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Stigma related to mental illness often discourages individuals from identifying whether they have a mental illness. Epidemiologic studies conducted in the US suggest that 50% to 60% of persons with mental distress do not seek treatment because of this stigma (1). Stigma surrounding mental illness is one of the 3 top obstacles preventing those with mental illness from obtaining high-quality mental health care (2); it is also a reason for not seeking help or for waiting until it is too late to seek help for mental illness (3). Depression is a common mental disorder affecting many individuals. A recent US epidemiologic survey reported a lifetime prevalence of 16.2% and a 12-month prevalence of 6.6% for MDD (4). In a summary of 9 epidemiologic studies conducted from 1950 to1992, 1-month prevalence of MDD ranged from 1.5% to 4.9% (5). Among individuals with depression, stigma is an important factor affecting discussing and seeking treatment (6–10). Because of the stigma associated with a depression diagnosis, physicians may choose to make a medical diagnosis rather than a depression diagnosis (11). In the US, the Asian-American population is rapidly increasing; during 2002–2003, the population increased 3.8%, more than triple the growth rate of the entire US population (12). Likewise, in Canada from 1981 to 2001, the percentage of Asian Canadians almost tripled (13). Depression estimates among this growing US Asian-American population vary, possibly owing to the great stigma associated with a depression diagnosis. Epidemiologic structured interview studies report a lifetime prevalence of MDD ranging from 4.3% to 6.9% (14) and a 12-month prevalence of MDD of 3.4% (15). Self-report depression scales such as the CES-D report much higher depression rates ranging from 19.1% to 24.2% (16,17). Among Asian Americans, there is great stigma and shame about mental health problems and about receiving treatment for them (18,19). For example, in Chinese society, there is a belief that mental illness can affect a family’s good name for generations (20) and that an individual with mental illness causes the entire family to “lose face” and be shamed (21). There is stigma associated with mental illness because revealing problems by seeking professional help is a sign of personal immaturity, weakness, and lack of self-discipline (22). In addition to the individual’s stigma beliefs, the family may discourage the individual from identifying or seeking help for a mental illness because of the belief that it is a punishment from God or the spirits owing to the family’s bad behaviour; further, seeking treatment will reveal hereditary problems that will shame the family (22). Among parents, the presence of a mental disorder suggests that their child had bad child-rearing practices (22). Among Asian Americans, lower acculturation levels are associated with greater stigma (23,24). Asian Americans are much less likely than are whites and other minority groups to seek treatment for mental health problems (24–26), and when treatment is sought, they terminate treatment at greater rates than do whites (24). Assessing depression via computer (27) and the Internet (28) is becoming more common, with available evidence indicating its efficacy. In this study, we use the Internet to administer a depression questionnaire. When persons screened positive for depression, we inquired about their beliefs regarding stigma for mental disorders with regard to their friends, employer, and family. Advantages of an Internet study, compared with interview or self-report, include that it is anonymous and that individuals are more likely to disclose personal information to a computer. We believe that this Internet sample design approach offers a comprehensive method of obtaining Asian-American beliefs about the sensitive topic of stigma for mental illness. We hypothesize that Asian Americans have greater stigma levels than whites. We also hypothesize that younger Asian Americans have lower levels of stigma associated with mental illness, compared with other Asian-American age categories, perhaps owing to their greater acculturation. Also, our relatively large sample allows us to compare subgroups that have not been compared, since other reports often have had smaller sample sizes. MethodProcedures We placed the CES-D depression scale on the Intelihealth Web site (www.intelihealth.com). Individuals were invited to take a depression test on this site. Also, individuals who used search engines and typed in “depression test” were able to find and complete the questionnaire. Demographic questions included race or ethnicity, sex, age category, and zip code. All subjects scoring above the depression scale cut-off score of > 16 were asked questions about stigma for mental disorders relating to friends, employer, and family. All data were collected from March 1999 through December 2002. We obtained IRB approval and waiver for informed consent for our use of anonymous data. Participants The CES-D was completed by 153 068 individuals. We used US 2000 census data to match zip codes and exclude non-US individuals, resulting in 118 937 individuals. We compared Asian Americans with whites, resulting in 102 827 subjects: 