Immigration-Related Factors and Depression Help-Seeking Behaviors Among Older Chinese Americans

ABSTRACT

Objectives

Asian Americans have the lowest mental health service utilization rate among all racial/ethnic groups. This study investigates how immigration-related factors shape the depression help-seeking behaviors of older Chinese Americans.

Methods

Data were collected from participants who reported experiencing any depressive symptoms in the Population-based Study of Chinese Elderly in Chicago (n = 907). Multinomial logistic regressions were conducted to examine the associations between immigration-related factors and help-seeking behaviors, including not seeking help (23.5%), seeking help from informal source(s) only (40%), seeking help from both informal and formal sources (28.7%), and seeking help from formal source(s) only (8.8%).

Results

Older Chinese Americans with lower levels of acculturation (OR = 0.88, 95% CI = 0.79–0.97) and those who lived in Chinatown (OR = 2.34, 95% CI = 1.21–4.52) were more likely to seek help from formal sources only (relative to not seeking any help).

Conclusions

Older Chinese Americans with depressive symptoms predominately relied on informal sources of help, either solely or in combination with formal sources, to address their depressive symptoms.

Clinical Implications

Leveraging informal support networks and ethnicity-specific resources represents a promising approach for this population.

KEYWORDS:

• Acculturation
• Chinese
• depression
• help-seeking
• immigration
• minority aging

Introduction

Asian Americans have the lowest mental health service utilization rate among all racial/ethnic groups in the United States (Alegría et al., 2008; Sue et al., 2012). Prior research has identified a variety of factors that contribute to this, including language barriers (A. W. Chen et al., 2009), a lack of culturally competent services (Thomson et al., 2015), and cultural stigma (Akutsu & Chu, 2006; Y. Y. Chao et al., 2020). Several important yet understudied factors relating to this group’s mental health service use include immigration-related factors, such as reasons for migration, length of stay in the United States, acculturation, and neighborhood environment (e.g., living in ethnic enclaves such as Chinatown for Chinese immigrants). The immigration process affects many aspects of migrants’ lives, including living arrangements, level of social support, language/cultural barriers, and knowledge of and access to mental health services, thus having profound implications for older immigrants’ mental health status and mental health service utilization (Akutsu & Chu, 2006; Thomson et al., 2015). This study aims to examine whether and how immigration-related factors (i.e., acculturation level, length of stay in the United States, Chinatown residence, and reasons for migration) shape their mental health service utilization. With the vast majority (85%) of U.S. Chinese older adults being foreign-born immigrants, the topic is particularly salient (Kim et al., 2010).

Moreover, seeking help from both formal sources (e.g., physicians, and mental health professionals) and informal sources (e.g., family members, and friends) plays a crucial role in facilitating the rehabilitation process for individuals with mental health conditions (Lauzier-Jobin & Houle, 2022). Nevertheless, most previous research has focused on formal sources of help. Our understanding of help-seeking behavior among older minority populations, particularly in terms of seeking help from informal sources or a combination of formal and informal sources, remains limited. Prior studies indicate that Chinese older adults typically follow a pathway model when seeking help, beginning with personal coping strategies, then turning to informal sources, and finally considering professional mental health services as a last resort (Derr, 2016; Pang et al., 2003). Therefore, the lack of attention given to help-seeking from informal sources for depression represents a significant gap, especially in Chinese communities, in which individuals consistently demonstrate a preference for informal support when experiencing mental disorders (Kung, 2003). This study aims to address this gap by incorporating both formal and informal sources of help to gain a fuller understanding of depression help-seeking behaviors among older Chinese Americans.

Acculturation, length of U.S. residence, and mental health service use

In traditional Chinese culture, mental disorders are commonly perceived as personal weakness, shame, and loss of face (Tieu & Konnert, 2014). Thus, it is unsurprising that U.S. Chinese older adults who are less acculturated tend to hold a negative view toward obtaining mental health assistance (Lai & Chau, 2007; Na et al., 2016; Tieu & Konnert, 2014). U.S. Chinese older adults with higher levels of acculturation are more inclined to adopt the biomedical perspective that mental disorders warrant professional intervention and services (Fung & Wong, 2007; S. Lee & Jang, 2016). Closely related to an immigrant’s level of acculturation is their length of stay in the host country, and length of residence in the United States has been the most commonly used temporal proxy of immigrants’ acculturation (Salant & Lauderdale, 2003). A shorter duration of residence is strongly associated with lower English proficiency and more difficulties in navigating the healthcare system, both of which may hinder the utilization of formal mental health services (Chung et al., 2018). Older immigrants with longer residence in the United States tend to be better acclimated to the U.S. healthcare system and thereby have greater access to mental health services (A. W. Chen et al., 2008). As such, acculturation and longer U.S. residence were expected to be positively associated with older Chinese Americans’ mental health service use.

