The COVID-19 pandemic has elevated levels of distress and resulted in anti-Asian discrimination in many countries. We aimed to determine the 10-month prevalence of depression symptoms in Asian adults in New Zealand during the pandemic and to see if this was related to experience of racism. An online survey was conducted and a stratified sample of 402 respondents completed the brief Centre for Epidemiological Studies-Depression (CES-D) scale. Analyses included: descriptive statistics, depression scores by age/gender, factor analysis of the 10 item CES-D and partial correlation network analysis of CES-D items together with questions about experience of racism. Results show that half of the sample reported clinically significant symptoms of depression. Depression was higher among younger participants but there was no gender difference. Internal consistency was high (α = 0.85) for the CES-D which revealed a clear two-factor structure. Network analysis suggested that sleeping problems might be the bridge between experiences of racism and depression. The prevalence of low mood was high with clinically significant levels of depressive symptoms. Depression was higher in younger people and had a modest positive correlation with personal experience of racism.

Introduction

The COVID-19 pandemic has increased stress and the prevalence of some mental disorders–at least where this has been researched. A systematic review in 2020, noted high levels of anxiety, depression, post-traumatic stress disorder and stress among the general population in China, Spain, Italy, Iran, the US, Turkey, Nepal, and Denmark, and these levels were generally higher than pre-pandemic rates (Xiong et al. 2020; De et al. 2021). Similarly, in New Zealand, there is evidence which suggests that its adult population experienced additional stressors impacting on psychological wellbeing. For example, Every-Palmer et al. (2020) used a commercial survey platform to examine the mental health of a demographically representative sample of 2,010 adult New Zealanders in April 2020. They found 30% of respondents reported moderate or severe psychological distress, 16% moderate or high anxiety, and 39% low wellbeing. Of particular concern 6% reported suicidal ideation, 2% reported suicidal plans and 2% suicide attempts.

Among all indicators of mental health, levels of depression and anxiety are two metrics that have been frequently examined to assess people’s mental wellbeing during the pandemic (Murata et al. 2021; Shevlin et al. 2020; Wu et al. 2021; Zavlis et al. 2021). For example, Shevlin et al. (2020) found a ‘modest increase’ (p. 8) in the prevalence of mental health symptoms in a stratified sample of 2,025 UK adults during the early days of the pandemic (March 2020)–with increases in anxiety, depression and trauma symptoms compared to three previous general population surveys. In New Zealand, based on an online survey of 681 adults in May-June 2020, Gasteiger et al. (2021) found that levels of depression and anxiety were significantly higher than (pre-pandemic) population norms during the pandemic. However, there is almost no research that focuses on the mental health of one significant ethnic group in New Zealand–i.e. the Asian population, the second largest, fastest growing, and most diverse non-European ethnic group. Of the limited research which focuses on this substantial ethnic minority, an online survey of 663 Asian New Zealanders in April–May 2021, commissioned by an Asian mental health service provider, reported 44% of participants reported symptoms of depression, with younger people more at risk and females only slightly more at risk than males (Zhu et al. 2021). However, there has been no study to date that disaggregates this population into different ethnic sub-groups to understand if the pandemic impacts on their depression levels differently or which variables might influence this.

Existing studies suggest that apart from major demographic variables (including younger age, being female, being unemployed/a student, urban dwelling, and having other health conditions) which predicted anxiety or depression during the pandemic (Shevlin et al. 2020)–having limited social and psychological resources, high exposure to social media and/or COVID-19 news, and experiencing racism are also detrimental to physical and mental health, especially mental health (Fitzpatrick et al. 2020; Paradies et al. 2015; Shi et al. 2022; Talamaivao et al. 2020). A study of seven countries in Asia during the pandemic found risk factors for psychological distress included age < 30, higher education, being single or separated, discrimination by other countries and contact with people with the COVID-19 virus. Protective factors included male gender, larger households, employment, confidence in doctors and spending less time viewing health information (Wang et al. 2021b). Wang et al. (2021a) compared mental health, as indexed by scores on the Depression, Anxiety and Stress Scale (DASS-21), in 4612 participants from eight countries using a chain mediation model. They found that physical health symptoms similar to those of COVID-19 were associated with higher levels of anxiety, depression and stress–but this relationship was mediated by both the individual’s need for health information and their perceived impact of the pandemic.

Some research suggests that racial discrimination Asians have experienced is positively associated with depressive symptoms during the pandemic (Lee et al. 2022; Woo and Jun 2021). It is worth mentioning that of the Asian population in New Zealand, 77% were born overseas, which means that a large majority of New Zealand Asian people are also immigrants (Stats NZ 2018). This immigrant status together with their Asian ethnicity and the recent pandemic’s political climate of growing hostility toward Asians, implies a potential risk of experiencing racism for this population during the pandemic (Liu et al. 2022), which could negatively impact on their mental health.

