Chronic physical conditions have been associated with an increased risk for depression in a range of cultural settings
[1–4], and the risk has been shown to increase with the number of conditions
. Mainland China, Hong Kong and Taiwan have been undergoing rapid urbanization and Westernization of lifestyles and these changes are associated with increasing risk of chronic disease
[6–8]. Nonetheless, Asian rates of depression remain relatively low. One estimate placed the prevalence of lifetime major depressive disorder in mainland Chinese communities at 6.1%, compared to 16.2% in the United States
The co-occurrence of chronic conditions and depressive symptoms can increase suffering among patients and their family members. Yet few studies have reported on depression prevalence or risk factors in a large general population sample of people with chronic medical conditions. To further examine the relationship between chronic medical conditions and depression, this study examined the prevalence of depressive symptoms among people with chronic conditions in a large Chinese community sample in Hong Kong. The second objective was to analyze factors that predict the development of depressive symptoms among those with chronic conditions.
Risk factors for developing depression have been mostly described in studies in Western countries. Yet Eastern cultural values and practices may have a protective role in mental health, so cultural factors that could modify the association between chronic conditions and depression have been studied in chronically ill Chinese samples. However, previous studies were small and focused on particular groups such as the elderly
[3, 11], or were limited to telephone interviews
. Various factors may protect against the development of depression, some of which could explain the apparent low incidence of secondary depression in Asian populations. Social support mitigates the development of depressive symptoms in people with chronic conditions both in the West
 and in China
. Indeed, social relations are of particular importance in Chinese populations
, and family support plays an essential role in Eastern cultures influenced by Confucianism, particularly in times of illness
 and during treatment
. An epidemiological survey in mainland China reported that depressive symptoms were more common in women than men
; a second study found that family support and health status explained most of the variation in depressive symptoms
. In studies from the West, lower social support is likewise associated with worse health status and more depressive symptoms over the year following an acute myocardial infarction, particularly for women
. Older women are more likely than older men to be adversely affected and to develop depressive symptoms when family support is weak
. Gender roles in Chinese societies are more differentiated than they are in the West
, but a possible interaction between gender and family support in protecting against depressive symptoms in chronic illness has not been investigated. Hence, we examined the relationship between satisfaction with family relationships and depressive symptoms, and assessed whether this effect differed for women and men. Prior studies
[16, 17] have often analyzed social relationships at one level instead of examining them at multiple levels (family, work, or neighborhood)
[19, 20]. Support at each of these levels could confer protection against depressive symptoms so we examined this possibility using multi-level analyses.
Life stress has been shown to be associated with both psychological and physical problems
, mostly in studies conducted in Western populations
[22, 23]. Recently, a case-control study from mainland China also found that patients with major depressive disorders were more likely to have experienced stressful life events than controls, and reported a dose-response relationship between stressful life events and major depressive disorders
. Therefore, an assessment of stressful life events has been included in the present study.
A potential complicating factor in studying depression in Asian populations is the tendency among some ethnic groups, such as Indians, Vietnamese, and Chinese, to somaticize their emotional experience
[25, 26]. For example, people in North India were found to describe depression using somatic metaphors such as ‘pressure on the mind’ or ‘sinking heart’
. Such presentations could lead to depression being mislabeled as a chronic physical ailment. In East-Asian populations, the influence of Chinese cultural ideologies of emotional calmness, self-restraint and adaptive strategies reduces the acceptability of expressing affective symptoms and also blurs boundaries between physical and mental illness
. Compared with the Caucasian population, somatic symptoms may be a more common reason for Chinese adults to seek psychiatric services for their mental health problems
. In a community sample of elderly people in Hong Kong, depression showed an independent relationship with six medically unexplained somatic symptoms including loss of appetite, fatigue, insomnia, recurrent gastro-intestinal problems, recurrent headache and dizziness, after adjustment for social-demographic and medical conditions
. Therefore, we have compared the somatic and non-somatic symptoms of depression among individuals with chronic conditions.
The objectives of this study were 1) to investigate the prevalence of self-reported depressive symptoms in a large community sample of individuals who reported chronic conditions; 2) to analyze risk factors for depressive symptoms in this sample; 3) to examine the potential effects of life stress and family support on depressive symptoms; 4) to compare the somatic and non-somatic symptoms of depression among individuals with chronic conditions.