This study examined ethnic differences in symptoms of major depressive disorder between Asian Americans and European Americans using a nationally representative community sample. Item response theory analyses were used to discern whether differences were due to expression of symptoms or degree of depressive symptomatology. The analyses found more similarities than differences between the groups, and when differences occurred, Asian Americans were less likely to endorse specific somatic and psychological symptoms even when matched for degree of depressive symptoms. The findings indicate depression is more similar between the groups, and differences reflect true differences in symptom expression rather than overall symptom severity.

1. The Expression of Depression in Asian Americans
and European Americans
Jean M. Kim and Steven Regeser López
University of Southern California
Past studies of the expression of depression in people of Asian
descent have not considered whether
observed ethnic differences in somatization or psychologization
are a function of differences in the
expression of the disorder or of group differences in the degree
of depressive symptomatology. In the
present study, we carried out �2 and Item Response Theory
(IRT) analyses to examine ethnic differences
in symptoms of Major Depressive Disorder in a nationally
representative community sample of nonin-
stitutionalized Asian Americans (n � 310) and European
Americans (n � 1,763). IRT analyses were
included because they can help discern whether there are
differences in the expression of depressive
symptoms, regardless of ethnic differences in the degree of
depressive symptomatology. In general,
although we found that Asian Americans have lower rates of
depression than European Americans, when
examining specific symptoms, there were more similarities (i.e.,
symptoms with no ethnic differences)
than differences. An examination of the differences using both
�2 and IRT analyses revealed that when
there were differences, Asian Americans were less likely to
endorse specific somatic and psychological
symptoms than European Americans, even when matched in
degree of depressive symptomatology.

2. Together, these community-based findings indicate that
depression among Asian Americans is more
similar than different to that of European Americans. When
differences do occur, they are not an artifact
of the degree of depressive symptomatology but instead a true
difference in the expression of the
disorder, specifically a lesser likelihood of expressing specific
somatic and psychological symptoms in
Asian Americans compared with European Americans.
Keywords: somatization, psychological symptoms, depression,
Asian Americans, Item Response Theory
It is a commonly held notion by anthropologists and psycholo-
gists that mood disorders are embedded in Western culture and
may not apply as well to people of non-Western cultural back-
grounds (e.g., Kleinman, 1988; Ryder et al., 2008). The
Diagnostic
and Statistical Manual of Mental Disorders-Fifth Edition (DSM-
5;
American Psychiatric Association, 2013) states that “culture
pro-
vides interpretive frameworks that shape the experience and ex-
pression of the symptoms, signs, and behaviors that are criteria
for
diagnosis” (p. 14). In support of this, past research has demon-
strated that participants of Asian background are more likely
than
participants of European background to express depression in
somatic terms (Yen, Robins, & Lin, 2000; Yeung & Chang,
2002).
Examples of somatic symptoms include fatigue, gastrointestinal
problems, headache, and pain. There are many descriptions and
theoretical discussions of somatization in people of Asian origin
(Kleinman, 1982; Parker, Gladstone, & Chee, 2001; Ryder et
al.,

3. 2008).
A recent literature review, however, reveals only limited evi-
dence that people of Asian background are more likely than
others
to report somatic symptoms (Uebelacker, Strong, Weinstock, &
Miller, 2009). On the one hand, some clinical studies suggest
that,
for example, Chinese American patients are more likely to
endorse
somatic symptoms than European American patients (e.g.,
Huang,
Chung, Kroenke, Delucchi, & Spitzer, 2006), and that depressed
Malaysian Chinese outpatients are more likely than depressed
Australian White outpatients to endorse a somatic symptom as
the
primary complaint (Parker, Cheah, & Roy, 2001). However, the
findings across studies, especially those using community
samples,
have not been robust or consistent (Uebelacker et al., 2009).
International community studies also do not find increased
somatization among Asian participants. Weiss, Tram, Weisz,
Re-
scorla, and Achenbach (2009) compared symptoms of
depression
in Thai and American children and adolescents from a
community
sample and found that the Thai and American groups endorsed
similar levels of somatic (and psychological) symptoms (effect
size of the mean contrasts � 0.00, CI [�.05 � .05]). When
Kadir
and Bifulco (2010) examined a community sample of Malaysian
women, they found that both somatic and psychological
symptoms

4. of depression were expressed by these participants. Although
this study was qualitative in nature, it is consistent with other
community-based studies (e.g., Cheng, 1989; Cheung, 1982)
that
suggest that the high prevalence of somatization in people of
Asian
background is not likely observed in community samples.
Similarly, Ryder and his research team also suggest that there
may be little difference between Asian origin and European
origin
adults in the presentation of somatic symptoms. They argue that
the difference is in people of Asian background endorsing fewer
This article was published Online First October 13, 2014.
Jean M. Kim and Steven Regeser López, Department of
Psychology,
University of Southern California.
We thank Richard John for his consultation with the statistical
analyses.
Correspondence concerning this article should be addressed to
Jean M.
Kim, Department of Psychology, University of Southern
California, 3620
McClintock Avenue, SGM 501, Los Angeles, CA 90089. E-mail:
[email protected]
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9. Journal of Abnormal Psychology © 2014 American
Psychological Association
2014, Vol. 123, No. 4, 754–763 0021-843X/14/$12.00
http://dx.doi.org/10.1037/a0038114
754
mailto:[email protected]
http://dx.doi.org/10.1037/a0038114
psychological symptoms than people of European background.
In
their study of outpatients, Ryder and colleagues (2008) found
that
Chinese participants endorsed a significantly higher level of so-
matic symptoms than European Canadian participants on two of
the three depression measures. The Chinese participants also en-
dorsed a significantly lower level of psychological symptoms
than
the European Canadian participants on all three depression mea-
sures. The effect sizes for psychological symptoms were larger
and
more consistently significant than the effect sizes for somatic
symptoms. Therefore, the authors argued that the “truly
distinctive
cross-cultural feature” in the expression of depression for
people
of Asian background may be their reporting of fewer psycholog-
ical symptoms than people of European background (Ryder et
al.,
2008). Psychologization can be defined as the tendency to
express
distress in affective or cognitive terms (Kirmayer, 2001). Exam-
ples of psychological symptoms include feelings of
worthlessness,

