Abstract
Background.
This study aimed to explore the prevalence and correlates of anxiety disorders and any anxiety symptoms among community-dwelling U.S. Chinese older adults.
Methods.
Guided by a community-based participatory research approach, 3,159 community-dwelling Chinese older adults in the Greater Chicago area were interviewed in person between 2011 and 2013.
Results.
Of 3,159 older adults surveyed, 8.5% had anxiety disorders and 65.0% reported having any anxiety symptoms. Being female, unmarried, poorer health status, lower quality of life, and worsening health over the past year were positively correlated with anxiety disorders and any anxiety symptoms. Living with fewer people and having fewer children were only correlated with any anxiety symptoms and lower income was only correlated with anxiety disorders.
Conclusions.
This study emphasizes that interventions for anxiety among Chinese older adults should give special attention to older women, those who are unmarried, with impaired health status, and poorer quality of life. Further longitudinal studies should be conducted to better understand risk factors and outcomes associated with anxiety among U.S. Chinese older adults.
Key Words: Anxiety disorders, Anxiety symptoms, Older adults, Chinese, Psychological health.
Anxiety is the most common mental illness among U.S. adults, with an estimated 12-month prevalence of 18.1%, of which 22.8% are severe anxiety disorders (1). Anxiety may cause significant adverse personal and societal outcomes. At the individual level, anxiety has been linked to physical disability (2), declines in cognitive function (3), and even suicidal ideation and mortality (4,5). At the societal level, anxiety may increase medical utilization and health care costs (6). According to a report on the economic burden of anxiety disorders, the cost of anxiety disorders is about $42 million per year—one third of the U.S. total mental illness bill (7).
Anxiety is a major health problem in late life, yet anxiety symptoms in older adults are often undiagnosed and untreated. A study with 713 men and 1,338 women in Kentucky found that although 20% of participants aged 55 and older experienced a high level of anxiety symptoms, only 10% of them acknowledged the need to seek mental health treatment (8). Despite the magnitude of the issue among older adults, compared with other mental health issues such as depression and dementia, anxiety has received significantly less attention from researchers and the public (9,10).
Additionally, the majority of studies on anxiety among older adults focused on the occurrence of disorders. Anxiety disorders may be manifested by a combination of symptoms such as having constantly worrying thoughts or not being able to sit at ease. Given that a diagnosis of anxiety disorders may require several symptoms, participants who endorsed one or more symptoms but did not meet the criteria for anxiety disorders may be excluded from the estimate of prior studies. Such exclusion of subsyndromal presentations may lead to the underestimation of the issue of anxiety among older adults (11). It is imperative for community epidemiology surveys to depict more accurate and comprehensive pictures of the extent of anxiety among older adults.
The prevalence, presentation, and expression of anxiety differ significantly by social and cultural factors. Anxiety, especially social anxiety, is common and more likely to interfere with social relationships in collectivistic cultures, where harmony is highly emphasized within family and society (12). In addition, responses to anxiety may vary by cultural and ethnic groups. The Chinese culture is distinctive in the great emphasis given to individual and family “face value,” in which respect and reputation are critical (13). Although anxiety may be regarded as personality disorders, Chinese older adults are often inclined to deny anxiety so as to protect family honor and save individual “face.” The tendency to deny symptoms or express anxiety symptoms as somatic symptoms such as pain or fatigue may add to the complexity of detecting anxiety among Chinese older adults. Despite possibly unique cultural patterns of anxiety, the research on anxiety disorders and anxiety symptoms among Chinese older adults, regardless of their place of residence, is still in its infancy.
The prevalence of anxiety cannot be fully understood without taking the immigration context into account. Language and cultural barriers experienced in a new country may increase intergenerational conflicts and breakdowns of traditional support systems (14–16). Furthermore, living in a conflict environment, financial strain, and separation from family members and relatives in the home country may predispose U.S. Chinese older adults to greater risk for anxiety. Over the past several years, the number of U.S. Chinese older adults has grown rapidly, to an estimated 540,000 people age 60 years or older in 2010 (17). The vulnerability and the growth in the population of U.S. Chinese older adults warrant a deeper understanding of their psychological well-being.
