Understanding risk and protective factors related to depression and suicidality among AA and NHPI youth in the U.S. requires an understanding of the ecological parameters that define the contexts and conditions under which AA and NHPI youth live and develop. Risk and protective factors for depression and suicidality in the lives of AA and NHPI youth are far from static and cannot be fully understood through an independent examination of the sum of its parts. Instead, they are part of a complex, integrated, diverse, and nonlinear network of systems. Consequently, individual risk and protective factors collide with numerous other agents in the social environment effecting varying developmental outcomes for individual AA and NHPI youth. In applying an ecological framework the clinician would need to see and treat the whole person, rather than assess and treat separate or specific entities of a person. For example, within this framework, gender can be understood as both a biological and a social construct. Moreover, identity is a multi-dimensional phenomenon, simultaneously influenced by varying levels of the social environment (e.g., social, political, legal, economic).

At its core, human ecology theory is “unique in its focus on humans as both biological organisms and social beings in interaction with their environment. … Emphasis is given to the creation, use, and management of resources for creative adaptation, human development, and sustainability of environments.”¹⁵ Rooted in this perspective is the understanding that youth are a product of their social environment. How youth think, feel, and act is a direct result of their interpersonal interactions within and exposure to overlapping social systems. These individual behaviors and experiences can be both maladaptive and symptomatic, such as depression or suicide, or they can be adaptive and take the form of protective and resilient mechanisms such as self-compassion, and ethnic pride.

The three systems surrounding the individual adolescent are commonly referred to as micro-, meso-, and macrosystems. Microsystems reflect the social environments in which adolescents live their day-to-day life. As such, microsystems are comprised of interpersonal relationships and social scenarios that youth engage with and encounter directly on a daily basis (e.g., with family, friends, school teachers, church personnel, extracurricular activities/settings). Microsystemic factors and variables have a direct impact on determining the adolescent’s behaviors, perceptions, and feelings, thereby contributing directly to his/her meaning making and to interpretation of experiences.

Mesosystems are the transmitters, mediators, and brokers of micro- and macrosystemic interactions. Mesosystem variables reflect interactions between two different microsystems present in the youth’s life. They also reflect standards of practice and norms that are passed down from the larger macrosystems. Parent-teacher conferences are an example of a mesosystemic interaction. For the AA community, Chinese language school or Korean churches, where the youths’ two microsystems may come together, are examples of mesosystemic activity and factors. Kinship networks are also meso-systemic interactions, as are the integration of adolescent peer networks with family life and vice versa (e.g., bringing a friend to family events).

Macrosystems are institutional and structural systems like political, social, and economical institutions and structures. Macro variables/factors establish and codify a collective social norm, thereby setting specific and uncompromising expectations about what is socially acceptable and what is not. Macrolevel factors and variables are formally established standards by which we conform or live. These are the gatekeepers, creating and reinforcing specific social norms and expectations. Such norms and expectations are codified into specific policies, regulations, and best practices, essentially defining what are acceptable systems of care and service delivery. They are distinguished from micro- and meso-level factors because the person of interest – in this case, AA and NHPI youth – do not directly engage or interact with macro-level factors, yet remain significantly affected by them. Immigration policies and service delivery practices and protocols that do not account for social determinants of health and well-being are examples of macro-level factors that affect AA and NHPI youth, even though youth may not be directly engaged with these systems or have direct influence on the development of the policies and practices.

A systematic review of the peer reviewed literature was conducted from which the authors extrapolated and synthesized evidence delineating specific risk and protective factors associated with depression and suicide among AA and NHPI youth living in the U.S. Pertinent questions associated with this effort include:

What do we know about risk and protective factors associated with depression and suicide among different AA and NHPI subgroups?

Currently no reporting protocol exists for this type of systematic review. When relevant, the system review guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were incorporated to aid in the structure of our approach and disseminating findings.¹⁶

A total of 2,722 citations were downloaded into a single EndNote library (Thomson Reuters, Philadelphia). After 695 duplicate citations were removed, titles and abstracts of 2,027 articles were screened for relevance according to inclusion and exclusion criteria. Of these, 304 articles were identified as potentially relevant and were read in full. A few depression studies were excluded based on what was deemed as specialized or unique circumstances. In all these cases depression was explored as a comorbid condition or as an outcome specific to very unique circumstances. For example, a few studies were excluded when depression was examined as a comorbid condition for other conditions, such as peer warmth,²² coping mechanisms,²³ discrimination,²⁴ religiousness,²⁵ and socialization.²⁶ Similarly, another study explored depression as a secondary or associated condition to smoking.²⁷ A few publications focused primarily on experiences of refugees or U.S. visitors with extended visas (e.g., foreign students).^28–30 In these cases, it was decided to exclude the studies due to the uniqueness of the conditions surrounding the particular subgroup’s experience with depression and/or suicidality. Including them in the final analysis would dilute their specific experiences with depression and eliminate the unique conditions and context associated with those experiences. A total of 66 publications were included for this review. A flowchart of the studies that were included and excluded at each stage is shown following the PRISMA 2009 flow diagram, and reasons for the second round of exclusions are provided (See Figure 1).

