The Mental Health of Asian and Pacific Island Elders: Implications for Research and Mental Health Administration

Colette Browne, Dr.P.H. Rowena Fong, Ed.D Noreen Mokuau, D.S.W.

Abstract

According to the 1990 census, the highly diverse Asian and Pacific Islander (API) American population has doubled in size from 1980 to 1990, and is now the nation's fastest growing minority group. Several studies have documented this population's comparative underuse of mental health services. A review of recent studies on the mental health of Asian and Pacific Island elders identifies a number of risk factors andprotectors. ElderAPIs appear to have poorer mental health compared to white counterparts but not the poorest mental health within their own ethnic group. Within-group differences emerge, with recent immigrant groups and colonized populations appearing as most at-risk for mental health problems. A critical variable on this population's mental health status appears to be socioeconomic status, and yet analysis of other demographic variables, notably nativity and gender, remain contradictory. A research agenda is proposed and implications for mental health administrators are suggested.

One of the most significant facts for the United States and other industrialized nations is the aging of their populations. Americans over the age of 65 years are estimated to be 33 million, or 12% of the total current population, and by 2025 they will constitute 20% of the total population. Addition- ally, at least half of these older adults will be over the age of 75.1 Between the years 1980 and 2000, the total U.S. population will increase by 7%, but the number of people 65 years and over will increase by 9%. Even more dramatic changes are projected for the 80 and over age group, which will grow by 28% in the same time frame. 2 Centenarians, numbering 25,000 in 1986, will reach one million by the year 2050. 3 The dramatic increase in this so-called old-old cohort (those over the age of 80) has vital and challenging implications for mental health professionals. Although many adults over the age of 80 years continue to lead active, satisfying lives, it is this age group that most often requires a wide array of formal and informal supportive and clinical mental health services to maintain optimal functioning.

Much of the social gerontological literature has concerned itself with the investigation of mental health in later life. Empirical evidence on the mental health status of older adults, however, remains contradictory. Some studies suggest that the later years are stressful and result in more mental health problems compared to younger years.4"s Such findings are disputed by other researchers, who instead suggest that the mental health of the aged is generally positive, 6'7 and others who question the existence of a relationship between age and mental health. 8

While the data on the mental health status of older adults is contradictory, data on the mental health status of Asian and Pacific Islanders (APIs) is not. APIs are those individuals who claim Asia

Address correspondence to Colette Browne, Dr.P.H., Assistant Professor, University of Hawaii, School of Social Work, 2500 Campus Road, Honolulu, HI 96822.

Rowena Fong, Ed.D., is an assistant professor in the School of Social Work at the University of Hawaii. Noreen Mokuan, D.S.W., is an associate professor in the School of Social Work at the University of Hawaii.

52 The Journal of Mental Health Administration 21:1 Winter 1994

and the Pacific Islands as their ancestral home. These individuals are members of one of the fastest growing groups in the United States. Previous studies have identified this ethnic minority group a s

being at higher risk for mental health problems compared to whites due to such stressors as immigration, adjustment to living in an alien culture, discrimination and prejudice, language barriers, education/occupation stresses, and disease. 911 Data to support such a view have been observed in higher levels of psychological symptoms in this population, and higher levels of depressive symptomatology compared to whites . 9'1~

Recent years have seen an increase in the number of studies on the mental health of APIs 1216 in recognition of their increase in the nation's population. However, limited attention has been given to understanding the relationship and effects of age and ethnicity on mental health. This is a serious gap in information as the aged are the fastest growing subgroup within API populations. 17 To correct this knowledge gap, a new subfield within gerontology, ethnogerontology, studies the causes and consequences of ethnicity/culture, race, and national origin on individual and population aging. The study of API elders is especially important for etiological reasons. Studies of ethnic/cultural differences in later life psychopathology have been few, and data on aging, aging and mental health, and ethnic and cultural variations of mental health remain inadequate. Ultimately, furthering such a knowledge base will aid in an understanding of what is and what is not universal aging. This article reviews what is presently known about the mental health status of API older adults, specifically Japanese, Chinese, Hawaiian, Korean, and Indochinese aged. It then offers a proposed research agenda and suggests implications for mental health administrators.

