Ethnicity & Health

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Community leaders’ perceptions of depression and

the perceived barriers in seeking mental health
services for older Korean Americans

Eunhye Kim, Tiffany R. Washington & Rosalyn Denise Campbell

To cite this article: Eunhye Kim, Tiffany R. Washington & Rosalyn Denise Campbell (2022)
Community leaders’ perceptions of depression and the perceived barriers in seeking mental
health services for older Korean Americans, Ethnicity & Health, 27:7, 1483-1500, DOI:
10.1080/13557858.2021.1910627

To link to this article: https://doi.org/10.1080/13557858.2021.1910627

Published online: 12 Apr 2021.

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ETHNICITY & HEALTH
2022, VOL. 27, NO. 7, 1483–1500
https://doi.org/10.1080/13557858.2021.1910627

Community leaders’ perceptions of depression and the

perceived barriers in seeking mental health services for older
Korean Americans
Eunhye Kima, Tiffany R. Washingtonb and Rosalyn Denise Campbell b

a
Department of Social Science, Augusta University, Augusta, GA, USA; bSchool of Social Work, University of
Georgia, Athens, GA, USA

ABSTRACT ARTICLE HISTORY

Objectives: This study explored community leaders’ understanding Received 20 October 2020
of depression among older Korean Americans and barriers to Accepted 25 March 2021
seeking mental health services. Depression is prevalent among
KEYWORDS
older Korean Americans, but they are less likely to seek help from Community leaders;
professionals and prefer to use informal methods. Older Korean depression; older Korean
Americans strongly prefer to maintain their ethnic traditions and Americans; understanding of
use community service agencies provided by their same ethnicity. depression; barriers
In this regard, community leaders who provide services for older
adults play a significant role in not only advocating for the
population but also in developing services and programs for their
communities.
Design: In this qualitative study, 12 Korean community leaders who
provide services for older adults were interviewed. Data were
analyzed thematically, and Nvivo 12 was used to organize the
data and to detect relevant themes.
Results: Findings showed that community leaders had an in-depth
understanding of the causes of depression from environmental and
cultural contexts including isolation, losing independence, cultural
factors, and lack of family support. However, although the leaders
were aware of the severity of depression among older Korean
Americans, they did not understand biologically-based factors;
rather, they considered it a natural part of aging. Findings
indicated that they were biased towards older adults like older
Korean Americans, attributing depressive symptoms to
personality issues. They also heavily rely on personal experiences
to understand depression instead of on having educational
training. Barriers to getting help for older adults include lack of
the perceived need of older adults, lack of professionals, and a
prevalent stigma against depression that encourages individuals
to hide their illness.
Conclusions: The findings indicated that community-based
educational training is necessary to increase understanding of
depression not only for the community leaders but also for
individuals and families.

CONTACT Eunhye Kim ekim1@augusta.edu Department of Social Science, Augusta University, 1120 15th St,
AH223, Augusta, GA 30912, USA
© 2021 Informa UK Limited, trading as Taylor & Francis Group
1484 E. KIM ET AL.

Introduction
Although depression is not a normal part of aging (Alexopoulos et al. 2001), it is a preva-
lent mood disorder among older adults (Valiengo, Stella, and Forlenza 2016). This is pro-
blematic because depression in later life negatively impacts one’s quality of life by
increasing risk of cognitive decline, dementia, and suicide (Brailean et al. 2016). As a con-
sequence, it increases the likelihood of requiring institutional services (Harris 2007) and
mortality (Bogner et al. 2012). Disparities in mental health still remain a large concern in
our society, particularly in older minority populations with mental health problems
(Abe-Kim et al. 2007; Centers for Disease Control and Prevention 2012). Depressive
symptoms are also more prevalent among ethnic minority populations than non-Hispa-
nic Whites (Kuo, Chong, and Joseph 2008; Sue et al. 2012). Ethnic minority populations
consistently have substantially unmet needs for mental health services (Jang et al. 2019;
Barrio et al. 2008), especially older Asian Americans.

