who are new zealand’s asian people?

Psychosomatic symptoms in Psychosomatic symptoms in Asian populations: more than Asian populations: more than

a headache?a headache?

Presentation byPresentation byDr. Gen Numaguchi, Ph.D.Dr. Gen Numaguchi, Ph.D.

WCMHT – QueenstownWCMHT – QueenstownSouthern DHBSouthern DHB

Who are New Zealand’s Asian Who are New Zealand’s Asian People?People?

Asian people are the New Zealanders who Asian people are the New Zealanders who identify with or feel they belong to one or identify with or feel they belong to one or more Asian ethnicities. The largest ethnicity more Asian ethnicities. The largest ethnicity among Asian people is Chinese, followed by among Asian people is Chinese, followed by Indian, Korean, Filipino, Japanese, Sri Indian, Korean, Filipino, Japanese, Sri Lankan, Cambodian, and ThaiLankan, Cambodian, and Thai..

Demographics of Asians in NZDemographics of Asians in NZ

4.5 million people live in NZ; up from 4.5 million people live in NZ; up from 4,241,448 in 2013 census.4,241,448 in 2013 census.

European descent = 70%European descent = 70% Maori = 14.1%Maori = 14.1% Asians = 11% (471,708)Asians = 11% (471,708) Pacific Islanders = 6.9%Pacific Islanders = 6.9% ““Other” = 1.6%Other” = 1.6%

Demographics of Asians in NZ Demographics of Asians in NZ (continued)(continued)

Assuming a medium level projection, a Assuming a medium level projection, a further 250,000 Asians migrants are further 250,000 Asians migrants are expected between 2006 and 2026.expected between 2006 and 2026.

DefinitionDefinition

From the perspective of evolutionary From the perspective of evolutionary psychiatry, psychiatry, depressiondepression is related to the is related to the response to the lossresponse to the loss of significant of significant interpersonal relationships, social status, or interpersonal relationships, social status, or incentives, while incentives, while anxietyanxiety is related to the is related to the anticipation of threatsanticipation of threats to safety or integrity of to safety or integrity of body or self.body or self. (Kirmayer) (Kirmayer)

Mental Health Service Use – Mental Health Service Use – General PopulationGeneral Population

Individuals with mental illness were Individuals with mental illness were more more likely to experience unmet health care likely to experience unmet health care needsneeds and and less likely to receive quality less likely to receive quality medical caremedical care compared to the general compared to the general population.population.

As well, people in most parts of the world As well, people in most parts of the world do do not view emotional problems as appropriate not view emotional problems as appropriate issuesissues for health care per se. for health care per se.

Fact Regarding Asian CultureFact Regarding Asian Culture

Asian American femalesAsian American females have the have the highest highest suicide ratesuicide rate among women 65 years of age among women 65 years of age or older.or older.

Study in Biological DifferencesStudy in Biological Differences

Tufts University psychologist Nalini Ambady, Tufts University psychologist Nalini Ambady, Ph.D., conducted a study on how culture Ph.D., conducted a study on how culture shapes biology. Ambady’s group based the shapes biology. Ambady’s group based the study on historical data showing that study on historical data showing that East-East-Asian cultures value submissivenessAsian cultures value submissiveness, while , while Western cultures value dominanceWestern cultures value dominance. In fact, . In fact, they found, they could see this they found, they could see this cultural cultural distinction in the way the brain responds to distinction in the way the brain responds to visual inputvisual input..

Biological Differences - 1Biological Differences - 1

When an American thinks about whether he When an American thinks about whether he is honest, his brain activity looks very is honest, his brain activity looks very different than when he thinks about whether different than when he thinks about whether another person is honest, even a close another person is honest, even a close relative. That’s not true for Chinese people. relative. That’s not true for Chinese people. When a Chinese man evaluates whether he When a Chinese man evaluates whether he is honest, his brain activity looks almost is honest, his brain activity looks almost identical to when he is thinking about identical to when he is thinking about whether his mother is honest.whether his mother is honest.


