The Mental Health Impact of COVID-19 Racial and Ethnic Discrimination Against Asian American and Pacific Islanders

Asian American Mental Health: Looking Beyond the COVID-19 Pandemic

Back to table of contents Previous article Next article ProfessionalFull AccessCall for Action to Address MH Disparities Impacting Asian Americans and Pacific IslandersPeter Jongho Na, M.D., M.P.H., Su Yeon Lee-Tauler, Ph.D., Hochang Ben Lee, M.D.Peter Jongho NaSearch for more papers by this author, M.D., M.P.H., Su Yeon Lee-TaulerSearch for more papers by this author, Ph.D., Hochang Ben LeeSearch for more papers by this author, M.D.Published Online:26 Mar 2021https://doi.org/10.1176/appi.pn.2021.5.31AbstractThe murder of six women of Asian descent in Atlanta on March 16 makes it even more urgent to stand together with Asian American and Pacific Islander communities in breaking the silence about mental illness.Asian Americans and Pacific Islanders were among the hardest-hit groups by COVID-19, not only in terms of job loss due to customers shunning small businesses but also of racial discrimination. The Asian Pacific Policy and Planning Council has reported nearly 3,800 incidents of anti-Asian harassment (including verbal slurs, physical assault, being coughed at/spat upon, or vandalism) since March 2020. Twice as many Asian women have reported victimization than men, and 1 of 8 incidents has involved adults 60 years or older.The most disturbing incident of them all occurred on March 16 with the mass shootings at three massage parlors in Atlanta resulting in the deaths of eight innocent lives, six of whom were women of Asian descent. This tragic event has sparked outcries from various Asian American and Pacific Islander communities, some of whom reflected on their own immigration history and others responded with fear and outrage about the violent crimes, which were primarily against working-class Asian women.Research on the mental health of Asian Americans and Pacific Islanders during the pandemic has shown significant deterioration of their mental health. Exposure to ongoing media coverage of the pandemic, anti-Asian incidents, and the mass shooting may affect these individuals’ sense of security, safety, and stability and partially mediate negative outcomes.Remembering the long history of prejudice against Asian Americans and Pacific Islanders is paramount to the importance of discussing the recent events magnifying racial tensions. From the 1850s, Chinese contract workers were thought to pose economic and moral threats to Americans, leading to the Chinese Exclusion Act in 1882 that restricted their immigration. The lesser-known Page Act of 1875 prohibited the entry of Chinese women who intended to immigrate for “lewd and immoral purposes.” These early examples of legal parameters perpetuated Asian stereotypes. Views of hypersexualized Asian American and Pacific Islander women have been culturally widespread since the 19th century as indicated by the trends of pornography, sex industry, and mail-order brides. Generational trauma since the early immigration history and the accumulation of discriminatory experiences have lasting negative psychological impact, including depression, anxiety, substance use, and suicidal ideation.Psychiatrists and the broader scientific community have the shared responsibility of breaking the silence of mental health disparities. We are calling for action on three domains. First, we call for data-driven, standardized approaches for monitoring mental health disparities experienced by Asian Americans and Pacific Islanders. Studies have shown that this population, particularly those with mood disorders, underuse mental health services. However, the literature is lacking up-to-date, generalizable studies on the mental health needs and service use of Asian Americans and Pacific Islanders. With dwindling national support for rigorous longitudinal surveys, it is critical that various research sites use consistent measures for data comparison and harmonization efforts. It is also important to examine the intersectionality of race with gender, age, and immigration history.Second, we call for developing and tailoring mental health interventions that incorporate lived experiences of Asian Americans and Pacific Islanders and address barriers to psychiatric care (for example, stigma, language, and financing). Culturally tailored community partnership is essential for generating creative solutions such as bringing mental health assessment and counseling to religious programs (for example, temples and churches) and workplaces (for example, groceries, nail salons, dry cleaners).Third, we call for leveraging online resources used by Asian Americans and Pacific Islanders to promote mental health. Distribution of infographics and public health messaging through specific social media channels (for example, KakaoTalk, Line, WeChat, and Telegram) can serve as powerful tools to reduce the stigma of mental illness and encourage help seeking. Creative content in such media as movies, documentaries, and songs may be impactful in providing psychoeducation. Furthermore, expanding access to virtual care through services by Asian American and Pacific Islander psychiatrists and mental health professionals may reduce geographic and cultural barriers to initiating mental health care.We invite you to stand together with Asian American and Pacific Islander communities in breaking the silence about mental health—in the efforts of monitoring mental health disparities, incorporating lived experiences into mental health interventions, and maximizing the use of online resources to promote mental health among Asian Americans and Pacific Islanders. ■ReferencesAP3CON. Stop AAPI hate reports: 2020-2021 national report. Accessed Mar 21, 2021.Wu C, Qian Y, Wilkes R. Anti-Asian discrimination and the Asian-white mental health gap during COVID-19. Ethn Racial Stud. 2021;44(5):819-835.Haft SL, Zhou Q. An outbreak of xenophobia: Perceived discrimination and anxiety in Chinese American college students before and during the COVID‐19 pandemic. Int J Psychol. 2021;E pub ahead of print.Woan S. White sexual imperialism: A theory of Asian feminist jurisprudence. Washington and Lee Journal of Civil Rights and Social Justice. 2008;14:275-301.Lee SY, Martins SS, Keyes KM, Lee HB. Mental health service use by persons of Asian ancestry with DSM-IV mental disorders in the United States. Psychiatr Serv. 2011;62(10):1180-1186.Peter Jongho Na, M.D., M.P.H., is an addiction psychiatry fellow at Yale University.Su Yeon Lee-Tauler, Ph.D., is a research scientist in the Department of Medical and Clinical Psychology at the Uniformed Services University of the Health Sciences.Hochang Ben Lee, M.D., is the John Romano Professor and Chair of the Department of Psychiatry at the University of Rochester School of Medicine and Dentistry. ISSUES NewArchived

