Asian Journal of Psychiatry 7 (2014) 71–73
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Mood disorders in Asians Albert Yeung a,*, Doris Chang b,1 a b
Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, One, Bowdoin Square, Boston, MA 02114, United States Department of Psychology, New School for Social Research, 80 Fifth Avenue, Room 607, New York, NY 10011, United States
A R T I C L E I N F O
A B S T R A C T
Keywords: Mood disorders Asians Culture Depression Diagnosis Treatment
Mood disorders are disorders that have a disturbance in mood as the predominant feature. They are common psychiatric disorders and are associated with significant distress and functional impairment. As the theory of mood disorders is based on the philosophy of mind/body dichotomy in the West, it contradicts the holistic tradition of medicine in the East. This may partially explain why many Asians with mood disorders emphasize their physical symptoms in discussions with their treatment providers. In the development of the DSM and ICD diagnostic systems, it is presumed that the diagnostic categories are applicable to all races and ethnicities. Similarly, many consider pharmacological and psychological treatment approaches to mood disorders universally applicable. To effectively treat Asians with mood disorders, clinicians need to customize biological and psychosocial interventions in consideration of patients’ potential genetic and cultural differences. ß 2013 Elsevier B.V. All rights reserved.
1. Introduction to mood disorders in Asians Mood disorders include unipolar depressive disorders and bipolar disorders. Previous international studies suggest that the prevalence of depression among Asians is lower than populations in the West, and US-based epidemiological studies also report lower rates of depression compared to non-Hispanic Whites (Alegria et al., 2004; Takeuchi et al., 1998). However, the use of measurement instruments developed for use in Western contexts and cultural variations in symptom expression likely produce biased estimates in depression prevalence. Nevertheless, depression remains a leading contributor to the burden of disease in Asian societies and contextual factors such as acculturation and experiences of discrimination have been found to significantly increase risk of depression in Asian Americans. In clinical settings, recognizing and treating depression in Asians can be particularly challenging. Although they acknowledge and report affective symptoms when specifically queried, Asians with depression tend to emphasize somatic complaints and conceptualize their illnesses as physical, rather than mental ailments. Subsequently, many Asians with debilitating symptoms of a mood disorder are frequently left undiagnosed and untreated. Depressed Asian patients also underutilize specialty mental health services, which has been linked to cultural stigmatization of mental disorders, low acculturation, language and cultural barriers
in access to care, and reliance on alternative forms of help-seeking (e.g., family support, alternative medicine, exercise). 2. Etiology of mood disorders in Asians Although the exact etiologies of mood disorders are still unclear, biological, psychological, and sociological models have been found to explain, at least in part, how mood disorders develop (Yeung and Chang, 2012). 2.1. Biological models The biological models include the biogenic amine hypotheses, neuroendocrine links, and genetic models. The biogenic amine model has been the basis for pharmacological treatment of mood disorder, which offers important symptom relief and remission to many patients with the illness. On the other hand, the biological models have been criticized for lacking specificity. In particular, approaches to increase blood and brain levels of biogenic amines are used not only to treat mood disorders, but also anxiety disorders, obsessive–compulsive disorder, post-traumatic stress disorder, and many other psychiatric disorders. These models most likely represent broader pathological responses towards stress, rather than just mood disorders. 2.2. Psychological models
* Corresponding author. Tel.: +1 617 724 5138; fax: +1 617 724 3028. 1 Tel.: +1 212 229 5727x3112; fax: +1 212 989 0846. 1876-2018/$ – see front matter ß 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2013.11.008
Numerous psychological models have been developed to explain the origins of depression, including psychodynamic,
72
A. Yeung, D. Chang / Asian Journal of Psychiatry 7 (2014) 71–73