When Americans viewed dominant When Americans viewed dominant silhouettes, but not submissive ones, reward silhouettes, but not submissive ones, reward circuitry fired in the brain’s limbic system. circuitry fired in the brain’s limbic system. The opposite happened among Japanese The opposite happened among Japanese participants; participants; their reward circuitry fired in their reward circuitry fired in response to submissive, but not dominant, response to submissive, but not dominant, silhouettessilhouettes..


Native Chinese, as opposed to Americans, Native Chinese, as opposed to Americans, are are more sensitive to the contextmore sensitive to the context in which an in which an object is embedded, and so focus greater object is embedded, and so focus greater attention on that object when it’s in an attention on that object when it’s in an inconsistent contextinconsistent context..


Westerners process human faces more Westerners process human faces more actively than East Asians, consistent with actively than East Asians, consistent with the the Western focus on individualityWestern focus on individuality..


Behavioral work by University of Michigan Behavioral work by University of Michigan psychologist Shinobu Kitayama, Ph.D., and his psychologist Shinobu Kitayama, Ph.D., and his colleagues showed that people from Japan are far colleagues showed that people from Japan are far better at judging the length of a line relative to the better at judging the length of a line relative to the size of a box in which it’s drawn, while Americans size of a box in which it’s drawn, while Americans are far better at judging the absolute length of the are far better at judging the absolute length of the same line. They attribute this difference to same line. They attribute this difference to findings from other studies showing that findings from other studies showing that Americans pay more attention to details and Americans pay more attention to details and Asians pay more attention to contextAsians pay more attention to context..


Northwestern University’s Joan Chiao, Northwestern University’s Joan Chiao, Ph.D., for example, has found that Ph.D., for example, has found that people people who live in collectivist cultures are more who live in collectivist cultures are more likely than those in individualistic cultures to likely than those in individualistic cultures to have a form of the serotonin transporter have a form of the serotonin transporter gene – the S-allele – that correlates with gene – the S-allele – that correlates with higher rates of negative affect, anxiety, and higher rates of negative affect, anxiety, and depressiondepression..


IIn contrastn contrast to what you might expect from to what you might expect from the genes alone, she also found that the genes alone, she also found that people people from collectivist societies are less likely to from collectivist societies are less likely to be depressedbe depressed. This suggests that . This suggests that collectivism, which tends to produce lower collectivism, which tends to produce lower levels of negative affect, may have co-levels of negative affect, may have co-evolved with the S-alleleevolved with the S-allele..


SSocieties of people with the S-allele ocieties of people with the S-allele developed a collectivist culture that reduced developed a collectivist culture that reduced stressstress and, therefore, risk of depression by and, therefore, risk of depression by emphasizing social harmony and social emphasizing social harmony and social supportsupport..

Roles of CultureRoles of Culture

Culture has Culture has effects on the neural systems, effects on the neural systems, psychological representations, and psychological representations, and interactional patternsinteractional patterns that constitute affect that constitute affect throughout the life-span.throughout the life-span.

Cultural ideologies, institutions, and Cultural ideologies, institutions, and practices provide the practices provide the context and rules for context and rules for interactional processesinteractional processes that underlie that underlie complex emotions.complex emotions.

Roles of Culture (con’t)Roles of Culture (con’t)

Cultural variations in the composition of the Cultural variations in the composition of the family, maternal-infant interactions, and family, maternal-infant interactions, and child-rearing practices all prime and shape child-rearing practices all prime and shape affect systems.affect systems.

Emotion ‘display rules’Emotion ‘display rules’ and body practices and body practices regulate socially acceptable and deviant regulate socially acceptable and deviant patternspatterns of emotional expression. of emotional expression.


Culture provides Culture provides categories and a lexicon categories and a lexicon for emotional experiencefor emotional experience, making some , making some feelings salient and others more difficult to feelings salient and others more difficult to articulate.articulate.