The suicide rate among Asian American and Pacific Islander veterans has increased; however, data aggregation for these groups, combined with underinclusion in research, limits understanding regarding risk. We conducted a secondary analysis of Comparative Health Assessment Interview Research Study 2018 data to compare suicidal ideation (SI) and suicide attempt (SA) prevalence among 668 post-9/11 veterans who identified as Asian American, Pacific Islander, or both and described SI and SA prevalence among specific subgroups. Veterans who identified as both Asian American and Pacific Islander were more likely to report experiencing SI (lifetime and during their military service), compared to those who identified solely as Asian American or Pacific Islander (military SI only). Statistically significant differences were not detected for SI preceding or following military service or for lifetime SA. Weighted estimates for lifetime SI and SA were 24.2% and 6.5%, respectively, and prevalence varied widely among specific Asian American and Pacific Islander groups. However, small cell sizes and wide confidence intervals were limitations. Increased clinical attention to screen for and mitigate suicide risk among veterans who identify as both Asian American and Pacific Islander may be warranted. To ensure that suicide prevention strategies optimally address their needs and experiences, research is needed to elucidate suicide drivers in this population. Considering the heterogeneity in SI and SA prevalence among different Asian American and Pacific Islander groups, continued research with larger subsamples that disaggregates analyses by race and ethnicity is essential to deliver prevention and health promotion strategies targeted to the highest-risk groups.

Mental health care among marginalized populations in the United States

Cervical cancer disparities in stage at presentation for disaggregated Asian Americans, Native Hawaiians, and Pacific Islanders

