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Drug use and suicidality among Asian American women who are children of immigrants

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Official websites use. Share sensitive information only on official, secure websites. Logistic regression models identified that a history of hard drug use alone or in combination with soft drug use has a significant association with both suicidal ideation and suicide attempts among Asian American women, adjusting for demographic covariates, history of psychiatric diagnosis, and family communication. These findings highlight the importance of addressing hard drug use when designing suicide prevention programs for Asian American women. Keywords: Asian Americans, Asian American women, API women, suicidal ideation, suicide attempt, suicidality comorbidity, mental health, substance use, drug use. A mental health crisis exists among young Asian American women in the United States. Asian American women aged had an alarming increase in suicide mortality rate, rising from 2. However, rates of completed suicide among Asian American women aged rose the most rapidly of all races and both sexes in the same age group, increasing by Native American women had the second largest increase Among Asian Americans as a group, Asian American women who were born in the United States showed a higher prevalence of suicidal ideation and suicide attempts In addition, progress has been made in understanding risk factors associated with suicidal behaviors among Asian Americans in general Cheng et al. Because gender has been included in these studies as a covariate or used as a demographic factor to represent a segment of the Asian American population, it is still uncertain how relevant these risk factors among the general Asian American population are for understanding suicidal behaviors specifically among young Asian American women who are children of immigrants. Thus, this study will fill the gap in the literature by focusing on young Asian American women and examining the specific risk factors for both suicidal ideation and suicide attempts among this subgroup. Although no study has directly tested the factors associated with suicidal behaviors among Asian American women who are children of immigrants, several reasons have been offered to describe why these women are particularly vulnerable to poor mental health functioning. Poor family communication stems from differential cultural gender role expectations between parents and daughters Rumbaut, In addition to the communication problems rooted in cultural gender norms, Asian American women also face communication problems with their parents due to language barriers. These language barriers can strain the parent-child relationship by limiting the development of a deep connection, articulation of emotions, and cultivation of mutual understanding of each other's differences in values Lee, Second, high suicide rates among Asian American women who are children of immigrants may be strongly associated with existing psychiatric illness or untreated mental disorders among this subgroup. A third factor that may be associated with suicidal behavior among young Asian American women is substance use and abuse. Asian American children of immigrants have significantly higher substance use rates compared to the rates of first-generation Asian American immigrants Gfroerer, ; Takeuchi et al. For instance, the prevalence of Diagnostic and Statistical Manual of Mental Disorders fourth edition alcohol abuse among young Asian American women aged rose significantly from 0. Based on the Treatment Episode Dataset, the average age for Asian American substance abuse treatment admission for marijuana was In fact, overwhelming evidence shows that the most important set of risk factors for completed and attempted suicide among young people in the general population is psychiatric illness and substance abuse Brent, However, the association between substance use and suicidal behaviors among Asian Americans has not been a focus of study in existing literature. Thus, our current study aims to elucidate the link between substance use and suicidal behaviors among Asian American women who are children of immigrants. In answering this question, we focused on both soft and hard drugs and excluded alcohol use see Study Limitations for further explanation. In answering this question, we controlled for factors that have been found in previous studies to be associated with suicidality among both the general population and Asian Americans. Studies focusing on the general population overwhelmingly indicate that the co-occurrence of psychiatric disorders and substance use is linked to attempted suicide Borges et al. According to the National Institute on Drug Abuse NIDA research report in , a person diagnosed with a substance use disorder is twice as likely to have a comorbid mental disorder as a person without a substance use disorder. Comorbidity between substance use disorders and mental disorders does not assume a simple causal relationship: drug abuse could lead to mental illness, and, conversely, mental illness could lead to drug abuse NIDA, However, both disorders could be linked to similar risk factors, making causality difficult to determine. We also controlled for level of family communication. As indicated