Culture Culture sets limits of tolerance for specific sets limits of tolerance for specific emotionsemotions and strong affect; it also provides and strong affect; it also provides lay theories and strategies for managing lay theories and strategies for managing dysphoria.dysphoria.


Culture Culture influences the sources of distressinfluences the sources of distress, the , the form of illness experience, symptomatology, the form of illness experience, symptomatology, the interpretation of symptoms, modes of coping with interpretation of symptoms, modes of coping with distress, help-seeking, and the social responsedistress, help-seeking, and the social response to to distress and disability.distress and disability.

Each of these ways in which culture may influence Each of these ways in which culture may influence the regulation of emotion has potential implications the regulation of emotion has potential implications for the expression of dysphoric affect in clinical for the expression of dysphoric affect in clinical settings.settings.

Cultural Differences - 1Cultural Differences - 1

People from collectivist culturesPeople from collectivist cultures, such as , such as China, think of themselves as China, think of themselves as deeply deeply connected to other people in their livesconnected to other people in their lives, , while while Americans adhere to a strong sense of Americans adhere to a strong sense of individualityindividuality..

Cultural Differences - 2Cultural Differences - 2

Asian Americans and Pacific Islanders Asian Americans and Pacific Islanders (APIs) generally place less emphasis than (APIs) generally place less emphasis than Western cultures place on individualism but Western cultures place on individualism but more on a collective corporate identify, such more on a collective corporate identify, such as family reputation.as family reputation.

In API cultures, the In API cultures, the family often is family often is considered to be more important than the considered to be more important than the individualindividual..

Perceptions of Mental IllnessPerceptions of Mental Illness

Stigmatization of people with mental illness Stigmatization of people with mental illness has persisted throughout history and is has persisted throughout history and is especially pronounced in Asian especially pronounced in Asian communities.communities.

Family members often try to conceal any Family members often try to conceal any history of mental illnesshistory of mental illness within the family to within the family to avoid any negative impact on the family and avoid any negative impact on the family and potential of the young person to become potential of the young person to become married to a suitable mate.married to a suitable mate.

Perceptions of MI (con’t)Perceptions of MI (con’t)

In seeking help for mental health needs, In seeking help for mental health needs, APIs APIs rely first on themselvesrely first on themselves to deal with to deal with any distress, and any distress, and only secondarily consider only secondarily consider seeking help from friends or family seeking help from friends or family membersmembers..

When these efforts do not work, When these efforts do not work, community community figuresfigures such as elders or spiritual healers such as elders or spiritual healers are sometimes consulted.are sometimes consulted.


They They rarely go to mental health rarely go to mental health professionalsprofessionals for help until they exhaust all for help until they exhaust all other possible resources, often waiting until other possible resources, often waiting until their conditions become severe and painful.their conditions become severe and painful.

Studies have found that Studies have found that primary care is the primary care is the major settingmajor setting where APIs seek services for where APIs seek services for psychological distress and disorders.psychological distress and disorders.


Many cultures view nonconfrontation and Many cultures view nonconfrontation and social harmony as paramount and social harmony as paramount and consequently consequently value the suppression or value the suppression or containment of both interpersonal and containment of both interpersonal and internal conflictinternal conflict..

As a result, individuals in these cultures are As a result, individuals in these cultures are less likely to open up to health care less likely to open up to health care providersproviders and to provide details of their and to provide details of their emotional state and social problems.emotional state and social problems.


Instead, Instead, emotional difficultiesemotional difficulties, including , including depression and anxiety, are often depression and anxiety, are often understood as sociomoral problemsunderstood as sociomoral problems more more appropriate to bring to a family member, appropriate to bring to a family member, elder, spiritual or community leader, or elder, spiritual or community leader, or someone else who is familiar with the someone else who is familiar with the complex web of social ties, past and complex web of social ties, past and present, that define a relational self.present, that define a relational self.