The objectives of the study were to (i) understand the prevalence of anxiety disorders and anxiety symptoms among U.S. Chinese older adults and (ii) explore demographic, socioeconomic, family structure, and health-related correlates of anxiety disorders and anxiety symptoms among U.S. Chinese older adults.
Methods
Population and Settings
Data of this study were collected from 2011 to 2013, as part of the Population Study of Chinese Elderly in Chicago (PINE). The PINE study is a community-engaged, population-based epidemiological study of U.S. Chinese older adults aged 60 and older conducted in the Greater Chicago area. The project was initiated by a synergistic community-academic collaboration among the Rush Institute for Healthy Aging, Northwestern University, and many Greater Chicago area community-based social service agencies and organizations.
To ensure the study’s relevance to the well-being of the Chinese community and increase community participation, the PINE study was guided by a community-based participatory research approach. A community advisory board played a pivotal role in providing insights for our research activities. Board members were community stakeholders and residents enlisted from more than 20 civic, health, and social advocacy groups and community centers and clinics in the city and suburbs of Chicago. The board worked extensively with the investigative team to develop and test study instruments to ensure cultural sensitivity and appropriateness.
Study Design and Procedure
The research team implemented a targeted community-based recruitment strategy by first engaging community centers in the Greater Chicago area. More than 20 social service agencies, community centers, health advocacy agencies, faith-based organizations, senior apartments, and social clubs served as the basis of study recruitment sites. Community-dwelling older adults aged 60 and older who self-identified as Chinese were eligible to participate in the study. Out of 3,542 eligible older adults approached, 3,159 agreed to participate in the study, yielding a response rate of 91.9%. Details of the PINE study design are published elsewhere (18).
Trained multicultural and multilingual interviewers conducted face-to-face home interviews with participants in their preferred language (English or Chinese) and dialect (eg, Cantonese, Taishanese, Mandarin, and Teochew). Based on the available data drawn from the U.S. Census 2010 and a random block census project conducted among the Chinese community in Chicago, the PINE study is representative of the Chinese aging population in the greater Chicago area (19). The study was approved by the Institutional Review Board of the Rush University Medical Center.
Measurements
Sociodemographics.
Basic demographic information including age (in years), years of education completed, annual personal income (0–$4,999 per year; $5,000–$9,999 per year; $10,000–14,999 per year; $15,000–$19,999 per year; or more than $20,000 per year), marital status (married, separated, divorced, or widowed), number of children, number of grandchildren, years in the community, and years in the United States were assessed in all participants. Living arrangement was categorized into four groups: (i) living alone, (ii) living with one person, (iii) living with two to three persons, or (iv) living with four or more persons.
Overall health status, quality of life, and health changes over the last year.
Overall health status was measured by “In general, how would you rate your health?” on a 4-point scale (1 = poor, 2 = fair, 3 = good, 4 = very good). Quality of life was assessed by asking “In general, how would you rate your quality of life?” also on a 4-point scale ranging from 1 = poor to 4 = very good. Health changes over the last year was measured by “Compared to one year ago, how would you rate your health now?” on a 3-point scale (1 = worsened, 2 = same, 3 = improved).
Anxiety.
We used the Hospital Anxiety and Depression Scale-Anxiety (HADS-A) to assess anxiety among Chinese older adults (20). Participants were asked if they currently experienced the following symptoms: (i) felt tense or wound up, (ii) had a frightened feeling as if something awful is about to happen, (iii) had worrying thoughts, (iv) sit at ease and feel relaxed, (v) had a frightened feeling like butterflies in the stomach, (vi) had feelings of restless, or (vii) had feelings of panic. Respondents indicated answers to each item on a 4-point scale ranging from 0 (not at all) to 3 (most of the time). The item “sit at ease and feel relaxed” was positively worded and reversed code as most of the time = 0, a lot of time =1, occasionally = 2, and not at all = 3. Participants scored eight or higher were considered as having anxiety disorders. In addition, the severity of anxiety disorders was categorized into three levels according to their score: mild (8–10), moderate (11–14), and severe (15–21). The HADS-A has been tested in Chinese populations and has shown good interrater reliability (21,22). The standardized Cronbach’s alpha for the Chinese anxiety measure in the PINE study was .80.
