Joyce Chu

Asian American mental health: a call to action.

The U.S. Surgeon Generals report Mental Health: Culture, Race, and Ethnicity--A Supplement to Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services, 2001) was arguably the best single scholarly contribution on the mental health of ethnic minority groups in the United States. Over 10 years have now elapsed since its publication in 2001. This article highlights advances and illuminates gaps in the knowledge gained about the mental health and psychotherapeutic treatment of Asian Americans in the past decade. Though larger epidemiological surveys point to lower prevalence rates of mental illness in Asian Americans, further advances are needed in culturally valid assessment and quantification of cultural biases in symptom reporting in order to draw definitive conclusions about the state of Asian American mental health. A focus on prevalence in Asian Americans as a whole also shrouds important subgroup elevations such as heightened suicide risk in Asian elderly women or greater posttraumatic stress disorder in Southeast Asian refugees. Despite important developments in our knowledge about mental health prevalence, help-seeking behaviors, and culturally competent treatments for Asian Americans, it appears that troublingly low rates of service utilization still remain even when one accounts for the seemingly low prevalence rates among Asian Americans. Some progress has been made in the cultural adaptations of psychotherapy treatments for Asian Americans. In order to reduce mental health care disparities, greater efforts are needed to provide outreach at the community level and to bridge the gap between mental health and other medical or alternative health facilities. We call for innovation and provide recommendations to address these issues in the next decade.

Depression and Emotional Reactivity: Variation Among Asian Americans of East Asian Descent and European Americans

Studies of Western samples (e.g., European Americans [EAs]) suggest that depressed individuals tend to show diminished emotional reactivity (J. G. Gehricke & A. J. Fridlund, 2002; G. E. Schwartz, P. L. Fair, P. Salt, M. R. Mandel, & G. L. Klerman, 1976a, 1976b). Do these findings generalize to individuals oriented to other cultures (e.g., East Asian cultures)? The authors compared the emotional reactions (i.e., reports of emotional experience, facial behavior, and physiological reactivity) of depressed and nondepressed EAs and Asian Americans of East Asian descent (AAs) to sad and amusing films. Their results were consistent with previous findings: Depressed EAs showed a pattern of diminished reactivity to the sad film (less crying, less intense reports of sadness) compared with nondepressed participants. In contrast, depressed AAs showed a pattern of heightened emotional reactivity (greater crying) compared with nondepressed participants. Across cultural groups, depressed and nondepressed participants did not differ in their reports of amusement or facial behavior during the amusing film. Physiological reactivity to the film clips did not differ between depressed and control participants for either cultural group. Thus, although depression may influence particular aspects of emotional reactivity across cultures (e.g., crying), the specific direction of this influence may depend on prevailing cultural norms regarding emotional expression.

Cultural adaptation of evidence-based practice utilizing an iterative stakeholder process and theoretical framework: problem solving therapy for Chinese older adults.

Main objectives were to familiarize the reader with a theoretical framework for modifying evidence‐based interventions for cultural groups, and to provide an example of one method, Formative Method for Adapting Psychotherapies (FMAP), in the adaptation of an evidence‐based intervention for a cultural group notorious for refusing mental health treatment.

A tool for the culturally competent assessment of suicide: The Cultural Assessment of Risk for Suicide (CARS) Measure.

