Explain why recorded rates of depression differ between cultures and populations, how culture shapes the expression, diagnosis and treatment of mental health disorders, and evaluate the research through bias, measurement and perspective.
Each is in the Psychology glossary, with every other term in the subject.
A treatment whose content, language, delivery or goals have been systematically changed to fit the culture of the people receiving it, while keeping its active ingredients.
A pattern of distress and behaviour recognised as an illness within a particular culture, with its own local name and explanation; DSM-5 calls these cultural concepts of distress.
The beliefs a person holds about an illness, including its name, cause, course, effects and appropriate treatment, which shape how they understand distress and what help they seek.
The process of looking for support for a health or mental health problem, from formal sources such as doctors or from informal sources such as family, religious leaders and traditional healers.
A culturally shared way of expressing and communicating suffering, such as “thinking too much” or “nerves”, which other members of the culture recognise and respond to.
A diagnosis of “weakness of the nerves”, with fatigue, headaches, poor concentration and poor sleep, widely used in China for distress often classed in the West as depression or anxiety.
The experience and expression of psychological distress mainly through bodily symptoms, such as fatigue, pain, poor sleep or dizziness.
Describe differences in the prevalence of major depressive disorder between countries and populations, using real survey data.
Explain factors that may produce real differences in prevalence and factors that may produce artefacts of measurement and diagnosis.
Explain how culture shapes the expression of distress, with reference to somatisation, emotion norms, idioms of distress and culture-bound syndromes.
Describe the aim, method, results and conclusions of Ryder et al. (2008).
Explain cultural differences in approaches to mental health, including explanatory models, help-seeking, Indigenous approaches and culturally adapted treatment.
Evaluate research on culture and mental health with reference to bias, measurement and perspective.
Apply knowledge of cultural differences to an unfamiliar scenario about mental health care.
Rates of major depressive disorder recorded in national surveys differ several-fold between countries, and the way people describe, explain and seek help for distress differs even more. Understanding these differences matters in practice: a diagnosis or a treatment developed in one culture may miss, misread or fail to help people in another.
The topic draws mainly on the sociocultural approach. It uses cultural dimensions, the emic approach and the etic approach to ask whether mental health disorders are universal conditions that look slightly different in each culture, or experiences that are partly created by cultural meanings. It also shows how biological, cognitive and sociocultural factors interact, since the same underlying distress can be felt mainly in the body in one setting and mainly as sadness in another. The concepts of
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Culture is the set of beliefs, values, norms and practices shared by a group and passed on through learning. Culture shapes what people expect to feel, which feelings they may show, how they explain misfortune and whom they turn to for help. All of these affect what a mental health disorder looks like and whether it is recorded.
Researchers take two broad starting points. A universalist position, close to the etic approach, holds that disorders such as depression exist in every culture with the same core features, so that a single set of criteria, such as those of the Diagnostic and Statistical Manual of Mental Disorders, can be applied everywhere and rates compared. A relativist position, close to the emic approach, holds that what counts as a disorder, and how it is experienced, depends on local meanings, so that applying one culture’s categories to another may produce misleading results. Most current research takes a middle position: some core features of depression are found widely, but their expression, recognition and meaning vary.
Prevalence is the proportion of a population that has a condition at a given time (point or 12-month prevalence) or at any time in their life (lifetime prevalence). Large cross-national surveys allow prevalence to be compared, because they use the same structured interview, translated into local languages, with random samples of adults.
The World Health Organization’s World Mental Health Surveys are the largest example. Bromet et al. (2011) reported data from 18 countries and 89,037 adults interviewed face to face with the WHO Composite International Diagnostic Interview, which assesses DSM-IV criteria for a major depressive episode. Average lifetime prevalence was 14.6% in the ten high-income countries and 11.1% in the eight low- and middle-income countries, while 12-month prevalence was similar in both groups (5.5% and 5.9%). Across the countries, women were about twice as likely as men to have had an episode.
