Depression

2.3.1 Definition and features

Depression is a significant mental disorder worldwide. The World Health Organization (WHO) reported that depression affects 350 million people across the world, and on average about 1 in 20 people reported having an episode of depression in the previous year. Depression is also the leading cause of disability worldwide in terms of total years lost due to disability (Marcus, Yasamy, Van Ommeren, Chisholm, & Saxena, 2012).

The definition of depression varies based on different theories. Nurcombe (1994) indicated that the term depression can be interpreted in several ways, including a momentary affect, a prevailing mood, a complex of conscious and unconscious ideas and feelings, a syndrome dominated by depressive mood, a disorder, or a hypothetical disease.

Also, Petersen, Compas, Brooks-Gunn, Stemmler, Ey, & Grant (1993) categorize the assessment of depression into three approaches:

(1) Depressed mood: Periods of sadness or unhappy mood which are commonly experienced by individuals in their life, and may occur in various situations, such as loss of significant others or failure on an important task. Depressive mood is typically measured by self-report instruments, either through measures

especially concerned with mood (e.g., Petersen, Schulenberg, Abramowitz, Offer, & Jarcho, 1984) or through items included in checklists of depressive symptoms (e.g., Radloff, 1977), based on an individual's perceived emotional status.

(2) Depressive syndromes: A series of psychological complaints that include symptoms relating to anxiety and depression, such as loneliness, fears of doing bad things, the need to be perfect, feeling unloved, a sense of worthlessness, nervousness, guilt, self-consciousness, suspiciousness, sadness and/or worries (Achenbach, 1991a, 1991b, 1991c as cited in Petersen et al., 1993).

(3) Clinical Depression: The most widely used definition of clinical depression, referred to as Major Depressive Disorder (MDD) by the American Psychological Association (APA), is a mental disorder with identifiable symptoms that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning for an individual. To meet the criteria of MDD, five or more symptoms (and at least one of depressed mood and loss of interest or pleasure) needs to be experienced by an individual in the same 2-week period:

(a) Depressed mood; (b) Loss of interest or pleasure; (c) Change in weight or appetite; (d) Insomnia or hypersomnia; (e) Psychomotor retardation or agitation;

(f) Loss of energy or fatigue; (g) Worthlessness or guilt; (h) Impaired concentration or indecisiveness; and (i) Thoughts of death or suicidal ideation or attempt (American Psychiatric Association, 2013, p.94-95).

Numerous research has pointed out that depressive mood, syndromes, and disorders often co-occur with other symptoms and disorders, and suicide is one of the most frequently mentioned (Petersen et al., 1993). Depressed mood has been reported as a strong predictor of suicidal ideation (Harrington, 2001; Kandel, Raveis, & Davies, 1991),

and a high proportion of suicide attempters are found to be depressed (Rotheram-Borus

& Troutman, 1988; Spirito, Overholser, Ashworth, Morgan, & Benedict-Drew, 1989).

Studies also found an increased rates of completed suicide in depressed adolescents, and that mood disorder such as MDD is one of the risk factors for completed suicide after an attempt (Harrell, 2000; Rao, Weissman, Martin, and Hammond, 1993). In addition, depressed mood, drug use, and suicidal ideation are strongly related (J. Block & Gjerde, 1990; Kandel et al., 1991).

Moreover, depression is also frequently related with eating disorders (Attie, Brooks-Gunn, & Petersen, 1990; Katon, Kleinman, & Rosen, 1982; Rivinus et al., 1984). It is one of the main factors for individuals who have experienced deliberate self-harm to repeat the behavior (Harrington, Kerfoot, Dyer, E., McNiven, F., Gill, J., Harrington, V., &

Byford, S. (1998). In addition, based on a follow-up study for averagely 15.6 years in the U.S., depressed mood is highly correlated with health behaviors associated with the development of diabetes among men and women aged 25–74 years (Carnethon, Kinder, Fair, Stafford, & Fortmann, 2003).

To sum up, depressive mood, syndromes, and disorders are related to a broad spectrum of other disorders and problems for both the clinical population and the general public, and thus need to be considered when evaluating an individual’s mental health. In this study, depression refers to depressed mood and depressive syndromes that represent the common experience of the majority of international students’ general emotional disturbance (or lack thereof) in the process of adapting to a new culture.

2.3.2 Depression among international students

Research has indicated that the experience of adapting to a new culture can have potentially detrimental psychological and emotional impacts on these students (Constantine, Okazaki, & Utsey, 2004; Sandhu, 1994; Wei et al, 2007). For example,

international students may experience psychological and interpersonal dysfunctions, such as communication barriers, maladjustment to weather or food, fear, academic stress, social withdrawal, ethnic discrimination, anger, and sadness (Chen 2011; Huang, 2008;

Shih, 2006).

