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Issues in Mental Health Nursing, 27:681–698, 2006
Copyright c
Taylor & Francis Group, LLC
ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.1080/01612840600643040
PERCEPTIONS OF DEPRESSION AMONG
ELDERLY THAI IMMIGRANTS
Rangsiman Soonthornchaiya, RN, PhD
Chulalongkorn University, Patumwan,
Bangkok, Thailand
Barbara L. Dancy, RN, PhD
University of Illinois at Chicago, Chicago,
Illinois, USA
Because little is known about elderly Thai immigrants’
conceptualization of depression, a qualitative descriptive
research study was conducted to explore their perception of
depression. Semi-structured individual face-to-face
interviews were performed with a purposeful sampling of
ten men and ten women aged 60 years and older at
participants’ homes or Thai Buddhist temples. The results
revealed that depression was defined as feeling
disappointment and pressure in the mind and included
symptoms of isolation, heart pounding, and dissatisfaction.
Coping strategies comprised practicing Buddhism and
acceptance. Gender differences existed and reflected
cultural expectations for men and women. These findings
provide a foundation for developing culturally sensitive
health care.
Little has been written about depression among elderly Asian immi-
grants in the United States even though depression has been identified
as a prominent concern among this population. It is estimated that the
prevalence of depression among elderly Asian immigrants ranges from
3.4% to 30% (Pang, 1995; Takeshita et al., 2002; Takeuchi et al., 1998)
and that depression will increase from 2.4% in 2000 to 6.5% in 2050
(U.S. Census Bureau, 2000) among Asians 65 years old and beyond.
Address correspondence to Barbara L. Dancy, University of Illinois at Chicago, College &
Nursing, 845 South Damen Ave., Office 1060, M/C 802, Chicago, IL 60612. E-mail: BDancy@
uic.edu
681
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682 R. Soonthornchaiya and B. L. Dancy
“Asians” refers to people from the Far East Asia, Southeast Asia, and
India.
Elderly Chinese immigrants who suffer from depression express feel-
ings of isolation (Mui, 1998), a physical sensation that something is
pressing on their chests (Kleinman, 1977; Mechanic, 1972; Hsu, 1971),
difficulty executing activities of daily living (Liu et al., 1997), and dis-
satisfaction with their family relationships (Lam, Pacala, & Smith, 1997;
Lu, Liu, & Yu, 1998). The latter is also true for elderly Koreans (Mui,
1998). In a Thai sample, Lotrakul, Saipanish, and Theeramoke (1996) re-
vealed that physical complaints of feelings of pressure as well as anxiety
and sadness were common. From a sample of elderly Japanese sample,
Kawamoto, Kajiwara, Oka, and Takagi (2003) and Iwamasa, Hilliard,
and Osato (1998) found that anxiety and a decline in work productiv-
ity were prevalent. Factors that enhance depression among Korean and
Chinese elders were lack of social support, lack of acculturation, and
limited English language abilities (Kuo & Tsai, 1986; Lee, Crittenden,
&Yu, 1996; Lam et al., 1997; Chang & Chang, 1999).
Unlike Western cultures, Asian cultures view depression as emo-
tional distress expressed through somatization (Furnham & Malik, 1994;
Tabora & Flaskerud, 1994; Pang, 1998; Herrick & Brown, 1999). Hsu
(1999), Kuo (1984), Pang (2000), Simon, VonKorff, Piccinelli, Fullerton,
and Ormel (1999), and Tabora and Flaskerud (1994) found that el-
derly Asian patients with depression complain about somatic symp-
toms more than psychological symptoms. Among Asian groups, the
most common somatic symptoms of depression included headache,
back pain, muscle pain, indigestion, constipation, lack of appetite, in-
somnia, weakness, tiredness, and vertigo (Herrick & Brown, 1999).
