Acculturation Stress and Depressionamong Asian Immigrant Elders

Ada C. Mui and Suk-Young Kang

This study examines the association between acculturation stress and depressive symptoms in aregional probability sample (n = 407) of six groups of Asian immigrant elders (Chinese,

Korean, Indian, Filipino, Vietnamese, and Japanese). Findings suggest that about 40 percent ofthe sample were depressed, indicating higher depression rates than found in other studies ofolder American or Asian elderly samples in the United States and Asia. Multiple regression

analyses indicated that acculturation stress caused by elders' perception of a cultural gapbetween themselves and their adult children was associated with high depression levels. Otherpredictors of depression were poor perceived health, stressful life events, religiosity, proximityof children, assistance received from adult children, and longer residence in the United States.

Data suggest that depression is prevalent among urban Asian immigrant elders and that there isgreat heterogeneity among Asian ethnic subgroups. Implications for social work practice are

discussed.

KEYWORDS: acculturation stress; Asian American elders; Asian immigrant elders; depression

Demographically.the United States faces twodramatic population changes: aging andincreasing ethnic and racial diversification.

The population segment age 65 and older (35 mil-lion) currently and until 2010 will comprise about12.4 percent of the total U.S. population (Hetzel &Smith, 2001). Between 2010 and 2030, the babyboomers will join this older population. By 2030,about 20 percent of the total U.S. population (69.4million) is projected to be age 65 and older. Thenon-Hispanic white share of the total population isprojected to fall steadily from 74 percent in 1995 to53 percent by 2050. At the same time, other racialand ethnic populations will increase in number.Thegroups with the highest expected rates of increaseare Hispanic, Asian, and Pacific Islander Americans.Data from the 2000 census indicate that the AsianAmerican and Asian immigrant elderly populationgrew by 76 percent from 1990 to 2000 and is pro-jected to grow by 246 percent from 2000 to 2025.This growth is comparable with the 9.2 percentand 73 percent growth rates in the same years amongthe white elderly population (U.S. Census Bureau,1990,2001).

The increasing number of Asian and other im-migrants results in greater demands for researchmethodology sensitive to cross-cultural issues. Al-though depression is a common psychological prob-lem among elderly populations, few researchers havestudied depression in older Asian Americans or eld-erly Asian immigrants. There is also a dearth ofempirical knowledge about within-group differ-ences among the Asian subgroups. Although avail-able national long-term care datasets have beenfound large enough to conduct analysis of non-Hispanic white and African American elderly popu-lations, Asian American and Asian immigrant eld-erly groups are rarely included in sufficient numbersto enable meaningful statistical analysis (LaVeist,1995). Moreover, previous studies on Asian Ameri-can and Asian immigrant elders used small localsamples and did not examine the association be-tween specific acculturation stress and depressionof Asian elders from different nationality back-grounds. Within-group variations may reflect dif-ferential patterns of acculturation, family dynam-ics, family values, or expectation in terms ofintergenerational exchanges.

CCC Code: 0037-8046/06 $3.00 O2006 National Association of Sociai Wori<ers 243

The study reported here fills this gap by usingan urban area probabihty sample of six differentAsian elderly groups (Chinese, Filipino, Indian,Japanese, Korean, and Vietnamese). It examinedcorrelates of depression and group differences inthem. The primary predictor of interest was accul-turation stress, defined as an acculturation gap be-tween the elderly person and his or her adult chil-dren. The specific research question examined wasall things being equal, what is the association be-tween acculturation stress and depression amongthe Asian elders? The importance of this researchis founded in the consistent reports that depres-sion is the risk factor most frequently associatedwith suicide (Bartels et al., 2002; Lapierre,Pronovost, Dube, & Delisle, 1992; Mui, 1996a;2001).

ELDER DEPRESSION

Prevalence and Incidence RatesA quarter of all late-life suicides are due to depres-sion (American Association of Retired Persons,1997). Depression may occur frequently in Asianimmigrant elders because they have limited re-sources in dealing with the multiple losses associ-ated with the process of adaptation, acculturation,and family disruption (Mui, 1996a; 1996b).Epide-miological studies in the United States have exam-ined the prevalence of depressive symptoms in com-munity samples of elders using a variety of self-ratingscales and interviews. Depending on the selectedcutoff points and instruments, estimates of the preva-lence of major depression vary widely. Using DSM-IV-based criteria for major depression, a one-yearprevalence rate is estimated at about 5 percent orless among community-dwelling people age 65 andolder (Mui, Burnette, & Chen, 2001). Depressivesymptoms or syndromes are more prevalent, withabout 15 percent to 20 percent of community-dwelling elders experiencing them (Gallo &Lebowitz, 1999). Prevalence rates of depressivesymptoms based on assessment with the GeriatricDepression Scale (Sheikh &Yesavage, 1986; Yesavageet al., 1983) among community-dwelling eldersfrom different ethnicity or nationality back-grounds ranged from 12 percent to 50 percent,indicating high rates of possible depression (Halier,Weggenmans, Ferry, & Guigoz, 1996; Mui, 1996b;2001 ;Shibusawa & Mui, 2001). Prevalence rates forethnic minority elderly populations may be under-estimated or biased because of low cultural relevance