3211 Asian Americans and 99 616 whites. The stigma questions were only asked to those who screened positive for depression, which resulted in 71 254 individuals (1944 Asian Americans and 69 310 whites). Because not everyone taking the CES-D completed the stigma questions, our final sample size comprised 68 656 subjects (1839 Asian Americans and 66 817 whites). Also, the exact sample sizes for the analyses vary slightly because not all individuals completed every demographic or stigma item. Measures We used the 20-item CES-D (29) to measure depression; higher scores indicate greater depressive symptoms. To measure stigma, we used a 5-point Likert scale (ranging from 0 = “strongly disagree” to 4 = “strongly agree”) to rate the following statements: 1) “I would be embarrassed if my friends knew I was getting professional help for an emotional problem”; 2) “I would not want my employer to know that I was getting professional help for an emotional problem” and 3) “If I had depression, my family would be disappointed in me.” We also used a similar Likert scale to rate the statement, “I feel that I need treatment for depression at this time.” Also, we requested that participants respond “yes” or “no” to the following question: “In the past 4 weeks, have you been very anxious, nervous, or panicky?” We asked this because anxiety levels may affect treatment help seeking. Statistical Analysis We used ANOVA to evaluate differences between Asian Americans and whites for the 3 stigma outcome variables (friends, employer, and family). We used ANCOVA to control for the covariates of age and sex and repeated the above analyses. Typically, surveys placed on the Internet are only completed once and not multiple times (30). However, to control for individuals completing the survey multiple times, we conducted a validation analysis, wherein we repeated the above ANOVA and ANCOVA analyses with the subset of the first completed unique combination of sex, age, race or ethnicity, and zip code. We separately stratified for female and male sex and also for the separate age categories (under 16 years, between 16 and 29 years, between 30 and 45 years, and between 46 and 60 years) and repeated the above ANOVA and ANCOVA analyses. For the sex analyses, age was included as a covariate. For the age analyses, sex was included as a covariate. These age categories were predetermined by the categories previously placed on the Intelihealth Web site. We also conducted analyses only among Asian Americans. For each of the 3 stigma outcome variables, we separately compared male with female participants, and we separately compared among age categories. We conducted both the ANOVA and ANCOVA analyses with the covariates, as described above. In the above analyses, we conducted 2-tailed tests and measured effect sizes with Cohen’s d, along with their 95%CIs. Because the Asian-American age comparisons had more than 2 groups, Bonferroni post hoc comparisons were calculated for the mean differences and partial eta squared for effect size. Finally, we separately regressed each of the 3 stigma outcome variables onto the “need treatment for depression” variable. We calculated the following 4 models: 1) need treatment + CES-D score, 2) need treatment + CES-D score + age + sex, 3) need treatment + CES-D score + anxiety, and 4) need treatment + CES-D score + anxiety + age + sex. We measured effect size with the adjusted R2. Whenever age was included as a covariate, it was dummy-coded with the age category of < 16 years as the reference category. We used SPSS (31) to conduct all analyses. Cohen’s d effect size was calculated with an effect size calculator (32). An a priori power analysis was conducted with GPOWER (33). Power Analysis The power analysis for the Asian American–white comparisons showed that each group needed 394 participants to detect a small effect (f = 0.10, 34) with a = 0.05 and power = 0.80. Because not all the age categories had that sample size, the a priori power only allowed for a medium effect requiring 64 participants in each group to detect a medium effect (f = 0.25, 34) with a = 0.05 and power = 0.80. ResultsDescriptive Statistics Descriptive statistics and analyses for the 68 656 individuals completing the “friends” stigma item are below. Race or ethnicity included 1839 Asian Americans (2.68%) and 66 817 whites (97.32%). Sex included 51 176 female (74.54%) and 17 480 male (25.46%) participants. The approximate female-to-male participation ratio was 2 to 1 for Asian Americans and 3 to 1 for whites. Age category sample size and percentages were as follows: < 16 years (n = 3130, 4.56%), between 16 and 29 years (n = 21 900, 31.90%), between 30 and 45 years (n = 26 177, 38.13%), between 46 and 60 years (n = 14 820, 21.59%), and over 60 years (n = 2629, 3.83%). CES-D mean scores were 34.97 for Asian Americans, SD 9.98 and 35.43 for whites, SD 9.91. Stigma Belief Comparisons Between Asian Americans and Whites Table 1 shows the stigma belief comparisons between Asian Americans and whites. With ANOVA, Asian Americans showed greater stigma beliefs than did whites with regard to friends, F1, 68,657 = 144.40, P < 0.001; employer, F1, 68,255 = 85.55, P < 0.001; and family, F1, 68,667 = 360.38, P < 0.001. Similar results occurred with ANCOVA.
