depression among elderly korean immigrants

DepressionAmong Elderly Korean Immigrants:

Exploring Socio-Cultural Factors

Hee Y. LeeAilee Moon

Bob G. Knight

ABSTRACT. This study examined predictors of depression in a sampleof 95 elderly Korean immigrants aged 60 or over. Depression amongKorean immigrants was hypothesized to be associated with socio-demo-graphic and cultural factors, including health status, gender, education,financial status, acculturation level, familism, social support, especiallyfrom the family, and family relationships. A face-to-face interview wasconducted in Korean using a structured questionnaire. Depression in thisstudy was measured using the Center for Epidemiological Studies of De-pression (CES-D) Scale. A substantial percentage of the sample was ex-periencing a high level of depression. The mean score on the CES-Dscale was 15.1, slightly below 16, a cut-off score for clinical depression,and almost 40% of the respondents scored 16 or above on the scale, indi-cating a high rate of clinical depression for the study sample. In multiple

Hee Y. Lee, MSG, MSW, is a Doctoral student, and Ailee Moon, PhD, is AssociateProfessor, Department of Social Welfare, University of California, Los Angeles. BobG. Knight is Professor, Andrus Gerontology Center, University of Southern California,Los Angeles.

Address correspondence to: Hee Y. Lee, Department of Social Welfare, School ofPublic Policy and Social Research, University of California, Los Angeles, 3250 PublicPolicy Building, Box 951656, Los Angeles, CA 90095-1656.

This article is in part based on Hee Y. Lee’s master thesis at the University of South-ern California Leonard Davis School of Gerontology.

Journal of Ethnic & Cultural Diversity in Social Work, Vol. 13(4) 2004http://www.haworthpress.com/web/ECDSW

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regression analyses, perceived health status and education were signifi-cant predictors among socio-demographic factors. Among cultural fac-tors, acculturation status was not a significant predictor; however,positive support from the family and family relationships were signifi-cantly associated with depression. The role of family as a risk factor fordepression in older Korean immigrants and implications for mentalhealth policy, programs, and future research are discussed. [Article copiesavailable for a fee from The Haworth Document Delivery Service:1-800-HAWORTH. E-mailaddress:<[email protected]>Website:<http://www.HaworthPress.com> © 2004 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Depression, elderly Korean immigrants, perceivedhealth status, cultural factors

INTRODUCTION

Depression negatively affects a person’s physiological, psychologi-cal, and social life. Severe depression slows a person’s mind and body,diminishes capacity to make decisions, and even reduces motivation forlife. Depression is the leading emotional disorder in later years and theestimated prevalence of depression in the White elderly population hasranged from 4% to 15% (Steffens et al., 2000; Stek et al., 2004). Depres-sion becomes more prevalent with increasing age due to the elderly’shealth-related conditions (Roberts et al., 1997) and non-health-relatedlife events, such as deterioration in financial status, death or illness inrelatives or friends, and caregiving (Fiske et al., 2003).

The prevalence of depression among the minority elderly populationis reported to be relatively higher than general elderly population. Stud-ies indicate that Asian Pacific Islander (API) elderly are more vulnera-ble to depression than White elderly (Kuo, 1984; Lam et al., 1997; Ying,1988). For example, the prevalence of depression measured by the Geri-atric Depression Scale (GDS) was 18% for elderly Chinese (Mui, 1996)and 20% for Japanese American elders (Shibusawa & Mui, 2001).

Research further suggests that recently immigrated Korean eldersexperience even greater depression compared to long-time residentsof other API populations (Kuo, 1984). Sung (1998) and Noh, Kaspar,and Chen (1998) in their respective studies of the mental health sta-tus of elderly Korean immigrants reported a CES-D mean score of15.9 and 16.3 respectively, with a cut-off score of 16 or higher rec-

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ommended by Radloff (1977) for a clinical depression. These meanscores are higher than that of the White frail elderly (13.8) (Rogers,1999) and older Chinese immigrants (8.9) (Casado & Leung, 2001).Furthermore, Korean elderly immigrants were identified as having thehighest prevalence rate (40%) (Sung, 1998) when compared to otherminority elderly groups, such as Mexican American elders (24.3% to27.4%) (Morton et al., 1989; Chiriboga et al., 2002; Frerichs et al.,1981) and Black elders (6.15% to 21.8%) (Husaini et al., 1991;Frerichs et al., 1981). These findings clearly indicate serious mentalhealth problems among Korean elderly immigrants, which may betriggered by immigration related stresses and psycho-social adapta-tion issues.

Many studies have shown (Kiefer et al., 1985; Murphy, 1977; Nann,1982) that immigration, particularly from an Asian culture, is stressfuland has long-lasting serious psychological effects due to cultural up-rooting and cultural differences in the new society. Recent older immi-grants who lack preparation for major changes in their livingcircumstances may be especially at risk. Older immigrants often expe-rience adjustment problems associated with unfamiliarity with differ-ent social and economic systems, language and cultural barriers, andlack of a social and kinship support network that is crucial to the socialand cultural needs of the newcomer. Theories of immigration suggestthat immigration creates a tremendous amount of stress due to variousfactors, such as the demanding task of acculturation, environmentalchanges, and a relatively isolated social life (Kuo, 1976).

