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Examining Cultural Differences in Processing Emotion as a Cause for Differing Rates of Depression in Western and Eastern Countries
Sadness is an emotion that is has a commonly negative connotation and yet, its persistence throughout the evolution of mankind indicates that it is indispensable. At a certain point, this emotion begins to interfere with our day-to-day functioning, resulting in depression. However, is it possible that certain groups of people are less likely to suffer from it purely due to their culture?
In a classical study, John Bowlby showed that pre-socialized babies are visibly distressed when their caregiver leaves them alone, as summarized by Horwitz and Wakefield (1). Bowlby hypothesized that this distress causes the caregiver to return, thus demonstrating its role. Another often cited study is by Ekman and Friesen (2) which determined sadness has a similar expression cross-culturally further stressing its importance from an evolutionary perspective.
In the modern world, however, some say sadness seems to be ignored, and in its stead, depression exists. Depression has been documented for a long time; Ancient Greek writings reveal the existence of what they termed ‘melancholia,’ which appears to share similarities with depressive disorder. Despite this, it wasn’t until the 1980s that the disorder was quantified to how we know it today, in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases, 11th revision (ICD-11) (1).
Since then, strides are being made to quantify and diagnose depression, but there is rampant criticism of the methods used. Many argue that the DSM and the ICD are not accurate representations of mental illness and have resulted in overdiagnosis of the illness, with physicians failing to distinguish between it and sadness especially in developed countries (3). The drug, ‘Prozac,’ has become a household word, as have many other SSRIs commonly used to treat depression with there being an increase ranging between 200% to 300% in prescription rates of SSRIs during the 1990s (1).
The increase in rates of depression has been particularly evident in Western countries rather than Eastern ones which have raised further doubts over the DSM and ICDs ability to diagnose it accurately. There have been theories to explain this difference in prevalence such as, these diagnostic manuals fail to take into account how culture affects the presentation of symptoms of the disease, or that there is more stigma surrounding mental illness in eastern countries which makes people less likely to acknowledge their symptoms. Finally, it is argued that these manuals simply fail to identify the multiple forms in which depression may manifest depending on the culture (4).
All these arguments have been explored extensively, and yet the only one that we have discovered is inconsistent is the one involving the role of stigma is diagnosis rates (5). The doubts surrounding the effectiveness of the DSM and the ICD to take culture into account during diagnosis remain and to counter this, attempts are being made to make the DSM and ICD more culturally inclusive (6, 7).
Therefore, culture appears to play a role in the diagnosis of depression which might be leading to its underdiagnosis in eastern countries when compared to the west However, what isn’t often explored is whether the cultural differences in the ability to process emotions might contribute to some of this variation, rather than the faults of diagnostic methods alone.
Eastern countries follow a holistic style of thinking which allows them to accept contradictions more easily than the West, where a more analytical style of thinking is followed. Consequently, emotions too are viewed differently with eastern countries more likely to be neutral towards positive and negative emotions as compared to the west where they favour positive emotions over negative emotions (8).
This variation in styles of thinking cross-culturally, and thus, the ability to process and accept negative emotions might affect whether the different groups are affected by depression, which could account for the significantly higher depression rates in the west when compared to the east and will be explored.
Currently, more than 300 million are affected by depression. Almost 800,000 people die by suicide due to depression every year. It is easy to see why statistics like these could be interpreted as evidence for the ‘depression epidemic,’ (9).
The standard of diagnosing mental health illnesses across most countries is the ICD-11 and the DSM-5. The DSM-5 has been published by the American Psychiatric Association (APA) in 2013 and is used worldwide much like the ICD-11 which has been compiled by the World Health Organization.
DSMs of previous years failed to take culture into account entirely. In its fourth publication, DSM-IV developed an Outline for Cultural Formulation (OCF) to bring culture into the diagnostic criteria for depression. This included a list of, ‘culture-bound syndromes,’ to help clinicians make appropriate diagnoses. However, the OCF failed to fulfil its designed function. Many argued that it was lacking in practical application and was further criticized on its ontological unfitness. To counter these, the DSM-5 then included a more effective, ‘Cultural Formulation Interview’ (CFI), which in the classical DSM style attempts to operationalize the effect of culture and condense it into an interview (6).
