Abstract
This study examined the association between anxiety symptoms, depressive symptoms, and Traditional Chinese Medicine (TCM) use among U.S. Chinese older adults. Data was obtained from the Population Study of Chinese Elderly in Chicago (N = 3157; mean age = 72.8). Anxiety symptoms were assessed with the Hospital Anxiety and Depression Scale (HADS-A). Depressive symptoms were assessed with the Patient Health Questionnaire (PHQ-9). TCM modalities included herbal products, acupuncture, massage therapy, Taichi, and other types of TCM. Although not significant, there was a trend indicating that higher levels of anxiety symptoms showed a higher rate of acupuncture use and massage therapy. Older Chinese Americans with depressive symptoms were more likely to use acupuncture and massage therapy; and they were less likely to use other TCM. Future research is needed to identify reasons for TCM use; and how these factors mediate or moderate the relationship between psychiatric symptoms and TCM use.
Keywords: Traditional Chinese medicine, Anxiety, Depression, Chinese older adults
Introduction
Anxiety and depression are common mental health concerns among older adults. The presence of anxiety and depression can lead to impaired health-related quality of life, can worsen physical, emotional, social, and cognitive function, and can significantly increase mortality rates and medical costs [1, 2]. Over the past few years, Asian Americans have the fastest growth rate of any major racial or ethnic group. A national epidemiologic study reported that the 12-month prevalence of mental disorders for Asian Americans was 23.6% [3]. Chinese Americans represent the largest Asian ethnic sub-group within the United States (U.S.) [4]. A National Latino and Asian American Study (NLAAS) reported that Chinese Americans (11.5%) suffered the highest lifetime prevalence of anxiety and depression, compared to Filipino (10.3%), Vietnamese (8.1%), and other Asian groups (10.0%) [5]. According to the stress process framework [6], migration is a stressor which may lead to psychological distress. However, Asian Americans have a lower rate of utilization of mental health services compared to other ethnic groups [7]. Many U.S. Chinese older adults are foreign-born with low acculturation levels [8], and may tend to delay seeking mental health services due to language barriers, the stigma associated with mental health, high service costs, and access to health care [9]. Complementary and Alternative Medicine (CAM) has been suggested as a reason for this group delaying or underutilizing access to Western psychiatric services [10].
Traditional Chinese Medicine (TCM) is a widely recognized CAM. TCM practice has different modalities, including acupuncture, moxibustion, Chinese herbal medicine, Tui Na (Chinese therapeutic massage), dietary therapy, and Taichi [11]. TCM, stems from Confucianism, Buddhism, and Daoism, emphasizing the unity of heaven and humanity [10], applying these underlying concepts to maintain health. For instance, according to Chinese philosophy, the principle of yin (hypo-) and yang (hyper-) is that there are two opposing complementary forces found within the human body and emotion. It is thought that disease can occur when these two forces are at an imbalance. Qi is considered as the energy flow, fluid, or hormone circulation of the body that performs multiple functions. A person may become sick or ill when the Qi in a specific organ or body system is attacked by a pathogen. TCM practitioners have applied these concepts to the prevention, diagnosis, and treatment for physical and mental illnesses [10, 11].
Many older adults use CAM for health maintenance. A U.S. national study reported that 27.7% of older adults and 48.6% of Asian older adults had used CAM for health maintenance within the last year [12]. Other than for the treatment of back or neck problems, the use of CAM was more commonly found among people with anxiety and depression than among those with any other chronic conditions [13, 14]. CAM use is influenced by individual preference and through the recommendation of family members, friends, or healthcare providers. Also, cultural norms within different ethnic groups play a crucial role in individual preference. For instance, TCM is often used as an alternative treatment by Chinese Americans [15]. However, many U.S. studies focus on CAM overall, rather than the subgroup of CAM known as TCM. As such, the utilization of TCM toward psychological well-being among Chinese older adults in the U.S. is not well understood.
