Cultural Factors Influencing Help-Seeking of Asian American Communities

Abstract

Mental Health Stigma (MHS) strongly affects help-seeking for mental health conditions. Previous research has found that people were willing to pay 40% less to treat a mental versus a physical illness despite perceived equal burden of these conditions. Furthermore, cultural context between generations may influence perceptions of mental health. Parents are more likely to accept conventional value systems derived from established family rules and cultural norms, whereas offspring are more prone to embrace emergent values and norms through peer socialization, or personal reasoning about their individuation and autonomy. This may cause MHS to manifest differently among different cultural generations, especially within Asian American communities, in part due to the cultural values of moderation and control at play. This may contribute to the lack of understanding Asian parents have towards mental health, creating a reluctance to seek help. Previous findings found that Asian Americans with a need for mental health treatment accessed care at a lower rate than their White peers. Therefore, it’s extremely important to disentangle the contributing factors towards low help-seeking rates within Asian American communities for equal quality of care across groups. As there is currently a dearth of research on this topic, this paper aims to fill in this gap by synthesizing the different causes that can contribute towards low help-seeking within Asian American communities in order to influence future research and treatment methods.

Introduction

Across cultures, the mental health crisis is on the rise and represents a significant global health crisis. From 2009 to 2019, the number of high school students with regular feelings of sadness or hopelessness increased by 40%; those who seriously considered a suicide attempt increased by 36%; and the number developing an actual suicide plan increased by 44%¹. Between 2011 and 2015, youth psychiatric visits to emergency departments for depression, anxiety, and behavioral needs increased by 28%². The COVID-19 pandemic added additional stressors to youth, causing 75.6% of youth to report that the pandemic had a negative impact on their mental health³. These increased levels of mental health conditions have in part been due to the prevalence of mental health stigma within communities. Mental Health Stigma (MHS) is a form of stigma aimed at individuals having a mental illness, and is perpetuated and reinforced by prejudicial attitudes and/or a multitude of discriminatory acts in all life domains⁴. Stigma is defined as stereotypes or negative views attributed to a person or groups of people when their characteristics or behaviors are viewed as different from or inferior to societal norms⁵. Bathje and Pryor found that having greater sympathy (a measured subscale of MHS) for someone getting help for depression was associated with more positive attitudes toward help-seeking⁶.

While the mental health crisis appears to be globally influential, we might expect to find differential effects across cultural groups. One cultural group of interest in the literature is Asian Americans. Asian Americans are defined as Americans of East or Southeast Asian descent, including but not limited to the countries of China, Japan, Mongolia, North Korea, South Korea, India, Indonesia, Vietnam, Thailand, Cambodia, Singapore and Malaysia. In particular, Chinese American culture often tends to be associated with increased levels of stigma: Chinese groups have consistently endorsed more severe negative stereotypes and social restriction towards people with mental illness⁷. This is because traditional Asian culture suggests that mental health problems exist because one cannot control oneself, and therefore having a mental health condition is considered shameful, reducing help-seeking and increasing stigma among Asian Americans, especially youth⁸. Such intensified stigma results in damaging internalization of stereotypes, concealment of illness, and other harmful psychological outcomes⁹. This is why studies have found that stigma towards mental illnesses like depression is more severe in Chinese Americans than Caucasian Americans¹⁰. This stigma may be a primary reason why Asian American youths are less likely to seek professional help for mental health problems than any other racial group⁸.