Despite important differences in suicide presentation and risk among ethnic and sexual minority groups, cultural variations have typically been left out of systematic risk assessment paradigms. A new self-report instrument for the culturally competent assessment of suicide, the Cultural Assessment of Risk for Suicide (CARS) measure, was administered to a diverse sample of 950 adults from the general population. Exploratory factor analysis yielded a 39-item, 8-factor structure subsumed under and consistent with the Cultural Theory and Model of Suicide (Chu, Goldblum, Floyd, & Bongar, 2010), which characterizes the vast majority of cultural variation in suicide risk among ethnic and sexual minority groups. Psychometric properties showed that the CARS total and subscale scores demonstrated good internal consistency, convergent validity with scores on other suicide-related measures (the Suicide Ideation Scale, the Beck Depression Inventory suicide item, and the Beck Hopelessness Scale), and an ability to discriminate between participants with versus without history of suicide attempts. Regression analyses indicated that the CARS measure can be used with a general population, providing information predictive of suicidal behavior beyond that of minority status alone. Minorities, however, reported experiencing the CARS cultural risk factors to a greater extent than nonminorities, though effect sizes were small. Overall, results show that the CARS items are reliable, and the instrument identifies cultural suicide risk factors not previously attended to in suicide assessment. The CARS is the first to operationalize a systematic model that accounts for cultural competency across multiple cultural identities in suicide risk assessment efforts.

Recruitment of African Americans and Asian Americans With Late-Life Depression and Mild Cognitive Impairment

OBJECTIVE The purpose of this study was to compare the relative effectiveness of several different strategies for recruiting elderly Asians, African Americans, and whites to participate in mental health research. PARTICIPANTS A total of 35 African American, 24 Asian American, and 215 white participants were phone screened for potential enrollment into a University of California, San Francisco, Department of Psychiatry treatment outcome study for older adults (aged 60 years and older) with major depression and mild cognitive impairment. DESIGN The methods by which participants were recruited were recorded, coded into composite categories, and statistically analyzed to determine whether certain recruitment strategies were disproportionately effective for recruiting participants from the three racial groups. RESULTS Fishers exact test analyses revealed that Asians and African Americans were significantly less likely than whites to be recruited through mental health-based methods, and African Americans were significantly more likely than whites and Asians to be recruited through referrals rather than solicitations. Logistic regression, which controlled for potential confounds, largely supported these findings. CONCLUSIONS Findings suggest that the recruitment of elderly African or Asian Americans into mental health treatment outcome research can be facilitated by a flexible consumer-oriented strategy that integrates multiple recruitment methods. Establishing study credibility through nonmental health media and professional referral sources may be especially effective in engaging the participation of elderly Asian Americans; and cultivating ongoing relationships with key gatekeepers, who can observe benefits to the community, may be particularly effective in recruiting elderly African Americans.

Advancement in the maturing science of cultural adaptations of evidence-based interventions.

Objective: Concerns about the maturing science of cultural adaptation of evidence-based interventions (EBIs) have encompassed deficient standardization of theoretical frameworks and inefficiencies adapting multiple EBIs for multiple ethnic groups. Others argue that original EBIs applied with fidelity address universal processes applicable across ethnicity without adaptation. Study goals were to (1) establish a unifying data-driven framework for culturally adapting mental health EBIs for ethnic minorities, and (2) provide information for the fidelity debate by examining the extent to which fidelity to core EBI components is achieved in the cultural adaptation process. Method: A systematic review of primary research was conducted utilizing an inductive approach via thematic synthesis to code 20 years of cultural EBI adaptation studies for mental health problems in ethnic minorities. Studies were coded for adapted EBI components and extent of EBI modification. Results: Results yielded the Cultural Treatment Adaptation Framework (CTAF), an overarching data-driven framework providing common concepts and language for adapted treatment components that unifies cultural adaption science. Findings also demonstrated patterns of adapted components. All adapted EBIs (100%) yielded changes in peripheral (engagement and treatment delivery) components. In contrast, only 11.11% of culturally adapted EBIs yielded core therapeutic component modifications. Instead, 60.0% required core additions that address sociocultural, cultural skill, and psychoeducation needs. Conclusion: Fidelity to core components is largely preserved in cultural adaptation, but core component addendums, delivery, and contextualization are substantially changed. The CTAF and its patterns represent a key step in advancement of a maturing cultural adaptation science.

