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This article was downloaded by: [UOV University of Oviedo]On: 17 October 2014, At: 06:09Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK
Clinical GerontologistPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/wcli20
Conceptualizing Anxiety andDepression: The JapaneseAmerican Older AdultPerspectiveGayle Y. Iwamasa PhD a , Kristen M. Hilliard BA a &Sheryl S. Osato PhD ba Oklahoma State Universityb West Los Angeles Veteran's Administration MedicalCenterPublished online: 11 Oct 2008.
To cite this article: Gayle Y. Iwamasa PhD , Kristen M. Hilliard BA & Sheryl S. OsatoPhD (1998) Conceptualizing Anxiety and Depression: The Japanese American OlderAdult Perspective, Clinical Gerontologist, 19:1, 77-93
To link to this article: http://dx.doi.org/10.1300/J018v19n01_07
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Conceptualizing Anxiety and Depression: The Japanese American Older Adult Perspective
Gayle Y. Iwamasa, PhD Kristen M. Hilliard, BA
Sheryl S . Osato, PhD
ABSTRACT. The current study is a qualitative investigation of the conceptualization of anxiety and depression among Japanese Ameri- can older adults. Wenty-nine older adults were interviewed at a se- nior center where they were members. Results of the interviews sug- gest that their conceptualization of these disorders is similar to the conceptualization used by most mental health practitioners. However, several participants conceptualized anxiety and depression differently, and at times defined each disorder using symptoms of the other disor- der. Most participants believed that both anxiety and depression were preventable, situational, and treatable, and were able to identify pos- sible risk and protective factors. There was some evidence that some of the participants believed that sex, age, and ethnic group differences existed in the seventy of anxiety and depression. Implications of the results and methodological considerations of the study ace discussed, and directions for future research are suggested. [Article copia avail- able for a fee from The Haworth Document Delivery Service: 1-800- 342-9678. E-mail address: getinfo@haworih. corn]
Gayle Y. Iwamasa and Kristen M. Hilliard are affiliated with Oklahoma State University. Sheryl S. Osato is affiliated with the West Los Angeles Veteran’s Administration Medical Center.
Address correspondence to: Gayle Y. Iwarnasa, Oklahoma State University, Department of Psychology, 215 North Murray, Stillwater, OK 74075.
The authors wish to extend appreciation to all of the participants and to the Seinan Senior Citizens’ Center staff for their cooperation and interest in the current project.
Clinical Gerontologist, Vol. 19( 1) 1998 0 1998 by The Haworth Press, Inc. All rights reserved. 77
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78 CLINICAL GERONTOLOGIST
Anxiety and depression have been cited as two of the most common mental health problems among older adults in the United States (Blazer, George, & Hughes, 1991; Blazer, Hughes, & George, 1987; Fernandez, Levy, Lachar, & Small, 1995; Himmelfarb & Murrell, 1984). Further, anxiety and depression have been targeted by the Vitality for Life Corn- miltee (Coordinating Committee for the Human Capital Initiative, 1993) as specific disorders in need of intense examination and increased research h d i n g among older adults.
Although epidemiological data have been collected on older adults of predominantly European American descent, few data exist on the preva- lence of anxiety and depression among ethnic minority oldcr adults (Iwa- masa & Hilliard, 1997). Baker (1992) has indicated that although there is some, albeit little, data on the mental and physical heaIth of African American and Hispanic older adults, there is no such comparable data avaiIable on Asian American older adults.
This lack of mental health data on ethnic minority older adults, particu- larly on Asian American older adults, is alarming, given the rapid rate at which the number of ethnic minority otder adults is growing. The Ameri- can Association of Retired Persons (AARP; 1995) estimates that of the 70 million older adults who will likely be living in the year 2030, approxi- mately 25% will be ethnic minorities. This figure will likely continue to grow, as the United States becomes increasingly culturally and ethnically diverse.
Asian Americans are often described as being one of the fastest grow- ing and most diverse ethnic groups in the United States, with estimates indicating that during the 1980s the Asian American population increased by 50% (Gelfand & Barresi, 1987). Furthermore, of all of the Asian American ethnic groups, Japanese Americans have the highest mean age (Gelfand & Barresi, 1987). This is IikeIy because Japanese immigrants were among the earliest Asian immigrants to the United States, resulting in a longer history in the United States as compared to some other Asian ethnic groups.
