research

Depression and Anxiety among Asian Americans: The Effects of Social Support and

Strain Cindy C. Sangalang and Gilbert C. Gee

It is almost taken for granted that social relationships benefit mental health, yet these rela- tionships may not always be protective. This study examines how the support and strains individuals derive from family and fiiends may be related to depression and anxiety among Asian Americans. Data come from the 2002-2003 National Latino and Asian American Study, the first nationally representative study of mental health outcomes among Asian Americans (rt = 2,066). Results indicate that farrdly support was associated with decreased odds oí Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) criteria for both major depressive disorder (MDD) and generalized anxiety disorder (GAD) among men and women. In addition, family strain was associated with increased odds of GAD equally among men and women. However, fiiend strain was associated with increased odds of GAD among women but not men, and faniüy strain was marginally associated with increased odds of MDD for women but was unrelated for men. The findings affirm the need to consider social strain along with social support, as well as their sources, with attention to the potentially stronger effects of strain for women. Implications for social work practice are discussed.

KEY WORDS; Asian Americans; mental health; social strain; social support; women

C onventional wisdom indicates that receipt of social support is universally beneficial. Social support from network

ties is beheved to be a fundamental aspect of psy- chological well-being and the therapeutic process (Kawachi & Berkman, 2001); however, social strain rooted in the same support networks may contribute to poorer mental health outcomes (Rook, 1992). Furthermore, research suggests support and strain may differentially affect men and women (Umberson, Chen, House, Hopkins, & Slaten, 1996). Recent research suggests that social networks and the ways individuals use these networks may also vary by culture, yet studies on minority communities, such as Asian Americans, are limited (H. S. Kim, Sherman, Ko, & Taylor, 2006).

Asian Americans are one of the fastest-growing minority groups in the United States (U.S. Census Bureau, 2011). Although prior research suggests that Asian Americans have lower rates of psychological disorder and use of mental health services than other racial and ethnic groups (Matsuoka, Breaux, & Ryujin, 1997), recent

studies indicate a substantial need for mental health care among Asian Americans (ManhaU, Schell, Elliott, Berthold, & Chun, 2005; Mui & Kang, 2006; Takeuchi et al., 2007). Shame and stignia associated with mental ulness may discour- age people from using formal mental health ser- •vices. This may be particularly true among Asian Americans, who often rely on famüy and members of their informal networks for support of their mental health problems (Leong & Lau, 2001; Spencer & Chen, 2004).

The purpose of this study is to investigate the effect of social support and strain on mental health among Asian Americans. This study has several unique features. First, in contrast to prior studies that only focus on either support or strain, we examine both factors simultaneously whüe distin- guishing between support and strain from friends and from farrdly. Second, we investigate major depressive disorder (MDD) and generalized anxiety disorder (GAD) because these are clinical outcomes that contribute to considerable disabuity (World Health Organization, 2001). Third, we explore possible gender differences in these

doi: 1O.1O93/sw/swrOO5 ® 2012 National Association of Social Workers 49

relations. Finally, we examine these issues among an understudied population and use a nationally representative sample.

BACKGROUND

Social Support, Social Strain, and Well-Being A large body of hterature has described the salu- brious effects of social support (Berkman 8c Glass, 2000; House, Landis, & Umberson, 1988). Berkman and Glass described social support as emotional, instrumental, tangible, and informa- tional resources that individuals obtain firom their network ties. These resources are known to promote mental health by enhancing self-esteem, strengthening effective coping, and mitigating dis- tress. In studies on Asian Americans, social support has been negatively associated with accul- turative stress and depression (Mui, 2001; Yeh & Inose, 2003). Social support also buffered the effect of Stressors on mental and physical health among diverse Asian American groups (Choi, 1997; Gee et al., 2006).