Data Analysis
We used univariate descriptive statistics to summarize demographic, socioeconomic, family structure, and health-related characteristics of the PINE participants. Chi-square statistics and/or t test were used to compare these characteristics between groups with and without anxiety disorders and any anxiety symptoms. Pearson correlation coefficients and Spearman’s rank correlation were calculated to determine the relationships of the demographic, socioeconomic, family structure, and health-related variables with anxiety disorders and anxiety symptoms. All statistical analyses were undertaken using SAS, Version 9.2 (SAS Institute Inc., Cary, NC).
Results
Characteristics of PINE Study Participants by Any Anxiety Symptoms
Of the 3,159 Chinese older adults surveyed, 58.9% were women. Approximately 8.5% of the participants had anxiety disorders. More specifically, 4.6% of the participants reported mild anxiety disorders, 2.7% had moderate anxiety disorders, and 1.1% had severe anxiety disorders. In addition, 65.0% of participants reported having any anxiety symptoms.
Participant characteristics are presented in Table 1. Compared with older adults without anxiety, those with anxiety disorders were more likely to be female (74.0% vs 56.5%), widowed (32.7% vs 23.7%), with poorer health status (49.4% vs 15.9%), with poor quality of life (9.1% vs 2.6%), and with worsening health status (65.5% vs 40.3%). Similarly, compared with those without anxiety symptoms, a larger percentage of those with anxiety symptoms were female (63.2% vs 50.9%), were widowed (26.0% vs 21.2%), had 0–1 children (17.1% vs 11.7%), lived alone (22.8% vs 18.5%), had poorer health status (22.7% vs 10.8%), had fair or poor quality of life (55.5% vs 37.2%), and had worsened health status over the past year (46.6% vs 34.3%).
Table 1.
Characteristics of PINE Study Participants by Any Anxiety Disorders
| Anxiety Disorders | Anxiety Symptom | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Any Disorders (N = 265) | No Disorders (N = 2,866) | χ2 | df | p Value | Any Symptoms (N = 2,054) | No Symptoms (N = 1,050) | χ2 | df | p Value | |
| Age, N (%) | ||||||||||
| 60–64 | 57 (21.5) | 622 (21.7) | 231 (22.0) | 447 (21.8) | ||||||
| 65–69 | 61 (23.0) | 577 (20.1) | 226 (21.5) | 403 (19.6) | ||||||
| 70–74 | 48 (18.1) | 556 (17.6) | 201 (19.1) | 399 (19.4) | ||||||
| 75–79 | 47 (17.7) | 504 (17.6) | 178 (17.0) | 371 (18.1) | ||||||
| 80–84 | 27 (10.2) | 361 (12.6) | 124 (11.8) | 259 (12.6) | ||||||
| 85 and older | 25 (9.4) | 246 (8.6) | 2.5 | 5 | .77 | 90 (8.6) | 175 (8.5) | 2 | 5 | .83 |
| Sex | ||||||||||
| Male | 69 (26.0) | 1,247 (43.5) | 755 (36.8) | 516 (49.1) | ||||||
| Female | 196 (74.0) | 1,619 (56.5) | 30.4 | 1 | <.001 | 1,299 (63.2) | 534 (50.9) | 44 | 1 | <.001 |
| Education (y), N (%) | ||||||||||
| 0 | 25 (9.5) | 162 (5.7) | 132 (6.4) | 55 (5.2) | ||||||
| 1–6 | 94 (35.6) | 1,079 (37.7) | 760 (37.1) | 405 (38.6) | ||||||
| 7–12 | 95 (36.0) | 1,007 (35.2) | 727 (35.5) | 364 (34.7) | ||||||
| 13–16 | 43 (16.3) | 531 (18.6) | 372 (18.2) | 197 (18.8) | ||||||
| 17+ | 7 (2.7) | 80 (2.8) | 6.9 | 4 | .14 | 58 (2.8) | 29 (2.8) | 2.4 | 4 | .67 |
| Income (USD), N (%) | ||||||||||
| $0–$4,999 | 105 (39.8) | 930 (32.7) | 669 (32.8) | 364 (34.9) | ||||||