Asian Americans and mental health

Depression in older Asian Americans deserves more attention. Despite being the fastest-
growing older population in the U.S. (Pew Research Center 2012), older Asian Ameri-
cans with mental health problems are underserved in health and community care, and
they likewise underutilize mental health services (Kim et al. 2015). Furthermore, many
older Asian Americans immigrated in their later life to the United States to reunite
with adult children. Older adults who immigrated in their late life are susceptible to
mental health issues due to difficulties adjusting to new linguistic, cultural, and social
environments. Previous studies found that limited English proficiency (Bernstein et al.
2011), acculturation stress (Mui and Kang 2006), and limited social networks (Hossen
2012; Kim, Sangalang, and Kihl 2012) are the main contributing factors to the poor
mental health status of older Asian Americans. Furthermore, the suicide rate of older
Asian Americans is high compared to other ethnic minorities (Centers for Disease
Control and Prevention 2014).
Among these minorities, older Korean Americans have reported an unusually high
level of depression (Bernstein et al. 2011; Kim et al. 2015). However, utilization of
mental health services among the population is low (Lee et al. 2014; Park et al.
2013). Previous research found that multiple factors are associated with the low utiliz-
ation of mental health services including the level of acculturation (Guo and Stensland
2018; Jang and Chiriboga 2010), language barriers (Kang et al. 2010; Lee et al. 2008),
transportation (Wu, Kviz, and Miller 2009), stigmas (Park, Jang, and Chiriboga 2018),
and mental health literacy (Jang, Gum, and Chiriboga 2011; Kim et al. 2017). Although
many studies have found associated factors with depression among minority popu-
lations at the individual level (Jang, Kim, and Chriboga 2011; Park et al. 2013) and
low utilization of mental health services (Jang et al. 2020; Lee et al. 2014), there has
been limited research examining how one’s community context could increase the
use of mental health services (Lee et al. 2008). Research findings of previous studies
have emphasized the importance of developing culturally tailored interventions to
increase access to mental health services for minority communities (Chung, Seo, and
Lee 2018; Kim et al. 2015). Still, little qualitative research has been done to attain a
 ETHNICITY & HEALTH 1485

deeper understanding of the role of the community and its leaders on older Korean
Americans’ use of mental health services.

The importance of community among older Korean Americans

Older Korean Americans tend to live in major U.S. metropolitan areas, and these com-
munities are vital places for prevention, early screening, treatment, and recovery of
mental health issues (Substance Abuse and Mental Health Services Administration
2013). Approximately 60% of all Korean Americans were concentrated in 10 metropoli-
tan areas, with the largest Korean American populations in Los Angeles, New York, and
Washington, DC (Pew Research Center 2017). Given the language barriers and cultural
differences, interacting with the same ethnic group helps immigrants share information,
receive social support, and build social capital (Lee 2014; Pew Research Center 2012).
Within Korean communities, most older adults live independently in subsidized
senior housing and use Korean-owned agencies and social services in areas with
Korean business concentrations. Service agencies targeting older Koreans provide infor-
mal supports to older adults and supply culturally tailored services including meals,
home care services, and case management (Kim and Lauderdale 2002). In addition,
older Korean Americans prefer to use services provided by their community agencies
or religiously affiliated agencies (Kim et al. 2013). In this regard, their communities
are vital for older adults not only to receive social and institutional support but also
mental health services.
In spite of the importance of community, cultural stigma toward mental health in the
form of isolation, blame, and neglect prevents older adults with mental health issues from
using professional services (Jung et al. 2020). Community leaders play a significant role in
advocating for their ethnic communities and participate in change policy to support
those minority groups as a gatekeeper. Their perception of need, their expertise, and
their environment are associated with the decision to personally provide services or
refer an individual to professional help (Stiffman, Pescosolido, and Cabassa 2004);
however, little is known about Korean community leaders’ perceptions about depression.
An examination of their perceptions is an important endeavor, because those who have
dual roles in providing services and being opinion leaders are important for facilitating
use of mental health services or referring services. In this vein, understanding the per-
spective of community leaders who work closely with older Korean Americans to
provide services helps capture insight about the community’s current attitudes toward
mental health issues, and it also provides a foundation to develop interventions to
increase access to mental health services.

Methods
This study employs qualitative methodology to explore the community leaders’ perspec-
tives and experiences regarding depression among older Korean Americans. Specifically,
this study uses the descriptive approach in which participants’ responses were interpreted
organically with attention to their voice and contexts. This approach stresses the impor-
tance of understanding less-understood populations. Ethical approval was obtained by
1486 E. KIM ET AL.

the researcher’s university Institutional Review Board (IRB). Participants received a $30
gift card as compensation at the end of the interview.