Chinatown residence and mental health service use

An emerging body of literature suggests that residence in ethnic enclaves, commonly defined as geographic areas with a high concentration of certain ethnic groups (e.g., “Chinatown”), has significant implications for immigrants’ health and access to care (Gresenz et al., 2009; Lim et al., 2017; Osypuk et al., 2009). Prior research indicates that ethnic enclave residence is empowering for immigrants, especially newer immigrants and immigrants of advanced age (Valtonen, 2002). Formal services tailored to the cultural needs of the community are easily accessible in Chinatown (Y. Y. Chao et al., 2020), and the availability of formal care without linguistic barriers or providing interpretation services in Chinatown facilitates older immigrants’ utilization of mental health services (Chung et al., 2018). In addition, enclave residence may facilitate the development of supportive social relations and networks with peers of similar backgrounds and experiences (Gresenz et al., 2009; Zhou & Lin, 2005). For older Chinese immigrants, living in Chinatown could provide cultural and social connections that facilitate their access to and utilization of mental health services. However, the relationship between Chinatown residence and depression help-seeking behaviors among U.S. Chinese older adults remains poorly understood.

Reasons for migration and mental health service use

Prior research has shown that most older immigrants migrate to the United States to provide childcare and other household assistance to their employed adult children (Treas & Mazumdar, 2004). These older immigrants, who are classified as having family reunification immigration status, can access social support and care from their existing kinship relations upon arrival (Carr & Tienda, 2013; Jasso & Rosenzweig, 1995; Newbold & Filice, 2006). Having easy access to family-based networks can assist older Chinese immigrants with language and cultural brokering, which in turn enhances their access to and utilization of mental health services (Newbold, 2009; Treas & Mazumdar, 2004). For instance, adult children can provide interpretation and assistance to their immigrant parents in health-related decisions, which enables them to access formal services (Chung et al., 2018). Older immigrants who migrate for non-family reasons, such as employment-based immigrants and refugees, may not have easy access to such family-based supportive networks to navigate the U.S. healthcare systems (Jasso & Rosenzweig, 1995). Considering the documented role of family networks in immigrants’ healthcare access (Newbold, 2009), we postulated that Chinese older immigrants who migrated for family reunification would be more likely to utilize mental health services than those who migrated for other reasons.

Using a large population-based sample of older Chinese Americans, the objectives of this study were to 1) examine patterns of their depression help-seeking behaviors (i.e., formal help, informal help, and a combination of both formal and informal help); and 2) investigate the relationship between immigration-related factors (level of acculturation, length of residence in U.S., Chinatown residence, reasons for migration) and patterns of depression help-seeking behaviors. It was hypothesized that higher levels of acculturation (H₁), longer residence in the United States (H₂), and Chinatown residence (H₃) would be associated with a higher likelihood of seeking help from formal sources. In addition, we hypothesized that those who immigrate for family reasons are more likely to seek formal and informal help relative to not seeking any help (H₄). To the best of our knowledge, this is the first study investigating the depression help-seeking behaviors of U.S. Chinese older adults using population-based representative data. The study findings have the potential to inform the development of intervention strategies and services to address racial/ethnic disparities in mental health service use in the diverse U.S. aging population.

Analytic framework

This study was guided by the Andersen behavioral model (Andersen & Newman, 2005), which has been used in previous studies to examine mental health service utilization among older Asian populations (Kim et al., 2010; Park et al., 2013). According to this model, individuals’ utilization of mental health services is influenced by three groups of factors: 1) their propensity to use mental health services (predisposing factors), 2) their ability to secure resources to access the services (enabling factors), and 3) their need for the services (need factors; Andersen & Newman, 2005). In this study, predisposing factors were age, gender, marital status, education, and immigration-related factors. Enabling factors were income, health insurance coverage, and household size, and need factors were self-reported health, physical limitations, and depressive symptoms.

