States. According to the U.S.
Census, Japanese Americans composed 0.13 percent (2,519 in 2000 and 4,142 in 2008) of the
Houston population (City-Data, 2010). Because
samplingjapanese American respondents is difficult
to achieve (Okazaki, 1997), we collected data from

204

various cultural events in Houston and reached a


convenience sample of 43 Japanese Americans in
2008, estimated to represent 1.04 percent of the
Japanese population in Houston (City-Data,
2010). These survey participants self-identified as
Japanese, were age 18 years or older, and resided in
the greater Houston area.
Instruments and Data Collection
After obtaining approval from the institutional
review board, the research team with four researchers and 10 trained volunteers attended 30 Asian
community gatherings to invite voluntary participation. An anonymous survey entitled "Asian Survey"
was designed to include 14 demographic items and
114 questions about needs and concerns. An
informed consent letter, which explained the purpose of the study, voluntary participation, and anonymity, was attached to the survey. Prior testing
provided good face and content validity in a study
among six Asian Americans ethnic groups conducted by Leung and Cheung (2008). Participants
were given small souvenirs as a token of appreciation
upon completion of the survey.
Predictive variables were operationalized in concrete measures, asking respondents to answer on
the basis of their individual or family needs, with a
four-point response scale to indicate the level of
concern (0 = none, 1 = a little, 2 = some, and 3 =
serious). The six main needs variables were measured by the average four-point score from a number of needs or concerns listed below.
1. Basic needs; food, housing, clothing, adequate income, access to medical care
2. Community/social issues: crimes against
people, crimes against property, unemployment, skills underutilized, transportation,
adequate education/job training, daycare for
children, 24-hour care for chOdren, daycare
for dependent adults, 24-hour care for adults,
lack of recreational activities, poor performance in job/school, language barriers,
financial assistance, discrimination, religious
support, ethnic group support, lack of child
mentoring programs, lack of Asian volunteen
in the community
3. Family/relationship issues: conflict between
family members such as problei-ns with
young children, problems with teenagers,
problems with parents, problems with in-laws.

Sociat Work

VOLUME 58, NUMBER 3

JULY 2013

problems with spouse or significant othen,


communication with family memben, conflicting st;/les of parenting, children losing
cultural roots, stdct parents,financialmanagement, child abuse, spousal abuse, elder abuse,
isolation
4. Health issues: chronic pain or illness, disabhng or terminal Olness, alcohol/dmg problems, pregnancy-related concerns, abortion,
eating disorders, sexual dysfunction, physical
problems without medical cause, developmental disabilities
5. Hardship: rape, robbery, murder, loss/separation of family, dramatic loss of income, serious illness, refugee camps, war trauma
6. Immigration issues: uncertainty of sponsorship, uncertainty of employment, waiting for
legal status, mode of transportation, political
freedom, rehgious freedom, political asylum,
family reunion, public financial assistance,
acculturation, discrimination, adequate legal
assistance
In addition to identifying these concems, the
Hopkins Symptoms Checklist (HSCL-25) was
used to measure mental health issues as reflected
by self-reported depression symptoms (Parloff,
Kelman, & Frank, 1954). HSCL-25 consists of 25
questions (10 on anxiety and 15 on depression)
with a 4-point response scale (1 = none and
4 = very often, with an average of 1.75 or higher
being symptomatic). Reliability of this scale has
been tested among Asian populations, with a
coefficient alpha of .89 in the Anxiety subscale and
.92 in the Depression subscale (Lhewa, Banu,
Rosenfeld, 8c Keller, 2007).
RESULTS
Respondent Characteristics

