INTRODUCTION
Disparities in mental health among minorities have been acknowledged as one of the significant public health issues in the United States.1,2 However, within the growing awareness of mental health disparities, the unique experiences and needs of Asian Americans(AAs) have frequently been overlooked or misunderstood.3 Despite being the fastest-growing minority group in the country,4 AA remain underrepresented and understudied in mental health-related research, leading to significant gaps in our understanding of the mental health status within this diverse population. The lack of comprehensive data and research not only hinders efforts to address mental health disparities but also reinforces misconceptions and stereotypes about the mental well-being of AAs.
As the fastest-growing minority group in the U.S., AA represent a wide range of ethnicities, nationalities, languages, cultures, and identities. According to the most recent data, the Asian population in the U.S. grew 81%, from 10.5 million to 18.9 million, between the years 2000 and 2019 and is projected to reach 46 million by 2060.4 It has been estimated that around 60% of AA (71% of AA adults) were foreign-born compared to 14% of all Americans and 17% of adults in the US.4 The AA population is highly diverse as more than twenty countries from East-, and Southeast Asia, and the Indian subcontinent represent the Asian communities in the United States.4,5 As most AAs are foreign-born and are represented by culturally diverse ethnic groups, they tend to face substantial challenges in healthcare and mental health. Despite the typical stereotype representation of AA as the model minority, which typically portrays them as academically and economically successful, a significant portion of this community wrestles with mental health challenges like depression, anxiety, and stress.6
Understanding the mental health challenges in the AA community is complex and multifaceted as shaped by the diverse cultural, social, and systemic factors within the population.7 Furthermore, mental health has been stigmatized within many Asian cultures, leading to a reluctance to accept the mental health challenges, seek professional help, and a preference for informal support networks such as family and community.8 Additionally, cultural and structural barriers such as limited access to culturally competent care, inadequate health insurance coverage, and discrimination within healthcare systems further exacerbate disparities in mental health outcomes among AA.9 Many AA face challenges in accessing mental health services that are sensitive to their cultural backgrounds and linguistic needs, leading to disparities in diagnosis, treatment, and outcomes.
Given the complexities and disparities of mental health among AAs, there is a need for research that is comprehensive, culturally sensitive, and inclusive of diverse AA communities to truly understand and recognize the mental health status of AAs. To address the disparities, it is essential to first recognize the status of behavioral, demographic, chronic health, and mental health characteristics among AAs. As such, the aims of this study are: 1) to determine the mental health statuses among AA, 2) to identify factors affecting mental health, 3) to determine the prevalence of chronic health conditions among AAs, and 4) to examine the associations between mental health disorders to behavioral and chronic health conditions among AAs, with a focus on understanding the factors that impact mental health outcomes in this population using 2023 National Survey on Drug Use and Health (NSDUH).
METHODS
Study Design and Participants
NSDUH, conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA), provides nationally representative data on substance use, mental health, and treatment utilization.10 The target population of NSDUH consisted of non-institutionalized individuals in the United States aged 12 or older at the time of the survey.10 The objective of NSDUH is to assess the prevalence and associations of substance use and mental health concerns in the US.10 This study includes the US adult population who were 18 years or older at the time of the survey. Additional details on the NSDUH methodology can be found in their website.11
Measures
Outcome – Mental Health Conditions
The Kessler-6 scale (K6 scale) was used to assess Serious Psychological Distress (SPD) based on symptoms of distress – nervousness, hopelessness, restlessness, sadness, worthlessness, and everything feeling like an effort. The responses were recorded on a 5-point Likert scale (all of the time to none of the time) with “all of the time” coded as 4 and “none of the time” coded as 1. NSDUH categorized a score of 13 or above out of the possible 24 in responses to the six symptoms of distress as SPD. Past-year SPD was defined by NSDUH as respondents who reported that there was a month in the past 12 months where he/she was more depressed, anxious, or emotionally stressed during the past 30 days. Major Depressive Episode (MDE) was defined based on the DSM-5 criteria. Past year MDE was defined as present when a respondent reported they had experienced 5 or more of the 9 symptoms of Major Depressive Disorder (MDD) in the past 12 months based on the DSM-5 criteria. To assess lifetime mental health issues, participants were asked whether they ever had a problem with their own mental health with responses of “Yes” or “No”.
Risk Factors and Covariates
Respondents were determined as having chronic health conditions if they have ever been told or informed by a doctor or other medical professional that they have ever had the following health conditions – Heart Condition, Diabetes, Chronic Bronchitis (COPD), Cirrhosis, Hepatitis B or C, Kidney Disease, Asthma, Cancer and Hypertension. Additionally, past-year and past-month use of alcohol and any tobacco products were also included.