Asian and Pacific Island Elders It must be emphasized that the API population is an extremely diverse population composed of

more than 30 cultures. Asians include but are not limited to Japanese, Chinese, Korean, Filipinos, Vietnamese, Asian Indians, Thais, Hmong, Indonesians, Pakistanis, Cambodians, and Laotians. Pacific Islanders include Polynesians (Hawaiians, Samoans, and Tongans), Micronesians (Chamorros, the indigenous people of Guam, and other groups), and Melanesians (Fijians).18 Each of these API groups represents a culture unique in language, values, lifestyles, history, and patterns of movement and adaptation to America.19 The Asian and Pacific Island group numbered 5.1 million, or 2.1% of the country's population in 198520 and is primarily Asian (93%). Of the remaining 7% who are Pacific Islander, Hawaiians are the most numerous (66%), followed by Samoans (15%), Chamorros (12%), and smaller numbers of other Pacific Islanders. 21 Of the total number of APIs, 221,509 were 65 years of age and over. The API population (all ages) grew by 120% between the years 1970 and 1980 and doubled again from 1980 to 1990. 22

In 1990, the nation's population numbered 248,709,873 with 7,273,662 identified as A P I s . 23

The probability is high that the aged population also grew dramatically during this same time frame. The same census report identified the largest Asian and Pacific Island groups in the United States to be the Chinese (1,645,720), Filipino (1,406,77), Japanese (847,562), Indian (815,447), Indochinese--Vietnamese and Laotian--(763,551), Korean (798,849), and Native Hawaiian (211,014). 23

The lack of differentiation among ethnic groups in the census and other statistics renders many of these figures less meaningful than they would otherwise be. Current information from the 1990 census and other studies of API elders remains insufficient. Too often, the various populations that compose APIs are not differentiated. 24 Second, the ages of those who are 65 years of age and over are not further broken down, even though the mental health, health, and socioeconomic profiles of the younger-aged (usually defined as those under 75 years of age) have been found to be quite different compared to the older-aged (those over the age of 75). ~ Third, data are not cross-classified by gender, even though separating larger ethnic groups by age and gender would provide more m e a n i n g f u l statist ics. 26 Finally, the census has been criticized for the underreporting of minorities. 27 Any discussion of the mental health status of API elders must begin with the aforementioned problems.

Mental Health o f APl Elders BROWNE, FONG. MOKUA U 53

The Mental Health of Asian and Pacific Island Elders

Mental health has been most often defined as the presence or absence of psychological symptoms, Mental health has also been related to life satisfaction, T M social networks, 12 and, in the study of ethnic minorities, associated with acculturation, 15 alienation, 16 and changing traditional values. 14 Studies about the mental health needs of APIs have been fragmentary and unsystematic, with the result that knowledge on this population is less developed compared to other ethnic minorities. 28 This is even more true for Asian and Pacific Island elders. The following section will briefly review what is presently known about APIs' needs for services. This will be followed by a review of what is presently known about the mental health status of five groups of API elders: Chinese, Japanese, Hawaiian, and the recent immigrants from Korea and Indochina.

APIs and the Need for Mental Health Services

Differences among racial and ethnic groups in changing patterns of use for mental health services among racial and ethnic groups have been well documented. 24'29'3~ A historical context provides background information on the majority of Asian Americans in the United States today, and the potential relationship between mental health and aging. The oldest Asians (Filipinos, Chinese, and Japanese) came to California and Hawaii between 1890 and 1920, and faced severe prejudice and discrimination in their social life and federal laws. In contrast, the more recent elder immigrants came to America in the 1960s, after the racist laws that had barred a number of their economic and social freedoms were repealed. Studies focusing on rates in treatment among API populations have found that Filipino, Chinese, and Japanese were severely underrepresented relevant to the size of their population--as first admissions to state mental hospitals. 31 Several reasons explain low service use, including family, culture, and worker-client mismatches in interpersonal styles and valuesfl

In a more recent study, Asians were found to use emergency services, inpatient, and case management services less than do whites but had higher use rates for individual outpatient services. 32 Services with high rates of use were located in a community that provided community mental health services specifically for Asians. Takeuchi and colleagues 24 conducted a review of the literature and came to the conclusion that cultural and social factors play a critical role in limiting the use of mental health services in the community. A number of different program models have been proposed to be culturally responsive, including client and therapist match (in language, ethnicity, or culture) and parallel services (services devoted to a specific group).33'34 While neither appear to improve outcome of treatment, they do appear to reduce premature termination and increase length of treatment in community mental health programs. 24

Prevalence of Mental Health Problems Among API Elders: Chinese and Japanese, Hawaiians, and Recent Immigrants

Data on the prevalence of mental health problems of APIs is empirically limited and yet has had a fairly consistent theme. APIs are identified as being more vulnerable to mental health disorders compared to whites 9'1~ In addition to limited study, another major shortcoming of current research has been in the homogenization of this population, ignoring the differences in culture, language, lifestyle, and history in this country. This lack of differentiation has been problematic in the interpretation of data for mental health professionals.