The ICD, on the other hand, isn’t just a classification manual for mental disorders like the DSM is, but also includes other diseases in it too. Thus, it isn’t unreasonable to conclude considering the DSMs extensive resources and specific focus on mental health, it will be more comprehensive than the ICD (10). However, despite this, the ICD maintains a high standard in the treatment of depression. More recently, it has recognized the role culture plays on the diagnosis of depression and is attempting to include it in its diagnostic criteria and in its existing structured interview called the Composite International Diagnostic Interview (CIDI) (7).
The specific role culture plays on the diagnosis of depression is under scrutiny too. It has been argued that the diagnoses for depression provided by the ICD and DSM fail to identify depression in Eastern cultures since the symptoms vary. This makes cross-national studies invalid, due to ‘category fallacy.’ However, studies indicate that more specifically, the language used in the DSM and ICD might result in a different diagnostic threshold being set for western and eastern countries due to linguistic and cultural differences.
In a study by Simon, Goldberg (11), 15 medical centres in 14 different countries were examined in an attempt to determine the reasons for the cross-national differences in the prevalence of depression. They utilized the CIDI to measure these rates.
They found that the CIDI was able to correctly diagnose depression across the varying cultures, thus bringing doubt over the idea of a ‘category fallacy.’ Overall, they found that the Western countries were more affected by depression than the Eastern countries, based on their prevalence alone.
Interestingly, they found that while the CIDI was able to diagnose depression, there was a significant difference in the severity of depression. The number of sufferers in the west was more but overall, they suffered from a less severe version of depression than those in the eastern countries did, despite those in eastern countries being smaller in number.
They attributed this to possible cultural and linguistic differences which resulted in a lower threshold for diagnosis in western countries when compared to the east. These results conflict with previous studies that claim the differences in symptoms are the reason for lower diagnosis of depression in the east, and further studies conducted by Chang, Hahm (12) support the claims made regarding diagnostic threshold.
However, even if this claim made regarding diagnostic threshold is true, the question remains regarding the role of culture in this sort of discrepancy. In what way have western culture and eastern culture affected individuals, causing this sort of difference in depression? How can linguistic differences alone cause this level of variation cross-nationally? To understand this, it is important to appreciate the history underlying the division between eastern and western cultures.
Ancient Greece, which gave rise to what we now refer to as western civilization was notably based on the importance of an individual. The rules that governed Ancient Greece were developed by the people themselves, with each person right down to a commoner possessing the right to change it (13). Tying in with this, they also emphasized the necessity of debate it in which everyone including the common people participated whether it be in ‘marketplace, or political assembly’ (13-15). Finally, they carried among them a sense of curiosity about the world which they seek to satisfy by observation and categorization of events, that could be used to predict future events (16, 17).
Ancient Chinese Society, on the other hand, influenced the development of East Asia, Japan, Korea and other parts of Southeast Asia. Unlike Ancient Greek civilization, the focus was on functioning as a collective rather than an individual. ‘Confucianism’ most distinctly emphasized the importance of social harmony (18, 19). Another feature contrasting with Ancient Greek society was that the Ancient Chinese strongly discouraged debate (20).
This brief summary of both cultures is hardly sufficient, yet it provides us with a clear idea of the kind of dichotomy between present-day eastern and western cultures. Nisbett, Peng (8) go on to specifically discuss the method of thinking employed by both cultures. In the east, a ‘holistic’ method of thinking appears to be common whereas, in the west, an ‘analytic’ method dominates.
The holistic method appears to focus on the entire available information and understanding how it works. The analytic method on the other tends to divide the information into categories based on rules and use logic instead i.e., there is more of a focus on what is true and what is false, which contrasts with the holistic method, that believes in a more dialectical approach.
Based on the history of eastern civilization and western civilization, the methods of thinking that were developed over time appear to be logically consistent. However, how do these methods impact their ability to process emotion?
The holistic style of thinking believes in a dialectical approach and applying this to emotions, we expect that eastern cultures tend to see negative and positive emotions as co-existing i.e., they do not value one over the other. In fact, in a study by Zhang and Cross (21), the Chinese appear to be more likely to view failure as an opportunity for self-improvement and success.