Lotrakul, Saipanish, and Theeramoke (1996) also found these symp-
toms to be prevalent among the Thai population, even though the Thai
language has words for describing emotional/psychological depressive
symptoms: “rok-sum-sao” translates broadly as tired sad illness; “hod-
hoo” translates as feeling down and lack of motivation; and “kid-mak”
translates as thinking too much or persistent thinking. The tendency
for depression to be manifested by somatic symptoms may be due to
the fact that somatic symptoms are less stigmatized than psycholog-
ical symptoms (Townsend, 1993) and are more culturally acceptable
(Kleinman, 1977). In Asian cultures mental illness, including depres-
sion, tends to be stigmatized. Families of persons with mental illness are
also stigmatized (Kleinman). Raguram, Weiss, and Channabasavanna
(1996) found that stigma was positively correlated to depressive symp-
toms among Indian patients diagnosed with depression. In addition,
stigma predicted treatment discontinuation among older patients (Sirey
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Depression Among Elderly Thai Immigrants 683
et al., 2001). Mental illness and the expression of emotional distress
or psychological symptoms cause the clients and their families to ex-
perience shame because mental illness demonstrates weakness (Kuo
&Kavanagh, 1994; Wolpert, 2001). Kleinman (1980) stated that the
reputation of the family and future generations is negatively affected
by a person’s mental illness. Due to the fear of losing the commu-
nity respect, the family tends to limit the amount of contact the men-
tally ill family member has with the community (Parker, Gladstone,
&Chee, 2001). However, if the dysfunction is expressed by physical
symptoms, the community is generally more accepting of the depressed
person.
Depressed Thai males generally do not openly express symptoms
of depression and have limited ways of expressing their symptoms be-
cause a Thai male is expected to assume the role of leader (Vredenburg,
Krames, & Flett, 1986). On the other hand, it has been shown that the
expression of symptoms of depression is sanctioned for Thai females,
albeit through somatic symptoms. Consequently, a Thai female reports
more somatic symptoms than her male counterpart (Lotrakul, Saipan-
ish, & Theeramoke, 1996). The Thai male is to be stronger and more
capable than the woman. Any man who expresses depressive symptoms
is viewed as weak or as a failure, and these traits are unacceptable in
the Thai culture (Cochran & Rabinowitz, 2003). In the Thai culture, the
women’s role is that of nurturer and mother. Women take care of chil-
dren, support their husbands, and maintain the household, especially
preparing food for the family (Betrus, Elmore, Woods, & Hamilton,
1995; Lundberg, 2000). Women are not expected to be wage earners,
even though employment may be added to the role of the modern Thai
woman (Sarutta, 2002).
A potential consequence of severe depression is suicide. In Thailand,
the average suicide rate of the elderly per 100,000 of the population age
60–64, 65–69, 70–74, 75 and older is 5.8, 5.2, 6.2, and 5.7, respectively
(Lotrakul, 1998). Lotrakul reported that causes of suicide in the elderly
were loneliness, loss of spouse, lack of financial support, and health
problems. Between 30% (Kooptiwoot & Yantadilok, 1998) and 35.5%
(Saipanish & Lotrakul, 1999) of Thai elderly patients with depression
reported suicide attempts and 43% (Saipanish & Lotrakul) had suici-
dal ideation. Although severely depressed patients may commit suicide,
the view of suicide among people from Asian cultures is different from
that of Western cultures. In Asian cultures, people view suicide as a
voluntary personal action to prevent shaming the family. Suicide is an
honorable solution to mental illness, whereas a family is dishonored by
a mental illness. In contrast, Westerners view suicide as an indication
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684 R. Soonthornchaiya and B. L. Dancy
of mental illness. Western families may experience guilt and be dis-
tressed and stigmatized if a family member commits suicide (Ryan,
1985).
In Asian cultures, people are more likely to believe that past karma
(action) is responsible for a person’s depression as opposed to Western
culture where people believe that current actions and thoughts are re-
sponsible for their depression (Saipanish & Lotrakul, 1999). According
to Buddhism, the major Thai religion that is very influential in Thai
life (National Identity Office of the Prime Minister [NIOPM], 1991),
life and suffering are explained by the law of karma. The karma of past
existence determines the present state, and the present karma will deter-
mine the next existence (National Office, 2002; Rajavaramuni, 1998).