10. irritability, tearfulness, and depressed mood. Thus, based on
Ryder
and colleagues’ findings, it is important that the study of
depres-
sion examines both somatic and psychological symptoms to
assess
whether people of Asian origin tend to somatize, people of
Euro-
pean origin tend to psychologize, or some combination of the
two.
The Diagnosticity of Somatic and
Psychological Symptoms
One problem with past studies that examine ethnic group dif-
ferences in symptom frequencies is that it is unclear whether a
difference in frequency reflects an ethnic difference in the
expres-
sion of depression or simply a difference in the degree of
depres-
sive symptomatology. For example, in the Ryder et al. (2008)
study, it may be that less psychologization among those of
Asian
background may actually reflect that they have less depressive
symptomatology overall and not simply lower levels of psycho-
logical symptoms. Thus, it is important that efforts be taken to
control for the degree of depressive symptomatology when
carry-
ing out these analyses.
Item Response Theory (IRT) provides a statistical approach to
examine whether ethnic group differences in depressive
symptoms
reflect differences in the expression of depression or group
differ-
ences in the level of the latent construct. IRT provides

11. mathemat-
ical expressions of the relationship between participants’
responses
on an item (in this case, symptoms) and the underlying latent
construct (in this case, depressive symptomatology). It accounts
for the potentially confounding effect of the degree of
depressive
symptomatology by assessing whether the association between
the
item and the latent construct differs depending on race or
ethnicity
(e.g., Asian or European origin) when both racial or ethnic
groups
are matched in the degree of depressive symptomatology (Uebe-
lacker et al., 2009). Although in Classical Test Theory, the trait
is
based on the total number of items endorsed, in IRT, the latent
trait
(�) is estimated based on the participants’ responses and the
properties of the items (Yang & Kao, 2014). Theta has a mean
of
0 and a SD of 1, with an arbitrary range for the latent construct
that
is measured. Those with a more negative value of theta are
thought
to have less of the latent construct of depressive
symptomatology,
and those with a more positive value of theta have more of the
construct of depressive symptomatology (Yang & Kao, 2014).
Another advantage of the IRT approach is that it may be a more
precise manner of testing whether there are ethnic differences in
symptom expression than the traditional frequency approach.
For
example, with the traditional approach, there may be significant
differences between two groups in the frequency of

12. psychological
symptoms endorsed, suggesting that the two groups express de-
pression differently; yet the association between a given
symptom
and the construct of depressive symptomatology may be no dif-
ferent for the two groups. Conversely, there may be no
difference
in the frequency of psychological symptoms reported for the
two
groups, suggesting no difference in the expression of the
disorder;
however, the relationship between a psychological symptom and
the construct of depressive symptomatology may be much
stronger
for one group than another.
In IRT, a mathematical function specifies an item characteristic
curve (ICC) that represents the probability of a response on an
item
varying with the level of the underlying latent construct, in this
case depressive symptomatology. The relative position and
slope
are two important characteristics of this curve. First, the
relative
position of the ICC indicates the trait strength of the underlying
construct (i.e., severity or difficulty parameter). A curve that is
shifted more toward the right indicates that the item is more
difficult for that group (compared with the group with a curve
that
is shifted more toward the left); this group requires more of the
latent construct (i.e., depressive symptomatology) than the other
group for the same probability of item endorsement. In other
words, given an equivalent degree of depressive
symptomatology,
the group with the curve that is shifted more to the right is less
likely to endorse the item. Second, the slope indicates the

13. discrim-
inability of the item (i.e., discrimination parameter). An item
with
a steeper ICC slope discriminates more effectively between dif-
ferent levels of the underlying construct. Differential item func-
tioning (DIF) is a statistical approach that is used to test the
null
hypothesis that these item parameters do not differ between two
groups.
The use of IRT methodology for analyzing depressive symp-
toms and testing the somatic hypothesis is an emerging area of
research (Uebelacker et al., 2009). Using IRT and a community
sample, Uebelacker and colleagues (2009) tested whether Asian
Americans would be more likely to “somatize” than European
Americans, given similar degrees of depressive
symptomatology.
This study utilized the National Epidemiologic Survey on
Alcohol
and Related Conditions (NESARC) dataset, a large, nationally
representative epidemiological sample of American adults.
Uebe-
lacker and colleagues examined symptoms of depression,
includ-
ing analyses comparing Asian Americans and non-Latino White
Americans. For the severity parameter, given similar degrees of
depressive symptomatology, Asian American participants were
more likely to endorse only suicidal ideation than non-Latino
White participants. For the discrimination parameter, only one
symptom met criteria for significant DIF; difficulty in
concentrat-
ing was less discriminating for Asian Americans than for
European
Americans. Overall, the results failed to find support for the
notion
that Asian Americans express depression differently than Euro-

14. pean Americans, even when controlling for degree of depressive
symptomatology as carried out by IRT. The study was limited,
however, in that their community sample included a relatively
small sample of Asian Americans (n � 291), compared with the
other racial or ethnic groups included in this study (ns ranged
from
468 to 10,958). The study also excluded those who were not
fluent
in English; thus, the sample likely reflected a more acculturated
T
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Ps
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A
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of
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16. lie
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rs
.
T
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18. be
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755ETHNICITY AND DEPRESSIVE SYMPTOMATOLOGY
Asian American sample, thereby reducing the likelihood of
finding
ethnic differences. Finally, the analyses focused only on seven
MDD symptoms in a 2-week episode of depressed mood or
anhe-
donia. Only one other study to date has used IRT to examine
DSM
symptoms of depression between groups (Simon & Von Korff,
2006). However, these researchers included depressed primary
care participants with and without a comorbid medical condition
and did not examine race or ethnicity differences.
There is also a large body of work using DIF analyses to
examine measurement bias (e.g., Camilli & Shepard, 1994; Em-