Study procedures and participants

To select Korean community leaders, the researcher contacted gatekeepers of the Korean
community because they are knowledgeable about the community’s resources and influ-
ential leaders in aging service fields. These gatekeepers, including individuals like the
chief editor of a Korean newspaper as well as reporters knowledgeable about the commu-
nity, were consulted in order to identify Korean community leaders. The gatekeepers
provided the list of community leaders who serve older adults in director positions at
their agencies. The participants were selected based on the following criteria: (1) work
at an agency that provides services for older adults and (2) be a leader, with a positive
reputation, who has been committed to the Korean community for over 10 years.
Twelve Korean community leaders were recruited from Georgia in the United States.
The interviews were conducted between April and June 2018, and each lasted between
60 and 90 minutes. Interviews used semi-structured, open-ended questions and a vign-
ette of a depressed older adult’s case.

Data collection
In-depth interviews were the data collection method of choice because they are particu-
larly effective in allowing Asian American participants to freely express opinions in their
own words without the restriction of close-ended data collection instruments (Iwamasa
and Sorocco 2002). To further encourage this freedom of expression, all interviews were
conducted in Korean, as interviewing the community leaders in their first language helps
the researcher to explore in greater depth the experiences of participants. The interviews
were conducted at a place and time that was convenient for the participants, and the
audio-recorded interviews were transcribed verbatim in Korean.

Data analysis
The first author conducted a thematic analysis on the interview transcriptions using
NVivo 12. Thematic analysis allows the researcher to identify, refine, and discover
themes within the data. The first author followed six phases of the analytical process
developed by Braun and Clarke (2006): (1) read the interview transcripts thoroughly
to familiarize oneself with data, (2) generate preliminary codes, (3) sort similar codes
and construct themes, (4) review the themes, selecting those that best reflect the data,
(5) define and refine themes so that they capture the essence of each theme and the
aspect of the data captured, and (6) report the results. In the process of transcription orig-
inal meaning and the nuance of words can be easily lost (Smith, Chen, and Liu 2008). To
maintain the participants’ own nuances and meaning in translation in qualitative studies,
interviews were transcribed verbatim first in Korean and used for data analysis; specific
paragraphs of Korean transcription were translated later to English to present direct quo-
tations. The first author then worked with bilingual social workers and native speakers of
 ETHNICITY & HEALTH 1487

English to ensure translations were understandable in English, while retaining their orig-
inal nuance and meaning.

Results
Sample characteristics
Twelve participants were interviewed to better understand community leaders’ perspec-
tives about depression and barriers to service use among older Korean Americans. To
represent a diverse group of voices of community leaders who serve older Korean
adults, participants were recruited from three main services: five participants from
healthcare agencies, four participants from community service agencies, and three par-
ticipants from senior academic centers that are commonly provided by religious organ-
izations. Participants ranged in age from 40 to 81 years, with a mean age of 61.3 years.
Almost 60% of participants identified as male, and 40% as female. A majority of partici-
pants had at least a bachelor’s level education, and 75% of them earned their final degree
in the United States. All participants were born in South Korea and preferred to use the
Korean language as their primary language. On average, they had resided in the U.S. for
30.6 years, with a range from 12 to 46 years.

Common themes related to perception of depression and perceived barriers

Through analysis process, 4 major themes emerged: depression as seen in Korean com-
munities, cause of depression in a Korean context, symptoms of depression, and barriers
to professional help-seeking. 15 subthemes were included to provide further context of
the large themes. These themes are shown in Table 1.

Depression as seen by Korean communities

Depression as a natural part of the aging process. Participants believed that depression is a
normal part of the aging process and did not recognize it as a mental health problem. One
participant expressed her belief regarding depression and communicating with older
adults about depression as follows:

Table 1. Themes and subthemes.

Themes Subthemes
Depression as seen by Korean Depression as a natural part of the aging process Prevalence of depression among
communities older Korean Americans
Lack of experience with depression in older adults
Relying on personal experience in understanding depression
Confusion with other diseases
Cause of depression in a Korean Losing independence
context Isolation
Lack of family support
Repression of emotion and patriarchal oppression in Korean culture
Attributing blame to elderly personality
Symptoms of depression Negative bias toward depressive symptoms
Barriers to professional help- Lack of awareness
seeking Stigma against depression
Hiding depression
Lack of professionals with their native language
1488 E. KIM ET AL.

