Cultural differences in depressive disorders
According to the World Health Organization (WHO) , depression is estimated to affect more than 300 million people worldwide and is the leading cause of disability globally. Depression is considered an emotion and can be either a symptom or a disorder.
Everyone, regardless of their country of origin or culture, can experience feelings of depression, which may be present during the grieving process or in various illnesses, or may be a symptom of a mental health disorder. In all these cases, loss is usually the central element of depression, sometimes manifesting as a reduced quality of life due to decreased functionality. Among refugees, for example, depression is a collective and personal experience of loss and trauma. However, what can make a real difference is how the loss is interpreted and what meaning is attributed to it .
In other words, depression is a universal disorder , but there are cultural aspects that will influence its manifestation and development, as specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5): "Culture provides interpretive frameworks that shape the experience and expression of the symptoms, signs, and behaviors that constitute diagnostic criteria.
The diagnostic assessment must therefore consider whether the individual's experience, symptoms, and behaviors differ from sociocultural norms and create adjustment problems in their cultures of origin and in certain social or family contexts.
Yolanda Osorio López
Although some cultures tend to attribute depressive disorders solely to genetic and biological factors, there are psychological, social, environmental, and cultural factors that influence their development and that we must also consider for diagnosis and treatment. Therefore, it is necessary to develop tools and personalize treatments, taking into account the symptoms and factors specific to each culture.
Distinct and common symptoms across cultures
Culture influences how symptoms are expressed and communicated, treatment decisions, interactions between medical teams and patients, and professional practices. Although depression has a universal component, some symptoms may differ across cultures . The cultural context simply tells you how much and what is important to pay attention to (Kleinman et al. 2004).
In Eastern cultures, people with depression tend to describe somatic symptoms, rather than the psychological aspects of their condition. Symptoms such as boredom (instead of sadness), pain, dizziness, and fatigue are common. In China, for example, somatic symptoms like insomnia, loss of appetite, and headaches are more prominent than psychological symptoms (feelings of sadness, worthlessness, etc.), which are more prevalent in Western cultures (Chang et al., 2017). Several cultural explanations have been proposed to explain why the Chinese population somatizes more than Western populations. The most developed of these suggests that in Chinese culture, mental health disorders are often considered a weakness of character and a cause of family shame (Chang et al., 2015).
Although depression has a universal component, some symptoms may differ between cultures.
The same is true in the Arab population , which tends to describe mental health problems as physical symptoms . Women appear to be more at risk of experiencing these disorders, exacerbated by gender inequality in some of these countries (Al-Krenawi, 2005). Although there are significant differences among these countries, Arab societies share many values, beliefs, and mental health practices that can be decisive in shaping their perceptions and management of all disorders, including depression (Dardas et al., 2016). For example, Gilat, Ezer, and Sagee (2010) found that when a member of an Arab family shows symptoms of a mental disorder, they often seek help from close relatives, family members who provide healthcare, a sheikh, or a religious leader. Only 11% seek help from mental health professionals , but they often face various factors, including a shortage of mental health specialists, lack of resources, lack of treatment guidelines, lack of access due to economic barriers, and the stigmatization of mental disorders in Arab cultures (Al-Krenawi, 2005).
The challenge of mental health in migrants
In this regard, the stigma of having a mental disorder exists in all Arab countries and is associated with significant negative effects on those affected and their families (Abdullah & Brown, 2011) (Dardas et al., 2016). The Quran (Quran 8:24, Al-Anfal, 24) (cited in Dardas et al., 2016) requires practicing Muslims, who constitute the majority of the population in Arab countries, to seek treatment for illness, especially when it is severe, treatable, or infectious. Negative attitudes toward mental health services prevent Arabs who experience depression from seeking help and receiving treatment. Furthermore, some Arab cultures still believe that supernatural forces (e.g., jinn, black magic, and the evil eye) cause the symptoms of mental disorders. Therefore, they do not typically consider depression to be a real illness that requires professional treatment. Consequently, this significantly delays the search for help and leads to greater stigmatization.
Some Arab cultures do not typically consider depression as a real illness that is subject to professional treatment.
Another example of these differences is shown in a study conducted by the Complutense University of Madrid (De la Torre-Luque et al., 2020), which compared the symptoms of depressive disorder between a group of elderly people living in Spain and another in Nigeria, looking for commonalities and differences. The most frequent symptom in the Nigerian group was hopelessness, while in the Spanish group it was fatigue and tiredness.
Although cultural differences are lessened by migratory flows between countries, especially immigration from countries like China, India, Pakistan and Africa to the West, the understanding of depression and its growing social acceptance remain different due to the difficult integration between cultures.
Factors common to all cultures
On the other hand, culture is inextricably linked to a person's economic, political, psychological, and biological conditions . Accepting the concept of culture as a dynamic process is important for understanding the diagnosis and treatment of depression. Thus, there are different risk factors for depression that are similar across cultures (gender, unemployment, traumatic events, etc.). In fact, several studies demonstrate that depression, regardless of country of origin, is more prevalent among poor people than among those with greater economic resources, and among women compared to men. Furthermore, traumatic events such as the loss of a loved one, natural disasters, or wars that can cause the loss of family members and material possessions provoke reactions such as sadness, anger, and distress, which are common to everyone .
However, not everyone can recognize that they need help, not everyone asks for it or asks for it in the same way, and not everyone is willing to accept and value it. Interestingly, culture can be a protective factor when the social support network is well integrated into society, while isolation and loneliness are risk factors for depression (Domènech-Abella et al., 2018).
Depression, regardless of country of origin, is more prevalent among poor people than among those with greater economic resources, and among women compared to men.
Regarding the treatment of depression , as with other illnesses, there are international guidelines that utilize both pharmacological and psychotherapeutic approaches. On the one hand, some psychotherapeutic approaches valid in the West, such as cognitive-behavioral therapy, have also proven effective in the East. Similarly, tools like meditation or mindfulness , of Buddhist origin, which have their benefits in the East, have also demonstrated their antidepressant efficacy in the West. But any therapeutic treatment, including medication, must also be adapted to cultural specificities .
Psychosocial support has proven to be an effective healing tool in all cultural contexts. Having someone nearby with whom to share and confront one's emotional states has a strong regulatory function on one's mood.
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