A 15-year-old Asian-American girl who was enrolled in high school and lived with her parents and two older sisters attempted suicide by ingesting 25 tablets of acetaminophen (each of which were 325 mg). The patient reported that her stress was triggered by an argument with her mother regarding the patient smoking cigarettes. After medical stabilization, the patient was transferred to our child and adolescent psychiatry unit.
This suicide attempt came after a long-standing conflict with her parents regarding her poor performance in school, which the patient attributed to depressed mood with decreased sleep and irritability. The patient began self-medicating with cannabis and alcohol, which eased her inhibitions about committing suicide and resulted in suicidal ideation with a plan to hang herself (which was prevented by her mother) and a suicidal gesture in which she cut her left wrist with a knife (an injury she hid from her mother and did not receive any medical care).
The patient reported a history of extreme anxiety that she attributed to the stress caused by her family's expectations for high academic achievement, which resulted in alleged physical and emotional abuse by her parents due to inability of the patient to meet those expectations. This resulted in maladaptive coping skills with self-injurious behavior such as repeated attempts at cutting her wrists and burning herself with cigarettes to relieve her anxiety. Her extreme distress worsened due to disappointing her parents because of her drug use, her grades (B's and C's), the fact that she was not in honors classes, and that she was not on track to succeed as her two older sisters already had (both of whom were graduates of Ivy League universities).
Major Depressive Disorder with a Possible Adjustment Disorder with Depressed Mood
On admission and throughout much of her hospitalization, the patient exhibited depressed mood with constricted affect and suicidal ideation without any plan. Borderline personality disorder was also considered as a diagnosis because of her feelings of emptiness, impulsivity, self-harm, and suicidal behavior. The patient was placed under constant observation for dangerousness to self and treated with individual and family psychotherapy in addition to psycho-pharmacotherapy (10 mg/day of fluoxetine). During the course of her stay, her liver function was monitored for damage from the overdose of acetaminophen (it improved from the time of admission and normalized before her discharge). Over time, her depressive symptoms began to remit. Despite intensive and ongoing family therapy, the patient ultimately required residential placement due to extreme family discord.
It has been repeatedly reported in the medical literature that adolescent Asian Americans, especially females, have one of the highest rates of major depressive disorder (MDD) among all ethnic groups in America, reaching as high as 71% in female adolescents from Southeast Asia.1 It has also been observed that between ages 15 and 24 years, female adolescent Asian Americans have a higher incidence of suicide rate than any other ethnic or racial group in that age bracket.2 Suicide is the fifth leading cause of death among Asian Americans (compared to ninth among Americans of European ancestry).1
Studies suggest a possible correlation in this specific ethnic group between MDD and parental pressure to become high achievers.3,4 This is compounded by the traditional focus on education in addition to the cultural belief in familial obedience and self-control. Another precipitating factor is that these adolescents have a lower rate of externalizing their problems.4
The term “Asian American” encompasses an extremely diverse group of people with various cultures, histories, views of mental illness, and views of suicide. It has been estimated that almost 50 distinct Asian-American ethnic groups, speaking approximately 30 different languages, live in the United States, with 68% being born in their native countries.3 As such, immigration status is a critical factor to study when investigating the risk for suicidal behaviors among adolescent Asian Americans.5 Immigration status and country of birth have shown to be significant factors for suicidal behaviors and completed suicide in ethnic populations.6
Acculturation is recognized as a significant factor in psychological functioning in immigrant populations.1 It refers to the manner in which people negotiate between two or more cultures when one culture is considered dominant and the other culture is perceived to have less value. Acculturation is a well-documented mediator and predictor of suicidal behavior and ideation and is strongly associated with depression among adolescent Asian Americans.1 In particular, acculturative stress is a strong predictor of depression and suicidal ideation among students from South Korea, suggesting that this group may experience more transcultural stress than Korean-Americans raised in the United States.1 Research indicates that Asian-American college students are more likely than other American cultural groups to have psychological concerns that could benefit from treatment.7,8
Asian Americans are one of the fastest-growing ethnic minority populations in the US. It is estimated that the Asian-American US population will be more than 40 million (9% of the total US population) by the year 2050.3 Having a cultural understanding of this group is necessary because of their views regarding mental health issues and their treatment. This is especially important given the fact that current data on mental health and treatment in adolescent Asian Americans are limited because much of the available research focuses on disparities in health care and health status among children of Hispanic and African-American descent.4 Because studies suggest that Asian Americans underuse mental health services and are less likely than their counterparts to reveal suicide ideation, some have used the term “hidden ideators” to describe them.9
Suicidality may also be influenced by age, religion, and sexual orientation. Suicide is the ninth leading cause of death in America, with the highest rates seen in both the elderly and adolescents.10 Immigrants from East Asia (eg, Korea, Japan, China) may be at higher risk of depression compared to immigrants from Southeast Asia (eg, Vietnam, Philippines), who have shown higher rates of anxiety.5,12 There has been little research on American populations from South Asia (eg, India, Pakistan). Moreover, there are a number of unique religious and spiritual issues that affect suicide risk in adolescent Asian Americans, as religious beliefs are often a mix of various influences (eg, Christianity, Islam, and Buddhism) with varying views on the morality of suicide.13
One study has shown that Korean parents who have immigrated to the US are more reluctant than other immigrants to adapt American culture.7 As a consequence, there is often a large cultural clash between Korean-American teens and their immigrant parents that is more pronounced than in other cultures, which can result in severe psychological and emotional distress.14 The conflicts likely involve Korean values of conformity, familial obligation, interdependency, and academic achievement.15 Moreover, Korean-American immigrant parents have been found to report higher levels of stress associated with acculturation than any other immigrant group.7 This stress may be due to or compounded by inter-generational conflicts with their children and changing family roles due to cultural adaptation in their children.7
Among adolescent Asian Americans, there is a heavy emphasis on children meeting parental expectations. As such, studies have shown that adolescent Asian Americans reported a higher frequency of academic and family related worry.16 This is compounded by emphasis placed on careers in highly competitive areas such as medicine, science, and law, which are viewed as the primary vehicles for social mobility in the US.16
Cultural awareness is required for the proper treatment of immigrant populations. Causes of depression and suicidality are multi-factorial, but more emphasis needs to be placed on culture-specific factors. Depression in adolescent Asian Americans may be masked by stigma, shame, and misinformation. Additionally, many Asian-American parents may have difficulties understanding mental illness due to varying cultural values and beliefs, combined with the stresses of adjusting to life in a new country. This indicates the need for awareness of these factors for proper treatment of this population.