| $5,000–$9,999 | 131 (49.6) | 1,480 (52.0) | 1,073 (52.6) | 516 (49.5) | ||||||
| $10,000–$14,999 | 19 (7.2) | 290 (10.2) | 196 (9.6) | 109 (10.5) | ||||||
| $15,000–$19,999 | 6 (2.3) | 62 (2.2) | 42 (2.1) | 26 (2.5) | ||||||
| $20,000 and over | 3 (1.1) | 84 (3.0) | 9.0 | 4 | .06 | 59 (2.9) | 28 (2.7) | 3.4 | 4 | .49 |
| Marital status, N (%) | ||||||||||
| Married | 164 (62.4) | 2,056 (72.2) | 1,414 (69.4) | 788 (75.4) | ||||||
| Separated | 7 (2.7) | 49 (1.7) | 45 (2.2) | 10 (1.0) | ||||||
| Divorced | 6 (2.3) | 67 (2.4) | 48 (2.4) | 25 (2.4) | ||||||
| Widowed | 86 (32.7) | 674 (23.7) | 12.5 | 3 | .006 | 530 (26.0) | 222 (21.2) | 16.0 | 3 | .001 |
| Number of children, N (%) | ||||||||||
| 0 | 18 (6.8) | 110 (3.8) | 96 (4.7) | 32 (3.1) | ||||||
| 1 | 34 (12.9) | 306 (10.7) | 250 (12.2) | 90 (8.6) | ||||||
| 2–3 | 136 (51.5) | 1,596 (55.8) | 1,096 (53.4) | 616 (58.7) | ||||||
| 4 and more | 76 (28.8) | 851 (29.7) | 7.1 | 3 | .07 | 609 (29.7) | 311 (29.7) | 16.2 | 3 | .001 |
| Living arrangement, N (%) | ||||||||||
| Living alone | 62 (23.4) | 608 (21.2) | 468 (22.8) | 194 (18.5) | ||||||
| 1 | 106 (40.0) | 1,197 (41.8) | 861 (41.9) | 431 (41.1) | ||||||
| 2–3 | 39 (14.7) | 440 (15.4) | 306 (14.9) | 171 (16.3) | ||||||
| 4 or more | 58 (21.9) | 620 (21.6) | 0.79 | 3 | .85 | 418 (20.4) | 254 (24.2) | 11.8 | 3 | .01 |
| Years in the United States, N (%) | ||||||||||
| 0–10 | 69 (26.2) | 771 (27.0) | 559 (27.3) | 272 (26.1) | ||||||
| 11–20 | 76 (28.9) | 877 (30.7) | 647 (31.6) | 307 (29.4) | ||||||
| 21–30 | 72 (27.4) | 690 (24.2) | 476 (23.2) | 273 (26.2) | ||||||
| 31 and more | 46 (17.5) | 518 (18.1) | 1.39 | 3 | .71 | 366 (17.9) | 192 (18.4) | 4.0 | 3 | .26 |
| Years in the community, N (%) | ||||||||||
| 0–10 | 153 (58.2) | 1,643 (57.5) | 1,205 (58.9) | 579 (55.2) | ||||||
| 11–20 | 63 (24.0) | 670 (23.4) | 455 (22.2) | 270 (25.7) | ||||||
| 21–30 | 31 (11.8) | 354 (12.4) | 252 (12.3) | 128 (12.2) | ||||||
| 31 and more | 16 (6.1) | 192 (6.7) | 0.26 | 3 | .97 | 135 (6.6) | 72 (6.9) | 5.4 | 3 | .15 |
| Country of origin, N (%) | ||||||||||
| Mainland China | 244 (92.1) | 2,661 (92.9) | 1,898 (92.4) | 982 (93.5) | ||||||
| Others | 21 (7.9) | 205 (7.2) | 0.22 | 1 | .64 | 156 (7.6) | 68 (6.5) | 1.3 | 1 | .25 |
| Overall health status, N (%) | ||||||||||
| Very good | 4 (1.5) | 135 (4.7) | 68 (3.3) | 71 (6.8) | ||||||
| Good | 41 (15.5) | 1,050 (36.6) | 589 (28.7) | 490 (46.7) | ||||||
| Fair | 89 (33.6) | 1,226 (42.8) | 930 (45.3) | 376 (35.8) | ||||||
| Poor | 131 (49.4) | 455 (15.9) | 187.6 | 3 | <.001 | 467 (22.7) | 113 (10.8) | 151.3 | 3 | <.001 |
| Quality of life, N (%) | ||||||||||
| Very good | 8 (3.0) | 208 (7.3) | 110 (5.4) | 105 (10.0) | ||||||
| Good | 66 (24.9) | 1,311 (45.8) | 804 (39.1) | 554 (52.8) | ||||||
| Fair | 167 (63.0) | 1,273 (44.4) | 1,069 (52.0) | 34 (34.7) | ||||||
| Poor | 24 (9.1) | 73 (2.6) | 71.7 | 3 | <.001 | 71 (3.5) | 26 (2.5) | 98.7 | 3 | <.001 |
| Health changes over the last year, N (%) | ||||||||||
| Improved | 28 (10.6) | 246 (8.6) | 190 (9.3) | 82 (7.8) | ||||||
| Same | 63 (23.9) | 1465 (51.1) | 907 (44.2) | 608 (57.9) | ||||||
| Worsened | 173 (65.5) | 1,155 (40.3) | 74.2 | 2 | <.001 | 956 (46.6) | 360 (34.3) | 53.2 | 2 | <.001 |
Note: df = degrees of freedom.