For the validation sample that eliminated any possible duplicate questionnaires, the means and SD values were either exactly the same or differed by less than 0.03 for all 3 stigma categories. Likewise, similar significance and effect sizes existed for all analyses. These validation analyses allowed us to further analyze the whole chosen sample. As shown in Table 2, with ANOVA, Asian-American women and girls had greater stigma beliefs than did white women and girls with regard to friends, F1, 51,176 = 103.98, P < 0.001; employer, F1, 50,822 = 58.25, P < 0.001; and family, F1, 51,170 = 228.12, P < 0.001. Among men and boys, Asian Americans had greater stigma beliefs than did whites with regard to friends, F1, 17,480 = 19.59, P < 0.001; employer, F1, 17,431 = 18.29, P < 0.001; and family, F1, 17,495 = 138.33, P < 0.001. Similar results occurred with ANCOVA for both female and male subjects.
As shown in Table 2, with ANOVA, Asian Americans aged under 16 years had greater stigma beliefs than did whites in the same age group for family, F1, 3,129 = 19.87, P < 0.001 but not for friends, F1, 3,128 = 2.15; ns, or employer, F1, 3,078 = 2.79, ns. Among subjects aged between 16 and 29 years, Asian Americans had greater stigma beliefs than did whites for all 3 stigma categories of friends, F1, 21,899 = 67.57, P < 0.001; employer, F1, 21, 899 = 50.33, P < 0.001; and family, F1, 21,942 = 237.24, P < 0.001. Among those aged between 30 and 45 years, Asian Americans had greater stigma beliefs than did whites for all 3 stigma categories of friends, F1, 26,176 = 40.95, P < 0.001; employer, F1, 26,163 = 20.56, P < 0.001; and family, F1, 26,252 = 55.60, P < 0.001. However, among those aged between 46 and 60 years, Asian Americans did not have stigma beliefs that differed from whites for all 3 stigma categories of friends, F1, 14,819 = 0.79, ns; employer, F1, 14,594 = 0.33, ns; and family, F1, 14,710 = 0.41, ns. For all age analyses, similar results occurred with ANCOVA. For overall sex and age analyses, effect sizes were consistently small for friend and employer stigma and medium for family stigma. Stigma Belief Comparisons Among Asian Americans In addition to comparing Asian Americans with whites, we also stratified for Asian Americans only and compared stigma beliefs between sex and age categories. As shown in Table 3, with ANOVA, male subjects had greater stigma beliefs than did female subjects for friends, F1, 1,838 = 18.96, P < 0.001; and employer, F1, 1,849 = 4.61, P < 0.05; but not family, F1, 1,850 = < 0.001, ns. These results were all maintained when we used ANCOVA and controlled for the age covariates. There were small effect sizes for both friends and employer.