Other research suggests that Asian cultural values related to collectivism can limit the health- ful benefits of social support. In contrast to Western individualism, a coUectivist orientation may hinder disclosure of personal problems for fear of burdening others, disrupting group harmony, or losing face (B.S.K. Kim, Atkinson, & Umemoto, 2001; H. S. Kim et al., 2006). Indeed, some studies have found that compared with white Americans, Asian Americans appear less hkely to seek social support in response to stress (Taylor et al., 2004) or after breast-cancer treat- ment (WeUisch et al., 1999). H. S. Kim et al. (2006) found that Asian American students sought less support firom family and friends and, further, perceived support to be less helpful in deahng with stress than white students. Taken together, the conflicting findings regarding social support's effectiveness for Asian Americans demonstrate a need for further investigation.

An emerging body of research suggests that the very relationships that provide support can also engender strain. Social strain includes conflicts, feelings of undue obhgation, and demands from one's friends and family (Lincoln et al., 2010; Lincoln, 2000; Mittelmark, 1999; Rook, 1992). Because greater attention is given to positive

rather than negative components of social interac- tions, only a handful of studies have simultaneous- ly examined both social support and social strain (Lincoln, 2000).

Some studies have found that strain and support are independently associated with well-being, such that strain is associated with diminished mental health while support is associated with improved mental health (Revenson, Schiaffino, Majerovitz, & Gibofsky, 1991; Stephens, Kinney, Norris, & Ritchie, 1987). Other studies have found that social strain exerts more robust effects on psychological well-being than social support (Fiore, Becker, & Coppel, 1983; Rook, 1984). Although promising, these studies have tended to focus on specific Stressors (for example, caregiving to spouses with Alzheimer's disease), which can obscure the presence of multiple straining rela- tionships and contexts (Fiore et al., 1983; Mittelmark, 1999). Moreover, these studies used speciahzed, nonrepresentative samples, raising questions about generalizabOity to other popula- tions (Monette, Sullivan, & Dejong, 2005).

The coUectivist orientation that characterizes many Asian cultures can also trigger social strain rooted in obhgation, expectations, and norms of reciprocity (B.S.K. Kim et al., 2001). For example, Asian Americans who are family oriented may feel burdened with obhgations that confhct with American norms of individuahsm (Yee, Huang, & Lew, 1998). Children and parents of Asian American famihes may have friction over parental expectations of educational and occupa- tional achievement (Yee et al., 1998). Individuals may face pressure to fulfill unspoken expectations of reciprocity and indebtedness to friends and other network des, such as the cultural value of utang na hob (feeling of mutual obligation) among Füipino Americans (Nadal, 2009). These aspects of cultural norms that can constrain social relations may not be captured in existing studies on social support for Asian Americans.

Social Support and Social Strain from Family versus Friends Family members and friends may not present the same types of support and strain. Family relation- ships are often of longer duration and can include legal responsibüities and benefits. Studies have produced equivocal evidence for family versus friend support, with some studies showing that

50 Social Work VOLUME 57, NUMBER I JANUARY 2011

famüy support may buffer health more (Procidano & HeUer, 1983; WeUisch et al., 1999), whereas other studies have found the convene (Walen & Lachman, 2000). These mixed findings may be due, in part, to the sampling of different cultural populations, in which the bonds of family may be more or less sahent than the bonds of fdendship.

With regard to Asian Amedcans, scholan have noted that the family is often the central social unit, not the individual (H. K. Kim & McKenry, 1998). Indeed, research suggests that many Asians avoid bdnging shame to their families (B. S. K. Kim et al., 2001) and have a strong sense of family obhgation (Fuhgni, 2001). Furthermore, family is often the fint line in seeking help for mental health problems (Lin, Inui, Kleinman, & Womack, 1982). Hence, family members may be more aware of one's mental health needs, and their support may play a greater protective role than support from one's fdends. Yet, for these same reasons, the strain from famuy may be even more salient than similar stresson coming from fdends.