Methods

Sample and setting

The data were from the Population Study of Chinese Elderly in Chicago (PINE), a population-based prospective cohort study examining the health and well-being of U.S. Chinese older adults. Details of the design and implementation of the PINE study have been published elsewhere (Dong, 2014; Dong, Wong, et al., 2014). The analyses used cross-sectional data from 3,132 Chinese older adults who completed face-to-face interviews between 2013 and 2015. Structured in-person interviews were conducted by trained bicultural and multilingual research assistants in respondents’ preferred language or Chinese dialect, including English, Mandarin, Cantonese, and Taishanese. All respondents signed informed consent forms. The institutional review board of Rush University Medical Center approved the study protocol. The analytic sample was limited to participants who reported any depressive symptoms (n = 907), as measured by the nine-item patient health questionnaire (PHQ-9; detailed information provided in the Measures section).

Measures

Dependent variables

The dependent variable in this study is help-seeking behaviors related to depression, assessed by asking respondents whether they sought help from a list of people or organizations regarding their depressive symptoms. The sources of help were categorized into formal sources (i.e., Western primary care physicians, Chinese medicine doctors, mental health professionals, community social services organizations, allied healthcare professionals, and phone helplines) and informal sources (i.e., partners, parents, adult children, children-in-law, grandchildren, other family members, friends/neighbors/colleagues, and religious workers). A similar categorization of sources of help has been used in prior studies (Brown et al., 2014; Cabassa & Zayas, 2007), to which we added Chinese medicine doctors as a formal source of help due to its relevance as an alternative treatment for mental disorders among older Chinese Americans (Y. Y. Chao et al., 2020). Four categories of help-seeking behaviors were then created to describe the overall patterns of help-seeking behaviors, including not seeking help, seeking help from informal source(s) only, seeking help from both informal and formal sources, and seeking help from formal source(s) only.

Independent variables

Immigration-related factors were level of acculturation, length of residence in the U.S. (in years), Chinatown residence (1 = yes, 0 = no), and reasons for migration (1 = migrated to reunite with spouse, children, or other family members, 0 = others). Acculturation level was measured using a 12-item scale assessing participants’ preference for speaking English or Chinese in various settings, using Chinese or English media, and having Chinese or American social contacts. Participants responded on a 5-point scale: 1 (only Chinese), 2 (more Chinese than English/American), 3 (both equally), 4 (more English/American than Chinese), and 5 (only English/American). The total score ranged from 12 to 60, with higher scores indicating greater levels of acculturation (Cronbach’s alpha = 0.88; Dong et al., 2015).

Covariates

Besides immigration-related factors, predisposing factors included age (in years), gender (male/female), marital status (married/not married), and educational attainment (in years). Enabling factors included income (self-reported annual income from all sources), health insurance coverage (yes/no), and household size (number of people in the household besides self). Need factors included self-reported health, functional limitations, and depressive symptoms. Self-reported health was assessed by asking participants, “In general, how would you rate your health?” on a 4-point scale ranging from 1 (poor) to 4 (very good). Functional limitations were measured by summing scores from the Katz index of activities of daily living (Cronbach’s alpha = 0.92) and the Lawton instrumental activities of daily living scales (Cronbach’s alpha = 0.90) (Dong, Chang et al., 2014). The total score ranged from 0 to 20, with a higher score indicating more functional limitations. Depressive symptoms were measured using a 9-item version of the patient health questionnaire (PHQ-9; Kroenke & Spitzer, 2002). Participants were asked to rate the extent to which they experienced nine symptoms: little interest or pleasure in doing things, feeling down, sleep problems, having little energy, poor appetite or overeating, feeling bad about themselves, trouble concentrating on things, feeling restless, and thoughts of being better off dead. The total score ranged from 0 to 27, with a higher score indicating higher levels of depressive symptoms (Cronbach’s alpha = 0.82; Chang et al., 2014).