The purpose of this study was to assess the rate of depression in asample of elderly Korean immigrants and to identify socio-culturalfactors associated with depression within a framework that hypothe-sizes three types of relationships between immigration status and de-pression: (1) some demographic and socio-economic variables (suchas age, gender, education, health status, religion, and financial sta-tus) are associated with depression in elderly Korean immigrants insimilar patterns to that in the general elderly population; (2) accultur-ation status will be a significant predictor of depression; and (3) im-migration and related issues of acculturation may result in valueconflicts and disruption of family support and relationships with anadult child, which in turn adversely affects depression.

Lee, Moon, and Knight 3

LITERATURE REVIEW

Social-Cultural Factors of Depression

An overview of existing studies on depression among elderly Koreanimmigrants identifies the following as socio-demographic predictors ofdepression: old age, gender, education, health status, employment and fi-nancial status, social isolation, and religion (Kiefer et al., 1985; Hurh &Kim, 1990; Kim et al., 1991; Moon & Pearl, 1991; Shin, 1993; Pang,1995; Lee et al., 1996; Kim et al., 1997). These variables are also predic-tors of depression for the general elderly population in the United States(Karel, 1997). There is moderate support for an association between de-pression and immigration and Korean-culture specific factors such as ac-culturation level, changing family ties, and family support (Kiefer et al.,1985; Kim et al., 1991; Lee, 1996; Moon & Pearl, 1991; Pang, 1995). Thefollowing are detailed descriptions of socio-demographic, immigrationand culture-related factors associated with depression in the general aswell as minority elderly population.

Demographic Factors

Vulnerability to depression has been studied for a number of yearsamong older adults. In a review of this literature, Karel (1997) notedthat self-reported depression has shown a curvilinear relationship toage, with young adults (in their 20s) and the oldest-old (75+) reportingmore depression than the middle-aged group. This pattern holds forboth men and women, with women generally reporting higher levels ofdepression at all ages. As noted in a review by Culbertson (1997), thehigher level of depression among women appears to be consistent inter-nationally. Ethnic differences in the relationship of age to depressionare, however, less clear. For example, Karel (1997) found a curvilinearrelationship between age and depression for the study’s African-Ameri-can sample, but Frerich et al.’s (1981) Latino sample showed a linear re-lationship in that older adults reported higher levels of depression thanthe young. Longitudinal studies provide support for the increase in de-pression with age in the Latino population (Barefoot et al., 2001; Fiskeet al., 2003; Rothermund & Brandtstadter, 2003).

Financial strain is related to depression in older adults, as it is at otherages. The impact of financial strain on depression may be more deleteri-ous within the elderly immigrant population due to its disadvantagedsocioeconomic status. Chiriboga et al. (2002) found that Mexican


American elders with lower income reported more depression. Shin(1993) reported that financial strain contributed to an increase in de-pression among Korean women immigrants. The same relationship isreported in longitudinal studies among Hong Kong Chinese elderly(Chi & Chou, 1999), confirming that greater financial strain is stronglyassociated with depression.

Poor health is an additional key factor in depression among olderadults. Health status consistently predicts depression within the generalelderly population (Kraaij et al., 2002; Dorfman et al., 1995; Rogers,1999) and immigrant elderly population (Chiriboga et al., 2002; Sung,1998).

The role of religion in protecting older adults against depression in theU.S. is still unclear. A cross-sectional study by Koenig et al. (1997) re-ported the positive effects of religion for older adults’ well-being, whileAtchley (1997) failed to find longitudinal effects of religion on depres-sion over a 14-year interval. Strawbridge et al. (1998) reported an inverseassociation between organizational religiosity and depression, but foundthat the buffering effect of religiosity was specific to non-family stressorsand exacerbated the effects of some family stressors.

The effects of religion may be different among Korean American el-derly. In general, most Korean Americans in the U.S. are ProtestantChristians, although traditional Korean society was predominantlyBuddhist. Chang and Moon (1997) reported that 77% and 14% of Ko-rean elderly Americans in the United States were Protestant and Catho-lic, respectively. Approximately 91 percent of Korean immigrants inLos Angeles are affiliated with churches, making the church an insepa-rable part of the community structure (Chang & Moon, 1997). Koreanchurches in the U.S. play a critical role for Korean elderly immigrants,not only for religious and spiritual support, but also for social service in-formation and for cultural activities which help new immigrants adjustto a new environment (Kim et al., 1997). Song (1998) reported religionas a significant predictor of life satisfaction among elderly Koreanimmigrants.

Level of education has consistently been found to be a significantpredictor of depression in one’s later years. Studies have reported thatthe more highly educated experience less depression. This inverse rela-tionship has been confirmed among Mexican immigrant women (Vega,Kolody, & Valle, 1986), American Indian elderly (Curyto et al., 1998),White elderly (Jang, Haley, Small, & Mortimer, 2002), and KoreanAmerican women (Shin, 1993), and in the Latino population (Rivera,2003).


Based on previous research findings, it is hypothesized that beingwomen, having low income, being in poor physical health, having noreligious affiliation, and having a lower level of education are associ-ated with depression among elderly Korean immigrants.

Acculturation Factors

Immigration from a non-Western culture and the process ofacculturating to a linguistically and culturally different society is a verystressful life event. Moon and Pearl (1991) found that the number ofyears in America is negatively correlated with poor mental health. Thestudy compared Koreans who recently immigrated to the U. S. withthose who immigrated a number of years ago and found that recent Ko-rean immigrants felt more alienated and powerless. However, evidencefor the effect of acculturation on the mental health of elderly Korean im-migrants is not conclusive. Lee et al. (1996) determined that the level ofacculturation has no significant effect on depression among elderlyKorean immigrants.

