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Prevalence of Depression among Vietnamese Elderly

An Exploratory Study
Tuyen D. Nguyen, California State University, Fullerton, United States of America
Susan Larsen, California State University, Fullerton, United States of America
Brian Lam, California State University, Long Beach, United States of America
Toan Phan, California State University, Fullerton, United States of America
Abstract: The subject of depression (a disorder of the representation and regulation of mood and emotion) in the elderly
population in the United States as well as specifcally the elderly Vietnamese immigrant has been emerging for a myriad
of reasons, many of which will be examined in this article. Investigating the mental health issues, specifcally depression
among the elderly Vietnamese population in the U.S., is of considerable importance, as few such empirical studies have
been conducted. The Vietnamese elderly are often a quiet sub grouping of individuals who all but go unobserved by mainstream
America as well as the academic community.
Keywords: Vietnamese, Depression, Elderly
INCE THE FALL of Saigon over thirty
years ago (1975), large waves of Vietnamese
immigrants, specifcally refugees seeking
political freedom, have entered the United
States in sweeping numbers. The Vietnamese are the
fourth largest ethnic group in the Asian and Pacifc
Islander category in the U.S. Estimates of the number
of Vietnamese in the United States are approximated
at nearly 800,000, an increase of 53 percent since
the late 1980s (U.S. Bureau of the Census, 2000).
The subject of depression (a disorder of the repres-
entation and regulation of mood and emotion) in the
elderly population in the United States as well as
specifcally the elderly Vietnamese immigrant has
been emerging for a myriad of reasons, many of
which will be examined in this article. Investigating
the mental health issues, specifcally depression
among the elderly Vietnamese population in the U.S.,
is of considerable importance, as fewsuch empirical
studies have been conducted. The Vietnamese elderly
are often a quiet sub grouping of individuals who all
but go unobserved by mainstream America as well
as the academic community.
Akey issue to consider while studying depression
in the Vietnamese elderly or in any population, is to
examine the role of social support, or lack there of,
as well as cultural defnitions of depression. The
purpose of this study was to investigate the etiology
of depression among a sample of Vietnamese elderly
immigrants. This study explored the prevalence of
depression among Vietnamese elderly immigrants
in order to build a knowledge base on the subject
which is lacking in the mental health literature.
What is Clinical Depression?
Major Depressive Disease (MDD)more commonly
referred to as Clinical Depression presently is the
leading cause of disability in the United States.
Moreover, 16% of the total world population will
encounter MDD at least once over the lifespan (Be-
mak, 2000). By defnition, depression is a disorder
of mood, characterized by sadness and loss of interest
in usually satisfying activities, a negative view of
the self, hopelessness, passivity, indecisiveness,
suicidal intentions, loss of appetite, weight loss, sleep
disturbances, and other physical symptoms (DSM-
IV). Some or all of these symptoms may exist in
people suffering from depression. The Diagnostic
and Statistical Manual of Mental Disorders (DSM-
IV), published by the American Psychiatric Associ-
ation, is the handbook used most often in diagnosing
psychiatric disorders in the United States and other
countries. The DSM-IV defnes several different
types and grades of depression. What is commonly
referred to as, clinical depression, yet is more ac-
curately detailed in the DSM-IVas major depressive
disorder, is a depression with symptoms that last
two weeks or more, and are so acute that they inter-
fere with daily living. The mean age of MDD in the
U.S., is in the mid-late 20s. Nearly two times more
women than men report or receive treatment for
clinical depression each year in the U.S. (Bemak &
Chung, 2000).
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Depression in the Elderly
Life contentment is a critical measurement to the
quality of life for senior citizens. The senior years
are predicated on the successful development and
enhancement of ones physical, secular and psychi-
atric well being. Persons over the age of 60 are the
fastest growing segment of the population in Amer-
ica. By the year 2010, the total population of this age
group is expected to be more than 18 million (U.S.
Bureau of the Census, 2000). Nearly 86% of all
seniors endure one or more chronic illnesses, includ-
ing the often devastating condition known as major
depressive disorder (Bemak & Chung, 2000).
