Influencing Factors of Depression among Adolescent Asians in North America: A Systematic Review

Background: Asian American adolescents experience rates of depression comparable to or greater than those of other ethnic minorities. The purpose of this systematic review is to summarize psychosocial factors related to depressive symptoms of Asian American adolescents between the ages of 10 to 19. Methods: Various electronic databases were systematically searched to identify research articles published from 2000 to 2021, and the psychosocial factors influencing depression among Asian adolescents in North America were examined. Results: A total of 81 studies were included in this systematic review. Consistent findings on relationships between depressive symptoms and influencing factors included (a) acculturative stress, (b) religious or spiritual significance for females, (c) parent–child cohesion, (d) harsh parenting style, (e) responsive parenting style, (f) racial or ethnic discrimination, (g) being bullied, (h) positive mentor presence, and (i) exposure to community violence. Collectively, the majority of included studies suggest that depressive symptoms were more likely found among Asian American adolescents who (a) are older, (b) are female, (c) have immigrant status, (d) exhibit coping behaviours, (e) face academic challenges, (f) face a poor socioeconomic situation, (g) perceive parent–child conflict, (h) perceive maternal disconnectedness, and (i) perceive negative peer relations. A number of conflictive findings also existed. Discussion/Conclusions: This systematic review provides a summary of the various psychosocial factors on individual, familial, and social levels, which influenced the depressive symptoms of Asian American adolescents. Such findings offer a starting point to examine what factors should be necessarily included in related depression-preventive intervention design and evaluation. Culturally sensitive care, strengthened family–school–community collaboration, and targeted research efforts are needed to meet the needs of Asian adolescents experiencing a range of depressive symptoms.


Introduction
Depression is defined as a mood disorder that causes persistent feelings of sadness and loss of interest [1]. Symptoms include persistent feelings of hopelessness, sadness, worthlessness, guilt, irritability, lethargy, or "emptiness" and may manifest as physical aches, pains, headaches, cramps, or irregular eating/sleeping habits. Adolescents may further experience an inability to focus and follow through with tasks, likely resulting in lower academic performance or disinterest in usual activities. More severe symptoms include substance abuse, strong feelings of guilt, and panic attacks, with the most serious one being recurrent thoughts of death or suicide [2]. Lifelong consequences can include inferences in a hierarchical structure [27]. The present review applies this theoretical framework to conceptualize the relationship between illness, distribution of depressive symptoms, and the resources or experiences that impact Asian American adolescents [24]. This present review applies the ecosocial framework to summarize existing research on the influencing factors of depression among Asian American adolescents. Our research questions were as follows: (1) What are the individual factors influencing the depressive symptoms of this population? (2) What are the familial factors influencing depression of this population? (3) What are the community and social (cultural/acculturation, racial/ethnic, etc.) factors influencing depression of this population?

Methods
The protocol and reporting of the results of this systematic review were based on the PRISMA statement [28].

Eligibility Criteria
Studies were included if they satisfied the following criteria: (a) included Asian adolescents who were 10 to 19 years of age; (b) identified a dimension of depression, such as depressive symptoms or depressed mood, as one of the outcome variables; (c) focused on the North American context; (d) examined the influence of psychosocial factors on depressive symptoms; and (e) were published in an English, peer-reviewed journal. Depressive symptoms can be assessed by different instruments, such as the Centre for Epidemiologic Studies Depression Scale [29], the 13-item Short Mood and Feelings Questionnaire [30], the Depression Self-Rating Scale for Children [31], the Beck Depression Inventory-Second Edition [32], and the Children's Depressive Inventory [33][34][35][36]. Studies were excluded if they met the following conditions: (a) did not have an author; (b) did not have predicted depression status or depressive symptoms as an outcome; (c) did not include Asian American groups in the sample of a study; (d) addressed adolescents under the age of 10 or over the age of 19; (e) focused on interventions or measurement validity and did not address psychosocial factors; (f) were a review, commentary, or dissertation; (g) were on an unrelated topic; (h) had no full text available.

Information Sources
Various health-related, psychological, sociological, and educational science databases, including MEDLINE, PsycINFO, Embase, CINAHL, ProQuest, Nursing and Allied Health Database, PsycARTICLES, and Sociology Database were selected for the literature search.