The Buddhist doctrine stresses living a balanced life, avoiding extremes
of indulgence or self-mortification, performing good acts toward others
to acquire merit for a better future life (NIOPM; Choowatanapakom,
1999), and accepting the impermanency of nature—that is, everything
will change and nothing is permanent (Buddradasa, 2001). Also filial
piety is a feature of the Thai culture that is reflected in Buddhist belief.
Young people, particularly children in a family, have the responsibil-
ity to take care of their elderly parents and to respect elderly people
(Wongsith, 1996). Additionally, in the Thai culture the family shares
responsibility for resolving or managing serious problems experienced
by family members (Lundberg, 2000).
Among Asian immigrants, least is known about depression among
elderly Thai immigrants. Depression may be conceptualized differently
in the Thai culture (Zobel, Yassouridis, Frieboes, & Holsboer, 1999).
Therefore, exploring depression as perceived by Thai elderly who are
connected to the Thai culture may provide a descriptive view about
depression from a Thai perspective. Their perceptions of depression
could be from their direct experience with depression or from their
direct observation of significant others in their life who have experi-
enced depression. Their descriptive frame of reference may be help-
ful for clinicians to gain a better understanding of depression and may
lay the basis for the development of culturally relevant assessment and
treatment.
The purpose of this qualitative descriptive study was to obtain the
perception of depression from elderly Thai immigrant men and women
who are connected to the Thai culture. Specifically data were sought on
their thoughts about (1) what is depression, (2) what are the symptoms of
depression, (3) what causes depression, (4) what impact does depression
have on the lives of depressed people, and (5) what strategies are used
to cope with depression?
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Depression Among Elderly Thai Immigrants 685
METHODS
Research Design
A qualitative descriptive research design was used to explore elderly
Thai male and female immigrants’ perceptions of depression. Sande-
lowski (2000) suggested that qualitative descriptive research methodol-
ogy is a valuable method for describing the facts as perceived by partic-
ipants on a particular topic in their everyday vocabulary. The outcome
of the qualitative description is a straightforward descriptive summary
of the data (Sandelowski). The data was collected through individual
face-to-face interviews with elderly Thai immigrant men and women.
Sample and Setting
A purposeful sampling was comprised of elderly Thai immigrants,
men and women, who were 60 years and older, have experienced de-
pression or have friends or relatives who have experienced depression,
were born in Thailand, were able to communicate in Thai, resided in a
large metropolitan community, and belonged to a Thai temple located in
their community. The investigation targeted Thai temples that served as
community centers for Thai immigrants and as such were opened to the
public daily and offered Buddhist classes, Thai language classes, Thai
cultural classes, Thai religious ceremonies, and other Thai traditional
cultural activities. Participants’ connection to these Thai temples was a
proxy for continued bond with the Thai culture. A modified version of
the maximum variation sampling (Patton, 2002) was used to seek men
and women with the above characteristics. This sampling procedure al-
lowed the exploration of unique views of depression across genders with
emphasis on shared patterns. Ten men and ten women were recruited
from three Thai temples in Illinois.
Instruments
The instruments for this study consisted of a demographic question-
naire and a semi-structured interview guide. The researchers developed
both instruments. The demographic questionnaire yielded descriptive
information, such as age, gender, education, occupation, marital sta-
tus, family income, and the length of time resided in the United States.
The semi-structured interview guide consisted of open-ended questions
that required the participants to describe depression, depressive symp-
toms, and possible causes of depression. In addition, the interview guide
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686 R. Soonthornchaiya and B. L. Dancy
elicited information about the impact of depression on the lives of de-
pressed people and about coping strategies associated with depression.