It is commonly suggested that sojourners tend to feel depressed in their new country, and many international students are reported to have feelings of depression, often described as down, depressed, and sad (Brown & Holloway, 2008). As various studies have indicated, adjusting to an unfamiliar environment requires personal, social, and environmental changes, which can lead to anxiety, confusion, and depression for an individual (Choi, 1997; Lin & Yi, 1997; Sandhu, 1994). Research also points out that during this period of adjustment, international students may experience isolation, loneliness, and hopelessness, and these symptoms may be the manifestation of depression (Mori, 2000; Sümer, Poyrzli, & Grahame, 2008).

Studies show that depression has been one of the top concerns among international students who seek help from university counseling centers (Nilsson, Berkel, Flores, &

Lucas, 2004; Yi, Lin, & Yuko, 2003). Wei et al. (2007) also reported that about 30% of Asian international students’ in the U.S. scores are above the cutoff point as an indicator for potential clinical depression. However, there is no research conducted in Taiwan that directly measures international students’ depression levels. Therefore, this study seeks to fill this current gap in the literature.

2.3.3 Depression and microaggressions

Many scholars have noted that racism and racial/ethnic discrimination is related to the poor mental health of minorities (Buser, 2009; Cortina, & Kubiak, 2006; Santana, Almeida‐Filho, Roberts, & Cooper, 2007; Williams & Williams-Morris, 2000). Evidence also suggests that microaggressive stressors can be implicated in the manifestation of

mental illness such as depression and anxiety (Balsam, Molina, Beadnell, Simoni, &

Walters, 2011; Sue, 2012; Torres, Driscoll, & Burrow, 2010). For example, in Sue, Nadal, Capodilupo, Lin, Torino, and Rivera’ study (2008), participants reported feelings of anger, frustration, doubt, guilt, or sadness when they experienced microaggressions. Also, Sue (2012) lists psychological symptoms reported by the recipients of microaggressions, such as fatigue, hopelessness, and withdrawal from social activities, all which are found to be correlated with depression.

Furthermore, even though there is no obvious evidence, various studies in Taiwan indicated the potential relation between microaggression and depression. For example, Fan and Ni (2013) indicated that immigrant women who experienced racial microaggression reported negative emotional responses, such as isolation and passiveness which are factors of depression. Similarly, Wu (2013) indicated that perceived discrimination is predictive of greater depression symptoms among immigrant Women.

As for the international student population, studies found that perceived discrimination, which includes instances of microaggression, to be a contributing factor to depression level. These studies then suggest that international students’ experience of discrimination may be a factor of their depression levels (Jung, Hecht, & Wadsworth.

2007; Noh and Kaspar’s 2003, Wei et al, 2008). Moreover, research shows that microaggressions may be linked to a negative impact on an individual's ability to cognitively process information, which is a depressive symptom (Boysen, 2012;

Salvatore, & Shelton, 2007). A qualitative study in Taiwan also implied that microassaults, such as being verbally insulted because of an international students’ skin color, may lead to increased mental distress and perceived hostility in a school environment (Shih, 2006).

Therefore, it was predicted that there would be a positive relation between perceived microaggressions and depressive symptoms for international students in Taiwan in the

present study.

2.3.4 Depression and acculturative stress

Research has indicated that entering into a new culture and adjusting to the unfamiliar environment can have potentially detrimental effects on people's mental health, including anxiety, confusion, and depression (Berry, 1997; Lin & Yi, 1997; Mallinckrodt

& Leong, 1992; Sandhu, 1994). Similarly, Berry (1988, as cited in Berry, 1997), addressed that when changes in a multicultural context exceeds an individual’s capacity to cope, psychological disturbance occurs and may lead to clinical depression and anxiety.

In addition, numerous studies have suggested that a higher acculturative stress level is predictive of greater mental health symptoms, depression in particular, among international students (Constantine et al., 2004; Lee, Koeske & Sales, 2004; Ying & Han, 2006; Wei et al., 2007).

For international students in Taiwan, Lee (2000) found a negative relationship between life stress level and psychological adjustment symptoms, including depression, anxiety, anger, sleep deprivation, etc. For other cross-cultural groups, research also shows a positive relationship between acculturative stress level and depressive symptoms/mental health, and a negative relationship between life stress level and general mental health, among immigrant women (Chang, 2008a; Fang, 2011; Jiang, 2006).

However, no study has explicitly stated the specific relationship between acculturative stress and depression for international students in Taiwan. Therefore, this study aims to explore how the process of acculturation relates to mental health issue of international students in Taiwan.