behavioral, social learning, cognitive/cognitive-behavioral, and interpersonal models. In recent years, the cognitive and cognitivebehavioral models have received the most attention. Within these frameworks, depression results from a dysfunctional cognitive structure characterized by inaccurate interpretations (cognitive distortions) of life situations, rigid and maladaptive assumptions, beliefs, and attitudes (negative schemas), and a global negative view of the self, the world, and the future (negative cognitive triad). Whereas psychodynamic, behavioral, and cognitive models of depression emphasize internal processes, interpersonal models view depression as contextually embedded in the interpersonal arena. Given the sociocentric emphasis in Asian cultures, the interpersonal models of depression may apply particularly well to Asians who prioritize social roles, obligations, and relationships. 2.3. Indigenous etiological models Given the influence of Western psychiatry and psychology worldwide, many of the psychological models reviewed above have been widely accepted by Asian mental health professionals. In contrast, few indigenous Asian models of depression have been described in the English language literature, with most studies focusing on Chinese populations. According to traditional Chinese medical theories, depression often results from an imbalance or blockage in one’s internal organs and their associated meridian systems. These blockages lead to stagnation of qi in the body and may produce emotional distress, mental disorder, illness and disease. Causes of qi imbalance are varied and may include physical and emotional stress or trauma, poor nutrition, hereditary predisposition, and environmental toxins. 3. Diagnosis of mood disorders in Asians While DSM-5 and ICD-10 diagnostic criteria were developed with the assumption of universal applicability, anthropologists contend that the concept of depressive disorder is rooted in Western cultures and may not apply well in other cultures. Among Chinese laypeople, for example, the tendency to emphasize the somatic aspects of depressive experience overlaps phenomenologically with the concept of shenjing shuairuo (neurasthenia), translated as ‘‘weakness of the nerves’’. Although the use of the term shenjing shuairuo has recently become less popular in Asia in part due to increasing exposure to Western models of illness, epidemiologic studies of Asian Americans report past-year prevalence rates ranging from 1.1% to 3.6% (Molina et al., 2012; Zheng et al., 1997). Another common idiom of distress among Koreans is hwa-byung (anger or fire disease), which describes a similar mix of somatic and affective symptoms with additional emphasis on ‘‘heat sensations’’ and flushing. Although it is often viewed as an anger syndrome, Korean Americans who labeled themselves as suffering from hwa-byung were significantly more likely to meet DSM criteria for major depression (Lin et al., 1992).
used as first-line medications for depression due to their more benign side effects. Typical and newer antipsychotic agents often are combined with antidepressants to treat patients with psychotic depression. Mood stabilizers (e.g., lithium, anticonvulsants such as valproic acid and lamotrigine) and some atypical antipsychotic drugs (e.g., olanzapine, quetiapine) are now used to treat mania as well as bipolar depression. Studies have shown that there are inter-individual and crossethnic variations in drug responses. Many medications, including practically all psychotropics, are dependent on one or more of the cytochrome P450 (CYP) enzymes for metabolism, and such enzymes show genetic variations across ethnicities. Existing studies have shown that compared to Caucasians, Asians tend to metabolize many psychotropic drugs slower and thus should be treated with a lower dose. Of equal importance, there is a wide range of intra-ethnic group variations requiring a highly individualized approach to clinical treatment. 4.2. Psychological treatments Research indicates that psychological treatments for depression, particularly behavioral, cognitive-behavioral and interpersonal therapies, are as effective as pharmacologic treatments in reducing symptoms of depression in the short-term and provide longer lasting protection against future relapse after treatment is withdrawn. Additional benefits of psychological treatments include the reduction of psychosocial impairments associated with depression, absence of side effects, and lower treatment costs than pharmacologic treatment. Although cognitive therapy (CT), cognitive behavioral therapy (CBT) and interpersonal therapy are well-established treatments for reducing symptoms of depression in children, adolescents, and adults, their efficacy for Asian Americans has not been definitively established due to the absence of randomized controlled trial data. However, non-randomized wait-list controlled trials of CBT for depression, including some culturally-adapted versions for Chinese samples, provide some evidence of its potential effectiveness. In another study, 68 Chinese patients with depression were randomized to receive (a) Taoist Cognitive Psychotherapy plus medication or (b) medication alone. Those receiving the cognitive intervention found greater reductions in depressive symptoms after 8 weeks of treatment and a significantly lower relapse rate at 6 months (Yang et al., 2005). 4.3. Indigenous treatments The use of specific Chinese herbs, acupuncture, and mind-body practices including meditation, yoga, taichi, and qigong are also frequently used by Asian patients for symptom relief. There is preliminary evidence showing the effectiveness of these treatments for the treatment of depression (Yeung et al., 2012; Yeung et al., 2013).