The overall health status was categorized into 5 different categories – Excellent, very good, good, fair, and poor – based on the question of “Would you say your health in general is excellent, very good, good, fair, or poor?” The effect of COVID-19 on the respondents’ mental health was also included in the study. The effects of COVID-19 on mental health were categorized as – Not at all, a little, some, quite a bit, and a lot – based on the question of “since the beginning of the COVID-19 pandemic, how much, if at all, has COVID-19 negatively affected your emotional or mental health?” Covariates such as sex, education, income level, health insurance coverage status, and county metro status were also included in the study to measure potential confounding effects.
Statistical Analysis
Secondary analyses of the 2021 NSDUH public-use data set were conducted using SAS, version 9.4.12 Weighted summary statistics were calculated to describe the frequency distribution of the outcome, risk factors, and covariates. Bivariate analyses were conducted to examine the effect of chronic health conditions, demographic factors, and other covariates. All the analyses used weighed sampling analysis techniques to account for the complex sampling survey design.13 The 2021 NUDUH data had very few missing data but the answer options such as “Refused”, “Not Ascertained”, and “Don’t Know” are categorized into missing data.
RESULTS
The study included 2,218 non-Hispanic AA adults (18+), representing approximately 16 million individuals in the US in 2023. Table 1 presents the sample characteristics of these individuals. Gender distribution was nearly even with 52.61% females and 47.39% males. The largest age group was 35-49 (32.48%), followed by 21.12% of 50-64 years old. Over half (56.58%) were college graduates, while 9.59% had less than a high school degree. More than half (58.13%) reported earnings of $75,000 or more, but 11.1% reported having annual income below $20,000. Around 50% of people reported they were employed full-time, while 6% were unemployed. The majority (58.7%) stated they were married, and 31% stated they had never married. Most participants (78%) resided in large metropolitan areas, and almost all (~93%) reported having health insurance. Regarding self-reported health status, most participants (89%) rated their health status as good to excellent, while 11% reported fair or poor health.
Table 2 presents behavioral, physical and mental health characteristics. Around 5% of the respondents reported past-year MDE, 9.3% reported having lifetime MDE, 10% past-year SPD, and 15% reported ever having mental health issues. Over half (~59%) reported that COVID-19 negatively affected their mental health. Approximately 14% of participants reported past-year use of any tobacco products or nicotine vaping, while 10.5% reported past-month use. Alcohol use was more prevalent with over half (50.9%) reporting past-year use and 34.3% past-month use. Only ~23% of respondents provided their chronic health conditions data. Among them, hypertension was the most common with 43% reported ever having high blood pressure, followed by diabetes (31%), asthma (26%), heart condition (19%), cancer (9.5%), Hepatitis B or C (9%), kidney disease (5%), COPD (4%), and cirrhosis of the liver (0.5%).
Table 3 presents the bivariate analysis of three mental health outcomes – past-year MDE, past-year SPD, and ever having mental health issue. Among demographic factors only marital status and overall health status were significantly associated (p<0.05) with past-year MDE. Income, marital status, overall health status, and age groups were significantly associated (p<0.05) with past-year SPD. Perceived mental health issues were significantly associated with educational levels, marital status, overall health status, employment status, and age groups. For behavioral factors, past-year and past-month tobacco use were significantly associated with past-year MDE, while alcohol uses were not. However, past-year and past-month tobacco use, along with past-year alcohol use were significantly associated with past-year SPD. Both past-year and past-month alcohol and tobacco use were significantly associated with perceived mental health issues. None of the chronic health conditions were significantly associated with past-year MDE. However, Hepatitis B or C was significantly associated (p=0.01) with past year SPD. Diabetes, COPD, asthma, and cancer were significantly associated with perceived mental health issue (p<0.05). Finally, negative mental health impacts from COVID-19 were significantly associated with all three mental health outcomes.
DISCUSSION
The findings of this study provide valuable insights into the mental health status and associated factors among AA adults in 2023. The prevalence of mental disorders among AA adults in 2023 highlights the significant burden of mental health issues within this population. Approximately 10% of AA adults reported experiencing SPD in the past year, while 5% reported experiencing a MDE during the same period. These findings are similar to the 12-month prevalence of any psychiatric disorders among AA reported in the National Latino and Asian American Study (NLAAS) by Takeuchi et al.,14 which was 9.46%. However, it is important to note that the NLAAS data is over 20 years old and includes a broader range of psychiatric disorders, unlike the two specific conditions—SPD and MDE—examined in our study. Despite these differences, our results suggest that the prevalence of mental disorders among AA has not decreased over the years. McGarity-Palmer et al.15 reported that 32.9% of Asian/AA adults reported having psychological distress in their study using 2021 AA and Native Hawaiian/Pacific Islander COVID-19 Needs Assessment Study. The high difference in the prevalence rate of psychological distress suggests that there may be significant variations in mental health outcomes among different subgroups within the AA population.