One of the more well-known studies to address both points was an epidemiologic survey conducted by K u o . 9 He studied within-group differences in levels of depressive symptomatology among different Asian populations in Seattle by administering the Center for Epidemiologic Studies-Depression scale (CES-D) to nearly 500 APIs. Findings identified higber rates of depression among APIs (Chinese, Filipino, Japanese, and Koreans) compared to whites. Within-group differ- ences identified Koreans with the highest rate of depression (the most recent immigrant group), followed by Filipino, Japanese, and Chinese. Gender differences were conlradictory. Among Chinese and Filipino, females were more depressed; in contrast, Japanese and Korean men were more depressed.

The aged were not the most depressed within their respective ethnic groups. Among those 60 years of age and over, those with the lowest depression scores were the Chinese. Older Filipino and

54 The Journal of Mental Health Administration 21:1 Winter 1994

Japanese respondents had lower depressive scores than did the youngest respondents in their own ethnic groups. Among Koreans, older respondents (those over the age of 40) scored significantly higher (increased depressive symptomatology); in contrast, higher scores were identified among those under the age of 30 with the other three ethnic groups. Those with the lowest degree of depression were those retired, and those who had a family income of $40,000 and over. Within-group differences persisted even after other demographic factors were controlled (i.e., socioeconomic status [SES]). The profile, then, of aged APIs in this sample is not one with high rates of depression, although within-group differences point to Korean elders as having greater depressive symptom- atology compared to other elders in the study. The following sections will examine available data on specific API elder populations.

The Chinese and Japanese Aged. The relative positive mental health of the Chinese aged found in Kuo's study appears incongruent with the findings of other studies that identify the elderly Chinese with a suicide rate three times as high as among their white peers. 35'~ This has been attributed to the incongruities between the Chinese elderly's values and the reality of their lives in an alien cdture. ~ To further examine the mental health of Chinese, Ying conducted a telephone survey to determine the rates of depression, measured by the CES-D, in a community-based Chinese American sample of 360 aged adults in San Franciscofl In general, Ying found levels of depressive symptoms among the sample were higher than of those compared to whites or Asians in other studies. Like Kuo, 9 the aged were not the most depressed age group; in fact, Ying found that an improved mood level existed among the aged. 1~ When education and occupation were allowed to vary, the relationship between age and mental health was significant. However, when SES was controlled, older adult participants reported significantly less, not greater, depression symptoms compared to younger persons. Y'mg hypothesized that SES can disguise mental health patterns as younger adults often have more wealth. Ying also found an inseparability of affective and somatic structures.

The mental health status of older Japanese aged has been discussed in narrative but rarely in empirical studies. 28'37 Mental health has been associated with changing values 38 and intergeneratio- nal conflict, TM and acculturation is often seen as the culprit. A popular hypothesis is that first- immigrant generations become disillusioned with their Americanized children's values, with a subsequent increase in depressive symptoms. Osako and Liu 14 explored the impact of social mobility of Nisei on the generational relationships of Issei and Nisei and the subsequent well-being of the older Japanese immigrant. Their sample included 100 pairs of Japanese American Nisei subjects (45-60 years) and their mothers (Isseis with a mean age of 80). The sample was relatively healthy and active, with close family ties and friendships. A healthy mental health profile of elderly Japanese Americans identified their recognition and awareness of two sets of cultural norms, their own and their children's, with each being seen as valid and desirable depending on the point of reference. Filial piety remained strong and benefited from their cultural legacy. In fact, such values of dependence and group orientation appear to help Isseis cope with their children's changing values. A different study 38 examined the impact of cross-cultural experiences and ethnic values on the well-being of Japanese elders. Findings suggested that the ability to adjust to aging was heightened by the congruence of their values with those of their peer groups, not of their children. Such f'mdings suggest that values may mitigate some of the negative effects of aging and perhaps even promote certain positive aspects of aging.

Hawaiian. Hawaiians, the indigenous people of Hawaii, are one of the high risk populations identified by the President's Commission on Mental Health. 39 Mokuau notes that the data on the mental health of Hawaiians does not provide comparisons at the national level but is restricted to comparisons of populations in Hawaii/~ A selected profile of indicators associated with mental illness suggests that Hawaiians have higher rates of suicide among young adults and elderly males, higher rates of alcohol and substance abUse, and higher rates of assaultive acts and antisocial behavior when compared to the State of Hawaii population. 4~ Hawaiians are often characterized as suffering from depression and hopelessness, a result and a cause of mental health problems. Hawaiians hold a holistic view of life, one that does not separate the psyche from the soma. Balance, the community, and spirituality are all important cultural values.