19. bretson & Reise, 2000; Holland & Wainer, 1993), including
stud-
ies not using IRT but other statistical methods. For depression
specifically, work using multiple regression (Birnholz & Young,
2012) and nonparametric kernel-smoothing techniques (Santor,
Ramsay, & Zuroff, 1994) has examined depressive symptom se-
verity scores and item bias between groups (i.e., female
sexuality
groups and males and females, respectively); however, these
stud-
ies did not test for race or ethnicity differences. Another study
(Dere et al., 2013) did examine race or ethnicity differences in
depressive symptoms. With a clinical sample, Dere et al. (2013)
used the standardized mean difference technique to assess for
DIF
among Han-Chinese and European Canadian participants. They
found no DIF for typical somatic symptoms but did find DIF for
atypical somatic symptoms and for psychological symptoms.
Spe-
cifically, the Chinese reported higher levels of “suppressed
emo-
tions” and “depressed mood,” and European Canadians reported
higher levels of atypical somatic symptoms and “hopelessness,”
relative to their overall symptom reporting.
Overview and Hypotheses
In the present study, we drew on the Collaborative Psychiatric
Epidemiology Surveys (CPES), a national psychiatric
epidemiol-
ogy database that includes both Asian Americans and European
Americans, to examine the expression of depressive symptoms
among Asian Americans and European Americans. The
advantage
of this database is that it is comprised of nationally
representative

20. samples of people residing in the community, whereas many
past
studies have only used clinical samples. Another advantage is
that
the CPES applies a broad definition of Asian American
reflecting
many countries of origin within Asia. In addition, unlike the
Uebelacker et al. (2009) study, non-English speaking Asian
Amer-
ican respondents were included, suggesting more variance with
regard to acculturation.
We applied two statistical approaches. The first was to identify
the specific symptoms for which the two groups differed, using
�2
analyses. The second approach was to examine whether these
differences held, even accounting for degree of depressive
symp-
tomatology, using IRT. Although we believe that the IRT
approach
is the more precise way to test our hypotheses, by including the
traditional approach, we were in a position to assess how our
findings map on to past research and how they compare with the
IRT approach. Accordingly, it allowed us to explore whether the
statistical methods lead to similar or different results.
Our first objective was to test whether Asian Americans and
European Americans differ with regard to both somatic and psy-
chological symptoms. Although Ryder et al. (2008) found
smaller
but significant differences in somatic symptoms between Asian
and European Canadian outpatients on two out of three
measures,
other studies using community samples (e.g., Cheng, 1989;

21. Cheung, 1982; Weiss et al., 2009) did not find a higher
prevalence
of somatization in people of Asian background. We predicted
that
Asian Americans and European Americans in this sample would
not significantly differ in their levels of somatic symptom
endorse-
ment. For psychological symptoms, consistent with previous
find-
ings by Ryder et al. (2008), we expected Asian Americans in
our
sample would endorse lower levels of psychological symptoms
than European Americans.
Next, we examined the relationship between the symptom and
the latent construct using IRT. For somatic symptoms, we ex-
pected that the severity parameters would not be significantly
different between the two racial or ethnic groups. In other
words,
Asian Americans and European Americans would have similar
probabilities of endorsing somatic symptoms, given the same
degree of depressive symptomatology, and thus, similar severity
parameters. On the other hand, for psychological symptoms, we
expected that the severity parameter would be greater for Asian
Americans than for European Americans. In other words, Asian
Americans would have a lower probability of endorsing psycho-
logical symptoms than European Americans with the same
degree
of depressive symptomatology. For the discrimination
parameter,
we explored whether somatization or psychologization is differ-
entially related to the construct of depressive symptomatology
for
Asian Americans or European Americans.
Method

22. Participants
The participants were part of the CPES, specifically the
National
Latino and Asian American Study (NLAAS) and the National
Comorbidity Survey Replication (NCS-R). These studies
together
create one combined, nationally representative dataset with
enough
power to examine cultural and ethnic correlates of mental
illness.
The Asian American data were selected from the NLAAS,
which included participants 18 years and older in the contiguous
United States and Hawaii. The NLAAS Asian American sample
(N � 2,095) included: Chinese (n � 600), Filipino (n � 508),
Vietnamese (n � 520), and “other” Asian (n � 467)
participants.
The category other Asian included Bangladeshi, Burmese, Cam-
bodian, Hmong, Indian, Indonesian, Japanese, Korean, Laotian,
Malaysian, Mongolian, Myanmai, Pakistani, Singaporean, Sri
Lankan, Taiwanese, and Thai participants. Among the Asian
Americans, 454 were born in the United States, 1,639 were born
outside of the United States, and two did not report their place
of
birth. Interviews were completed in English, Mandarin,
Cantonese,
Tagalog, and Vietnamese. The mean age was 41.0 (SD � 14.7).
Forty-seven percent of the Asian Americans were male, and
53%
were female. The response rate for Asian Americans was 69.3%.
As this was a first step to examining ethnicity and culture using
IRT and a nationally representative sample, Asian Americans
were

23. studied as an entire group, as were European Americans. To
only
focus on one of the specific ethnic groups (e.g., Chinese Ameri-
cans) would restrict the focus to that specific group instead of a
national sample of Asian origin adults. Moreover, the sample
size
of a specific group would be limited. In addition, using the
entire
sample is consistent with other NLAAS studies that examine
Asian
Americans as one group (e.g., Gee, Ro, Gavin, & Takeuchi,
2008;
T
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25. its
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.
T
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ly

26. fo
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27. t
to
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dl
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756 KIM AND LÓPEZ
Leu et al., 2008; Marques et al., 2011; Takeuchi, Alegría,
Jackson,
& Williams, 2007). The term “Asian American” is used here
because the participants reported national origin in a country
located in the continent of Asia and they reported having
residence
in the United States.
The Asian Americans who received the Depression Module
(N � 310) included: Chinese (n � 100), Filipino (n � 61),
Vietnamese (n � 50), and other Asian (n � 99) participants