A prevalent view exists among the Chinese that TCM treats the fundamental cause of illness via traditional holistic conceptions of health while Western medicine treats symptomatology based on anatomical knowledge of disease [10, 16]. However, Chinese Americans may change their attitudes toward TCM use after exposure to U.S. culture and Western biomedicine. As the Chinese American population is growing and aging rapidly [17], it is important to understand TCM use for psychological well-being within this specific population because its associations may be different from both Chinese populations in China and Western populations due to factors related to immigration. Therefore, we used a large, population-based sample to examine the association between anxiety symptoms, depressive symptoms, and TCM use among community-dwelling U.S. Chinese older adults. The specific aims are to: (1) examine the frequency of different subtypes of TCM usage across the severity of anxiety symptoms and depressive symptoms; and (2) examine the association of anxiety symptoms, depressive symptoms, and different types of TCM use. This study allowed us to test our hypothesis that anxiety symptoms and depressive symptoms are strongly associated with TCM use among U.S. Chinese older adults.
Methods
Population and Settings
The study was a secondary data analysis from the Population Study of Chinese Elderly in Chicago (PINE), a community-engaged, population-based epidemiological study of U.S. Chinese older adults aged 60 and older in the Greater Chicago area. The PINE study is a random block census project based on the data from the 2010 U.S. Census. Culturally appropriate community recruitment strategies, guided by community-based participatory research approaches, were utilized to collect community data of Chinese older adults in an effort to examine the key cultural determinants of health and well-being [18]. Trained bicultural and bilingual research assistants conducted face-to-face home interviews in each participant’s preferred language, including English, Mandarin, Cantonese, and other dialects of Chinese (i.e., Taishanese, and Teochew). Out of 3542 eligible participants, 3159 agreed to participate in the study (response rate of 91.9%) [19]. The study was approved by the Institutional Review Board at the Rush University Medical Center.
Measures
Dependent Variables
The utilization of TCM was assessed by asking participants the question “How many times per year do you use…?” during the previous year. Responses were given on a 5-point Likert scale (0 = none, 1 = at least once in the previous year, 2 = at least once a month, 3 = at least once a week, 4 = at least once a day). Eight subtypes of TCM were assessed, including prescribed herbal products, over-the-counter herbal products, prescribed herbal topical, over-the-counter herbal topical, acupuncture, massage therapy, Taichi, and other types of TCM (e.g. qigong, cupping, and other forms of unspecified exercise) [15]. For this paper, we are including the first four subtypes of TCM into one overall herbal type. Hence, the original eight subtypes of TCM in the assessment have been grouped into five modalities: herbal, acupuncture, massage therapy, Taichi, and other types of TCM. Next, we categorized each TCM modality into the dichotomized variable as “no use” and “any use.”
Independent Variables
Anxiety Symptoms
The anxiety subscale from the Hospital Anxiety and Depression Scale (HADS-A) was used to assess the presence of anxiety among Chinese older adults. Participants were asked if they currently experienced anxiety symptoms, including (a) felt tense or wound up, (b) had a frightened feeling as if something awful is about to happen, (c) had worrying thoughts, (d) cannot sit at ease and feel relaxed, (e) had a frightened feeling like butterflies in the stomach, (f) had feelings of restless, or (g) had feelings of panic. Responses to each item was on a 4-point scale ranging from 0 (not at all) to 3 (most of the time) [2]. A total score ranges from 0 to 21, with a higher score indicating more anxiety symptoms. The reliability of the HADS-A in the PINE study was excellent (Cronbach’s alpha = .80) [2]. The severity of anxiety symptoms in this paper was categorized into four levels according to their score: No anxiety (0–7), mild anxiety (8–10), moderate anxiety (11–14), and severe anxiety (15–21).
Depressive Symptoms
Depressive symptoms were assessed with the 9-item Patient Health Questionnaire (PHQ-9). Participants were asked how often they have been bothered by the following depressive symptoms in the last 2 weeks: (a) changes in sleep; (b) changes in appetite; (c) fatigue; (d) feelings of sadness or irritability; (e) loss of interest in activities; (f) inability to experience pleasure, feelings of guilt, or worthlessness; (g) inability to concentrate or make decisions; (h) feeling restless or slowed down; and (i) suicidal thoughts. Responses were given on a 4-point scale (0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day). The total score ranges from 0 to 27, with a higher score indicating more depressive symptoms [20]. The reliability of PHQ-9 in the PINE study had good validity and excellent reliability (Cronbach’s alpha = .82) [21]. The severity of depressive symptoms in this paper was categorized into four levels according to their score: No depression (0), Minimal depression (1–4), mild depression (5–9), and moderate to severe depression (10–27).