In addition to increased levels of stigma within Asian American communities, Asian American youth may also be vulnerable to an increased level of mental illness. The reason for this may lie in the intergenerational conflict created by differing rates of acculturation. Acculturation is a broad term that refers to an individual’s level of psychological, behavioral, and social adaptation in response to sustained intercultural contact, such as during immigration¹¹. Previous research has introduced the concept of acculturation dissonance—a mismatch in the cultural values, attitudes, and beliefs between children and parents due to differing rates of integration with the mainstream culture^12,13,14.This dissonance can be disturbing and lead to greater parent–adolescent conflict over core cultural beliefs for Asian American immigrant families compared to US-born Asian families.^15,13,14,16. This difference is particularly pronounced for Chinese American families, because of the great difference in cultures that Chinese American youth experience. Chinese American families, and possibly other Asian American families, navigate two contrasting cultural systems: traditional Chinese culture emphasizes a collectivistic, family over self orientation, with closed communication patterns and rigid, hierarchical relationships that expect obedience from children, while mainstream US culture emphasizes an individualistic orientation, with an emphasis on personal autonomy^14,16,17. After immigration to the US, Asian parents are more likely to support conventional value systems derived from established family rules and Asian cultural norms, whereas offspring are more prone to embrace emergent values and norms of US culture through peer socialization, or personal reasoning about their individuation and autonomy^18,19,20. As the values prioritized by Asian parents become significantly different than the values Asian American youth adopt from their peers, this may increase cultural clash, which may be a factor in why Asian Americans reported higher levels of acculturation-based conflict compared with Latinx & European Americans²¹. These acculturative conflicts between Asian American parents and adolescents, concerning conventional Asian values such as showing respect to elders, sacrificing personal interests for family interests, and wishing for more physical/verbal affection from parents have been linked to negative outcomes such as greater depressive symptoms, psychological distress, and poorer academic performance^14,17,21,22.

Given the problem of increased MHS and mental health conditions within Asian American communities, the proposed study is designed to answer the following research question: How does cultural contrast between first-generation Asian Americans and their parents, especially regarding mental health, contribute to their children’s mental wellbeing? Regarding this question, this paper has three aims. First, this paper will review literature on MHS and acculturative conflicts within Asian American communities to understand the impact they would have on help-seeking behaviors. Second, this paper will examine the existing literature for both MHS and acculturative conflicts to hypothesize the nature of the relationship between MHS, acculturative conflict, and psychological outcomes. Finally, this review will discuss implications for future research on MHS, acculturative conflict, and treatment seeking within Asian American communities.

Methods

The goal of this research is to synthesize existing literature on two separate topics: Mental Health Stigma and Intergenerational Cultural Conflict/acculturative conflict. To address the research question, this paper will use a literature review approach. To this end, practical steps will include an extensive literature review using Google Scholar, informed first by a provisional literature search and then updated iteratively with more literature reading. Official searches will be conducted for research using keywords generated by the research team, related to themes such as norms, values, mental health, stigmas, and acculturative conflict and including keywords such as US, Asian American adolescent, perceived, and help-seeking.

Next, the formal literature search will be conducted on a peer-reviewed research database. Google Scholar poses some significant advantages as a database for this kind of literature review. For example, in the context of the open science movement, Google Scholar is a clear leader in that it democratizes access to peer-reviewed research, aligning with contemporary values in the field to make science accessible and inclusive. Google Scholar is therefore a strong and ethical alternative to other databases that exist behind a certain paywall. As such, we have selected Google Scholar as the primary research database for this study.

Finally, the research team will use an organizational system like a spreadsheet to keep track of literature reviewed. This organizational system will be color-coded based on major themes (e.g. MHS) to help organize findings. The resulting manuscript will align with proper APA formatting and citations, and  include a discussion of  limitations and future directions. Finally, as this paper will reflect the findings of a literature review, and not a systematic review, PRISMA is not formally applied. However, processes and findings will be represented using an adapted PRISMA flowchart (see Figure 1).

Results

This literature review revealed findings that fit into three broad categories: mental health stigma, intergenerational culture clash, and the effects on help-seeking. The process for obtaining these categories started with general research in MHS. Through this process, I found that multiple Asian cultural groups, but especially Chinese Americans, viewed MHS through different lenses. Digging deeper into this reading, the concept of intergenerational culture clash (ICC) emerged as a specific explanation for increased tensions toward mental health. Finally, the emergence of this concept directed the focus of further research to regard the question of its impacts on mental health itself, namely help-seeking.