Among older Hispanics, language acculturation is significantly re-lated to depression (Krause & Goldenhar, 1992; Zamanian, Thackrey,Starrett, 1992). In a study by Chiriboga et al. (2002), Mexican Americanelderly who were more likely to use Spanish at family gatherings weresignificantly more likely to report depression than those who speakEnglish at home. Similarly, English deficiency is significantly associ-ated with depression among Asian refugees (Westermeyer, Tou-fu, &John, 1983). It is hypothesized in this study that older Korean immi-grants who are more proficient in English and more acculturated intothe American way of life will suffer less from cultural and other adjust-ment related stressors, and, therefore, report lower levels of depression.

Cultural Factors

Filial piety for elder parents is a strong theme for elderly KoreanAmericans as well as other Asian Americans (Ishisaka & Takagi, 1982).In general, there is an expectation that Korean immigrants will maintainan intact and harmonious extended family structure in which the elderplays an important and respected role. However, younger generations ofKorean Americans are more likely to be acculturated into the Americannorms and values, such as emphasis on the nuclear family and individu-alism, than those of the Korean traditional values, such as extendedfamily and collectivism. Tran’s study (1991) found that the family was


the most crucial factor in the promotion of social adjustment among el-derly Indochinese refugees, and there was an inverse relationship be-tween age and adjustment, with older refugees having a poorer sense ofsocial adjustment. Old age was also associated with a lack of prepara-tion for adjustment to life in America and poor knowledge of English,which led to numerous problems with help seeking and serviceutilization (Tran, 1990).

Based on these findings, it is expected that elderly Korean immi-grants would more highly value familism than individualism, and thestronger familism values would be associated with higher depression. Itis, therefore, hypothesized that familism in older Korean immigrants ispositively related to depression.

Moreover, since the younger generation is likely to be more accept-ing of various aspects of American culture than their immigrant parents,intergenerational conflict in the family is likely to cause stress and de-pression in elderly Korean immigrants. Conversely, a sense of supportand cultural congruence among family members, and little or no famil-ial conflict would be associated with a lower level of depression. It ishypothesized that both positive support and conflictual relationshipswithin the family are important factors related to depression among Ko-rean elderly immigrants: the former protects against depression whilethe latter contributes to the elder’s depression.

METHODS

Sampling and Data Collection

The 95 study participants were native Koreans aged 60 years or olderand were residing in Los Angeles County in 1997. Purposive and con-venience sampling methods were employed to recruit study subjects.However, to reduce sampling bias inherent in such non-probabilitysampling, a number of sampling sites such as supermarkets, senior citi-zen centers, barbershops, beauty salons, senior citizen housing sites,and shopping malls were used to recruit study participants. In addition,study respondents were recruited from different areas across Los An-geles County, including the San Fernando Valley, San Gabriel Valley,South Bay, West Los Angeles, Downtown Los Angeles, and East LosAngeles.

A structured questionnaire in Korean was employed in face-to-faceinterviews that lasted approximately 60 minutes. The interviews were


conducted by the first author and three trained graduate students, whowere all native speakers of Korean and had knowledge and experiencein interviewing. To minimize the refusal rate, respondents were offered$10.00 as compensation for participating in the study. The response ratewas 92% for the sample.

The participants were asked a set of demographic and socio-eco-nomic profile questions that included gender, age, marital status, livingarrangement, number of children, years in the U.S., education, healthstatus, employment, income, immigration background, citizenship, reli-gion, importance of religion, and social activity. Using scales, partici-pants were asked to rate items for depression, acculturation, familism,family relationship with adult children, and social support.

Measures

Income was reported in 10 categories from under $200 per month to$1800 or more per month. For measurement of perceived health status,a 5 point Likert-type scale ranging from “very poor” to “excellent” wasutilized, with higher scores indicating better perceived health. Educa-tion was measured by years of formal education.

Depression was measured by Radloff’s (1977) CES-D scale consist-ing of 20 statements answered on a 4 point Likert-type scale (0-3) interms of how frequently the individual experienced the feelings de-scribed in the statement during the past week. The possible range ofscores is 0 to 60, with higher scores indicating a higher depression level.The cut-off score for indicating clinical depression recommended byRadloff (1977) is 16. The scale has high reliability and validity witholder adults and across White, African American, and Asian subgroups(Radloff & Teri, 1986). The scale’s internal consistency or reliability(Cronbach’s alpha) was .88 on the current study’s sample.

Adopting Krause and Bennett’s (1989) measurement of acculturationamong Latino older adults, the acculturation level of elderly Korean Amer-icans was assessed by asking a series of questions concerning number ofyears in the U.S., ethnic identification, proficiency in the English language(speaking, reading, and listening), changes in value system, and changes inlife style. Years in the U.S. was recorded as reported, and ethnic identifica-tion was measured by three categories: (1) “identification with Korean,”(2) “identification with Korean American,” and (3) “identification withAmerican.” The proficiency in English was answered on a 5 pointLikert-type scale, rating from (1) “very good” to (5) “very poor.” The changein value system and life style was measured by three categories: (1) “more


Korean way,” (2) “half Korean way and half American way,” and(3) “more American way.”

A 16-item scale was used to measure familism, which refers to strongfamily solidarity, emphasis on the family’s common goals, commonproperty, mutual support, and the desire to pursue the perpetuation of thefamily (Bardis, 1959a). Sample items of this scale are: “A person shouldalways support his or her uncle or aunts if they are in need,” or “At leastone married child should be expected to live in the parental home.” Itemswere rated from (1) “strongly disagree” to (5) “strongly agree,” withhigher scores representing higher familism. In the scale’s developmentsamples (Michigan college students), Spearman-Brown’s split half reli-ability coefficients ranged from .77 to .84 with a 30 day retest reliabilityof .90 (Bardis, 1959a, 1959b, & 1959c). Validity was established by re-porting expected mean differences between reference groups (the Michi-gan college students with Greek students in a “familistic community”)(Bardis, 1959b). Cronbach’s alpha for familism was .83 for the presentstudy’s sample.