Covariates
Covariates include age, gender, education level (years), annual income (< $5000, $5000–10,000, > $10,000), marital status (married, not married), household composition (with 1 person, with 2–3 persons, with ≥ 4 persons), the number of children, the number of years in the U.S., the number of years in the neighborhood in which they reside, and acculturation.
Data Analysis
Descriptive statistics were used to examine the frequency of anxiety symptoms and depressive symptoms across the use of different types of TCM modalities. The prevalence of each TCM modality was calculated. Chi square tests were used to compare the severity of anxiety symptoms and severity of depressive symptoms between the groups, with any TCM use and no TCM use across the different modalities of TCM. To examine the association of anxiety symptoms, depressive symptoms, and each modality of TCM use, multivariate logistic regression models were used to control for potential confounding variables. Anxiety symptoms and depressive symptoms were treated first as continuous variables. Then, anxiety symptoms and depressive symptoms were treated as categorical variables. No anxiety symptoms and no depressive symptoms were used as a reference group. The models used for analysis adjusted for age, gender, education, income, marital status, household composition, the number of children, years in the U.S., years in the community, and acculturation. Odds ratios (ORs), 95% confidence intervals (CIs), and significance levels were reported. All statistical analyses were conducted using SAS, Version 9.2 (SAS Institute Inc., Cary, North Carolina).
Results
Sample Characteristics
Of the 3157 participants, participants had a mean age of 72.8 years (SD = 8.3, range = 60–105). Among the participants, 58.9% were female, 78.9% had at least a high school education, and 85.1% had an annual income below US$10,000. 71.3% were married, and 55.6% had three or more children. 73.7% had been in the U.S for more than 10 years and 42.5% had been in the community for more than 10 years [18, 22]. 65% of older adults reported experiencing any anxiety symptoms [2]; and about 54.4% reported any depressive symptoms [1]. Over three-fourths (76%) of the participants reported any use of TCM within the past year [15]. Sociodemographic characteristics of the PINE study participants for TCM use were reported in the previous studies [15, 17].
Frequencies of Anxiety Symptoms and Depressive Symptoms According to TCM Use
For those with moderate or severe anxiety symptoms, overall TCM users, herbal products users, acupuncture users, massage therapy users, and Taichi users were more than non-users. There were no significant differences of TCM use across different levels of anxiety symptoms (Table 1). For those with mild depressive symptoms, acupuncture users and massage therapy users were more than non-users. For those with moderate/severe depressive symptoms, herbal product users, acupuncture users, massage therapy users, and Taichi users were more than non-users. There were significant differences between the severity of depressive symptoms with acupuncture use (p < .01) and other TCM use (p < .001) (Table 2).
Table 1.
Frequency of severity of anxiety symptoms by TCM use, N (%)
| Anxiety symptoms |
p value | ||||
|---|---|---|---|---|---|
| No anxiety (N = 2863) | Mild anxiety (N = 145) | Moderate anxiety (N = 85) | Severe anxiety (N = 35) | ||
|
| |||||
| Overall TCM | |||||
| No use (N = 739) | 690 (93.37) | 30 (4.06) | 12 (1.62) | 7 (0.95) | 0.14 |
| Any use (N = 2389) | 2174 (90.96) | 115 (4.81) | 73 (3.05) | 28 (1.17) | |
| Herbal products | |||||
| No use (N = 1239) | 1152 (92.98) | 48 (3.87) | 29 (2.34) | 10 (0.81) | 0.12 |
| Any use (N = 1888) | 1711 (90.58) | 97 (5.13) | 56 (2.96) | 25 (1.32) | |
| Acupuncture | |||||
| No use (N = 2757) | 2530 (91.73) | 130 (4.71) | 71 (2.57) | 27 (0.98) | 0.10 |
| Any use (N = 371) | 334 (90.03) | 15 (4.04) | 14 (3.77) | 8 (2.16) | |
| Massage therapy | |||||
| No use (N = 2739) | 2518 (91.90) | 123 (4.49) | 71 (2.59) | 28 (1.02) | 0.22 |
| Any use (N = 389) | 346 (88.95) | 22 (5.66) | 14 (3.60) | 7 (1.80) | |
| Tai Chi | |||||
| No use (N = 2737) | 2510 (91.67) | 125 (4.57) | 74 (2.70) | 29 (1.06) | 0.81 |
| Any use (N = 391) | 354 (90.54) | 20 (5.12) | 11 (2.81) | 6 (1.53) | |
| Other TCM | |||||
| No use (N = 2394) | 2180 (91.02) | 117 (4.89) | 69 (2.88) | 29 (1.21) | 0.32 |
| Any use (N = 734) | 684 (93.19) | 28 (3.81) | 16 (2.18) | 6 (0.82) | |
Table 2.
