“You wished the ground would open and swallow you up”: Expert opinions on shame, the collective, and other cultural considerations for suicide prevention among Asian American and Pacific Islander veterans

Monteith L.L., Forster J.E., Holliday R., Miller C., Bahraini N.H., Akhtar F.Z., Schneiderman A.I., Brenner L.A., Hoffmire C.A.

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

Leung C.A., Lai J.

Monteith L.L., Kittel J.A., Schneider A.L., Miller C.N., Gaeddert L.A., Holliday R., Brenner L.A., Hoffmire C.A.

IntroductionKnowledge of suicide rates and methods among Asian American, Native Hawaiian, and Pacific Islander (AANHPI) Veterans remains sparse. Age- and sex-specific suicide rates, methods, and trends were examined among AANHPI Veterans and were compared with findings reported for all Veterans.MethodsFor this population-based retrospective cohort study, average annual suicide rates (2005–2019) were computed in 2023 using population (U.S. Veterans Eligibility Trends and Statistics) and mortality (National Death Index [NDI]) data. The cohort included 416,454 AANHPI Veterans (356,146 males, 60,229 females) separated from military service and alive as of 1/1/2005. Suicide was determined from NDI underlying cause-of-death ICD-10 codes.ResultsThe age-adjusted average annual suicide rate among AANHPI Veterans increased 36.85% from 2005–2009 to 2015–2019 (2015–2019: 30.97/100,000). Relative to other ages, 2015–2019 suicide rates were highest among AANHPI Veterans 18–34 (overall: 53.52/100,000; males: 58.82/100,000; females: 32.24/100,000) and exceeded those of similarly aged Veterans in the overall Veteran population (overall: 44.71/100,000; males: 50.59/100,000; females: 19.24/100,000). The sex difference in suicide rates was lower among AANHPI Veterans than in Veterans overall (relative risk [males to females]=1.65 and 2.33, among those 18–54). Firearms were used less and suffocation more among AANHPI Veterans, relative to Veterans overall.ConclusionsSuicide among AANHPI Veterans is an increasing public health concern, with younger males and females at particularly elevated risk. Lethal means safety strategies for AANHPI Veterans should consider distinctions in suicide methods compared to the overall Veteran population. Research is warranted to understand the lower magnitude sex difference in suicide rates among AANHPI Veterans.

Monteith L.L., Kittel J., Miller C., Schneider A.L., Holliday R., Gaeddert L.A., Spark T., Brenner L.A., Hoffmire C.A.

The suicide rate among Asian American, Native Hawaiian, and Pacific Islander (AANHPI) Veterans increased from 2001 to 2020. Identifying regions where suicide rates are elevated and increasing among AANHPI Veterans would inform targeted prevention efforts for members of this cohort. We conducted a population-based retrospective cohort study of 377,833 AANHPI Veterans to examine suicide rates and methods (2005-2019) by United States (US) region and over time (2005-2009, 2010-2014, 2015-2019), using US Veteran Eligibility Trends and Statistics and Joint DoD/VA Mortality Data Repository data. AANHPI Veterans across most regions experienced increases in suicide rates from the earliest to latest period; however, patterns differed by region. Age-adjusted suicide rates increased across all three periods among those in the Northeast and West, but increased, then declined in the Midwest and South. In 2015-2019, the age-adjusted suicide rate among AANHPI Veterans was highest in the Northeast (42.0 per 100,000) and lowest in the West (27.5). However, the highest percentages of AANHPI Veteran suicide deaths in 2005-2019 occurred in the West (39.5%) and South (34.7%), with lower percentages in the Midwest (15.0%) and Northeast (10.8%). Across regions, those ages 18-34 had the highest suicide rates. Firearms were the most frequently used suicide method across regions (44.4%-60.2%), except the Northeast (35.2%), where suffocation was more common (38.3%). Results suggest particular needs for suicide prevention efforts among AANHPI Veterans in the Northeast and to ensure that lethal means safety initiatives for AANHPI Veterans encompass both firearms and suffocation, with some variations in emphasis across regions.

Akhter S.

This chapter provides a short description of the key informant interview (KII), an important data collection method in qualitative research. Then, the chapter explains the suitability of this method in qualitative research. The chapter discusses the selection process of key informants with the roles of researcher and interviewer. The chapter gives important guidelines of the steps to conduct KII. The chapter also provides some guidelines about the data process, data presentation, and data analysis strategies of KII. The chapter ends with a description of the advantages and disadvantages of KII.