28. from
the countries of origin noted earlier. Among these Asian Ameri-
cans, 106 were born in the United States, 202 were born outside
of
the United States, and two did not report their place of birth.
The
mean age was 38.7 (SD � 14.1), and 39% were male.
The European American data were selected from the NCS-R,
which included participants 18 years and older in the contiguous
United States. The non-Hispanic White sample included 4,180
people with a mean age of 46.5 years (SD � 17.8). Forty-six
percent of the European Americans were male, and 54% were
female. Their response rate was 70.9%.
The European Americans who received the Depression Module
included 1,763 participants. Among these European Americans,
1,658 were born in the United States, 38 were born outside of
the
United States, and 67 did not report their place of birth. The
mean
age was 44.2 years (SD � 15.0), and 36% were male.
Measures
Composite International Diagnostic Interview. The Com-
posite International Diagnostic Interview (CIDI, World Health
Organization) is a structured diagnostic interview that generates
International Classification of Diseases (ICD-10) and
Diagnostic
and Statistical Manual of Mental Disorders-Fourth Edition
(DSM–IV) diagnoses. It was designed to be used across
cultures.
Trained, nonclinical interviewers administered the CIDI in
person.
This study primarily focused on the following sections of the

29. CIDI.
Screening section. In this section, participants were asked
three questions specific to depression. These items consisted of
questions asking about times when most of the day, one felt
“sad,
empty, or depressed,” “very discouraged about how things were
going,” or when one “lost interest in most things [he or she]
usually [enjoys].” If the participant endorsed at least one of the
screening items, they went on to answer the questions in the
depression module.
Depression module. This module consisted of symptoms that
mapped on to the Diagnostic and Statistical Manual of Mental
Disorders-Fourth Edition-Text Revision (DSM–IV–TR) criteria
for
Major Depressive Disorder. It included nine somatic symptoms
(e.g., “Did you have a much larger appetite than usual nearly
every
day?”) and 23 psychological symptoms (e.g., “Did you feel
hope-
less about the future nearly every day?”). The depressive symp-
toms were separated as somatic or psychological based on con-
sensus from past studies (e.g., Kadir & Bifulco, 2010;
Kleinman,
1982; Ryder et al., 2008; Uebelacker et al., 2009; Weiss et al.,
2009; Yen et al., 2000) and the face validity of the items.
Results
Overview
We first examined the entire sample to see whether there were
ethnic group differences in the depression screening items. We
then carried out two distinct sets of analyses with those who

30. screened positive for possible depression. These analyses were
carried out with this subsample because all of the depressive
symptoms were assessed with this group. To examine the rate of
endorsement of specific somatic and psychological symptoms
by
Asian and European Americans, we conducted �2 analyses to
examine specifically where (i.e., in which symptoms) the racial
or
ethnic group differences may lie. Because of the potentially
con-
founding effect of the degree of depressive symptomatology in
evaluating group differences in the expression of depression,
our
next set of analyses used IRT to examine any potential DIF in
somatic and psychological symptoms.
Ethnicity and Degree of Depression
Across all assessments of depression, Asian Americans re-
ported significantly less depression. First, when the overall
sample is considered, a smaller percentage of Asian Americans
than European Americans reported any of the depression
screening items. For example, 31.9% of Asian Americans en-
dorsed the item “sad/empty/depressed,” whereas half of Euro-
pean Americans (49.9%) endorsed this item (p � .001, Cram-
er’s V � 0.16; see Table 1). Second, when considering the
screened-in sample (i.e., those who received the full depression
module), a smaller percentage of Asian Americans than Euro-
pean Americans reported two of the three depression screening
items. For example, 84.2% of Asian Americans endorsed the
item “discouraged about life,” whereas 92.0% of European
Table 1
Rates of Depression Screening Item Endorsement by Race or
Ethnicity (%) for the Overall Sample and for Those Who
Screened In to

31. Receive the Depression Module
Depression screening item
Overall sample Screened in sample
Asian American
(n � 2284)
European American
(n � 6696) Cramer’s V
Asian American
(n � 310)
European American
(n � 1763) Cramer’s V
Sad/empty/depressed 31.9 49.9��� 0.16 89.0 91.7 0.03
Discouraged about life 32.4 52.6��� 0.18 84.2 92.0��� 0.10
Lost interest in enjoyable things 24.7 36.9��� 0.11 73.9 79.8�
0.05
Note. For Asian Americans, the number of “refused” responses
ranged from 1–2, and the number of “don’t know” responses
ranged from 0–1. For
European Americans, there were no “refused” responses, and
the number of “don’t know” responses ranged from 1–5.
� p � .05. ��� p � .001.
T
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33. ca
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.
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ar
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36. y.
757ETHNICITY AND DEPRESSIVE SYMPTOMATOLOGY
Americans endorsed this item (p � .001, Cramer’s V � 0.10;
see Table 1). There was no significant difference between racial
or ethnic groups for the item sad/empty/depressed in the
screened-in sample. Last, Asian Americans had lower rates of
Major Depressive Disorder than European Americans (Pearson
�2, ps � .001); this was the case for lifetime (Asian Americans:
9.2%; European Americans: 18.0%; Cramer’s V � 0.11) and
12-month Major Depressive Disorder (Asian Americans: 4.5%;
European Americans: 7.2%; Cramer’s V � 0.05).
Ethnicity and Symptom Endorsement
Asian Americans and European Americans did not differ in the
median somatic symptoms endorsed (Asian Americans: 4.00
symptoms, European Americans: 4.00 symptoms; �2 � 1.24, p
�
.30). However, Asian Americans were significantly lower in the
median psychological symptoms endorsed, when compared with
European Americans (Asian Americans: 13.00; European
Ameri-
cans: 14.00; �2 � 5.62, p � .02). In terms of the specific symp-
toms, �2 analyses revealed that Asian Americans were signifi-
cantly lower than European Americans in their endorsement rate
for 3 of the 9 somatic symptoms (33%) and 9 of the 23 psycho-
logical symptoms (39%). An example of a somatic symptom that
was endorsed less by Asian Americans is a larger appetite; 8.2%
of
the Asian Americans reported having a larger appetite, whereas
14.3% of the European Americans reported having a larger
appe-