4. Treating mood disorders in Asians
5. Implications for understanding mood disorders in Asians
4.1. Pharmacological approaches
The development and worldwide acceptance of the DSM-5 and ICD-10 classification systems have enhanced the consistency of clinical diagnosis of mental disorders across cultures. International epidemiological studies have shown that most psychiatric disorders can be identified among people from different races and cultures, even though the prevalence, meaning, and prognosis may vary significantly. On the other hand, clinicians have been faced with obstacles and problems when they diagnose Asians with mood disorders. The concepts of mood disorders, such as mania or depression, are rooted in Western culture. Many Asians with traditional illness
For both unipolar depression and bipolar disorder, psychotropics are the mainstay of biological treatment. Traditionally, tricyclic and tetracyclic antidepressants have been used for the treatment of unipolar depression. With the introduction of the selective serotonin reuptake inhibitors (SSRIs; e.g., fluoxetine, paroxetine, luvoxamine, citalopram), dual-action serotonin–norepinephrine reuptake inhibitors (e.g., venafaxine, duloxetine), and other newer antidepressants (e.g., mirtazepine, nefazodone), the new generation of antidepressants are now increasingly being
A. Yeung, D. Chang / Asian Journal of Psychiatry 7 (2014) 71–73
beliefs are unfamiliar with these disease concepts. The discrepancy between professional and lay disease concepts may contribute to low health literacy, high stigma towards mood symptoms, and under-utilization of mental health services. To overcome these obstacles, it would be beneficial to provide outreach and psychoeducation to Asian communities to help demystify mood disorders and convey that depression is a treatable condition that improves with treatment just like many other medical problems. Future versions of the DSM and ICD should incorporate both Western and Eastern conceptions of mental disorder so that diagnostic categories may be more readily accepted by patients from non-Western cultures. In the meantime, clinicians who serve Asians with traditional illness beliefs need to serve as a bridge to link indigenous beliefs and professional concepts, and discuss mood disorders in a culturally sensitive way so that Asian patients will understand and accept treatment for them. Two clinical tools may facilitate this process. In the DSM-5, the Cultural Formulation and the Cultural Formulation Interview (CFI) have been designed to help clinicians gain a better understanding of patients’ illness beliefs. Another brief instrument, the Engagement Interview Protocol (Yeung et al., 2011), may be used to successfully engage Asian patients in treatment for depression by enhancing cultural sensitivity. References Alegria, M., Takeuchi, D., Canino, G., Duan, N., Shrout, P., Meng, X.L., Vega, W., Zane, N., Vila, D., Woo, M., Vera, M., Guarnaccia, P., Aguilar-Gaxiola, S., Sue, S., Escobar,
73