Presence of Symptoms of Anxiety
Table 2 presents the prevalence of each anxiety symptom. Feeling tense or wound up was the most common anxiety symptom (29.7%), followed by having worrying thoughts (26.7%), feeling restless (24.0%), having frightened feeling like butterflies in the stomach (21.4%), having frightened feeling like something awful is about to happen (19.1%), sudden feelings of panic (16.5%), and inability to sit at ease and relax (12.6%).
Table 2.
Presence of Symptoms of Anxiety
| HADS-Anxiety Items | Not at All (%) | Occasionally (%) | A Lot of Time (%) | Most of the Time (%) |
|---|---|---|---|---|
| Tense or “wound up” | 2,201 (70.3) | 760 (24.3) | 132 (4.2) | 40 (1.3) |
| Frightened feeling, something awful is about to happen | 2,531 (80.8) | 377 (12.0) | 173 (5.5) | 51 (1.6) |
| Worrying thoughts go through my mind | 2,259 (73.3) | 58 (18.9) | 162 (5.3) | 81 (2.6) |
| Sit at ease and relaxed | 395 (12.6) | 153 (4.9) | 758 (25.1) | 1,793 (57.4) |
| Frightened feeling like “butterflies” in stomach | 2,458 (78.7) | 524 (16.8) | 85 (2.7) | 58 (1.9) |
| Feel restless as I have to be on the move | 2,370 (75.8) | 431 (13.8) | 242 (7.5) | 85 (2.7) |
| Sudden feelings of panic | 2,610 (83.5) | 290 (9.3) | 174 (5.6) | 53 (1.7) |
Note: HADS = Hospital Anxiety and Depression Scale.
Prevalence of Symptoms of Anxiety by Self-reported Health Status
Table 3 presents anxiety disorders and anxiety symptoms by health status. The prevalence of anxiety disorders and anxiety symptoms increased with poorer health status—older adults with poor health status had the highest prevalence of anxiety disorders (22.4%) and anxiety symptoms (80.5%). Similarly, the presence of anxiety disorders and symptoms was high among those whose health status worsened over the past year (disorders: 13.0%; symptoms: 72.6%). Anxiety disorders and symptoms were reported by a higher percentage of older adults with fair (disorders: 11.6%; symptoms: 74.6%) or poor quality of life (disorders: 24.7%; symptoms: 73.2%) compared with older adults with good or very good quality of life.
Table 3.