Norder S.J., Visvalingam S., Norton P.J., Norberg M.M.

Shaligram D., Chou S., Chandra R.M., Song S., Chan V.

Asian American and Pacific Islanders (AAPI) are the fastest growing racial minority in the United States. With more than 40 subgroups in the diaspora, 1 in 10 American youths will be of Asian origin by 2060. Racism-defined as prejudice, discrimination or antagonism on the basis of membership in a particular racial or ethnic group-is increasingly recognized as a public health crisis.1 Anti-AAPI racism, such as unequal resource distribution in housing, education, employment, and health care, exclusionary naturalization policies and violence1,2 (eg, Pacific coast riots, Japanese Americans' internment during World War II, recent Atlanta shootings) is well documented. Anti-AAPI microaggressions-that is, the subtle, sometimes unintentional forms of racism such as characterizations as perpetual foreigners, ascriptions of intelligence, oversexualization of women, invalidated interethnic differences, and model minority myth-are common. The model minority stereotype dismisses real struggles1 and pits AAPIs against other racial minorities. Despite the proud tradition of AAPI activism , discrimination is often endured in silence, probably stemming from cultural values of stoicism and harmony, and tacit societal acceptance of racism.3.

Zhou S., Banawa R., Oh H.

Hate crimes against Asian American/Pacific Islanders (AAPIs) have surged in the United States during the COVID-19 pandemic to alarming new levels. We analyzed data from the Healthy Minds Study, and found that COVID-19 related racial/ethnic discrimination was associated with greater odds of having depression, anxiety, non-suicidal self-injury, binge drinking, and suicidal ideation among AAPI university students (N = 1,697). Findings suggest that the COVID-19 pandemic precipitated discrimination, which has been linked to mental health problems, calling for more preventive interventions to address the AAPI population, especially given their low rates of formal treatment utilization.

Yip T., Cheah C.S., Kiang L., Hall G.C.

In 1992, the United States government expanded a 1978 decision to observe Pacific Heritage Week to a month-long recognition of the contributions of Americans to the country's history and ongoing cultural milieu. Since 2000, the population in the United States has grown by 72%-the fastest rate of any racial/ethnic group in the country. Today, the Census reports that Asians comprise 22 million United States residents. Despite this unprecedented growth, Americans remain largely invisible in the national dialogue and in scientific research. This special issue features theoretical, empirical, and policy articles that highlight Americans in psychology. Americans remain marginalized and invisible in scientific endeavors for several reasons. For example, consolidating many ethnic groups under an Asian American pan-ethnic umbrella masks meaningful cultural, linguistic, ethnic, migration, gender, sexual/gender identity/expression, and socioeconomic differences. These intersectional identities result in experiences that are multiply marginalized, contributing to invisibility. The model minority stereotype highlights high-achieving and successful individuals, rendering the segment of the population that is struggling irrelevant and unworthy of attention. This special issue directly interrogates sources of invisibility to synthesize theory, research, and policy focused on Americans. The articles in this special issue focus on the intersectional spaces that Americans occupy, unpacking the diversity behind the Asian American pan-ethnic label, experiences of identity and discrimination across a range of groups, and areas of theory/research/policy where experiences have been overlooked. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Randles R., Finnegan A.

IntroductionServing military personnel and veterans have been identified to have a high prevalence of mental health disorders. Despite this, only a significantly small number seek mental healthcare. With the UK beginning to invest further support to the armed forces community, identification of barriers and facilitators of help-seeking behaviour is needed.MethodsCorresponding literature search was conducted in PsycINFO, PsycArticles, Medline, Web of Science and EBSCO. Articles which discussed barriers and facilitators of seeking help for mental health concerns in the veteran population were included. Those which discussed serving personnel or physical problems were not included within this review. A total of 26 papers were analysed.ResultsA number of barriers and facilitators of help-seeking for a mental health issue within the veteran population were identified. Barriers included stigma, military culture of stoicism and self-reliance, as well as deployment characteristics of combat exposure and different warzone deployments. Health service difficulties such as access and lack of understanding by civilian staff were also identified. Facilitators to help combat these barriers included a campaign to dispel the stigma, including involvement of veterans and training of military personnel, as well as more accessibility and understanding from healthcare staff.ConclusionsWhile some barriers and facilitators have been identified, much of this research has been conducted within the USA and on male veterans and lacks longitudinal evidence. Further research is needed within the context of other nations and female veterans and to further indicate the facilitators of help-seeking among veterans.

