The primary aim of the current study was to examine the influence of culturally related factors on lifetime suicidal ideation and suicide attempts in a nationally representative sample of Asian Americans. We found that 2.5% of Asian Americans reported a suicide attempt and 8.8% reported thinking about suicide in their lifetime. In contrast, the National Comorbidity Survey (NCS, Kessler et al., 1994
) surveyed a representative sample of U.S. households and found a 4.6% prevalence of suicide attempts and a 13.5% prevalence of suicidal ideation (Kessler et al., 1999
) though the former is at the high end of the range of estimates of suicide attempts reported in previous epidemiological studies conducted in the United States (Mościcki et al., 1988
; Paykel, Myers, Lindenthal, & Tanner, 1974
Rates of suicidal ideation differed across Asian American subgroups. Chinese Americans were more likely to report suicidal ideation than those in the other Asian category (e.g., Asian Indian) and than Vietnamese and Filipino (although these differences did not reach statistical significance). Similar variations also have been found in the rates of suicide mortality in their countries of origin. For example, suicide rates in China are higher than in the Philippines (no data is available from Vietnam; World Health Organization, 2008
). Although the presence of a depressive disorder is a robust risk factor for suicide in the literature, anxiety disorder and co-occurring depression and anxiety emerged as stronger correlates in our analyses.
Perhaps the most interesting findings were those pertaining to cultural considerations. We found that high levels of family conflict and perceived discrimination were independently associated with suicidal ideation and suicide attempts. The finding on family conflict highlights the importance of familial integration in Asian cultures. Given that almost 70% of Asians in the United States are foreign born (Reeves & Bennett, 2004
), differences in acculturation level are often linked to intergenerational conflicts in immigrant families. Immigrant parents are generally less acculturated compared to their children, who adapt to the U.S. culture more rapidly. It is speculated that differences in rates of acculturation may induce high levels of conflict at home, which ultimately lead to suicidal behaviors (Ying & Han, 2007
). Future research should examine the kinds of family conflicts that are associated with suicide risk. In contrast, a high level of ethnic identity was found to be associated with lower rates of suicide attempts for Asian Americans. Ethnic identity may serve as a buffer against suicide risk by providing a sense of belonging and social support to the ethnic community.
Overall, Asian Americans shared some correlates of suicidal ideation and suicide attempts with the general U.S. population, including younger age, female gender, being never married, depression, anxiety, and the presence of chronic conditions. Consistent with previous studies conducted with the general U.S. population, the presence of DSM–IV
psychiatric disorders (i.e., depression, anxiety, and co-occurring depression and anxiety) emerged as a strong correlate of suicidal ideation and suicide attempts in Asian Americans (Nock et al., 2008
Some gender differences were also observed. For women, depressive disorder was the strongest correlate of suicidal ideation; for men, depression alone was not related to suicidal ideation. Indeed, only one in 20 Asian male suicidal ideators in the sample had a DSM–IV
depressive disorder, while almost one in four Asian female suicidal ideators did. Similarly, for women, the presence of chronic conditions was not related to suicidal ideation, whereas for men the presence of chronic conditions or co-occurring depression and anxiety were among the strongest correlates of suicidal ideation. This is consistent with findings in White samples that the presence of chronic medical conditions is a stronger correlate of suicidal ideation and suicide for men than for women (Fairweather et al., 2007
). This gender pattern may be similar across cultures, although further investigations are needed.