The instruments were reviewed by a panel of experts on Thai culture, de-
pression, and qualitative research, and were pre-tested on a small number
of Thai elderly. The instruments are available in both English and Thai.
Procedure
After approval was obtained from the Institutional Review Board at
the University of Illinois at Chicago, the principal investigator contacted
the ministers of each Thai temple by phone and scheduled a meeting to
discuss the research study and request permission to use a room at the
temple to interview participants. Fliers with a brief description of the
study and with the principal investigator’s telephone numbers were dis-
tributed in the Thai temples. The principal investigator also announced
the study at activities at the Thai temples. In addition, participants learned
of the study by word-of-mouth.
During the principal investigator’s initial contact with the participants,
either in person or by telephone, the principal investigator made an ap-
pointment with participants to schedule a convenient time and a comfort-
able setting for the interview (at the Thai temple or at their homes). After
informed consent was obtained from the participants, the demographic
data were collected and the semi-structured interview conducted. The
duration of the interview was approximately 60 to 90 minutes. Partic-
ipants did not receive incentives for their participation. All interviews
were conducted in Thai by the principal investigator who is bilingual in
Thai and English. All interviews were audiotaped and all data collection
was completed in eight weeks.
Data Analysis
After each audio taped interview, the tape was transcribed verbatim in
the Thai language by the principal investigator. A bilingual Thai scholar
independently reviewed all transcripts to ensure that the transcripts cor-
rectly reflected the audiotapes. Qualitative content analysis, a dynamic
iterative process (Sandelowski, 2000) that seeks commonalities in el-
derly Thai immigrants’ perceptions of depression, was used to analyze
the data. The primary focus of the analysis is to present a description of
depression as perceived by elderly Thai immigrants. The principal in-
vestigator reviewed the transcripts to obtain an overall understanding of
the phenomenon of depression and afterward thoroughly read the tran-
scripts to detect regularities and patterns. The data were manually sorted
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Depression Among Elderly Thai Immigrants 687
and categories were developed followed by the identification of themes
within each category. A second bilingual Thai professional indepen-
dently analyzed a random selection of 50% of the transcripts for themes
emerging from each of the categories. The inter-rater reliability between
the principal investigator and the bilingual professional was 86%. At
this point, the principal investigator translated the themes into English,
and two additional bilingual professionals independently checked a ran-
dom selection of 50% of the translated themes for accuracy. The initial
inter-rater reliability of the two bilingual professionals was 75%. How-
ever after discussion, consensus of the two bilingual professionals was
reached and the inter-rater reliability increased to 95%.
RESULTS
Sample Characteristics
The majority of participants (80%) were interviewed at Thai temples;
only three (30%) women and one (10%) man were interviewed in their
homes. The men ranged in age from 60 to 70 years with a mean age
of 64 years. All were currently married, with one reporting that he was
separated from his wife. Eighty percent of the men had either a bachelor
or master degree. They were currently retired but had worked in the
U.S. as technicians, businessmen, and engineers. Sixty percent of the
men lived with family members and none of the men reported receiving
financial support from relatives. The men had been in the U.S. for an
average of 30.5 years. The women ranged in age from 60 to 84 years with
a mean age of 71 years. Only 40% were currently married; 20% of the
women were widowed, 10% were divorced, and 30% had never married.
Forty percent had a diploma in nursing, 20% had a bachelor degree,
and 40% had not completed high school. The women were currently
retired and had worked in the U.S. primarily as registered nurses. Seventy
percent of the women lived with family members, and only 10% reported
receiving financial support from their relatives. They had been in the
U.S. for an average of 28.5 years. Thirteen of the participants (7 females
and 6 males) had friends and family members who had experienced
depression whereas seven of the participants (3 females and 4 males)
had experienced depression themselves at least once.