The tension of aging and the depression that often
coincides is recurrently felt not only by the aged but
also by the persons and society responsible for their
care. Risk factors for depression in U.S. Seniors are
numerous and include: age, gender, unmarried or
widowed, marital status, marital satisfaction, less
than a high school education, economic hardship,
concomitant disease, cognitive impairment, function-
al disability, poor social support, history of psychiat-
ric illness, retirement, fewinterests, negative attitude
toward aging, loneliness, poor self-esteem, low per-
sonal control, stressful life events, and lowlife satis-
faction (Brugha, 1995; Chung, et al, 1997). The ef-
fects of age and gender fuctuate for depression.
Nonetheless, people with concomitant disease, cog-
nitive impairment, functional disability, and poor
social support may be uniquely likely to exhibit poor
adaptation and poor outcomes.
In the year 2040, it is projected that nearly all re-
porting countries will have at least 30 percent of their
population over the age of sixty. Given the staggering
growth of the elderly it is crucial to turn national and
global attention to the disturbing common issue of
(MDD) in the elderly. The APA (American Psychi-
atric Association) reports that depression ranks
higher than dementia in individuals over the age of
65. Under-diagnosis of MDD in the elderly is well
documented in the medical literature. Studies show
as few as one quarter of elderly individuals with
MDD are diagnosed. In addition, other mood dis-
orders and anxiety disorders are cited as common
mental health problems in the elderly (Hays, 1991),
and both may be exacerbated by loss (one of the
realities of aging is the phenomenon of loss: loss of
a spouse, loss of a job and status through retirement,
loss of health, and loss of friendships and social op-
portunities, alcohol or drug use).
Depression is a frequent outcome of the losses
related to aging and is also a common consequence
of alcohol and drug problems (prescribed medica-
tions) among the elderly (Dhooper, 1997). Recogniz-
ing depression in the elderly is imperative as this is
a group that has a propensity towards suicide. There
is an assumption among doctors, therapists and the
greater society, that depression is part of the normal
aging process. This assumption creates a dangerous
acceptance and therefore a general apathy in MDD
in the elderly. These responses can affect the persons
ability to concentrate on their personal care and
safety. Depression can also lead to confusion and
disorientation, which can contribute to the risk of
falling (Triandis, 1996). This situation is derived in
part from long-standing negative social perceptions
of the elderly. There is a general consensus that with
aging come frailty, weakness, and disease. If this is
so, then it is not a surprise and or concern that the
elderly suffer with depression.
Depression in the Vietnamese Elderly
There exists a great dichotomy in the few studies
that have been conducted on the Vietnamese elderly
immigrant besieged with depression. Case in point,
some studies reveal that elderly Vietnamese immig-
rants in the U.S. tend to have a strong social network
via being revered culturally as the wise one,
thereby decreasing their rates of depression given
the high rate of social status (Furukawa et al, 1999;
Freeman, 1989). Conversely, other researchers have
found that Vietnamese elderly immigrants that have
close ties to their ethnic group tend to have more
psychological distress compared with those with
additional non-ethnic social supports (Brugha, 1995;
McKelvy et al, 1993).
Few researchers have studied the signifcant role
that culture plays in the interpretation and or expres-
sion of depression. That is, the notion that depression
may be signifcantly relative to ones cultural per-
spective of psychological distress. If this is so, could
it be that Westerners are misinterpreting the calm,
quiet, and reserved culturally appropriate nature of
the typical Vietnamese elderly immigrant for a de-
pressed individual? Or, is it that it is simply culturally
incorrect to display ones feelings and or emotions
and culturally shameful to seek outside help for de-
The sentiment of many elderly Asians is that to
admit depression is to acknowledge weakness, and
moreover to seek psychological assistance outside
of the family is an extreme cultural taboo. Studies
have identifed several predictors of mental distress
in the Vietnamese elderly immigrant including yet
not limited to: employment status, social support,
anxiety, life satisfaction, PTSD, family confict,
dissatisfaction with life in the U.S., acculturation and
biculturalism, social support, coping, and premigrat-
ory stressors (Brugha, 1995; Tran, 1988; Center for
Mental Health Services, 1998). In addition, research-
ers have noted a signifcant variance in depression
among frst wave versus second wave elderly Viet-
namese immigrants.