In an extensive search of the empirical literature, only two studies that focused specifically on the mental health of elderly Japanese Americans were found. Yamamoto et al. (1985) interviewed two groups of Japanese American older adults using the Diagnostic Interview Schedule (Robins, Helzer, Croughan, & Ratcliff, 1981). The first sample consisted of 78 “normal” participants (17 men and 61 women), and the second sample consisted of 44 (16 men and 28 women) participants who lived in an assisted-living facility. With the first sample, 27% had symptoms of dys- thymia and 3% had symptoms of major depression. Interestingly, only one
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Iwamasa. Hilliard, and Osato 79
individual met criteria for an anxiety disorder, social phobia. With the second sample, 39% had symptoms of dysthymia, 16% had symptoms of major depression, and 11% had symptoms of either panic disorder or agoraphobia. The authors concluded that Japanese American older adults have as many mental problems as do other groups of American older adults.
The second study examined the utility of the Geriatric Depression Scale (GDS; Yesavage et al., 1983) with 86 Japanese American older adult senior center members (Iwamasa, Hilliard, & Kost, 1997). Results indi- cated that the GDS had good internal consistency and reliability, with coefficients similar to the original sample. Furthermore, results also indi- cated that GDS scorcs for the sample were low, indicating Iow levels of depression. However, the authors cautioned that this sample was possibly biased in that it consisted predominantly of high functioning older adults who were very active and energetic. Thus, the applicability of the GDS with lower functioning and less active Japanese American older adults must still be demonstrated.
In light of the lack of attention to the mental health issues of Japanese American older adults, the current researchers have begun a program of research on the mental health of Japanese American older adults. One of our concerns has been that the applicability and appropriateness of the current diagnostic nosology being used to assess the mental health of older adults in general, and ethnic minority older adults specifically, have not been examined. Thus, the percentages cited in the Yamamoto et al. (1 985) study should only be interpreted as data from a Western-based diagnostic system, and not interpreted as actual self-report of distress. How Japanese Americans conceptualize psychological distress has yet to be determined. Thus, it is uncertain whether the percentage of individuals in Yamamoto et al.’s study who met criteria for depression and anxiety accurately matches the percentage of individuals actually experiencing distress.
Kleinman, Eisenberg, and Good (1978) discussed the important role that culture plays in the expression and experiencc of psychological dis- tress. They proposed an explanatory model of illness (EMI) which ex- plains the relationship between culture, belief systems, and the pattern of symptom expression and help-seeking behaviors. According to the EMI, disease refers to abnormalities in the structure and function of body organs and systems, whcreas illness refers to the human experience of sickness. Kleinman et al. suggested that illness is shaped by cultural factors govem- ing perception, labeling, explanation, and evaluation of the discomforting experiences; processes which are embedded in a complex family, social, and cultural nexus. These authors criticized Western health care, which
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tends to focus on the disease aspect of sickness. They suggested that this results in patient noncompliance, patient and family dissatisfaction with professional health care, and inadequate, and sometimes inappropriate, health care. Support for this notion comes from figures cited by the Pmsi- dent’s Commission on Mental Health (1 978), which indicated high prerna- lure termination rates and a general ineffectiveness of more traditional mental health services for ethnic minority groups.
Specifically regarding Asian Americans, Kleinman et d.’s suggestions also have some support. Research has shown that Asian Americans under- utilize mental health services (O’Sullivaa, Peterson, Cox, & Kirkeby, 1989; Sue, Fujino, Wu, Takeuchi, & h e , 1991). Cheung (1980) listed a number of factors that affect Asian Americans’ utilization of mental health services, with inappropriate services listed as one of the major impedi- ments to treatment. Sue and Zane ( I 987) proposed that effective treatment must incorporate the client’s cultural beliefs and practices. They suggested that effective intervention is linked to two basic processes-credibility of the treatment provider and giving to the client. Credibility of the treatment provider is only established if the treatment provider is able to accurately assess the individual’s problem, communicate to the client that he/she understands the problem, and develop a treatment plan that is culturally appropriate. Sue and Zane also suggested that clients @articularly Asian American clients) need to experience immediate benefits from treatment- the “giA giving” part of treatment. Clearly, with this hypothesis, the treatment provider can give a ‘‘gift” only if an accurate assessment has first been conducted and an appropriate treatment plan is deveIoped.