Among the 43 Japanese American participants,


approximately 56 percent were female, and 61 percent were married. A typical respondent was
approximately 38 years of age and lived in a threemember household in the United States for almost
nine years (indicating non-U.S. bom). Of the
respondents, more than one-third (37 percent) were
residing in a one-generation household, while
approximately 18 percent reported living with one
penon under age 18, and 14 percent reported living
with one penon over the age of 60 in the same

household. Approximately two-thirds (65 percent)


obtained a bachelor's degree or higher, and more
than half of the respondents (51 percent) had an
annual household income of 150,000 or above.
However, more than one-third (37.2 percent)
reported that they were not employed (see Table 2).
Bivariate Analyses
Chi-square results showed that two dichotomy variables had statistically significant relationships with
depressive symptoms: having anxiety symptoms
[X^(l, A'= 37) = 17.311, ;j<.001] and holding a
master's degree [x^(l, iV= 37) = 5.025, p=.02S].
Independent-sample t tests evaluated whether
Japanese Americans, with or without depressive
symptoms, differed in association with the
continuous-scaled variables in the survey. Only one
variable was found to possess statistical significance:
Japanese Americans experienced more health issues
if they also had depressive symptoms compared
with those who did not have depressive symptoms
[i(34) = 2.499, p = .017, Cohen's d = 1.055].
Predicting Depressive Symptoms
As measured by HSCL-25, the prevalence of
depression among the Japanese Americans in this
study was 11.6 percent. Compared with the 4.1
percent prevalence found in Tanaka et al. (2011)
study on Japanese Americans who had perceived
poor health status, the rate found in this study is
much higher. On the basis of the statistical criterion p < .05, all significant independent variables
resulting from the aforementioned bivariate analyses and the interaction effects between the categorical variable "holding a master's degree" and a
health concem variable were included in a logistic
regression for predicting depressive symptoms.
Results from the logistic regression (n = 43)
revealed that the overall model was significant
in the relationship between participants' characteristics and the HSCL depressive symptoms
[X^(5, N= 36) = 15.665, p < .01 with Negelkerke
R^=.638]. Although individual variables in this
model do not show statistical significance, the
overall model shows statistical significance when
having health issues, anxiety symptoms, and a master's degree are included to predict depressive
symptoms. The combination of these factors with
having health issues, such as having health issues
with anxiety symptoms and having health issues

CHEUNG ET AL. I Japanese Americans' Health Concems and Depressive Symptoms: Implications for Disaster Counseling

205

Table 2: Demographic Characteristics of Respondents (A/= 43)


Variable
Age
Missing
Number of years in United States
Missing
Gender
Male
Female
Missing
Marital status
Single
Married
Divorced/separated
Living with significant other(s)
Currendy employed
Yes
No
Missing
Education
High school
Some college
Bachelor's degree
Master's degree
Other
Missing
Household income
Less than $19,999
$20,000 to $39,999
$40,000 to $59,999
$60,000 to $79,999
$80,000 and over
Missing
Number of people living in the household, including the respondent
' 1-2

3-4
5 and over
Missing
Number of generations
1
2

3
Missing
Number of household members underage 18 years
0
1
2-3
Missing
Number of household members age 60 years and over
0
1
2
Missing

206

n
34
9
42
1

17
24
2

39.5
55.8
4.7

15
26
1
1

34.9
60.5
2.3
2.3

26
16

60.5
37.2
2.3

1
3

M(SD) \

38.3(12.2)

79.1
20.9
97.7
2.3

10

17
8
4
1

3
10

14
8
6
2

9.3 (8.4)

7.0
23.3
39.5
18.6
9.3
2.3
7.0
23.3
32.6
18.6
14.0
4.7
2.7(1.5)

21
13

5
4

48.8
30.3
11.6
9.3
1.5(0.7)

16
14
3
10

37.2
32.6
7.0

20
8
4

46.5
18.6

11

25.6

20

46.5
14.0
9.3
30.2

23.3

0.5 (0.8)

9.3

0.5 (0.7)

6
4
13

Social Work

VOLUME 58, NUMBER 3

JULY 2013

Table 3: Logistic Regression Model for Depressive Symptoms (n = 36)


95% CI for OR
Variable
Constant
Anxiety symptoms
Master's degree holder
Health issues
Health issues x anxiety symptoms
Health issues x masoer's degree holder

SE
-3.695
1.802
1.622
-0.396
2.445
0.019

1.504
2.242
2.056
2.431
2.768
2.639

and holding a master's degree, also seem to predict


the presence of depressive symptoms (see Table 3).