The Name of Hate

Background: Asian American and Pacific Islander races are two distinct groups that continue to be aggregated in many large, national mortality statistics in the United States (US), which leads to structural biases encoded into databases and inaccurate health implications that may deprive Pacific Islander individuals from opportunities for interventions aimed at reducing health disparities. Examining mortality rates for disaggregated Asian American and Pacific Islander populations across all 50 states was not possible until 2018. We compared the leading causes of death between Asian American and Pacific Islander individuals in the US during 2018-2020, stratified by sex and age. Methods: Cause of death among non-Hispanic Asian American and Pacific Islander individuals aged ≥20 years who died during 2018-2020 were obtained from the US National Center for Health Statistics. Age-standardized all-cause mortality rates (MRs) and the 5 leading causes of death were reported per 100,000 person-years separately for Asian American and Pacific Islander individuals, by sex (female/male) and age (20-54/55-64/65-74/75- 84 years). MR ratios (MRRs) were calculated by comparing MRs among Pacific Islander with Asian American individuals (reference group), by sex and age. Results: During 2018-2020, 63,338 female and 85,601 male deaths occurred among Asian American adults, and 4,116 female and 5,512 male deaths occurred among Pacific Islander adults. Compared to Asian American individuals, all-cause mortality was higher for Pacific Islander females (MRR=2.50,95%CI=2.43-2.59) and males (MRR=2.10,95%CI=2.04-2.16). Cancer was the leading cause of death for Asian American (MR=93.8) and Pacific Islander females (MR=181.6) and second for Asian American (MR=100.4) and Pacific Islander males (MR=185.2) after heart disease. Death rates for leading causes were substantially higher for Pacific Islander compared to Asian American females: cancer (MRR=1.93,95%CI=1.82-2.06), heart disease (MRR=3.18,95%CI=2.95-3.42), stroke (MRR=2.41,95%CI=2.13-2.73), diabetes (MRR=4.03,95%CI=3.55-4.56), and COVID-19 (MRR=2.60,95%CI=2.25-3.01) and for Pacific Islander compared to Asian American males: heart disease (MRR=2.56,95%CI=2.42-2.71), cancer (MRR=1.52,95%CI=1.42-1.62, diabetes (MRR=3.14,95%CI=2.81-3.50), accidental death (MRR=2.60,95%CI=2.33-2.88), and COVID-19 (MRR=2.04,95%CI=1.82-2.27). The largest relative cancer mortality rate disparity occurred in those aged 20-54 years and declined with older age among women (MRR range=1.37-2.67) and men (MRR range=1.16-2.26). Conclusion: Cancer was among the leading cause of death for both Asian American and Pacific Islander individuals, but cancer mortality rates were twice as high among Pacific Islander women and men compared to Asian American women and men. These disparities persisted among Pacific Islander individuals for nearly all leading causes of death, regardless of sex and age, underscoring the need to disaggregate Pacific Islander from Asian American race data to improve tailored health equity-focused interventions. Citation Format: Jacqueline B. Vo, Jazmyn L Bess, Kekoa Taparra, Paloma R. Mitra, Amy Berrington de Gonzalez, Neal D. Freedman, Meredith S. Shiels, Jaimie Z. Shing. Leading causes of death among Asian American individuals compared with Pacific Islander individuals in the United States, 2018-2020 [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A069.

The Challenge of Providing Culturally Competent Services

Psychological research on sexual and gender minority (SGM) people of color has grown in recent years; however, little is still understood about the experiences of Asian American and Pacific Islander SGMs. The purpose of this chapter is to synthesize the current research that examines the intersections of the racial identity of Asian Americans and Pacific Islanders, SGM identity, and the mental health of Asian American and Pacific Islander SGMs. Historical contexts of attitudes toward SGMs in Asian and Pacific Island countries as well as in the United States are provided to contextualize the specific sociocultural issues faced by Asian American and Pacific Islander SGMs in the United States. The authors also discuss the role of specific Asian American and Pacific Islander cultural values such as gender norms, family values, and loss of face in the development and expression of SGM identity. This chapter also examines the unique mental health risks faced by Asian American and Pacific Islander SGMs through the lens of double minority stress. The authors conclude with recommendations for directions of future research.