- Duldulao AA, Takeuchi DT, Hong S. Correlates of suicidal behaviors among Asian Americans. Arch Suicide Res. 2009;13(3):277–290. doi:. doi:10.1080/13811110903044567 [CrossRef]
- National Alliance on Mental Illness. Asian American teenage girls have highest rates of depression; NAMI releases report. https://www.nami.org/Press-Media/Press-Releases/2011/Asian-American-Teenage-Girls-Have-Highest-Rates-of. Accessed June 14, 2017.
- Saw A, Berenbaum H, Okazaki S. Influences of personal standards and perceived parental expectations on worry for Asian American and white American college students. Anxiety Stress Coping. 2013;26(2):187–202. doi:10.1080/10615806.2012.668536 [CrossRef]
- Huang K-Y, Calzada E, Cheng S, Miller LM. Physical and mental health disparities among young children of Asian immigrants. J Pediatr. 2012;160(2):331–336. doi:. doi:10.1016/j.jpeds.2011.08.005 [CrossRef]
- Choi Y, He M, Harachi TW. Intergenerational cultural dissonance, parent–child conflict and bonding, and youth problem behaviors among Vietnamese and Cambodian immigrant families. J Youth Adolesc. 2008;37(1):85–96. doi:10.1007/s10964-007-9217-z [CrossRef]
- Kim KS. Young Asian American women: under double pressure. Hardboiled, the Asian Pacific American Newsmagazine at UC Berkeley. 2011;14(4):9. https://hardboiled.berkeley.edu/wordpress/wp-content/uploads/2011/04/14.4.pdf. Accessed June 6, 2017.
- Choi Y, Kim YS. Acculturation and the family: core vs. peripheral changes among Korean Americans. Chaeoe Hanin Yon Gu. 2010;21(2010):135–190.
- Choi H, Dancy BL. Korean American adolescents' and their parents' perceptions of acculturative stress. J Child Adolesc Psychiatr Nurs. 2009;22(4):203–210. doi:. doi:10.1111/j.1744-6171.2009.00200.x [CrossRef]
- Morrison LL, Downey DL. Racial differences in self-disclosure of suicidal ideation and reasons for living implications for training. Cultural Diversity Ethnic Minority Psychol. 2000;6(4):374–386. doi:. doi:10.1037/1099-9809.6.4.374 [CrossRef]
- Suicide Prevention Research Center. Suicide among racial/ethnic populations in the U.S. Asians, Pacific Islanders, and Native Hawaiians. http://www.sprc.org/sites/default/files/migrate/library/API%20Sheet%20August%2028%202013%20Final.pdf. Accessed June 14, 2017.
- Detzner D, Xiong B. Background on Southeast Asian parenting. https://www.extension.umn.edu/family/families-with-teens/resources-parents/bicultural-parenting/background/. Accessed June 5, 2017.
- Pathak R, Sharma RC, Parvan UC, Gupta BP, Ojha RK, Goel NK. Behavioral and emotional problems in school going adolescents. Australas Med J. 2001;4(1):15–21. doi:10.4066/AMJ.2011.464 [CrossRef]
- Leong F, Leach MM, Yeh C, Chou E. Suicide among Asian Americans: what do we know? What do we need to know?Death Stud. 2007;31(5)417–434. doi:. doi:10.1080/07481180701244561 [CrossRef]
- Lee RM, Su J, Yoshida E. Coping with intergenerational family conflict among Asian American college students. J Counsel Psychol. 2005;52(4):389–399. doi:10.1037/0022-018.104.22.1689 [CrossRef]
- Hurh WM. The Korean Americans. Westport, CT: Greenwood Press; 1998.
- Sue S, Okazaki S. Asian-American educational achievements. A phenomenon in search of an explanation. Am Psychol. 1990;45(8):913–920. doi:10.1037/0003-066X.45.8.913 [CrossRef]