Preference for Informal Care


The results did not show any significant relationships between help-seeking behavion and depression, suggesdng that Japanese Americans are
disinclined to ask for help when experiencing
depression. As a result, analysis of help-seeking
behaviors was based on the total results from all
respondents. Approximately one-fourth (23.3 percent) of the respondents did not indicate any service prefererKe, whereas more than half (53.3
percent) indicated that they would prefer seeking
advice from friends or famuy. Approximately 40
percent of the respondents preferred consuldng
physicians, and 23.3 percent assumed that the
problem would take care of itself Only 14 percent
consulted mental health professionals, and a small
portion turned to religious leaders (7 percent) and
herbal docton (4.7 percent) for assistance. Overall,
Japanese Americans tended to seek advice from
friends or relatives and were unlikely to seek professional consultadon when facing family difficulties.
Further analyses were performed to examine the
help-seeking pactems by demographic characteristics. The statisdcs indicate that female respondents
are more likely than male respondents to seek help
from religious leaders [x^(l, 4) = 4.00, p= .046].
Excluding gender, other demographic data did not
show any significant differences in relation to helpseeking beha\iors.
DISCUSSION
Research Implications
In this study, gender was not found to be predicdve
of depression, but it was significantly correlated to
seeking reUgious leaders for support in this sample.

OR
0.025
6.061
5.061
0.673
11.533
1.020

.014
.422
.430
.871
.377
.994

Lower

Lower

.075
.090
.006
.051
.006

491.340
284.546
78.972
2,618.303
179.620

The World Health Organizadon (2008a) reported


that religious convicdon may be a protecdve factor
against suicide (see also, Vijayakumar, 2002). Krause,
Ingersoli-Dayton, and Liang (1999) interviewed a
nadonal probability sample of 2,153 elderly men in
Japan and found that greater involvement in religion
was associated with providing help to others. In our
study, female Japanese Americans were more likely
than their male counterparts to approach religious
leaders for help. Further studies may focus on how
providing help for others through religious support
can link to posidve health and mental health outcomes.
Our findings support that in crisis counseling,
both risk and protective factors of depression
should be assessed in relation to cultural variables
and gender socialization. The vulnerability to stress
and the adaptive capacity to buOd resilience are
complex, thus both clinicians and researchers
should focus on examining the effectiveness of culturally relevant approaches to prevent, assess, and
treat depression. Although only a few factors were
found to be significant in predicting depression,
social workers may stUl use this information to plan
prevention programs, similar to FRIENDS for Life
(Rose, Mer, Sf Martinez, 2009). These programs
may serve as a means to amplify chents' strengths,
as many Japanese people are dealing with various
Stressors in different hfe stages, and as an educadonal opportunity to enhance a positive view of
psychological well-being.
Another implication is that social work researchers must examine how study limitations such as a
small convenience sample and reliance on volunteer
pardcipants may restrict generaHzabity. First, random selecdon of pardcipants was not feasible
because the pardcipants were difficult to reach and
surveys were filled out only by those who were willing tO' pardcipate. Second, this community survey

CHEUNG ET AL. I Japanese Americans' Health Concerns and Depressive Symptoms: Implications for Disaster Counseling

207

reached potential participants from various community events through voluntary participation, which
might not represent all voices. Given that two-thirds
of the entire Japanese American population was
bom in the United States, this sample overrepresented nonU.S.-bom immigrants (with an average
of nine years of residence in the United States).
Third, because U.S.-bom Japanese Americans may
not be likely to identify with their Japanese culture
(because of the reasons described by Toji, 2003) and
this study recruited subjects from Asian cultural
events, it is hkely that very few U.S.-bom Japanese
people attended these events or participated in this
study. Thus, future studies may need to use other
recruitment strategies to include more participants.
In addition, it is important to collect additional
qualitative data to further explore the cultural meaning of depression for this ethnic group.

