The association between self-reported racial discrimination and 12-month DSM-IV mental disorders among Asian Americans nationwide
Introduction
A hallmark report by the Surgeon General of the United States lists racial discrimination as a critical risk factor for mental disorders (US Department of Health and Human Services, 2001). However, while prior studies have laid an important foundation for the Surgeon General's finding, it is difficult to know if the association between self-reported discrimination and mental disorders might be due to other factors such as a socially desirable response style and other stressors. In this study, we focus on the relationship between self-reported discrimination and mental disorders among a nationally representative sample of Asian Americans (AAs). Our major hypothesis is that reports of discrimination will be associated with mental disorders after accounting for physical health conditions, other stressors, sociodemographic characteristics, and socially desirable responses.
Discrimination can be defined as actions from individuals and institutions that negatively and systematically impact socially defined groups with less power (Jones, 2000). Asians have experienced a long history of discrimination within the US, including the exclusion of AAs from numerous rights, such as citizenship, suffrage, land ownership and due process under the law (Okihiro, 2001; Zia, 2000). Discrimination was institutionalized through Congressional actions (e.g. Chinese Exclusion Act of 1882), Presidential declarations (e.g. Executive Order 9066 interning Japanese Americans), and interpretations of the Supreme Court (e.g. United States v. Bhagat Singh Thind, ruling Asian Indians ineligible for citizenship in 1923). Many of these actions resulted from fears of a “yellow peril,” that hordes of unscrupulous and “unassimilable” persons would threaten the “American” way of life and economy (Chan, 1991).
More recent reports document that AAs experience hate crimes, racial profiling by police, and employment discrimination (Lai & Arguelles, 2003; Lien, 2002; Umemoto, 2000; US Commission on Civil Rights, 1992; Young & Takeuchi, 1998). Although explicit racial prejudice has diminished over time (Bobo, 2000), a sizeable group of Americans voice negative sentiments about AAs. In 2001, one in four Americans agreed that Chinese Americans are “taking away too many jobs from Americans” and one in five Americans endorsed that Chinese Americans “don’t care what happens to anyone but their own kind” (Committee of 100, 2001). A national audit study in 2001 found that Asian American homebuyers encountered systematic discrimination in the housing market 21.5% of the time, a level similar to that of African Americans (Turner, Ross, Bednarz, Herbig, & Lee, 2003).
Reports of experiences with discrimination have been associated with several mental health indicators, including self-rated mental health status, self-esteem, happiness, depression, and generalized anxiety disorder among Blacks, Latinos and Whites (Finch, Kolody, & Vega, 2000; Kessler, Michelson, & Williams, 1999; Caughy, O’Campo, & Muntaner, 2004; Landrine & Klonoff, 1996; Schneider, Hitlan, & Radhakrishnan, 2000). Several studies have examined the association between perceived discrimination and mental health among Asian and Pacific Islanders worldwide, including Southeast Asian refugees and Koreans in Canada (Noh, Beiser, Kaspar, Hou, & Rummens, 1999; Noh & Kaspar, 2003); Vietnamese youth in Finland (Liebkind, 1996); South Asians and Chinese in the United Kingdom (Bhui, et al., 2005; Karlsen & Nazroo, 2002); and Pacific Islanders and Southeast Asians in New Zealand (Pernice & Brook, 1996).
Studies in the US are finding similar associations. Perceived discrimination was associated with depressive symptoms (Mossakowski, 2003) and substance use (Gee, Delva, & Takeuchi, in press) among Filipino Americans in Honolulu and San Francisco. Perceived discrimination was also associated with poor mental health (Gee, 2002) and decreased use of mental health services (Spencer & Chen, 2004) among Chinese Americans in Los Angeles. Rumbaut (1994) found that discrimination was associated with depressive symptoms among Filipino, Vietnamese, Laotian and Cambodian elementary school youth in San Diego. Yoshikawa, Wilson, Chae, and Cheng (2004) reported associations between discrimination and depressive symptoms among a convenience sample of gay AAs in a northeast city. Liang, Li, and Kim (2004), however, did not find associations between discrimination and mental health symptoms among AA students at a mid-Atlantic university. These studies have all focused on mental health symptoms, but have not examined if discrimination might also be associated with mental disorders. An investigation of disorders will aid clinicians and inform the allocation of resources.
How might discrimination influence mental disorders? Discrimination may lead to affective reactions (e.g. sadness) and shape one's appraisal of their world (Harrell, 2000). Discrimination may also influence one's self-concept by hindering their ability to control their environment, reinforcing secondary social status, and impacting self-esteem (DuBois, Burk-Braxton, Swenson, Tevendale, & Hardesty, 2002). Williams and Williams-Morris (2000) suggested that discrimination may assault victims’ ego identity and contribute to the internalization of negative stereotypes. Discrimination may also threaten one's sense of control and foster hopelessness (Perlow, Danoff-Burg, Swenson, & Pulgiano, 2004). These factors in turn may lead to depression, anxiety and other mental disorders (Williams & Williams-Morris, 2000). Further, contemporary discrimination is more symbolic and covert than discrimination of the past (National Research Council, 2004). The subtle nature of current-day discrimination lends itself to ambiguity which may lead to rumination, a risk factor for depression (Harrell, 2000; Nolen-Hoeksema, Larson, & Grayson, 1999).