Prevalence of Anxiety Disorders by Self-reported Health Status
| Overall Health Status | Very Good (N = 139) | Good (N = 1,091) | Fair (N = 1,315) | Poor (N = 586) | ||||
|---|---|---|---|---|---|---|---|---|
| N (%) | N (%) | N (%) | N (%) | |||||
| Anxiety | Any Symptom | Anxiety | Any Symptom | Anxiety | Any Symptom | Anxiety | Any Symptom | |
| 4 (29) | 68 (48.9) | 41 (3.8) | 589 (54.6) | 89 (6.8) | 930 (71.2) | 131 (22.4) | 467 (80.5) | |
| Quality of Life | Very Good (N = 216) | Good (N = 1,377) | Fair (N = 1,440) | Poor (N = 97) | ||||
| N (%) | N (%) | N (%) | N (%) | |||||
| Anxiety | Any Symptom | Anxiety | Any Symptom | Anxiety | Any Symptom | Anxiety | Any Symptom | |
| 8 (3.7) | 110 (51.2) | 66 (4.8) | 804 (59.2) | 167 (11.6) | 1,069 (74.6) | 24 (24.7) | 71 (73.2) | |
| Health Status Changes Over the Last Year | Improved (N = 274) | Same (N = 1,528) | Worsened (N = 1,328) | |||||
| N (%) | N (%) | N (%) | ||||||
| Anxiety | Any Symptom | Anxiety | Any Symptom | Anxiety | Any Symptom | |||
| 28 (10.2) | 190 (69.9) | 63 (4.1) | 907 (60.0) | 65.5 (13.0) | 956 (72.6) | |||
Correlations Between Anxiety and Demographic, Socioeconomic, Family Structure, and Health-Related Variables
Being female (r = .10, p < .001), lower income (r = .05, p < .01), unmarried (r = .06, p < .001), poorer health status (r = .21, p < .001), lower quality of life (r = .15, p < .001), and worsening health status (r = .14, p < .001) were positively correlated with anxiety disorders.
Being female (r = .14, p < .001), unmarried (r = .07, p < .001), living with fewer people (r = .05, p < .01), having fewer children (r = .04, p < .05), poorer health status (r = .27, p < .001), lower quality of life (r = .22, p < .001), and worsening health status (r = .15, p < .001) were positively correlated with having one or more symptoms of any anxiety.
Discussion
The PINE study represents the first large-scale population-based epidemiological study of anxiety among community-dwelling U.S. Chinese older adults. We found that anxiety was a significant mental health issue among U.S. Chinese older adults, with 8.5% of participants reported anxiety disorders and 65.0% of participants reporting one or more symptoms. Being female, unmarried, poorer health status, lower quality of life, and worsening health over the past year were positively correlated with anxiety disorders and any anxiety symptom. Living with fewer people and having fewer children were correlated with anxiety symptoms only, whereas lower income was only correlated with anxiety disorders.
This study extends current knowledge of anxiety among minority older adults. Our academic-community partnership and community engagement facilitated the design of culturally and linguistically appropriate research methods (23). Due to our community-based participatory research approach, participants may have been more comfortable conversing in their preferred dialects, more trusting of research assistants, and more willing to express emotions and acknowledge their feelings.
Different measurement and sampling methods employed in other studies makes it difficult to make clear comparisons; nevertheless, the prevalence of anxiety disorders among U.S. Chinese older adults found in this study was comparable to that in other aging populations. In a population-based study of 61,349 older participants in Norway using the HADS-A with the same cutoff point, 9.6% of the participants reported having anxiety disorders (24). As for the scope of anxiety symptoms, our finding showed that anxiety symptoms may be higher among U.S. Chinese older adults than older adults in the general population. For example, in a study of 3,041 older adults aged 70–79 years old, 15%–43% reported anxiety symptoms as assessed using the Hopkins Symptom Checklist (25). In another study of 966 persons aged 78 and older, anxiety symptoms were present in 24.4% of participants as assessed with the Comprehensive Psychopathological Rating Scale (26). This may be partly explained by daunting acculturation stress, intensive intergenerational conflicts, and poor coping strategies as results of immigration. It should be noted that we did not have specific age subgroup restriction cutoff points (aged 60 and older) for the assessment of the anxiety symptoms, which could potentially explain the higher prevalence of anxiety symptoms in our sample. Comparisons of our findings with studies among other Chinese populations could achieve a better understanding of cultural influences on the prevalence of anxiety symptoms, but we are impeded by the scarcity of relevant data. Hence, there is a great need for improving our understanding of anxiety symptoms among Chinese older adults.
In accordance with a wide range of prior studies (3,8), this study demonstrates that both anxiety disorders and anxiety symptoms were more prevalent in older women than in older men. Gender differences in anxiety may be explained by various biological and psychosocial factors. Women often assume the role of kin keepers and are more likely to develop confiding relationships with people other than the spouse (27). Given that older women are more embedded in network relationships, they may be more prone to network strains that increase the risk of anxiety symptoms. In addition, as influenced by patriarchal cultural values, Chinese women are socially and economically subordinate to men and may suffer from financial burdens and educational disadvantages that may increase the risk for experiencing anxiety. However, gender differences in prevalence of anxiety should be interpreted with caution due to potential reporting bias. Compared with men, women may be more emotionally expressive and, thereby, may be more likely to disclose anxiety symptoms.