logistic regression in this study indicated that those


who had depressive symptoms may present their
problem as a physical health issue. It is important
to listen to their somatic complaints because the
disclosure of physical symptoms can serve as a
means for reporting psychological distress. Similar
to the findings by Kung and Lu (2008), chents
who somaticize depression are less reluctant to seek
medical help for their psychological distress. When
working with chents who face issues after a crisis or
disaster, clinicians can help them think about
counseling as a means to enhance personal functioning, promote interpenonal relationships, and
maintain social hamiony. Practitioners who pay
attention to clients' complaints of having a high level
of anxiety can help them develop a positive attitude
toward seeking help. The health care focus will minimize the impact of social stigma caused by the perceived negativity toward mental health disorders.

Clinical Practice Implications

A second implication is related to the stress resulting from high expectations, particularly related to
educational achievement in the context of the
model-minority stereotype. In our study, 65.1 percent of the respondents hold a bachelor's degree or
higher, which is higher than Japanese Americans as
a whole (41.9 percent indicated in the 2000 census;
Li & Wang, 2008). Japanese Americans with a master's degree may have high expectations for selfachievement that can lead to stress and depression.
This finding is similar to that from a study of 26
medical undergraduates in Japan that confirmed a
significant impact of chronic academic Stressors on a
student's mental state (Kurokawa et al., 2011). Social
work practitioners can also assess how family and
cultural values reinforce high parental expectations
of academic success for Japanese Americans in order
to find ways of helping families design coping methods and make necessary changes.
A third implication is related to the lack of service
udlizadon as a result of the stigma of mental illnesses.
It is important to reframe help seeking as a means of
finding support to release tension. The findings here
suggested that anxiety can predict depression, which
has been well documented (Leung et al., 2012;
Brawman-Mintzer et al., 1993; HHard & Iwamasa,
2001; Iwamasa, Hilliard, & Osato, 1998; Wilhams
et al., 2002, 2005). The correlation between anxiety
and depression supports the use of a depression
instrument to simultaneously assess depression and
anxiety (Ledley et al, 2007). To help families in
treatment planning, social workers can use the

A main practical implication of this study relates to


the help-seeking pattems of Japanese Americans.
Most respondents tended to seek help from informal support networks (like friends and relatives)
and physicians rather than mental health professionals. This finding is consistent with existing
research on Japanese Americans (for example, Narikiyo & Kameoka, 1992), particularly regarding the
cultural expectations of living up to the model
minority image, family obligations, and the cultural values of this population (Lee et al., 2009).
Low rates of use of mental health services do not
always correlate with severity of mental health
problems (Meadows, 1997), but rather are a function of cultural considerations such as avoiding disruption of family harmony. Therefore, we urge
community educators to break down the barriers
to treatment of mental health disorders and raise
pubhc awareness about depression. Mass media can
play a role in promoting healthy well-being, positive mental health, and help-seeking behavior in
society. With the federal government's increasing
attention on the mental health needs of racial and
ethnic minorities, more health-related interventions may be promoted, for example, via the
National Minority Mental Health Awareness
Month that began in July 2010.
This study also provides three clinical implications for improving social work practice. First, as
supported by the literature (Jang, Shin, Cho, Kim,
& Chiriboga, 2011; Mui & Kang, 2006), the