Social Support, Social Strain, and Gender Gender may also influence how strain and support are related to mental health. Umbenon et al. (1996) descdbed the ways in which social relation- ships may have greater demands and responsibil- ities for women than for men. One factor relates to increased exposure to stress due to role strain. Compared with men, women tend to have add- itional demands from vadous relationships, par- ticularly for those who have chüdren, are manried, or care for Ul family memben (Umbenon et al., 1996). Another factor involves differential sensitiv- ity to social strain. Several scholan have suggested that social relationships are more important for women than men and that disordered relation- ships may be particularly harmful for women (BeUe, 1982; Miller, 1988). Accordingly, this sug- gests that social strains may place a greater psycho- logical burden on women than men.

Studies indicate that social support for Asian Amedcan women is pdmarily family based (Meemeduma, 1992; WeUisch et al., 1999). WeUisch et al. found that Asian Amedcan women survivon of breast cancer relied less on social support compared to Anglo Amedcan women, in hne with previous work that suggests Asian Amedcan women prefer to provide rather than

receive care and are concerned with maintaining interpenonal harmony. Taken together, the afore- mentioned hnes of research suggest that social support may be less protective of mental illness for women than men and, further, that social strain may be more strongly related to mental Ulness for women than for men. Moreover, the effects of family support and strain should be stronger among women for these same reasons.

Based on the hterature, we examine the foUow- ing four hypotheses:

1. Social support is related to lower dsk of de- pressive disorder and generahzed anxiety disorder.

2. Social strain is related to higher dsk of de- pressive disorder and generahzed anxiety disorder.

3. Support and strain firom family wül be more strongly related to these mental health pro- blems than support and strain from fdends.

4. Gender wül moderate these associations, such that famuy or fdend support wül be more protective for women and strain wül be a greater dsk for women than men.

Because depressive disorder and generahzed anxiety disorder (CAD) often co-occur (Bakish, 1999), we anticipate that the relationship between both social support and social strain wül have par- aUel effects across both disorden.

METHOD Data and Sampling This study is based on data from the National Latino and Asian Amedcan Study (NLAAS), a psychiatdc epidemiologic survey conducted between 2002 and 2003 across the United States (Alegda et al., 2004a, 2004b; Heerenga et al., 2004). Eligible respondents were age 18 yean or older and were not in the muitary or institutiona- hzed. The current analysis is restdcted to Asian Amedcan respondents.

The NLAAS used a three-stage stratified prob- abüity sampling design. Fint, pdmary stage units of single counties or groupings of adjacent coun- ties were devised into strata on the basis of size, location, and population charactedstics. Second, within primary stage units, census blocks compds- ing area segments were stratified by geographic

SANGALANG ANO G E E / Depression and Anxiety among Asian Americans 51

location and the race/ethnicity of household respondents. High-density supplemental samples were obtained firom areas with five percent or greater of targeted ethnic groups. Sampling was performed within probabilities proportionate to census blocks for each area segment. Third, sys- tematic random sampling was used to select housing units within area segments. Within con- senting households, eligible main respondents were randomly selected, and then secondary respondents from the same household were also recruited. Interviews were conducted in the respondents' choice of Cantonese, English, Mandarin, Spanish, Tagalog, or Vietnamese using computer-assisted survey instruments. The re- sponse rate was 69.3 percent for main respondents and 73.7 percent for secondary respondents. Sample weights were developed to account for the complex sampling design and to allow esti- mates to be nationally representative (Heerenga et al., 2004).

The NLAAS is designed to be valid and reliable for diverse Asian and Latino communities. Briefly, this involved five steps: (1) identification of con- structs that are relevant to the target population; (2) collaboration among a multicultural study team that included researchers with ethnic back- grounds similar to those of the target population; (3) translations and back-translations of research materials, and by extension, the availability of the study in sbc languages; (4) use of key-informant interviews with members of the target population across several states (and in Puerto Rico) to assess materials; and (5) pilot testing and revision of the materials as needed. Further details are available elsewhere (Alegria et al., 2004a, 2004b).