One of the difficulties with applying this “credibility and giving” hy- pothesis to Asian Americans is that it has never been formally rested. This is llkely due to the fact that there are no data on how Asian Americans conceptualize specific mental health problems. This problem becomes even more pronounced when examining the mental health of older adults. Hayes (1996) discussed the need for more culturally responsive assess- ment for diverse older adults, including the need to consider generational influences, ethnicity, and socioeconomic status. Additionally, in their re- view of the research on assessment of anxiety in older adults, Hersen, Van Hasselt, and Goreczny (1993) emphasized that more research needs to be conducted on diagnostic issues with older adults. They list problems with comorbidity and etiology as two areas of particular concern regarding diagnoses. These issues can only be deciphered by obtaining data from the groups of interest.
As a step toward ameliorating the lack of data on the mental health of Asian American older adults, the current study was conducted. The pur-
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pose of the current study was to assess how Japanese American older adults conceptualize anxiety and depression. A qualitative approach was selected because we did not want to limit participants’ responses to our questions, nor did we want to a priori categorize participants’ responses (Strauss & Corbin, 1990). Given the lack of epidemiological data on Japanese American older adults and the exploratory name of the study, no a priori hypotheses were established. Participants were interviewed using open-ended questions, and their responses were categorized.
METNOD
Participants in this study were 29 (Men, N = 11; Women, N = 18) Japanese American older adults. Participants were recruited from the Sei- nan Senior Citizens’ Centcr, a day program for older adults located in Los Angeles, CA. The center provides a variety of services and activities to over 1,200 older adults, most of whom are of Japanese descent. Mean age of the sample was 75.6 years, and ranged from 59 to 93 years. More than half of the sample was widowed, 10 participants were married, and 4 were single. Thirteen participants were interned in concentration camps for an average of 25 months during World War 11. The average number of days per week participants attended the senior center was four. All participants were fluent in English and volunteercd to participate.
Procedure
Participants were recruited by written announcements in the center’s monthly newsletter, and by verbal prompting from the center staff on the days of interviews. Interviews were conducted by the authors over the course of several days. After being asked some demographic questions, participants were asked sets of questions about anxiety andor depression. Participants who answered one set of questions and did not show signs of fatigue were then asked a second set of questions. For those participants who were askcd both sets of questions, half received the depression ques- tions fmt, and the other half received the anxiety questions first. Thirteen out of 29 participants completed both sets of questions. A total of 23 depression interviews and 19 anxiety interviews were completed. Length of interviews ranged from eight to 25 minutes. Interviews were tape re- corded and then transcribed. Once transcribed, responses were catego- rized.
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RESULTS
The questions, responses, and a sampling of participants’ answers are summarized below. The majority of the respondents’ answers were cate- gorized as “yes” or “no.” “I don’t know” responses were combined with the “not indicated category.” Every question is summarized independent- ly of the other questions. Attempts were made to present quotes from participants as verbatim. However, a few responses were edited in order to be more clear to the reader.
Anxi@
What is anxiety? Eight participants (42%) defined anxiety utilizing t e r n associated with anxiety according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-R American Psy- chiatric Association [APA], 1994). Participants defined anxiety using DSM-IY symptoms such as worry, increased heart rate, and feeling keyed up. Three participants (16%) defined anxiety utilizing the following symp- tom associated with DSM-W major depression: irritability, sleep distur- bance, and depression.
What me the symptoms ofanxiety? Ten participants (53%) listed symp- toms that were similar to symptoms of generalized anxiety disorder in DSM-IT? Of the symptoms reported, the following were the same as symp- toms included in generalized anxiety disorder in DSM-IF worrying, irrita- bility, and sleep disturbance. Is anxiery preventable? y yes, how? Fourteen participants answered
“yes” (74%) and five answered “no” (26%)). Among those e c i p m t s who answered “yes,” ten (53%) provided explanations for how anxiety could be prevented. Prevention strategies mainly involved religion and increasing social interactions. Examples included:
You go to church.
By associating with more people.
Well, I guess one could see a psychologist, or someone like that.
Zs anxiety permanent or does it go muy on its own? None of the participants thought anxiety was permanent.
Is anxiety inherited from one 5 parents? Four participants (2 1 %) said “yes,” while 13 participants responded “no” (68%) to this question. Two participants (1 1%) did not answer the question.