208

Social Work

VOLUME 58, NUMBER 3

JULY 2013

assessed result as a means to refirame anxiety and


depression as health issues to analyze how these
issues connect to the client's life Stressors.
Unlike studies of other ethnic groups such as
Chinese and Asian Indians (Leung & Cheung,
2008; Leung et al., 2012) and studies of Asian older
adults (e. g., Harada et al., 2011), this study did not
identify employment status and other sociocultural
correlates (such as family relationship, domestic
violence, and acculturation concerns) as predictors
of depression for Japanese Americans. This is perhaps due to the underreporting of depression
symptoms, which is not uncommon among this
ethnic group (World Health Organization,
2008b). The finding of informal care preference in
this study implies that, as a result of the shame and
stigma associated with depression, Japanese Americans might have a tendency to keep problems to
themselves rather than opening up to mental
health professionals or others. It is important to
provide educational information about depression
and refirame the negative concept of seeking mental help as addressing a health care need.
In addition, it is important to note that the devastating earthquakes and tsunami have caused
chronic pain and Olness among the survivors in
Japan and their overseas relatives (Psychology
Advice, 2011). Even though our data were collected before the March 11, 2011, Japan earthquake, this report aims to instul hope for Japanese
Americans to deal with life stress and build resilience so that they can use their strengths (such as
academic success and cultural knowledge) to share
their experience, which is framed as helping others.
Clinicians may design assessments that focus on
health care needs and also address Japanese Americans' post-traumatic reactions. They can also highlight individual and family strengths while clients
are analyzing their reactive depression to crises and
Stressors. It is essential to treat depression using
information from the clients about their perceptions of observable symptoms.

As implied in one of its findings connecting


depression to health care, primary health care professionals may serve as an important entry point for
treatment of Japanese help seekers, particularly for
those clients who have waited until a crisis affected
their physical and psychological well-being. One
treatment approach is to promote an exchange dialogue with the chents to learn about Japanese cultural practices and health care concepts. Service
providers should pay attention to the interview setting, service arrangement, and confidentiality of
treatment, as we as analyze clients' expressions of
distress. Knowing that a caring professional is listening to their physical complaints, clients niay
become more willing to talk about how the illness
may have been caused by stressful matten that
affected their individual and family functioning.
Programs that address health care concerns may use
a combined staff-development effort to train both
medical and mental health professionals so that
their shared practice wisdom can be incorporated
in treatment planning.

Conclusion

Harada, N., Takeshita,J., Ahmed, I., Chen, R., Petrovitch,


H., Ross, G. W., & Masaki, K (2011). Does cultural
assimilation influence prevalence and presentation of
depressive symptoms in olderjapanese American
men? The Honolulu aging study. American foumal of

REFERENCES
Aragona, M., Tatsitani, L., Colosimo, F., Martinelli, B.,
Raad, H., Maisano, B., & Geraci, S. (2005). Somatization in primary care: A comparative survey of immigrants from various ethnic groups in Rome, Italy.
International Journal of Psychiatry in Medicine, 35,

241-248.
Brawman-Mintzer, O., Lydiard, R. B., Emmanuel, N.,
Payeur, R., Johnson, M., Roberts, J., et al. (1993).
Psychiatric comorbidity in patients with generahzed
anxiety disorder. American foumal of Psychiatry, 150,

1216-1218.
Chan, R.K.H., & Hayashi, K. (2010). Gender roles and
help-seeking behaviour: Promoting professional help
amongjapanese men. JoHma/of Sofia/ Work, 10,
243-262.
City-Data. (2010, August). Asian population in Houston.
Retrieved from http://www.city-data.com/forum/
houston/368301-asian-population-houston-3.htm]
Dennis, C. (2004, June 17). Asia's tigers get the blues.
Nature, 429, 696-698.
French, H. (2002). Depression simmers in Japan's culture of
stoicism. New York Times. Retrieved from http://
www.nytimes.com/2002/08/10/world/depressionsimmers-in-japan-s-culture-of-stoicism.htnil
GeUis, Z. D., & Taguchi, A. (2004). Depression and health
status among community-dweUingJapanese American
elderly. Chnical Gerontologist, 27, 2338.

Understanding the concept of depression as it


relates to the psychological impact of life stresson is
instrumental to the study of Japanese Americans'
help-seeking behaviors. In this study, the 11.6 percent prevalence finding confirmed that Japanese
Americans, who are often held to model minority
standards, are not shielded from having depression.