J., Lin, K.M., Gong, F., 2004. Considering context, place and culture: the National Latino and Asian American Study. International Journal of Methods in Psychiatric Research 13 (4) 208–220. Lin, K.M., Lau, J.K., Yamamoto, J., Zheng, Y.P., Kim, H.S., Cho, K.H., Nakasaki, G., 1992. Hwa-byung: a community study of Korean Americans. Journal of Nervous and Mental Disease 180 (6) 386–391. Molina, K.M., Chen, C.N., Alegrı´a, M., Li, H., 2012. Prevalence of neurasthenia, comorbidity, and association with impairment among a nationally representative sample of US adults. Social Psychiatry and Psychiatric Epidemiology 47 (11) 1733–1744. Takeuchi, D.T., Chung, R.C.Y., Lin, K.M., Shen, H., Kurasaki, K., Chun, C.A., Sue, S., 1998. Lifetime and twelve-month prevalence rates of major depressive episodes and dysthmia among Chinese Americans in Los Angeles. American Journal of Psychiatry 155, 1407–1414. Yang, J.Q., Zhao, L.M., Mai, X.L., 2005. A comparative study of Taoist Cognitive Psychotherapy from China and mianserin in the treatment of depression in late life. Chinese Journal of Nervous and Mental Disease 31 (5) 333–335. Yeung, A., Chang, D., 2012. Mood disorders in Asians. In: Edward, C. (Ed.), Handbook of Adult Psychopathology in Asians: Theory, Diagnosis, and Treatment. Oxford University Press. Yeung, A., Trinh, N.H., Chang, T.E., Fava, M., 2011. The Engagement Interview Protocol (EIP): Improving the Acceptance of Mental Health Treatment among Chinese Immigrants. International Journal of Culture and Mental Health 4 (2) 91–105. Yeung, A., Lepoutre, V., Wayne, P., Yeh, G., Slipp, L., Fava, M., Denninger, J., Benson, H., Fricchione, G., 2012. Tai Chi treatment for depressed Chinese Americans: a pilot study. American Journal of Physical Medicine & Rehabilitation 91 (October (10)) 863–870. Yeung, A., Slipp, L.E., Jacquart, J., Fava, M., Denninger, J.W., Benson, H., Fricchione, G.L., 2013. Treatment of depressed Chinese Americans using Qigong in a health care setting: a pilot study. Evidence-Based Complementary and Alternative Medicine 2013, 5, http://dx.doi.org/10.1155/2013/168784, Article ID 168784. Zheng, Y., Lin, K., Takeuchi, D., Kurasaki, K.S., Wang, Y., Cheung, F., 1997. An epidemiological study of neurasthenia in Chinese–Americans in Los Angeles. Comprehensive Psychiatry 38 (5) 249–259.
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Mood disorders in Asians Albert Yeung a,*, Doris Chang b,1 a b
Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, One, Bowdoin Square, Boston, MA 02114, United States Department of Psychology, New School for Social Research, 80 Fifth Avenue, Room 607, New York, NY 10011, United States
A R T I C L E I N F O
A B S T R A C T
Keywords: Mood disorders Asians Culture Depression Diagnosis Treatment
Mood disorders are disorders that have a disturbance in mood as the predominant feature. They are common psychiatric disorders and are associated with significant distress and functional impairment. As the theory of mood disorders is based on the philosophy of mind/body dichotomy in the West, it contradicts the holistic tradition of medicine in the East. This may partially explain why many Asians with mood disorders emphasize their physical symptoms in discussions with their treatment providers. In the development of the DSM and ICD diagnostic systems, it is presumed that the diagnostic categories are applicable to all races and ethnicities. Similarly, many consider pharmacological and psychological treatment approaches to mood disorders universally applicable. To effectively treat Asians with mood disorders, clinicians need to customize biological and psychosocial interventions in consideration of patients’ potential genetic and cultural differences. ß 2013 Elsevier B.V. All rights reserved.