The first category of findings is mental health stigma. Research has documented the increased stigmatization of mental health conditions compared to physical health issues. Smith et al found that people were willing to pay 40% less for a mental versus a physical illness despite perceived equal burden of these conditions²³. Previous research proposes the possibility of correlation between mental health stigma and individuals valuing treatment more for physical conditions instead of psychological ones⁴. Previous research also supports the idea that MHS develops from a universally-held motivation to avoid danger, either manifesting from a physical (tangible) or symbolic threat²⁴. However, MHS has also been shown to manifest in distinct ways within Chinese American families, often at increased levels compared to European American families²⁴. This may be explained in part by enduring Confucian traditions within Chinese culture, which emphasize self-cultivation via moderate behavior²⁵. Currently, common mental illness stereotypes across cultures may cast people as dangerous and unpredictable, which challenges cultural norms of restrained and moderate behavior. This increased threat may lead to increased fear and stigma towards mental health²⁶. In addition, given the stereotype that mental illness is due to a person’s lack of self-restraint, the presence of mental illness indicates that a failure has occurred by the family and society responsible for providing guidance and well-being, and thereby threatens Chinese social order²⁵. This may be because of the influence of Confucianism’s values within Chinese society. According to this philosophy, each member of society is obligated to follow clear moral demands to achieve personal and social harmony. The perceived unpredictability of the mentally ill causes people who experience mental health conditions to be viewed with extreme disfavor and social sanction, because they serve as a threat to the Confucian principles governing social order and harmony²⁷. Widespread beliefs about psychiatric/mental illnesses in Chinese societies ascribe a moral “defect” to the mentally ill, which may cause shame²⁸. This sense of shame may lead to negative effects for the person experiencing the mental illness on a societal scale. Within Chinese culture, in order to become a ‘full adult’ member of Chinese society, an individual has the obligation to produce offspring and to cultivate the lineage’s reputation²⁹. Current research finds that mental health conditions and the stigma that comes with it may influence marriage rates. When comparing Chinese-Americans with European-Americans, Chinese-Americans were more likely to endorse that people with mental illness should not get married or have children, and that they are less willing to date, marry, or have a baby with the sibling of a person with mental illness²⁴. In addition, Chinese groups have consistently endorsed more severe negative stereotypes and social restriction towards people with mental illness²⁶. Taken as a whole, these findings may indicate higher levels of stigma within Chinese communities, in part due to factors including but not limited to enduring cultural values surrounding Confucianism and moderate behavior.And, importantly, these cultural values are not specific to China nor are they nationally bound. For example Korean, Japanese, and Vietnamese culture have all been influenced by Confucianism as well, opening the possibility that these findings may apply to other Asian American cultures as well³⁰.