Frequency of severity of depressive symptoms by TCM use, N (%)
| Depressive symptoms |
p value | ||||
|---|---|---|---|---|---|
| No depression (N = 1422) | Minimal depression (N = 1077) | Mild depression (N = 383) | Moderate/severe depression (N = 256) | ||
|
| |||||
| Overall TCM | |||||
| No use (N = 744) | 324 (43.55) | 246 (33.06) | 107 (14.38) | 67 (9.01) | 0.12 |
| Any use (N = 2394) | 1099 (45.89) | 831 (34.70) | 276 (11.52) | 189 (7.89) | |
| Herbal products | |||||
| No use (N = 1243) | 572 (46.02) | 411 (33.07) | 162 (13.03) | 98 (7.88) | 0.48 |
| Any use (N = 1894) | 851 (44.91) | 665 (35.09) | 221 (11.66) | 158 (8.34) | |
| Acupuncture | |||||
| No use (N = 2767) | 1264 (45.66) | 966 (34.90) | 318 (11.49) | 220 (7.95) | 0.003** |
| Any use (N = 371) | 159 (42.86) | 111 (29.92) | 65 (17.52) | 36 (9.70) | |
| Massage therapy | |||||
| No use (N = 2750) | 1264 (45.95) | 945 (34.35) | 324 (11.78) | 218 (7.92) | 0.09 |
| Any use (N = 388) | 159 (40.98) | 132 (34.02) | 59 (15.21) | 38 (9.79) | |
| Tai Chi | |||||
| No use (N = 2746) | 1238 (45.07) | 948 (34.51) | 338 (12.30) | 223 (8.12) | 0.84 |
| Any use (N = 392) | 185 (47.19) | 129 (32.91) | 45 (11.48) | 33 (8.42) | |
| Other TCM | |||||
| No use (N = 2404) | 1058 (43.99) | 808 (33.60) | 320 (13.31) | 219 (9.11) | < .0001*** |
| Any use (N = 734) | 365 (49.73) | 269 (36.65) | 63 (8.58) | 37 (5.04) | |
p< 0.05
p< 0.01
p< 0.001
Association Between Presence of Anxiety Symptoms, Depressive Symptoms, and TCM Use
After controlling for covariates, compared to no anxiety symptoms, there was a trend indicating that higher levels of anxiety symptoms showed a higher rate of acupuncture use and massage therapy. However, the severity of anxiety symptoms was not significantly associated with any modalities of TCM use (Table 3). Compared to no depressive symptoms, Chinese older adults with mild depressive symptoms were 65% more likely to use acupuncture [odds ratio (OR) 1.65, p < .01] and 40% more likely to use massage therapy (OR 1.40, p < .05) than no use at all (Table 4).
Table 3.