Publications were categorized by study objectives, methodology, percentage of the sample who were AA and NHPI, and specifically if any specific subgroups were analyzed (Table 1). A majority of the studies were focused on depression (86%), and geographically, the Western part of the U.S. was well represented (47%). The majority of studies were cross-sectional (75.8%) as opposed to longitudinally designed. About two-thirds of the studies looked specifically at AA and NHPI samples, while 16.7% had an AA or NHPI sample size that was less than 25%. Only 3% of the studies represented the experiences of NHPI as a sub-ethnic group, and approximately 61% of the studies were conducted on a specific AA or NHPI ethnic subgroup. The AA ethnic subgroup reflected most often were Chinese, followed by Korean, Vietnamese, and Filipino. Depressive symptoms across the reviewed publications consisted of participant self-reports of typical neurovegetative signs of depression (e.g., feelings of sadness, loss of appetite, poor sleep hygiene, etc.), and ratings of study participants’ depressive symptoms. In some cases, standardized scales of depression were administered (e.g., Center for Epidemiological Studies Depression Scale and the Beck Depression Inventory). For suicide, all the reviewed studies included one or more of the criteria for suicide (e.g., ideation, planning, and attempts).

What follows is a summary of the findings from the reviewed studies organized by the four framing questions that guided the systematic review. The results were further organized by themes using an ecological framework: Risk and protective factors for depression (Table 2) and risk and protective factors for suicide (Table 3). These themes are associated with the primary system where the most observable transmission occurs. Together, they represent nested and interdependent transactions between systems exerting reciprocal and dynamic influence versus separate and linear processes. Therefore, a macro systemic factor like discrimination exerts direct and indirect depression related risk to AA and NHPI youth through effects on individual and family functioning. Likewise, individual and family functioning exerts direct and indirect effect on discrimination through mesosystemic interactions. For example, how an individual or family navigates the effects of discrimination influences their social behavior in other social settings, which affects how they are perceived and informs larger social beliefs about them as a racial being or group. Specific findings from each of the studies are summarized in each section. Interpretation and analysis of the findings from an ecological lens is provided in the discussion section along with recommendations for further research, policy, and practice.

The studies provided some insight on the literature available on suicide and depression among AA and NHPI youth, and the risk and protective factors identified for AA and NHPI youth specifically. For example, the majority of the studies were conducted on the Western coast of the U.S., primarily in California. As such, AA and NHPI groups in California are not the same as in other areas of the country, and there are Asian ethnic enclaves forming all over the U.S., away from the coastal regions that were once prominent migration centers. A sizable proportion of the studies also used national data, which aggregated AA and NHPI groups into one group comparable to Whites, Hispanics, and Blacks. These studies are not able to take into account the cultural differences that exist between AA and NHPI subgroups.

It is also important to note risk factors for these samples often included more encompassing frameworks such as acculturation and acculturative stress, as well as enculturation and generational status that would not be present among non-ethnic and non-immigrant youth. Additionally, family variables such as support, conflict, and engagement were often seen as risk and protective factors among AA and NHPI youth. Moreover, other established risk factors including family history of depression were not assessed across the 66 reviewed studies and previous experience with violence was only assessed in two studies to understand suicide risk.^49,80 However, other risk factors such as older age and female gender were identified, that are also evident among non-minority youth. It is important to consider the AA and NHPI youth are at various stages of acculturation, and some have lived in the U.S. for longer than others, adopting different cultural values than youth in their home countries. Collectively, these studies highlight the lack of explanatory power of acculturation theory and the presence of bicultural conflict and tension in the process of ethnic identity development. Additionally, they suggest a complex interaction between macrosystemic, or cultural norms and expectations on microsystemic processes (e.g., family functioning and peer relationships) and individual functioning (e.g., adolescent depression and suicide).

Across these studies, acculturation and acculturative stress were measured in varying ways. This in part could explain some of the variation in findings. Collectively, these studies highlight the lack of explanatory power of acculturation theory and the presence of bicultural conflict and tension in the process of ethnic identity development. Additionally, they suggest a complex interaction between macrosystemic, or cultural norms and expectations on microsystemic processes (e.g., family functioning and peer relationships) and individual functioning (e.g., adolescent depression and suicide).

To fully understand the complex and interdependent social, cultural, and developmental context of the AA and NHPI youth living in the U.S. as it relates to the manifestation of depression and suicidality, it is useful to draw on Norton’s elaboration of ecological thinking.⁹⁵ Norton suggests a dual perspective, which involves consideration of the interaction between a person’s nurturing system (Context #1) and the same person’s sustaining system (Context #2). Drawing from ecological theory, Norton suggests that an adolescent’s nurturing system is comprised of her micro system – the immediate social context in which she lives and would therefore include her family, extended family, and the immediate neighborhood in which she lives. The sustaining system is the macro system, in which the micro nurturing system is embedded. Of particular relevance to the findings from this review is that majority and minority groups synchronously occupy both systems and are in constant interaction through mesosystemic mechanisms (e.g., interaction between microsystems through structured programming like school and extracurricular activities).