earlier, research has identified that poor family communication driven by intergenerational conflicts, emotional disconnection, and gaps in English proficiency between children and parents contributes to poor mental health among Asian American women who are children of immigrants. Another study found that Asian American youths who experience high levels of intergenerational conflict had a fold increased risk for suicidal ideation and self-harm Lau et al. These findings indicate that family communication is an important confounder in the association between suicidality and history of psychiatric diagnosis. Thus, controlling for a history of psychiatric diagnosis and level of family communication is critical for understanding the independent roles of both soft and hard drug use in suicidality among Asian American women. Finally, we also controlled for country of birth. The rationale for controlling for country of birth is because Duldulao and colleagues found that being foreign born was a protective factor in association with suicidality, particularly among the Asian American women. Specifically, we examined if either history of hard drug use alone or history of hard drug use combined with soft drug use such as tobacco or marijuana was associated with suicidal ideation and suicide attempts in these women's lifetime. The present study seeks to make a unique contribution in documenting the role of substance use in suicidal ideation and suicide attempts among young Asian American women who are children of immigrants, which may aid in designing effective suicide interventions for this high-risk population. In addition, these ethnic groups are among the five most prevalent Asian ethnic populations in the study's location, Massachusetts. Among Asians in Massachusetts in , Japanese women were excluded from the study because of their small population size compared to other Asian racial groups. In , Japanese individuals counted for only 1. To be eligible for the study, each participant had to be: 1 a single unmarried woman; 2 between ages years; 3 self-identified as Chinese, Vietnamese, Korean, or a mix of these ethnicities; 4 a child of immigrants 1. Special efforts were made to achieve a diversity in socioeconomic status SES and a balance between 1. AWSHIP also made efforts to obtain a balanced sample of both current college students and women in the community. Community samples were recruited from 20 community resources, including various health centers, community centers, and ethnic supermarkets. We recognize that college samples may have higher SES than community samples, which potentially plays a role in mental health differences between the two samples National Commission on Asian American and Pacific Islander Research in Education, Thus, an analysis was conducted to identify if there were significant differences between our college sample those who were currently in college versus our community sample those who were currently not in college in the predictors and outcomes not shown in the tables. There was no statistically significant difference between the college and community samples in prevalence of suicidal ideation, suicide attempt, drug use, or other predictors including history of psychiatric diagnosis. Even though we targeted children of immigrants whose language of choice would be predominantly English, the majority of our outreach workers were bilingual and bicultural Chinese, Korean, and Vietnamese women. Participants were free to choose a convenient interview location, such as the research institution, community-based sites, libraries, coffee shops, or the participant's home. A total of 12 translators and back translators 2 translators and 2 back translators each for Chinese, Korean, and Vietnamese developed consent forms and CASI survey questions for each of the designated Asian languages, thus making the survey available in five different languages English, traditional and simplified Chinese, Korean, and Vietnamese to accommodate potential language barriers. Lifetime Suicidal Ideation was ascertained by asking how many times the participant had ever seriously thought about committing suicide, and lifetime suicide attempt was measured by asking how many times the participant had ever actually attempted to commit suicide. Age at the time of the interview was categorized into 2 groups: 1 18 to 27 years and 2 28 to 35 years. Country of birth was coded as dichotomous variables: US born second generation versus foreign-born 1. Ethnicity was categorized as Chinese, Korean, Vietnamese, or Other, which indicated a mix of any of these ethnicities. History of psychiatric diagnosis was measured by asking if the participant had ever been diagnosed with a psychiatric disorder by a psychiatrist or psychologist. High reliability of the family communication scale was indicated by a Cronbach's coefficient alpha of 0. These 10 questions were added up to a maximum score of 50 and divided into three levels of family communication: low, medium, and high. Scores between 31 and 50 indicated a high level of communication within the family, scores between 21 and 30 indicated a medium level, and scores below 21 indicated a low level of family communication. History of cigarette use was coded Yes if the participant had ever smoked an entire cigarette; otherwise, the answer was coded No. Previous studies