The second category is intergenerational cultural clash, which is often connected with the rate of acculturation. This subject involves the relationship between two different generations of immigrants. As described in the introduction, acculturation is a broad term that refers to the process of psychological, behavioral, and social adaptation in response to sustained intercultural contact, such as during immigration³¹. These differential strategies to adjust to the U.S. mainstream thus may create acculturation mismatch (AM) within immigrant families, which in turn generates greater frequency and intensity of intergenerational discord¹². In this review, parents are defined as immigrant parents from China/other Asian countries to America with children, and offspring are defined as their first generation American children. Offspring may be more likely to interact with the mainstream culture through schooling, peers, and media than their parents. Parents (Asian immigrants) are more likely to accept conventional value systems derived from established family rules and cultural norms, whereas offspring (Asian American children) are more prone to embrace emergent values and norms through peer socialization, or personal reasoning about their individuation and autonomy^18,19,20. Throughout the literature, conventional values described included showing respect to elders, sacrificing personal interests for family interests, and a lack of physical/verbal affection from parents¹⁴. This separation-individuation process in which offspring form clearer boundaries from their parents, identify the self as an autonomous figure, and become increasingly independent in their own decision-making and self-regulation, is the most salient and potential cause of mainstream intergenerational conflict during adolescence³². One example of this conflict comes from differences in academic values. Qualitative analyses found that among academically high achieving adolescents (defined by high school grade point average), immigrant Chinese parents with psychologically distressed offspring tended to rigidly apply parenting behaviors that reflect traditional Asian values of high parental authority and hierarchy, emphasize solely on academic achievement, and use non-open communication, which resulted in poor parent-offspring cohesion and high levels of intergenerational conflict³². This conflict may also lead to downstream risks for mental health for both offspring and parents. ICC has been shown to decrease parent–offspring cohesion, increase psychological distress for both offspring and parents, and yield deleterious mental health and educational outcomes¹². Juang et al also find that higher acculturation-based conflict was associated with higher depressive symptoms and lower self-esteem¹⁷.

The final category of findings is the individual effects of MHS and differences in acculturation rates on help-seeking. Previous research has found that negative attitudes toward mental illness, such as mental health stigma, were associated with unmet mental illness needs, decreased medication compliance and overall treatment adherence³³. In addition, further research finds that for individuals with severe mental illness, stigma led to poorer treatment adherence³⁴. MHS stems from a lack of knowledge about mental illnesses and the help needed for those suffering from them. Self-directed, peer, and societal stigma are significant hindrances to help-seeking in youth struggling with mental illness³⁵. In Asian American communities, this stigma tends to manifest from cultural values, because it is oftentimes taboo to openly discuss mental health in many Asian cultures, so people tend to hide, neglect, or deny symptoms rather than seek help⁸. In fact, Asian American participants in several different focus groups perceived that being “1.5 or 2nd generation immigrants” was a strong contributor to stress in their lives (In this focus group, 2nd generation immigrants are defined as people who were born in the U.S., and 1.5 generation are defined as immigrants who came to the US before age 16)⁸. Relatedly, Asian Americans with a need for mental health treatment accessed care at a lower rate than their white peers³⁶. The increased stigma towards mental health that is built into Asian culture also influences Asian Americans’ preference for the type of care they seek; in a study of Chinese immigrants, informal help from relatives or friends was most often preferred, followed by help from other informal sources and, finally, help from medical and mental health practitioners³⁷. In another study with a sample of Korean immigrants and nonimmigrants, 52% preferred to go to family and friends for help with mental health problems, 40% preferred religious consultation, and only 9% preferred a mental health professional³⁸. In addition to this, Asian culture also has a higher attunement to somatic (physical) symptoms of mental health conditions. Low-acculturated Asian Americans who seek mental health treatment may be more likely to receive psychotropic medication than psychotherapy because stigma around mental illness may decrease when mental health issues are presented as physical (somatic) symptoms and because medication is standard treatment for physical symptoms³⁹. In addition, because issues with physical health are generally less stigmatized in Asian cultures, this is a possible explanation for why Asian Americans report somatic symptoms more than psychological symptoms and may prefer medication⁴⁰. Previous researchers note that this somatization may be more prevalent among Asians because open displays of emotional distress are discouraged, possibly because of differences in value orientation and strong stigma associated with mental illness⁴¹. Displays of psychological symptoms of depression may be perceived as characteristic of personal or emotional weakness. As a result, Asians may deny, suppress, or repress the experience and expression of emotions. This is not to say that Asians and Asian Americans do not experience psychologically related depressive emotions per se. Instead, there may be cultural differences in selective attention (e.g., amount of focus on the mind vs. body), ordering of such foci (e.g., focusing on somatic symptoms first because this is more culturally acceptable and less stigmatized than acknowledging cognitive and emotional symptoms), and/or willingness to express distress based on what’s culturally appropriate or accepted (e.g., greater stigma associated with mental illness and/or differences in divulging problems to people outside of the family)⁴¹. See Supplementary Table 1 for a more detailed summary of the key findings identified.