Expressions of Mental IllnessExpressions of Mental Illness

APIs tend to seek professional help through APIs tend to seek professional help through primary care providers and present their primary care providers and present their emotional distress through emotional distress through somatic signs somatic signs and symptoms instead of mental/emotional and symptoms instead of mental/emotional problemsproblems..

Significantly, they tend to Significantly, they tend to focus only on focus only on somatic suffering when seeking mental somatic suffering when seeking mental health carehealth care. Somatization among APIs has . Somatization among APIs has been well documented.been well documented.

Expressions of MI (con’t)Expressions of MI (con’t)

Hsu and Folstein (1997) found that Hsu and Folstein (1997) found that cardio-cardio-pulmonary and vestibular symptoms are the pulmonary and vestibular symptoms are the predominant physical complaintspredominant physical complaints among among Chinese American people.Chinese American people.

Miller and her colleagues (2003) also found Miller and her colleagues (2003) also found that that cardiovascular disease is the most cardiovascular disease is the most common physical condition among common physical condition among individual with chronic mental disordersindividual with chronic mental disorders..


The six leading principal physical diagnoses The six leading principal physical diagnoses among APIs with secondary psychiatric among APIs with secondary psychiatric diagnoses were (diagnoses were (1) nonspecific chest pain, 1) nonspecific chest pain, (2) poison with other medicine or drugs, (3) (2) poison with other medicine or drugs, (3) coronary atherosclerosis and other heart coronary atherosclerosis and other heart disease, (4) acute myocardial infarction, (5) disease, (4) acute myocardial infarction, (5) acute cardiovascular disease, and (6) acute cardiovascular disease, and (6) poison by psychotropic agentspoison by psychotropic agents..


The impression that Asians, Africans, and The impression that Asians, Africans, and others are more prone to somatize than others are more prone to somatize than North Americans has been based largely on North Americans has been based largely on anecdotal observationanecdotal observation or on research that or on research that compares people in very different health compares people in very different health care systemscare systems (Kirmayer). (Kirmayer).


The most common somatic symptoms of The most common somatic symptoms of depression and anxiety are musculoskeletal depression and anxiety are musculoskeletal pain and fatiguepain and fatigue (Kirmayer).(Kirmayer).

Japanese Specific ConceptsJapanese Specific Concepts

The culturally distinctive form of social The culturally distinctive form of social phobia termed phobia termed Taijin kyofusho (TKS)Taijin kyofusho (TKS) in in Japan provides an instructive example of Japan provides an instructive example of cultural influences on anxiety.cultural influences on anxiety.

Taijin kyofusho (TKS)Taijin kyofusho (TKS)

It is associated with It is associated with concerns about concerns about upsetting othersupsetting others rather than simply with rather than simply with one’s own embarrassment.one’s own embarrassment.

Awkward social behaviorAwkward social behavior, especially an , especially an inappropriately placed or timed gaze, is inappropriately placed or timed gaze, is viewed as harming othersviewed as harming others..

Taijin kyofusho (TKS) (con’t)Taijin kyofusho (TKS) (con’t)

A wide range of types and severity of social A wide range of types and severity of social anxiety, including apparently delusional anxiety, including apparently delusional forms, are grouped together by many forms, are grouped together by many Japanese psychiatrists as forms of TKS that Japanese psychiatrists as forms of TKS that may be responsive to similar cognitive may be responsive to similar cognitive interventions.interventions.

Taijinkyofusho predominantly Taijinkyofusho predominantly afflicts young afflicts young malesmales..


While While “pure”“pure” taijinkyofusho sufferers taijinkyofusho sufferers attribute their condition to some kind of attribute their condition to some kind of personal or character weaknesspersonal or character weakness involving involving their their inability to cope with interpersonal inability to cope with interpersonal situationssituations and eventually seek some form of and eventually seek some form of psychiatric help, psychiatric help, “serious”“serious” taijinkyofusho taijinkyofusho sufferers lack such insights, sufferers lack such insights, perceive their perceive their problems as realproblems as real, and attempt to deal with , and attempt to deal with them accordingly.them accordingly.