Search Strategy and Selection of Evidence
The databases were systematically searched using the combination of keywords, (Asia* OR India* OR Afghan* OR Bengal* OR Bangla* OR Bhutan* OR Nepal* OR Pakistan* OR Sri Lanka* OR Cambodia* OR Chin* OR Filipi* OR Taiwan* OR Korea* OR Japan* OR Vietnam* OR Thai*) AND (North America* OR Canad* OR America* OR USA OR U.S.A* OR United State*) AND (adolesc* OR teen* OR youth* OR child* OR young OR pediatric*) AND (depress*). The citations were exported into EndNote to remove any duplicates. The titles and abstracts of all citations were screened for relevance based on the established eligibility criteria. All eligible articles were searched for full-text documents, and full-text documents were carefully reviewed. Further, the reference lists of all eligible articles were manually searched for additional titles not returned in the initial search. The most recent search was conducted in January 2021.

Quality Assessment
The United Kingdom's Critical Appraisal Skills Programme checklists (https://caspuk.net/casp-tools-checklists/) are used as quality assessment tools to assess included articles [37]. These checklists are not designed to generate a final quantitative score but to draw attention to elements of a rigorous study and evaluate the study as a whole.
Using these checklists, we classified the quality of included papers as low, moderate, or high. Two researchers independently evaluated each article, discussing disagreements in quality ratings according to the guidelines until consensus was reached. Papers rated as low quality were excluded. Thus, all papers included in this review were of moderate to high quality.

Data Extraction
Data were independently extracted by two reviewers based on predetermined criteria. From each article, various data, including authors, year of publication, study population, research design, recruitment method, sample size, sample characteristics, comparison group, outcomes, measurements, and significant findings, were extracted. The data were collected and organized into an Excel spreadsheet. The reviewers discussed disagreements regarding data extraction until consensus was reached.

Data Analysis and Synthesis of Results
Once the data was organized in Excel, descriptive statistics were used to present the characteristics of included studies. Thematic analysis was then used to summarize the findings to each research question. Categorization results were compared among reviewers, and any disagreements among reviewers were resolved with a consensus decision.

Characteristics of Included Studies
In this review, 81 studies were included ( Figure 1). Thirty-seven (45%, 37/81) studies were original, independent studies, while forty-four (54%, 44/81) consisted of secondary analyses of national surveys. Only considering Asian American adolescents and not comparisons or parent groups, the sample size among independent studies ranged from 26 [38] to 451 [39] adolescents. Among studies conducting secondary analysis of national surveys, the sample size ranged from 84 [40]  Ascribed indicators are social categorizations consisting of inherited or ascribed traits such as age, gender, immigration status, or ethnicity. A total of twenty-eight (34.6%, 28/81) studies addressed the relation between depressive symptoms and at least one ascribed indicator [32,35,36,. Six (7.4%, 6/81) studies examined the correlation between age and depressive symptoms [35,[42][43][44]49,54]. Of these, four (4.9%, 4/81) studies found that depressive symptoms increased with age [35,42,43,54], while another found depressive symptoms to decrease with age [44]. One study found age to not be associated with depressive symptoms [49]. Thus, the correlation between age and depressive symptoms was inconclusive, with a majority of studies identifying a positive correlation.  Gender was assessed in thirteen (16%, 13/81) studies, twelve (14.8%, 12/81) of which reported that female adolescents experience more numerous or more severe depressive symptoms [35,36,41,45,48,52,53,55,59,[64][65][66]. Of the twelve studies, one study further found the relation between perceived chronic daily discrimination and severe depressive symptoms to be significant for females only [53]. The remaining study found no difference in rates of depressive symptoms between male and female adolescents, making our findings inconclusive [62]. Nevertheless, a majority of studies found that female adolescents experienced greater depressive symptoms.
Generational status and length of stay are factors relevant to the acculturative process. Three (3.7%, 3/81) studies addressed such factors, one of which found that increased length of stay was non-significantly linked to reduced depressive symptoms [51]. Similarly, another study found that generational status was not related to depressive symptoms [49]. In contrast, the third study found that third-generation Chinese Americans scored higher than other generations in somatic symptoms such as poor appetite, trouble falling asleep, and frequent crying spells [74]. Thus, the relation between increased length of stay and depressive symptoms was inconclusive.
Furthermore, adolescents cope with acculturative stress in different ways, which may also mediate the relationship with depression as addressed in five (6.2%, 5/81) studies. One study found that adolescents were taught to mistrust others and coped by preparing for bias, which was associated with higher levels of depression and lower self-esteem [47]. Adolescents who coped by practicing wishful thinking were also found to experience more depressive symptoms [70]. Anger suppression and increased emotional sensitivity significantly predicted depressive symptoms [71,72]. However, another (1.2%, 1/81) study found that general emotional suppression did not correlate with depressive symptoms [73]. While the overall findings were inconclusive, the majority of studies found that coping behaviours correlated with more depressive symptoms.
Religious identity and daily spiritual experience were significant predictors of reduced depressive symptoms in three (3.7%, 3/81) studies [66,76,78]. Of these, two (2.5%, 2/81) specified the relation between higher personal spirituality and fewer depressive symptoms among female adolescents [46,76]. Overall, religious or spiritual significance was related to reduced depressive symptoms for female, Asian American adolescents only.
Three (3.7%, 3/81) studies addressed the relation between BMI or diet and depressive symptoms; two of which had conflicting findings [30,79,80]. One study found that deviation from the average ethnic group BMI was associated with increased depressive symptoms in East and Southeast Asian female adolescents [80]. The other found correlations between BMI and dieting with depressive symptoms to be insignificant for all Asian ethnic groups [30]. A third study uniquely found that high potato and/or carrot intake was related to reduced depressive symptoms in Asian American adolescent students [79]. Overall, the findings were wholly inconclusive.