The majority of frst-wave elderly Vietnamese
immigrants adjusted relatively well to life in the
United States and in many cases received assistance
fromthe U.S. government to do so. Many of the frst
wave elderly Vietnamese immigrants stayed with
family members and didnt have many of the extreme
fnancial burdens that the second and third wave
immigrants have experienced. Conversely, the second
and third wave immigrants, many of whomwere war
refugees and who have in varying degrees experi-
enced violence and deprivation, have signifcantly
higher rates of mental health problems than the frst
wave (Danieli, 1988; Lum, 2000; Lum, 2003). This
has been partially attributed to the crisis of resettle-
ment and exposure to war, violence, and deprivation.
If left unaddressed, torture and other war-related
traumas can lead to depression and anxiety, inability
to concentrate, memory problems, disruptive behavi-
or, learning diffculties, and acts of fghting and
other violence (Center for Victims of Torture, 1998).
Researchers have found that Vietnamese elderly
immigrants tend to have greater diffculties accultur-
ating to the U.S. and thus, as a general rule reported
being more depressed than their younger fellow Vi-
etnamese immigrants. The elderly Vietnamese have
greater diffculties fnding work, are thus more often
on welfare, and have the lowest family income
(Matsuoka, 1993) all of which lead to greater rates
of depression. Elderly Vietnamese typically report
dissatisfaction with their lives in the U.S. and report
more family confict. Most studies indicate that the
mental distress of the elderly Vietnamese immigrants
is related to their lack of adjustment to life in the
United States. Data strongly suggest that Asian eld-
erly immigrants in the U.S. are at risk of depression,
indicating a need for the design of culturally sensitive
mental health programs (US Department of Health
& Human Services, 1999).
A cross sectional survey design was used to determ-
ine the prevalence of depression among elderly Viet-
namese immigrants. A convenience sample of 200
elderly Vietnamese immigrants, aged 60 and above,
residing in the Orange County, California was re-
cruited to participate in the study. After securing the
approval of program directors at three senior citizen
centers, data collection took place.
Sociodemographic Questionnaire: This questionnaire
was developed for the purposes of gathering research
participants information on demographic variables
including age, gender, marital status, education
completed, fnancial status, social support network,
and help-seeking behavior for depression.
Vietnamese Short Version of the Geriatric Depres-
sion Scale: (Sheikh & Yesavage, 1986). The instru-
ment consists of 15 closed-ended items in which
participants answered Yes or No to questions used
to assess their depression level. The Vietnamese
version of the scale has been found to have 92%
sensitivity and 89% specifcity (Kurlowicz, 1999).
A total of 200 elderly Vietnamese men and women
drawn fromthree senior citizen centers in the Orange
County, California area participated in the study.
The average age of the total sample was 63 years,
ranging from 62 years old to 94 years old with a
mean of 63 years. There were 55% (n=110) women
and 45%(n=90) men made up of the sample. In terms
of marital status, 80%(n=160) identifed as married,
5% (n=10) divorced, 2% (n=4) separated, and 13%
(n=26) widowed. As a group, 42%(n=84) had a high
school education, 47% (n=94) had less than a high
school education, and the remaining had attended or
completed a university education. Thirty-fve percent
(n=70) of the sampled participants worried about
their fnancial situation, 38% (n=76) somewhat
worried, and 27% (n=54) not worried. With respect
to social support network, 39% (n=78) strongly
agreed that they had a strong social support network,
27% (n=54) disagreed, and 34% (n=68) strongly
disagreed (Table 1).