Mental Health of API Elders BROWNE, FONG, MOKUA U 55

In historical Hawaii, kupuna (elders) were the grandparents or of the grandparent generation, and they were the accepted sources of wisdom, the arbitrator of family disputes, the troubleshooters in family problems, and the custodians of family history. 4~ Little is known about the mental health of Hawaiian elders. In Hawaii, where the majority of the Hawaiian population reside, only 6% of the total Native Hawaiian state population of 185,000 are 65 years of age and over. 4~ This percentage reflects the fact that this population has one of the shortest life expectancies of any ethnic group in the United States. 4~ Some researchers are fearful that the changing role of the importance of the kupuna will manifest itself in poorer mental health among Hawaiian elders. 2~176

Recent Immigrants: Korean and the lndoChinese Aged. Koreans are one of the most rapidly growing members of API groups. The 1990 census listed 798,894 in all age groups, a more than doubling of the 1980 census. 42 It is estimated that the Korean elder population is approximately 45,000. 43 Koreans are immigrating at a faster rate than other API groups (other than Filipinos), and projections estimate that their numbers will increase from 10% to 15% of the API population by 2020. 42

Many Korean elders immigrate to the United States to be closer to their younger family members who immigrated before them. Arecent study by Kiefer and colleagues examined the relationship of stress to emotional difficulties among a sample of recently arrived Korean elders residing in the community. Semistructured interviews were used to examine the respondents' experience of loss of social status, measuring their psychological health with the Symptom Checklist-90-R (SCL), adapted from the Cornell-Medical Index. 42 Findings identified those most at risk for poor psychoso- cial adaptation were the recent arrivals, those who lived alone, and who had lower levels of education. When compared to a matched sample of Caucasian elders of the same age also living in San Francisco, Korean elders scored significantly higher on 21 of the 42 symptoms, a result of higher levels of stress. Researchers also found a higher rate of somatic symptoms in the low-adapted group of Koreans, which indicated an attempt to defend against depression. In sum, Korean-born aged suffered several years of psychological distress following the immigration to America, and the degree of their distress was related to education and their living situation. In another study of Korean eiders, Moon and Pearl ~6 administered the Dean's Alienation Scale (DAS) to 137 Korean immi- grants, aged 60 years and over, who had immigrated to the United States (Oklahoma and Los Angeles) in the past five years. The elders typically followed their children. Elders appeared more alienated in Oklahoma; the study 16 suggested the importance of family ties, maintenance of close ethnic ties, and SES in the maintenance of well-being. Hurh and Kim's study 29 examined mental health status and life satisfaction among a sample of Korean immigrants in Chicago and also found higher rates of mental health problems compared to whites, thus suggesting that immigration and stress result in increased mental health symptoms.

The most recent immigrant population to the United States are the Indochinese refugees. These are refugees who have immigrated to the United States since 1975 from Cambodia, Laos, and Vietnam. While seen as homogenous, each ethnic group has its own language, ethnic identity and history, and culture.~5 Noting the critical importance of refugee status and the stress of immigration, a number of studies have focused on this population. T M

Tran 15 examined the social adjustment of 258 elderly Indochinese (Lao and Vietnamese) male and female refugees 55 years of age and over (mean age 61 years) from five different locations representing the diversity of the Indochinese refugee community in the United States since 1970. Social adjustment was defined in terms of the refugee's sense of satisfaction with life and living environment. The family was the most critical factor in the promotion of social adjustment. There was an inverse relationship between age and adjustment, with older refugees having a poorer sense of social adjustment compared to younger refugees. This could be due, in part, to the greater status loss experienced by elders, as poor social adjustment has been found to be related to depression."

In another study, 45 old age was associated with poor knowledge of English and a lack of preparation for adjustment to life in America. The inability to speak English led to numerous problems with seeking help, and the use of services. Finally, Rumbaut's longitudinal study 44 on the mental health of a probability sample of Indochinese in San Diego, measured by the General

56 The Journal of Mental Health Administration 21:1 Winter 1994

Well-Being Index (GWB) scale, found that there were higher levels of depression among women and those with low SES, the unemployed, and those who were 50 years of age and over.