of standardized measures (Mui et al.,2001). Alongwith physical, cognitive, and functional impairment,sociocultural factors, such as differences in accul-turation, perception, interpretation, valuation, ex-pression, and tolerance of symptoms, may contrib-ute to this bias (Mui, 1996a, 1996b). Despitesubstantial prevalence rates, symptoms of depres-sion are often underrecognized, underdiagnosed,and undertreated because of patient- and healthcare-related barriers and problems in the organiza-tion, financing, and delivery of mental health ser-vices for older adults (Gottlieb, 1991; Mui et al.,2001).

Acculturation StressAcculturation is a process by which one culturalgroup adopts the beliefs and practices of a hostculture (Mills & Henretta, 2001). The associationbetween acculturation and depression is intrigu-ing.The acculturation process is multidimensional,including physical, psychological, financial, spiri-tual, social, language, and family adjustment. Thisprocess can be very stressful for immigrant eldersin the United States because they have fewer re-sources, such as income, education, and Englishproficiency, to assist them in adapting to their newlife situation (Black, Markides, & Miller, 1998;Casado & Leung, 2001). Research on accultura-tion and depression has found that less accultur-ated elderly Hispanic immigrants \vere more likelyto be depressed than were their more acculturatedcounterparts (Black et al.; Falcon & Tucker, 2000;Gonzalez, Haan, & Hinton, 2001; Hovey, 2000). Afew small sample studies of Asian elders also re-ported that immigrants who were more accultur-ated to the host society tended to have better men-tal health status than those who were lessacculturated (Pang, 1998; Stokes, Thompson,Murphy, & Gallagher-Thompson, 2001). Othercorrelates of minority elders' high depression rateinclude shorter lengths of residence in the UnitedStates, poorer health, more life stresses, more fi-nancial strain, poor English proficiency, dependenceon children, social isolation, and lack of social sup-port (Casado & Leung; Falcon &Tucker; Gonzalezet al.; Lee, Crittenden, &Yu, 1996; Stokes et al.;Tran, 1992). In sum, immigrant elders' depressionmay be due to migration stress and grief, adapta-tion difficulties, poverty, illness, and weakening fam-ily support (Gelfand &Yee, 1991; Mui, 1996b, Muiet al.,2001).Acculturation is a psychologically and

Z44 SocialWork VOLUME 51, NUMBER 3 JULY 2006

socially complex process, and further understand-ing of the relationships between acculturation stressand mental health status may be able to inform thedesign of effective intervention programs for olderimmigrants.

Social Support and Elder DepressionResearchers have also studied the role of social sup-port, particularly that provided by family members,and its impact on the psychological well-being ofelders from different ethnic backgrounds. Findingsshow that fewer family contacts and a smaller socialnetwork are associated with higher depression(Hovey,2000;Lee et al, 1996;Pang, 1998;Stokes etal, 2001). By and large, studies on Asian family sup-port have shown that Asian elders receive a consid-erable amount of emotional and instrumental sup-port from adult children (Mui, 2001; Shibusawa &Mui,2001).In addition, these Asian families have astrong sense of family obligation that often super-sedes the needs of individual family members. Asianelders expect their family to assist them in their oldage and to treat them with respect (Mui, 1996b,2001).These studies suggest that there is a culturalexpectation factor in family support among elderlyAsian immigrants that may differ from other ethnicgroups. Despite a high level of social support ex-change and reciprocity between generations ofchildren and grandchildren, Chinese and Koreanimmigrant elders still report high levels of depres-sion (Mui, 1996b, 2001). It is not clear whetherthese respondents' depression was due to high unmetneeds or higher family expectation inintergenerational exchange. These are unansweredquestions in the literature.

CONCEPTUAL FRAMEWORK FOR STUDYINGACCULTURATION STRESS AND DEPRESSIONIn this study of Asian immigrant elders, a stress andcoping framework (Aldwin, 1994; Lazarus &Folkman, 1984) was used to conceptualize and ex-amine the relationships between life and accultura-tion stress, coping resources, and depressive symp-toms. Ways of coping with stress are determined bycognitive appraisal and include both cognitive andbehavioral efforts to manage stresses that are ap-praised as taxing. The stress and coping frameworkacknowledges the importance of personal and en-vironmental stress (stressful life events, accultura-tion stress, and health stress) and their effects onelderly Asian American and Asian immigrant el-

ders' psychological well-being. Coping resourcesusually include spiritual, fmancial, and social sup-ports that are available to individuals (Burnette &Mui, 1994; Lazarus & Folkman; Mui, 1993; 1996b).Based on the stress and coping framework, this studyexamines the effects of stress (acculturation stress,stressful life events, poor health conditions) andcoping resources (English proficiency, social sup-port, religiosity) on the self-reported depressivesymptoms among an elderly Asian immigrantsample.