Living Situation (Household Size, Socioeconomic Status)
The living situation consists of the family size within a household and economic status. Family size was of interest since it is the main form of social support for many Asian adolescents. A total of five (6.2%, 5/81) studies addressed the association of depression with living situations (i.e., household size, economic situation) [32,43,55,62,77]. One study found a negative correlation between living with both parents and symptoms such as suicidal thoughts and distress [32]. In contrast, another study found that increasing family size was not associated with depressive symptoms [55]. Thus, the general findings were wholly inconclusive.
Regarding socioeconomic status, four (4.9%, 4/81) studies addressed its influence on depressive symptoms [43,55,62,77]. One found that socioeconomic status was not significantly correlated with depressive symptoms [62], while the other found it to be a negative predictor of depression [43]. Similarly, adolescent perception of financial constraint was correlated with increased depressive symptoms [55,77]. Overall, studies were inconclusive, though a majority found poor socioeconomic situation to predict depressive symptoms.
A total of seven (8.6%, 7/81) studies examined the specific relationship of either the mother-or father-child dyad on adolescent depressive symptoms [39,45,84,85,87,98,104]. Of these, one study found that both parents had identical influences on their child's depressive symptom levels [39]. Three studies found that bonding with one's mother was significantly protective, while the father's negative attributes such as hostility or low paternal warmth impacted depressive symptoms [67,87,104]. In two studies, maternal hostility positively correlated with depressive symptoms, while maternal connectedness negatively correlated with depressive symptoms; neither study addressed the fatheradolescent relationship [45,84]. The remaining study found that mother-reported conflict positively correlated with depressive symptoms but again, left father-reported conflict unaddressed [85]. Overall, the findings regarding mother-and father-child relationships were inconclusive, though a majority of studies found that maternal connectedness reduced depressive symptoms.
Parenting style as a part of the family dynamic was examined in nine (11.1%, 9/81) studies [43,57,64,68,87,[99][100][101][102]. Of these, four (4.9%, 4/81) found that overbearing family dynamics or an authoritarian parenting style, characterized by demanding behaviour towards adolescents, led to greater reporting of depressive symptoms [64,68,91,101]. However, it is worth noting one of the four studies was specific to refugee adolescents, a unique circumstance [64]. Another four (4.9%, 4/81) studies found that supportive parenting, characterized by warmth and responsiveness to their child led to reduced depressive symptoms [57,87,100], though one of these specified that only concurrent depressive symptoms were affected [39]. One study examined the influence of promoting children's understanding of ethnic heritage values and racial barriers in preparation for bias in the community and found no change in adolescent depressive symptoms [102]. Overall, a harsh parenting style was related to increased reporting of depressive symptoms, while a warm parenting style was related to reduced depressive symptoms.