In the aging process, due to hormone change, every older adult can have depression. I
recommend to them that they simply accept their depressed feelings and consider them
as friends. Sadness and depressed feelings are a part of our life. Older adults often feel fru-
strated because they cannot achieve what they plan or want. So they need to get used to
losing their abilities and giving up and also accept that depression is a normal part of
getting older. (Participant 6)

Another community leader stated that depression is part of aging process:

There are differences in terms of severity of depression, but most older adults do have it.
Suffering depression is a natural process of aging. In some severe cases, they may need to
take pills and participate in spiritual care. Life is up and down. Life is not always happy,
and sometimes, we struggle to maintain our lives because they are not as we planned
them. Physical pain impacts emotional changes as well. (Participant 7)

In addition, another participant expressed that depression is a common disease and

that they consider it a chronic illness among older adults:
The major reason that people do not pay attention to depression is that it does not cause
death immediately. Typically, it does not cause severe problems in the beginning, so
older adults who suffer from depression only seek help later when it becomes severe. Gen-
erally, depression is too common of an illness and we honestly need to consider it as a
chronic disease. (Participant 8)

Prevalence of depression among older Korean Americans. Most community leaders per-
ceive that depression among older Korean Americans is common and prevalent. Leaders
demonstrate a lack of awareness of depression:
Older adults do not express that they are depressed, but I know a lot of older Koreans suffer
from depression in this area. Depression among older adults is fairly common in Korean
communities. (Participant 5)

Another leader who works at the healthcare facilities stated that they observed high
prevalence of depression, but the clients tend to strongly deny and do not admit they
have depression:
Depression among older adults is pretty common in Korean communities. Almost 60 to
70% of older adults in my agency suffer from depression. They are slightly aware of
their depression, but they never admit they are depressed. They are taking an anti-
depressant pill, but they believe that they are taking it for their general health, not
for mental health problems. Older adults do not believe they have depression. (Partici-
pant 12)

Lack of experience with depression in older adults. Most community leaders fre-
quently interact with older Korean Americans through their work and social activities
and also acknowledge the severity of depression among older Korean Americans.
However, community leaders who primarily serve older adults in community service
programs stated that they had not seen many people suffer from depression in these
settings:
I have committed this agency to serve Koreans for over ten years. I haven’t seen anyone who
suffers from depression in our program. These people do not come out to seek help, instead
staying at home. We have provided free counseling for people who suffer from mental health
issues, but no one came to here to use the services. (Participant 3)
 ETHNICITY & HEALTH 1489

Another participant stated the lack of contact with older adults with depression
because of the characteristics of their services:
I know many older adults suffer from depression and they need help. We need to go to out-
reach to support them; however, there is no channel to contact those people unless someone
refers them to us. Actually, it is hard to meet older adults with depression because our
agency provides services for active adults. (Participant 8)

Relying on personal experience in understanding depression. Community leaders not only

serve Korean communities but also provide services for older adults in their agencies.
However, all community leaders do not have an opportunity to have official training
about mental illness, nor do they always understand depression based on their personal or
family suffering. For some, personal experience helps them understand aspect of depression:
I know a little bit about symptoms of depression and how individuals react to their illness.
My brother currently suffers from depression because of extreme stress. He can’t sleep well
and experiences radical emotional changes. I recommended to him that he see a doctor, but
he strongly denies the symptoms and illness. I think he is in the initial stage of depression.
(Participant 1)

Another participant expressed that she had depression for six months because of her
spouse’s sudden death, and it was helpful for understanding how people with depression
survive from it:
I never understood why people with depression struggled to such an extent to overcome it
before I had it. I had depression for six months after my husband passed away. I lost my
appetite, it was hard to sleep, and all I did was lay down all day. I didn’t have energy to
do anything. (Participant 9)

Confusion with other diseases. Participants confused depression with dementia and
expressed increasing interest in dementia among older adults. A participant expressed:
I think if depressive symptoms become severe, it develops into dementia. Lethargy and loss
of memory can be symptoms of Parkinson’s disease as well. All these types of conditions
begin with depression. (Participant 6)

Another participant stated the strong connection between depression with dementia
and an increasing interest in dementia:
When people stay alone at home without working, they become absorbed in oneself and
have delusions and then cannot get restful sleep at night. When those symptoms become
severe, it is a beginning sign of depression. So they become more isolated and have demen-
tia. Many older adults are interested in dementia, so I also provide information regarding
dementia. (Participant 1)

In addition, participants were aware of the need for dementia treatment in Korean
communities and expressed the importance of support for people with dementia:
Depression is a problem among older Korean Americans. However, many older adults have
dementia, and older adults are more interested in preventing it. The president of the senior
academic program maintained his position over 20 years and awarded presidential recog-
nitions, but he cannot come to this program anymore because of his dementia. I do not
know anyone who suffers from depression, but I know many people with dementia. We
need to pay more attention to dementia. (Participant 5)
1490 E. KIM ET AL.