METHOD

Data Sources and SampleData analyzed here are firom the Asian American Eldersin NewYork City, 2000, a survey sponsored by theAsian American Federation of New York (Ryan,Mui, & Cross, 2003). The study researched AsianAmericans age 65 and older who belonged to oneof the following six ethnic groups: Chinese, Fili-pino, Indian, Japanese, Korean, and Vietnamese.These six groups were selected because they repre-sented 94.4 percent of all Asian American and Asianimmigrant elders in the United States (U.S. CensusBureau, 2000). The survey explored how health,mental health, fmancial well-being, informal sup-port systems, formal service utilization, accultura-tion and immigration experiences, and quality-of-life issues related to depression and overall lifesatisfaction.

The sample was drawn from a 1990 US. censuslist of more than 5,785 block groups in the fiveboroughs of NewYork City. Census block groupswere ranked according to the percentage of Asianhouseholds recorded in the 1990 census. A cut-offwas made when the block groups represented 70percent of all Asians 65 and older contained in the1990 census data. The fmal sample consisted of 60block groups or primary sample units (PSUs) thatmet the inclusion criteria.This survey used an areaprobability sample. Area probability samples aredesigned to give each eligible population memberor household in the area a known chance of beinginterviewed. Using a street map and specially de-signed listing sheets, trained bilingual interviewerswent to a randomly designated point in the areaand listed housing units. For each of the 60 se-lected block groups, 100 to 150 households werelisted and then screened for interviewing. For thisstudy, interviewers were required to contact a se-lected household up to four times to determine

M U I A N D K A N G / Acculturation Stress and Depression among Asian Immigrant Elders

eligibility for study inclusion. Because of the na-ture of the random sampling procedure, no house-hold substitution was allowed.Therefore, when aninterviewer identified an eligible respondent, heor she was required to call back up to four timesto procure an interview. One respondent perhousehold was interviewed. If more than one eli-gible respondent lived in the household, then theperson who had most recently celebrated a birth-day was selected as the respondent.

A total of 407 Asian immigrants age 65 and olderwere interviewed in their homes. There were noAmerican born Asian elders identified in this sample,all respondents were foreign born, having immi-grated to the United States in middle to late middleage. Interviewers for each subgroup of these Asianelders received a bilingual interviewing manual anda set of question instructions to minimize the sys-tematic errors and to increase the inter-rater reli-abihty.The completed survey response rate was 84.3percent of those eligible to participate. Interviewsaveraged one hour and 30 minutes in length andwere conducted between February 2,2000 and May31, 2000. Interviews were conducted in EngHsh,Chinese,Tagalog, Hindi, EngHsh, Korean, andViet-namese.The questionnaire was prepared in Englishand was translated and back-translated into differ-ent ethnic languages by panels of bilingual profes-sionals to ascertain that the items were culturallyvalid, and conceptually and linguistically consistent.The respondents were administered the question-naire in either English or the ethnic language theypreferred. Most participants used the native lan-guage questionnaire consistent with their ethnicity.The Japanese elders used the English questionnaire.

MeasuresThe coding scheme, mean, and standard deviationof all the variables in the study are presented inTable 1 .The dependent variable—depression—wasmeasured by the 30-item GDS. These items con-sist of symptoms similar to DSM-IV criteria, suchas depressed mood, feelings of hopelessness andworthlessness, diminished interest in activities, poorconcentration,and indecisiveness (Mui et al., 2001).The assessment of depression in an elderly popu-lation is more difficult than in a younger popula-tion because of the higher prevalence of somaticcomplaints, genuine physical problems, and medi-cation use. One of the strengths of the GDS is thatit contains no somatic items that can introduce age

bias into the depression screening scale and infiatetotal scores among the elderly population (Kessler,Foster,Webster, & House, 1992). Respondents wereclassified as depressed on the basis of the standardcutoff point of the total GDS score, which is a 11(Yesavage et al., 1983). Literature suggests that theGDS is a reliable measure of depression for AsianAmerican elderly groups, and it has shown ad-equate internal consistency reliability (Mui, 1996c;Mui, Kang, Chen, & Domanski, 2003).The com-puted alpha coefficients of the GDS for differentgroups in this study ranged from .85 to .92 (seeTable 1), indicating satisfactory reliabihty perfor-mance of this measure.