Data analysis

Descriptive statistics were used to summarize the sample characteristics. Multinomial logistic regression models were conducted to examine the relationships between immigration-related factors and types of depression help-seeking behaviors, controlling for covariates. Independent variables were entered into regression models in a stepwise fashion according to the Andersen model: Model 1 contained immigration factors and predisposing factors, Model 2 contained the variables in Model 1 and the enabling factors, and Model 3 contained the variables in Model 2 and the need factors. All analyses were conducted using SAS Version 9.2 (SAS Institute Inc., Cary, NC).

Results

Sample characteristics

Table 1 summarizes the sample characteristics based on depression help-seeking categories. Among the respondents, 66% were female, 65% were married, 88% had health insurance, 82% rated their health as poor or fair, 58% lived in Chinatown, and 74% had migrated to the United States to reunite with their families. On average, the participants were 75 years old, had lived in the United States for 21 years, and had 8.8 years of education, three ADL/IADL limitations, and low levels of acculturation (M = 15.38 out of 60). Overall, compared to U.S. Chinese older adults who did not seek help, those who sought any type of help were significantly more likely to be younger, female, and married, and have more depressive symptoms, shorter length of U.S. residence, and higher levels of acculturation.

Table 1. Sample characteristics by help-seeking categories.

Variables	Total sample (N = 907)	No help (n = 211)	Informal help only (n = 350)	Formal help only (n = 79)	Informal & formal help (n = 257)	p value
Age, mean (SD)	74.78 (8.30)	76.59 (8.65)	73.20 (7.64)	78.07 (8.42)	75.07 (8.21)	<.0001
Gender, n (%)
Female	655 (66.36)	128 (60.66)	250 (71.43)	46 (58.23)	176 (68.48)
Male	332 (33.64)	83 (39.34)	100 (28.57)	33 (41.77)	81 (31.52)	0.0193
Marital status, n (%)
Married	640 (64.91)	120 (57.14)	243 (69.43)	39 (49.37)	170 (66.15)
Not married	346 (35.09)	90 (42.86)	107 (30.57)	40 (50.63)	87 (33.85)	0.0009
Education, mean (SD)	8.75 (5.27)	8.43 (5.81)	9.80 (5.21)	8.23 (5.57)	7.90 (4.70)	<.0001
Health insurance, n (%)
Yes	867 (87.84)	190 (90.05)	285 (81.43)	76 (96.20)	238 (92.61)
No	120 (12.16)	21 (9.95)	65 (18.57)	3 (3.8)	19 (7.39)	<.0001
Income, mean (SD)	1.90 (0.91)	1.97 (1.04)	1.86 (0.89)	1.95 (1.04)	1.91 (0.79)	0.4997
Overall health status, n (%)
Poor	407 (41.24)	3 (1.42)	7 (2.00)	1 (1.27)	3 (1.17)
Fair	402 (40.73)	39 (18.48)	57 (16.29)	10 (12.66)	32 (12.45)
Good	159 (16.11)	81 (38.39)	147 (42.00)	37 (46.84)	104 (40.47)
Very good	19 (1.93)	88 (41.71)	139 (39.71)	31 (39.24)	118 (45.91)	0.6680
Functional limitations, mean (SD)	2.88 (3.75)	2.93 (3.83)	2.60 (3.85)	3.28 (2.93)	3.14 (3.72)	0.0003
Depressive symptoms, mean (SD)	5.44 (4.57)	5.16 (4.25)	5.94 (4.88)	5.80 (4.66)	5.67 (4.62)	0.2013
Acculturation, mean (SD)	15.38 (4.48)	16.08 (5.76)	15.53 (4.27)	14.30 (2.73)	15.18 (4.11)	0.0085
Length of U.S. residence, mean (SD)	21.47 (12.48)	23.28 (12.85)	19.08 (11.85)	24.09 (11.66)	22.66 (11.97)	<.0001
Chinatown residence, n (%)
Yes	569 (58.24)	119 (57.21)	192 (55.33)	60 (75.95)	153 (60.00)
No	408 (41.76)	89 (42.79)	155 (44.67)	19 (24.05)	102 (40.00)	0.0085
Family reunification, n (%)
Yes	735 (74.47)	161 (76.30)	248 (70.86)	58 (73.42)	202 (78.60)
No	252 (25.53)	50 (23.70)	102 (29.14)	21 (26.58)	55 (21.40)	0.1621

The p value refers to the difference between the 4 help-seeking categories.