Jeung R., Horse A.Y., Popovic T., Lim R.

This report offers aggregated national data and some selected personal testimonials about Asian American experiences with anti-Asian violence. The data is presented by types of discrimination and violence experienced, the ethnic breakdown of those being targeted, and the locations where Asian Americans were targeted.

Kim S.B., Lee Y.J.

Asian Americans are underutilizing mental health services. The aim of the current systematic review was to identify protective and risk factors of mental health help-seeking patterns among the disaggregated Asian Americans and to classify types of help. A systematic literature review was conducted using the PRISMA guidelines. The Health Belief Model served as the theoretical framework for this review. Thirty-four articles were reviewed, and the studies investigated one of the following Asian ethnic subgroups: Chinese, Filipino, Asian Indian, Korean, or Vietnamese. Data were extracted based on the study characteristics, sample characteristics, and protective and risk factors to mental health help-seeking patterns. Predisposing factors like female gender, higher levels of English proficiency, and history of mental illness increased the likelihood for help-seeking across several ethnic groups. Interestingly, cues to action and structural factors were under-examined. However, cues to action like having a positive social network did increase the likelihood of using formal support services among Chinese and Filipinx participants. Structural factors like lacking ethnic concordant providers and access to healthcare served as barriers for Korean and Vietnamese participants. The findings showed a need for ethnic tailored approaches when supporting mental health help-seeking patterns. Asian ethnic group’s immigration status, acculturation level, and psychological barriers to help-seeking should continue to be emphasized. Psychoeducational groups can be beneficial to expand the knowledge base surrounding mental illness and to link group members to culturally responsive resources.

Mayer L., Corrigan P.W., Eisheuer D., Oexle N., Rüsch N.

The decision whether to disclose a mental illness has individual and social consequences. Secrecy may protect from stigma and discrimination while disclosure can increase social support and facilitate help-seeking. Therefore, disclosure decisions are a key reaction to stigma. The first aim of this study was to test a newly developed scale to measure disclosure attitudes, the Attitudes to Disclosure Questionnaire (AtDQ). The second aim was to examine the impact of attitudes towards disclosing a mental illness on quality of life and recovery. Among 100 participants with mental illness, disclosure attitudes, quality of life, recovery, benefits of disclosure, secrecy, social withdrawal, self-stigma, and depressive symptoms were assessed at weeks 0, 3 and 6. Psychometric properties of the AtDQ were analysed. Longitudinal associations between disclosure attitudes at baseline and quality of life and recovery after 6 weeks were examined in linear regressions. The analyses of the AtDQ indicated one-factor solutions, high acceptability, high internal consistency, and good retest reliability for the total scale and the subscales as well as high construct validity of the total scale. Results provided initial support for sensitivity to change. More positive disclosure attitudes in general and in particular regarding to family at baseline predicted better quality of life and recovery after 6 weeks. The current study provides initial support for the AtDQ as a useful measure of disclosure attitudes. Disclosing a mental illness, especially with respect to family, may improve quality of life and recovery of people with mental illness.

The Lancet

Racist anti-Asian incidents and rhetoric in the USA have been on the rise during the COVID-19 pandemic, by some accounts increasing as much as 150%. The horrific mass shooting on March 15, 2021, in which six of eight people killed in three spas in Atlanta, Georgia, were Asian women, has prompted urgent conversations about prejudice against Asian Americans. Organisations including the American Medical Association were swift to underscore that racism, in addition to gun violence, is a public health crisis.

Tessler H., Choi M., Kao G.

In this essay, we review how the COVID-19 (coronavirus) pandemic that began in the United States in early 2020 has elevated the risks of Asian Americans to hate crimes and Asian American businesses to vandalism. During the COVID-19 pandemic, the incidents of negative bias and microaggressions against Asian Americans have also increased. COVID-19 is directly linked to China, not just in terms of the origins of the disease, but also in the coverage of it. Because Asian Americans have historically been viewed as perpetually foreign no matter how long they have lived in the United States, we posit that it has been relatively easy for people to treat Chinese or Asian Americans as the physical embodiment of foreignness and disease. We examine the historical antecedents that link Asian Americans to infectious diseases. Finally, we contemplate the possibility that these experiences will lead to a reinvigoration of a panethnic Asian American identity and social movement.