Quality of social support was measured using a 17-item question-naire developed by Knight (1992), with subscales for perceived positivesupport and for conflict. The respondents were first asked who theirmain source of support was and then answered the 17 items with regardto the principal helper. Using a 5 point Likert-type scale, the questionwas answered ranging from 1 to 5 with 1 being “a great deal” and 5 be-ing “not at all.” Twelve of the questions measured perceived positivesupport, while the remaining 5 assessed perceived conflictive support.Positive support items included: “How much would your main helpermake sure you were cared for if you were ill?” or “How much is yourmain helper willing to listen when you need to talk about your worriesor problems?” Conflictive support involved items such as: “How muchdoes your main helper argue with you?” or “How much does your mainhelper create tensions or conflicts for you?” For positive support, therange of possible scores was from 12 to 60, and higher scores were in-dicative of greater perceived positive support, because items in thissubscale were reverse coded. For conflictive support, the range of possi-ble scores was from 5 to 25 with higher scores indicating less perceivedconflict. More than 60% of the respondents in this study designatedtheir spouse as the main source of help, while more than 30% of the sub-jects regarded their daughter or son as a principal helper. Cronbach’salphas were .82 for positive support and .73 for conflictive supportamong this study’s sample.


Developed in Korea by Youn and Song (1991), the family relationshipscale was used to assess the relationship between elderly Korean parentsand their adult children in the context of America. The measure assesseshow an elderly person perceives conflicts and problems in relationshipswith his or her adult children, using 7 items including “My children try tohelp me enjoy my later life,” or “My children ask for my opinion in mak-ing important family decisions.” Responses are given on a 5 pointLikert-type scale ranging from (0) “almost always” to (4) “almost never.”The total score of those 7 items ranged from 0 to 28. Higher scores meanta better relationship with adult children. Cronbach’s alpha of the scale onthe sample was .59 in this study.

Scales taken from English versions were translated from English toKorean by a bilingual expert and back translated from Korean to Eng-lish by another bilingual expert. The back translated English scaleswere compared to the original English version scales for consistency ofmeaning of the scales by a native English speaker who had knowledgeand experience in research on the mental health of ethnic elderly. Thebilingual expert also had research experience and knowledge in thisfield. In addition, prior to distribution of the questionnaire, existing in-struments were pilot-tested for use with the elderly Korean immigrantsby phone and personal interview. Some of the items in the CES-D, so-cial support, and familism scales were modified to be culturally appro-priate and more clearly understood by older Korean immigrants. Forinstance, the term “blue” in the CES-D depression scale did not exist inthe Korean language. Thus, it was translated into “sad” in Korean.

Data Analysis

Frequency distributions were used to examine sample characteris-tics, levels of depression, social support, family relationship, andfamilism, and to develop an item analysis of the depression scale and anacculturation profile of the study participants. Bivariate analyses, suchas t-test, one way ANOVA and chi-square in cross-tabulation, wereconducted to examine subgroup differences in socio-demographic char-acteristics on the depression scale. Pearson’s correlation was used to as-sess the strength and direction of association between depression andindependent variables, including socio-demographic variables, socialsupport, familism, and family relationship. Finally, multiple regressionanalysis of depression was conducted, using a three-step model of inde-pendent variables: (1) socio-demographic variables, (2) years in the


U.S. as an acculturation indicator, and (3) social support and familyrelationship as cultural factors.

FINDINGS

Sample Characteristics

As seen in Table 1, the respondents consisted of more women(62.1%) than men (37.9%). The ages of the respondents ranged from 61to 88 years and slightly more than half of the sample (51.6%) were be-tween the ages of 70 and 79, with an average age of 73.3. About 60% ofthe respondents were married, and 36% of the sample were widowed.More than half (53%) were living with a spouse, and about 34% of thesample were living alone. For perceived health status, nearly one-third(31%) of the respondents reported their health status as being excellentor good, while 35% of the sample reported their health status as bad orvery bad. Almost two-thirds of the sample (60%) had less than highschool education. The majority of the sample (87%) were low income,and most depended on Supplementary Security Income (SSI) as theprimary source of income.

Nearly two-thirds of the sample (63%) were Protestant, with 29.5%Catholic, and only 4.2% Buddhist. All respondents, except for three, re-garded religion as very important (63%) or important (31%) in theirlives. Almost three-quarters of respondents (73%) reported that they didnot participate in any kind of social activity, except church and religiousactivities. The majority of the respondents (60%) lived in the U. S. formore than 10 years, but less than 20 years, with the average of 13.7years. About one-fifth (20%) lived in the U.S. less than 10 years. Ap-proximately half of the respondents (51%) were U.S. citizens at the timeof interview.