1. Introduction to mood disorders in Asians Mood disorders include unipolar depressive disorders and bipolar disorders. Previous international studies suggest that the prevalence of depression among Asians is lower than populations in the West, and US-based epidemiological studies also report lower rates of depression compared to non-Hispanic Whites (Alegria et al., 2004; Takeuchi et al., 1998). However, the use of measurement instruments developed for use in Western contexts and cultural variations in symptom expression likely produce biased estimates in depression prevalence. Nevertheless, depression remains a leading contributor to the burden of disease in Asian societies and contextual factors such as acculturation and experiences of discrimination have been found to significantly increase risk of depression in Asian Americans. In clinical settings, recognizing and treating depression in Asians can be particularly challenging. Although they acknowledge and report affective symptoms when specifically queried, Asians with depression tend to emphasize somatic complaints and conceptualize their illnesses as physical, rather than mental ailments. Subsequently, many Asians with debilitating symptoms of a mood disorder are frequently left undiagnosed and untreated. Depressed Asian patients also underutilize specialty mental health services, which has been linked to cultural stigmatization of mental disorders, low acculturation, language and cultural barriers
in access to care, and reliance on alternative forms of help-seeking (e.g., family support, alternative medicine, exercise). 2. Etiology of mood disorders in Asians Although the exact etiologies of mood disorders are still unclear, biological, psychological, and sociological models have been found to explain, at least in part, how mood disorders develop (Yeung and Chang, 2012). 2.1. Biological models The biological models include the biogenic amine hypotheses, neuroendocrine links, and genetic models. The biogenic amine model has been the basis for pharmacological treatment of mood disorder, which offers important symptom relief and remission to many patients with the illness. On the other hand, the biological models have been criticized for lacking specificity. In particular, approaches to increase blood and brain levels of biogenic amines are used not only to treat mood disorders, but also anxiety disorders, obsessive–compulsive disorder, post-traumatic stress disorder, and many other psychiatric disorders. These models most likely represent broader pathological responses towards stress, rather than just mood disorders. 2.2. Psychological models
* Corresponding author. Tel.: +1 617 724 5138; fax: +1 617 724 3028. 1 Tel.: +1 212 229 5727x3112; fax: +1 212 989 0846. 1876-2018/$ – see front matter ß 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2013.11.008
Numerous psychological models have been developed to explain the origins of depression, including psychodynamic,
72
A. Yeung, D. Chang / Asian Journal of Psychiatry 7 (2014) 71–73
behavioral, social learning, cognitive/cognitive-behavioral, and interpersonal models. In recent years, the cognitive and cognitivebehavioral models have received the most attention. Within these frameworks, depression results from a dysfunctional cognitive structure characterized by inaccurate interpretations (cognitive distortions) of life situations, rigid and maladaptive assumptions, beliefs, and attitudes (negative schemas), and a global negative view of the self, the world, and the future (negative cognitive triad). Whereas psychodynamic, behavioral, and cognitive models of depression emphasize internal processes, interpersonal models view depression as contextually embedded in the interpersonal arena. Given the sociocentric emphasis in Asian cultures, the interpersonal models of depression may apply particularly well to Asians who prioritize social roles, obligations, and relationships. 2.3. Indigenous etiological models Given the influence of Western psychiatry and psychology worldwide, many of the psychological models reviewed above have been widely accepted by Asian mental health professionals. In contrast, few indigenous Asian models of depression have been described in the English language literature, with most studies focusing on Chinese populations. According to traditional Chinese medical theories, depression often results from an imbalance or blockage in one’s internal organs and their associated meridian systems. These blockages lead to stagnation of qi in the body and may produce emotional distress, mental disorder, illness and disease. Causes of qi imbalance are varied and may include physical and emotional stress or trauma, poor nutrition, hereditary predisposition, and environmental toxins. 3. Diagnosis of mood disorders in Asians While DSM-5 and ICD-10 diagnostic criteria were developed with the assumption of universal applicability, anthropologists contend that the concept of depressive disorder is rooted in Western cultures and may not apply well in other cultures. Among Chinese laypeople, for example, the tendency to emphasize the somatic aspects of depressive experience overlaps phenomenologically with the concept of shenjing shuairuo (neurasthenia), translated as ‘‘weakness of the nerves’’. Although the use of the term shenjing shuairuo has recently become less popular in Asia in part due to increasing exposure to Western models of illness, epidemiologic studies of Asian Americans report past-year prevalence rates ranging from 1.1% to 3.6% (Molina et al., 2012; Zheng et al., 1997). Another common idiom of distress among Koreans is hwa-byung (anger or fire disease), which describes a similar mix of somatic and affective symptoms with additional emphasis on ‘‘heat sensations’’ and flushing. Although it is often viewed as an anger syndrome, Korean Americans who labeled themselves as suffering from hwa-byung were significantly more likely to meet DSM criteria for major depression (Lin et al., 1992).