The chart shows that the variation does not follow a simple rich–poor pattern. France and the United States have high rates, but so does São Paulo; Japan, a high-income country, has one of the lowest rates, close to Shenzhen in China. An earlier ten-country study by Weissman et al. (1996), using a similar method, found an even wider range of lifetime rates, from 1.5% in Taiwan to 19.0% in Beirut.
Differences also exist between populations within one country. Rates differ by sex, age, income, ethnicity and migration history. In the World Mental Health data, younger adults had the highest 12-month rates in high-income countries, while in several low- and middle-income countries older adults did. Such patterns raise the same question as cross-national differences: are they real differences in suffering, or differences in how suffering is expressed, recognised and counted?
A difference in recorded prevalence can arise in two broad ways. It can be real, meaning that more people in one population actually develop the disorder, because they face more risk factors or fewer protective ones. Or it can be an artefact, meaning that it is produced by the way distress is expressed, recognised or measured, so that the same amount of disorder is recorded differently. Most researchers think both are at work, and separating them is one of the main challenges in the area.
Social and economic conditions. Poverty, unemployment, war, displacement and violence raise the risk of depression. Bromet et al. (2011) concluded that depression is “strongly linked to social conditions”; in their data the strongest demographic correlates were separation from a partner in high-income countries and divorce or widowhood in low- and middle-income countries. These factors are the subject of environmental explanations of mental health disorders.
Social support and family structure. Close family and community ties can protect against depression after stressful events. In more collectivist cultures support may be more available, although obligations to the group can also be a source of stress.
Cultural values and the self. In more individualist cultures, success and failure are seen as the individual’s own, which may increase self-blame after setbacks. This is a hypothesis rather than an established finding, because national scores on cultural dimensions cannot be applied to individuals without committing the ecological fallacy.
Migration and acculturation. People who move between cultures face acculturative stress, such as discrimination, language barriers and loss of status, which can raise the risk of depression in migrant populations compared with both their country of origin and their new country.
Other population factors. Diet, alcohol use, the age structure of the population and access to treatment can all affect rates.
Expression of symptoms. If distress is experienced and reported mainly as bodily complaints, an interview that focuses on sadness and guilt will record fewer cases.
Recognition, stigma and reporting. Where mental illness is heavily stigmatised, people may not admit symptoms to an interviewer from outside their community. A systematic review of 144 studies by Clement et al. (2015) found that stigma had a small to moderate negative effect on help-seeking, and that ethnic minorities, young people and men were especially deterred.
Measurement and translation. Words such as “depressed” have no exact equivalent in many languages, and questions written in one culture may not mean the same in another. Using an instrument developed in one culture to measure another is an imposed etic.
Diagnostic thresholds. A cut-off point that separates “disorder” from “distress” in one population may not be meaningful in another.
Sampling. Some national surveys covered only one city or region, and response rates differed widely, so the samples may not represent the whole population.
Correlations between national characteristics and national prevalence are especially risky. Hibbeln (1998) reported that countries with higher fish consumption had lower rates of major depression, and a culture-based explanation could be built on cultural dimension scores in the same way. Both are correlations between country averages: they cannot show that individuals who eat more fish, or who hold collectivist values, are less likely to be depressed, and many other differences between the countries could explain them.
Culture shapes not only whether distress is reported but what it feels like and how it is shown. Three ideas are central: somatisation, emotion norms and culturally specific ways of describing distress.
Somatisation is the experience and expression of psychological distress mainly through bodily symptoms, such as headaches, fatigue, dizziness, poor sleep or chest pain. Its counterpart, psychologisation, is the expression of distress mainly through emotional and cognitive symptoms, such as sadness, guilt and worthlessness. Bodily symptoms are part of depression everywhere, but the balance between the two kinds of symptom, and which ones people mention first to a doctor, varies.