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Is ihere a stigma attached 10 being anxious? Ifyes. please describe. Six participants answered “yes” (32%) and 11 answered “no” (58%). Two participants (1 1%) did not indicate a response. Responses from partici- pants who indicated that there is a stigma associated with being anxious mainly involved the idea that others might not enjoy being around some- one who is anxious:
Some people don’t like people who are too anxious.
Is anxiety marable? rfyes how? Sixteen participants (84%) thought anxiety was treatable and three participants ( lTA) did not indicate whether or not anxiety was treatable. Of those who believed anxiety was treatable, five specifically stated that anxiety could be treated by going to a psychol- ogist or psychiatrist. Other forms of treatment reported included religion, keeping oneself busy, and talking with others.
Are there things that put people ai risk for anxiery? Vyes. what? Ten participants (53%) thought there were factors that put people at risk for anxiety. Three participants (16%) did not think there were any risk factors, and six participants (32%) did not know whether there were any factors that put people at risk for anxiety. Several of the ten participants who thought that there were factors that put people at risk for anxiety were able to specifL particular factors:
People who do not slow down and relax will become more anxious.
If they just look at the bad things and just worry about things . . . Does a n r i e ~ affect men and women dij’ewntt)? gyes, how? Six partic-
ipants responded “yes” (32%) and eight responded “no” (42%). Five participants did not know whether anxiety affects men and women differ- ently. Four of the six participants who responded “yes” thought that anxiety affected women more than men. There were no significant sex differences.
Does anxiety affect older and young people digerently? If yes, how? Twelve participants said “yes” (63%) and five said “no” (26%). Two participants did not know whether there were age differences in anxiety. Six of the twelve participants who said “yes” thought anxiety affected older adults more than younger adults:
I think it affects older people more, because they’re always afraid of getting closer and closer to death, your physical strength is going down, and you cannot do things that you used to do, so you’re afraid more.
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Younger people you wouId say, . . . in Japanese you would say nonki You know, they don’t worry too much llke older adults.
Well, I think the older ones are kind of lonesome, scared I think. Whereas young ones don’t care.
A younger person seems like they can overcome it faster.
Does anxiety affect Japunese American older adulfs diflerentb than Caucasian older adults? Ifyes, how? Fifteen participants (79%) did not think that anxiety affected Japanese American older adults differently than Caucasian older adults. Three participants (16%) did not know whether anxiety affected older adults of the two ethnic groups differently. DO you think that Japanese American older adults who do not come to
the Seinan Center regularly have diflerent levels of anxiety than those who do come to the center wgularly? Eleven participants (58%) thought those individuals who regularly attended the center had different levels of anxi- ety than those individuals who do nor attend regularly. Nine of these participants thought that the Japanese American older adults who attended the center regularly were less anxious than those who did not attend regularly. Six participants (32%) did not think that there was a difference in Jevel of anxiety between the two groups.
Depression
What is depression? Eleven participants (48%) defined depression us- ing terns similar to symptoms of major depression according to DSM-IF unhappiness, weight loss, and loss of interest. Three participants (13%) used the term “worry,” a main symptom of generalized anxietydisorder in DSM-IK to define depression. Nine participants (39%) did not define depression.
What am the symptoms of depmsion? Fourteen participants (61%) de- scribed symptoms of depression similar to DSM-Iv criteria including sad- ncss, no interest in activities, no desire to live, lethargy, and weight loss.
Is depression pmentable? Ifyes, how? Nineteen out of twenty-three participants (83%) thought that depression was preventable and two (11%) did not. Participants indicated that depression could be prevented by chang- ing one’s outlook on life, turning to religion, and seeing a psychiatrist.
Is depression permanent, or does it go may on its own? Twenty-one of the participants (9 1 %) did not think that depression was permanent, while one participant believed depression was permanent.
Is depression inherited fmm one b paren&? Ten participants (43%) did not think that depression was inherited from one’s parents, five partici-
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Iwamosa, Hilliard, and Osato 85
pants (22%) thought depression was inherited from one’s parents, and eight participants (35%) did not indicate whether or not depression was inherited from one’s parents.
Is there a stigma attached to being depressed? ryes , describe. Eight participants (35%) thought there was a stigma attached to being depressed, but ten participants (43%) did not believe that there was a stigma associated with being depressed. Participants who claimed there was a stigma attached to being depressed stated that depressed individuals were hard to get along with socially.
Well, some peopIe would stay away from them bccause they are not a happy person.