Cause of depression in a Korean context

Contributing factors to depression in late life can vary. Late life depression can result
from a complex interaction among genetic factors, psychosocial factors (low social
support, poor life satisfaction, or stressful event), and physical factors (including
chronic illness and reduced daily activity). The participants themselves understood the
causes of depression to be loss of independence, isolation, lack of family support, repres-
sion of emotion, or an attribute of personality.
Losing independence. After immigrating to the United States later in life, many older
Koreans experience a loss of independence that can cause depression:
Many older Koreans cannot drive, particularly if they are over 70 years old. They cannot
go anywhere without transportation supports from others. I heard many older adults say
that ‘I became a stupid person since I moved into the U.S. because I cannot do anything
independently without help from my children.’ They feel frustrated and depressed
because they lost all independence and cannot gather with others freely without help.
(Participant 12)

Another participant stated that increasing dependence due to physical changes is

related to depression among older adults:
Older adults feel frustrated because of physical decline. Their think they are young, but their
body does not work like young people. I know many cases when they cannot drive any
longer or go outside independently; they become depressed. When they are dependent on
others, they become lethargic and depressed. (Participant 11)

Isolation. Participants stated that lack of social interaction or communication is a

primary factor that causes depression among older Koreans:
Older Korean Americans do not have friends to talk to and struggle to communicate with
their adult children. They have a different culture than their adult children who are growing
up in the U.S. and language barriers. They become more isolated by getting older, so they
become depressed. (Participant 9)

Another participant stated that older Korean Americans who immigrated later in life
struggle to make this transition, which results in isolation:
I guess there are many older Korean Americans suffering from depression. Many older
Korean Americans came to the United States to reunite with their adult children. In the
case of immigrating to the U.S. over 60 years old, their lives are limited to home or their
families, so they only take care of their grandchildren and do some house chores. When
grandchildren grow up and do not need care from their grandparents, their adult children
let their parents live independently. Thus, many older adults live alone in senior apartments.
They think they are abandoned by their children and have chronic illnesses, so they become
depressed. (Participant 6)

Lack of family support. There is strong emphasis on the importance of family among
Korean Americans. Participants believe that family members’ care is important and lack
of care from their children contributes to depression. A participant stated the importance
of family support:
I think family members have a responsibility to take care of their families. I don’t understand
how their family members let them suffer from depression. Family members need to express
how much they care about them and give them more attention. (Participant 5)
 ETHNICITY & HEALTH 1491

Another participant valued filial piety and said that lack care from their children con-
tributes to depression:
Everyone can be depressed, particularly because depression can often come from loneliness.
Older adults are less likely to be depressed when their children live to close to them and they
get support from them. On the other hand, older adults living alone tend to feel more lonely,
so they try to resolve it by drinking alcohol, smoking or crying at night. Older adults who are
able to come to an adult daycare center are much better, but the other older adults, who
couldn’t come, tend to be more severe in their symptoms and struggle to manage their
depression. (Participant 12)

In addition, another participant described limited communication with family

members, exacerbated by language barriers:
If older adults freely talk or communicate with others, they would be less depressed. They
cannot speak English so they communicate with only their family members. But their family
members are busy and don’t take care of them, so they have no relationships with others.
(Participant 3)

Repression of emotion and patriarchal oppression in Korean culture. Participants

believe that in a patriarchal society, older Korean women are oppressed and forced to
sacrifice their lives to support their spouses and children. A participant expressed how
this oppression can lead them to repress emotion through their lives in Korean
culture, which influences their depression:
In Korean culture, Korean women tend not to express their emotion or repressed feelings.
They should be encouraged to express their suppressed feelings with others. Their unre-
solved feelings compile over time and cause depression. (Participant 9)

Another participant stated that a lack of expressed feeling in Korean culture is aggra-
vated through the challenge of immigrant life:
I think Korean women suffer from depression more than other populations because they
have been influenced by Confucianism and always oppressed by others. Korean culture
pushes them to sacrifice their lives to support their husband and children and even
society. Communication is critical to them to express their repressed feelings; however,
they may feel frustrated because they cannot communicate with their adult children and
grandchildren due to language barriers. (Participant 4)

Attributing blame to elderly personality. Participants expressed that older adults with
depression have personality problems. They believe depression is caused by individual
personality and can be overcome by changing their attitudes:
The problem is older adults do not admit they are old. They also do not listen to other’s
advice. They need to change their mindset. However, they are so stubborn and don’t
want to talk with others. Older adults need to change themselves to treat the depression.
If they do not have an open mind to others, they cannot change nor overcome depression.
(Participant 1)

Symptoms of depression
Common symptoms of depression in older adults include experiencing depressed mood
or loss of interest in most activities for at least two weeks . However, most participants
connect depressive symptoms to negative behaviors.
1492 E. KIM ET AL.