Association between severity of anxiety symptoms and TCM use
| Outcome: TCM use, OR (95% CI) | ||||||
|---|---|---|---|---|---|---|
| Overall TCM | Herbal products | Acupuncture | Massage therapy | Tai chi | Other TCM | |
|
| ||||||
| Age | 0.99 (0.98, 1.00)* | 0.98 (0.97, 0.99)*** | 0.98 (0.96, 0.99)** | 1.01 (0.99, 1.03) | 1.02 (1.00, 1.03) | 1.01 (0.99, 1.02) |
| Gender | 1.51 (1.25, 1.81)*** | 1.16 (0.99, 1.37) | 1.65 (1.28, 2.11)*** | 1.28 (1.00, 1.64)* | 1.34 (1.05, 1.71)* | 1.29 (1.07, 1.55)** |
| Education | 1.00 (0.98, 1.02) | 0.96 (0.95, 0.98)*** | 1.01 (0.98, 1.03) | 1.01 (0.98, 1.03) | 1.12 (1.09, 1.15)*** | 1.02 (1.00, 1.04) |
| Income | 0.95 (0.88, 1.03) | 0.96 (0.89, 1.03) | 0.94 (0.84, 0.25) | 0.95 (0.85, 1.06) | 0.88 (0.79, 0.98) | 0.97 (0.89, 1.05) |
| Married status | 1.00 (0.81, 1.25) | 0.94 (0.77, 1.14) | 0.91 (0.69, 1.19) | 0.66 (0.50, 0.86)** | 0.80 (0.61, 1.06) | 1.02 (0.82, 1.27) |
| Household composition | 1.00 (0.95, 1.05) | 1.00 (0.96, 1.05) | 1.00 (0.94, 1.07) | 0.97 (0.91, 1.04) | 0.98 (0.92, 1.05) | 0.94 (0.90, 0.99)* |
| Children | 1.02 (0.96, 1.08) | 1.06 (1.01, 1.13)* | 0.99 (0.91, 1.08) | 0.91 (0.84, 0.98)* | 0.99 (0.91, 1.08) | 0.94 (0.88, 1.00)* |
| Years in the U.S. | 0.99 (0.98, 0.99)** | 0.99 (0.98, 1.00)* | 1.00 (0.99, 1.01) | 1.00 (0.99, 1.01) | 0.98 (0.97, 0.99)** | 0.99 (0.98, 1.01) |
| Year in community | 1.01 (1.00, 1.02)* | 1.02 (1.01, 1.03)*** | 1.02 (1.00, 1.03)** | 1.02 (1.01, 1.03)** | 1.01 (0.99, 1.02) | 0.98 (0.97, 0.99)** |
| Acculturation | 0.99 (0.97, 1.01) | 0.96 (0.94, 0.98)*** | 1.01 (0.98, 1.03) | 1.01 (0.99, 1.04) | 1.05 (1.02, 1.07)*** | 1.02 (1.00, 1.04)* |
| Mild anxiety | 1.14 (0.75, 1.75) | 1.27 (0.88, 1.83) | 0.83 (0.48, 1.44) | 1.16 (0.72, 1.89) | 1.16 (0.70, 1.92) | 0.74 (0.48, 1.13) |
| Moderate anxiety | 1.77 (0.95, 3.29) | 1.23 (0.77, 1.97) | 1.34 (0.74, 2.42) | 1.32 (0.73, 2.40) | 1.06 (0.54, 2.05) | 0.70 (0.40, 1.23) |
| Severe anxiety | 1.08 (0.47, 2.49) | 1.52 (0.72, 3.22) | 1.96 (0.88, 4.42) | 1.69 (0.72, 3.95) | 1.34 (0.54, 3.35) | 0.58 (0.24, 1.42) |
Anxiety symptoms were categorical variables. No Anxiety symptoms were reference group. Model adjusted age, gender, education, income, married status, household composition, number of children, years in the U.S., and years in community OR odds ratio, CI confidence interval
OR odds ratio, CI confidence interval
p < 0.05
p < 0.01
p < 0.001
Table 4.
Association between severity of depressive symptoms, and TCM use
| Outcome: TCM use, OR (95% CI) | ||||||
|---|---|---|---|---|---|---|
| Overall TCM | Herbal products | Acupuncture | Massage therapy | Tai chi | Other TCM | |
|
| ||||||
| Age | 0.99 (0.98, 1.00) | 0.98 (0.97, 0.99)*** | 0.97 (0.96, 0.99)** | 1.01 (0.99, 1.03) | 1.02 (1.00, 1.03)* | 1.01 (1.00, 1.02) |
| Gender | 1.55 (1.29, 1.86)*** | 1.17 (0.99, 1.38) | 1.63 (1.27, 2.09)*** | 1.26 (0.99, 1.62) | 1.38 (1.08, 1.75)* | 1.33 (1.10, 1.61)** |
| Education | 1.00 (0.98, 1.02) | 0.97 (0.95, 0.98)*** | 1.01 (0.98, 1.03) | 1.01 (0.98, 1.03) | 1.12 (1.09, 1.15)*** | 1.02 (1.00, 1.04)* |
| Income | 0.95 (0.88, 1.02) | 0.96 (0.89, 1.03) | 0.94 (0.85, 1.05) | 0.95 (0.86, 1.06) | 0.87 (0.78, 0.97)* | 0.96 (0.88, 1.04) |
| Married status | 0.98 (0.78, 1.21) | 0.92 (0.76, 1.12) | 0.92 (0.70, 1.21) | 0.66 (0.50, 0.85)** | 0.80 (0.61, 1.06) | 1.01 (0.81, 1.26) |