used as first-line medications for depression due to their more benign side effects. Typical and newer antipsychotic agents often are combined with antidepressants to treat patients with psychotic depression. Mood stabilizers (e.g., lithium, anticonvulsants such as valproic acid and lamotrigine) and some atypical antipsychotic drugs (e.g., olanzapine, quetiapine) are now used to treat mania as well as bipolar depression. Studies have shown that there are inter-individual and crossethnic variations in drug responses. Many medications, including practically all psychotropics, are dependent on one or more of the cytochrome P450 (CYP) enzymes for metabolism, and such enzymes show genetic variations across ethnicities. Existing studies have shown that compared to Caucasians, Asians tend to metabolize many psychotropic drugs slower and thus should be treated with a lower dose. Of equal importance, there is a wide range of intra-ethnic group variations requiring a highly individualized approach to clinical treatment. 4.2. Psychological treatments Research indicates that psychological treatments for depression, particularly behavioral, cognitive-behavioral and interpersonal therapies, are as effective as pharmacologic treatments in reducing symptoms of depression in the short-term and provide longer lasting protection against future relapse after treatment is withdrawn. Additional benefits of psychological treatments include the reduction of psychosocial impairments associated with depression, absence of side effects, and lower treatment costs than pharmacologic treatment. Although cognitive therapy (CT), cognitive behavioral therapy (CBT) and interpersonal therapy are well-established treatments for reducing symptoms of depression in children, adolescents, and adults, their efficacy for Asian Americans has not been definitively established due to the absence of randomized controlled trial data. However, non-randomized wait-list controlled trials of CBT for depression, including some culturally-adapted versions for Chinese samples, provide some evidence of its potential effectiveness. In another study, 68 Chinese patients with depression were randomized to receive (a) Taoist Cognitive Psychotherapy plus medication or (b) medication alone. Those receiving the cognitive intervention found greater reductions in depressive symptoms after 8 weeks of treatment and a significantly lower relapse rate at 6 months (Yang et al., 2005). 4.3. Indigenous treatments The use of specific Chinese herbs, acupuncture, and mind-body practices including meditation, yoga, taichi, and qigong are also frequently used by Asian patients for symptom relief. There is preliminary evidence showing the effectiveness of these treatments for the treatment of depression (Yeung et al., 2012; Yeung et al., 2013).
4. Treating mood disorders in Asians
5. Implications for understanding mood disorders in Asians
4.1. Pharmacological approaches
The development and worldwide acceptance of the DSM-5 and ICD-10 classification systems have enhanced the consistency of clinical diagnosis of mental disorders across cultures. International epidemiological studies have shown that most psychiatric disorders can be identified among people from different races and cultures, even though the prevalence, meaning, and prognosis may vary significantly. On the other hand, clinicians have been faced with obstacles and problems when they diagnose Asians with mood disorders. The concepts of mood disorders, such as mania or depression, are rooted in Western culture. Many Asians with traditional illness
For both unipolar depression and bipolar disorder, psychotropics are the mainstay of biological treatment. Traditionally, tricyclic and tetracyclic antidepressants have been used for the treatment of unipolar depression. With the introduction of the selective serotonin reuptake inhibitors (SSRIs; e.g., fluoxetine, paroxetine, luvoxamine, citalopram), dual-action serotonin–norepinephrine reuptake inhibitors (e.g., venafaxine, duloxetine), and other newer antidepressants (e.g., mirtazepine, nefazodone), the new generation of antidepressants are now increasingly being