Patterns of help-seeking behaviors

Of the entire sample, 23.5% did not seek help for depressive symptoms, 40% sought help from informal sources only, and 28.7% sought help from both informal and formal sources. Only 8.8% of the sample sought help from formal sources exclusively. Table 2 presents the frequencies of specific types of help sought by the respondents. The most frequently used sources of informal help were adult children (44.4%), partners (38.4%), and friends/neighbors/colleagues (28.5%). The most frequently used sources of formal help were primary care physicians (32.1%), allied healthcare professionals (such as social workers and nurses; 4.9%), and Chinese medicine doctors (such as herbalists and acupuncturists; 3.0%). Less than 1% of respondents sought help from mental health professionals (such as psychologists and psychiatrists).

Table 2. Frequencies of specific types of help sought among those who sought help.

	Specific sources of help sought^a	Frequencies,^bn (%)
Informal sources of help	Adult children	410 (44.42)
	Partner	354 (38.35)
	Friends, neighbors, colleagues	263 (28.49)
	Other family members	109 (11.83)
	Children-in-law	101 (11.48)
	Grandchildren	47 (5.09)
	Religious workers (from church, temples)	36 (4.01)
	Parent	11 (1.19)
Formal sources of help	Primary care physicians^a	288 (32.11)
	Allied healthcare professionals ^b	44 (4.91)
	Chinese medicine doctors^c	27 (3.01)
	Community social services organizations	16 (1.78)
	Mental health professionals^d	7 (0.78)
Any help	Help sought from any listed sources	714 (76.94)

^aIncluded family doctors, geriatricians, internists.

^bIncluded social workers, nurses, physical therapists.

^cIncluded traditional Chinese medicine practitioners, herbalists, acupuncturists, massage therapists.

^dIncluded psychologist, psychiatrist.

Immigration-related factors and depression help-seeking behavior patterns

The results from the full regression models predicting the four types of help-seeking behaviors (with not seeking help as the reference group) are presented in Table 3. The results from the stepwise models are not shown, because the results remained largely unchanged. The results showed that U.S. Chinese older adults who had lower levels of acculturation (OR = 0.87, 95% CI = 0.79–0.97) and who lived in Chinatown (OR = 2.19, 95% CI = 1.13–4.28) were more likely to seek help from formal sources only (relative to not seeking any help). The associations between immigration-related factors and seeking help from informal sources only and both informal and formal sources were not statistically significant.

Table 3. Multivariable associations between immigration-related factors and depression help-seeking behaviors (reference group is “no help”).

	Informal help only	Formal help only	Informal & formal help
	OR (95% CI)	OR (95% CI)	OR (95% CI)
Predisposing factors
Immigration-related factors
Acculturation	0.97 (0.93, 1.02)	0.87 (0.79, 0.97)*	0.91 (0.91, 1.01)
Length of U.S. residence	0.99 (0.97, 1.01)	1.00 (0.97, 1.03)	1.01 (0.99, 1.03)
Chinatown residence	1.27 (0.85, 1.98)	2.19 (1.13, 4.28)*	1.11 (0.73, 1.70)
Family reunification	0.66 (0.43, 1.02)	1.06 (0.56, 2.01)	1.05 (0.66, 1.66)
Age	0.96 (0.93, 0.99)**	0.99 (0.95, 1.04)	0.97 (0.94, 1.00)*
Female	2.08 (1.38, 3.14)**	0.96 (0.52, 1.75)	1.52 (0.99, 2.33)
Married	1.49 (0.97, 2.29)	0.85 (0.45, 1.58)	1.62 (1.03, 2.54)*
Education	1.07 (1.03, 1.11)**	1.05 (0.99, 1.12)	1.00 (0.96, 1.04)
Enabling factors
Health insurance	0.72 (0.39, 1.34)	2.31 (0.61, 8.74)	1.66 (0.80, 3.43)
Income	0.94 (0.75, 1.18)	1.11 (0.75,1.64)	1.01 (0.79, 1.28)
Household size	0.93 (0.84, 1.04)	0.90 (0.75, 1.07)	0.96 (0.86, 1.07)
Need factors
Overall health status	1.17 (0.91, 1.50)	1.08 (0.75, 1.56)	0.92 (0.71, 1.20)
Physical function	1.03 (0.97, 1.09)	1.00 (0.92, 1.09)	1.03 (0.97, 1.09)
Depressive symptoms	1.05 (1.01,1.10)*	1.02 (0.96, 1.09)	1.02 (0.98, 1.07)

OR = Odds Ratio. CI = Confidence Interval.