Geriatric Psychiatry. doi:10.1097/

JGR0b013e3182107e3b
Hilliard, K. M., & Iwamasa, G. Y. (2001). The conceptualization of anxiety: An exploratory study ofJapanese
American older adults. JoHma/of C/nc/ Geropsychology, 7(1), 53-65.

CHEUNG ET AL. I Japanese Americans' Health Concerns and Depressive Symptoms: Implications for Disaster Counseling

209

Mui, A. C , & Kang, S. Y. (2006). Acculturation stress and


Iwamasa, G. Y., Hilliard, K. M., & Osaco, S. S. (1998).
depression among Asian immigrant elders. Social Work,
Conceptualizing anxiety anel depression; Thejapanese
5, 243-255.
American older adult perspective. Clinical Cerontologist,
9{)
Narikiyo, T. A., & Kameoka, V. A. (1992). Attributions of
{
mental illness and judgments about help seeking
Jang, Y., Shin, J., Cho, S., Kim, G., & Chiriboga, D. A.
amongjapanese American and white American stu(2011). The interactive role of chronic medical condidents. Journal of Community Psychology, 39, 363369.
tions and sleep disturbance in predicting depressive
symptoms among Korean American older adults.
Okazaki, S. (1997). Sources of ethnic differences between
Aging & Mental Health, 15, 198-203.
Asian American and white American college students
on measures of depression and social anxiety. Jowma/ of
Kamo, Y., & Zhou, M. (1994). Living arrangements of
Abnormal Psychology, 106,52-60.
elderly Chinese and Japanese in the United States.
Journal oJMarriage and the Family, 56, 544558.
Ono, Y., Yoshimura, K., Yamauchi, K., Asai, M., Young,
J., Fujihara, S., &Kitamura, T. (2000). Somatofonn
Kanazawa, A., White, P. M., & Hampson, S. E. (2007).
symptoms in a Japanese community population: PrevEthnic variation in depressive symptoms in a commualence and association with personality characteristics.
nity sample in Hawaii. Cultural Diversity and Ethnic
Transcultural Psychiatry, 37, 219-228.
Minority Psychology, 3(l), 35-44.
Krause, N., Ingersoli-Dayton, B., &Liang,J. (1999).
Padilla, A. M., Wagatsuma, Y., & Lindholm, K.J. (1985).
Religion, social support, and health among the
Acculturation and personality as predictors of stress in
Japanese elderly. Jouma/ of Health and Social Behavior,
Japanese and Japanese-Americans. Jouma/ of Social Psy40,405-421.
chology, 125, 295-305.
Kung, W. W., & Lu, P. C. (2008). How symptom manifesParloff, M. B., Kelman, H. C , & Frank, J. D. (1954). Comtations affect help seeking for mental health problems
fort, effectiveness, and self-awareness as criteria for
among Chinese Americans. Jonma/ of Nervous and
improvement in psychotherapy. American Journal of
Mental Disease, 196, 46-54.
Psychiatry, 3, M3-351.
Kuo, W. (1984). Prevalence of depression among Asian
Psychology Advice. (2011). The chronic pain of earthquakes.
Americans. JoKraa/ of Nervous and Mental Disease, 112,
Retrieved from http://www.psychology-advice.net/
449-457.
the-chronic-pain-of-earthquakes
Kurokawa, K., Tanahashi, Y., Murata, A., Akaike, Y.,
Rose, H., Millier, L., & Martinez, Y. (2009). "FRIENDS
Katsuura, S., Nishida, K., et al. (2011). Effects of
for Life": The results of a resilience-building, anxietychronic academic stress on mental state and expression
prevention program in a Canadian elementary school.
of glucocorticoid receptor a and isofomis in healthy
Professional School Counseling, 12, 400-407.
Japanese medical students. Stress, 14, 431438.
Shibusawa, T., & Mui, A. (2001). Stress, coping, and
Laser, J., Luster, T., & Oshio, T. (2007). Risk and promodepression amongjapanese Americans elders. Jowma/ of
tive factOK related to depressive symptoms among