The classic research is Kleinman’s (1982) study of 100 outpatients diagnosed with neurasthenia at the Hunan Medical College in China. Neurasthenia (in Chinese, shenjing shuairuo, “weakness of the nerves”) was then a common diagnosis for patients with fatigue, headaches, poor concentration and sleep problems. When Kleinman reassessed them with DSM-III criteria, 87 of the 100 met the criteria for major depressive disorder. He argued that the same distress was being experienced and understood through the body, in a culture where a physical complaint carried less stigma and was a more acceptable reason to seek help.
Cultures differ in which emotions are valued and how strongly they should be expressed. Chentsova-Dutton et al. (2007) showed sad and amusing films to depressed and non-depressed European Americans and Asian Americans of East Asian descent. Depressed European Americans cried less in response to the sad film than non-depressed European Americans, the usual Western finding of “blunted” emotion in depression. Depressed Asian Americans showed the opposite pattern: they cried more than non-depressed Asian Americans.
The researchers explained this with the cultural norm hypothesis: depression disrupts a person’s ability to respond in the way their culture regards as ideal. European American culture values open emotional expression, so depression shows as reduced expression; East Asian cultures value emotional moderation, so depression shows as a loss of that control. The finding means that a symptom checklist built on one culture’s pattern, such as “reduced emotional reactivity”, could misread depression in another.
Every culture has familiar ways of talking about suffering. An idiom of distress is a culturally shared way of expressing distress that is understood by others in the community, such as “thinking too much”, “nerves” or a “heavy heart”. Idioms of distress need not indicate a disorder: they are a language for suffering, and recognising them helps clinicians understand what a person is communicating.
A culture-bound syndrome goes further: a recognised pattern of symptoms that is specific to a culture or region and has a local name and explanation. DSM-5 replaced the term with “cultural concepts of distress”, which includes cultural syndromes, cultural idioms of distress and cultural explanations of what causes distress. Its list includes the examples in the table.
Cultural concept | Where it is described | Main features |
|---|---|---|
Ataque de nervios (“attack of nerves”) | Latin American and Caribbean communities | Episodes of intense emotional upset (shouting, crying, trembling, feeling of heat rising, sometimes aggression), often after a family conflict or loss |
Kufungisisa (“thinking too much”) | Shona speakers in Zimbabwe | Ruminating on troubling thoughts, seen as a cause of anxiety, depression and physical problems |
Shenjing shuairuo (neurasthenia) | China | Mental and physical fatigue, poor concentration, headaches and sleep problems |
Taijin kyofusho | Japan | Intense fear that one’s body, appearance or behaviour will offend or embarrass other people |
Dhat syndrome | South Asia | Anxiety and fatigue attributed to the loss of semen |
Some cultural concepts overlap with Western categories. Taijin kyofusho resembles social anxiety, but its focus is on causing offence to others rather than on being embarrassed oneself, which fits a culture that emphasises the effect of one’s behaviour on the group. Kufungisisa resembles rumination. Other concepts do not map onto any single DSM category, which is why listing them as “syndromes” is debated.
YouTubeDiagnosis is a judgement made by a clinician who belongs to a culture, using criteria developed in a culture, about a patient who may belong to another. Cultural bias in diagnosis occurs when cultural differences between clinician and patient lead to systematic over-diagnosis, under-diagnosis or misdiagnosis.
Under-diagnosis happens when a patient expresses depression in ways the clinician does not recognise, for example through bodily complaints or a cultural idiom. Over-diagnosis happens when culturally normal experiences are mistaken for symptoms. In many cultures, hearing the voice of a dead relative during mourning is a normal experience, not a sign of psychosis. In the USA, a meta-analysis by Olbert, Nagendra and Buck (2018) found that Black patients had about 2.4 times the odds of being diagnosed with schizophrenia that White patients had, and that studies using structured diagnostic interviews did not show a significantly smaller disparity.
Diagnostic systems have responded. DSM-5 introduced the Cultural Formulation Interview, a set of questions that asks patients how they understand their problem, what they think caused it, what support they have and what help they expect. The aim is to bring the patient’s own explanatory model into the assessment instead of fitting the patient into the clinician’s categories. Whether such tools reduce bias in everyday practice is still being studied.