| Household composition | 1.00 (0.95, 1.05) | 1.00 (0.96, 1.04) | 1.00 (0.94, 1.07) | 0.97 (0.91, 1.04) | 0.98 (0.92, 1.05) | 0.94 (0.90, 0.99)* |
| Children | 1.01 (0.95, 1.07) | 1.07 (1.00, 1.12)* | 0.99 (0.91, 1.08) | 0.90 (0.83, 0.98)* | 0.98 (0.89, 1.07) | 0.93 (0.87, 0.99)* |
| Years in the U.S. | 0.99 (0.98, 0.99)** | 0.99 (0.98, 1.00)* | 1.00 (0.99, 1.01) | 1.00 (0.99, 1.01) | 0.98 (0.97, 0.99)** | 1.00 (0.99, 1.01) |
| Year in community | 1.01 (1.00, 1.02)* | 1.02 (1.01, 1.03)*** | 1.02 (1.01, 1.03)** | 1.02 (1.01, 1.03)** | 1.01 (0.99, 1.02) | 0.98 (0.97, 0.99)** |
| Acculturation | 0.99 (0.97, 1.01) | 0.96 (0.94, 0.98)*** | 1.00 (0.98, 1.03) | 1.01 (0.99, 1.03) | 1.04 (1.02, 1.06)*** | 1.02 (1.00, 1.04)* |
| Minimal depression | 0.96 (0.79, 1.17) | 1.10 (0.93, 1.30) | 0.90 (0.69, 1.17) | 1.09 (0.85, 1.41) | 0.87 (0.68, 1.12) | 0.91 (0.76, 1.10) |
| Mild depression | 0.72 (0.55, 0.94)* | 0.93 (0.73, 1.18) | 1.65 (1.20, 2.27)** | 1.40 (1.00, 1.95)* | 0.84 (0.58, 1.20) | 0.51 (0.38, 0.70)*** |
| Moderate/severe depression | 0.76 (0.56, 1.04) | 1.04 (0.78, 1.38) | 1.30 (0.87, 1.94) | 1.26 (0.85, 1.86) | 0.93 (0.62, 1.41) | 0.46 (0.31, 0.67)*** |
Depressive symptoms were categorical variables. No no depressive symptoms were reference group. Model adjusted age, gender, education, income, married status, household composition, number of children, years in the U.S., and years in community
OR odds ratio, CI confidence interval
p < 0.05
p < 0.01
p < 0.001
Discussion
To our knowledge, this study is the largest to examine the association between anxiety symptoms, depressive symptoms, and TCM use among U.S. Chinese older adults. Acupuncture and massage therapy have beneficial effects in relieving anxiety and depressive symptoms [23, 24]. Our findings showed that acupuncture and massage therapy were significantly associated with depressive symptoms, but not anxiety symptoms. The potential reason for the demand for acupuncture and massage therapy could be due to the somatic symptoms. Somatization is the expression of psychological distress as physical (somatic) symptoms, such as pain, fatigue, tiredness, and gastrointestinal complaints. Somatization in depressive patients tends to be in chronic nature that requires more treatment; whereas, somatization in anxiety patients tend to decrease with less treatment [25]. Older adults are active consumers of over-the-counter agents and prescription medications. Chinese herbal products are perceived as safe, causing fewer side effects and less dependency. Since Western medication causes various adverse events, the number of people who use herbs to benefit their health and psychiatric problems is increasing [26]. However, our study did not show significant findings of herbal product use among Chinese older adults with anxiety symptoms and depressive symptoms. One possible explanation may be related to health literacy levels. Our participants had relatively high Chinese health literacy levels [27]; but, our study did not indicate if our participants had an understanding of the applications of herbal products. Also, the linguistic barrier of reading English product labels may decrease older Chinese Americans’ desire to use the over-the-counter herbal products. Other reasons included an individual’s beliefs about the benefits and efficacy of herbal regimen for mood disorders [10, 28] as well as not having access to herbal products.