Life stress and acculturation stress were opera-tionally defined by six variables: length of stay in theUnited States, self-rated health (1 = poor, 5 = ex-cellent), number of medical conditions, number ofstressful life events, family responsibility expecta-tion, perceived cultural gap between the respon-dent and his or her adult children.The stressful lifeevents variable was a composite score of a list of upto six stressful life events experienced by the re-spondent in the preceding three years. Examples ofthese events included major losses in life, such asdeath of spouse, family member, or good friend;serious illness or injury; being robbed or havinghome burglarized;having adult children who movedout; and relocation.

Acculturation stress measures are found in Table2. Family responsibility expectation was a compos-ite score of 12 family value items, which measuredthe degree of family value acculturation of the el-ders (a = .80).The 12 family value questions mea-sured elders' expectations regarding extended fam-ily, nuclear family, elder care, marriage, divorce,gender roles, and family living arrangements. El-ders answered each question in terms of how theyfelt about these statements on a four-point scaleranging from 0 = not at all important to 3 = veryimportant. High scores indicated elders who wereless acculturated because they adhered more to theirtraditional cultural beliefs. The perceived culturalgap variable was a global measure evaluated by ask-ing elders to assess how their view regarding thesefamily values differed from that of their children ona four-point scale ranging from 0= not at all differ-ent to 3 = different in a very important way.

Indicators of coping resource variables were el-ders' English proficiency, religiosity, number of chil-dren living within a two-hour driving distance, and

246 SocialWork VOLUME 51, NUMBER 3 JULY 2006

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the amount of instrumental, financial, and emo-tional assistance received fi-om children. Englishproficiency was assessed in terms of respondents'ability to read, write, and speak English. In this study,English proficiency was conceptualized as a copingresource because it represents elders' behavioralefforts to cope with the host culture. Religiosityassessed respondents' perception about the level ofimportance of religion in their lives on a four-pointscale. Sociodemographic variables, including gen-der, living arrangements, marital status, age, andMedicaid coverage, were used as controls. Becausethe income measure had a lot of missing data,Medicaid coverage was used as a proxy measure ofelders' financial status. Even though Medicaid en-titlement may not be a precise measure of eco-nomic resources, it uses means testing and incomerelated to federal poverty guidelines as eligibilityrequirements.

RESULTS

Univariate and Bivariate AnalysisTable 1 presents a descriptive profile of the six groupsof Asian immigrant elderly respondents {n = 407).Respondents were 25.8 percent Chinese (M = 105),12.8 percent Filipino (w = 52), 24.6 percent Indian(n = 100), 6.1 percent Japanese (n = 25), 24.6 per-cent Korean (w = 100), and 6.1 percentVietnamese(n = 25). Data show that the entire sample wereborn in Asian countries and typically immigratedto the United States in middle age. The data alsoconfirmed that this Asian immigrant elderly samplewas not a homogeneous group. Group differencesincluded gender composition, living arrangements,marital status, age, time in the United States, stress,coping resources, and acculturation experiences. Ofthe total sample, 44 percent were men, 19 percentlived alone, and 49 percent were married. Com-pared with the general older population and withother Asian groups in the study, there were moremen in the Indian andVietnamese groups (62 per-cent and 64 percent, respectively) .Those in the Fili-pino and Indian groups were less likely to live alone(only 4 percent and 3 percent, respectively) thanw ere those in the other groups. Compared withother groups,Japanese and Korean elders were lesslikely to be married (40 percent and 29 percent,respectively). The ages of the sample ranged from65 to 96 (M = 72.4 years, SD = 6.2), with theVietnamese group being significantly younger thanthose in the other groups (M = 68.8 years).The

average length of residence in the United States forall the respondents was 20.8 years {SD = 13.2,range= 1 to 72 years), with the Vietnamese group re-porting the shortest U S. residence (seven years only).The whole sample had some high school educa-tion in their home country. About 41 percent {n =167) of the total sample received Medicaid.

In terms of stress and coping resources, the Viet-namese participants were in the poorest conditioncompared with others in the sample.The Vietnam-ese elders reported significantly poorer health, moremedical conditions, a greater perceived cultural gapbetween themselves and their adult children, andpoorer English proficiency. On the other hand, theyhad more children living in proximity and consid-ered religion as more important in their lives.Theywere also more likely than their counterparts toreceive Medicaid (91 percent).