Parental Descriptors (Parental Language Use; Parental Psychological Factors)
Parental descriptors are qualities of the parent that are acquired or modifiable over time, such as language, parental education, and psychological factors (e.g., trauma, depression). A total of nine (11.1%, 9/81) studies examined the relationship between parental descriptors and adolescent depressive symptoms [50,52,54,55,58,76,90,97,102]. Three (3.7%, 3/81) studies examined the relation between parental language use and adolescent depressive symptoms [54,76,90]. One study found that a mothers' Chinese language proficiency was protective against depressive symptoms when the adolescent was also highly proficient [54]. Another study found that parental use of English at home negatively correlated with depressive symptoms in adolescent girls [76]. The remaining study found that adolescents who translated for their parents were more likely to feel alienated from them, which positively correlated with depressive symptoms [90]. Overall, the studies addressed different dimensions of parental language use and were inconclusive. Six (7.4%, 6/81) studies examined parental psychological factors such as trauma, depression, and education [50,52,55,58,97,102]. Of these, two (2.5%, 2/81) studies found that parental education positively correlated with initial or later adolescent depressive symptoms [50,55]. One of them hypothesized that it may be due to parents expecting more academically of their children, resulting in greater academic stress [55]. In contrast, one (1.2%, 1/81) study found that parental levels of education had no effect on depressive symptoms [97]. Only one (1.2%, 1/81) study specific to parental trauma found that previous maternal traumatic distress did not have a significant impact on adolescent depressive symptoms [58]. Finally, the remaining study found that parents experiencing depressive symptoms were more likely to practice harsh discipline, a lack of reasoning, and low monitoring of adolescent activities. In turn, this led to more depressive symptoms among their adolescents [52]. Due to the variety of psychological factors addressed, findings regarding psychological factors were inconclusive.

Racial/Ethnic Discrimination
Racial and ethnic discrimination is defined as unfair, differential treatment based on race or ethnicity and includes discrimination enacted by peers, adults, and strangers [49]. A total of twelve (14.8%, 12/81) studies addressed the influence of racial and/or ethnic discrimination on adolescents [40][41][42]49,53,56,63,102,[105][106][107][108]. All twelve studies found that experienced or perceived discrimination was related to more severe depressive symptoms. One study specified that daily discrimination resulted in increased reporting of depressive symptoms such as lower grade point average, lower self-esteem, and physical complaints [108]. Two studies specified peer discrimination to be positively correlated with more severe depressive symptoms [40,56]. Another two studies specified a negative school climate, characterized by negative peer interactions and teacher-enacted discrimination, to predict greater depressive symptoms [41,63]. Finally, one study examined the impact of microaggressions; brief and regular verbal and behavioural acts that communicate hostile, negative racial insults [107]. This study found that the experience of microaggresions positively correlated with increased depressive symptoms, particularly among female adolescents [107]. Overall, racial or ethnic discrimination was related to greater depressive symptoms.

Peer Relations
Peer relations are defined as the interrelationships between peers and the adolescent's sense of belonging, support, and integration. Additionally, it includes dimensions of psychological, verbal, and physical bullying experienced between peers. A total of twelve (14.8%, 12/81) studies examined the association of peer relation factors and adolescent depressive symptoms [31,32,35,40,57,79,82,88,96,105,[109][110][111]. Five (6.2%, 5/81) of these studies found that positive peer relations, support, or a sense of belonging was related to significantly reduced depressive symptoms and higher self-esteem [31,35,88,96,105,111]. In contrast, one study found that perceived support from peers of a different ethnicity was related to increased reporting of depressive symptoms [32], while another found no correlation between peer support and depressive symptoms [57]. Overall, findings were inconclusive, though a majority of studies found that positive peer relations was related to fewer depressive symptoms.
A total of four (4.9%, 4/81) studies addressed the influence of bullying or unpopularity on adolescent depressive symptoms [79,82,109,110]. Two (2.5%, 2/81) studies found that victims of bullying were more likely to report more severe depressive symptoms [82,110]. These two studies also found contradictory results regarding adolescent bullies and bystanders who observed this behaviour. One found that bullies and bystanders experienced greater depressive symptoms [110], while the other found no correlation [82]. Another study found that unpopularity among same-ethnicity peers was related to greater depressive symptoms, while unpopularity among cross-ethnicity peers showed no association [109]. The remaining study found that lower rates of bullying on school property was related to increased reporting of depressive symptoms [79]. The study went on to discuss the possibility of unobserved parental or peer support variables that may have buffered the relationship between bullying on school property and adolescent depressive symptoms [79]. Overall, being a victim of bullying was related to more severe depressive symptoms. Other dimensions of bullying or unpopularity were inconclusive.