Participants The Asian Ametican subsample includes 2,095 respondents. The current analysis is restricted to individuals with no missing values for variables of interest (n = 2,066). Weighted sample characteris- tics are presented in Table 1.

Measures MDD and GAD. The dependent variables were based on measures from the World Health Organization's expanded version of the Composite International Diagnostic Interview (WHO-CIDI) (World Mental Health Survey Consortium, 2004). Diagnostic outcomes were

derived from algorithms of participant responses to the WHO-CIDI that were then used to classify an individual as meeting criteria for MDD or GAD, respectively, as defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) (DSM-IV-TR) (American Psychiatric Association [APA], 2000). These dichotomous

Table 1: Sample Characteristics of Asian Americans in the National Latino and

Asian American Study, 2002-2003 (n = 2,066)

DSM-IV—TR major depressive disorder (past 12 months)

DSM-IV—TR generalized anxiety disorder (past 12 months)

Family support (range: 1—4)

Friend support (range: 1—4)

Family strain (range: 1—4)

Friend strain (range: 1-4)

Gender

Male

Female

Age (range: 18-95 years)

Ethnicity

Chinese

Filipino

Vietnamese

Other Asian

Education

Less than high school

High school graduate

Some college

College graduate

Work status

Employed

Unemployed

Not in the labor force

Marital status

Married

Divorced/separated/widowed

Never married

Nativity status

U.S. born

Foreign born

Region

West

Northeast

Midwest

South

4.6

1.4

47.41

52.59

28.51 21.58

12.87 37.04

14.29 17.77 25.07 42.87

63.82 6.40

29.78

68.66

8.31 23.03

23.7 76.30

68.01

15.53 8.56 7.89

2.73 2.66 1.96 1.68

41.27

0.03 0.03 0.02 0.02

0.70

Notes: Data are weighted to reflect population percentages. DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders {4th ed., text rev.) (American Psychiatric Association, 2000).

52 Social Work VOLUME 57, NUMBER I JANUARY 2012

variables indicated the presence or absence of the disorder within the past 12 months (0 = absent, 1 = present).

Social Support among Family and Friends. Social support was measured with a brief six-item scale previously examined in the NLAAS with Latinos by Mulvaney-Day, Alegria, and Sribney (2006). Three questions asked about the firequency of support (1 = none to 4 = a lot) by three specific means: (1) talking on the phone or getting to- gether with relatives, (2) relying on relatives for help with a serious problem, and (3) relying on relatives to talk about worries. Family support was assessed by averaging across these three items (Cronbach's alpha = 0.71); higher values indicated greater social support. The same three questions were repeated, but with regard to friends, to create an analogous measure of friend support (Cronbach's alpha = 0.77).

Social Strain among Family and Friends. Two items measured family strain, or the firequency of respondents' confiicts and demands with family members. Respondents were asked two questions: (1) how often their relatives and children make too many demands, and (2) how often they argue with family. Responses ranged from 1 = not at all to 4 = often. Items were averaged to create an index in which higher scores reflected greater strain (Cronbach's alpha = 0.59). Friend strain was measured with two similar items (Cronbach's alpha = 0.60).

Control Variables. The multivariate analyses control for the following sociodemographic char- acteristics: gender, age, education, work status, marital status, ethnicity, and nativity (immigrant versus nonimmigrant). These characterisdcs have all been previously related to psychological well- being and disorder (Aneshensel, Rutter, & Lachenbruch, 1991; Dohrenwend et al., 1992; Mirowsky & Ross, 1992; Peadin & Johnson, 1977; Stronks, Van De Mheen, Van Den Bos, & Mackenbach, 1997; Takeuchi et al., 2007).