Table 1: Participants Sociodemographics
Maximum Minimum Mean N Variable
94 62 63 years 200 Age
Percentage % N Variable
100% 200 Gender:
45% 90 Male
55% 110 Female
100% 200 Marital Status:
80% 160 Married
5% 10 Divorced
2% 4 Separated
13% 26 Widowed
Percentage % N Variable
100% 200 Education:
42% 84 High School
47% 94 <High School
11% 22 >High School
100% 200 Financial Situation:
35% 70 Worried
38% 76 Somewhat Worried
27% 54 Not Worried
100% 200 Support Network:
39% 78 Strongly Agreed
27% 54 Agreed
34% 68 Strongly Disagreed
Prevalence of Depression
Among the sampled participants, 21% (n=42) were
identifed as clinically depressed and 79% (n=158)
as non-depressed. For the sampled participants, 13%
(n=26) stated they would seek a medical doctor to
treat their depression; 32% (n=64) would consult
with family members; 21% (n=42) would consult
with friends; 34%(n=68) would do nothing to obtain
treatment for their depression (Table 2).
Table 2: Depression Prevalence
Percentage % N Variable
100% 200 Depression Prevalence:
21% 42 Depressed
79% 158 Non-Depressed
100% 200 Help-Seeking Behavior:
13% 26 Consult Medical Doctor
32% 64 Consult Family Members
21% 42 Consult Friends
34% 68 Do Nothing
This quantitative research study explored the preval-
ence of depression among the elderly Vietnamese
residing in the Orange County, CA. This study is
one of the few studies that document the prevalence
of depression among the underserved elderly Viet-
namese population. Based on this studys conveni-
ence sample, it was found that 21% of the sampled
participants were identifed as depressed. This fnd-
ing is consistent with some studies that have been
conducted with other elderly Vietnamese populations
throughout the United States (e.g., Yee, 1997; Nel-
son, Bui, Samet, 1997). This studys results also
showed that 34% of the sampled participants would
choose to do nothing as a way of dealing with their
depression. According to Carey et al (1997), peoples
health beliefs and misconceptions of mental illness
impede their recognition of early warning signs and
delay their access to medical treatment. In the Viet-
namese community, mental illness is considered a
taboo topic; as a result, average citizens normally do
not seek treatment for their depression.
The main limitation of this study is that the sample
was a convenience sample and the participants self-
selected to be in the study. Therefore, the results
cannot be generalized to other elderly Vietnamese
immigrants across the United States. Despite the
studys limitation, the results of this exploratory
study revealed that depression is prevalent among
the sampled elderly Vietnamese immigrant popula-
tion, and community outreach/intervention is greatly
needed. Levels of psychological distress as it relates
to the elderly in general, as well as elderly Viet-
namese suggests that differential distress occurs in
part as a function of aging, along with other mitigat-
ing factors such as lack of social support, fnances,
ability to acculturate, among many other issues. De-
pression within the elderly Vietnamese population
is often explained by pre-migration stresses, night-
mares, acculturation stresses, personal ineffcacy,
age, gender, marital status, and English ability (Yee,
Second and third wave elderly Vietnamese immig-
rants who witnessed war, including: beatings, psy-
chological abuse, sexual abuse, torture of loved ones,
deprivation, etc. have a greater risk of suffering from
depression. In some cases, they endure the ongoing
physical and emotional anguish that their torturers
intended, ranging from chronic pain in muscles and
joints to severe depression, constant anxiety, and
frequent thoughts of suicide (Center for Victims of
Torture, 1998). Just like any other individual suffer-
ing with depression, psychotherapy and psychophar-
macology, alone or more advantageous in combina-
tion, are the best treatment for most elderly patients
with depression. Depression in the Vietnamese eld-
erly is often chronic and reoccurring and thus must
be identifed and treated with great urgency.
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About the Authors
Dr. Tuyen D. Nguyen
California State University, Fullerton, United States of America
Dr. Susan Larsen
Dr. Larsen is an assistant professor of human services at California State University at Fullerton.
Dr. Brian Lam
Dr. Lam is an assistant professor of social work at California State University at Long Beach.
Toan Phan
Mr. Phan is a graduate student in the gerontology department at California State University at Fullerton.