"All happy families are alike, each unhappy family is unhappy in its own way," Leo Tolstoy.
Poets and philosophers have long mused about the universal and idiosyncratic signature of our emotions. The human family shares a similar biology. Yet, culture leaves an undeniable imprint on our emotional narratives, including the way we feel and think of distress, how it manifests and how we cope with it. In her cross-cultural research on depression, psychologist Yulia Chentsova-Dutton likens depression’s constellations of symptoms to the starry sky. It’s the same universal experience of suffering, the same black vastness above our heads dotted with bright and dim lights. However, when we look at the night sky, as with the expression of depression around the world, we might notice some stars and miss others depending on where we are.
Here is Dr. Chentsova-Dutton in her own words on culture’s multifaceted influence on depression:
Many of the risk factors for depression are similar across cultures. These include gender, unemployment, traumatic events. The themes of depression tend to revolve around loss. But what people make of their losses and how they interpret their distress differs tremendously across cultures. In the West, we have increasingly pathologized depression and attributed it to biomedical factors. We tend to think that distancing people from their distress can be a functional way of helping them. However, teaching people that this very complex social, cultural, and biological phenomenon is entirely biological can backfire. It encourages people to ignore environmental factors, and instead, essentialize depression as a characteristic of themselves and their biology.
The meaning that people assign to suffering varies richly across cultures. Buddhism approaches suffering as an essential characteristic of life. We are mindful of it, yet, we don't try to chase it away. In Eastern European Orthodox Christianity and traditional Catholic contexts, there are two religious perspectives on suffering. On one hand, excessive suffering that blocks your goals is thought to be a sin. Simultaneously, suffering that allows you to stay engaged in your life is thought to bring you closer to God. It’s almost like broadcasting your suffering highlights you as a more complex and virtuous human being in other people’s eyes. Moreover, in India and Ecuador suffering can be interpreted as a rift in social networks that requires mending.
We have evidence that public education efforts to teach people in non-western countries how to be properly depressed western-style result in changes in how people think about their distress. In Japan, for example, pharmaceutical companies once engaged in a systematic campaign to train people to recognize both major and minor depression as problems (“a cold of the soul”). I can imagine if somebody is suffering and finally there is a label, they might get treatment, which would be a positive outcome. I can also imagine people who have formerly obtained support and would have done well through the use of social networks and traditional mood regulation, are now thinking of themselves as sick. The older immigrants have a lot of cultural wisdom. Why do we assume that our knowledge is best for them, instead of learning from them and understanding how they cope? It’s a major direction for research for the next decades.
Genetic vulnerability differs substantially from country to country. East Asian contexts, for example, show a high prevalence of genes associated with depression. Yet, despite these vulnerabilities, they develop fewer cases of the disorder. One hypothesis is that genetic vulnerabilities have co-evolved with culture, creating extra protective factors (in this case, extra interdependence). However, when these people leave their cultural contexts, they have a higher risk of developing depression.
Social stability and functional relationships are big protective factors against depression. East Asian contexts promote stable social networks. For example, most adults in Japan are still in frequent contact with someone they have known since childhood. In countries like the U.S., that’s rarer because of high mobility levels. (Of course, it depends on the quality of the relationships: if you are stuck with people who create tensions for you, it can be problematic.) Another leading hypothesis is that some cultures reinforce ways of regulating emotions that may be more functional than others. Finally, by virtue of prioritizing emotions and personal happiness, in contexts like the U.S., we are creating a discrepancy between how we feel and how we are supposed to feel. This can lead to additional problems.
Emotion regulation is increasingly becoming understood as a core factor in all affective disorders. In western societies, we don't see enough adaptive strategies like reappraisal: learning to tell yourself a different story that would eventually lead to different emotions. There is also not enough social regulation of emotion, which occurs by sharing our emotions with others. Research shows that cultures can facilitate functional regulation strategies. For example, Igor Grossmann’s work shows that Russians make rumination (generally considered a dysfunctional strategy) more functional by encouraging people to ruminate about the self from another person’s perspective, making rumination almost reappraisal-like in its quality.
Best studied differences in expression of depression are whether symptoms are primarily experienced in the body, or as disorders of emotions and cognitions. In the U.S., we officially look for both, with an emphasis on affective features; you can’t be diagnosed with depression unless you have either depressed mood or anhedonia (lack of pleasure). On the other hand, research based on Chinese samples shows that people there are more likely to experience and express depression as bodily symptoms: the person is tired and not sleeping, they don't have energy and aren’t concentrating well. Historically, it’s the diagnosis of neurasthenia (weakness of the nerves), which migrated to China from Europe via the Soviet Union. Essentially, it’s major depression without the affective features.
People don't seek help in the same manner, and help is not available in the same way. Moreover, the extent to which symptoms are recognized as pathology vs. an unpleasant but normative characteristic of life might differ. Assessment is a challenge in part because many of our assessment tools are based on the western set of criteria. Because of commonalities, we might catch some symptoms, but we might also miss presentations of the disorder that look different. We have started to develop tools that incorporate locally meaningful symptoms.
Pharmaceutically, we know that prescriptions and doses need to be altered based on various factors, including ethnicity. There is accumulating data showing that some approaches that are effective in the U.S. (e.g., cognitive-behavioral therapy) are also looking promising in other cultures. Similarly, mindfulness approaches from the East have been found to be effective in western samples. We have this idea of therapy as individual-based, yet we know from research that having somebody next to you, even if you don't discuss your problems, is regulatory. Thus, approaches that make use of social ties have a lot of promise, particularly outside highly individualistic contexts. I’m hoping that this gap in clinical science will get increasingly filled and we will enrich our toolset of approaches for treating depression.
Many thanks to Yulia Chentsova-Dutton for being generous with her time and insights. Dr. Chentsova-Dutton is an Associate Professor of Psychology at Georgetown University and the head of the Culture and Emotions lab.