I once knew a girl in college named Shirley. Though we weren’t that close, I chatted with her each time I saw her in the hallway or on campus. One afternoon, I was sitting at my desk in my dorm room when I heard the news. Shirley was found dead after falling from her dorm room window. She had committed suicide. Several other suicides had taken place on campus, and it was perhaps an eerie coincidence that a few of the victims were also Asian American women. I began to wonder, was it all just a coincidence? Or was something larger at play? If so, what made Asian American women more susceptible to suicide than the general population? Or was it that they were less inclined to seek treatment for depression?

I wondered.

Depression is defined as a mood disorder that causes one to feel sad or hopeless for a long period of time. It is more than the normal temporary feelings of sadness and hopelessness that accompany difficult life events. Symptoms can include depressed mood, problems concentrating, lack of interest in activities, significant weight loss or gain, or thoughts of death or suicide. By the year 2020, depression will be the second largest disease in the world. At present it ranks third in mortality and lost workdays.

So how are Asian American women affected? In 2001 the Center for Disease Control and Prevention reported that Asian American women ages 15 to 24 have the highest rate of suicide across all racial groups in that age group. Asian American women over the age of 65 have the highest suicide rate among all women. And among all ethnic populations, Asian Americans utilize mental health services the least.

There seem to be two explanations for the phenomenon. First, the conflict between Asian culture and American culture can be a source of anxiety for the Asian American woman. Second, certain aspects of Asian culture discourage seeking treatment.

Cultural Barriers

Asian Americans face stressors specific to their ethnicity. One’s immigration status can be a source of stress. Moving to a new country and adapting to a new culture, lifestyle, and language are enormous adjustments. Eighty-nine percent of the Asian American women who have committed suicide have been immigrants. And suicide rates are higher for foreign-born Asian Americans than for American-born Asian Americans.

Asians may also face discrimination and stereotypes. In addition to “traditional” outright racism, there is the stereotype of Asians being the “model minority,” that is, the stereotype that all Asians are smart, hard-working, and successful. Those who feel they “should be smart” yet fall short of the stereotype may feel isolated and inferior.

Additionally, Asian Americans may grapple with their ethnic identity. They may embrace certain Asian values that conflict with American culture and even their own personal aspirations. There are familial expectations and standards of success. Immigrant parents move to America and toil so that their children can succeed. Any deviation from one’s parents’ dreams would be a betrayal. In a study conducted by the National Asian Women’s Health Organization (NAWHO), some Asian American women felt they were unable to pursue academics or activities of interest to them and were instead pressured to pursue more “secure” careers, such as medicine. The women thus felt they were not in control over their life.

There are gender-specific cultural expectations. A woman has a very particular role in the family. There is the pressure to marry and have children, yet at the same time, balance the family with a successful career. Asian American women in domestic violence situations face an even heavier burden. NAWHO reports that “intimate partner violence is believed to be the single most important precipitant for female suicide attempts in the country.”

NAWHO further observed that the lower one’s self-esteem, self-confidence, and sense of control over one’s life, the more at risk the woman was for depression.

Treatment Barriers

Asian American women also face barriers to treatment. Cultural customs and stereotypes can limit access to proper healthcare. Without treatment or counseling, the depressed Asian American suffers even more in silence.

A significant number of Asian Americans are immigrants or refugees. This population may be particularly susceptible to advanced depression because of economic circumstances and language barriers. Being unable to afford or communicate with healthcare providers prevents this population from accessing healthcare.

The model minority stereotype can again play a role. NAWHO notes how some providers perceive Asians to be well-adjusted. These providers mistakenly believe that there is less of a need among Asian Americans. This false thinking limits education, prevention, and treatment efforts for this community.

In 2003 Bryan S. K. Kim from the University of California, Santa Barbara and Michael M. Omizo from the University of Hawaii at Manoa conducted a study on Asian American college students who ranged from first generation to sixth generation Asian Americans.¹ The study revealed that Asian Americans who adhered to traditional Asian cultural values the most were less inclined to seek treatment or counseling.

Certain Asian values emphasize internalizing problems, restraining strong emotions, and conforming to social norms. “Deviating from the norms by admitting psychological problems can be easily perceived as a violation of Asian cultural values, resulting in shame to the family,” say Kim and Omizo. Problems must therefore be kept secret and private. The social stigma associated with mental illness deters treatment-seeking even more.

Another valued trait is self-sufficiency. People should resolve problems on their own rather than seeking outside help.

Deborah S. Lee, director of Asian American Mental Health Services in New York City, notes that certain Asian cultures interpret symptoms of mental illness as spiritual signs. For example, her Chinese clients have interpreted mental illness as punishment for wrongdoing carried out by their family or ancestors. Consequently, they feel ashamed to seek treatment.

Healthcare facilities should therefore be culturally competent and sensitive to different ethnicities. Dr. Stanley Sue, director of the National Research Center on Asian American Mental Health in Davis, California, advocates training mental health workers on aspects of Asian culture, using Asian consultants in mainstream facilities, and targeting Asians through community education.

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There certainly are barriers other than those mentioned that contribute to depression among Asian American women. However it is important to note how culture intersects with depression and lack of treatment. With education and cultural sensitivity, healthcare facilities will hopefully better serve the Asian American community. And perhaps in the end, we can save just one more woman from the deafening silence of depression.

Where to go for help

NAWHO is launching TAKE A CHANCE. TAKE CHARGE, a public awareness campaign for Asian American women and mental health. The campaign's brochure recognizes depression as a problem and suggests where Asian American women can go for help. To hear more about the campaign or to order materials, contact Jennifer Stoll-Hadayia at 415-989-9747 or visit the Web site at http://www.nawho.org.

Pick Your Path to Health is a national public health education campaign sponsored by the Office on Women's Health within the U.S. Department of Health and Human Services. For more information about the campaign, please call 1-800-994-WOMAN or 1-888-220-5446 (TDD), or visit the National Women's Health Information Center at http://www.womenshealth.gov/

¹ Bryan S. K. Kim, Michael M. Omizo, Asian Cultural Values, Attitudes Toward Seeking Professional Psychological Help, and Willingness To See a Counselor, THE COUNSELING PSYCHOLOGIST, Vol. 31 No. 3, May 2003, 343-361.

Kristine Chung is Korean American. She studied Psychology at Barnard in New York City and enjoys writing about Asian American issues in her spare time.