Negative bias toward depressive symptoms. Most participants view depressive symp-
toms and behaviors negatively. They feel that older adults with depression show negative
behaviors against others and struggle to interact well with others:
People who are suffering depression do not trust others, are extremely self-defensive, protect
themselves, do not get along with others and are agitated. They drink a lot of alcohol to over-
come depression. They are hard to make eye contact with and shake their body while they
are talking. (Participant 12)

Another participant expressed aggressive behavior as a depressive symptom:

I saw many older Koreans with depression. Those people do not eat or sleep well and do not
get along with others. Furthermore, they always blame others and show unstable behavior.
They tend to speak rudely, are fickle, and reject others. (Participant 9)

However, one participant expressed that two key factors can lead to the need to see a
doctor:
As I know, symptoms of depression vary, even the causing factors. Most common symptoms
are difficulty sleeping, experiencing unexplained physical pain, and having extreme
emotional swings, and so on. They need to see a doctor if these symptoms last over two
or three weeks (Participant 8).

Barriers to professional help-seeking

Understanding what community leader consider barriers to using mental health services
is important because they are stakeholders that can develop services for older adults
within their communities.
Lack of awareness. Most community leaders indicated that older adults do not recog-
nize their depression. A participant expressed that lack of awareness of depression is
common among older Korean American:
Depression among older Korean Americans is prevalent and severe. They do not recognize
signs of depression. When they stay at home alone, they may find it difficult to recognize
that they are depressed. They really do not know the symptoms of depression. (Participant
11)

Another participant stated that in case of acknowledging their illness, older Koreans
do not admit that they feel depressed or have symptoms of depression:
Almost all older adults deny or do not admit they are depressed. Korean people believe when
people see psychiatric doctors or take pills regarding mental illness, they think they are a
crazy person. Among 10, only one or two older adults talk to us about their depression.
Sometimes, they will joke and say, ‘I’m depressed,’ but they are hardly aware that it is
severe, and they need to see a doctor or take pills to treat it because of the stigma attached
to mental illness. (Participant 6)

Stigma with depression. Stigma is strongly attached to mental illness in Korean culture.
Stigma along with pride prevent older Korean Americans from admitting their struggles
with depression:
Older Koreans believe that depression is a sort of severe psychiatric problem and feel embar-
rassed to tell someone their illness because of the stigma associated with depression. They
are the first generation of immigrants and have worked so hard to settle down in the U.S.
 ETHNICITY & HEALTH 1493

Some older adults did not graduate from elementary school and are sensitive to the thought
of being looked down upon by others. They do not admit or disclose their struggles with
anyone because having mental health problems can be stigmatized and cause one to be
looked down upon by others. (Participant 12)

Another participant expressed that older adults’ perception regarding mental illness is
strongly stigmatized and that it is hard to refer them to services:
I think our understanding of depression and psychiatrists is quite different from the older
adults’ understanding. We think that a psychiatrist is another type of doctor; however, older
adults believe they only see the psychiatrist when they are really crazy or maniacs. It is hard
to refer them directly to the doctor, so I usually talk with their adult children first. (Partici-
pant 11)

Hiding depression. Most participants expressed that even though some older adults are
aware of their illness, they do not seek help or express their depression:
Older adults need to admit they are depressed. Older adults heavily rely on antidepressants.
However, they tend to refuse to talk about or express their depression. Older adults experi-
encing depression come to me and talk a little about their depression but told me ‘It’s secret
and please do not to talk to anyone about my illness’. (Participant 10)

Another participant stated that Korean culture prevented them from seeking help:
Saving face is dominant in Korean culture. People with depression never express their
depression nor admit it. These people do not seek help from professionals and do not
openly talk about depression. (Participant 9)

Furthermore, religious organizations support older adults emotionally and spiritually,

but older adults are less likely to seek mental health support in religious communities:
Older adults with depression do not actively seek help or express their depression. They are
hiding it even with church members. Although clergy provide support for them, they may
not express … . Unless the case becomes severe. They will never tell anyone about their
depression. (Participant 4)

Lack of professionals with their native language. Given the cultural stigma against
depression, Korean professionals need to support older adults with depression. Partici-
pants stated that there are no mental health professionals who speak Korean and
deeply understand Korean cultures in their communities. The scarcity of the needed pro-
fessionals was expressed:
I know many mental health clinics and treatment centers that serve for native speakers, not
for Korean speakers. If they want to see a doctor, they need to bring a translator to under-
stand English. It is hard to take a translator whenever they see the doctor. There are subtle
gaps in meaning and understanding symptoms and illness between doctors and older adults
because of different cultures and language barriers. Even their children cannot take their
parents to the clinic because of their work. (Participant 12)