It is important to keep in mind that about one in three Asian Americans who attempted suicide had no evidence of DSM–IV
depressive or anxiety disorders, whereas only 2.2% of Latinos who attempted suicide had no evidence of DSM–IV
depressive or anxiety disorders in the NLAAS Latino subsample (Fortuna, Perez, Canino, Sribney, & Alegria, 2007
). The Chinese American Psychiatric Epidemiological Study also found that Chinese Americans had low-to-moderate prevalence rates of depressive disorders compared to Whites (Takeuchi, et al., 1998
). However, neurasthenia, a culture-bound syndrome including somatic symptoms of depression such as fatigue, inability to concentrate, and sleep disturbances, could be diagnosed in about 7% of the respondents (Zheng et al., 1997
). Although the presence of these somatic or cognitive symptoms, by themselves, do not constitute a depressive disorder, multiple studies of specific symptoms of depression (i.e., depressed affect, positive affect, somatic and retarded activity, and interpersonal) using the Center for Epidemiological Studies Depression Scale (CES–D; Radloff, 1977
) have shown that Asian Americans self-reported higher levels of depression than White Americans (Sue & Chu, 2003
). Asian Americans rarely distinguish depressive affect from somatization, although the distinction is generally made by White Americans (Lin & Cheung, 1999
; Ying, 1988
). Even among those with a diagnosis of depressive disorder, Asian Americans still reported higher levels of somatization. Thus, it has been speculated that Asian Americans are more likely to express psychological distress through somatic complaints. The discrepancy between higher rates of self-reported symptoms of depression but lower prevalence rates of “actual” depressive disorders suggests that the DSM–IV
approach to mood and anxiety disorders may not capture the unique expressions of these disorders in Asian Americans. Indeed, the same underlying disorder may manifest differently in Asian Americans (U.S. Department of Health and Human Services, 2001
). If mental health providers solely rely on standard Western diagnostic tools, Asian Americans who express psychological distress in terms of somatic complaints may not be identified as requiring treatment. Intriguingly, smaller proportions of individuals suffer from DSM–IV
psychiatric disorders in some Asian countries such as China and Japan, but they exhibit higher rates of suicide compared to the United States (Dennis, 2004
). Therefore, several lines of evidence suggest that meeting criteria for a DSM–IV
psychiatric disorder (e.g., depressive disorder) may not be a good indicator of suicide risk for Asian Americans as it is for White Americans. Alternatively, we speculate that Asian Americans may have different suicide motives, such as loss of face, honor, and shame (Range et al., 1999
Our study has several limitations. Some respondents might have felt uncomfortable endorsing their suicidal ideation or prior suicide attempts in face-to-face or phone interviews, leading us to underestimate the prevalence of lifetime suicidal ideation and suicide attempts. However, respondents were interviewed in their native language to minimize discomfort and promote open dialogue. Although the NLAAS is the largest national study conducted with Asian Americans, we did not have enough respondents with reported suicidal ideation or suicide attempts in the past 12 months for separate analyses. Thus, we did not distinguish lifetime suicidal ideation and suicide attempts from the more recent ones, nor were we able to conduct analyses within specific high risk groups such as: older women, refugees, and those who have substance use, psychotic, or personality disorders. Although we did not include substance use disorder in our analyses (given that few respondents met diagnostic criteria), previous research found that Asian Americans had the lowest rate of substance dependence or abuse compared to other ethnic groups in the United States (U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2009
). Data on psychotic and personality disorders were unavailable. The NLAAS is a cross-sectional survey, so no causal relationships can be drawn. Future research should more precisely determine the causal relationships between these correlates and suicidal ideation and suicide attempts in longitudinal studies. Finally, this study focused only on three major Asian ethnic groups. Despite these limitations, this study used a large, nationally representative sample, which represents a great improvement over prior studies of suicide risk in Asian Americans that have been typically conducted solely in English with convenience samples, usually college students. Future research should (1) extend this line of suicide research to other Asian subgroups such as Korean, Hmong, and Cambodian; (2) identify risk factors for suicidal ideation and suicide attempts among Asian Americans in longitudinal studies; and (3) examine the interactive relationships between gender and chronic medical conditions in suicide among Asian Americans.
Our findings have several important implications for primary care and mental health providers. The high proportion of suicide attempters without a DSM–IV
depressive or anxiety disorder suggests that clinicians should attend to other sociocultural correlates in addition to the diagnosis of psychiatric conditions. For instance, family conflict, perceived discrimination, and ethnic identity are important factors to be explored. Although depression may still play an important role in suicide for Asian Americans, the level of self-reported psychological distress may not reach the classification of clinical depression based on the DSM–IV
criteria. Thus, clinicians should not overly rely on the DSM–IV
to identify patients at risk for suicide. When asking about suicidal ideation, clinicians must keep in mind that ethnic minority clients, including Asian Americans, are less likely than Whites to disclose their suicidal ideation voluntarily (Morrison & Downey, 2000
). In addition, clinicians should pay particular attention to Asian American men with chronic illness and the markedly increased risk of suicidal thoughts among men with co-occurring depression and anxiety disorders.