An analytic style of thinking, on the other hand, would be more likely to categorize the emotion, which is clearly revealed in the inherent preference for positive emotions over negative ones in western countries (22). As a result, a contrast is created in terms of which emotion should be preferred, which makes it harder for western culture to value and ultimately, deal with negative emotions. Consequently, negative emotions will have a worse impact on western when compared to eastern cultures.
The holistic style of thinking is also more likely to believe emotions to be transient, which is consistent with their view of expectation of change (23). Eastern cultures will be more likely to believe that negative emotions are not persistent whereas western cultures might see negative emotions as being more permanent. This is important as new evidence reveals a link between the changing nature of emotion perceived by people and their ability to regulate it, thus playing an important role in reducing distress (24). Additionally, holding the view that emotions are in a state of flux, makes negatives ones less intimidating for people (4).
Finally, the role of ‘self’ is important in peoples’ perceptions of emotions. As discussed, in the holistic style of thinking, there is the tendency to view the information on the whole whereas as the analytic style focusses on viewing it individually (8). This style of thinking can be applied to peoples’ interpretation of self too. Eastern cultures are more likely to see the self as being tied to society and an external social context, whereas western cultures will view the self as being a discrete, independent identity. As a result, when faced with negative emotions, western cultures might see it as it is their fault (25), whereas eastern cultures will more likely see it as a result of social context (4).
Western countries tend to categorize, understand, and make predictions about the world, and it makes sense that they internalized this method of thinking to everything, even themselves and how they feel. In fact, the DSM-5 and ICD-11 which have strong western influences appear to support this style of thinking by dividing a complex disorder like depression into a set of symptoms. The effect of culture too is broken down into smaller parts and studied to explain differences in prevalence. Despite this, in an almost paradoxical scenario, they fail to consider whether this difference is primarily due to the West’s inability to contend with negative emotions. Is there something to be learnt about emotional regulation from Eastern cultures?
Holistic thinking encourages dialectical thinking, viewing emotions as transient, and understanding that the self cannot be separated from the social context in which it exists. As a result, they can deal better with negative emotions, although it doesn’t necessarily have to mean they suffer from less such emotions. However, there is no doubt that they are at lesser risk of suffering from depression. Perhaps this is why the threshold for diagnosis of depression is very high in eastern cultures because they are better adapted to addressing their negative emotions without developing a pathological condition. They might not see themselves as being depressed, or having a problem because of what their culture has taught them which is a possible explanation for the discrepancy in depression rates. There might be some effect of linguistic barriers, but different styles of emotion processing too could be playing a crucial role in how depression is diagnosed and could be explored in future studies.
Styles of thinking are a product of thousands of years of development across different cultures and cannot be changed easily. Neither can their effect be ignored when considering depression and the ability of people to deal with their emotions.
Overdiagnosis of depression in the West, or underdiagnosis in the East, is a topic of much debate as the epidemic continues to spread. However, whether either of these actually takes place is very difficult to determine.
Reasons for cross-national differences in depression rates have often been put down to culture, and how it affects the threshold for diagnosis of the disease. Does this mean that depression is, in fact, underdiagnosed in the east, or is it possible that in the east depression does have a lower prevalence?
To put the difference in the prevalence of depression cross-nationally definitively down to different thresholds in diagnosis is very difficult, and indeed to do so would perhaps reflect the Western method of thinking that we’ve developed that trains us to analyse separate parts of phenomena.
The DSM and ICD definitely need to be improved, there is no denying that. Despite their steps to include culture in diagnoses of mental illnesses, they are still lacking, but we cannot say that it is due to these manuals alone that depression rates differ.
Perhaps people from the east do not appear to suffer from ‘mild’ or ‘moderate’ depression on the scale that the west does simply because of how their culture has helped them develop emotional regulation strategies. To make a conclusive statement regarding overdiagnosis or underdiagnosis would be difficult because we cannot separate culture from a disease like depression, so at best we can attempt to bring a similar style of emotional regulation to the west to help them become more comfortable with their emotions.
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