Discussion

This literature review revealed evidence that mental health stigma may be more extreme in Chinese-American and other Asian American communities. The majority of literature found in this review focused on an Asian-American sample broadly, or a Chinese-American sample specifically, therefore my insights are based on these samples. There are several possible explanations for this, based on my reading of the literature. First, cultural values and beliefs within these groups, such as Confucianism, which is wide-reaching and has international cultural influence, emphasize moderate and controlled behavior, along with self-restraint. However, because the nature of mental health, especially in a stereotypical context, is seen as unstable, it clashes with these held cultural values. As a result, people with mental health conditions are more often seen as defective and shameful. This perception has a larger ripple effect particularly into the rest of Chinese society, as traditional Chinese culture emphasizes a collectivistic, family-over-self orientation. Given the often shared social belief system – Understandably, then, mental health is an especially threatening condition in the Asian American cultural context, as opposed to in other groups, as it especially threatens social cohesion and family life.

Furthermore, evidence suggests that the rate of acculturation differs from person to person, across generations. Evidence also suggests that younger generations are more likely to adapt to the new culture first. The impacts of discrepant acculturation rates within families include tension and conflict surrounding cultural differences, such as in terms of respecting elders and prioritizing family over personal interests. However, the rate of acculturation is especially difficult to study in a teenage-parent sample, because it is difficult to differentiate between typical teenage conflicts and broader culture-related conflicts. However, research shows that for immigrant families, conflicts over everyday issues can exacerbate conflicts over broader issues of acculturation, such as stigma against sexuality. Findings suggest that this increased conflict can lead to more mental illness through a couple of pathways. First, differing rates of acculturation lead to conflict, and conflict can both perpetuate and exacerbate mental illness. For example, higher acculturation-based conflict was associated with higher depressive symptoms and lower self-esteem. Second, tense living environments can come from conflict, which increases the stress that adolescents may feel and can exacerbate the development of mental health conditions. Finally, the tense living environments created can decrease access to social support at home, as adolescents may not feel comfortable reaching out to parents for help. These decreased levels of help-seeking may also exacerbate mental illnesses.

Finally, in Asian American samples throughout this research, we see differing symptomatology, which can impair access to appropriate mental-health services. The main difference is that Asian Americans tend to only somatize their symptoms, without acknowledging the psychological side of their condition. This can lead to longer latency between symptom onset and appropriate care, as physicians do not have lots of expertise dealing with mental illnesses. In addition, this can become incredibly invalidating for the patient, as physicians may continue to tell them they are physically perfectly healthy. This constant denial of symptoms that Asian American patients feel by an authority figure like a physician can weaken their mental health even further.

Finally, findings supported that within Asian American communities, specifically Chinese American communities, there is more stigma towards mental health. This often results in lower levels of help-seeking. However, these cultural factors are not well explored or widely used in treatment right now, which is why the somatization of symptoms is not better understood by the medical community. Therefore, Asian Americans are an underserved group.

Limitations and Future Directions

 However, this study was subject to some limitations. The review itself was limited in scope, so it is probable that important literature was missed. In addition, the research identified often was not recent, maybe indicating an overall dearth of research. The research identified often also lacked diversity, with many papers focusing on a broad, often undefined classification of Asian Americans or Chinese Americans in specific, and not on other nationalities within the Asian American scope. This may limit the generalization of this paper’s conclusions to all Asian American populations. Finally, as I was the only researcher on this project, this paper is also subject to some personal biases as I am an Asian American.

This paper focused on adolescent children of first-generation Asian immigrants, therefore future research should consider the first generation perspective. Additionally, this paper also focused on help-seeking by the individual, but did not explore help-seeking as a community factor, which is especially salient in a culture prioritizing social cohesion. Future research should also explore this condition.