Discrimination may also act as a stressor (Clark, Anderson, Clark, & Williams, 1999; Harrell, 2000). Stressors are “conditions of threat, demands, or structural constraints that … question the operating integrity of the organism” (Wheaton, 1999, p. 177). Illness may result when stressors exceed one's ability to meet these demands (Lazarus & Folkman, 1984). Stressors associated with discrimination should be examined independent of other stressors (Harrell, 2000). However, it is unclear whether discrimination is an important stressor in itself or proxies for other stressors because many studies do not measure discrimination alongside with other stressors (Williams, Neighbors, & Jackson, 2003).
To address this issue, we examine three other potential stressors: acculturative stress, low family cohesion, and poverty. Acculturative stress refers to the strains of adjustment among migrants, including the burdens of learning a new culture, worries about legal status, and potential guilt for leaving behind loved ones (Berry, Kim, Minde, & Mok, 1987). Acculturative stress has been associated with depression, anxiety and other health outcomes among Korean (Noh & Kaspar, 2003) and Latino immigrants (Finch & Vega, 2003; Hovey, 2000). Family cohesion denotes the emotional bonding between family members. Individuals from low cohesion families are often at higher risk for depression, suicidal ideation, anxiety and social avoidance (Harris & Molock, 2000; Reinherz, Paradis, Giaconia, Stashwick, & Fitzmaurice, 2003). Poor family functioning was associated with depression among Chinese Americans (Crane, Ngai, Larson, & Hafen, 2005). Discrimination was associated with parent–child conflict among Asian and other immigrant families, possibly because youths’ experiences with discrimination conflicted with their parents’ expectations of a meritocritous society (Rumbaut, 1994). Racial discrimination has been associated with lower socioeconomic position, including limited educational attainment, lower probability of employment and advancement, and depressed wages (Krieger, 1999; Williams, Yu, Jackson, & Anderson, 1997). Among AAs, reports of discrimination were associated with education and economic mobility (Goto, Gee, & Takeuchi, 2002; Cabezas, Tam, Lowe, Wong, & Turner, 1989). Socioeconomic position, in turn, is associated with mental disorders (Eaton & Muntaner, 1999). For example, the National Co-Morbidity Replication Survey found a threefold greater odds of major depression for people in poverty compared to those not in poverty (Kessler et al., 2003).
We consider physical illness as another potential stressor. Illnesses bring with them numerous demands, including worries about finances and prognosis, adherence to therapy, and potential life changes (Beverridge, Berg, Wiebe, & Palmer, 2006; Patterson & Garwick, 1994). Prior studies report that discrimination is associated with a variety of physical ailments, including high blood pressure, chronic conditions and poor self-rated health (Krieger & Sidney, 1996; Williams et al., 2003). Physical health problems, in turn, may lead to mental health problems and vise versa (Creed, 1999; Roose, Glassman, & Seidman, 2001). Thus, physical health can be considered both an independent stressor as well as a potential consequence of discrimination.
An important consideration in studies of discrimination and mental disorders are potential response factors. One such factor is socially desirable reporting, the tendency for individuals to answer surveys in ways to make them “look good” and avoid looking “bad” (Paulhus, 1991). Social desirability is associated with increased responsiveness to social influence, avoidance of evaluation by others, and minimization of conflict (Kiecolt & McGrath, 1979; Paulhus, 1991). Among Asians, social desirability may be related to “saving face,” whereby individuals tend to understate problems to prevent shaming their families (Gong, Gage, & Tacata, 2003; Zane & Yeh, 2002). Social desirability has been associated with lower reporting of discrimination and may bias the association between self-reported discrimination and health (Krieger, Smith, Naishadham, Hartman, & Barbeau, 2005).
Hence, our study examines whether self-reported discrimination is associated with increased risk of mental disorders after controlling for a variety of potential stressors, socially desirable reporting, and sociodemographic characteristics.
Section snippets
Sample
The data come from the US National Latino and Asian American Study (NLAAS), a household survey conducted between 2002 and 2003. The current analyses focus on the Asian respondents. Three components comprise the sampling design: (1) core sampling of primary sampling units (metropolitan statistical areas and counties) and secondary sampling units (from continuous groupings of Census blocks) were selected using probability proportional to size, from which housing units and household members were
Results
Table 1 describes the participants’ responses. Participants reported high family cohesion (11.0 on a 3–12 scale). On average, respondents endorsed 2.3 of 10 indicators of social desirability. The prevalence of any DSM-IV disorder, any DSM-IV major depressive disorder, and DSM-IV anxiety disorder over the past 12 months was 9.19%, 4.73%, and 5.75%, respectively. Participants reported 1.3 chronic illnesses on average and a mean self-rated health of 3.5 (between good and very good). As with prior
Discussion
Our data indicate that self-reported discrimination was associated with 12-month mental disorders and co-morbidity among AAs. We challenged the association between discrimination and mental disorders with several potential confounders, including other stressors, health conditions, and social desirability. Discrimination was a robust predictor of mental disorders when these factors and other sociodemographic characteristics were controlled.
One challenge came from other stressors as measured by
Acknowledgments
The National Latino and Asian American Study is funded by the National Institute of Mental Health Grant # U01 MH62209 and U01 MH62207 with additional support from the Office of Behavioral and Social Science Research and the Substance Abuse and Mental Health Services Administration. We thank Wendy Lin and several anonymous reviewers for helpful comments on a prior draft of this paper. This article is dedicated in memorium of our dear friend, Lucy Shum, and her fight for social justice and mental
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