Cultures differ not only in how distress appears but in what people think causes it and what should be done about it. These differences affect whether people seek help, from whom, and whether a treatment makes sense to them.
Arthur Kleinman introduced the idea of the explanatory model: the set of beliefs a person (or a clinician) holds about an illness, covering what it is called, what caused it, why it started when it did, what it does to the body and mind, how serious it is and what treatment it needs. A patient and a doctor may hold very different explanatory models of the same problem.
Karasz (2005) presented a vignette describing symptoms of depression to 36 South Asian immigrants and 37 European Americans in New York and interviewed them about it. The South Asian participants mostly described the problem in social and moral terms and suggested self-management and help from family and friends. The European American participants more often offered biological explanations, such as a hormonal imbalance, alongside a life-stress explanation.
Explanatory models of depression range widely. Distress may be explained as a chemical imbalance, as the result of stress or loss, as a moral or spiritual weakness, as a sign of disrupted relationships, or as the result of supernatural forces. A biomedical explanation can reduce blame but may also suggest that the problem is permanent; a social explanation directs attention to circumstances that could change.
Help-seeking is the process of looking for support for a health problem, whether from professionals, family, friends, religious leaders or traditional healers. Explanatory models shape help-seeking directly. A person who sees their problem as physical will visit a general doctor and describe bodily symptoms; one who sees it as spiritual may consult a religious leader; one who sees it as a family matter may never leave the family circle.
Stigma, cost and the availability of services also differ between cultures. Only about a third of people with depression in high-income countries receive mental health treatment, and far fewer do in many low- and middle-income countries, where mental health professionals are scarce. In many places, traditional and religious healers are the first and most trusted source of help, which is one reason why services that work with communities are more likely to reach people than services that wait for patients to arrive.
Sources: WHO, Depression fact sheet (2023 estimates).
Indigenous approaches to mental health often treat it as inseparable from physical, family, spiritual and land-based well-being. In New Zealand, Mason Durie’s Te Whare Tapa Whā model represents Māori health as a house with four walls, the physical (taha tinana), mental and emotional (taha hinengaro), family and social (taha whānau) and spiritual (taha wairua), all of which must be strong for the house to stand. Services built on the model involve families and attend to cultural identity as part of treatment, rather than focusing on the individual’s symptoms alone.
Such approaches illustrate a holistic perspective on mental health. They also raise a question for research, because outcomes that matter within the model, such as restored family relationships or a stronger cultural identity, are not captured by a symptom questionnaire.
Most psychological treatments for depression, such as cognitive behavioural therapy, were developed in Western countries. Culturally adapted treatment changes the language, examples, goals, delivery or explanation of a treatment so that it fits the culture of the people receiving it, while keeping its active ingredients. Adaptations may include using local idioms of distress, involving family members, using metaphors and stories from the culture, or delivering the treatment through people from the community.
A meta-analysis by Hall et al. (2016) of 78 studies with 13,998 participants, 95% of them not European American, found that culturally adapted interventions were more effective than unadapted versions of the same intervention, with a medium effect size (g = 0.52). The advantage was larger for treatment than for prevention.
Where there are few mental health professionals, treatment can be shared with trained lay health workers from the community. In the Friendship Bench trial in Harare, Zimbabwe, Chibanda et al. (2016) randomly assigned 24 primary care clinics either to six sessions of problem-solving therapy delivered on a wooden bench by trained lay health workers, or to enhanced usual care. The 573 participants had screened positive on the Shona Symptom Questionnaire, a measure developed locally and built partly around kufungisisa, “thinking too much”. After six months, participants in the Friendship Bench group had far fewer symptoms.
A trial of the Healthy Activity Program in Goa, India, by Patel et al. (2017) found the same for a brief behavioural activation treatment delivered by lay counsellors. Both trials show that treatments can work across cultures when they are delivered in a form that fits local language, explanations and resources.