Depression
Both men and women agreed in describing depression as feelings of
disappointment (“pid-wang”) and loneliness (“wa-wae”) accompanied
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688 R. Soonthornchaiya and B. L. Dancy
by obsessive thoughts about unsolvable problems concerning their
health, living situation, family members, and jobs. Regarding disap-
pointment, one participant said, “Depressed people are unsatisfied about
themselves in their living situations; unsatisfied about things they have.”
Another said, “A depressed person is disappointed because he cannot
solve his problems.” Loneliness was reflected in missing their home-
town, friends, and relatives. Those participants who experienced “wa-
wae” mentioned that the U.S. was not their home, and, subsequently,
there was a lack of connectedness to the people around them.
More men than women tended to define depression as feelings of
pressure in the mind due to their living situations and family relation-
ships. “Kod-dan” referred to feelings of pressure on one’s heart making
it heavy or to problems pressing on one’s mind. A participant said, “De-
pression is feelings of pressure in the mind (“kod-dan”) and cause me to
become a different person. My mind changes to be abnormal.” Another
participant said, “A depressed person feels pressure, a sinking feeling,
and he cannot let go of it.”
Depressive Symptomatology
Participants reported five types of depressive symptoms: (a) behav-
ioral symptoms, (b) somatic symptoms, (c) cognitive symptoms, (d)
affective symptoms, and (e) verbal symptoms. Both men and women re-
ported behavioral symptoms that included being unfriendly, withdrawn,
isolated, and silent. One participant said:
A depressed person is usually quiet, does not converse with others, and
is not talkative. In the past, when he met his friends, he was friendly and
talked with all of them. Right now, he is very quiet. If anyone asked him,
he only answered one time. Sometimes, he did not answer at all.
Another participant said:
When I was depressed, I was quiet and felt that I had become a different
person. I did not want to talk to anybody. My behavior was changed. I
sat and did nothing. I did not say anything. I kept the conflict deep within
myself.
While both men and women reported somatic symptoms involving
the heart, men were more likely to report feeling pressure on the heart
or mind and women to report heart pounding. A man said, “Something
is pressing on my mind and it makes my mind sink to the bottom.” The
feeling of something pressing on their hearts occurred when they spent
too much time thinking about their problems. A woman said, “If I don’t
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Depression Among Elderly Thai Immigrants 689
feel good today, I felt that my heart was racing. Whenever I lay down, I
heard my heart beating.”
Cognitive symptoms are any ideas or thoughts expressed by the de-
pressed person. Both men and women reported that depressed people had
negative thoughts about themselves. These negative thoughts were re-
lated to viewing one’s self as unlucky, blaming the self for their children’s
lack of success and for failure to achieve goals, and having thoughts of
being worthless. One participant said, “I am an unlucky person. Other
Thai people have better living situations than me. No one is like me: both
physically and in mental health. My health and life are so bad.” Another
participant said, “Suppose I think of something good that I could do, but
then I could not do it. I felt sorry that I could not accomplish my goal.
What’s wrong with me?” Yet, another participant said:
Elderly parents who could not take good care of their children were de-
pressed when comparing their children to other people’s children. They
wondered why other people’s children are successful whereas their chil-
dren are not. The parents may blame themselves about the way they raised
their children.
Men were more likely to report that depressed people viewed themselves
as worthless. One man said:
Depression occurs in the elderly because they think that they no longer
have abilities to do things. Especially Thai elders think this way because
their children do not want them to do anything. So, the depressed person
thinks that he or she is worthless.
Men and women reported that the affective symptoms of depression
were unhappiness and dissatisfaction. Unhappiness and dissatisfaction
are reflected in these statements: “I saw a depressed person who was
lonely and unhappy. She had a sad face;” “She was not happy;” “The
person who was depressed was not cheerful.” Some people observed
that depressed people were not in a good mood and expressed suffering
as reflected in this statement: “His face showed how much suffering he
had. He did not smile.”
Verbal symptoms referred to the words and tone used by people with
depression. Men and women reported that a person who was depressed
did not want to talk to anyone and only talked when it was necessary.