With ANOVA, the Asian-American age categories differed from each other for stigma beliefs about friends, F3, 1,809 = 4.53, P < 0.01 (Table 4). Bonferroni post hoc analyses showed that only those aged between 46 and 60 years differed from the other 3 age categories, with a lower mean. Also, the Asian-American age categories differed from each other for stigma beliefs about employers, F3, 1,1820 = 9.17, P < 0.001. Bonferroni post hoc analyses showed that subjects aged between 46 and 60 years differed from those aged between 16 and 29 years and 30 and 45 years, with a lower mean. Also, the Asian-American age categories differed from each other on stigma beliefs about family, F3, 1,820 = 15.59, P < 0.001. Bonferroni post hoc analyses showed that each of the age categories differed from each of the other 3 age categories. For all 3 stigma outcome variables, when we used ANCOVA analyses and adjusted for the sex covariate, the significant results were maintained. Because there were more than 2 categories, we could not use Cohen’s d as a measure of effect size and instead report partial eta squared. The partial eta squared values accounting for the proportion of the effect and error variance that is attributable to the effect are shown in Table 4.
Treatment Need for Depression and Stigma Beliefs As shown in Table 5, we sought to determine the relation between a belief in the need for depression treatment and each of the stigma beliefs. Consistent for all models, where we separately regressed any of the 3 stigma beliefs of friends, employer, or family onto various models, we found that there was a stigma belief decline for each unit increase in treatment need for depression. In the models not including the covariates of age and sex, stigma for friends had the greatest beta weights (–0.123 and –0.120), whereas stigma for employer (–0.075 and –0.077) and family (–0.076 and –0.076) were of similar magnitude. When we included the covariates of age and sex, there was a pattern where the beta weights were greatest for stigma for friends (–0.127 and –0.126), lower for stigma for employer (–0.084 and –0.086), and least for stigma for family (–0.059 and –0.059). This pattern of beta weights indicates that stigma declines for each unit increase in treatment need for depression and that it is the greatest for friends, lower for employer, and least for family.
DiscussionWe show that Asian Americans have greater stigma beliefs than do whites for stigma related to friends, employer, and family. This is consistent with the literature reporting high stigma levels associated with mental disorders among Asian Americans (18,19). Our large sample size obtained through the Internet allowed us to study the stigma beliefs of a large number of Asian Americans and to compare their beliefs with the beliefs of whites. We avoid the potential bias associated with studies placed on the Internet of repeated survey completion. Our validation method eliminated duplicates from anyone with the same combinations of variables and still obtained the exact same results. In our analyses by sex, we found similar results: both male and female Asian Americans have greater stigma beliefs than do whites for stigma related to friends, employer, and family. We also noted that 34% of the Asian-American participants were male, which is higher than the 25% of white male participants. This anonymous Internet medium might have allowed these Asian-American subjects to feel comfortable completing the depression test and stigma questions, which they might have been uncomfortable completing elsewhere. In our analyses by age category, among those aged under 16 years, we observed an interesting pattern of Asian Americans having greater stigma beliefs than whites for stigma related to family, but not to friends or employers. This may be because younger Asian Americans are more acculturated than the older Asian-American age groups. Their experience attending school in the US and interacting with white peers allows them to feel comfortable discussing mental health issues with friends and employers who may be either Asian American, white, or from another ethnic minority group. However, for stigma related to family, Asian Americans aged under 16 years have greater stigma beliefs than do whites, because they are aware of the traditional beliefs about mental illness perceived by their parents and other family members. It is possible that, when subjects discuss mental health topics with their family, the result is often a denial of mental health difficulty and (or) criticism for their weakness in having a mental health difficulty. Among participants aged between 16 and 29 years