37. tite (p � .004, Cramer’s V � 0.06; see Table 2). An example of
a
psychological symptom endorsed less by Asian Americans is
guilt;
only 41.9% of the Asian Americans reported guilt, whereas
50.9%
of the European Americans reported this symptom (p � .004,
Cramer’s V � 0.06; see Table 3).
Item Response Theory
For the IRT analyses, Mplus Version 6.12 was used, applying a
two-parameter model (2PL), which involves estimating a
severity
and discrimination parameter for each symptom. The 2PL model
was preferred over the one-parameter (1PL) model, using
Akaike
information criterion (AIC) and sample-size adjusted Bayesian
information criterion (BIC). Assumptions of unidimensionality
of
the trait (� � .99), local independence of items, and ability to
model the response for an item via an item response function
were
met. Analysis was run containing all of the depressive
symptoms
(i.e., both somatic and psychological symptoms) in one IRT
anal-
ysis, but the symptoms are presented in separate somatic and
psychological symptom tables for clarity and consistency with
our
discussion of the results. The item parameters were compared
across groups according to Linacre and Wright (1986). Results
from these analyses are shown in Tables 4 and 5, which list the
severity and discrimination parameters for each somatic and
psy-

38. chological depressive symptom across the racial or ethnic group
comparisons.
For somatic symptoms, only two out of nine somatic symp-
toms (22.2%) exceeded criteria for statistical significance in
DIF for the severity parameter (see Table 4). For example,
Asian Americans were less likely to endorse the somatic symp-
tom “fatigue/loss of energy” than European Americans, given
similar degrees of depressive symptomatology. This item’s
ICCs are plotted in Figure 1a. The severity parameter is typi-
cally examined from the horizontal axis, where the probability
of endorsement of the item is 0.5 or 50%. Figure 1a shows that
the curve for Asian Americans is shifted more toward the right.
This indicates that this item is more “difficult” for Asian
Americans, or requires more of the latent construct (i.e., de-
pressive symptomatology) for the same probability of endorse-
ment as European Americans. Stated another way, given equiv-
alent degrees of depressive symptomatology, Asian Americans
tended to be less likely to endorse the item fatigue/loss of
energy than European Americans. In addition, one somatic
symptom was more discriminating for Asian Americans than
European Americans—psychomotor agitation. The item’s ICCs
are plotted in Figure 1b. Again, the discrimination parameter
refers to the degree to which the item discriminates between
participants along the continuum of depressive symptomatol-
ogy. The steeper slope for Asian Americans than European
Americans in Figure 1b indicates that the item “psychomotor
agitation” is more discriminating for Asian Americans than
European Americans.
Table 2
Rates of Depressive Somatic Symptom Endorsement for Those
Who “Screened In” to the
Depression Module by Race or Ethnicity
Depressive somatic

39. symptom of CIDI
Asian American European American
Cramer’s V% endorsement n % endorsement n
Lost weight 62.7 149 82.4��� 846 0.18
Gained weight 7.0 229 10.7 1,322 0.04
Smaller appetite 69.0 294 64.2 1,699 0.04
Larger appetite 8.2 293 14.3�� 1,711 0.06
Insomnia 76.5 294 72.9 1,702 0.03
Hypersomnia 12.2 295 16.8� 1,728 0.04
Psychomotor agitation 9.9 292 13.6 1,701 0.04
Psychomotor retardation 50.9 293 51.8 1,679 0.01
Fatigue or loss of energy 82.8 296 83.3 1,715 0.01
Note. The number of respondents per item varies given the
computer algorithm of the Composite International
Diagnostic Interview (CIDI) and its “skip function.” The
maximum subsamples by ethnicity are Asian American
n � 310 and European American n � 1,763.
� p � .05. �� p � .01. ��� p � .001.
T
hi
s
do
cu
m
en
t
is

40. co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
Ps
yc
ho
lo
gi
ca
l
A
ss
oc

41. ia
tio
n
or
on
e
of
its
al
lie
d
pu
bl
is
he
rs
.
T
hi
s
ar
tic
le
is

42. in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du

43. al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
758 KIM AND LÓPEZ
For the psychological symptoms, an examination of DIF showed

44. that 11 of these items differed across racial or ethnic groups in
terms of severity or difficulty, and one item (thoughts about
death)
differed in terms of discrimination. The 11 of 23 psychological
symptoms (47.8%) that exceeded criteria for statistical signifi-
cance in DIF for the severity parameter are shown in Table 5.
As
an example, the ICCs for the item “guilt” are plotted in Figure
2a.
This shows that given equivalent degrees of depressive
symptom-
atology, Asian Americans are less likely to endorse feelings of
guilt than European American respondents. In addition, the dis-
criminability of the item “thought about death” is plotted in
Figure
2b, showing a steeper slope (i.e., better discriminability) for
Asian
Americans than European Americans.
Discussion
We found that Asian Americans within a national sample of
U.S. residents are less likely to present with depressive
symptoms
and disorders than European Americans. Despite the clear
differ-
ence in prevalence rates, there were more ethnic similarities in
the
report of symptoms than differences. There were no differences
in
nearly two-thirds (62.5%) of the depressive symptoms—6 of the
9
Table 3
Rates of Depressive Psychological Symptom Endorsement for

45. Those Who “Screened In” to the
Depression Module by Race or Ethnicity
Depressive psychological
symptom of CIDI
Asian American European American
Cramer’s V% endorsement n % endorsement n
Felt depressed 89.0 310 92.9� 1,763 0.05
Nothing could cheer 60.4 275 64.2 1,636 0.03
Discouraged 79.7 310 86.7�� 1,762 0.07
Hopelessness 61.5 247 68.6� 1,521 0.05
Loss of interest 69.0 310 74.1 1,760 0.04
Nothing was fun 62.3 308 67.2 1,755 0.04
Worthlessness 38.3 295 41.0 1,719 0.02
Loss of confidence 73.6 295 77.9 1,717 0.04
Not as good as others 61.1 296 59.5 1,718 0.01
Guilt 41.9 296 50.9�� 1,719 0.06
Trouble concentrating 73.8 294 78.0 1,716 0.04
Indecisiveness 54.9 295 62.7� 1,701 0.06
Thoughts come slowly 57.6 295 55.4 1,700 0.02
Thought about death 51.0 296 57.6� 1,726 0.05
Better if dead 41.6 296 42.6 1,720 0.01
Thought about suicide 27.5 295 32.0 1,727 0.04
Made suicide plan 11.5 295 10.6 1,729 0.01
Made suicide attempt 8.5 295 8.0 1,730 0.01
Irritability 60.9 294 58.0 1,723 0.02
Could not cope with responsibility 45.4 295 56.3�� 1,726 0.08
Wanted to be alone 69.9 296 76.8� 1,721 0.06
Less talkative 80.4 296 81.5 1,719 0.01
Tearfulness 61.1 296 67.6� 1,727 0.05
Note. The number of respondents per item varies given the
computer algorithm of the Composite International