***p < .001, ** p < .01, *p < .05.

Among other covariates, younger age (OR = 0.97, 95% CI = 0.94–1.00), and being married (OR = 1.62, 95% CI = 1.3–2.54) were associated with a higher likelihood of seeking help from both informal and formal sources. In addition, U.S. Chinese older adults with younger age (OR = 0.96, 95% CI = 0.93–0.99), female gender (OR = 2.08, 95% CI = 1.38–3.14), higher educational levels (OR = 1.07, 95% CI = 1.03–1.11), and more depressive symptoms (OR = 1.05, 95% CI = 1.01–1.10) were more likely to seek help from informal sources only, relative to not seeking help from any sources.

Discussion

Using large-scale population-specific data, this study examined patterns of depression-related help-seeking among U.S. Chinese older adults and the relationship between immigration-related factors and their help-seeking behaviors. Our results indicate that nearly one in four (24%) U.S. Chinese older adults with depressive symptoms did not seek help at all, highlighting the potential unmet mental health needs of this population. Further, they reported low utilization of specialized mental health services, such as those provided by psychiatrists (less than 1%) and social workers (less than 5%), reaffirming mental health service underutilization as a major mental health disparity among Asian Americans (Sue et al., 2012).

It is also worth noting that primary care physicians were the most frequently sought source of formal help in our sample (32.1%). This finding is in line with the extant literature documenting the tendency of Chinese Americans to present with somatic symptoms for mental disorders (Kong et al., 2019; Parker et al., 2001; Wu et al., 2010). However, the discrepancy in the frequency of visits to mental health specialists contradicts earlier research indicating that primary care physicians frequently refer individuals to specialists for treatment (A. W. Chen et al., 2010). One possible explanation is that Chinese immigrants may face difficulties communicating their mental health problems to primary care physicians due to language and cultural differences, resulting in delays in receiving a diagnosis. It is also possible that even when primary care providers refer them to specialists, they do not access appropriate services.

The findings showed that U.S. Chinese older adults with depressive symptoms most frequently solicited help from informal sources, either exclusively (39.0%) or in combination with formal help (28.7%). The strong reliance on informal help, particularly on adult children (44.4%) and spouses (38.4%), is consistent with existing studies documenting the preference for informal help with mental disorders among ethnic minorities (Kung, 2003; Woodward et al., 2011). By considering both formal and informal sources of help, our findings also showed that a sizable proportion (28.7%) of U.S. Chinese older adults sought help from formal and informal sources simultaneously to cope with their depressive symptoms. Practitioners working with this population need to be cognizant of this complementary help-seeking approach.

We also examined immigration-related factors in relation to the aforementioned help-seeking patterns. Contrary to our first hypothesis, U.S. Chinese older adults with higher levels of acculturation were less likely to use formal help exclusively to cope with depression than their less acculturated counterparts. Findings from prior research on this association have been inconsistent. Most studies have reported a positive relationship between acculturation level and mental health service use (Kung, 2003; S. Lee & Jang, 2016), while others have found no significant association between the two variables (Ramos-Sánchez & Atkinson, 2009). It is possible that U.S. Chinese older adults with higher acculturation levels are more likely to live outside of Chinatown. For these older immigrants, barriers such as language difficulties and a lack of transportation to culturally and linguistically appropriate mental health services may contribute to their lower likelihood of seeking help from formal sources only.

With regard to our second hypothesis, the relationship between length of stay in the United States and help-seeking behaviors was not significant. Length of stay in the host society has been commonly used as a proxy for acculturation experience, assuming that a longer stay in the host society is associated with greater opportunities for acculturation and assimilation. In our sample, the majority of the respondents (65%) migrated in later life (50+), and most migrated to reunite with their families. Family-driven migration in later life is associated with limited opportunities for acquiring a new language or new job, regardless of length of residence in the United States. This may partially explain the lack of association between length of residence and respondents’ mental health-related help-seeking behaviors.