Conclusion

This research has important implications for improved, efficient, and culturally informed treatment. I recommend more research on somatization of symptoms regarding mental health to improve diagnostics for Asian Americans. For example, future research could focus on how certain mental health conditions, like depression, manifest with somatic symptoms such as headaches or pain elsewhere in the body. More research into these specific culturally-sensitive symptoms would help clinicians and other mental health workers transition into higher-quality interventions. Currently, most interventions are based on white male subjects, causing important cultural factors to be systematically ignored and possibly creating false diagnoses and frustration within these cultures. Therefore it’s important to incorporate somatic symptoms for mental health, which are prevalent in Asian American culture, to improve the quality of diagnoses for these subjects. Much future research is needed to parse cultural factors that influence help seeking and systematize them in a way that can be readily used by clinicians to deliver tailored interventions, making treatment more accessible and effective.

All in all, scientists have the responsibility to bring objective and high-quality care to everyone they serve, no matter their culture or race. My hope is that this research brings the awareness needed to do so.

Acknowledgments

I would like to thank the following individuals and groups for their support, expertise, and assistance throughout all aspects of this research, and for their continued support in my journey. Specifically, I would like to thank my research mentor Madison Schmidt, who provided support with the logistical research process, helped me develop provisional literature review tools, and provided resources to aid my research. I would also like to thank the Lumiere writing center staff, specifically my writing coach Sanvitti Sahdev, for writing assistance that included language editing, proofreading, and preparation or submission to a journal. Next, I would like to thank my program manager Anish Kumar for logistical support and coordination with everyone involved in this paper. In addition, I would like to thank my publication specialist Kiana Manian for helping me design reasonable goals for publications and narrow down my journal search. Finally, I would like to extend a thank you to the Lumiere program generally for creating the opportunity for me to explore new ideas with my research.