46. Diagnostic Interview (CIDI) and its “skip function.” The
maximum subsamples by ethnicity are Asian American
n � 310 and European American n � 1,763.
� p � .05. �� p � .01. ��� p � .001.
Table 4
Differential Item Functioning of DSM-IV Somatic Symptoms of
Major Depressive Disorder for
Asian and European Americans
Somatic symptoms
Severity or difficulty parameter Discrimination parameter
Asian
American
European
American p
Asian
American
European
American p
Lost weight �1.10 (0.78) �4.01 (1.12) 0.02 0.24 (0.12) 0.22
(0.06) 0.44
Gained weight �0.90 (1.60) 22.75 (179.82) 0.55 0.26 (0.33)
�0.01 (0.09) 0.22
Smaller appetite �2.20 (1.01) �1.93 (0.41) 0.60 0.21 (0.09)
0.18 (0.04) 0.38
Larger appetite 1.02 (0.42) 0.41 (0.12) 0.08 0.60 (0.23) 0.52
(0.07) 0.37
Insomnia �2.72 (1.08) �2.74 (0.50) 0.49 0.26 (0.10) 0.22
(0.04) 0.36

47. Hypersomnia �0.29 (0.43) �0.61 (0.09) 0.23 0.35 (0.21) 0.76
(0.10) 0.96
Psychomotor agitation 0.69 (0.23) 1.28 (0.27) 0.95 1.03 (0.29)
0.38 (0.06) 0.01
Psychomotor retardation 0.05 (0.11) �0.07 (0.06) 0.17 0.81
(0.13) 0.63 (0.05) 0.10
Fatigue or loss of energy �1.22 (0.19) �1.70 (0.13) 0.02 0.98
(0.19) 0.66 (0.06) 0.05
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e

48. A
m
er
ic
an
Ps
yc
ho
lo
gi
ca
l
A
ss
oc
ia
tio
n
or
on
e
of
its
al

49. lie
d
pu
bl
is
he
rs
.
T
hi
s
ar
tic
le
is
in
te
nd
ed
so
le
ly
fo
r

50. th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to

51. be
di
ss
em
in
at
ed
br
oa
dl
y.
759ETHNICITY AND DEPRESSIVE SYMPTOMATOLOGY
somatic symptoms and 14 of the 23 psychological symptoms.
When there were ethnic differences, however, Asian Americans
were less likely than European Americans to report both
somatic
and psychological symptoms. Our hypothesis that Asian Ameri-
cans would endorse similar levels of somatic symptoms
compared
with European Americans was not fully supported. For the
major-
ity of the somatic symptoms, similar to other studies using com-
munity samples, there were no differences between the two
groups
in level of endorsement. However, for one-third of the somatic
symptoms, a lower percentage of Asian Americans than
European

52. Americans endorsed these symptoms, which is opposite to what
Ryder et al. (2008) found using their clinical Chinese and Euro-
pean Canadian sample and contrary to what would be expected
according to the somatization hypothesis. However, our finding
is
consistent with Dere et al. (2013), who also found larger
appetite
and hypersomnia to be less common in Han Chinese than Euro-
pean Canadian outpatients in their study. For psychological
symp-
toms, the frequency analysis supports our hypothesis and
Ryder’s
prior clinical findings that a lower percentage of Asian
Americans
endorse psychological symptoms than European Americans.
To rule out the possibility of an artifact of less depressive
symptomatology among Asian Americans compared with Euro-
pean Americans, we carried out IRT analyses. As mentioned, an
advantage of the IRT approach over the typical frequency ap-
proach is that it accounts for the potentially confounding effect
of
degree of depressive symptomatology, and it may be a more
precise manner of testing whether there are ethnic differences in
symptom expression. With the IRT analyses, we found very
sim-
ilar results to the frequency analyses. There were more ethnic
similarities than differences for both somatic symptoms (7 of 9
severity parameters; 8 of 9 discrimination parameters) and psy-
chological symptoms (12 of 23 severity parameters; 22 of 23
discrimination parameters). However, when there were ethnic
dif-
ferences, relative to European Americans, Asian Americans
were
less likely to endorse specific somatic and psychological symp-

53. toms, given similar degrees of depressive symptomatology. The
IRT analyses suggested some true differences in the expression
of
depression, but largely in the severity parameter for these symp-
toms. Asian Americans were less likely to endorse two somatic
symptoms and 11 psychological symptoms. This may reflect dif-
ferences in the relevance of these items across ethnic groups,
particularly with psychological symptoms.
Overall, it can be seen that the ethnic differences are largely the
same using both the frequency and IRT approaches. The �2 and
IRT analyses yielded significant differences across ethnic
groups
for both somatic and psychological symptoms, such that when
there were differences, Asian Americans were less likely to en-
dorse both somatic and psychological symptoms than European
Americans. The IRT findings indicate that Asian Americans’
lower rates of some somatic and psychological symptoms are
not
an artifact of different degrees of symptomatology among Asian
Americans compared with European Americans. Together, these
findings challenge the view that persons of Asian origin
somatize
their depression.
New neural evidence supports our findings that when there are
differences between Asian Americans and European Americans,
Asian Americans are less likely to endorse specific somatic and
psychological symptoms. Immordino-Yang, Yang, and Damasio
(2014) provide physiological and imaging data that suggest that
Chinese and East Asian American participants use
somatosensory
Table 5
Differential Item Functioning of DSM-IV Psychological
Symptoms of Major Depressive Disorder