Within this dual perspective, bicultural conflict and tension arises as a result of incongruence between cultural norms and beliefs between different cultural groups in the shared social and systemic locations and spaces. For example, differences in cultural beliefs about health, help-seeking, stress, and child rearing can create conflict and tension as AA and NHPIs navigate daily living. More specifically as reflected in the findings associated with Kim et al.’s study, marginalization is one manifest outcome of such tensions and something important to attune to in assessing the needs of AA and NHPI youth especially in the context of depressive symptoms.⁵⁶

Joiner’s Interpersonal-Psychological Theory of suicidal behavior contends that individuals gradually acquire the ability to enact lethal self-injury when they have previous experience with self-injury; this ability is not acted upon unless the desire for death includes two factors: the desire for death and a sense of failed belongingness.⁹⁶ Juxtaposed with Norton’s thinking about nurturing and sustaining systems, this hybrid framework may be applicable to AA communities because of its emphasis on unmet interpersonal needs, congruent with Asian cultural norms that emphasize the centrality of interpersonal relationships. From this perspective, suicidal ideation and pressure can stem from disruption of interpersonal functioning and needs within the nurturing system – that is, between the AA and NHPI youth, their family and extended kin network, which is imposed by a surrounding sustaining system demanding conformity to social and familial norms and expectations that are incongruent with the nurturing system’s values and beliefs. For example, the focus on development of a collective identity, or we as central to Asian individual development, is in direct contrast to the focus on individuation or independence from family that is critical to Western individual development. The role of family and norms of interpersonal functioning within each cultural reference point is therefore also different and can thwart one’s interpersonal needs.

The sequential connection between depressive mood and cigarette smoking found in a few studies is consistent with self- medication hypothesis and motivational theory, which propose that smoking may develop in an attempt to cope with psychological distress and feelings of depression.⁹⁷

Interpreting the systems and environments that influence and affect AA and NHPI youth further allude to the various contexts that must be taken into account in thinking about research, policy, service delivery, and practice. Several themes in this vein that surfaced in our findings include the persistent and pervasive role of stigma as an important variable. While stigma was not measured in any of these studies to date, marginalization, alienation, and discrimination were measured. Moreover, marginalization and alienation, in and of themselves, are a form of social exclusion illustrative of discrimination. All three of these factors underlie the phenomenon of stigma, possibly de-confounding some of these findings.³⁸ The U.S. Department of Health and Human Services considers stigma “the most formidable obstacle to future progress in the area of mental illness and health”.⁹⁸ For instance, foreign-born AAs are less likely than U.S.-born AAs to seek mental health care services.⁹⁹ Given cultural factors of social stigma and shame around these two facets of health, minority groups are less likely to report mental health issues to peers or medical providers^99–101 or seek care,¹⁰² and they are more likely to attribute mental health problems to religious and other culturally sanctioned belief systems.^99,101 Collectively these factors, along with racism, discrimination, and the model minority myth, converge to effectively disable help-seeking behaviors among AAs and NHPIs and, thereby, sustain myths about mental illness within the community that can perpetuate stigma and shame.

It is critical to dispel the model minority myth, stigma and shame around mental illness, and recognize provider discrimination and biases in referral and treatment of care. This will require development of future research focused on accurately differentiating between depression, anxiety, and trauma as well as co-morbidity between these conditions within AA and NHPI youth. Related to this issue is the need to educate providers about the effects of stigma and shame in compromising the ability for individual patients to communicate symptoms and providers to make accurate diagnoses related to mental health.^{100,103–106} Convening disparate and diverse groups of AAs and NHPIs with their providers around mental health and illness is paramount in fostering collective agency and reducing isolation and stigma. Integrated delivery strategies combined with community and provider education may further break down the barriers associated with stigma and create both patient- and family-centered approaches to health and, ultimately, reduce population health disparities.

In terms of cultural variables: socioeconomic status, family cohesion, family conflict, intergenerational conflict, parent-child conflict, cultural orientation, and ethnic pride seem to be outcomes in some ways of larger cultural beliefs though they have not been measured as such. Acculturation appears to erase important protective factors, and it surfaces the tension, stress, and conflict that can come about or arise from the pressures to conform to dominant norms. Acculturation is complex, and factors such as English language proficiency, length of residence in the U.S., and nativity have a significant impact on mental health, access, and utilization of mental health services.^107–109

Our findings also suggest religion and spirituality as a protective factor in a study of Korean American youth. This is an emerging area that requires more exploration in other AA and NHPI groups given the social roles and points of intervention that faith-based organizations and spiritual leaders may play on the influence of stigma, issues of spirituality, religiosity, death and suicide. Along with religiousness, this area of study on social comparison has surfaced and is an important area to pursue.