Levels of Depression, Social Support, Family Relationship,and Familism

Table 2 presents findings on levels of depression, quality of socialsupport, family relationship, and familism. It shows relatively high lev-els of depression in the elderly Korean immigrant sample. The CES-Dscale score ranged from 0 to 48 with the mean of 15.05 (SD = 10.10).This mean score is slightly lower than the cut-off score of 16 for clinicaldepression as recommended by Radloff (1977). More importantly,



TABLE 1. Demographic Information of Respondents (N = 95)

Variables Items Frequency (N) Percent (%)

Gender Male 36 37.9Female 59 62.1

Age 60-69 28 29.570-79 49 51.680-89 18 18.9

Marital Status Married 56 58.9Separated 3 3.2Widowed 34 35.8Divorced 2 2.1

Living Arrangement Living Alone 32 33.7Living with Spouse 50 52.7Living with Others 13 13.6

Perceived Health Excellent 6 6.3Good 23 24.2Not Good/Not Bad 33 34.7Bad 24 25.3Very Bad 9 9.5

Years of Education 0 15 7.41-6 34 35.87-9 16 16.8

10-12 19 20.013 or over 16 16.8

Income $ 0-199 7 7.4$ 200-599 34 35.8$ 600 -999 42 44.2$ 1,000-1,399 6 6.3$ 1,400-1,799 2 2.1$ 1,800 or over 4 4.2

Financial Situation Excellent 1 1.1Good 13 13.7Not Good/Not Bad 56 58.9Bad 17 17.9Very Bad 8 8.4

Religion No Religion 3 3.2Protestant 60 63.2Catholic 28 29.5Buddhist 4 4.2

Importance of Religion Very Important 60 63.2Important 29 30.5Not Important 3 3.2

Social Activity Yes 26 27.4No 69 72.6

Years in the U.S. 1-5 10 10.76-9 9 9.510-15 35 36.816-19 21 22.120 or over 16 17.2

Citizenship Yes 48 50.5No 47 49.5

39.3% of the sample (n = 37) scored at 16 or above on the CES-D scale,indicative of clinical depression.

Examination of the subscales of the CES-D shows that while mostmean scores of the CES-D subscale in this sample are similar to thosefrom previous research, the mean score (5.96) of the “positive affect”subscale was remarkably high. The subscale’s mean score is evenhigher than that of community dwelling frail elderly (3.5) (Barusch,Rogers, Abu-Bader, 1999). Item analysis of “positive affect,” “de-pressed affect,” “somatic problem and retarded activity,” and “interper-sonal problems” is presented in Table 3.

The overall mean score of positive social support was 35.19 (SD =15.92), with a range from 12 to 59, implying that the respondents re-ceived, on average, a fair amount of positive social support. The con-flictive social support’s mean score was 20.25 (SD = 8.04), with a rangefrom 5 to 25, indicating relatively low levels of perceived conflict. Themean score of family relationships was 21.07 (SD = 4.0), with a rangefrom 12 to 28, implying that the study sample maintained good relation-ships with their adult children.

Acculturation Indicators

Table 4 presents elderly Korean immigrants’ acculturation profile. Amajority of the respondents identified themselves as Korean (63%) andKorean American (26%). About 85% of the sample reported problems


TABLE 2. Mean and Standard Deviation of Depression, Quality of Social Sup-port, Family Relationship, and Familism Scale

Scales Mean S.D.

Subscales of Depression Scale (Mean = 15.05, SD = 10.10, Range = 0-48)

Somatic Problems and Retarded Activities (7 items) 4.80 6.29

Depressed Affect (7 items) 3.79 5.55

Interpersonal Problems (2 items) 0.49 1.15

Positive Affect1 (4 items) 5.96 4.68

Subscales of Social Support Scale (Mean = 63.50, SD = 8.39, Range = 43-84)

Positive Social Support (12 items) 35.19 15.92

Conflictive Social Support (5 items) 20.25 8.04

Family Relationship Scale (Range = 12-28) 21.06 3.99

Familism Scale (Range = 48-80) 62.01 6.43

1. Items in positive affect were reverse-coded and the mean and S.D. reflect these scores.

with speaking English, and about 93% reported problems with readingEnglish. Similarly, 92% of the respondents reported having problems inunderstanding spoken English. The findings also show that the majorityof the respondents maintained Korean values while adopting Americanlifestyles; about 56% reported their value systems are consistent morewith the Korean way, while almost two-thirds (65%) indicated that theirlifestyles have become more Americanized. Only 5.4% of the respon-dents reported changing their lifestyles to a more Korean way, and 28%of the respondents reported no change in lifestyle.