Another participant stated that they do not prefer to see a doctor in treating
depression because of the lack of availability of Korean doctors in their communities:
I know this community well, so I would not even consider seeing Korean professionals
because there are no Korean mental health professionals or doctors. I would rather to
seek help from a religious organization. It will be extremely hard to get support or treatment
1494 E. KIM ET AL.

because there is a lack of community resources regarding mental health treatment or pro-
grams. I would seek help, but I cannot get help from professionals in Korean communities in
my native language. (Participant 8)

Discussion
This study examined community leaders’ perceptions of depression and the barriers in
seeking help for mental health services among older Korean Americans. Four emerging
themes include depression as seen by Korean communities, causes of depression in a
Korean context, symptoms of depression, and barriers to professional help-seeking are
overlapping and thus are discussed together.
Beliefs and expression about mental illness vary based on a person’s social and cultural
environment (Kleinman 1980; Kirmayer 2001). Korean community leaders had recog-
nized the severity and prevalence of depression among older Korean Americans;
however, their understanding of the severity of depression was inconsistent with clinical
criteria. The leaders understood the socio-cultural contexts contributing to the experi-
ence of depression in older Korean Americans (Lee, Moon, and Knight 2005), but
lacked knowledge about the clinical manifestations of depression. This is particularly
concerning because undetected or misdiagnosed depression in older adults may
prolong feelings of hopelessness, fatigue, or other common symptoms. The community
leaders, like many older Korean Americans, believed that depression in late life is a
natural process of aging, and older adults should accept it as a chronic illness or a part
of their lives (Jang, Gum, and Chiriboga 2011). Indeed, older adults have an increased
risk for depression, but it is not an automatic consequence of aging (Centers for
Disease Control and Prevention 2017). This lack of recognition of depression as a
mental health problem is concerning because the leaders frequently interact with older
Korean Americans through their services and communities, but there are likely missed
opportunities to address depression. It is good that leaders acknowledge that older
Korean Americans are susceptible to having poor mental health issues because of
losing independence in the immigration process because the majority of older Korean
Americans lived alone in low-income. Older Korean Americans immigrate to the U.S.
to reunite with their children, but in the period of adjustment, they recognize their
dependency brings a burden to their children, causing them to decide to live alone. Find-
ings of this study showed that community leaders believed that isolation and losing inde-
pendence are two of the primary reasons older Korean Americans experience depression.
Living alone, older adults are likely to have higher rates of depression (Lee and Holm
2011; Park et al. 2013). In addition, findings revealed that older adults have a lack of
support from their adult children and tend to have family conflict. Older adults living
with their children also experience disruption of relationships and are likely to have
emotional stress because of the conflict of traditional family values (Lee 2007; Lee and
Holm 2011). Similar to previous studies, the leaders believed that older adults having
family conflict is a substantial factor in having depression among older Korean Ameri-
cans (Guo and Stensland 2018; Chung, Jeon, and Song 2016; Lee, Moon, and Knight
2005). Furthermore, the community leaders believed that emotional repression due to
patriarchal gender roles is a profound reason for depression among older Korean Amer-
icans (Jang, Kim, and Chiriboga 2011).
 ETHNICITY & HEALTH 1495