There is a consensus among Japanese There is a consensus among Japanese psychiatrists that taijinkyofusho is a psychiatrists that taijinkyofusho is a culture-culture-bound disorderbound disorder..

Western psychiatrists tend to diagnose Western psychiatrists tend to diagnose Japanese cases of taijinkyofusho as Japanese cases of taijinkyofusho as paranoia and paranoid schizophreniaparanoia and paranoid schizophrenia..


Miyoshi (1970) has suggested that the Miyoshi (1970) has suggested that the disorder is generated by the disorder is generated by the conflict conflict between the individual’s strong feelings of between the individual’s strong feelings of self-conceitself-conceit, which convince him that he is , which convince him that he is essentially different from others, and the essentially different from others, and the value of Japanese society places on value of Japanese society places on conformityconformity, which stresses that people are , which stresses that people are essentially the same.essentially the same.


Iwai (1982) views the major complaint underlying Iwai (1982) views the major complaint underlying taijinkyofusho disorders as less an actual “fear of taijinkyofusho disorders as less an actual “fear of strangers” than a strangers” than a state of anxiety aroused by state of anxiety aroused by doubts concerning one’s acceptability to othersdoubts concerning one’s acceptability to others, , and suggests that a more appropriate term for the and suggests that a more appropriate term for the disorder might be “jikitaimenkyofusho” or disorder might be “jikitaimenkyofusho” or fear of fear of self-presentationself-presentation. According to Iwai, the object of . According to Iwai, the object of fear is not the social situation or other people as fear is not the social situation or other people as much as it is oneself in the context of presenting much as it is oneself in the context of presenting that self to others and how that self will be that self to others and how that self will be received by those others.received by those others.

Japanese Specific Concepts (con’t)Japanese Specific Concepts (con’t)

The The greater social acceptability of anxiety greater social acceptability of anxiety compared with depressioncompared with depression may also account for may also account for the low levels of clinical diagnosis and treatment of the low levels of clinical diagnosis and treatment of depression in Japan until recentlydepression in Japan until recently..

The majority of patients with symptoms of The majority of patients with symptoms of depression in Japan are still depression in Japan are still treated by internists treated by internists primarily with benzodiazepinesprimarily with benzodiazepines, although with the , although with the recent introduction of selective serotonin reuptake recent introduction of selective serotonin reuptake inhibitors, antidepressant use is increasing.inhibitors, antidepressant use is increasing.


Victim-consciousness is embedded in the Victim-consciousness is embedded in the Japanese language itself, as is seen in the Japanese language itself, as is seen in the so-called suffering passive inflection of so-called suffering passive inflection of Japanese verbs where Japanese verbs where something just something just happens and one is made to suffer as a happens and one is made to suffer as a consequenceconsequence..


Munakata (1986) has argued that Japanese Munakata (1986) has argued that Japanese attitudes toward mental illness also have an attitudes toward mental illness also have an impact on the diagnosis of neurasthenia, which impact on the diagnosis of neurasthenia, which until recently was diagnosed by Japanese until recently was diagnosed by Japanese psychiatrists and doctors to psychiatrists and doctors to disguise socially disguise socially stigmatized mental illnessesstigmatized mental illnesses such as such as schizophrenia in order to spare their patients and schizophrenia in order to spare their patients and families the psychological shock and ostracism families the psychological shock and ostracism that would accompany the diagnosis of more that would accompany the diagnosis of more severe mental illnesses.severe mental illnesses.


ShinkeishitsuShinkeishitsu (constitutional neurasthenia) (constitutional neurasthenia) is a widely used diagnostic term in Japan is a widely used diagnostic term in Japan applying to a condition which would be applying to a condition which would be diagnosed as an anxiety disorder in the diagnosed as an anxiety disorder in the WestWest..