YouTubeRyder et al. (2008) aimed to test the long-standing claim that Chinese people express depression mainly through somatic symptoms, and to find out whether the difference from Western patients is real or an artefact of how symptoms are measured. A second aim was to test explanations of any difference.
The study was a cross-cultural quasi-experiment in which culture was the independent variable. Participants were 175 Han Chinese outpatients at a psychiatric outpatient clinic of a large teaching hospital in Changsha, Hunan, China, and 107 Euro-Canadian outpatients at the depression clinic of a large psychiatric hospital in Toronto, Canada. All were recruited in 2002 and were receiving help for depression.
Symptoms were measured in three ways, a form of method triangulation. In spontaneous problem report, patients described in their own words the problems that had brought them to the clinic, and these were coded as somatic or psychological. In a structured clinical interview, based on the SCID for DSM-IV and extended with Chinese and international criteria for depression and neurasthenia, clinicians rated every symptom on a 0–3 scale. In a symptom questionnaire, patients rated their symptoms privately.
The researchers first checked that each method produced somatic and psychological subscales that measured the same thing in both cultures (measurement equivalence). They also measured alexithymia, including externally oriented thinking, a tendency to focus on external events rather than on inner emotional experience.
Method | Somatic symptoms | Psychological symptoms |
|---|---|---|
Spontaneous problem report | Chinese reported more | Euro-Canadians reported more |
Structured clinical interview | Chinese reported more | Euro-Canadians reported more |
Private questionnaire | No significant difference | Euro-Canadians reported more |
Sources: Ryder, A. G., Yang, J., Zhu, X., Yao, S., Yi, J., Heine, S. J. and Bagby, R. M. (2008). The cultural shaping of depression: somatic symptoms in China, psychological symptoms in North America? _J Abnorm Psychol, 117(2), 300–313._
All three methods produced subscales that were equivalent across the two cultures, so the comparison was meaningful. The psychological symptom difference was larger and more consistent than the somatic one: Euro-Canadians reported more psychological symptoms whichever method was used, whereas Chinese patients reported more somatic symptoms when speaking to a clinician but not on the private questionnaire. The cultural difference in somatic symptoms was explained statistically (mediated) by externally oriented thinking. Difficulty in identifying and describing feelings did not differ between the groups.
Culture shapes the presentation of depression, and the difference is not simply a measurement artefact, because it appeared across more than one method. Chinese patients identified their emotions as well as Euro-Canadians did, and a culturally encouraged focus on external, practical matters led them to emphasise bodily symptoms. Because somatic symptoms of depression are common worldwide, the authors suggested that the strong Western emphasis on psychological symptoms, psychologisation, may be more culturally specific than Chinese somatisation.
Using three methods and testing measurement equivalence before comparing scores addresses the main criticism of earlier research, that differences come from a single instrument or a poor translation. The pattern across methods is itself informative: Chinese patients reported more somatic symptoms in contact with a clinician but not in private, which suggests that somatic emphasis is partly about what is appropriate to present to a doctor. A later reanalysis of the same patients by Dere et al. (2013) added that Chinese patients spontaneously reported depressed mood about as often as Euro-Canadians, which warns against overstating the contrast.
Both samples were outpatients who had sought psychiatric help in large cities, so they may not represent people with depression who never seek help, or people in rural areas. Help-seekers in China, where psychiatrists are scarce, may be a more selected group than help-seekers in Canada. Comparing one Chinese city with one Canadian city also treats each as representing a whole culture, and differences between hospitals could be confused with cultural differences.
Culture could not be manipulated, so the study cannot show that culture causes the difference; it shows an association that is consistent with a cultural explanation. The mediation by externally oriented thinking is a statistical result from data collected at one time, which suggests but does not prove a mechanism. Researcher reflexivity also matters: the study was designed by a team that included Chinese and Canadian researchers, which reduces, though does not remove, the risk that one culture’s assumptions shaped the coding of “somatic” and “psychological”.