have used a similar measure for cigarette use Lerman et al. History of marijuana use was coded Yes if the participant had ever used marijuana; otherwise, No was the coded answer. History of hard drug use was coded Yes if the participant had ever used prescription medicines that had not been prescribed to her or any illegal drugs except for marijuana , including crystal meth, cocaine, LSD, phencyclidine, ecstasy, mushrooms, inhalants, ice, and heroin. No substance use was coded Yes if the participant reported never using any type of the above substances including cigarettes, marijuana, or hard drugs. History of cigarette use, marijuana use, or both indicates that the participant reported ever having smoked an entire cigarette, used marijuana, or both a, b and c in Figure 1. History of hard drug use plus other substances includes cases where the participant reported ever having used hard drugs or a combination of hard drugs and soft drugs d, e, f and g in Figure 1. None indicates that the participant reported no history of ever having used any hard or soft drugs. To test whether the three independent variables measuring multiple substance use none; history of cigarette use, marijuana use, or both; and history of hard drug use plus other substances were differently associated with lifetime suicidal ideation and suicide attempts, we performed Pearson chi-square tests. We developed three logistic regression models to provide odds ratios ORs and confidence intervals CIs for lifetime suicidal ideation and suicide attempts to study how models and odds ratios of the substance use variables changed when adding history of psychiatric diagnosis and level of family communication to the models while controlling for demographic variables. Model 1 included the following variables: substance use, age, education, country of birth, and ethnicity. Then sequentially we added a variable for history of psychiatric diagnosis to examine the association between substance use and suicidality model 2 , and finally we controlled for level of family communication model 3. A threshold of 0. Table 1 describes the demographic characteristics of our sample. Among the study participants, Chinese ethnicity Most of women in the sample Note: Percentages are weighted, and may not total because of rounding. For explanation of family communication level, psychiatric diagnosis, substance use, lifetime suicidal ideation, and lifetime suicide attempt, see text on this page. Soft Drug Use indicates a history of cigarette use, marijuana use, or a combination of both. Hard Drug Use alone or in combination with soft drugs indicates a history of hard drug use alone or a combination of soft and hard drug use. In terms of the prevalence of substance use among the Asian American women in our sample, we found that approximately half Approximately one third of the sample Approximately To more fully understand differences among participants who reported a history of substance use, we created Figure 1. Among those with a history of substance use, approximately 1 in 4 Specifically, history of using all three substance types—cigarettes, marijuana, and hard drugs—was more prevalent \[ We examined the proportions of suicidal ideation and suicide attempts in 3 groups of women Table 2 : 1 women who had never used soft or hard drugs, 2 women who had a history of soft drug use, and 3 women who had a history of hard drug use alone or in combination with soft drugs. Those who had no history of substance use had the lowest reports of lifetime suicidal ideation Reports of lifetime suicidal ideation Soft Drug Use indicates a history of cigarette use, ever marijuana use, or a combination of both. To examine the unique contribution of substance use to lifetime suicidal ideation and suicide attempts, we developed three sequentially built models for lifetime suicidal ideation Table 3 and suicide attempts Table 4. The models for Tables 3 and 4 have similar patterns: sequentially moving by adjusting for demographic covariates only, then additionally adjusting for history of psychiatric diagnosis, and finally adjusting for level of family communication. Hard Drug Use alone or in combination with soft drug use indicates a history of hard drug use alone or a combination of soft and hard drug use. None of the demographic characteristics were associated with suicidal ideation. Furthermore, having a history of psychiatric diagnosis significantly increased the odds of suicidal ideation. All three multivariate models for suicide attempts Table 4 showed similar patterns to the models for suicidal ideation Table 3. In the second model, history of psychiatric diagnosis was associated with suicide attempts. Moreover, history of psychiatric diagnosis continued to be a significant factor associated with lifetime suicide attempts. Our analysis identified three key study findings concerning Asian American women: 1 a high prevalence of suicidal ideation, suicide attempts, and multiple drug use; 2 a robust relationship between hard drug use alone or in combination with soft drugs and suicidal ideation and suicide attempts; and 3 strong significant associations of suicidal ideation and suicide attempts with levels of family communication and history of psychiatric illness. Our study found that the prevalence of lifetime suicidal ideation and suicide attempts This similarity