Additionally, our analysis identified a high prevalence of chronic health conditions among AA adults, which include hypertension, diabetes, heart conditions, and cancer. These findings are consistent with previous research highlighting the disproportionate burden of chronic health conditions among minority populations in the United States.16–18 A systematic review conducted by Islam and others found a significant burden of mental health conditions among Asian adults living with chronic health conditions.18Though, our study did not find significant associations between all chronic conditions to past-year MDE, we found that Hepatitis B or C was significantly associated to past-year SPD, and diabetes, COPD, asthma, and cancer to having perceived mental health issue. The co-occurrence of mental disorders and chronic health conditions among AA adults underscores the need for integrated approaches to healthcare that address both mental and physical health needs holistically.
Furthermore, our study found that the majority of the participants (59%) reported that COVID-19 negatively affected their mental health to some extent. The result indicates that the effect on COVID-19 on AA are still lingering as it is crucial to highlight the substantial rise in discrimination and violence directed towards AA communities during the COVID-19 pandemic.19 Previous studies have also documented significant increases in mental health conditions among AA during the pandemic,20,21 with one study reporting a sevenfold increase in the prevalence of depression and anxiety among this population.20 Similarly, in our study, respondents who reported negative impacts of COVID-19 on their mental health were significantly more likely to have experienced a past-year MDE, SPD, and perceived mental health issue. The study findings underscore the critical need to address the unique mental health challenges encountered by AA communities, especially within the context of the COVID-19 pandemic and heightened instances of discrimination and violence. Additionally, these findings highlight the interconnectedness of physical and mental health and the importance of addressing both aspects of well-being in healthcare interventions and policies as the self-reported overall health status was found to be significantly associated with each of the three mental health outcomes in which individuals who rated their overall health as fair or poor were more likely to have mental health issues compared to individuals who rated good, very good, or excellent.
Future research is needed to explore the complex relationships between mental and physical health outcomes among AA adults and identify potential underlying mechanisms. Overall, the findings from this study underscore the importance of addressing mental health disparities within the AA population and implementing targeted interventions to promote mental well-being and reduce the burden of mental disorders.
Recommendations
Given the findings in this study, which highlight the persistent mental health challenges among AA adults, it is essential to translate this evidence into actionable policies and practices. The results from this study emphasize that the results may not truly represent the needs of all AA communities as the data are aggregated and the results may obscure important differences across AA subgroups. As demonstrated in the past study by Sorkin et al., mental health needs can vary significantly by subgroups within the AA communities.23 To effectively address these disparities, we recommend continuing to promote data disaggregation in national health surveys, increasing AA representation in research, developing culturally tailored mental health programs, and integrating mental and physical health services for Asian Americans.
Limitations
This study has several limitations. First, the cross-sectional design of NSDUH limits the ability to establish causal relationships between the factors. Second, the study may be subjected to sampling bias as sample population may not accurately represent the broader AA population in terms of demographics, geographic distribution, or socioeconomic status and the data may not adequately represent the diversity within the AA subgroups. Third, as the data was collected through self-reporting methods, it may be subjected to biases. Lastly, as the study only utilized data from a single source, it may not fully capture the range of mental health experiences and health outcomes among AA adults. Despite these limitations, the study was able to utilize a large, nationally representative data to determine the mental health status among AAs and examine factors that are affecting mental health in the AA communities.
CONCLUSION
This study offers insights into the mental health status along with behavioral and physical health characteristics among AA adults, underscoring significant disparities and challenges faced within this diverse population that are often underrepresented in research. Despite the rapid growth of the AA population in the United States, there remains a critical gap in understanding and addressing their mental health needs. The findings underscore the prevalence of mental disorders and chronic health conditions within this demographic, emphasizing the interconnectedness of behavioral, physical, and mental well-being. Moreover, the impact of COVID-19 on mental health underscores the need for targeted interventions to address the unique challenges exacerbated by the pandemic, including increased discrimination and violence. By recognizing and addressing these disparities, along with the study’s limitations, we can advance efforts to understand mental health status, promote overall well-being, and lessen the prevalence of mental disorders and chronic health conditions within AA communities.
Disclosure Statement
The authors have no relevant financial disclosures or conflicts of interest.
About the Authors
RoiSan Nhpang, MPH
RoiSan Nhpang is a doctoral student in the College of Public Health at The University of North Texas Health Science Center in Fort Worth, Texas. Her research areas include Aging, Mental Health, Epidemiology, and Health Disparities. She received her MPH from UT Health Houston School of Public Health in Austin, Texas.
Shilpa Patil, MPH
Shilpa Patil is a doctoral student in the College of Public Health at The University of North Texas Health Science Center in Fort Worth, Texas. Her research areas include Immigrants Health, Women health, Health Disparities, and Aging. She received her MPH from UT Health Houston School of Public Health in Dallas, Texas.
Dr. Malinee Neelamegam, PhD, MPH, CPH
Dr. Malinee Neelamegam is an assistant professor of Population and Community Health in the College of Public Health at The University of North Texas Health Science Center in Fort Worth, Texas. Her research areas include epidemiology, Alzheimer’s Disease and Alzheimer’s Disease Related Dementias, Aging, Aging with HIV, and Implementation Science. She received her formal training from the University of South Florida.