Summary on API Elder Mental Health and Proposed Research Agenda

These studies suggest a number of intriguing although hardly conclusive facts. Foremost is the relative scarce research that has been conducted on APIs, whom the census reports as the fastest growing minority population in the countryY '23 Specifically, older APIs have poorer mental health compared to whites but not the poorest mental health within their own ethnic group, lending some support to studies on white populations that identify older adults as less depressed than younger adults. 6'7 Within-group differences reveal that Koreans and Hawaiian elders may have the poorest mental health and suggests that a relationship may exist between mental health and stress from recent immigration and from the effects of colonization. Exactly what role acculturation plays in mental health is not clear, and neither is there consensus on how to measure it. The inseparability of affective and somatic factors among some of the API populations makes a reexamination of mental health instruments that include somatic scales worthy of more investigation. SES is a critical variable, and when controlled for, mental health problems appear to decrease in older adults compared to younger age groups in their own ethnic groups (although the rate is still higher than their white counterparts). SES remains a critical variable regardless of how long one lives in the United States. On the other hand, the limited work on gender has lead to inconclusive results.

A proposed research agenda would include a stronger focus on various subgroups within the API population and gender differences within each group, and on the study of other relevant influences on mental health (i.e., SES and acculturation). 26'46'47 Furthermore, critical work needs to be done on understanding how different cultures define mental health, the role of acculturation, and a more sophisticated definition of ethnicity. Cultures differ in their definitions, manifestations, and preferred treatments for mental health. 4~ Therefore, studies on ethnicity and mental health suggest that the psychometric properties of mental health instruments be assessed for cultural reliability and validity.

Finally, studies need to distinguish between somatic symptoms and affective dimensions. This is especially true for the aged, 49 who may have actual somatic complaints, and for some API populations 24 who have been found to somatize their mental health problems. Future studies may or may not advocate the inseparability of the psyche from the soma, but this inseparability clearly deserves further study due to complications of age. Instruments measuring the presence or absence of psychological distress may require separate somatic subscales to assess the possible inflation of overall scores.

Implications for Mental Health Administration In light of the serious deficiencies in the existing knowledge based on the mental health of API

elders, recommendations for future consideration in developing social service delivery systems are made in the area of resources, clinical management, and program design.

Resources. Mental health administrators, juggling the reality of scarce resources, must continue to pay attention to data that suggest that certain populations have increased risk for mental health services. How one then reaches this population and provides services that are acceptable becomes increasingly critical as the numbers of API elders are expected to swell. For example, programs with suspected or actual underuse of services should, in addition to providing bilingual/bicultural staff, 46 educate staff members to recognize help-seeking behaviors in API elders, based on the cultural norms of those elders.

Administrators can maximize the research findings that conclude Asian and Pacific Island elders are using independent outpatient services more than emergency services, inpatient services, and case management. This information can be used in allocating resources to understanding why independent outpatient services are less threatening to API eiders than other service delivery systems.

Mental Health of API Elders BROWNE, FONG, MOKUA U 57

Clin ical M a n a g e m e n t . With the aged, administrators and workers must be knowledgeable of the history of the population that they are working with and their definitions of mental health and treatment. In future program planning, administrators could borrow ideas from the Older Americans

Act, such as including indigenous elders in the planning o f services. Indigenous communit ies can be used to inform people of services via ethnic-oriented radio programs, churches, television, civic clubs, and other clubs usually located in their ethnic communities. Administrators need to understand that, for elders who can neither read nor write English, literature should be bilingual and transpor- tation should be provided to improve access. Clinical management should also require that personnel be educated to detect ageism in addition to racism and sexism in policies and practice and develop explicit strategies to ensure that all aged persons are respected and served.

P r o g r a m Des ign . Administrators can use the practice implications of the studies reviewed in this article in designing future programs for API elders. For example, studies document the sometimes devastating consequences to Korean elders ' emotional well-being after immigrating to America. In the future, a culturally sensitive mental health program's therapeutic design would incorporate such information by working with the family and preparing them for the needs and challenges that elder family members will face in America.

Identification of the most needy populations will help administrators design more effective programs. Particular ethnic minorities appear to have poorer mental health throughout their lives. Additionally, mental disorders are frequently related to poorer health, lower income, widowhood, and social isolation. These are problems faced more often by older women compared to older men. Furthermore, although mental health administrators may be knowledgeable in gerontology and are aware that their elder clients have multiple needs, needs of API elders may be different. Staff members should be alert to the wide array of services available through the Older Americans Act

to provide for all of the needs o f API elderly that affect their mental health.

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