Gerontological Social Work, 36(1-2), 63-81.
Japanese youth. American Journal of Orthopsychiatry, 77, Takeuchi, D., Zane, N., Hong, S., Chae, D. H., Gong, G.,
523-533.
Gee, G. C , et al. (2007). Immigration-related factors
and mental disorders among Asian Americans. AmeriLedley, D. R., Pai, A., Franklin, M. E., Antony, M. M.,
can Journal of Public Health, 91, 84-90.
Purdon, C , & Summerfeldc, L. J. (2007). Treating
comorbid presentations: Obsessive-compulsive
Tanaka, H., Sasazawa, Y., Suzuki, S., Nakazawa, M., &
disorder, anxiety disorders, and depression. In
Koyama, H. (2011). Health status and lifestyle factors
M. M. Antony, C. Purdon, & L. J. Summerfeldt
as predictors of depression in middle-aged and elderly
(Eds.), Psychological treatment of obsessive-compulsive
Japanese adults: A seven-year follow-up of the
disorder: Fundamentals and beyond (pp. 281293).
Komo-Ise cohort study. BMG Psychiatry, 1 (l),
Washington, DC: American Psychological Association.
20-29.
Lee, E., Mitchell-Herzfeld, S.D., Lowenfels, A.A., Greene,
Tang, M. (2007). Psychological effects on being perceived
R., Dorabawila, V., & DuMont, K. A.(2009).
as a "model minority" for Asian Americans. New
Reducing low birth weight through home visitation:
Waves: Educational Research and Development, 17(3),
A randomized controlled trial. American Journal of
11-16. Retrieved from http://www.caerda.org/
Preventive Medicine, 36, 154160.
joumal/inde.\'.php/newwaves/article/viewFile/ll/9
Leung, P., & Cheung, M. (2008). A prevalence study on
Toji, D. S. (2003). Asian nation: Asian American history, demopartner abuse in six Asian-American ethnic groups.
graphics, and issues-Japanese Americans. Retrieved from
International Social Work, 5, 635-649.
http://www.asian-nation.org/japanese.shtnil
Leung, P., Cheung, M., 8c Tsui, V. (2012). Help-seeking
U. S. Census Bureau. (2010a). 2010 Census data. Retrieved
behavion among Chinese Americans with depressive
from http://un,vw.census.gov/2010census/data/
symptoms. Social Work, 57, 6171.
U. S. Census Bureau. (2010b). Race reportingfor the Asian
population by selected categories 2010. Retrieved from
Lhewa, D., Banu, S., Rosenfeld, B., & Keller, A. (2007).
http://factfinder2.census.gov/faces/tableservices/jsf/
Validation of a Tibetan translation of the Hopkins
pages/productview.xhtml?pid=DEC_10_SFl_
Symptom Checklist-25 and the Harvard Trauma
QTP8&prodType=table
Questionnaire. Assessment, 14, 223-230.
Li, G., & Wang, L. (2008). Model minority myth revisited: An
Vijayakumar, L. (2002). Religion: A protective factor in
interdisdplinary approach to demystifj'ing Asian American edu- suicide. Suicidology, 2, 912.
cational experience. Charlotte, NC: Infomiation Age Pub. Waza, K., Graham, A. V., Zyzanski, S. J., & Inoue, K.
(1999). Comparison of symptoms in Japanese and
Machizawa, S., & Lau, D. (2010). Psychological needs of
American depressed primary care patients. Family
Japanese American elders: Implications for culturally
Practice, 16, 528-533.
competent interventions. JoMma/ of Cross-Cultural
Gerontology, 25, 183-197.
Williams, J.K.Y., Else, I.R.N., Hishinuma, E. S., Goebert,
Meadows, M. (1997, September). Mental health and
D. A., Chang, J. Y., Andrade, N. N., & Nishimura,
S. T. (2005). A confirmatory model for depression
minorities: Cultural considerations in treating Asians.
amongjapanese American and part-Japanese AmeriClosing the Gap. Retrieved from http://www.nabho.
can adolescents. Cultural Diversity and Ethnic Minority
rg/pdf/nimh-info/Closing%20the%20Gap%20Asian
Psychology, 11, 41-56.
%20997.pdf