Based on an online survey, the present article aims to fill a knowledge gap around the prevalence of symptoms of depression in the New Zealand Asian community during the first ten months of the COVID-19 pandemic, and to clarify which variables are associated with higher symptom levels. Specifically, we examine the relationship between demographic variables (age, gender, geographical location, and ethnicity), experience of racial discrimination/stigmatisation and symptoms of depression. We included questions concerning racism after media reports that the pandemic was resulting in an increase in bullying and harassment of Chinese and other Asian people (Foon 2020). We focused on the first ten months of the emerging pandemic. This period was the time when many uncertainties were still surrounding COVID-19, vaccines were unavailable, and New Zealand experienced a series of strict lockdowns; hence our focus on monitoring symptoms of anxiety and depression.

The significance of this paper is that it is the first study which focuses on depression symptoms among different Asian groups within New Zealand and systematically investigates variables that might influence depression. Quite often, public health statistics in New Zealand group diverse Asian groups together as one single ‘Asian’ ethnic group without recognising the inherent heterogeneity and diversity, this research challenges this arbitrary categorisation of this ethnic population and presents evidence-based information about the prevalence of depression of this important ethnic group in New Zealand during the pandemic to aid public health decision making and interventions. The result of this research is timely because Asians have been historically and consistently overlooked in the country’s health sector. The last comprehensive Asian health report funded by the Ministry of Health was 16 years ago, and the most recent analysis of Asian health data from the annual New Zealand Health Survey was completed six years ago. Most recently, in the latest planning report of New Zealand’s health sector transformation–Te Whatu Ora has also failed to address Asian health needs (Xia 2022).

Methods

Results

Discussion

The major finding in this study was a relatively high prevalence of symptoms of depression, compared with annual prevalence for the general population (see below), among a sample of 402 Asian participants living in New Zealand during the first ten months of the pandemic. However, these rates were comparable with samples in Hong Kong during the pandemic (Cheng et al. 2021). To place this finding in context the data were collected over a fortnight in December 2020 when the country was enjoying relative normality due to elimination of the first wave of the pandemic (Jefferies et al. 2020). It was the first month of summer and the entire country was in Level 1 of the New Zealand (level 1–4) alert system which involved few restrictions and New Zealand had been at this level since October 7 (New Zealand Government 2022). However, participants were specifically asked about their experience of all10 symptoms since the outbreak of COVID-19 in March 2020, with all 10 symptoms summed to yield a single global score, so these data should be interpreted as the annual (or 10 months) prevalence of mood symptoms in 2020 rather than the point prevalence in December.

We found a high prevalence of clinically significant depressive symptoms with 51.2% of the sample scoring ≥ 10 (more information is available in the supplement) which is the generally accepted CES-D10 cut-off score for clinically significant levels of symptoms. A national survey conducted in 2006 found the overall annual prevalence of major depression, as diagnosed by a structured interview, in NZ was 5.7% (Wells et al. 2006). However, it is important to note that among our sample the severity of symptoms ranges widely and includes mild, moderate and severe cases. We can compare these results with (Cheng et al. 2021) who surveyed 481 Hong Kong adults from April 20 to May 19 in 2020 during what the authors called Hong Kong’s ‘second wave’ of COVID-19 infections. They reported a mean CES-D10 score of 9.85 (SD = 2.96) and noted that ‘slightly more than half (52%) were categorised as having probable depression’ (Cheng et al. 2021, p. 5). They also found that persons higher in depression had less flexible coping strategies and greater COVID-19 related anxiety, but sex and age-cohort or ‘generation’ (Cheng et al. 2021, p. 5) (they compared Millennials, Generation X, Baby Boomers, Silent Generation) were not related to depression . In summary, we observed a high annual prevalence of symptoms of depression in our New Zealand Asian sample that was comparable with the point prevalence observed in a Hong Kong sample early in the pandemic.

In the present study there was no significant difference in the levels of depression for males and females, but younger participants reported higher rates of depression. There was a modest, significant positive correlation between depression and experiences of racism with a network analysis suggesting that direct personal experience of racism and disturbed sleep might conceivably act as a bridge or mechanism by which racism influences mood. However, this is based on a cross-sectional, correlation network and must be regarded as a hypothesis arising from our results, one that requires closer examination with a longitudinal study. At the same time, it is consistent with longitudinal studies indicating that sleep mediates the effect of perceived racism on depression among African-American and Latin American people in the United States (Steffen and Bowden 2006; Pichardo et al. 2021).

The CES-D10 proved to be a reliable measure for use with an Asian sample in New Zealand as shown by a Cronbach’s α of 0.85 which reflects high internal consistency or scale reliability. The two-factor structure (positive and negative symptoms) we observed in the present study was also quite consistent with the structure reported in studies from other countries e.g. South Africa (Baron et al. 2017). The separation into positive and negative dimensions of mood was confirmed by the network analysis which also saw these two sets of symptoms or items forming two distinct albeit connected clusters. The network analysis also identified three symptoms as the most central in the network–‘I had trouble keeping my mind on what I was doing’ (concentration), ‘I felt depressed’ (low mood) and ‘I could not get going’ (low energy). As the most central symptoms, these three items have the greatest number of connections with other symptoms, the strongest correlations with other symptoms and most often act as the pathway or link between pairs of unconnected symptoms. Interestingly, they formed three of the four highest loading items on the first rotated factor of Negative Mood.