Table 1 also shows the GDS mean scores for thetotal sample (M = 10.1; 5D = 7.0) and for eachgroup. About 40 percent of the total sample scored11 or higher on the GDS, indicating possible de-pressive symptomatology.There were within-groupdifferences experienced by members of the sixgroups.Japanese respondents reported significantlyhigher risk of depression than the other groups (M= 15.0; SD = 7.7), followed by Vietnamese (M =12.4; SD = 5.7), Chinese (M= 11.4; SD = 7.7), andIndian (M = 11.1; SD = 6.8) respondents. Koreanand Filipino respondents reported significantlylower levels of depressive symptoms (M =7.8; SD= 5.8 and M = 6.2; SD = 5.0, respectively). Theincidence rates of depression (those who scored 11points or more on the GDS) in this sample wereJapanese (76 percent), followed by Vietnamese (64percent), Indians (50 percent), Chinese (45.7 per-cent), Koreans (24 percent), and Filipinos (15.4percent).These findings all exceed the 15 percentto 20 percent prevalence rates of depressive symp-toms or syndromes among community-dwellingelders as reported by Gallo and Lebowitz (1999).

Multivariate AnalysisHierarchical linear regression analyses were usedto examine significant correlates of depression. First,a simple additive model was used to test the addi-tive effects of demographic, coping resources, andacculturation stress on depression levels. Then, anadditive and interactive model was used to test theinteraction effect between acculturation stressvariables and dummy-coded nationality variables.

M U I AND KANG / Acculturation Stress and Depression among Asian Immigrant Elders 249

Statistically, the interaction model tested whetherthe impact of acculturation stress on depressionlevels would vary by nationality groups. Only Ko-rean, Chinese, and Indian elders' data were used tocreate dummy variables with Chinese as the refer-ence group because that group is more known,relatively speaking, in the literature (Mui, 1996b).The Vietnamese, Filipino, and Indian groups weretoo small for meaningful comparison in multivari-ate testing. Normality of variables and regressionassumptions were checked.There was no violationof regression assumptions. Zero-order correlationsamong independent variables ranged from .01 to.37, indicating that multicollinearity was not aproblem.

Table 3 presents results of the hierarchical re-gression model ofthe GDS for the whole sample.Findings indicate that demographic variables as aset explained 5 percent of the variance in depres-sion scores when entered first. Entered second, thecoping resources as a set accounted for an addi-tional 6 percent ofthe variance in the model.Theacculturation stress variables as a set added another36 percent variance in the model after demographicand coping resources variables were taken into ac-count. In the interaction model, the two dummy-coded nationality variables (Korean versus Chinese;Indian versus Chinese) and all the two-way inter-action terms between nationality dummy-codedvariables and stress variables were entered. None of

Table 3: Linear Regression Model of Depressive Symptomsby Six Groups of Elderly Asian Immigrants

Independent variable Pearson r*

Sociodemographics

Gender

Living arrangement

Marital status

Age

Medicaid coverage

/P at this step

Coping resources

English proficiency

Religiosity

No. of children living within twohours driving distance

Assistance from children

Increment to i? at this step

Life stress and acculturation stress

Length of stay

Perceived health

No. of medical conditions

No. of stressful life events

Family responsibility expectation

Perceived cultural gap

Increment to R^ at this step

7?2 Total

Adjusted R^ Total

-.02,15****

-.10

-.07

.13*

-.18***

-.06

-.15**

.02

.16**

-.56****,38****

3g****

.0328****

Step 1UnstandardizedCoefficient (5£)

1.23 (.85)

1.62(1.06)

1.21 (.91)

.95 (.83)

1.52 (.75)*

.05*

7^5, 319) = 3.03*

Step 2UnstandardizedCoefficient (S£)

1.45 (.97)2.10(1.22)

-1.72(1.00)

-1.01 (.91)

1.70 (.87)

-.72 (.42)

.03 (.43)

-.80 (.25)**

.28 (.17)

.06***

7='(9, 260) = 3.61***

Final StepUnstandardized StandardizedCoefficient (S£) Coefficient

.26 (.78)

.78(1.02)

-.48 (.79)

-.74 (.76)

-.25 (.72)

-.06 (.37)

-.88 (.37)*

-.70 (.20)***

.38 (.13)**

.06 (.03)*

-1.05 (.12)****

.23 (.19)

1.24 (.23)****

.10 (.07)

1.24 (.48)**

.36****

.02

.04

.04

.05

-.02

.01

-.13*

.17***

.14**

.12*

.50****

.07,27****

.08

.13***

F(X5,247) = 14.86****

4-7****

44****

•Zero-order correlation coefficients between GDS and independent variables.*p < .05. •*p < .01. ***p < .001. ****p < .0001.

250 SocialWork VOLUME 51, NUMBER 3 JULY 2006

the nationality dummy variables or the interactionterm between nationality and stress variables werestatistically significant (they are, therefore, not shownin the table).These results mean that the impact ofacculturation stress on depression did not vary bynational origin among these Asian elders and thatthe additive model fits the data better than the in-teractive model. On the other hand, the lack ofsignificant results in the interaction model may bedue to insufficient power in the model.