TABLE 3. Item Analysis of Depression Among Elderly Korean Immigrants

Items Level¹ Mean SD

Never orless thanone day

Seldomor 1-2days

Most ofthe timeor 3-4days

All, nearlyall of thetime, or5-7 days

Somatic Problem and Retarded Activity 4.80 6.29

1. I was bothered by things that usually don't bother me. 44.2 43.2 8.4 3.2 .70 .76

2. I didn't feel like eating; my appetite was poor. 44.2 36.8 6.4 8.4 .75 .91

5. I had trouble keeping my mind on what I was doing. 58.9 28.4 7.4 4.2 .56 .81

7. I felt that everything I did was an effort. 49.5 25.3 12.6 11.6 .86 1.00

11. My sleep was restless. 61.1 15.8 9.5 12.6 .73 1.10

13. It seemed I talked less than usual. 50.5 26.3 14.7 7.4 .78 .96

20. I could not get going. 70.5 18.9 6.3 3.2 .41 .75

Depressed Affect 3.79 5.55

3. I felt that I couldn't shake off the blues even with helpfrom my family and friends.

61.1 25.3 7.4 5.3 .56 .85

6. I felt depressed. 42.1 44.2 3.2 9.5 .79 .89

9. I thought my life had been a failure. 57.9 26.3 10.5 4.2 .60 .84

10. I felt fearful. 69.5 23.2 4.2 2.1 .38 .67

14. I felt lonely. 54.7 23.2 10.5 10.5 .76 1.00

17. I had crying spells. 75.8 18.9 3.2 1.1 .28 .58

18. I felt sad. 71.6 20.0 4.2 3.2 .38 .72

Interpersonal Problems .49 1.15

15. People were unfriendly. 74.7 17.9 4.2 1.1 .30 .60

19. I felt people disliked me. 86.3 7.4 4.2 1.1 .19 .55

Positive Affect 5.96 4.68

4. I felt I was just as good as other people.² 28.4 24.2 29.5 16.8 1.4 1.10

8. I felt hopeful about the future.² 29.5 8.4 25.3 35.8 1.7 1.20

12. I was happy.² 32.6 13.7 27.4 25.3 1.5 1.20

16. I enjoyed life.² 28.4 21.1 24.2 25.3 1.5 1.20

Note: 1. Indicates frequency during the last week before the interview.2. Items in positive affect were reverse-coded and the frequency and mean reflect these scores.

Bivariate Analysis of Socio-Demographic Characteristicswith Depression Scale

The means, standard deviations, percent and number of respondentsscoring 16 or higher on the CES-D scale of socio-demographic vari-ables were examined by conducting t-tests, one way ANOVAs, andcross-tabulations. Statistically significant subgroup differences werefound among four socio-demographic variables: living alone, social ac-tivity, income, and religion (see Table 5). Those who lived with familymembers and participated in social activities reported, on average, lessdepression than those who did not participate in activities and lived


TABLE 4. Acculturation Level of Elderly Korean Immigrants

Items Frequency (N) Percent (%)

Ethnic Identification Korean 60 63.2Korean American 25 26.3American 8 8.5

Speaking Ability in English Very Good 0.0 0.0Good 1 1.1Not Good/Not Bad 12 12.6Poor 33 34.7Very Poor 48 50.5

Reading Ability in English Very Good 3 3.2Good 0.0 0.0Not Good/Not Bad 3 3.2Poor 22 23.2Very Poor 66 69.5

Listening Ability in English Very Good 2 2.1Good 1 1.1Not Good/Not Bad 4 4.2Poor 25 26.3Very Poor 62 65.3

Change in Value System More Korean Way 13 13.7Somewhat More Korean Way 40 42.1Half Korean Way/Half American Way 21 22.1Somewhat More American Way 19 20.0Very Much More American Way 5 5.3

Change in Life Style Somewhat More Korean Way 5 5.4No Change 27 28.4Somewhat More American Way 52 54.7Very Much More American Way 10 10.5

N = 95

alone. Those with a monthly income between $600 and $999 reportedhigher depression than those who fell into lower or higher income cate-gories. In addition, those who belonged to an organized religion, such asProtestants and Catholics, tended to report less depression than thosewho were Buddhists or non-religious. However, caution is needed in in-terpreting this result because the sample included only four Buddhistsand three non-religious people. Due to its lack of variance, religion wasremoved from the hierarchical regression analysis. No significant dif-ference in depression levels was found between subgroups categorizedby gender, marital status, age, acculturation, and citizenship.


TABLE 5. Bivariate Analysis of Socio-Demographic Characteristics with De-pression Scale

Variables N Mean S.D. df t or F NScoring� 16

PercentScoring� 16

Gender MaleFemale

3658

13.615.9

8.910.8

84.60 1.12 1423

38.939.7

Living Alone YesNo

3262

18.313.4

11.98.7

48.63 2.08* 1720

53.132.3

Social Activity YesNo

2562

11.716.2

7.910.5

56.14 �2.22* 829

32.042.1

Marital Status YesNo

5539

13.716.8

8.911.4

68.91 1.42 1918

34.549.8

Age 60-6970-7980 or over

284818

13.015.417.1

10.48.8

12.5

93.0 .96 1018

9

35.837.550.0

Income $0-199$200-599$600-999$1,000 or over

7334210

13.112.318.010.8

10.29.09.69.8

91.0 2.99* 27

235

28.521.254.750.0

Religion No religionProtestantCatholicBuddhist

36027

4

29.614.014.820.0

5.69.98.8

15.0

93.0 2.75* 32210

2

100.036.636.650.0

Change inValue System

More Korean WaySomewhat More Korean WayHalf Korean Way/Half American WaySomewhat More American WayVery Much More American Way

13402119

0

14.215.415.514.50

9.211.011.38.20

93 .064 31610

60

23.140.047.631.60

Change inLifestyle

Somewhat More Korean WayNo ChangeSomewhat More American WayVery Much More American Way

5275210

15.417.713.118.2

7.49.79.9

12.0

93 1.63 21516

4

40.055.630.840.0

Citizenship YesNo

4846

13.616.5

8.211.7

80.32 �1.39 2017

41.737.0

Total 94 15.05 10.10 37 39.3

*p < 0.05Note: N is ranged from 82 to 95.

In order to assess the relationships of depression with education andhealth status, Pearson’s correlation was utilized (Table 6). Educationand perceived health status were negatively associated with depression,indicating that respondents with a higher level of education and betterhealth status reported significantly lower levels of depression than theircounterparts. Significant variables among socio-demographic variableswere included in the final multiple regression analysis.