Analysis We first examined bivariate relations between variables and then proceeded with multivariate models using logisdc regression for each depend- ent variable. First, we examined the associations between family support and the dependent vari- able (MDD or GAD within the past 12 months) and between friend support and the dependent

variable, controlling for covariates. Second, we examined the associations between faniuy strain and the dependent variable and between friend strain and the dependent variable, controlling for covariates. The final model included family support, friend support, family strain, friend strain, and covariates simultaneously. We then examined the effect of gender on the associations between support and strain and dependent variables with interaction terms. These analyses centered con- tinuous variables at their mean to reduce multi- coUinearity and to facilitate interpretation (Aiken & West, 1991). Finally, significant interacdons were graphed to aid interpretation. All analyses were weighted to account for complex sampling design and to make the estimates nationally repre- sentative. We used the Stata software program, version 10.0 (StataCorp, 2007).

RESULTS

Of the respondents, 4.6 percent could be classified as having MDD and 1.4 percent as having GAD within the past 12 months (see Table 1). Respondents as a whole reported moderate levels of social support; a mean of 2.73 from family and 2.66 from friends suggests that respondents relied on these people "sometimes." A relatively lower level of social strain was reported; a mean of 1.96 from family and 1.68 from friends indicates that conflicts and demands fix)m these people occurred "rarely."

The bivariate associadons between measures of social support and strain from family and friends and the odds of meeting criteria for MDD and GAD within the last year are presented in Table 2. Unadjusted bivariate analyses showed that family strain was positively associated with

Table 2: Bivariate Odds Ratios (ORs) of 12-Month Major Depressive Disorder

(MDD) and Generalized Anxiety Disorder (GAD) (n = 2,066)

IMDDJ [GÀDl

Family support

Friend support

Family strain

Friend strain

• O R S 0.75

1.35

1.83***

1.64

K.95%tCll 0.56, 1.00

0.91, 2.00

1.42,2.37

0.94, 2.88

• P R l 0.55*

1.06

1.90*

1.76

•95yo'[Cj 0.32, 0.94

0.59, 1.89

1.10,3.28

0.94, 3.28

Note: CI = confidence interval. *p<.05. ***p<.001.

SANGALANG AND GEE / Depression and Anxiety among Asian Americans 53

higher odds of MDD. Specifically, a one-unit in- crease in family strain resulted in 1.83 greater odds of MDD (95 percent confidence interval [CI] [1.42, 2.37]). Unadjusted bivariate analyses also showed that family support was negatively asso- ciated with the odds of meeting criteria of GAD (odds ratio [OR] = 0.55; 95 percent CI [0.32, 0.94]) and family strain was positively associated with the odds of meeting criteria of GAD (OR = 1.90; 95 percent CI [1.10, 3.28]).

Associations between Support and Strain and MDD Models la to 5a in Table 3 show the associations between support and strain firom family and friends and MDD, controlling for covariates (tables omit the covariates for parsimony, but they are available from the authors). These models indicated that both famuy support and family strain were associated with MDD within the last year. In model la, family support was associated with decreased odds of MDD (OR = 0.63; 95 percent CI [0.48, 0.83]), whereas in model 3a, family strain was associated with increased odds of MDD (OR = 1.63; 95 percent CI [1.28, 2.07]). We found no significant associations between friend support and MDD or fiiend strain and MDD (models 2a and 4a). With the inclusion of all of the support and strain variables, model 5a shows a similar pattern of relations, in which greater family support was associated with reduced odds of MDD (OR = 0.63; 95 percent CI [0.48, 0.82]) and greater family strain was associated with greater odds of MDD (OR = 1.15; 95 percent CI [0.64, 2.05]).

Associations between Support and Strain and GAD Models lb to 5b in Table 3 show the associations between support and strain firom family and fiiends and GAD, controlling for covariates. Model lb indicated that increased family support was protective against GAD (OR = 0.44; 95 percent CI [0.26, 0.74]). In model 3b, a one-unit increase in family strain was associated with 1.78 higher odds of meeting criteria for GAD (95 percent CI [1.04, 3.05]). Models 2a and 4a show that neither fiiend support nor friend strain was associated with GAD. In model 5b, family support and strain variables exerted similar effects on GAD with the inclusion of all independent

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54 Social Work VOLUME 57, NUMBER I JANUARY 2012

variables. Specifically, family support was nega- tively associated with meeting criteria for GAD (OR = 0.42; 95 percent CI [0.27, 0.65]). Further, in the presence of famüy support, family strain continued to be related to higher odds of meeting criteria for GAD (OR =1.69; 95 percent CI [1.13,2.51]).

