Role of Pain and Cultural Factors on Depression Among Chinese-American Cancer Patients with Pain

Background/Purpose:  Chinese-Americans are the largest Asian subgroup and many include recent immigrants who are economically-disadvantaged, medically underserved, and have low acculturation.  Cancer is the leading cause of death for this population.  Chinese-Americans with cancer have high rates of severe pain, and unrelieved pain can impair psychosocial and physical functioning.  However, few studies have assessed cancer pain and its associations with cultural factors and depression in immigrant populations.

Pain is a biopsychosocial phenomenon, and influenced by a complex interaction of non-disease related factors, including psychological status, sociocultural factors, and perceptions.  These factors shape patient behavioral responses and impact adjustment.  For example, in traditional Chinese culture, stoicism and fatalism may be important values that modify pain experience.  However, no known studies have evaluated stoicism or fatalism and their associations with pain and depression in Chinese immigrants with cancer pain.     

We evaluated the association between pain severity and depressive symptoms, when controlling for the effects of stoicism, fatalism, linguistic acculturation, as well as demographic and treatment related factors in Chinese-Americans.

Methods:  This was a secondary analysis of baseline data from a larger quality improvement intervention to enhance symptom management among Chinese immigrants presenting to four oncology practices in New York.  Data were collected between 2009-2015.  The IRB at Mount Sinai Beth Israel approved the protocol and patients consented before study participation.

Participants and Procedures:  Ambulatory cancer patients undergoing care at the practices were screened for eligibility by research assistants.  Eligible patients: spoke Chinese or English as their primary language; had active cancer; reported pain caused by cancer or cancer therapy; and reported pain duration for ≥3 months.  Patients were interviewed in their primary language. 

Measures:  Interviews included validated measures: the Chinese Health Questionnaire-12 (CHQ-12; depressive symptoms); Brief Pain Inventory-Short Form-Chinese; Pain Attitudes Questionnaire (stoicism); Barriers Questionnaire-Taiwan (fatalism); Marin and Marin linguistic acculturation subscale; and sociodemographics.     

Results:  The sample included 362 patients (mean age=58.1±11.3 years; 57.6% men; 45.1% with a H.S. education or less).  Worst pain intensity in the past week averaged 5.9±2.1. Based on univariate analyses and theorized importance in predicting depressive symptoms, worst pain severity, stoicism, fatalism, linguistic acculturation, and age were entered into a multivariate regression model.  Four variables were associated with higher depressive symptoms: higher worst pain severity (β=0.88), higher fatalism (β=0.22), lower stoicism (β= -0.11), and younger age (β= -0.62); [F (5,309) = 10.4, p < .01]; they explained 15.7% of the variance in depressive symptoms.  Linguistic acculturation was not associated with depressive symptoms, and interaction terms for cultural factors were not significant.

Conclusions and Implications:  We evaluated associations between pain severity and depressive symptoms when controlling for cultural influences in first-generation, Chinese-speaking cancer patients with pain.  Findings confirm the importance of pain and cultural factors on psychological functioning in this population.  Fatalistic beliefs may contribute to maladaptive responses to pain, and should be considered when screening for depression in this population. Stoicism may be an adaptive response to pain and a source of resiliency.  Future studies should further clarify these cultural mechanisms, and control for cancer-related variables.