Broader Community Impact
Broader community impact is defined as the impact of community or school members who may range from strangers to mentor figures and who fall outside of the peer relations category. A total of five (6.2%, 5/81) studies examined such factors [76,103,[112][113][114]. Of these, four (4.9%, 4/81) found that the presence of a warm and accepting mentor in an adolescent's life negatively correlated with depressive symptoms [76,103,112,113]. The mentor figure was identified as a teacher [103] and a religious advisor [76]. Uniquely, the fifth study determined an adolescent's exposure to community violence to be a very strong predictor of depressive symptoms [114]. Overall, a positive mentor was related to less depressive symptoms, while exposure to community violence was related to greater depressive symptoms.

Summary of Findings
Findings of this review revealed that influencing factors of depression among Asian American adolescents range across the individual, familial, and community environment levels. Individual factors included ascribed indicators, acculturation factors, and psychological indicators; familial factors included living situations, parent-child relations, and parental descriptors; community factors included racial or ethnic discrimination, peer relations, and broader community impacts. Some factors were critical in predicting depressive outcomes, though contrary findings have also been identified. In our systematic review, there were consistent findings on relationships between depressive symptoms and influencing factors, including (a) acculturative stress, (b) religious or spiritual significance for females, (c) parent-child cohesion, (d) harsh parenting style, (e) responsive parenting style, (f) racial or ethnic discrimination, (g) being bullied, (h) positive mentor presence, and (i) exposure to community violence. Collectively, the majority of included studies supported that depressive symptoms were more likely to be among Asian American adolescents who (a) are older, (b) are female, (c) have immigrant status, (d) exhibit coping behaviours, (e) face academic challenges, (f) face poor socioeconomic status, (g) perceive parent-child conflict, (h) perceive maternal disconnectedness, and (i) perceive negative peer relations. The association between depression and ethnicity, length of stay, English language proficiency, religious or spiritual significance for males, BMI and diet, household size, variance in mother-or father-child relationships, parental language use, parental psychological factors, and bullying others or observing bullying were less conclusive due to either contradictory findings or a paucity of evidence.

Individual Factors
Our findings indicated that religious or spiritual significance was related to reduced depressive symptoms for Asian American female adolescents. More than ninety observational studies examining the relation between religion and depression in the general population exist, with the majority stating that those who are more religious experience fewer depressive symptoms [115]. Due to the limited evidence within this review, this is an important influencing factor for future interventions among female Asian American adolescents. Future research should examine why religious or spiritual significance might have a differential impact depending on gender.
Our findings indicated that the co-relationship between female Asian American adolescents and depressive symptoms is supported by a majority of included studies but remains inconclusive. The significance of gender as a potential predictor of depression is important, considering the association is also found among adult Asian immigrant populations [116]. Notably, the study addressing adult Asian Americans found that family conflict was especially detrimental for Asian women who strongly identified with their ethnic culture [116]. Extending this to Asian adolescent females, a stronger ethnic identity may be tied to traditional gender roles. Since females may be expected to spend more time within the family context, family conflict can negatively impact females' mental health [116]. Gendered mechanisms of psychosocial influence on depressive outcomes requires further research attention.
Our findings indicated that ethnicity is wholly inconclusive in predicting depressive symptoms. Similarly, a systematic review of American adolescents found minimal racial or ethnic differences in adolescent depression in regard to national trends [4]. Still, six studies within this review found a variety of Asian ethnicities to predict greater depressive symptoms than their White counterparts or other ethnic minorities. This is consistent with one review's finding that Asian Americans experience higher rates of suicide and use fewer mental health services than their white counterparts [16]. Overall, these contradictory findings may point to ethnicity and race being correlated with other factors that more directly influence the rates and severity of depressive symptoms in Asian American adolescents. For example, perceived discrimination is more likely to be experienced by Asian ethnic minorities, and in turn, be linked to depressive symptoms.
Our findings indicated that the co-relationship between academic challenges and depressive symptoms is inconclusive but supported by the majority of studies. This influencing factor is particularly important since Asian Americans emphasize academic value within their ethnic cultures [65,117]. Academic performance is innately tied to family-, school-, and peer-related pressures, which may influence adolescents' psychological adjustment. However, the experience of academic challenges may also vary across different Asian ethnicities. One study examining high school students in China found academic stress to predict depressive symptoms and highlighted the high-achievement/low psychological adjustment paradox [118]. Thus, future research addressing academic challenges in Asian American adolescents should seek to disaggregate data between Asian ethnic subgroups.