While the precise interpretation of centrality measures in the application of NA to psychological networks remains the focus of some debate and uncertainty there is a good argument that more central symptoms could be the focus of assessment and intervention (Bringmann et al. 2019). Recently, Cheung and colleagues used NA to examine depressive symptoms among 11,072 Hong Kong residents during the early stages of the COVID-19 pandemic (March to April 2020) (Cheung et al. 2021). Their study used the PH9 to measure symptoms of depression and found the three most central symptoms were Guilt, Sad Mood and Energy. As the CES-D10 and the PHQ9 have quite different sets of items it is not possible to make direct comparisons. For example, the PHQ9 has items about guilt and suicide which the CES-D10 does not while the CES-D10 alone has positive mood items. Nonetheless the Sad Mood (Feeling down, depressed or hopeless) and Energy (Feeling tired or having little energy) items are similar in content to the two CES-D10 items I felt depressed and I could not get going–suggesting some degree of similarity across results. Interestingly, a systematic review of network analyses of major depression that included 254 studies of general and clinical samples and compared 58 cross-sectional networks concluded that fatigue and depressed mood were the two most central symptoms playing a critical role in or understanding of this disorder (Malgaroli et al. 2021).

Finally, the present study highlights the need to consider and plan for the mental health consequences of future pandemics in addition to their direct effects on physical health, and begs the question of what governments can do in this regard? While addressing this question is beyond the scope of the present research, our study underscores the vital need to learn from the COVID-19 pandemic and prepare for future pandemics and other catastrophic events (see Campion et al. 2022; Sachs et al. 2022). For example, there is evidence from a meta-analysis of 33 countries that those countries which implemented more stringent measures to restrict the spread of COVID-19, experienced a lower prevalence of depressive symptoms (Lee et al. 2021).

Limitations

The present study had several limitations which need to be acknowledged. First, it is a cross-sectional study which limits the conclusions which can be drawn from it. For example, it is not clear to what extent the prevalence of depressive symptoms was unusually high due to the pandemic, or if these rates might actually be typical of the New Zealand Asian community. Moreover, we could not find well validated cut-off values to distinguish mild, moderate and severe depression using the CES-10. A longitudinal study is necessary to demonstrate that the pandemic actually produced an increase in low mood among the Asian community. Second, we asked about symptoms since the pandemic started, similar to annual prevalence, whereas most studies using the CES-D10 ask about the past few weeks meaning point prevalence. Hence caution needs to be exercised when comparing our prevalence rates with other studies. Third, for practical reasons of minimising participant burden, we only focused on one dimension or category of psychological distress, namely depression or low mood. It would have been informative to ask about a more diverse range of forms of distress including anxiety, alcohol/drug abuse and loneliness. It would also have added balance to inquire about some more positive aspects of wellbeing such as coping and resilience. Certainly, it would be worth exploring these avenues in the future using longitudinal studies with our Asian community. A fourth limitation, is that our sample comprised only small numbers of participants from Asian countries other than China, India, Korea and the Philippines, limiting the generalisability of our findings to other ethnic groups. Moreover, 77% of our sample was drawn from two major cities (Auckland and Wellington). While this closely reflects the geographical distribution of the total Asian population in New Zealand (see https://www.stats.govt.nz/tools/2018-census-ethnic-group-summaries/asian), it suggests that future research might focus on the experience of Asian people in rural areas with very small Asian communities. Future studies might also want to make a special effort to recruit older Asian participants as our sample of 402 only included 33 people aged 65 + .

Conclusion

The annual prevalence of low mood was quite high with half the sample scoring above the cut-off point for clinically significant levels of depressive symptoms and this rate was comparable with a Hong Kong sample collected early in the pandemic. However, this figure aggregates mild, moderate and severe depression. Depression was higher in younger people and had a modest positive correlation with personal experience of racism–possibly due to its effect on sleep. There was no difference in severity of depression observed between males and females. The CES-D10 proved a robust tool for the measurement of mood in an Asian New Zealand sample. Longitudinal studies that examine a broader range of dimensions of distress and employ a longitudinal design are now needed.

Acknowledgements

We would like to firstly thank the unsung heroes of this research–the participants. Without them, this paper would not have been possible. This paper would not have been possible without the generous financial support from the funding body the New Zealand Health Research Council (HRC). We also acknowledge four community supporters for this project. They are: (1) Chinese New Settlers Services Trust (CNSST) Foundation; (2) Auckland Northshore Chinese Network; (3) Auckland Central Chinese Community Coalition; and (4) East Auckland Chinese Health Working Group.

Disclosure statement

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

This study was funded by the Health Research Council of New Zealand (Grant Number 20/985).