54. for Asian and European Americans
Psychological symptoms
Severity or difficulty parameter Discrimination parameter
Asian
American
European
American p
Asian
American
European
American p
Felt depressed �2.03 (0.32) �2.16 (0.14) 0.36 0.77 (0.16) 0.95
(0.09) 0.84
Nothing could cheer �0.25 (0.11) �0.48 (0.05) 0.03 1.03 (0.17)
0.84 (0.06) 0.15
Discouraged �1.21 (0.17) �1.56 (0.08) 0.00 0.93 (0.16) 1.02
(0.08) 0.69
Hopelessness �0.16 (0.11) �0.52 (0.05) 0.00 1.05 (0.19) 0.97
(0.07) 0.35
Loss of interest �0.70 (0.12) �0.91 (0.06) 0.06 0.97 (0.15) 1.03
(0.07) 0.64
Nothing was fun �0.44 (0.11) �0.68 (0.05) 0.02 1.00 (0.15)
0.89 (0.06) 0.25
Worthlessness 0.07 (0.10) �0.23 (0.06) 0.01 1.49 (0.31) 1.06
(0.10) 0.09
Loss of confidence �0.81 (0.14) �1.13 (0.07) 0.02 0.94 (0.16)
0.86 (0.07) 0.32
Not as good as others �0.34 (0.12) �0.35 (0.05) 0.47 0.86
(0.14) 0.82 (0.06) 0.40

55. Guilt 0.43 (0.14) �0.02 (0.06) 0.00 0.66 (0.12) 0.59 (0.04) 0.29
Trouble concentrating �0.95 (0.18) �1.17 (0.08) 0.13 0.75
(0.14) 0.81 (0.06) 0.65
Indecisiveness �0.16 (0.14) �0.49 (0.05) 0.01 0.59 (0.11) 0.80
(0.06) 0.95
Thoughts come slowly �0.23 (0.12) �0.19 (0.05) 0.62 0.81
(0.14) 0.82 (0.06) 0.53
Thought about death 0.03 (0.11) �0.35 (0.06) 0.00 0.87 (0.14)
0.56 (0.04) 0.02
Better if dead 0.35 (0.10) 0.29 (0.05) 0.30 1.05 (0.17) 0.89
(0.06) 0.19
Thought about suicide 0.94 (0.15) 0.78 (0.06) 0.16 0.90 (0.15)
0.76 (0.05) 0.19
Made suicide plan 1.27 (0.35) 1.63 (0.17) 0.82 0.48 (0.21) 0.50
(0.08) 0.54
Made suicide attempt 2.14 (0.71) 2.88 (0.54) 0.80 0.39 (0.20)
0.31 (0.08) 0.36
Irritability �0.46 (0.17) �0.46 (0.08) 0.50 0.57 (0.11) 0.44
(0.04) 0.13
Could not cope with responsibility 0.20 (0.09) �0.20 (0.04)
0.00 1.27 (0.19) 1.10 (0.07) 0.20
Wanted to be alone �0.91 (0.21) �1.32 (0.10) 0.04 0.59 (0.12)
0.63 (0.05) 0.62
Less talkative �1.54 (0.32) �1.61 (0.12) 0.42 0.60 (0.13) 0.64
(0.06) 0.61
Tearfulness �0.85 (0.35) �1.47 (0.20) 0.06 0.30 (0.09) 0.30
(0.04) 0.50
T
hi
s
do
cu
m

56. en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
Ps
yc
ho
lo
gi
ca
l

57. A
ss
oc
ia
tio
n
or
on
e
of
its
al
lie
d
pu
bl
is
he
rs
.
T
hi
s
ar

58. tic
le
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in

59. di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.

60. 760 KIM AND LÓPEZ
information significantly less than non-Asian Americans in the
expression of emotion. This is consistent with Chinese
Confucian
principles, which emphasize settling the body to be better able
to
tune in to the social context (Markus & Kitayama, 1991). In
contrast, it may be a more “mainstream American” strategy to
use
bodily information to aid in the assessment of one’s emotions. It
is
possible then that Asian Americans are less likely to endorse
some
somatic and psychological symptoms, because for Asian Ameri-
cans they are not as interrelated and used in conjunction to
assess
emotional state. In contrast, Immordino-Yang, Yang, and
Damasio
(2014) suggest that European Americans may use somatic words
to describe psychological states. Thus, it is not surprising that
in
our sample, Asian Americans are less likely to endorse somatic
symptoms of Major Depression than European Americans, oppo-
site of the somatization hypothesis.
The study by Immordino-Yang et al. (2014), however, does not
explain the difference seen between clinical and community
sam-
ples. Past studies using clinical samples (e.g., Huang et al.,
2006;
Parker et al., 2001; Ryder et al., 2008) have found greater soma-
tization in Asian origin than European origin patients. In
contrast,

61. our community study, along with Uebelacker et al. (2009) and
Weiss et al. (2009), found no difference in somatization
between
Asian origin and European origin groups. An interesting area
for
future research is to better understand why we tend to see a
pattern
of somatization of depression in Asian origin clinical samples
but
not community samples. One possibility is that in Chinese
societ-
ies there is less tolerance for disclosing one’s illness outside the
family (e.g., Lin, Tardiff, Donetz, & Goresky, 1978). To reduce
the “burden of stigma”, Asian origin persons who seek profes-
sional help may tend to present their distress in somatic
symptoms
rather than in psychological symptoms, as somatic symptoms
are
less stigmatized (Goldberg & Bridges, 1988). Certainly, there is
a
body of evidence that suggests that mental illness is
stigmatized, at
least in Chinese societies (e.g., Chan & Parker, 2004; Chung &
Wong, 2004). In contrast, in community samples, there is more
heterogeneity—those who do not have psychiatric illness,
partic-
ipants who have kept illness to themselves or within the family,
and some who have sought help outside the family. Therefore,
compared with a clinical sample where 100% of the participants
have revealed a potentially stigmatized illness identity outside
the
family, there may be less of a need to emphasize somatic symp-
toms of depression. As stated in Ryder et al. (2008),
“[s]omatiza-
tion allows psychologically distressed individuals to inhabit the