Family Factors
Our findings indicated that parent-child cohesion and a warm, responsive parenting style was related to reduced depressive symptoms, while harsh parenting was related to greater depressive symptoms. This finding is consistent with a systematic review examining parenting styles in relation to depressive symptoms and suicidal ideation in a global population of adolescents [119]. Future studies should focus on the parent-child relationship and parenting style as a point of intervention.
Our findings indicated that the co-relationship between parent-child conflict and depressive symptoms is inconclusive but supported by the majority of studies. This finding is consistent with studies regarding familial conflict and African American, European American, and mainland Chinese adolescent depressive symptoms [117,120,121]. While Asian Americans are comparable to other ethnicities in relation to family factors, they have the unique mediator of acculturative stress, which is thoroughly addressed in the current literature [122]. Since parental support is a critical factor in adolescent development, future research may consider parent-child acculturative discrepancies to be the focus of potential interventions [123]. Furthermore, future research may consider what parentrelated facilitators and barriers Asian American adolescents face regarding mental health service utilization due to acculturative discrepancies.
Our findings indicated that the variance in influence of mother-and father-child relationships is inconclusive, though a majority of included studies found maternal connectedness to reduce depressive symptoms. This finding may be due in part to fathers being underrepresented in family research. Future research should address the barriers fathers face and consider how to better engage them in research.

Community and Social Factors
Our findings indicated that racial or ethnic discrimination was related to greater depressive symptoms. This finding is supported by two reviews examining a general sample of adolescents [124] and a sample of minority adolescents in the U.S. [125]. The latter systematic review stressed the importance of applying an intersectional lens when assessing experienced discrimination. This lens considers the cumulative psychological impact of multiple social identities such as ethnicity, class, and gender, as well as individual experiences of discrimination [125]. Future research should seek to apply an intersectional lens to identify high-risk subgroups who are particularly vulnerable to discrimination. This would allow the creation of targeted prevention and treatment interventions.
Our findings indicated that being a victim of bullying and exposure to community violence was related to greater depressive symptoms. Bullying victimization is an important influencing factor due to its volatile impact on adolescents. A systematic review addressing a general sample of adolescents found that depressive symptoms were a mediator for self-harm and school bullying [126]. Furthermore, bullying coupled with mental health disturbances has been found to result in high-risk behaviours among Asian American youth, including heavy drinking, sexual promiscuity, and tobacco use [127]. A review of adolescents in the United States found that exposure to community violence is increasing at exceedingly high rates and is placing adolescents at a higher risk for emotional and behavioural problems such as antisocial and suicidal behaviour [128]. School-based interventions for bullying must be urgently assessed for effectiveness to prevent self-harm, high-risk behaviours, and worsening symptoms of depression.