Earlier puberty is associated with adverse health outcomes, such as mental health issues in adolescence and cardiometabolic diseases in adulthood. Despite rapid growth of the Asian American, Native Hawaiian, and Pacific Islander populations in the US, limited research exists on their pubertal timing, potentially masking health disparities. To examine pubertal timing among Asian American, Native Hawaiian, and Pacific Islander children and adolescents by disaggregating ethnic subgroups. This retrospective cohort study included Asian American, Native Hawaiian, and Pacific Islander youths aged 5 to 18 years assessed for pubertal development at Kaiser Permanente Northern California, a large, integrated health care delivery system. Follow-up occurred from March 2005, through December 31, 2019. Data were analyzed in October 2023. Race and ethnicity, categorized into 11 ethnic subgroups: Asian Indian, Chinese, Filipino, Japanese, Korean, Native Hawaiian and Pacific Islander, Other South Asian, Other Southeast Asian, Vietnamese, multiethnic, and multiracial. Pubertal timing was determined using physician-assessed sexual maturity ratings (SMRs). Outcomes included the median age at transition from SMR 1 (prepubertal) to SMR 2 or higher (pubertal) for onset of genital development (gonadarche) in boys, breast development (thelarche) in girls, and pubic hair development (pubarche) in both boys and girls. In this cohort of 107 325 Asian American, Native Hawaiian, and Pacific Islander children and adolescents (54.61% boys; 12.96% Asian Indian, 22.24% Chinese, 26.46% Filipino, 1.80% Japanese, 1.66% Korean, 1.96% Native Hawaiian and Pacific Islander, 0.86% Other South Asian, 3.26% Other Southeast Asian, 5.99% Vietnamese, 0.74% multiethnic, and 22.05% multiracial), the overall median ages for girls' pubarche and thelarche were 10.98 years (95% CI, 10.96-11.01 years) and 10.13 years (95% CI, 10.11-10.15 years), respectively. For boys' pubarche and gonadarche, median ages were 12.08 years (95% CI, 12.06-12.10 years) and 11.54 years (95% CI, 11.52-11.56 years), respectively. Differences between subgroups with earliest and latest median age at onset were 14 months for girls' pubarche, 8 months for thelarche, 8 months for boys' pubarche, and 4 months for gonadarche. In general, Asian Indian, Native Hawaiian and Pacific Islander, and Other South Asian subgroups had the earliest ages at onset across pubertal markers, while East Asian youths exhibited the latest onset. Restricting to those with healthy body mass index did not substantially change the findings. In this cohort study of Asian American, Native Hawaiian, and Pacific Islander children and adolescents, pubertal timing varied considerably across ethnic subgroups. Further investigation is warranted to assess whether these differences contribute to observed health disparities in adulthood, such as type 2 diabetes and cardiovascular diseases.

Ocean Passages: Navigating Pacific Islander and Asian American Literatures

Background Asian American and Pacific Islander (AAPI) sexual and gender minority (SGM) young and emerging adults are an especially high-risk group to consider in mental health research, holding multiple marginalized identities & report discrimination based on race/ethnicity & immigration status at double the rate of overall SGM youth. There is a need for extensive national studies that capture the experience of AAPI SGM youth to comprehensively elucidate the mental health burden on this often-overlooked population in the COVID-19 era. This study aims to describe the national landscape of AAPI SGM university student mental health & treatment usage. Methods We data from the Healthy Minds Study, conducted between September 2021-May 2022 (n = 89,255) across 133 campuses in the United States. We used bivariate analyses & cross-sectional logistic regression models to evaluate mental health symptoms, risk/protective factors, & treatment utilization across AAPI SGM students. Results Preliminary findings indicate that 78% of AAPI SGM respondents report the presence of one or more positive screens for depression, anxiety, eating disorder, suicidal ideation, or non-suicidal self-injury. Among these students, approximately 57% report utilizing therapy or psychotropic medication. Experiences of discrimination & financial stress were the strongest correlates of mental health symptoms. Self-reported experiences of discrimination based on race, culture, & sexual orientation were associated with higher odds of treatment utilization for AAPI SGM domestic students but not for international students. Conclusions The data underscore the need to consider the adequacy of current approaches in supporting AAPI SGM mental health, as well as unique ways to foster protective institutional & intrapersonal factors & increase investments to culturally responsive, gender-affirming treatment & prevention programs that address mental health disparities already looming in minoritized communities.