The Moderating Effect of Gender Our analyses suggested that gender moderated strain. Specifically, we found a significant inter- action between gender and friend strain with GAD {p < .05) and a marginally significant inter- action between gender and family strain with MDD (p = .06). The interaction between friend strain and gender with GAD, wherein friend strain was associated with increased log odds of GAD among women but not among men is illu- strated in Figure 1. Among men, friend strain was associated with decreased log odds of GAD. In a similar manner. Figure 2 presents the interaction between family strain and gender with MDD. For both genders, family strain was associated with increased log odds of MDD, but this association appears attenuated among men compared with women. Finally, gender did not moderate the effect of support from family or friends on MDD or GAD.

Figure 1: Gender Differences in the Influence of Friend Strain on Generalized

Anxiety Disorder (GAD)

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DISCUSSION The aims of this study were to examine the main effects of social support and social strain firom family and fiiends on mental health variables (MDD and GAD) and to investigate possible gender differences in these relationships among a nationally representa- tive sample of Asian Americans.

Our data showed that support from famüy, but not friends, was associated with decreased odds of MDD and GAD, after controlling for sociodemo- graphic characteristics. Many studies combine support fi'om family and friends (for example, Noh & Kaspar, 2003; Taylor et al., 2004; Yang & Clum, 1995). Our study indicates that it is im- portant to consider who is providing this support.

Furthermore, strain from family, but not friends, was related to increased odds of MDD and GAD. These results are aligned with other studies that demonstrate greater levels of social strain are hnked to psychological distress and dis- order (Revenson et al., 1991; Walen 6¿ Lachman, 2000). In particular, measures of familial strain related to confiicts and demands such as those reported presently have also been captured in earher studies on Asian Americans that examined issues such as intergenerational confHct and care- giver burden (Adams, Aranda, Kemp, & Takagi, 2002; Ying& Han, 2007).

SANGALANG AND G E E / Depression and Anxiety among Asian Americans 55

Moreover, this finding demonstrates the con- tinued influence of family strain after controUing for receipt of support vadables and other demo- graphic charactedstics. This suggests that famuy support and strain are independent constructs that are not necessadly invenely related (Lincoln et al., 2010; Rook, 1984). Hence, future studies should not merely infer strain based on low social support but rather measure strain and support as distinct concepts.

Although strain and support from famüy were associated with GAD and MDD, there were no such associations for support from fdends. The prominence of famüy network faetón compared with fdendship network faetón is consistent with other research suggesting that for Asian popula- tions the major social unit is the fanúly (B. S. K. Kim et al., 2001). Although pdor research indi- cates that social support may be less effective for mitigating distress among Asian Amedcans com- pared with European Amedcans (H. S. Kim et al., 2006; Taylor et al., 2004), our findings provide another interpretation of these weaker associa- tions: Perhaps the effects were attenuated because past studies did not distinguish between famuy and fdends. We do not have non-Asian popula- tions represented in our study, although future re- search should examine whether some of the population differences in support could be explained by the source of support (that is, firom fdends venus famüy).

The data provided partial support for the hy- pothesis that the effects of support and strain vaded by gender. There were no gender differ- ences for support, but there were for strain. Strain firom relatives was related to increased dsk of MDD for women but not for men.

Several interpretations of these findings are pos- sible. The sahence of social relationships in women's lives may contdbute to a greater impact of social strain for women. If women's psycho- logical development is rooted in the quality of their social relationships, as Miller (1988) sug- gested, social strain may be more toxic for women than it is for men.