Multiple Regression Analysis

The multiple regression analysis proceeded in three steps. In the firststep of analysis, the effects of demographic variables on depression as adependent variable were explored. The first regression analysis in-cluded living alone, social activity, education, and perceived health sta-tus, which were identified as significant variables in a bivariate analysis(Table 7). This set of variables yielded a significant regression equationwith an adjusted R2 = .23, F (4, 74) = 6.94, and p = .001. However, onlythe coefficient for education (β = �.23) and perceived health status (β =�.29) were found as significant. Of the hypothesized socio-demo-graphic relationships, only education and perceived health status wereconfirmed.

In the second step, as a proxy indicator of acculturation status, yearsin the U. S., was entered to test the hypothesis that acculturation levelwould be negatively associated with depression. This variable added lit-


TABLE 6. Pearson Correlations Among Nine Independent Variables andCES-DScale

Variables 1 2 3 4 5 6 7 8 9 10

1. Age 1.00

2. Education �.22* 1.00

3. Perceived Health Status �.09 .38** 1.00

4. Income �.04 .21 .12 1.00

5. Years in the U.S. .16 .19 .15 .45** 1.00

6. Positive Social Support �.16 .30** .36** .03 .23* 1.00

7. Conflictive Social Support �.11 .19 .29** �.10 .19 .89** 1.00

8. Familism .09 �.06 .11 �.06 �.15 .19 .11 1.00

9. Family Relationship �.07 .26* .26* �.01 .04 .29** .15 .07 1.00

10. CES-D Scale Score .14 �.33** �.47** �.01 �.13 �.45** �.45** .11 �.36* 1.00

*p < 0.05 ** p < 0.01Note: N is ranged from 82 to 95.

tle to the explanatory power of the regression and was not a statisticallysignificant predictor of depression.

Before examining the effect of family relationship and the social sup-port measures in the regression equation, Pearson correlations were in-spected, because the social support measures were similar in apparentitem content and collinearity was likely to occur. As can be seen in Ta-ble 6, the perceived positive and conflictive social support were highlycorrelated (r = .89, p < .001). The conflictive social support was deletedfrom further analyses due to the high covariance with perceived positivesocial support.

In the final step, the two variables of positive social support and fam-ily relationship were entered to assess the effect of cultural factors. Thisset of variables added an additional 9% of explained variance, whichwas a significant increase, for a total adjusted R2 = .32, F(2, 71) = 6.34,and p = .003. The significant standardized regression coefficients (β) inthis model were �.26 for positive social support and �.21 for family re-lationship. As expected, positive social support from the family andfamily relationship with adult children were inversely associated withdepression. In this step, education and perceived health status were nolonger statistically significant.


TABLE 7. Multiple Regression Analysis of Socio-Cultural Variables ExplainingDepression Among Elderly Korean Immigrants

Step 1 Step 2 Step 3

Variable List B SE β B SE β B SE βLiving Alone1 2.11 2.17 .10 2.16 2.20 .10 1.52 2.06 .07

Social Activity2�3.70 2.25 �.17 �3.71 2.27 �.17 �2.75 2.15 �.12

Education �.41 .20 �.23* �.40 .20 �.22* �.25 .19 �.14

Perceived health status �2.76 1.07 �.29* �2.7 1.09 �.29* �1.81 1.04 �.19

Years in the U.S. �.02 .17 �.03 .03 .16 .01

Positive Social Support �.16 .07 �.26*

Family Relationship �.53 .26 �.21*

Adjusted R2 .23 .23 .32

Change in R2 .23 .00 .9

F for Change in R2 6.94** .07 6.34**

Multiple R .52 .52 .62

F 6.94** 5.50** 6.31**

*p < .05, **p < .01.Note: 1. Living Alone was entered as a dummy variable: 1 = Yes, 0 = No

2. Social Activity was entered as a dummy variable: 1 = Yes, 0 = No

DISCUSSION

This study examined the prevalence of depression and socio-culturalfactors associated with depression among elderly Korean immigrants.The study found a relatively high rate of clinical depression among el-derly Korean immigrants. The CES-D mean score (15.05) for the el-derly Korean respondents is higher than that reported by othercommunity-dwelling samples of older adults whose CES-D meansranged from 7.96 to 11.71 (Casado & Leung, 2001; Husaini et al., 1991;Vernon et al., 1982) and it is closer to the mean reported by homeboundWhite frail elderly (M = 18.59, Davidson et al., 1994). The higher de-pression level of elderly Koreans confirms other studies that have re-ported similar findings in Korean-American younger adult populations(Kuo, 1984) and Korean elderly immigrants (Sung, 1998; Noh et al.,1998). In Kuo’s study, it was suggested that about 40% of the sampleshould be screened for clinical depression and might need counselingservices.

Findings from the subscale analysis of the CES-D scale indicated acultural response pattern on the items of the CES-D scale. Elderly Ko-rean immigrants in this study reported higher scores for the positive af-fect items, “enjoying life,” “feel happy,” and “feel hopeful about thefuture.” Higher scores (indicting higher depression levels) for items ofpositive affect among elderly Korean immigrants were also found inNoh et al.’s study (1998), which reported that the average score on thefour items of the positive affect was four times higher among KoreanCanadian males than American males. The higher scores on the PositiveAffect items reported by both studies may suggest that Positive AffectItems have differential item functioning (DIF) for Korean samples insuch a way that they are less likely to admit to positive affect items as apart of depressive symptomology. Because DIF was not formally testedin this study, no definitive conclusion can be reached as to whether thehigher scores of Positive Affect items are due to elderly Korean immi-grants’ tendency not to admit to positive affect items or are a reflectionof their actual lack of positive affect. This calls into question the assess-ment of depression among Korean elderly, with the possibility that aculturally-influenced response set leads to overestimation of depres-sion, inasmuch as scores of positive affect items might have beeninflated in this study sample above and beyond the expected level.