In our study, poor health status was correlated with anxiety disorders and any anxiety symptoms. This lends credence to prior studies that suggest close associations between health status and anxiety (8,24). Lower levels of self-reported health status may give rise to sleep disturbance, fatigue, and pain that may trigger worry and anxiety among older adults. The inverse association between anxiety and health status also raises the possibility that anxiety may cause poorer health status. We postulate that the presence of anxiety may be associated with lower compliance to medical treatments, thus undermining health. In addition, anxiety among our sample of community-dwelling older adults may be related to fears of falling. Such fears of falling may be salient during icy weather in Chicago and prevent older adults from going outside. Their reduced social interaction and physical activity may exacerbate anxiety and affect health status.
This study should be interpreted with limitations. First, our analyses did not consider the effects of comorbid depression, but anxiety symptoms often occur with depressive symptoms among older adults. Future studies may need to distinguish between correlates of pure anxiety symptoms and anxiety comorbid conditions. Second, this study only investigated the prevalence of the anxiety disorders and anxiety-related symptoms among U.S. Chinese older adults and future studies should examine more specific symptoms corresponding with specific anxiety disorders, such as generalized anxiety disorders, social phobia, panic disorders, and obsessive-compulsive disorders. Third, the study did not explore important risk and protective factors such as elder mistreatment and social support of anxiety among U.S. older adults (28). Fourth, we do not have qualitative data to further understand the social and cultural context of anxiety. Last, this study utilized a cross-sectional design, and we could not postulate temporal correlations. Future longitudinal studies should be conducted to better examine risk factors and outcomes associated with anxiety among U.S. Chinese older adults.
Despite these limitations, this study has important research and policy implications. The findings suggest a need for more research to better understand the epidemiology of anxiety among minority older adults. In addition to epidemiologic investigations on prevalence and risk factors of anxiety, concerted efforts should be put into developing evidence-based psychotherapy treatments such as cognitive behavioral therapy for minority older adults. Moreover, health care professionals should improve the detection of anxiety symptoms among Chinese older adults and provide culturally sensitive treatments. In this study, sociodemographic and health-related characteristics were similar among those with disorders and those with any symptoms, emphasizing that special attention should be given to older women, those who are unmarried, with impaired health status, and poorer quality of life.
Furthermore, community organizations should improve awareness on anxiety in Chinese populations. Educational workshops that focus on the knowledge and coping strategies of anxiety may be one way to improve awareness among Chinese older adults. To reduce the access barriers for mental health services, increased efforts should be given to improving home-based mental health care, promoting mental health navigation services and assuring language assistance in clinic-based mental health services.
Conclusion
This study suggested that anxiety is a significant mental health issue among U.S. Chinese older adults. Being female, unmarried, poorer health status, inferior quality of life, and worsening health over the past year were correlated with having anxiety disorders and any symptoms of any anxiety among U.S. Chinese older adults. Future longitudinal studies should explore risk factors and outcomes of anxiety among U.S. Chinese older adults.
Funding
X.D. and M.S. were supported by National Institute on Aging grant (R01 AG042318, R01 MD006173, R01 CA163830, R34MH100443, R34MH100393, P20CA165588, R24MD001650, and RC4 AG039085), Paul B. Beeson Award in Aging, The Starr Foundation, American Federation for Aging Research, John A. Hartford Foundation, and The Atlantic Philanthropies.
Acknowledgment
We are grateful to Community Advisory Board members for their continued effort in this project. Particular thanks are extended to Bernie Wong, Vivian Xu, and Yicklun Mo with the Chinese American Service League (CASL); Dr. David Lee with the Illinois College of Optometry; David Wu with the Pui Tak Center; Dr. Hong Liu with the Midwest Asian Health Association; Dr. Margaret Dolan with John H. Stroger Jr. Hospital; Mary Jane Welch with the Rush University Medical Center; Florence Lei with the CASL Pine Tree Council; Julia Wong with CASL Senior Housing; Dr. Jing Zhang with Asian Human Services; Marta Pereya with the Coalition of Limited English Speaking Elderly; and Mona El-Shamaa with the Asian Health Coalition.
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