In addition the findings may be related to one's abüity to control his or her strains. Low control has been linked to the development of depression and anxiety (APA, 2000; Seligman, 1975). Women may be more hkely to encounter social strains that are less controUable in nature due to

gendered expectations about women's social roles. For example, women are often expected to be caregiven and may feel unable to avoid a caregiv- ing role (Adams et al., 2002). Men, on the other hand, may not face this type of role strain and may feel more able to escape from obligations and responsibüities tied to their social networks.

FinaUy, studies have descdbed gendered expres- sions of distress, in which men and women may equaUy expedence distress but express it different- ly. For example, women are more likely to be diagnosed with mood disorden, whereas men are more likely to be diagnosed with alcohol or sub- stance abuse (Aneshensel et al., 1991). The low prevalence of alcohol and drug abuse in our sample did not aUow for compadson across clinic- al outcomes. Future research should detennine whether our results are replicable and investigate the potential mechanisms that may underhe these potential gender differences.

A caveat, however, is that the interaction of gender and famüy strain for MDD was only mar- ginaUy statisticaUy significant. One interpretation is that this particular result was an artifact of the data because the interaction was significant at p< .06. That is, on the basis of a very stdct cdtedon of alpha, it would be reasonable to argue that men and women showed simuar associations between famuy strain and MDD. However, interactions are often statistically underpowered and the hne between .05 and .06 arbitrary (Abraham & RusseU, 2008; Aücen & West, 1991; Greenland, 1983). Hence, it would be prudent to consider these po- tential gender differences with the undentanding that future research is required to verify them.

There was also a statistically significant inter- action between strain firom fdends and gender with regard to GAD. Strain from fdends was related to increased dsk of GAD for women, but unexpectedly, this strain was related to decreased dsk for men. Hence, the nuU association between fHend strain and GAD seen in the aggregated ana- lysis resulted from the trends from women and men canceUing each other.

It is unclear why men seemed to have lower dsk of GAD with increasing strain. We speculate that there may be an omitted vadable related to how men process questions related to strain. GAD is often charactedzed by excessive worry (Borkovec & CosteUo, 1993). Perhaps men who report strain are simultaneously dismissive of these

56 Social Work VOLUME 57, NUMBER I JANUARY 2012

demands (for example, "my fiiends make too many demands on me, but that's them and I don't worry about it"). Future research is required to clarify the veracity of these ideas and mechan- isms that may underlie our anomalous finding.

In addition to the caveats already mentioned, several othen should be acknowledged. First, the low prevalence of MDD, GAD, and strain may contribute to type II errors—that is, diminished ability to detect potential relations, such as the as- sociation between friend support and MDD and GAD. Furthermore, these lô w rates may be re- flective of Western diagnostic criteria based on the DSM—IV—TR, which may have underestimated the actual prevalence of depression and anxiety due to cultural bias in instrumentation (Ying, 2002). This may be particularly relevant to the data in the sample as three-quarters of respondents are foreign bom.

Second, our measures coUapse across various types of social support and strain. For example, we were unable to distinguish between emotional and instrumental support. An important next step is to make these finer distinctions in the types of support and strain Asian Americans encounter. Indeed, one prior study found that instrumental, but not emotional, support was related to chronic physical ülness among Filipino Americans (Gee et al., 2006).

Third, cross-sectional data cannot confirm the causal direction of the hypothesized relationships. For example, the reverse may be true, with indivi- duals with depression and anxiety encountering greater strain from their social ties. Longitudinal data is needed to enhance our understanding of these relationships.

Fourth, we did not examine additional Stressors, such as caregiving responsibilities, physical health, or trauma exposure (Adams et al., 2002; Leong & Lau, 2001; Patterson & Garwick, 1994). It is im- portant to note that such variables can mutually affect and be influenced by social relationships as well as conditions like depression and anxiety. For instance, caregiving responsibilities may moderate family strain (that is, people who must care for family members may have more depression for a given level of family strain than people without such responsibilities). Future studies should include these and similar factors.