Among socio-demographic factors, perceived health status and edu-cation were identified as significant predictors of depression amongolder Korean immigrants. This result is consistent with findings from


the general elderly population, whose depression is believed to bestrongly related to poor health (Cummings, 2002; Rogers, 1999; Kraaij,Arensman, & Spinhoven, 2002; Geerlings, Beekman, Deeg, & VanTilburg, 2000; Means-Christensen, 2000). Dorfman et al. (1995) re-ported that depression risk was correlated with health status. Those whohad poor health status were three times more likely to be at risk for de-pression than those who had an excellent health status.

Education was identified as a significant predictor of depressionamong elderly Korean immigrants. Those who have attained a higherlevel of education show lower levels of depression. This result is in ac-cordance with previous studies, which identified education as one of themajor predictors of depression across various ethnic groups (Glazer etal., 2002; Lee, 2003; Means-Christensen, 2000; Rivera, 2003).

Elderly Korean immigrants’ extensive involvement in the ethnicchurch has become an important way of life, and source of support, spir-ituality, and socialization in the United States. The great majority of theparticipants were either Protestant (63.2%) or Roman Catholic (29.5%).Religion was shown to affect the level of depression among elderly Ko-rean immigrants, but religion was dropped in the multiple regressionanalysis due to its lack of variance. However, it was observed that spiri-tual and religious beliefs, and the social aspects of religious activitieshelped mitigate depressive feelings.

The level of acculturation was quite low for these first generation elderlyKorean immigrants. The majority of the participants had language prob-lems and were not exposed to the English language media at all. This find-ing suggests that the respondents’ social participation and interpersonalrelations would be largely confined to their own ethnic group. Older Kore-ans’ primary group relations did not extend beyond their families, relatives,Korean friends, neighbors, and Korean churches and organizations. In or-der to clarify the specific relationship between acculturation and depres-sion, several markers of acculturation were explored. Most of these showedtoo little variation within this sample to test for systematic covariation ofacculturation and depression.

As a proxy acculturation variable, years in the U. S. was utilized, but itwas not significantly related to depression. This result is consistent with astudy by Lee et al. (1996), which reported that level of acculturation hasno significant effect on depression of elderly Korean immigrants. How-ever, given the low level of variation in acculturation, conclusions aboutthese relationships should be postponed until future cohorts of Ko-rean-American elderly with a greater range of acculturation can be stud-ied.


Consistent with the hypotheses, greater positive support from thefamily and good family relationships were significantly associated withelderly Koreans’ depression. The older adult’s perception of the qualityof his/her relationship with adult children proved to be significantly re-lated to the level of depression among elderly Korean immigrants. Thisfinding indicates that conflict in family relationships is an importantrisk factor for depression, similar to an earlier finding that the percep-tion of intimacy with children was a most powerful predictor of moralefor the elderly Korean in Los Angeles (Moon, 1996).

IMPLICATIONS FOR PRACTICE AND FUTURE RESEARCH

Before discussing the implications of the current study, the limitationsof the study must be recognized. First, the use of a convenience sampleplaces limitations on the generalizability of these findings. Therefore,caution should be used in applying the findings in this study to the generalelderly Korean immigrant population in the U. S. Second, since the re-spondents were recruited in Los Angeles, they may be less acculturatedthan other elderly Korean immigrants. Further research should include el-derly Koreans living in a small city or in the suburbs to improvegeneralizability. Third, the failure to find significant results for accultura-tion status with depression may be due, at least in part, to the measuresused to assess acculturation. In fact, adequate operationalization of accul-turation constitutes a significant challenge for culturally-oriented re-search on immigrant populations, because there are many differentdimensions to the Americanization of elderly Korean immigrants. Thatis, while the majority of the sample was not acculturated in language andvalue systems, they reported being acculturated into U.S. lifestyles.These differences point to the complexity of the measurement of accul-turation status.

This study calls attention to high levels of depression among elderly Ko-rean immigrants. Clearly, this group deserves greater attention from re-searchers, service providers, and policy analysts. The findings suggest thatelderly Korean immigrants who are in poor health, have a lower level ofeducation, receive a lower level of perceived family support, and have con-flictive family relationships with their children are especially at risk for thedevelopment of depression. Further, these findings indicate that the provi-sion of mental health services or programs appropriate to the cultural needsof elderly Korean immigrants is an urgent need. Given the acculturation


level of the population, mental health services should be provided by bilin-gual and bicultural practitioners.

The significance of family issues and relationships with regard to de-pression indicates that the mental health practitioner should view elderlyKoreans’ depression in the broad context of the family environment andshould include their family members in the process of treatment. Outreach,targeting both Korean elders and their adult children, is warranted to edu-cate them about depressive symptoms, available mental health services,and the important role of family in mental health status. In addition, to ex-pand their support network, the practitioner should encourage the Koreanelderly to utilize community-based social programs.

The relationship between poor health and increased risk for depres-sion suggests the need for a collaborative effort between social workand medical professionals, alerting the medical professionals to referpatients for depression screening and intervention. This is particularlyimportant in that Korean and other Asian immigrant populations aremore likely to seek help from medical than mental health professionals.

Finally, Korean elders did not endorse positive affect items and thisseems to heighten their depression score. This finding clearly leads tothe need for qualitative research on depression among elderly Koreanimmigrants. Identifying underlying components of depression and ex-ploring cultural patterns to express depression are greatly needed to de-velop ethnic culture-specific depression measurement.

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