and 30 and 45 years, there was a consistent pattern of Asian Americans having greater stigma beliefs than whites for stigma related to friends, employer, and family. Surprisingly, for those aged between 46 and 60 years, there were no differences at all for any of the stigma categories. However, previous analyses suggest that, for this age group, the Internet leads to substantially biased estimates, and results need to be interpreted with extreme caution (28). Also, persons aged between 46 and 60 years may be seeking a confirmation of their depression diagnosis and may not be representative of this age category. We suggest this because 1) this age category had a much smaller percentage of participants than those typically participating in community depression screenings (35); and 2) the mean stigma scores for this age category were much lower than the other scores; this is the only age category that differed from all the other Asian-American age categories with regard to friend and employer stigma. In our analyses focusing on Asian Americans, we found that male subjects had greater stigma beliefs than did female subjects for the friends and employer categories but not for family. This differs from the results reported by Atkinson and Gim (23), who found no sex differences. Our results may differ because we have 3 separate stigma categories rather than the generic term of stigma. In that study (23), participants might have assumed that stigma referred just to topics about the most important stigma (that is, stigma related to family) and found no differences, similar to our finding of no differences with regard to family stigma. In our analyses of Asian Americans by age category, we found a pattern where stigma for family was greatest for those aged under 16 years and systematically decreased throughout the older age categories. All 3 age categories did not differ with regard to friend or employer stigma. Although we also found that respondents aged between 46 and 60 years differed from all the other age categories with regard to friend and employer stigma, this may be an artifact of seeking a depression diagnosis confirmation, as explained above, and not an indicator that this age category truly differs from the other age categories. Our analyses relating stigma to the increased recognition of a need for depression treatment showed a pattern where the greatest stigma decreases occurred first for friends stigma, next for employer stigma, and then for family stigma. Unlike the study by Abe-Kim and others (36), where the authors used a 1-item measure of stigma and found that it did not relate to mental health service seeking, this study shows that stigma relates to a belief in mental health service seeking. Our results may be more accurate because we investigated 3 specific forms of stigma, whereas they used a generic stigma term of “what others might think.” Clinical ImplicationsAddressing stigma among Asian Americans is important. Individuals who suffer from mental health difficulty should seek relief for their symptoms rather than suffer and not seek treatment because of the stigma associated with mental dis- orders. The largest effect sizes found in this study related to family stigma. Because only 29% of Asian Americans had no concerns about family stigma, clinicians have a lot of oppor- tunity to address the overwhelming majority who are concerned about family stigma, which may be a barrier for their seeking depression treatment. Clinicians may choose to talk with the patient’s family and (or) provide handouts about depression for the patient to give to family members. Also, clinicians should be aware that Asian Americans from younger age groups are less concerned with stigma from friends and employers. Unlike older Asian Americans, who still have a lot of stigma concerns, they may be more open to depression treatment recommendations as long as their family stigma concerns are addressed. Future Directions The strengths of this study include our assessment of 3 different types of stigma for depression treatment (among friends, employers, and family), the large sample size, and our use of the Internet as a screening tool to ensure anonymity. Weaknesses of this study include the following: 1) we did not identify the specific ethnicity of Asian Americans; 2) there was no formal measure of acculturation used; and 3) by ensuring anonymity in the data collection, we are unsure whether our sample is truly representative of the Asian Americans living in the US. Future areas of research might include formal measures of acculturation that request the specific Asian-American ethnicity and longitudinal studies of stigma after a culture-specific intervention is applied. At this time, when Asian Americans often fear stigma associated with depression, our method of using the Internet may be an effective way to screen for stigma among Asian Americans. Funding and SupportThis study was supported by the National Institutes of Health (NIH) through the Loan Repayment Program for Clinical Researchers (CR-LRP). References1. Cooper AE, Corrigan PW, Watson AC. Mental illness stigma and care seeking. J Nerv Ment Dis 2003;191:339–41. 