Culturally-Informed Assessment of Depression and Distress in Asian American Men across Life Stages

Depression and other mental health conditions are among the leading causes of disability worldwide, significantly affecting quality of life, productivity, and public health.^1,2) While women are diagnosed with depression at higher rates, men exhibit disproportionately higher rates of suicide, substance use disorders, and interpersonal violence, which are realities strongly linked to psychological distress yet frequently overlooked by conventional diagnostic frameworks.³) This paradox reflects modifiable misdiagnosis and underdiagnosis of depression in men, driven largely by diagnostic criteria that may not capture men’s unique experiences of distress.²)

Traditional diagnostic frameworks, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), rely predominantly on symptomatology derived from consensus-based methods grounded in historically homogenous populations, emphasizing internalizing affective symptoms such as sadness, hopelessness, and feelings of failure.^4,5) However, men often express distress differently, presenting with externalizing symptoms such as irritability, anger, aggression, risk-taking, substance misuse, and somatic complaints that are frequently not considered clinically significant.⁵) When the National Comorbidity Survey Replication was reanalyzed with a gender-inclusive scale adding these alternative symptoms, the usual sex disparity in depression disappeared, with men and women meeting criteria in nearly equal proportions.²) This misalignment between diagnostic criteria and men’s lived experiences may drive widespread underdiagnosis, leaving conditions untreated and worsening morbidity and health outcomes for men.⁶)

Asian American men face unique mental health challenges shaped by cultural, societal, and systemic factors. In the United States, cultural conceptions of distress have been explored in Latino populations but not among Asian Americans, and specifically not Asian American men. Despite experiencing mental health issues at rates comparable to other populations, Asian American men are significantly less likely to seek services: only 8.6% of Asian Americans use mental health services, compared with 18% of the general U.S. population.⁷) This underutilization reflects not lower prevalence but cultural and structural barriers.⁷) In many Asian cultures, mental health problems are viewed as personal weakness or a source of family shame, discouraging individuals from acknowledging their struggles.⁸) The model minority stereotype, which portrays Asian Americans as successful and self-reliant, adds pressure to avoid appearing vulnerable, while language barriers and a lack of culturally competent services further limit access to care.^5,7,8) Many men instead express distress through somatic symptoms, such as headaches or fatigue, that are easily misdiagnosed or dismissed,⁹) underscoring the need for diagnostic approaches sensitive to cultural expressions of mental health.

To address these diagnostic challenges, our research team has developed a methodology that draws on both qualitative and quantitative approaches, conceptualizing distress as a continuum rather than a binary of present or absent disease. It integrates phenomenological interviews with culturally adapted structured clinical tools for a more nuanced understanding of distress. Previously, Wahid and colleagues used latent class analysis (LCA) to delineate groups by depressive symptom severity among slum-dwelling young men in Bangladesh.⁵) The analysis identified three groups: "wellness," "distressed," and "severely distress," capturing expressions of distress missed by traditional symptom-count procedures.⁵) Some symptoms followed a continuum across groups, whereas the most severe, such as anhedonia, emerged predominantly in the severely distressed group.⁵) Complementary phenomenological interviews underscored culturally specific idioms of distress, such as "tension," which subsumed a range of severity, mirroring the continuum identified in the LCA.⁵) Prioritizing qualitative methods alongside quantitative measure grounded the model in participants’ lived realities.⁵) Unlike the DSM-IV Cultural Formulation Interview, this approach lets lived-experience data reshape the measure itself: its items and severity thresholds, not only their interpretation.

Similar culturally specific idioms have been documented in Korean populations. Hwabyung, a Korean syndrome recognized within the DSM-IV cultural concepts of distress framework, is characterized by suppressed anger, emotional burden, and somatic symptoms arising in response to chronic psychosocial stressors.¹¹) It frequently overlaps with anxiety, depression, and somatic presentations while reflecting culturally shaped patterns of emotional suppression among Koreans and Korean Americans.^10,11) Its persistence highlights the culturally situated ways distress is experienced and communicated in these communities, suggesting that idioms such as Hwabyung may be important pathways for understanding how Asian American men conceptualize, express, and cope with psychological suffering outside Western diagnostic frameworks. For non-Korean groups, other idioms, such as Khyal attacks among Cambodians, may shape the experience of suffering but require community-based, lived-experience research to establish their use and salience.¹²)

This methodology is also intersectionality-informed, recognizing that men’s mental health experiences are shaped by the interplay of age, social determinants of health, and systemic factors such as stigma and structural inequities, producing variability across life stages that diagnostic models homogenize and that is most consequential in later life. Later-life depression in older men is often missed, its symptoms attributed to aging or coexisting illness, while somatic presentations overlap with multimorbidity. For older Asian American men, culturally shaped somatic idioms compound this, and aging-specific stressors, including social isolation, bereavement, functional and cognitive decline, and shifting caregiving roles, shape how distress is expressed; intergenerational change maybe acute for immigrants whose anticipated filial support has eroded. A continuum-based, culturally responsive assessment can distinguish depression from the changes of aging and surface distress older men may be reluctant to voice, a task well suited to geriatric primary care.

Although this evidence spans Bangladeshi, Korean, and Cambodian groups, we draw on it not to generalize specific syndrome to Asian American men but to show a common principle: distress is culturally shaped, expressed through locally specific idioms that standardized criteria miss and that must be elicited within each community rather than assumed. Applying this approach therefore holds particular promise for Asian American men, who remain underserved by traditional mental health models. Because Western-developed diagnostic tools may not capture the culturally influenced ways these men express distress, through somatic symptoms, social withdrawal, irritability, and occupational impairment rather than overt sadness, a continuum-based, culturally responsive assessment is well suited to their needs.⁷) It is also well suited to primary care, where the regularity of visits and established patient relationships make these settings crucial points of intervention.

Integrating this assessment into routine care raises practical questions of workflow, clinician burden, training, validation, and feasibility. We envision a stepped approach: a brief, self-administered continuum-based measure, spanning somatic, externalizing, and culturally salient items, completed at intake, with only elevated scores prompting a short clinician follow-up. In that follow-up, the quantitative score would flag the severity and dimensions of distress, while brief structured qualitative probes would invite patients to describe their experience in their own terms, so the clinician interprets the score against the patient’s own framing rather than in isolation. This design limits clinician burden, and training would be modest, focused on recognizing culturally shaped and somatic presentations. The measure would require psychometric validation against structured clinical interviews, with attention to reliability and measurement invariance across language, nativity, and generation. Feasibility would depend on pilot testing in primary care, attentive to multilingual administration, electronic health record integration, and time and reimbursement constraints. We thus frame primary care integration not as a finished tool but as a tractable next step grounded in this work.