Our results revealed that Chinese older adults with anxiety symptoms or depressive symptoms tend to use acupuncture and massage therapy, but not other TCM modalities. We believe our study can be explained by the following reasons. First, Chinese older adults tend to report somatic symptoms (e.g. insomnia, bodily pain, dizziness, and fatigue) rather than psychological symptoms [29]. Chinese older adults may use TCM for physical illness (e.g. musculoskeletal symptoms [30] or cancer prevention [17]); but not for mental illness. A national survey of Chinese Americans for TCM use reported that Chinese Americans view psychiatric conditions as being different from physical disorders, with psychiatric illness less treatable when compared with physical illness [10]. Hence, our findings should be carefully explained because those Chinese older adults who seek acupuncture and massage therapy may be due to musculoskeletal symptoms (i.e., stiffness, back pain, redness of joins), insomnia, or other disease-related symptoms, rather than anxiety symptoms or/and depressive symptoms. Second, U.S. Chinese older adults’ perspectives of seeking TCM treatment for psychiatric illness may decrease with being more acculturated to Western Medicine. Our findings can be supported by the previous study that Chinese older adults who had lived in the U.S. more than 10 years used less complementary medical services [31], as 73.7% of our participants had been in the U.S for more than 10 years [22]. In addition, another study found that U.S.-born Chinese individuals reported a perceived lower efficacy of TCM treatment for psychiatric conditions than their foreign-born counterparts, in part because U.S.-born Chinese’s perspectives on treatment were more consistent with Western mental health professionals [10]. Other issues related to TCM use for mental health in current practice could be inferred from the previous studies of CAM use. For example, a lack of effective communication between patients and healthcare providers. Many older adults use CAM in health self-management; however, they do not disclose the CAM use to their physicians [32]. In addition, clinicians often do not ask their patients about CAM use because they may lack knowledge, confidence, and training to provide proper guidance for CAM users [33]. As such, issues of safety and efficacy of TCM use can be a public health problem because it may cause delayed treatment, disease complications, and even death.
Limitations
There are several limitations in this study. First, this study only examined the Chinese older adults living in the Greater Chicago area. The availability of TCM practitioners or access to mental health care can be varied in different geographic regions. Thus, our findings could not be generalizable to Chinese older adults residing in different areas. Second, this study utilized a cross-sectional design to examine the associations between anxiety symptoms, depressive symptoms, and TCM use. Hence, we could not postulate on the potential causal relationships. Future studies are needed to evaluate the effectiveness of TCM use on psychological well-being. Third, this study is based on quantitative data, which restricted the available information. Future qualitative studies should be conducted to explore the experience of TCM use and how TCM beliefs change with acculturation, immigration, or modernization for psychiatric conditions among older Chinese Americans.
Implications
TCM is useful and culturally relevant to Chinese older adults. Chinese older adults may use some types of TCM; but, they may not disclose the use of TCM to clinicians. Hence, clinicians should be sensitive to the magnitude of older adults’ use of herbs and herbal formulas in combination with Western medicine and be prepared to advise patients for the side effects of medications and potential drug interactions. On the other hand, Chinese Americans may perceive it as less shameful to utilize TCM rather than Western psychiatric services for mental disorders [28]. Hence, clinicians are suggested to understand patients’ health beliefs associated with their health concerns in order to provide culturally patient-centered care. Factors such as immigration status and generation status could impact TCM use for psychiatric conditions. Future research is needed to identify reasons for TCM use or lack of use, and how these factors mediate or moderate the relationship between psychiatric symptoms and TCM use.
Conclusion
Our results showed that Chinese older adults with anxiety symptoms or depressive symptoms tended to use acupuncture and massage therapy, but not other TCM modalities. Further studies should be conducted to identify reasons of TCM use or lack of use for psychiatric conditions in Chinese older adults within the U.S. In addition, future research is needed to understand how this population differs from other ethnicities for TCM use. Altogether, we will have a better understanding of TCM use in psychiatric conditions and could further improve culturally patient-centered care for this population.
Acknowledgements
We thank the study participants and staff of the Chinese Health, Aging, and Policy Program (CHAPP), Rush Institute for Healthy Aging. Dr. XinQi Dong was supported by National Institute on Aging Grants (Grant Nos. R01 AG042318, R01 MD006173, R01 AG11101, and RC4 AG039085), Paul B. Beeson Award in Aging (Grant No. K23 AG030944), the Starr Foundation, American Federation for Aging Research, John A. Hartford Foundation, and the Atlantic Philanthropies.
Footnotes
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no competing interests.
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