Somatic rather than dysphoric complaintsSomatic rather than dysphoric complaints are characteristic of both Japanese are characteristic of both Japanese depression and shinkeishitsu.depression and shinkeishitsu.

ShinkeishitsuShinkeishitsu

Generally, when used popularly, Generally, when used popularly, shinkeishitsu describes a person who is shinkeishitsu describes a person who is overly sensitiveoverly sensitive to certain features of his or to certain features of his or her immediate environment, “nervous,” her immediate environment, “nervous,” “worrisome,” “easily agitated,” and “worrisome,” “easily agitated,” and “anxious.“anxious.””

Shinkeishitsu (con’t)Shinkeishitsu (con’t)

Sufferers are believed to be Sufferers are believed to be “nervous” by “nervous” by temperamenttemperament, individuals being , individuals being predisposed predisposed at birthat birth to the disorder (the term to the disorder (the term shinkeishitsu itself means ‘of nervous shinkeishitsu itself means ‘of nervous temperament.”).temperament.”).

Generally, the disorder is seen as not Generally, the disorder is seen as not particularly serious and as particularly serious and as physical rather physical rather than mental in naturethan mental in nature..

Shinkeishitsu (con’t)Shinkeishitsu (con’t)

In some cases, the diagnosis of In some cases, the diagnosis of shinkeishitsu is shinkeishitsu is used to disguise depressionused to disguise depression, , legitimizing the sufferers’ distress by giving it legitimizing the sufferers’ distress by giving it a a physical basisphysical basis, and thereby , and thereby circumventing circumventing stigmatizationstigmatization..

DSM-IV-TR:DSM-IV-TR:Outline for Cultural FormulationOutline for Cultural Formulation

Cultural identity of the individual.Cultural identity of the individual. Cultural explanations of the individual’s Cultural explanations of the individual’s

illness.illness. Cultural factors related to psychosocial Cultural factors related to psychosocial

environment and levels of functioning.environment and levels of functioning. Cultural elements of the relationship Cultural elements of the relationship

between the individual and the clinician.between the individual and the clinician. Overall cultural assessment for diagnosis Overall cultural assessment for diagnosis

and care.and care.

Practical GuidelinesPractical Guidelines

1) The basis of any general ability to work 1) The basis of any general ability to work with people from diverse cultural with people from diverse cultural backgrounds begins with the backgrounds begins with the clinician’s clinician’s knowledge of their own ethnocultural knowledge of their own ethnocultural identityidentity and the implicit biases this brings. and the implicit biases this brings.

2) A second step involves 2) A second step involves careful careful consideration of the cultural bases and consideration of the cultural bases and biasesbiases of contemporary psychiatric of contemporary psychiatric practice.practice.

Practical Guidelines (con’t)Practical Guidelines (con’t)

3) A third skill concerns working with interpreters 3) A third skill concerns working with interpreters and culture-brokers able to and culture-brokers able to provide the missing provide the missing social and cultural contextsocial and cultural context..

4) Finally, the clinician must consider his or her 4) Finally, the clinician must consider his or her own position in the health care system, as well as own position in the health care system, as well as that of the clinical or institutional setting, vis-à-vis that of the clinical or institutional setting, vis-à-vis the specific ethnocultural community to the specific ethnocultural community to consider consider problems of power, racism, and accessibilityproblems of power, racism, and accessibility that that may impede forming a therapeutic alliance and may impede forming a therapeutic alliance and negotiating effective care.negotiating effective care.

Working with Asian ClientsWorking with Asian Clients

Explain and reframe the roleExplain and reframe the role of the therapist of the therapist and the client in the beginning of therapyand the client in the beginning of therapy..

Therapists emphasize their role is an Therapists emphasize their role is an ‘expert ‘expert in therapy’in therapy’ and the client is the and the client is the ‘expert in his ‘expert in his or her life.’or her life.’

Don’t discount physical complaintsDon’t discount physical complaints.. Avoid asking too many personal questionsAvoid asking too many personal questions

during initial sessions.during initial sessions.