210

Social Work VOLUME 58, NUMBER 3

JULY 2013

Williams, J.K.Y., Goebert, D., Hishinuma, E., Miyamoto,


R., Anzai, N., Izutsu, S., et al. (2002). A conceptual
model of cultural predictors of anxiety amongjapanese
American and part-Japanese American adolescents.
Cultural Diversity & Ethnic Minority Psychology, 8,
320-333.
World Health Organization. (2008a). Socio-economic, cultural
and religious factors ajfecting suicide prevention in Asia.
Retrieved from http://www.who.int/mental_health/
resources/suicide_prevention_asia_chapter2.pdf
World Health Organization. (2008b). Suicide and suicide prevention in Asia. Retrieved from http://www.who.int/
mental_health/resources/suicide_prevention_asia.pdf
Yamamoto, J., Machizawa, S., Araki, F., Reece, S., Steinberg, A., Leung,J., & Cater, R. (1985). Mental health
of elderly Asian Americans in Los Angeles. American
Journal of Social Psychiatry, 1, 3746.
Yamawaki, N. (2010). The effects of self-construal and masculinity vs. femininity: A comparison of American and
Japanese attitudes towards mental health services. Jowrnal of Mental Health Counseling, 32, 154-167.
Yamawakj, N., & Tschanz, B. T. (2005). Rape perception
differences between Japanese and American college
students: On the mediating influence of gender-role
traditionality. Sex Roles, 52, 379-392.
Yeung, A., Chan, R., Mischoulon, D., Sonawalla, S.,
Wong, E., Nierenberg, A., & Fava, M. (2004).
Prevalence of major depressive disorder among
Chinese-Americans in primary care. General Hospital
Psychiatry, 26(1), 24-30.
Yoshihama, M. (2001). Model minority demystified: Emotional costs of multiple victimizations in the lives of
women ofjapanese escer\t. Journal ofHuman Behavior
in the Social Environment, 3(3-4), 201-224.
Young, J. (2003). Mind-body concepts and mental illness:
A study ofjapanese values. Seishin Shinkeigaky Xasshi,

105, 1016-1025.
Monit Cheung, PhD, is professor, and Patrick Leung,
PhD, is professor. Graduate College of Social Work, University
of Houston. Venus Tsui, PhD, is assistant professor. Social
Work at the Worden School of Social Service, Our Lady of the
Lake University, San Antonio, TX. Address correspondence to
Monit Cheung, Graduate College of Social Work, OHA
Social Work Building, University of Houston, Houston, TX
77204; e-mail: mcheung@uh.edu.
Original manuscript received November 8, 2011
Final revision received March 12, 2012
Accepted May 30, 2012
Advance Access Publication June 20, 2013

Customize the Power of Your


NASW Membership

CHILD WELFARE
leciaIty Practice Section

As a social worker in the field of child welfare,


current information on trends and policy issues
affecting practice and service delivery is a must.
NASW's Child Welfare Specialty Practice Section
(SPS) links you with the key information,
resources, and expertise you need to stay at the
forefront of your practice specialty;
Specialized newsletters
Practice updates
Opportunity for FREE CE credits by reading
InterSectiotis in Practice, the SPS annual
bulletin
Members-only Web-based products
designed to enhance your professional
development within the child welfare
community

JOIN TODAY!
Go to www.socialworkers.org/sections or call
202.408.8600 ext. 476.
*Vbi/ must be o current NASW member to join a Specialty
Practice Section.
ASJ05004

#NASW.SPS
National Association of Social Workers
Specially Practice Sections
www.socialworkers.org/sections
202.408.8600 ext. 476

CHEUNG ET AL. / Japanese Americam' Health Concerns and Depressive Symptoms: Implications for Disaster Counseling

211

Copyright of Social Work is the property of National Association of Social Workers and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.