Supplementary Table

Citation	Sample Characteristics	Key Findings
Smith et al, 2012	710 US adults, nationally representative sample over the age of 21	Participants believed that mental illnesses were more burdensome than general medical illnesses, but were still willing to pay 40% less to avoid the mental illnesses.
Eisenberg et al, 2008	199 Parent-Child Dyads, child age at Time 1 was between 64-125 months	Children’s temper control and negative emotions, as well as personality resiliency, were associated with the quality of conflict reactions over time
Smetana et 0al, 2003	82 families of Middle-class African American adolescents and parents	African American adolescents used personal jurisdiction to justify a conflict, while parents justified conflicts with conventional or pragmatic issues
Traub et al, 1988	415 college students and 557 of their guardians	Based upon differential interaction patterns and the acceptance of divergent norms, there is a gap/dissonance between adults and children
Yang et al, 2020	108,404 White and 8,121 Asian Civilian non-institutionalized US population adults, ages 18-64	Asians were less likely than whites to have accessed mental health treatment in the past year in all analyses.
Centers for Disease Control and Prevention, 2020	5 cross-sections of Nationally Representative Sample of US Students, in grades 9-12	“More students experienced persistent feelings of sadness or hopelessness from 2009 through 2019, regardless of race/ethnicity.”
Kalb et al, 2019	Emergency Department Visits Data from the 2011–2015 National Hospital Ambulatory Medical Care Survey and U.S. Census Bureau	Largest increases in psychiatric ED visits were observed among adolescents (54%), along with a 2.5x increase in suicide-related visits
Bell et al, 2023	767 young people (ages 12-25), with and without mental health care needs	“Findings revealed high levels of clinical depression (48%), anxiety (51%), and loneliness in both groups.”
Sickel et al, 2014	Literature review.	Defines MHS as a form of social stigma aimed at individuals having a mental illness, which may activate stereotypes and lead to prejudice and discrimination.
Dudley, 2000	Literature Review.	Redefined stigma as stereotypes or negative views attributed to a person or groups of people when their characteristics or behaviors are viewed as different from or inferior to societal norms.
Bathje & Pryor, 2011	211 college students (52% female) at a large Midwestern university, with a mean age of 19.91	Public stigma awareness and endorsement of public stigma (ratings of sympathy) were found to predict self-stigma, with endorsement of public stigma (greater sympathy) directly related towards attitudes towards seeking mental health counseling.
Yang, 2007	Literature Review.	Extreme and negative stereotypes within Chinese society may be internalized by people within the community with mental health disorders (ex. schizophrenia), resulting in harmful psychological outcomes
Lee et al, 2009	17 participants (5 males, 12 female) between 18-30 years old, representing eight Asian American communities (Asian Indian, Cambodian, Chinese, Indonesian, Korean, Taiwanese, Thai, and Vietnamese)	Findings suggest that AA youths are less likely to seek professional help for their mental health problems compared to other racial and ethnic groups, and that stigma was the biggest deterrent in health seeking behavior.
Lee et al, 2005	Out-patients with schizophrenia (n=320, (217 men, 103 women) and diabetes (n=160, 78 men, 82 women), age range 17-62	“Significantly more patients with schizophrenia (>40%) than diabetes (average 15%) experienced stigma from family members, partners, friends and colleagues.”
George Hsu et al, 2008	Total sample of 100, with 50 white (62.5% male) and 50 Chinese (51.2% male)	Stigma towards depression was worse among Chinese Americans than Caucasian Americans
Berry et al, 2006	Book Chapter Review.	Defines the concept of acculturation as an individual’s level of psychological, behavioral, and social adaptation in response to sustained intercultural contact, such as during immigration.
Portes & Rumbaut, 1996	Book Chapter Review.	Introduces the concept of acculturation dissonance among immigrant families
Kwak, 2003	Literature Review.	Intergenerational differences caused conflict between adolescents and parents, with adolescents insisting upon their autonomy and parents insisting upon family cohesion and the obligations of their children.
Lee et al, 2000	153 Asian American college students (41 men, 109 women, 3 unidentified), range of 17-24. 50 Chinese, 20 Filipino, 21 Vietnamese, 13 Japanese, 9 Korean, 7 Indian, 6 Hmong/Mien, 2 Laotian, 2 Cambodian, 20 biracial, 3 unidentified.	“High-acculturated Asian American children who perceived their parents to be less acculturated reported more frequent conflict than high-acculturated children with high-acculturated parents.”
Juang et al, 2007	166 Chinese American Parent-Child Dyads	Greater discrepancies between adolescents and their parents on parental control related to greater adolescent depressive symptoms
Qin, 2006	Author picked 2 case studies from the Longitudinal Immigrant Student Adaptation Study, which had a sample of ~400 recently arrived immigrant students.	Both case studies showed greater alienation between Chinese immigrant parents and children by the end of the 5-year period. One reason was “dissonant acculturation”, with sharp differences in values of Chinese and American parenting increasing conflict