When they did speak, the typical verbal statement used by individu-
als with depression was: “I am unlucky.” Men, however, were more
likely to report that when people with depression talked they used an
angry, impolite, or mean tone to convey their message. Sometimes they
yelled and used aggressive verbal statement. One participant said, “He
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690 R. Soonthornchaiya and B. L. Dancy
might shout loudly and angrily to not bother him. Go away, leave me
alone.”
Causes of Depression
Participants reported that the causes of depression were family ten-
sion, work problems, and losses. Both men and women described family
tension as dissatisfaction with familial interpersonal relationships. One
participant said:
If their children did not come to visit them, they would be depressed
easily. The children did not take good care of their parents as well as the
parent took care of them. The parents hope that their children would take
care of them. However, the children did not take care of them in return.
The parent should be sad and depressed.
Women, however, were more likely to describe family tension as
arguments. One woman said:
We had arguments about our children. My husband was picking on me.
He wanted me to be as he wanted and he wanted our children to be as he
wanted also. Sometimes I disagreed with him. It happened frequently; it
occurred again and again. I told him. I talked to him that I did not like that
and this. I did not want to be this, but he did not listen to me. It caused
problems between us. It made me depressed because it happened many
times. When talking, we did not understand each other. We had quarrels
and arguments frequently. Our ideas were different. Misunderstanding
between husband and wife lead to depression.
Another woman said:
When she taught her children, her children scolded her. So, she had to
keep quiet. She was upset with this situation. She could not teach her
children to be as good as she wanted them to be. She felt hopeless and
depressed.
Work issues, especially the inability to perform work, were perceived
by the majority of men and women as a cause of depression. One par-
ticipant said, “Work performance caused depression because we had
problem with English.” Another participant said, “If I could not finish
my work, I would be depressed. I did not ask anyone for help because I
was afraid that other people would look down on me.”
The majority of both men and women perceived that the loss of a loved
one was a cause of depression. The loved one might be a parent, a child,
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Depression Among Elderly Thai Immigrants 691
spouse, other relative, friend, or a respected person. One participant
said:
Some couple lived together for a long time. When one passed away,
another person felt lonely and passed away later in a short period of time.
If a wife held the thought that her husband was not supposed to die yet, she
wasvery sad. She would think that if he was alive, he would sit with her
and they could have breakfast together. She believed that he should not die.
Impact of Depression on Individual’s Life
Both men and women reported that depression negatively affected
the person’s general appearance. One participant said, “I saw my friend
who was depressed. He did not take care of himself. He did not dress
properly. He sometimes did not comb his hair.” Additionally depression
interfered with performance of daily activities. “He could not concentrate
on what he was doing. For example, he wanted to boil water; he turned
on the gas and left the room. He forgot what he did. It could cause
a fire.”
Another impact of depression was the inability to maintain a job due to
frequent absences, poor work performance, and poor relationships with
coworkers. More men than women reported this impact. One participant
said, “A depressed person suffered from his thought. He could not work
effectively because of his suffering and anxiety. He could not work to
his full potential.” Another participant said:
A depressed person did not trust his coworker. He thinks that his cowork-
ers were not sincere. He isolated himself. He did not want to socialize or
work. He could not work for a long time; then he had to resign because
he did not associate with others.
Coping Strategies for Depressive Symptoms
Coping strategies for depressive symptoms reported by both men and
women were practicing Buddhist teaching and meditation, going to the
temple, and participating in favorable activities. Regarding Buddhist
teaching, one participant said:
Thai Buddhist teaching teaches about good things. People’s thoughts
would not preoccupy their lives. Buddhism teaches that nothing is per-
manent (“anitjang”); this was the nature of everything. Buddhism teaches
about “anitjang”. The truth is the truth. Buddhism made people under-
stand the truth that everything is impermanent.
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692 R. Soonthornchaiya and B. L. Dancy
Another participant said:
Practicing Dharma means making the mind peaceful. Our mind usually
is not peaceful because we think about many things. If we put our mind at
one place, meaning focusing on one thing (thinking about the Buddha),
our mind will not go any which way. This way makes our mind peaceful,
and we will not think about other things.