Cultural versus classic risk and protective factors for suicide

ABSTRACT The current study examined the predictive value of cultural versus classic risk and protective factors for suicide in a community sample of 322 ethnic, sexual, and gender minority adults. Cultural factors played a significant and substantial role in predicting suicide attempts (explained 8% of variance in attempts and correctly classified 8.5% of attempters) over and above the classic factors of hopelessness, depression, and reason for living (which explained 17% of variance in attempts and correctly classified 14.1% of attempters). Findings suggest that cultural factors are important to include in standard suicide practice.

Innovations in the practice of culturally competent suicide risk management.

Although guidelines for culturally competent suicide risk management are sparse, recent advances in theory and assessment provide direction for culturally competent practice. The Cultural Theory and Model of Suicide (Chu, Goldblum, Floyd, & Bongar, 2010) was one of the first comprehensive efforts to provide a framework that guides an understanding of how culture influences suicide risk across multiple cultural identities. The Cultural Assessment of Risk for Suicide (CARS), a 39-item self-report measure assessing culturally specific suicide risk factors, was developed based on the Cultural Theory and Model of Suicide. These theoretical and measurement works, although foundational in their importance for synthesizing a broad literature, have not been tested and translated into applied clinical practice. The current case study is a translational effort that applies these approaches to culturally competent suicide practice with “Zoe,” an Asian American veteran trans woman in her early thirties with moderate-high suicide risk. Application of the Cultural Theory and Model of Suicide and the CARS illuminated cultural risk factors that were not considered in Zoe’s original safety plan (e.g., family conflict, minority stress; hidden suicidal ideation and behaviors; and cultural expressions of suicidal distress as anger, fatigue, and shame). These results yielded differences in Zoe’s risk management plan and created a culturally informed approach that corresponded with a concomitant decrease in suicidal symptoms. This study demonstrated that the CARS may detect alternative cultural expressions of suicidal distress and behaviors and yield important implications for suicide risk assessment and management planning for culturally diverse clients.

An Empirical Model and Ethnic Differences in Cultural Meanings Via Motives for Suicide

OBJECTIVE The importance of cultural meanings via motives for suicide - what is considered acceptable to motivate suicide - has been advocated as a key step in understanding and preventing development of suicidal behaviors. There have been limited systematic empirical attempts to establish different cultural motives ascribed to suicide across ethnic groups. METHOD We used a mixed methods approach and grounded theory methodology to guide the analysis of qualitative data querying for meanings via motives for suicide among 232 Caucasians, Asian Americans, and Latino/a Americans with a history of suicide attempts, ideation, intent, or plan. We used subsequent logistic regression analyses to examine ethnic differences in suicide motive themes. RESULTS This inductive approach of generating theory from data yielded an empirical model of 6 cultural meanings via motives for suicide themes: intrapersonal perceptions, intrapersonal emotions, intrapersonal behavior, interpersonal, mental health/medical, and external environment. Logistic regressions showed ethnic differences in intrapersonal perceptions (low endorsement by Latino/a Americans) and external environment (high endorsement by Latino/a Americans) categories. CONCLUSION Results advance suicide research and practice by establishing 6 empirically based cultural motives for suicide themes that may represent a key intermediary step in the pathway toward suicidal behaviors. Clinicians can use these suicide meanings via motives to guide their assessment and determination of suicide risk. Emphasis on environmental stressors rather than negative perceptions like hopelessness should be considered with Latino/a clients.

A Shortened Screener Version of the Cultural Assessment of Risk for Suicide

The current study aimed to establish a shortened version of the Cultural Assessment of Risk for Suicide (CARS) measure that can be more widely utilized under time constraints in clinical and applied settings. Based on a sample of 485 adults, confirmatory factor analysis, bivariate correlations, and Receiver-Operating Characteristic analyses were employed to determine the most psychometrically valid shortened version. The 14-item, 8-factor CARS screener (CARS-S) evidenced high reliability, high correlation with the original full version of the CARS questionnaire, and high convergent validity with measures of other suicide-related constructs of depression, hopelessness, suicidal ideation, and lifetime suicide attempts. The suggested clinical cut-off is 38.5. The shortened CARS-S offers a time-efficient assessment of cultural suicide risk factors.