As noted inTable 3, three coping resources vari-ables and four stress variables were significant cor-relates in explaining GDS depression scores, otherthings being equal. Stress variables as a group hadthe strongest impact on depression scores. Specifi-cally, poor perceived health had the strongest effect((3 = -.50), followed by the number of stressful lifeevents ((3 = .27), number of children living in prox-imity (P = -17), assistance from adult children (P =.14), perceived cultural gap (P = .13), religiosity (P= -.13), and length of stay (P = .12). The familyresponsibility expectation factor did not make anysignificant impact on depression levels, but the per-ception of these family value differences betweengenerations did.

DISCUSSION AND IMPLICATIONSThe findings support the authors'primary researchquestion that higher acculturation stress is associ-ated with higher depression levels among the sixsubgroups ofAsian immigrant elders in the sample.The findings suggest that these Asian immigrantelders, like other elderly groups, are vulnerable topsychological distress in the form of depressivesymptoms. Our findings also confirm that Asianimmigrant elders are not a homogenous group asobserved in the significant differences in depres-sion experienced among the six Asian ethnic groups.Compared with other studies in the literature, therates and incidence of depression in these six groupsofAsian elders were higher than observed in mostother community ethnic elderly samples. Statisti-cally, survey results based on subgroups of smallsample size can be subject to large sampling error(Kerlinger & Lee, 1999). Readers should, therefore,be cautioned that the higher rate of depressionobserved in this study might be a statistical artifactof the limited size of each ethnic group. Neverthe-less, depression has been documented as a risk fac-tor associated with suicide and is more likely to beundetected or misdiagnosed in ethnic minority el-

ders, partly because of cultural barriers to diagnosisand treatment (Mui, 1993,1996a, 1996b, 2001).Thefindings of this study suggest that health and socialservice agencies need to set as a priority examina-tion of the depression among these six subgroupsofAsian immigrant elders and development of cul-turally appropriate interventions that address theirmental health needs. Depression is a treatable dis-ease. As such, these findings urge social workers toengage in early screening and intervention of de-pression among elders in these Asian subgroups.Where screening depression is concerned, practi-tioners should err on the side of caution.

Relatively speaking, the data suggested that theseFilipino and Korean immigrant elders seemed tohave adjusted better than other groups because theyadmitted to a much lower rate of depression in thestudy. On the other hand, the data also suggestedthat the incidence of depression among Japanese,Vietnamese, Chinese, and Indian immigrant elderswas higher than other elderly American popula-tions in the literature (Gallo & Lebowitz, 1999;Hazuda,Wood, Lichtenstein, & Espino, 1998). El-ders in these Asian subgroups varied in their emo-tional well-being. It is difficult to speculate whythis variance was found. It may be based on vari-ance in the total life experiences of this sample.Based on a life course perspective, people's earlylife experiences affect their worldviews and devel-opment of adaptive resources (Stroller & Gibson,1999).Exploring the diversity in the social and his-torical contexts in which today's cohort ofAsianAmerican and Asian immigrant elders experiencedsignificant life course events is essential in under-standing their social reality and personal struggleswith aging. Each group ofAsian immigrant eldersmay have been through war-related trauma or po-litical turmoil in their early lives.These life experi-ences may become painful memories, especially ifthey had hardship, regrets, accumulated stresses, orunresolved family conflicts (Mui, 1996b; 2001). Forexample, Japanese American and Japanese immi-grant elders in the United States during and afterWorld War II may have experienced more preju-dice and discrimination (Shibusawa & Mui, 2001).The Vietnamese elders may have suffered from ahigher degree of migration grief than other groupsbecause they immigrated to the United States in-voluntarily after the Vietnam War (Ngo,Tran, Gib-bons, & Oliver, 2001).Elders from China may haveexperienced the horrible pohtical turmoil during

M U I A N D K A N G / Acculturation Stress and Depression among Asian Immigrant Elders 251

WWII as well as the Cultural Revolution.The Par-tition of India may have left Indian immigrantsdevastated because of the loss of many lives in theriots (Keen, 1998). As immigrants in the UnitedStates, these six subgroups of Asian elders are disad-vantaged and underprivileged by age, ethnicity, class,and language (Mui, 1996a;2001; StroOer & Gibson,1999).These human dimensions cannot be under-stood in additive terms because they interlock toshape the social reality and emotional responses ofthese Asian elders. They do, however, add to ourunderstanding of the potential that the unique lifeevents experienced by these elders may have onthe risk of the higher incidence of depression ob-served within the Asian ethnic subgroups studiedhere.