2. 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Available: http://www.census.gov/Press-Release/www/2003/ cb03-ff05.html Accessed 2004 Jan 22. 13. Asia Pacific Foundation of Canada: proportion of total population 2004. Available: http://www.asiapacific.ca/data/people/demographics_dataset2_byprov.cfm. Accessed 2004 Mar 10. 14. Iwamasa GY, Hilliard KM. Depression and anxiety among Asian American elders: a review of the literature. Clin Psychol Rev 1999;19:343–57. 15. Takeuchi DT, Chung RC, Lin KM, Shen H, Kurasaki K, Chun CA, and others. Lifetime and twelve-month prevalence rates of major depressive episodes and dysthymia among Chinese Americans in Los Angeles. Am J Psychiatry 1998;155:1407–14. 16. Kuo WH. Prevalence of depression among Asian-Americans. J Nerv Ment Dis 1984;172:449–57. 17. Ying YW. Depressive symptomatology among Chinese-Americans as measured by the CES-D. J Clin Psychol 1988;44:739–46. 18. Root MPP. Guidelines for facilitating therapy with Asian American clients. Psychotherapy 1985;22:349–56. 19. Surgeon General. Mental health: culture, race, ethnicity. Supplement to mental health: a report of the Surgeon General. Washington (DC): Government Printing Office; 2001. 20. Tabora B, Flaskerud JH. Depression among Chinese Americans: a review of the literature. Issues Ment Health Nurs 1994;15:569–84. 21. Tabora BL, Flaskerud JH. Mental health beliefs, practices, and knowledge of Chinese American immigrant women. Issues Ment Health Nurs 1997;18:173–89. 22. Uba L. Asian Americans: personality patterns, identity, and mental health. New York: Guilford Press; 1994. 23. Atkinson DR, Gim RH. Asian-American cultural identity and attitudes toward mental health services. J Counsel Psychol 1989;36:209–12. 24. Leong FT, Lau AS. Barriers to providing effective mental health services to Asian Americans. Ment Health Serv Res 2001;3:201–14. 25. Surgeon General. Mental Health. A report of the Surgeon General. Washington, DC, Government Printing Office, 1999. 26. Zhang AY, Snowden LR, Sue S. Differences between Asian and white Americans’ help seeking and utilization patterns in the Los Angeles area. J Community Psychol 1998;26:317–26. 27. Greist JH. Computer interviews for depression management. J Clin Psychiatry 1998;59(Suppl 16):20–4. 28. Houston TK, Cooper LA, Vu HT, Kahn J, Toser J, Ford DE. Screening the public for depression through the Internet. Psychiatr Serv 2001;52:362–7. 29. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement 1977;1:385–401. 30. Rhodes SD, Bowie DA, Hergenrather KC. Collecting behavioural data using the world wide web: considerations for researchers. J Epidemiol Community Health 2003;57:68–73. 31. SPSS. Version 10.0. Chicago: SPSS; 1999. 32. Coe R. What is an ‘effect size’? A guide for users. Available: http://cem.dur.ac.uk/ebeuk/research/effectsize/Calculator.htm. Accessed 2004 Jan 3. 33. Erdfelder E, Faul F, Buchner A. GPOWER; a general power analysis program. Behav Res Methods Instrum Comput 1996;28:1–11. 34. Cohen J. A power primer. Psychol Bull 1992;112:155–9. 35. Magruder KM, Norquist GS, Feil MB, Kopans B, Jacobs D. Who comes to a voluntary depression screening program? Am J Psychiatry 1995;152:1615–22. 36. Abe-Kim J, Takeuchi D, Hwang WC. Predictors of help seeking for emotional distress among Chinese Americans: family matters. J Consult Clin Psychol 2002;70:1186–90. Author(s)Manuscript received and accepted March 2005. Previously presented at the 23rd Annual Conference of the Canadian Academy of Child and Adolescent Psychiatry, November 2 to 4, 2003; Halifax, Nova Scotia. 1. Assistant Professor, Department of Economics, Brooklyn College, City University of New York (CUNY), Brooklyn, NY, US. 2. Professor, Department of Epidemiology; Professor, Department of Health Policy and Management, Johns Hopkins University, Bloomberg School of Public Health; Professor, Department of Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD. Address for correspondence: Dr J Fogel, Brooklyn College, City University of New York, Department of Economics, 218A, 2900 Bedford Ave, Brooklyn NY, 11210 e-mail: joshua.fogel@gmail.com
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