Is depression twatable? r f yes, how? Twenty-one participants (9 1%) thought that depression was treatable and two participants (-09%) did not know. Six participants thought depression was preventable through seek- ing medical attention either a psychiatrist or physician. Another six partic- ipants thought that depression could be treated by talking or seeing a counselor, and two participants thought depression coutd be aIleviated by keeping busy.
Are there things that put people at risk for depression? If yes, what? Fifteen participants (65%) thought there were risk factors associated with depression. Seven participants (30%) were unsure as to whether there were risk factors associated with depression. Ody one participant did not believe there were risk factors for depression. hsk factors listed by partic- ipants included personality differences, genetic predisposition, extensive worrying, inactivity, isolation, feeling sorry for oneself, and a series of bad life events.
Does depression uflect men and women differently? Ifres, haw? Fifteen participants (65%) thought depression affected men and women diffeerent- ly, and six participants (26%) did not know if there were any sex differ- ences in depression. Six of the 15 participants thought that depression affected women more than men. Three participants explained that this sex difference in depression was because women worry more. Two partici- pants thought men get depressed more than women, and three participants indicated that men try to hide their depression.
Women wony more about life.
You have to convince men when they are depressed.
Does depression aJecct older and youngpeople dt$erently? rfves, how? Sixteen participants responded “yes” (70%) and five participants (22%) did not think there was an age difference in depression. Five of the 16
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participants thought that older individuals were more likely to be de- pressed, whereas four of the 16 participants thought younger people were more likely to be depressed. The other seven out of the 16 participants did not indicate specifically how depression affected older and younger people differently. Three participants claimed the level Qf depression be- tween age groups was simply due to the fact that each generation was at a different stage of their lives.
Does depression uflect Japanese American older adults diferently than Caucasian older adults? rfyes. how? Eight participants (35%) did not think that there was a difference between the two ethnic groups. Thirteen participants (57%) believed there was a difference in depression among Japanese American older adults compared to Caucasian older adults. Two of these participants (1 5%) thought depression affected Japanese Ameri- can older adults more so than Caucasian older adults because Japanese American older adults wony about life more and are more vulnerable. The other 11 participants (85%) thought Caucasians were more likely to be depressed. In addition, two participants thought Japanese Americans would be more lrkely to hide their depression.
I think the Japanese way is . . , to hold things back.
Do you think that older Japanese American adults who do not came to the Seinan Center regularly have d$erent levels of depression than those who do come to the center regularly? Sixteen participants (70%) thought that there was a difference in depression level depending on whether or not you attended the center regularly, while four participants (17%) did nor think there would be a difference in depression level between the two groups. AIl sixteen participants who thought there was a difference in level of depression thought attendees would be lcss depressed than those individuals who did not attend regularly,
DISCUSSION
Summary of Anxiely Conceptualization
The conceptualization of anxiety of most participants in the current study appeared to be similar to the conceptualization of anxiety found in DSM-LK However, several participants also conceptualized anxiety in terms of depressive symptoms. This would indicate that there may be some overlap in how some Japanese American older adults perceive anxi- ety and depression.
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Iwamasa. Hilliard, and Osam 87
Most participants believed that anxiety was preventable by focusing on spirituality and by increasing social contacts. One participant even ac- knowledged that working with a traditional mental health care provider, a psychologist, would prevent the onset of anxiety.
Most participants viewed anxiety as a situational problem, without the burden of a stigma. Furthermore, most participants believed anxiety to be treatable, once a disorder did develop. Several respondents indicated the belief that traditional menta1,health services, such as seeing a psychologist or psychiatrist, would be effective treatments for anxiety. Other interven- tions were nontraditiond-being involved more in church activities, dis- tracting behaviors, and talking with others informally. Interestingly, these are all behavioral interventions which couId easily be incorporated into prevention and treatment interventions.
Risk factors identified by the participants included not being able.to relax and having negative thoughts and ruminating. Perceptions about SCX differences in anxiety disorders were equivocal, with some respondents believing that sex differences existed (With more of an emphasis that women were more anxious than men), and other not believing in sex diffmences, or not knowing.
Of the respondents who believed there were age differences in anxiety, most believed that older adults were more anxious than young people. Most of the statements made by participants indicated that older adults have more issues to worry about, such as getting closer to death, losing physical health, being lonely, and being unable to do things one used to do.