Our third hypothesis was supported by the findings, showing that U.S. Chinese older adults who lived in Chinatown were more likely to seek help from formal sources to cope with depressive symptoms. This finding underlines the importance of the community context in understanding help-seeking behaviors among aging migrant populations. This finding is congruent with a broader body of evidence documenting the facilitating role of residence in ethnic enclaves in immigrants’ access to care (Choi, 2009). Mental health services in Chinatown are more likely to be culturally and linguistically concordant to meet the specific mental health needs of older Chinese immigrants, leading to a greater likelihood of these services being utilized.

The associations between family-based immigration and help-seeking from formal and informal sources were not statistically significant. We postulate that the attributes of family relationships, such as the quality and closeness of family relations, may exert a more significant influence on depression help-seeking than immigration-related factors. Future qualitative studies are necessary to elucidate the determinants of informal mental health help-seeking behaviors among older Chinese Americans.

Limitations

Several limitations of this study warrant discussion. First, the cross-sectional design of this study limits our ability to determine causal relationships among the factors. Second, the data in this study were collected in Chicago, and the findings may not be generalizable to older Chinese adults in other geographic areas and other Asian populations. Third, help-seeking behaviors were self-reported and may be subject to recall bias, and future studies using service claims data could verify these findings. Fourth, due to the limitations of the secondary analysis, additional factors related to depression help-seeking, such as knowledge and perceptions of mental health, attitudes and stigma related to mental health help-seeking, English language proficiency, socioeconomic status (e.g., wealth and financial support from children), and the level of closeness to family members, were not examined in this study. This calls for further research utilizing more refined datasets. Fifth, the data used in this study were collected between 2013 and 2015 and do not capture the impact of recent events such as the COVID-19 pandemic on mental health help-seeking.

Clinical implications

Despite these limitations, our findings have significant clinical and research implications. Informal sources represent the main source of help for U.S. Chinese older adults with depressive symptoms. Collaborating with informal caregivers may be a culturally appropriate approach for enhancing the recognition and timely treatment of mental issues in the Chinese community. When families recognize and acknowledge the need for formal support systems and actively seek help from them, the capacity of formal support systems to provide prompt assistance is important. There is a pressing need for mental health professionals who possess the cultural and linguistic competence to cater to the mental health needs of older Chinese Americans.

Furthermore, the high frequency of help-seeking from primary care physicians indicates that a collaborative care model, in which mental health professionals collaborate with primary care clinicians, may be a promising approach to promoting U.S. Chinese older adults’ access to mental health services. Outreach and community education programs from existing mental health services are needed. Such outreach initiatives need to consider the needs of Chinese older adults who live outside of ethnic enclaves. Leveraging the existing ethnic mental health organizations and infrastructures in Chinatown is also recommended (J. S. Yang & Kagawa-Singer, 2007).

Ethnicity-specific barriers and facilitators in seeking formal help for mental disorders among Chinese Americans warrant further investigation. Qualitative studies are particularly suitable for generating nuanced understandings of such barriers and facilitators and the lived experiences of the Chinese community regarding mental health help-seeking behaviors. In addition to disparities in access to culturally and linguistically appropriate care, future studies should examine differences in the quality of mental health care and its determinants among U.S. Chinese older adults. Understanding the relationship between Chinese-specific cultural factors (such as face concern and harmony) and depression help-seeking behaviors should be an objective of future research.

Conclusion

U.S. Chinese older adults with depressive symptoms reported low utilization of help from formal sources, particularly specialized mental health services. Instead, they mainly relied on informal sources of help, either exclusively or in conjunction with formal sources of help, to address their depressive symptoms. The findings demonstrate the importance of immigration-related factors (i.e., acculturation and residence in ethnic enclaves) in understanding depression help-seeking behaviors in this minority aging population. Leveraging informal support networks and ethnicity-specific resources in Chinatown represents a culturally appropriate approach to facilitate mental health help-seeking among older Chinese Americans.

Clinical implications

• Culturally appropriate intervention strategies for informal caregivers, particularly adult children, are imperative in addressing U.S. Chinese older adults’ mental health needs.

• A collaborative care model for promoting mental health service access holds potential in the Chinese community.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available on request from the corresponding author.

Additional information

Funding

Dr. Dong is supported by R01MD006173, R01AG042318, R34MH100443, R01NR014846, 09EJI0015, 09EJI0016, and P30AG059304