Community leaders have knowledge about depression from a cultural perspective, but
lacked recognition of it as a disease to be treated medically in spite of their high awareness
of the prevalence of depression. Knowledge of mental health is strongly related to the use
of mental health services among older Korean Americans (Kim et al. 2017). The findings
showed that leaders heavily rely on personal experiences to understand depression. Con-
sistent with previous literature, older adults with higher depression literacy obtain
knowledge through informal methods (Baird et al. 2019). Regardless of their fields in pro-
viding services, the leaders have not had any educational training regarding mental
illness. All community leaders offer services to older adults, but they had not participated
or had mental illness training, nor are they seeking educational training.
In addition, the findings showed that the leaders wanted to provide general health
information for older adults and were less likely to discuss depression or other mental
health issues. Community leaders perceived that hiding mental illness is prevalent in
Korean communities because of shame and cultural stigma. These cultural stigmas nega-
tively influence people with mental illness from seeking help or using mental health ser-
vices (Park et al. 2013, 2015). The findings of this study indicated that the leaders also
have negative attitudes toward older adults with depression. Regarding the symptoms
of depression, the leaders believed that depressed older adults have personality problems
such as distrust, self-defensive tendencies, and anger management issues. Thus, the
leaders believed that older adults should change their personalities themselves to cope
with depression. Such negative attitudes and perceived cultural stigma not only
prevent the leaders from providing or referring older adults with depression to mental
health services but also make older adults reluctant to consult or seek help from pro-
fessionals. As community leaders are also service providers, they are the first point of
contact for many in the target population. However, due to the prevalence of stigma
in their population regarding mental health and previous negative experiences with care-
givers and the older adults, the leaders are more likely to avoid open discussion and
support for mental healthcare. It is important to help community leaders overcome
stigma and provide appropriate support for older adults.
Furthermore, the leaders also pointed out the low awareness of depression among
older adults is prevalent. Similar to previous studies, low level of awareness of
depression and failure to perceive the need for professional help prevent older
adults from using mental health services (Lee-Tauler et al. 2016; Park et al. 2013).
In this regard, the findings suggest that providing culturally tailored education about
depression for community leaders on how to communicate with older adults about
mental health problems is essential. In addition, offering training on ways to incorpor-
ate information about depression into their programs providing general health infor-
mation is effective by decreasing the avoidance of discussing mental health
problems. Lastly, community leaders addressed the lack of bilingual and culturally
competent professionals in their communities. The findings indicated that an increase
in Korean and Korean-language professionals may not overcome the deeply rooted cul-
tural differences and attitudes that currently discourage usage of mental health services.
In this regard, these results suggest that community-based interventions are vital for
older adults and educational sessions not only for the community leaders and older
adults are essential to increase the understanding of depression. In addition, local
states and health care providers need to collaborate with community leaders by
1496 E. KIM ET AL.

empowering them and providing resources and educational opportunities to support

the older Korean Americans actively.

Implications and limitations

The findings from this study have implications for community-based mental health
interventions within Korean communities. Because community leaders lacked knowl-
edge of depression and normalized the depressive symptoms of older adults in spite of
the awareness of the high prevalence of the issues in Korean communities, providing
educational training for community leaders may help improve attitudes and knowledge
toward mental illness. Their perception that depression is not a mental health disease is
deeply rooted in cultural and environmental contexts. Through their frequent interaction
with older adults, they fully understood how the cultural and environmental factors
influence older adults with depression. Thus, community-based interventions would
require cultural-tailoring in their design (e.g. materials written in Korean, images of
Korean Americans) and delivery (e.g. appropriate location).
Through the lens of the community leaders’ experience, this study reaffirms that feel-
ings of shame when seeking mental health services prevent older adults from seeking help
from professionals. The findings of this study suggest that promoting awareness of
depression is essential not only for the community leaders but also for older Korean
Americans. Community-based mental health practitioners will need to overcome this
utilization barrier to reach this population. Future research should identify facilitators
of mental health utilization among Korean Americans and use those tools to inform
intervention.
The findings of this study, however, should be interpreted with caution due to limit-
ations. The participants consisted of community leaders mainly from Georgia, which is a
newly emerging Korean community in the U.S. Also, most leaders were the first gener-
ation of Korean Americans, and this group may hold different beliefs and perceptions
than second generation Korean Americans. Inclusion of more young community
leaders from diverse service fields may provide different insights because second gener-
ation Americans have different assimilation experiences in the U.S. and different help-
seeking behaviors (Abe-Kim et al. 2007; Kim and Im 2015). In addition, although the
leaders included worked in diverse settings, including health care, ethnic academia,
and community activity programs, the study was limited to only understanding the com-
munity leaders who provide community and adult day care services for older adults
because medical providers or other professionals were not included. Future studies
should include community leaders from diverse fields and locations in both rural and
urban settings.

Conclusion
This study’s findings expand our understanding of how both older Korean Americans
and their community leaders share the lack of knowledge of mental illness and the
resources needed to address mental health problems. Community leaders also share
the same deep-rooted cultural stigmas on depression, leading them to fail to advocate
for older Korean Americans with depression or mental illness. Our findings on
 ETHNICITY & HEALTH 1497

community leaders’ understanding of depression help increase awareness of the impor-

tance of culturally tailored interventions and systematic approach to the Korean Amer-
ican community at the micro and macro level for supporting all older adults, family
members, and community leaders.

Acknowledgements
This work was supported by a graduate grant from the University of Georgia Dean’s Award.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
This work was supported by a graduate grant from the University of Georgia Dean’s Award.

ORCID
Rosalyn Denise Campbell http://orcid.org/0000-0001-6251-841X

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