A. Yeung, D. Chang / Asian Journal of Psychiatry 7 (2014) 71–73
beliefs are unfamiliar with these disease concepts. The discrepancy between professional and lay disease concepts may contribute to low health literacy, high stigma towards mood symptoms, and under-utilization of mental health services. To overcome these obstacles, it would be beneficial to provide outreach and psychoeducation to Asian communities to help demystify mood disorders and convey that depression is a treatable condition that improves with treatment just like many other medical problems. Future versions of the DSM and ICD should incorporate both Western and Eastern conceptions of mental disorder so that diagnostic categories may be more readily accepted by patients from non-Western cultures. In the meantime, clinicians who serve Asians with traditional illness beliefs need to serve as a bridge to link indigenous beliefs and professional concepts, and discuss mood disorders in a culturally sensitive way so that Asian patients will understand and accept treatment for them. Two clinical tools may facilitate this process. In the DSM-5, the Cultural Formulation and the Cultural Formulation Interview (CFI) have been designed to help clinicians gain a better understanding of patients’ illness beliefs. Another brief instrument, the Engagement Interview Protocol (Yeung et al., 2011), may be used to successfully engage Asian patients in treatment for depression by enhancing cultural sensitivity. References Alegria, M., Takeuchi, D., Canino, G., Duan, N., Shrout, P., Meng, X.L., Vega, W., Zane, N., Vila, D., Woo, M., Vera, M., Guarnaccia, P., Aguilar-Gaxiola, S., Sue, S., Escobar,
73
J., Lin, K.M., Gong, F., 2004. Considering context, place and culture: the National Latino and Asian American Study. International Journal of Methods in Psychiatric Research 13 (4) 208–220. Lin, K.M., Lau, J.K., Yamamoto, J., Zheng, Y.P., Kim, H.S., Cho, K.H., Nakasaki, G., 1992. Hwa-byung: a community study of Korean Americans. Journal of Nervous and Mental Disease 180 (6) 386–391. Molina, K.M., Chen, C.N., Alegrı´a, M., Li, H., 2012. Prevalence of neurasthenia, comorbidity, and association with impairment among a nationally representative sample of US adults. Social Psychiatry and Psychiatric Epidemiology 47 (11) 1733–1744. Takeuchi, D.T., Chung, R.C.Y., Lin, K.M., Shen, H., Kurasaki, K., Chun, C.A., Sue, S., 1998. Lifetime and twelve-month prevalence rates of major depressive episodes and dysthmia among Chinese Americans in Los Angeles. American Journal of Psychiatry 155, 1407–1414. Yang, J.Q., Zhao, L.M., Mai, X.L., 2005. A comparative study of Taoist Cognitive Psychotherapy from China and mianserin in the treatment of depression in late life. Chinese Journal of Nervous and Mental Disease 31 (5) 333–335. Yeung, A., Chang, D., 2012. Mood disorders in Asians. In: Edward, C. (Ed.), Handbook of Adult Psychopathology in Asians: Theory, Diagnosis, and Treatment. Oxford University Press. Yeung, A., Trinh, N.H., Chang, T.E., Fava, M., 2011. The Engagement Interview Protocol (EIP): Improving the Acceptance of Mental Health Treatment among Chinese Immigrants. International Journal of Culture and Mental Health 4 (2) 91–105. Yeung, A., Lepoutre, V., Wayne, P., Yeh, G., Slipp, L., Fava, M., Denninger, J., Benson, H., Fricchione, G., 2012. Tai Chi treatment for depressed Chinese Americans: a pilot study. American Journal of Physical Medicine & Rehabilitation 91 (October (10)) 863–870. Yeung, A., Slipp, L.E., Jacquart, J., Fava, M., Denninger, J.W., Benson, H., Fricchione, G.L., 2013. Treatment of depressed Chinese Americans using Qigong in a health care setting: a pilot study. Evidence-Based Complementary and Alternative Medicine 2013, 5, http://dx.doi.org/10.1155/2013/168784, Article ID 168784. Zheng, Y., Lin, K., Takeuchi, D., Kurasaki, K.S., Wang, Y., Cheung, F., 1997. An epidemiological study of neurasthenia in Chinese–Americans in Los Angeles. Comprehensive Psychiatry 38 (5) 249–259.