IntroductionRecent studies suggest that exposure to racist online interactions and content may be associated with depressive symptoms and suicide risk among racially minoritized individuals. Despite the hate and violence easily encountered online, individuals use social media platforms to engage with their mental health concerns and seek support. Hence, the current study aimed to explore whether online mental health engagement would buffer the depressive symptoms and suicide risk associated with online racism among Black and Asian American Pacific Islander (AAPI) emerging adults (18–29) who are exposed to anti-Black and anti-Asian hate online.MethodUsing survey data from 1,224 Black (Mage = 23.99, SD = 3.11) and 1,553 AAPI (Mage = 23.96, SD = 3.29) emerging adults, we conducted latent moderated structural equation modeling to examine online mental health engagement as a moderator between online racism and depressive symptoms, and online racism and suicide outcomes [suicide ideation in the past 2 weeks, lifetime suicide ideation, past-year suicide ideation, lifetime suicide attempt, past-year suicide attempt, and non-suicidal self-injury (NSSI)].ResultsFor both groups, online mental health engagement associated with a stronger link between online racism and suicide-related risk. For AAPI emerging adults, higher levels of engagement significantly amplified the association between online racism and suicidal ideation (recent and lifetime), suicide attempts (lifetime), NSSI, and depressive symptoms. For Black emerging adults, this risk-exacerbating finding was observed only for recent suicidal ideation.DiscussionThe findings highlight the suicide risk that may be associated with online racism and concerns regarding the helpfulness of online mental health engagement.

Episiotomy and severe perineal laceration among Asian American, Native Hawaiian, and Pacific Islander nulliparous individuals in California.

BackgroundThe COVID-19 pandemic forced the world to quarantine to slow the rate of transmission, causing communities to transition into virtual spaces. Asian American and Pacific Islander communities faced the additional challenge of discrimination that stemmed from racist and xenophobic rhetoric in the media. Limited data exist on technology use among Asian American and Pacific Islander adults during the height of the COVID-19 shelter-in-place period and its effect on their physical and mental health.ObjectiveThis study aims to examine Asian American and Pacific Islander adults’ attitudes, perspectives, and experiences regarding their use of technology during the COVID-19 pandemic.MethodsWe collaborated with community partners and used social media to distribute the COVID-19 Effects on the Mental and Physical Health of Asian Americans and Pacific Islanders Survey Study, a nationwide multilingual survey available in English, Chinese, Korean, Samoan, and Vietnamese. The survey was administered from October 2020 to February 2021, and participants rated their level of agreement (1=not at all to 5=extremely) on 6 items assessing their attitudes toward technology use. Thematic analysis was conducted on responses to the open-ended question “Is there anything else you want to tell us about your use of technology during COVID-19?” The qualitative responses were reviewed, analyzed, coded, and organized into corresponding themes.ResultsThe mean age of respondents was 45.9 (SD 16.3; range 18-98) years, with 5398 participants completing the quantitative survey and 1115 (20.66%) providing unique responses to the open-ended question. In the quantitative survey, 68% (3671/5398) of the respondents reported being comfortable using technology; the majority indicated that it helped them keep up with the news (4318/5398, 79.99%), maintain social connections (4102/5398, 75.99%), and provide care for others (2537/5398, 46.99%). However, responses were mixed regarding the usefulness of technology for health: 39.99% (2159/5398) agreed that it was helpful for mental health but disagreed regarding physical health. Four main themes emerged from the qualitative analysis: (1) technology was critical for functioning across many aspects of life and maintaining physical, mental, and emotional well-being; (2) technology was often the only means of interpersonal social connections; (3) overuse led to negative physical and mental health outcomes; and (4) technology use was associated with multiple challenges and barriers.ConclusionsOur findings revealed diverse perspectives and experiences related to technology use by Asian American and Pacific Islander adults during the height of the COVID-19 pandemic. Dependence on technology may have exacerbated social inequities, particularly for those with lack of access to devices and Wi-Fi and limited English proficiency, affecting their ability to work, apply for jobs, and communicate virtually. Further qualitative research would be beneficial in amplifying the perspectives of Asian American and Pacific Islander adults to uncover concerns and address health disparities.