Going to the temple was perceived to be a coping strategy because
the temple had a calming effect and was the perfect place to go to
study Buddhist teachings and to pray. Likewise, engaging in favorable
activities—activities they enjoyed doing—had a calming effect. These
activities included talking to friends, traveling, going to parties, and
participating in hobbies.
In addition to the above strategies, women, more than men, tended to
report acceptance of life situations as a coping strategy. “Plong” is the
Thai word used for “acceptance” of life situations, such as diseases and
economic problems. One participant said, “Plong” means we hold on to
Buddhist teaching that when the time is to lose, we have to lose it. It’s like
whatever will be will be. We need to accept things that have happened.”
Another said, “When Thai elders were depressed, they needed to accept
their situation. If something happened, they needed to accept it.” On the
other hand, men, more than women, reported that talking to the monk was
a coping strategy. Talking to the monk was useful in helping depressed
persons solve their problems, especially if the monk was knowledgeable
about psychology. One participant said, “Talking to the monk helps the
depressed person to have fun, to calm down, and not to think too much.”
Another said:
For me, I would go talk to the monk. When I had a problem, I could not
think, then, I went to talk to the monk. He would give me advice and try
to solve the problem. When I could not figure out the problem, it made
me angry in my mind. If I went to talk to the monk or practice meditation,
Iwould forget my anger. I would understand what events had happened
and why I had problems.
DISCUSSION
The participants reported some symptoms of depression that were
similar to symptoms reported in other studies: isolation (Mui, 1998),
unhappiness (Lotrakul, Saipanish, & Theeramoke, 1996), dissatisfaction
(Lam, Pacala, & Smilth, 1997; Lu, Liu, & Yu, 1998), and the inability to
maintain one’s personal appearance (Liu et al., 1997). These participants
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Depression Among Elderly Thai Immigrants 693
also spoke of heart pounding that may be analogous to pressure in the
chest reported by Kleinman (1977), Mechanic (1972), and Hsu (1971).
However, although these participants did report somatic symptoms, other
symptoms, including cognitive, affective, and verbal symptoms were
equally reported. Their report of somatic symptoms included feeling
pressure on the heart or mind and heart pounding. The somatic symptoms
of headache, back pain, muscle pain, insomnia, fatigue, and lack of
appetite reported by Herrick and Brown (1999) were not reported by
this sample of elderly Thai immigrants. In addition, this study is the first
to report silence and negative view of self as symptoms experienced by
elderly Thai immigrants. Family tension and work problems as factors
related to depression are similar to reports from Lu et al. (1998), Lam
et al. (1997), Iwamasa, Hilliard, and Osato (1998), and Sangon (2004).
Viewing depression as disappointment (“pid-wang”) and loneliness
(“wa-wae”) may be related to Thai elders’ feeling that they are a burden
to their children. In general, a Thai family is an extended family that
values filial piety. This value is expressed through children caring for
their aged parents. In Thailand, elderly parents live with or near their
adult children and grandchildren and expect to be valued, honored, and
cared for by their children (Choowatanapakorn, 1999). However, Thai
elders who live with their children and grandchildren in the United States
face situations and environmental pressures that are different from those
experienced in Thailand. In the U.S., Thai elders’ sole responsibility is
caring for their grandchildren. They no longer assume the role of the
families’ decision makers and may be disappointed that they have lost
the honored leadership positions in their families (Detzner, 1996). In
addition, lack of acculturation and lack of integration in the community
(Lam, Pacala, & Smith, 1997) may lead to feelings of loneliness.
Symptoms reported by the participants shared some similarities to
those reported in the Diagnostic and Statistical Manual of Mental Dis-
orders (DSM-IV-TR) (American Psychiatric Association [APA], 2000).