Most participants did not believe an ethnic group difference existed in the experience of anxiety between Japanese American and European American older adults. However, many of the participants believed that involvement in the senior center mediated the experience of anxiety, with higher involvement resulting in lower levels of anxiety. Thus, the activities at the center were seen as serving as protective factors in the development of anxiety symptoms.
Summary of Depression Con cephtalizarian
As with anxiety, most participants appeared to conceptualize depres- sion similarly to how'depression is described in DSA4-N However, a few respondents did use anxiety terms to describe depression. Again, this indicates the potential overlap some individuals may have in their percep- tions of depression and anxiety.
Most respondents believed that depression was situational and prevent- able. Prevention interventions suggested by participants included chang- ing one's thoughts, turning to religion, and seeing a mental health profes-
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sional; More people believed that there is a stigma attached to being depressed as compared to being anxious. Most of this was expressed as the perception that others would not want to be around a person who was not
Most participants believed that depression was treatable via medical attention, seeing a counseIor, and as with anxiety, a few participants be- lieved that engaging in distracting behaviors was an effective treatment. Risk factors identified by the respondents included personality differ- ences, genetic predisposition, extensive worrying, inactivity, isolation, negative thoughts about oneself, and negative life events.
Many respondents believed that sex diffcrcnces in deprcssion exist, with more belicving that women were depressed more than men, and only MO respondents believing that men get depressed more than women. However, a few participants also noted that men are just as likely to get depressed as women, only they tend to try to hide it. Most respondents also believed that age differences in depression exist. However, the responses appeared to be equivocal, with some participants believing that older people are more likely to get depressed and others indicating that younger people are more likely to be depressed.
Interestingly, although most respondents did not believe there were ethnic group differences between Japanese American and European Amen- can older adults in terms of anxiety, results indicated that respondents were more likely to report ethnic group differences in level of depression. Although two participants indicated that Japanese American older adults were more likely to get depressed, most respondents believed that Euro- pean American older adults were affected by depression more than Japa- nese American older adults. This finding is particularly interesting given that almost one half of the sample were interned in concentration camps during World War II. Japanese Americans who were interned were forced to give up virtually all of their possessions, including their homes and land, and experienced great setbacks in education and employment. Final- ly, a few rcspondents indicated that Japanese American older adults would be more likely to try to hide their depression as compared to European American older adults.
All of the respondents who believed there were differences in level of depression among senior center members and non-members bclieved that members were less likely to be depressed than non-members. Again, this indicates that these participants believed that the senior center they at- tended served as a protective factor in the development of depressive symptoms.
happy.
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lwarnasd, Hilliard, and Osalo 89
IMPLICATIONS OF THfi RESULTS
The results of this study shed light on how Japanese American older adults perceive depression and anxiety. For most, it would appear that they conceptualize these disorders in much the same way as traditional mental health practitioners would. However, it is important to note that several participants described each disorder using symptoms of the other disorder. For example, describing depression as anxiety, and vice versa. This is consistent with previous research which has shown some difficulty in differentiating between anxiety and depression in older adults (Blazer, Hughes, & Fowler, 1989). This also raises the issue of the possibility of thc co-morbidity of anxiety and depression among some older adults. These results would indicate that health care practitioners who work with Asian American older adults should fully assess both anxiety and depres- sive symptoms. Furthermore, an additional factor for clinicians to consider is the existence of subsyndromal symptoms. Although some older adults may not meet criteria for an actual diagnosis of an anxiety or mood disorder, they may be cxperiencing subsyndromal symptoms that interfere with functioning (George, 1996).
A positive implication of the results of this study is that it appears that many of these Japanese American older adults would be receptive to cognitive and behavioral interventions for anxiety and depressive symp- toms. This finding supports the conclusions of Zeiss and Breckenridge (1 9971, who also found that older adults had gcnerally positive attitudes toward such treatments. Additionally, participants in this study indicated a number of factors that they perceived as putting older adults at high risk for anxiety and depression. Inability to relax, negative ruminative thoughts, isolation and negative Iife events all could easily be assessed by heaIrh care practitioners. Each of these risk factors could easily be addressed utilizing cognitive and behavioral techniques such as relaxation training.
Several respondents also described the idea that some individuals may try to hide their psychological distress, particularly depression. This has direct implications for health care workers, who may need to develop alternative and creativc ways to assess depression among Japanese Ameri- can older adults, and warrants further investigation.