corroborates our finding that Asian American women have a substantially higher prevalence of suicidal ideation and suicide attempts compared to the national prevalence, and therefore should be considered an urgent public health issue and receive both clinical and research attention. We also identified that approximately one third of the sample This prevalence is lower than the national prevalence of reported lifetime cigarette use Our results also show that 1 in 10 However, despite a lower prevalence of overall drug use compared to other ethnic groups McCabe et al. This study found a significant association between drug use and prevalence of suicidal ideation and suicide attempts. Specifically, when we examined the proportions of suicidal ideation and suicide attempts among participants grouped by their substance use history based on level of drug use, those who had never used substances had the lowest reports of lifetime suicidal ideation Finally, among participants who had a history of hard drug use alone or in combination with soft drugs, reports of lifetime suicidal ideation Similarly, findings from three sequentially built logistic regression models indicate that even after controlling for history of psychiatric diagnosis and level of family communication, the association between hard drug use and suicidal behaviors was robust: Asian American women with a history of hard drug use alone or a combination with soft drugs were three times more likely to have had suicidal ideation and 4. Our findings call for both further investigation of factors that explain hard drug use among Asian American women and development of new interventions targeting this at-risk population. It is worthwhile to note that the magnitude of the relationship between hard drug use alone and in combination with soft drug use and suicidal ideation and suicide attempts somewhat diminished after we adjusted for history of psychiatric diagnosis and level of family communication, suggesting that drug use overlaps with family communication and history of mental illness 3. The change in magnitude of association between drug use and suicidal ideation and suicide attempts after controlling for level of family conflict supports previous research on intergenerational family conflict Lau et al. Moreover, the odds of psychiatric diagnoses consistently remained statistically significant in both of the final models predicting suicidal ideation and suicide attempts. This finding indicates that history of psychiatric diagnosis remains an important risk factor along with family communication and hard drug use alone or in combination with soft drug use. In our study, being born in the United States was not a significant risk factor associated with suicidal ideation and suicide attempt. This may be due to the fact that our study only sampled children of immigrants aged years and that differences between our second-generation participants born in the United States versus 1. Thus, our finding is similar to that of Breslau and Chang's study, which demonstrated no differences between 1. This finding suggests that being born in a foreign country is only protective of mental health among those who immigrated to the United States as adults, not as children. Several limitations of this study should be considered. First, AWSHIP data are cross sectional, and as such, the relationship between substance use and suicidality should be cautiously interpreted as association rather than causality. A clear picture of a causal relationship dynamic between substance use and suicidality could not be captured, especially since both suicidality and substance use were measured across each participant's lifetime. Given the design of our study, it is difficult to conclude whether a history of substance use triggered women to have suicidal thoughts and suicide attempts or whether having had suicidal thoughts and suicide attempts triggered substance use. Thus, our study findings do not disentangle the relationship between substance use and suicidal behavior. A follow-up longitudinal study that further compares substance users to nonsubstance users in terms of suicidality would help elucidate the causal mechanisms of these relationships. Second, we excluded alcohol use from our analyses because the scope and interest of our study was to focus just on history of soft and hard drug use rather than history of alcohol use, as the majority of our sample regardless of substance use level reported having used alcohol in the past 12 months Census Bureau, This may be the reason why we did not find subgroup differences for either suicidal ideation or suicide attempts. Future studies should include more ethnic subgroups in order to possibly uncover important disparities among specific subpopulations regarding suicidal behavior. These efforts would lead to a more precise and comprehensive understanding of the relationships between drug use and suicidality among Asian American women. In the future, qualitative studies on suicidality should be conducted within the most vulnerable groups: those who use hard drugs alone or in combination of soft drugs. This could provide further insight into the context in which these women become involved in substance use and the process of how drug use affects their likelihood to engage in suicidal behavior. The essential contribution of this study