Juang et al, 2012	316 Chinese American adolescents who identified their father/mother to be of Chinese descent	“Greater levels of acculturation-based conflict were associated with higher anxiety/somatization, loneliness, depressive symptoms, and lower self esteem.”
Lee & Liu, 2001	406 college students. Age range 18-25, Chinese American (n=41), Vietnamese American (n=20), Indian American (n=23), Korean American (n=16), Filipino/a American (n=12), other Asian (n=5) and Latinx + European American (n=252)	Asian American youth consistently report higher levels of parent–adolescent conflict than Latino, European American, and African American youth
Bahrassa et al, 2011	140 self-identified Asian American participants (88 women, 52 men), ages 17-19. Ethnic groups included Hmong (n=93), Vietnamese (n=13), and Chinese (n=9)	The results indicate that higher family conflict prior to college was related to lower first-semester college GPA
Yang et al, 2007	Literature Review.	Core effects of stigma are the threatening of loss/diminution or the actual diminishing of a lived value
Fei et al, 1992	Book Chapter Review.	Talks about major cultural influences on Chinese behavior, including Confucianism and attitudes towards mental health.
Yang et al, 2013	Subsample of Chinese-Americans (n=56) and European-Americans (n=589) age ≥18	Study indicated increased levels of stigma (i.e., social restriction and intimate social distance) among Chinese groups.
Kirmayer, & Young, 1998	Selective review of an epidemiological survey and ethnographic study of help-seeking and health care, utilization of a random sample of 2246 residents	Traditional Chinese medicine didn’t believe in psychology as a realm of medicine; instead, it only focused on how mental health issues caused disharmony in relationships due to Confucian social order
Lin & Lin, 1981	Book Chapter.	Details Chinese family concern for conformity from individual members due to Confucian ethics, which is why Chinese communities think mental illness is caused by “misconduct” and is a punishment for deviation from socially prescribed behavior.
Yan 2003	Book Review.	Talks about societal expectations towards family responsibility, especially the idea of cultivating reputation within your lineage
Koepke & Denissen, 2012	Literature Review.	As childrens’ need for autonomy grows stronger, they push against parental boundaries, leading to increased intergenerational conflict
Qin, 2008	Chinese immigrant families: non-distressed adolescents (n = 20), high levels of academic achievement and high levels of psychological well-being; and distressed adolescents (n = 18), high levels of academic achievement but low levels of psychological well-being	Parents of distressed adolescents placed heavy emphasis on the traditional, hierarchical parental roleParents of non-distressed adolescents worked to adapt the broader tenets of Chinese parenting (respect, education, self-cultivation) into the new cultural context of the US
Broadbent et al, 2008	203 high users of mental health services (age = 17-65)	More negative perceptions about mental illness conditions were associated with higher ratings of unmet needs, along with poorer attitudes towards medication
Fung et al, 2007	108 mental health consumers (51 males and 57 females, age range 30-46) suffering from mental illness	Stigma played a detrimental role in undermining self-esteem, self-efficacy and psychosocial treatment compliance.
Yap et al, 2013	Computer-assisted telephone interviews with 3021 participants (age: 15-25).	“Beliefs that mental illness is a sign of personal weakness were associated with less intention to seek professional help and less endorsement of their helpfulness.”
Leung et al, 2012	Survey of 516 Chinese Americans (mean age 48.3, SD=18.1, 219 female, 293 male)	34.9% of respondents first prioritized seeking advice from friends/relatives when help-seekingOnly 4.7% would first prioritize seeking assistance from mental health professionals
Cheung et al, 2011	Survey of 205 Korean and Korean American participants (mean age 44, SD=11, 55% women, 45% male)	Only 9% of respondents would consult mental health professionals if they were suffering from mental health problems52% of respondents ranked their top preference when dealing with mental health problems as consulting friends or family.
Wu et al, 2018	345,070 self-identified non-Hispanic whites and 16,418 self-identified Asian Americans – age over 18	Non-Hispanic white patients were more likely to accept a psychotropic treatment than Asian American patients
Kalibatseva et al, 2014	Used a sample of 310 Asian Americans and 1974 European Americans who reported depressive symptoms from the Composite International Diagnostic Interview  (CIDI)	Asian Americans at risk for depression had high rates (>70%) for somatic depressive symptoms, including trouble sleeping and low energyLess acculturated Asian Americans may be more likely to manifest somatic symptoms.
Chun et al, 1996	Book Chapter.	Mentions the increased rate of somatization among Asian American cultures and offers the explanation that this may be because cultures discourage open displays of emotions and additionally have a heavy social stigma towards mental illness
Weiming, 2024	Encyclopedia Britannica article.	Confucianism applies to several other Asian American cultures besides Chinese culture, including Korean, Japanese, and Vietnamese culture.

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