METHODOLOGICAL CONSIDERATIONS
The qualitative nature of this study prevents the definitive conclusion that Japanese American older adults conceptualize anxiety and deprcssion
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in the exact way that these disorders are described in DSM-IK However, these findings do support the results of a master’s thesis project supervised by the first author (Kost, 19971, which found that 62% of Japanese Ameri- can older adults presented with a description of an individual who met criteria for depression labeled the person’s problem as depression, or as a depressive symptom. Thus, there does appear to be a high degree of similarity in conceptualization, particulady of depression.
Another consideration is that we conducted voluntary interviews with respondents. Participants were informed of the nature of the questions. Thus, their responses may be different from the responses of those elders who chose not to participate. Additionally, responses may be different from the responses we would have received had we utilized a written survey format.
A fmal methodological consideration is that unfortunately, although we assessed whether or not the participant was interned during World War 11, for those who were interned we did not ask specific questions about how the internment experience might have influenced their perceptions of anxiety and depression. It seems quite plausible that experiencing the trauma of being forcibly removed from one’s home, having most of one’s personal p o p e 9 taken away, and being forced to relocate and Iive in internment camps for an extended period of time, might have some effect on percep- tions of anxiety and depression. Furthermore, methods of coping both dur- ing and after the internment were not assessed in the current study. Such information could provide valuable insight into how Japanese American older adults dealt with the stress of discrimination and internment over an extended period of time and, as a result, how that might q a c t their current state of mental health. Given the resuIts of this study, one might hypothesize that Japanese American older adults who were interned during World War I1 possess some sort of resilience quality or characteristic which has resulted in a more positive and optimistic outlook on life as they age.
DIXECTIONS FOR FUTURE RESEARCH
The results from this study suggest several directions for research. First, although issues related to conceptualization of depression and anxiety are clearer, more research needs to examine the issue of co-morbidity of these disorders, as well as consideration of a mixed anxietydepressive disorder, as is suggested in DSM-/J! Another focus of research should be more extensive epidemiological surveys of anxiety and depression among Asian American older adults. We still do not have adequate data on prevalence rates of these disorders among this population of older adults. Thus, we do
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not know if this group of older adults have higher or lower rates of psychological distress as compared to older adults of other ethnic groups.
Another area for additional attention would be a study of Japanese American older adults’ perception of mental health issues in aging and, in general, how they perceive the aging process. Additional information is needed on how the internment experience during World War I1 has shaped Japanese Americans’ perceptions on mental health and coping. If we find that Japanese American older adults have low rates of anxiety and depres- sion, and perceive themselves to be mentally healthy, their methods of coping may serve as the foundation for preventive interventions for older adults. In other words, w e may find that Japanese American older adults can serve as a resource on how to agc successfully. The concept of suc- cessful aging has been examined among non-minority adults, and models for successful aging have been posited (Rowe & Kahn, 1997), but success- ful aging has yet to be examined among ethnic minority elderly. Such data on Japanese American older adults would be a significant contribution to the literature.
Yet another direction for research would be to focus on this issue of “hiding” distress. Questions such as “Why would an individual wish to hide such difficulties?” and “How does one hide fiom others the fact that he/she is depressed?” would be interesting to ask Asian American older adults as well as older adults from other ethnic groups. We could then examine whether or not ethnic group and sex differences exist on this issue. A fifth direction for research is to focus on more detailed examina- tion of the potential risk and protective factors for anxiety and depression among Asian American older adults. The responses of participants in this study provides a place for researchers to begin identifying what potential factors might be. Finally, more research needs to be conducted on potential sex and age differences in the conceptualization, experience and expres- sion of anxiety and depression among Japanese Americans. Results of this type of research can then lead to the development, implementation and examination of effectiveness of prevention and treatment interventions.
CONCLUSION
The results of this qualitative investigation of the conceptualization of anxiety and depression among Japanese American older adults suggests that their conceptualization of thcse disorders is similar to the conceptual- ization used by most mental health practitioners and disorders as defined in DSM-m However, several participants did conceptualize anxiety and depression somewhat differently, and at times defined each disorder with
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symptoms of the other disorder. Additionally, these participants believed that both anxiety and depression were preventable, situational, and treat- able. Respondents also were ablc to identify possible risk and protective factors. There was some evidence that some of these Japanese American older adults believed hat sex, age, and ethnic group differences existed in levels of anxiety and depression. Implications of the results and rnethod- ological considerations of the study were discussed, and directions for future research highlighted.
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