is the discovery that not all types of drug use are associated with suicidal ideation and suicide attempt; specifically, use of hard drugs alone or in combination with soft drugs has a robust association with both suicidal ideation and suicide attempts among Asian American women who are children of immigrants. An important clinical implication suggested from this finding is that mental health clinicians should not adhere to the model minority myth and thereby underestimate the impact of substance use when treating young Asian American women, especially those with suicidal risk. Additionally, standard substance use assessment instruments should be used as routine practice in clinical and college mental health settings. Noting that Asian Americans are the fastest growing sector of United States college students and increased from 0. Department of Education, National Center for Education Statistics, , implementation of substance use assessment for Asian American college students may impact future suicidal rates. In addition, by developing sequential logistic regression models, we were able to discern the overlapping roles of family communication level, history of psychiatric diagnosis, and substance use in suicidal ideation and suicide attempts among young Asian American women. Hence, this study adds new evidence to the literature that, similar to what has been demonstrated in other racial groups, suicide is a multidetermined outcome for young Asian American women. Specifically, those who have low to moderate levels of family communication have increased susceptibility to suicidal ideation and suicide attempts. These findings highlight the need to design and test interventions that respond to comorbid mental health and substance use problems while also improving family communication in this population. For instance, suicide reduction intervention programs for young Asian American women should include not only strategies to assess and reduce substance use but also family components to improve family bonding, validation of children's emotions, and understanding of each other's cultures across generations. It may be beneficial for suicide interventions to also include a mental health component that will reduce cultural shame and stigma related to seeking help and breaking the silence of private suffering. Future studies should replicate our findings with clinical samples as well as nationally representative samples of young Asian American women in order to provide solutions to the growing public health threat of suicidal behaviors. Family communication is the degree of understanding and openness among family members. For Asian American who are children of immigrants, family communication can also depend on agreement between parent-child cultural values. Cultural shame implies that adherence to cultural values causes avoidance, shame, and embarrassment in certain behaviors or activities that are not traditionally accepted. The model minority myth posits that because of strong cultural and family values, Asian Americans are specifically poised for success in education, income, and socioeconomic status while also maintaining low risk factors, such as decreased mental health and crime. However, the myth creates social isolation, discrimination, and ignores group diversity. Intergenerational conflicts are struggles between parents and their children that become especially common during early adolescence through young adulthood. Intergenerational conflict can usually attributed to children's greater autonomy and independence as they establish their own personal identities, value systems, and social relationships. In relation to Asian Americans, intergenerational conflicts are also attributed to assimilation. Asian parents and U. Hyeouk Hahm, Ph. Jisun Jang , M. Cecilia Vu, B. In the future, she hopes to continue pursing research that will bring attention to health disparities in overlooked populations and public health inefficiencies. Melissa Alexander, B. Along with her interest in clinical psychology, Melissa is passionate about mental health advocacy and awareness. Her other research interests include women's health, prenatal health, substance use, and self-harm. Kelsie E Driscoll, B. Kelsie is particularly interested in women's health and health disparities, and hopes to contribute to the creation of informed policy solutions. Lena Lundgren, Ph. Lundgren has together with her community-based collaborators brought more than 18 million dollars in HIV prevention and addiction treatment funds to the Commonwealth of Massachusetts. Currently, Dr. As a library, NLM provides access to scientific literature. Subst Use Misuse. Published in final edited form as: Subst Use Misuse. Find articles by Hyeouk Hahm. Find articles by Jisun Jang. Cecilia Vu , B. Find articles by Cecilia Vu. L Melissa Alexander , B. Find articles by L Melissa Alexander. Kelsie E Driscoll , B. Find articles by Kelsie E Driscoll. Lena Lundgren , Ph. Find articles by Lena Lundgren. Issue date Dec. PMC Copyright notice. The publisher's version of this article is available at Subst Use Misuse. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Family Communication Level. Psychiatric Diagnosis. Lifetime Suicidal Ideation. Lifetime Suicide Attempt. A History of Psychiatric Diagnosis.

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