Concept | Issue in research on culture and mental health |
|---|---|
Bias | Diagnostic criteria and instruments come mainly from Western research (imposed etic); clinicians’ cultural expectations can lead to under- or over-diagnosis, as Olbert et al. (2018) found; most research is done by researchers from outside the cultures studied. |
Measurement | Prevalence depends on translation, cut-offs and the willingness to report; triangulating methods, as Ryder et al. (2008) did, and testing measurement equivalence improve comparisons. |
Perspective | Etic research allows comparison but may miss local meanings; emic research captures meanings but makes comparison difficult. Combining them (derived etic) is the usual recommendation. |
Causality | Culture cannot be manipulated, so cross-cultural studies are quasi-experiments or correlational; country-level correlations risk the ecological fallacy. |
Responsibility | Labelling cultural expressions of distress as disorders can pathologise normal experiences; failing to recognise depression can deny people treatment. Exporting Western categories and treatments without adaptation raises questions of respect and effectiveness. |
A balanced judgement is that culture affects every step from distress to diagnosis. Some cross-national differences in prevalence are probably real, reflecting social conditions such as poverty, conflict and family disruption, while others reflect differences in how distress is expressed, recognised and measured. The evidence that culturally adapted and community-delivered treatments work suggests that the core of depression is shared widely enough for treatments to transfer, provided they are translated into local terms.
Culture also interacts with biological and cognitive factors. A person’s explanatory model is a cognitive factor learned from their culture, and it shapes which bodily sensations they notice and how they interpret them. Biological changes in depression, such as disturbed sleep and fatigue, are found across cultures, but whether they become the centre of a person’s complaint depends on cultural norms. A complete explanation of cultural differences therefore needs all three approaches.
Cultural differences in mental health can appear in Paper 1 Section B, where an unseen scenario asks you to apply an approach term such as the etic approach, the emic approach or cultural dimensions to a mental health situation, and in Paper 1 Section C, where an essay combines this area of study with a concept, most often bias, measurement or perspective.
Section C essays need a line of argument that is visible from the introduction to the conclusion. For an essay on bias, the difference between artefacts and real differences gives the argument a clear structure.
Recorded lifetime prevalence of a major depressive episode ranged from 21.0% in France to 6.5% in Shenzhen, China, in the World Mental Health Surveys reported by Bromet et al. (2011).
Differences in prevalence may be real (poverty, conflict, social support, acculturative stress) or artefacts of expression, stigma, help-seeking, translation and diagnostic criteria.
Culture shapes the expression of distress: somatisation, emotion norms (the cultural norm hypothesis), idioms of distress and cultural concepts of distress such as ataque de nervios and taijin kyofusho.
Kleinman (1982) found that 87 of 100 Chinese patients diagnosed with neurasthenia met criteria for major depressive disorder.
Ryder et al. (2008) found that Chinese outpatients reported more somatic symptoms to clinicians and Euro-Canadians more psychological symptoms on all three methods, suggesting that Western psychologisation is the unusual pattern.
Cultural bias in diagnosis leads to under- and over-diagnosis; the Cultural Formulation Interview brings patients’ explanatory models into assessment.
Explanatory models shape help-seeking; Indigenous approaches such as Te Whare Tapa Whā treat mental health holistically.
Culturally adapted and lay-delivered treatments, such as the Friendship Bench and the Healthy Activity Program, are effective in low-resource settings.
I can describe differences in the prevalence of depression between countries and populations, using real data.
I can explain factors that may produce real differences in prevalence and factors that may produce artefacts.
I can explain how culture shapes the expression of distress, using somatisation, emotion norms and cultural concepts of distress.
I can describe the aim, method, results and conclusions of Ryder et al. (2008).
I can explain cultural differences in approaches to mental health, including explanatory models, help-seeking and culturally adapted treatment.
I can evaluate research on culture and mental health with reference to bias, measurement and perspective.
I can apply knowledge of cultural differences to an unfamiliar mental health scenario.