Similarities include social isolation, silence, negative thoughts about
oneself, unhappiness, and dissatisfaction. However, somatic complaints
reported by participants, such as the feeling of pressure, differ from the
weight changes, insomnia, appetite changes, and fatigue listed in DSM-
IV-TR. Thai elderly may report pressure on the heart (Estin, 1999) as
opposed to reporting being depressed because mental illness, includ-
ing depression, tends to be stigmatized. In addition, suicidal ideation, a
DSM-IV-TR criterion, was not a prevalent expression of depression for
these participants.
Although no studies have yet definitively established actual causes of
depression, the findings of this study include elements consistent with
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694 R. Soonthornchaiya and B. L. Dancy
Freud’s (1957) concept of depression as a consequence of perceived loss.
Participants reported that loss of a loved one could cause depression. Ac-
cording to Freud, people could develop depression (melancholia) from
the loss of a loved one as a result of the internal mental conflict between
the loved self and the hated self (Siegel & Kuykendall, 1990; Ugarriza,
2002). The findings are also consisted with Hahn’s (1995) discussion
of depression as a condition influenced by both culture and environ-
ment. In fact, practicing Buddhist teachings, thus incorporating Hahn’s
ideas of the importance of culture, may serve as a protective factor
against loss. The protective factor of religion against depressive symp-
toms in later life has been supported by Braam et al. (1998) who found
asignificantly negative correlation between church attendance and the
incidence of depressive symptoms. In addition, Nooney and Woodrum
(2002) revealed that the benefits of church attendance were mediated
by church-based social support. Likewise, Tongprateep (1998) explored
the essential elements of spirituality among rural Thai elders and found
that the teaching and activities at the Thai temple were helpful in reliev-
ing Thai people’s suffering. Buddhist teachings encouraged people to
think positively, to clear their minds, and to place themselves in a neutral
state of peace (Rajavaramuni, 1998). Therefore, it is not surprising that
our sample reported practicing Buddhist teachings and meditation as a
coping strategy.
The findings indicate that gender plays a role in elderly Thai immi-
grants’ perceptions of depression. Men perceived depression as feelings
of pressure, worthlessness, and anger in addition to loneliness and dis-
appointment. Not being able to meet the expectation of the culture, that
is to assume the role of wage earner to support the family, could lead
men to experience depression differently from women. Women, on the
other hand, perceive depression as loneliness and disappointment. Thus,
the failure to meet the cultural expectation of wage earner may have a
profound consequence for men, leading them to have a more intense
experience with depression.
These results provide important preliminary findings that have signif-
icant implications for clinical practice and the development of assess-
ment and treatment interventions for depression among elderly Thai
Buddhist immigrants. The results provide support for faith-based treat-
ments, including Thai Buddhist teachings, that can be integrated into
treatment and prevention efforts. Treatment for and assessment of de-
pression may need to be gender-specific. Health care providers may
encourage elderly Thai men to go to the Thai temple, talk to the monk,
and get involved in temple activities. For elderly Thai women, health
care providers might encourage them to initiate enjoyable activities and
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Depression Among Elderly Thai Immigrants 695
to practice Buddhist teachings, especially acceptance of situations they
can not control, which is consistent with the findings of Sethabouppha
(2002). The need for acceptance of the present situation by Thai elders is
consistent with the law of karma. The law of karma states that situations
in the present reflect actions in the past and one must accept the present
to compensate for one’s past (National Office, 2002; Rajavaramuni,
1998). Assessment instruments should evaluate feelings of pressure,
worthlessness, and anger as well as loneliness and disappointment
to ensure that the impact of depression on men is comprehensively
considered.
Policies are needed to support the development and implementation
of culturally relevant treatment for elderly Thai Immigrants. Health care
providers should be rewarded for integrating Buddhist practices into
treatment interventions that incorporate respect and acceptance of Thai
culture. In addition, health care providers should be encouraged to in-
clude family members into the treatment intervention to augment the
family’s ability to support the depressed individual.
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