Specifically, the results from the multivariateanalyses confirmed some existing notions aboutcorrelates of depression among elders of Asian heri-tage. The findings suggest that life stress and accul-turation stress are major concerns of Asian immi-grant elders. Consistent with the literature (Blacket al., 1998; Falcon & Tucker, 2000; Mills &Henretta, 2001), self-rated poor health had thestrongest effect on depression among these elders.The comorbidity and coexistence of depressionwith poor health is a very complex issue (Mui,1996b). It reflects the "which comes first" causalphenomenon: Does physical illness result in de-pression or vice versa? Methodologically, longitu-dinal research is needed to examine the causal re-lationship between health status and depression andhow depression changes over time. Poor perceivedhealth may be an indication of lack of access tohealth care. Coping with physical and psychologi-cal losses associated with illness and disability canbe extremely challenging.This is especially true forAsian elders who may lack the financial resourcesand language proficiency to negotiate the UnitedStates health care system.This finding points, there-fore, to the importance of designing culturally sen-sitive health maintenance and health promotionprograms to meet Asian elders' health care needs.

The second-most-powerful correlate of depres-sion was the stressful life events variable. This is awell-documented relationship among the generalolder population as well as ethnic elderly popula-tions (Casado & Leung, 2001; Swenson, Baxtor,Shetterly, Scarbro, & Hamman, 2000).The stressfullife events variable measured major emotional, psy-chological, relationship, and social losses through

death, illnesses, victimization, relocation, or sepa-ration from children. Coping with multiple lossesand victimization (from robbery, burglary, micro-aggression, prejudice, racial discrimination, or ra-cial oppression) may be extremely difficult for theseAsian immigrant elderly subgroups, especially ifthey lack proficient language skills and other re-sources to deal with their social realities. Some ofthe life events in this composite variable may haveprofound cultural impacts on Asian elders. Socialwork practitioners need to be sensitive to thesecultural differences. For example, death of a sig-nificant person in an elder's life may be more diffi-cult for the Asian elders because they lost not onlythe loved one, but also a significant source of sup-port and hope (Mui, 1996b, Shibusawa & Mui,2001).

This study's findings also point to the need to domore research to understand intergenerational fam-ily relationships and the way these family ties canlead to emotional distress and family conflict in-stead of support and comfort (Mills & Henretta,2001). Another stressful life event of great emo-tional impact for Asian elders is the split of house-hold between the elderly parent and his or her adultchildren.This is especially so for those elders whomay still have high expectations of family solidarityand coresidence (Mui, 1996b). Culturally, the splitof family household may be another indication ofintergenerational conflicts (Falcon &Tucker, 2000;Lee et ah, 1996). The Asian parent may be con-fronted with the loss of power and respect becausehis or her role as cultural conservator and familydecision maker may be undermined. Social work-ers need to be sensitive to the cultural meanings ofthese changes within a family system and be able toprovide services to support Asian Americanintergenerational families to deal with the disjunc-tions between expectations of family support andchanging social reality.

Other stress-related predictors of depressionwere a perceived cultural gap and a longer lengthof residence in the United States The associationof acculturation stress and depression is consistentwith the literature (Falcon & Tucker, 2000; Hovey,2000). It is interesting that the measures of elder'slevels of acculturation in terms of family responsi-bility expectations had no effect on depression, butthe perception of these value differences betweengenerations did matter. This seems to indicate thatamong these elders, intergenerational agreement

252 SocialWork VOLUME 51, NUMBER 3 JULY 2006

on family expectations was of greater importancein preventing depression than what the exact ex-pectations were. Longer residence in the UnitedStates usually is associated with lower levels of de-pression (Lam, Pacala, & Smith, 1997; Mills &Henretta, 2001). In this study, the direction of thisrelationship is reversed. A possible cultural expla-nation for this finding is that the longer the elderhad lived in the United States the more likely heor she was to have American-born children andgrandchildren whose acculturation and family ex-pectations differed from the foreign-born elder.Theperceived cultural gap between generations mayreflect elders' anxiety and worries about the fu-ture. They may not be sure whether children willbe there to help when they need them.

Acculturation is a multidimensional process (Mills& Henretta, 2001).Perceived intergenerational dif-ferences in cultural values may manifest in suchareas as sense of ethnic identity, communicationstyle, family values, family role and gender roleexpectations, or hfestyle choices. When workingwith Asian American clients, social workers mustbe sensitive to assessing intergenerational dynam-ics. In families with high levels of intergenerationaltension, social workers are advised to provide fam-ily counseling to enable these Asian families to workthrough the cultural value and expectation differ-ences. Such intervention may result in reduceddepression among the elderly parents and less stressamong their children.