Fifth, although the internal consistency reliabil- ity of our social support measures are considered

acceptable, the Cronbach's alpha for the strain measures could be improved. This is not surpris- ing given that our strain measures consisted of only two items, and it is well known that alpha increases with the number of items in the scale. To check our findings, we performed additional analyses that used the individual items in lieu of the scales (not shown). These analyses are consist- ent with those reported here, suggesting that our findings are robust to the specification of the strain measures. Nonetheless, future studies should develop more comprehensive measures of strain.

Finally, due to the low prevalence of MDD and GAD, we did not disaggregate among Asian ethnic groups. However, a key step for future re- search would be to examine the diversity within Asian Americans. For example, the types of social strains experienced by Vietnamese Americans, who tend to have low rates of out-marriage and larger families, may differ from those of Japanese Aniericans, who tend to have higher rates of out- marriage and smaller families (Huang, Saenz, & Aguirre, 1997).

With these caveats recognized, several strengths of our study deserve mention. Fint, we analyzed the contributions of social support and strain sim- ultaneously. Second, we investigated important and clinically relevant mental disorders using a highly structured and previously validated instru- ment. The WHO-CIDI was developed by groups of experts from across the world, including Asian and Asian American collaborators, -who sought to develop a valid and reliable measure of mental dis- orders applicable across diverse cultures (Kessler & Ustun, 2006). Third, we examined an understud- ied but rapidly growing population. Finally, our data are nationally representative of Asian Americans living in the United States.

Social Work Implications Although social workers have generally recog- nized the positive sides of social relationships, our study serves as an important reminder not to assume that individuals always enjoy benefits firom their networks. Mental health interventions aimed at enhancing social support among indivi- duals with depression and anxiety may be more effective by understanding the quality of a client's social relationships. Our findings are consistent with what practitionen already understand—that individuals can have both positive and negative

SANGALANG AND G E E / Depression and Anxiety among Asian Americans 57

interactions with members of their social network. This notion can be commonly taken for granted, and social workers must be cognizant of the ways in which clients' relationships can both alleviate and cause psychological distress. Furthermore, greater specificity in our under- standing and assessment of the positive and nega- dve aspects of social relationships need to be developed for both research and practice (Lincoln, 2000).

With regard to cultural considerations for Asian American clients, a key finding is that social workers should pay close attention to strain and support (k>m family members in pardcular. Indeed, social workers should consider how Asian American families could be a primary source of their clients' troubles. Accordingly, culturally sensi- tive pracdce could include interventions that focus not only on individuals, but also on their families.

Potendal differences between men and women should also be considered. Women may be pardcu- larly vulnerable to social strain, possibly due to greater exposure or sensitivity to distress. An im- portant implication is that social workers should be attuned to gender differences when identifying therapeutic approaches. For Asian American women, understanding their role in relation to others in the family may be pardcularly important.

In conclusion, social workers must be attuned to the quality of their chent's social relationships and interactions as well as the various flmctions of their social networks. Although our study focused on Asian Americans in the United States, future studies should investigate these same issues of support and strain among other racial and ethnic groups. Our findings further support the need to acknowledge the benefits and costs associated with social networks, particularly for Asian Americans.

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Cindy C. Sangalang, MSW, is a PhD candidate. Department of Social Welfare, School of Public Affairs, and

Gilbert C. Gee, PhD, is associate professor. Department

of Community Health Sciences, School of Public Health,

University of California, Los Angeles. Address correspondence

to Cindy C. Sangalang, 3250 School of Public Affairs, Los

Angeles, CA 90095; e-mail: [email protected].

The authors thank Todd Franke and the anonymous reviewers

for their comments on the manuscript. This study was sup-

ported by the Council on Social Work Education Minority

fellowship Program. An earlier version of this article was pre-

sented at a meeting of the Society for Social Work and

Research, January 16, 2010, San Francisco.

Original manuscript received December 2, 2008 Finai revision received Juiy 8, 2010 Accepted Juiy 9, 2010

Social Work VOLUME 57, NUMBER I JANUARY 201260

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