Integrative View
Among the included studies, a total of forty-two (52.8%, 42/81) studies addressed individual factors, forty-nine (60.5%, 49/81) addressed familial factors, and twenty-six (32.1%, 26/81) addressed community or societal factors. The categorization of these factors through the ecosocial framework allows for simplified conceptualization of the ever-changing relationships between adolescents and their environment, other people, and collective institutions. While classified separately, all interact and influence one another to varying degrees and at different times. Overall, this review presents a need to further investigate community or societal factors to the same depth achieved with individual and familial factors. Considering the conclusive findings regarding community factors (i.e., racial or ethnic discrimination, being bullied, positive mentor presence, and exposure to community violence), this level of social ecology may have imminent implications. The economic, physical, and psychological burdens of COVID-19 on Asian American communities, as well as the rise in violence against Asian Americans, make this need urgent [129]. These broad social burdens may create or severely exacerbate negative individual or familial dynamics. For example, a recent study found that parent's depressive symptoms worsened with perceived racial discrimination due to COVID-19 [129]. Due to a paucity of evidence, this present review found parental psychological factors to be wholly inconclusive. However, a preliminary study identified parental depression to correlate with harsher parenting practices, which led to worse adolescent depressive symptoms [52]. These are the overlapping complex interactions that may occur, and they require careful consideration. Though COVID-19 highlights such issues, the media coverage of anti-Asian sentiments will inevitably subside. When that occurs, the inequalities and long-lasting burdens faced by Asian American communities will still exist. Clinicians ought to persist in examining how the risk and protective factors identified in this review fit into the unique context of each adolescents' life.

Limitations
Firstly, this review examined data in aggregate without separating Asian ethnic subgroups, despite Asian Americans being a heterogeneous population. This was due to our research goal of summarizing information focused on a general population of Asian American adolescents. Additionally, subgroup comparisons were not possible across all studies as diverse Asian subsamples were not large enough. The failure to identify individual Asian subgroups could mask disparities and result in inaccurate conclusions regarding assessment, needs, intervention design, and research [130]. Thus, future reviews may consider only including studies with large-enough Asian subsamples for disaggregated data analysis. Secondly, the included papers were heterogenous in their measures of depression, which led to difficulties in comparisons and limited the generalizability of the findings. Assessment of the comparative validity between various measures and methodologies may allow future reviews to overcome this limitation. Thirdly, to reduce risk of bias, included studies were appraised using tools from the Critical Appraisal Skills Programme as done in other systematic reviews [20]. In addition, two independent reviewers screened studies for eligibility, with a third available in the event of disagreements [131]. Future reviews may choose alternative appraisal tools if deemed more methodologically rigorous. Lastly, all studies included within this review were co-relational studies, which does not imply any causal relationship. Relationships discussed in this review require further experimental research to determine causality.

Implications and Future Direction
Findings of this review have implications for healthcare providers, families, and schools. Culturally sensitive care that considers the unique factors influencing depression among Asian American adolescents is crucial. Healthcare providers should take into consideration the central value of parent-child relations in Asian American adolescent lives. Therapeutic conversations with adolescents and their families can offer insight into the adolescents' functioning, school performance, the influence parents hold, and potential familial barriers in receiving mental health services. This interaction between healthcare providers and adolescents would also provide an opportunity to connect families with more ethnic social support to address potential financial, social, or language burdens. Since parental support is a critical factor in adolescent development, parent-child cohesion and warm, responsive parenting should be promoted. A parent-child conflict should be discussed and solved in a mutually respectful approach. School-based interventions should be encouraged and assessed for their effectiveness on adolescents' mental health.
This review identified several implications for further research. Firstly, there is a need to disentangle conflicting findings and highlight potential protective factors that are embedded within the results of the literature. For example, future studies should explore potential early life predictors of depression such as age, length of stay, immigrant status, English language use, and socioeconomic status. Secondly, since acculturative discrepancies or parent-child conflict may hinder access to mental health services, future research should examine the cultural stigma surrounding mental health that is present in many Asian American adolescents' lives [1]. Thirdly, considering the essential role of family relations in Asian American adolescents' lives, future research should assess the therapeutic effects of family-centred interventions and preventative strategies.

Conclusions
This systematic review provides a summary of the various psychosocial factors on individual, familial, and social levels, which influence the depressive symptoms of Asian American adolescents. Such findings offer a starting point to examine what factors should be necessarily included in depression-preventive intervention design and evaluation. Cul-turally sensitive care, strengthened family-school-community collaboration, and targeted research efforts are needed to meet the needs of Asian adolescents experiencing a range of depressive symptoms.