Coping resources variables (fewer children liv-ing in proximity, more assistance from children, andbeing less religious) also had a significant impact onlevels of depression among this study sample. Theassociation between fewer children Hving in prox-imity and depression is consistent with research inthe United States and Asia (Chi & Chou, 2001;Hovey,2000;Lee et al., 1996). Culturally, Asian eld-erly parents may still expect their adult children tolive with them or to live in proximity so that theywill be available to provide support to them. Feweraccessible children may lead to the elder's sense ofsocial isolation and insecurity. Additional researchon this association is advised to develop culturallymeaningful social support and intervention.

In terms ofthe effects of receiving assistance onpsychological well-being, these Asian elders reportedhigher levels of depression when they received moreassistance from children. This is consistent with anational study that also found that "over-benefit-

ing" as a care recipient was associated with increaseddistress (Liang,Krause,&Bennett,2001).This study'sfindings provided more specificity in the relation-ship between social support and well-being in thesesubgroups of Asian immigrant elders. Social work-ers should not assume more assistance from familyto elders is always better. It is possible that moreassistance from children and frequent encountersbetween the two generations may jeopardize thequality of their relationships. Social work interven-tion needs to be sensitive to this association and toassess whether the frequency of intergenerationcontact is a cause ofthe elder's depression or is theresult of the depression. Interventions should betargeted based on whether and which causal rela-tionship exists.

The link between religiosity and depressionnoted here is also consistent with research on reli-gion and health (Ai, Dunkle, Peterson, & Boiling,1998; Hovey, 2000). The literature suggests thatmost immigrants continue or rebuild their spiri-tual lives in the new land (Min & Kim, 2002). Inthis study, high religiosity was assumed when re-spondents reported that they considered religionto be very important to them. Religious interpre-tation of stressful life events may have power tobring believers to a state of inner peace or accep-tance of a situation that is beyond their control(Idler, 2002). Religion is a powerful spiritual cop-ing resource (Ai et al.).The finding observed hereon the association of higher religiosity and less de-pression points to the importance of collaborationbetween religious or faith-based organizations andthe health care systems so that holistic mentalhealth care to Asian immigrant elders and to eld-erly populations in general is possible.

Overall, evidence from the data confirms thatthere is diversity within diversity among the Asianimmigrant subgroups in the study. This study datasuggest that there is substantial variation in thedepression experienced among Asian immigrantelderly subpopulations. Social workers need to notethe ethnic variations observed here and be carefulnot to assess Asian elders as a single group. Thestudy found that these groups differ in sociodemo-graphic backgrounds, financial status, English pro-

. ficiency, level of religiosity, support from children,length of residence in the United States, healthconditions, life stresses, acculturation level, perceivedcultural gap, and sense of psychological well-being.Findings point to the need to equip social workers'

M U I AND K A N G / Acculturation Stress and Depression among Asian Immigrant Elders 253

cultural competence with evidence-based knowl-edge about these culturally diverse subgroups ofAsian immigrant elders.

Although this may be the first study with an areaprobability sample of Asian American elders, itsgeneralizability is somewhat limited because of thedesign and small size of the subgroups. It is alsolimited by the fact that all respondents were for-eign born, so differences between native and for-eign-born Asian elders were not studied. Readersneed to be cautious in drawing inferences aboutthe wider population of Asian American elders,Asian immigrant elders, and specific Asian Ameri-can nationality subgroups. Because the study wasbased on a sample of Asian elders living in an ur-ban setting densely populated by people of Asiancultural heritage, the findings may be more indica-tive of characteristics of Asian elders who live inurban ethnic enclaves than it is of those who aremore dispersed. Despite such limitations, the find-ings of this study provide extremely importantempirical information for social workers and otherhelping professionals working with Asian immi-grant elders and their families. Findings also havesubstantial implications for mental health programsand practice. Data point to the need to design cul-ture-sensitive, bilingual depression screening, pre-vention and intervention programs for elderlyAsian populations. The within-group differencesin this study confirm the importance of not group-ing all Asian elders into one cultural group whenscreening, assessing, and treating depression. Thisstudy reinforces that more research is needed tounderstand the internal heterogeneity within thispopulation.

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Ada C. Mui, PhD,ACSW, is associate professor,

Columbia University School of SocialWork, 1255

Amsterdam Avenue, NewYork, NY 10027, e-mail: acm5@

columbia.edu. Suk-Youitg Kang, PhD, is assistant

professor. School of SocialWork, Arizona State University,

Tempe. The authors would like to thank the Asian American

Federation of NewYork and Brookdale Center on Aging,

Hunter College for their collaboration in this research. The

opinions expressed in this article are those of the authors and

should not attribute to the collaborating organizations.

Original manuscript received January 8, 2004Final revision received March 25, 2005Accepted June 1, 2005

M U I AND KANG / Acculturation Stress and Depression among Asian Immigrant Elden