ReferencesReferences

American Psychiatric Association (2000). American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition – Text Revision (TR). Disorders, Fourth Edition – Text Revision (TR). Washington, DC: American Psychiatric Washington, DC: American Psychiatric Association, 897-903.Association, 897-903.

Azar, B. (2010). Your brain on culture. Azar, B. (2010). Your brain on culture. American American Psychological Association Monitor, 41Psychological Association Monitor, 41 (10). (10). Available: Available: http://www.apa.org/monitor/2010/neuroscience.aspx

http://www.apa.org/monitor/2010/neuroscience.aspx

http://www.apa.org/monitor/2010/neuroscience.aspx

References (continued)References (continued)

Chen, H. J. (2005). Mental illness and Chen, H. J. (2005). Mental illness and principal physical diagnoses among Asian principal physical diagnoses among Asian American and Pacific Islander users of American and Pacific Islander users of emergency services. emergency services. Issues in Mental Issues in Mental Health Nursing, 26Health Nursing, 26, 1061-1079., 1061-1079.

Demographics of New Zealand.Available: Demographics of New Zealand.Available: http://en.wikipedia.org/wiki/Demographics of New_Zealand

http://en.wikipedia.org/wiki/Demographics%20of%20New_Zealand

http://en.wikipedia.org/wiki/Demographics%20of%20New_Zealand


Kirmayer, L. J. (2001). Cultural variations in the Kirmayer, L. J. (2001). Cultural variations in the clinical presentation of depression and anxiety: clinical presentation of depression and anxiety: Implications for diagnosis and treatment. Implications for diagnosis and treatment. Journal Journal of Clinical Psychiatry, 62of Clinical Psychiatry, 62 (13), 22-30. (13), 22-30.

Oshima, A., Higuchi, T., Fujiwara, Y., Iida, M., Oshima, A., Higuchi, T., Fujiwara, Y., Iida, M., Iwanami, A., Kanba, S., Motohashi, N., Uchitomi, Iwanami, A., Kanba, S., Motohashi, N., Uchitomi, Y., Yamada, K., & Yamawaki, S. (1999). Y., Yamada, K., & Yamawaki, S. (1999). Questionnaire survey on the prescribing practice Questionnaire survey on the prescribing practice of Japanese psychiatrists for mood disorders. of Japanese psychiatrists for mood disorders. Psychiatry and Clinical Neurosciences, 53 Psychiatry and Clinical Neurosciences, 53 (Suppl.)(Suppl.), S67-S72., S67-S72.


Population and Sustainable Development. Population and Sustainable Development. Available: Available: http://www.population.govt.nz/information-by-subject/population-groups/asian-people.aspx

Russell, J. G. (1989). Anxiety disorders in Russell, J. G. (1989). Anxiety disorders in Japan: A review of the Japanese literature Japan: A review of the Japanese literature on shinkeishitsu and taijinkyofusho. on shinkeishitsu and taijinkyofusho. Culture, Culture, Medicine and Psychiatry, 13Medicine and Psychiatry, 13, 391-403., 391-403.

http://www.population.govt.nz/information-by-subject/population-groups/asian-people.aspx




Southern District Health Board Website. Southern District Health Board Website. Available: Available: http://www.southerndhb.govt.nz/

Statistics New Zealand. Available: Statistics New Zealand. Available: http://www.stats.govt.nz/infoshare/

Tracey, M. D. (2006). Cultural worlds Tracey, M. D. (2006). Cultural worlds intersect. intersect. American Psychological American Psychological Association Monitor, 37Association Monitor, 37 (2). Available: (2). Available: http://www.apa.org/monitor/feb06/intersect.aspx

http://www.southerndhb.govt.nz/

http://www.stats.govt.nz/infoshare/

http://www.apa.org/monitor/feb06/intersect.aspx

http://www.apa.org/monitor/feb06/intersect.aspx

who are new zealand’s asian people?

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