62. sick role in their societies without bearing the burden of stigma
(Goldberg & Bridges, 1988)” (p. 302). Thus, it is possible that
the
pattern of greater somatization in Asian origin participants
repre-
Figure 1. (a) Illustrative item characteristic curves for the
“fatigue/loss of
energy” somatic depressive symptom item derived from Asian
and Euro-
pean Americans. (b) Illustrative item characteristic curves for
the “psy-
chomotor agitation” somatic depressive symptom item derived
from Asian
and European Americans.
Figure 2. (a) Illustrative item characteristic curves for the
“guilt” psy-
chological depressive symptom item derived from Asian and
European
Americans. (b) Illustrative item characteristic curves for the
“thought about
death” psychological depressive symptom item derived from
Asian and
European Americans.
T
hi
s
do
cu
m
en

63. t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
Ps
yc
ho
lo
gi
ca
l
A

64. ss
oc
ia
tio
n
or
on
e
of
its
al
lie
d
pu
bl
is
he
rs
.
T
hi
s
ar
tic

65. le
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di

66. vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
761ETHNICITY AND DEPRESSIVE SYMPTOMATOLOGY

67. sents a help-seeking bias in clinical samples. The source of the
sample is a potentially important moderator for future studies to
examine.
Our findings add to the literature in important ways. First,
although past literature has emphasized potential differences in
the
expression of depression, these results reveal greater
similarities
between community samples of Asian and European Americans
in
the expression of both somatic and psychological symptoms of
depression. Second, the IRT analyses suggest that there truly
are
some differences in the expression of depression, but largely in
the
severity parameter for somatic and psychological symptoms.
Com-
pared with European Americans with a similar degree of depres-
sive symptomatology, Asian Americans in a community sample
are less likely to report some somatic and psychological symp-
toms, and they require more depressive symptomatology to
report
these symptoms. These findings differ from the IRT analysis of
Uebelacker and colleagues (2009) who found only one ethnic
difference for the severity parameter and one ethnic difference
for
the discrimination parameter. We place more confidence in the
findings of the current study given the large sample size and
given
that the sample likely represents more sociocultural variability
in
the expression of depression, because those who did not speak
English fluently were included in the present study but not in

68. the
Uebelacker et al. (2009) study. Another contribution of this
study
is that prior research indicating less psychologization in Asian
Americans compared with European Americans was based
largely
on clinical populations. The current study provides
complementary
evidence using a nationally representative, community sample
of
noninstitutionalized populations. This is one of a few studies
using
a nationally representative community sample of Asian and
Euro-
pean Americans that examines both somatic and psychological
symptoms. Moreover, with the exception of Uebelacker et al.
(2009) and Dere et al. (2013), the prior clinical and community
studies (e.g., Weiss et al., 2009) only carried out frequency
(i.e.,
classical test theory) analyses and did not include DIF analyses,
which take into account degree of depressive symptomatology.
The findings also have potential clinical implications. Keeping
in mind this pattern of less somatization and psychologization
in
Asian Americans may assist clinicians in the detection and
assess-
ment of depression. Although the DSM is heavily weighted
toward
psychological symptoms (i.e., more than 50% of the DSM
criteria
are psychologically minded), it may be important to consider
that
it may take an Asian American who has more depressive symp-
tomatology to endorse some specific psychological symptoms
than

69. a European American client. These findings also challenge the
notion that Asian Americans, at least in a community sample,
somatize their depression. Being cognizant of these patterns has
the potential to assist clinicians in better detecting depression in
Asian Americans who are experiencing the disorder.
Limitations and Future Directions
Because of the nature of the survey, this dataset did not allow
us
to examine depressive symptoms in the entire sample, as only
those who passed the screening items received the depression
module. Thus, these results may only apply to those who are
already more elevated in depressive symptoms and not a true
community sample. It will be important to replicate these
findings
in future studies, using both an entire community and clinical
sample.
Second, there may be important subgroup differences, within
the broad ethnic categories. For example, some research
suggests
that Korean female participants report more somatic symptoms
than Japanese female participants, but that somatic symptoms
account for less variance in Beck Depression Inventory scores
for
the Korean participants than for the Japanese participants
(Arnault
& Kim, 2008). Our intent was not to apply a broad brush in
examining Asian Americans and European Americans as two
groups, but the current project was an initial study on ethnic
differences, and thus, we did not examine subgroup differences
within Asian Americans and within European Americans. There
might be variability within these two groups, because of
national-

70. ity, acculturation, language, country of birth, gender, age, and
so
forth. These would be interesting and important areas of future
research, especially as the neural data begin to show some of
these
differences.
Another limitation is that we only used depressive symptoms
defined by the DSM–IV. This may be a narrow lens by which to
identify depression in our two ethnic groups, and thus, it may
contribute to the detection of few group differences. It may be
that
group differences in the expression of depression would be
more
easily identified if culture-specific manifestations of depression
were included in the assessment.
Conclusions
Although the somatization hypothesis has been popular in past
theory and research of symptom expression in racial and ethnic
minority groups, more recent studies, particularly those using
community samples, do not support this hypothesis. For the ma-
jority of both somatic and psychological symptoms of
depression
in Asian and European Americans, there were no differences in
level of endorsement. Where there were differences, we found
less
somatization in Asian Americans than in European Americans,
contrary to the somatization hypothesis. In addition, similar to
Ryder et al. (2008), when there were differences, we found less
psychologization in Asian Americans than in European Ameri-
cans. These results were supported by IRT analyses as well,
which
suggest that the observed ethnic differences are not an artifact
of

71. less depressive symptomatology among Asian Americans com-
pared with European Americans. Thus, the presumed cultural
differences in the expression of depression, especially the
notion
that Asian Americans tend to present depression in somatic
terms,
receive little support in a nationally representative community
sample of Asian Americans and European Americans.
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http://dx.doi.org/10.1023/A:1021738929069The Expression of
Depression in Asian Americans and European AmericansThe
Diagnosticity of Somatic and Psychological SymptomsOverview
and HypothesesMethodParticipantsMeasuresComposite
International Diagnostic InterviewScreening sectionDepression
moduleResultsOverviewEthnicity and Degree of
DepressionEthnicity and Symptom EndorsementItem Response
TheoryDiscussionLimitations and Future
DirectionsConclusionsReferences