East and West: Two Faces of Depression

"This post is co-written by Michael Sun and guest writer Rachel McCrystal, both authors contributed equally.” Sam Davis* is a 20 year old sophomore at UCLA. He attends class every day, and by and large, Sam lives a relatively normal college student life. But lately, he has been weighed down by something he finds hard to explain: he frequently skips breakfast and lunch, has been late to class due to oversleeping, and has found himself getting colds more often; he mentions that he “doesn’t get the point of going through the usual routine”; he finds himself unwilling to get out of bed, and the activities he used to enjoy, such as fishing and basketball, no longer seem appealing. Sam exhibits clear symptoms of clinical depression. Fortunately, he has friends and family he can talk to and a support system he can rely on to get through tough days.

Across the lecture hall of Sam’s biology class sits Wilson Chan*, a first-generation Chinese American student. Wilson’s family uprooted itself from Beijing, China to start a new life in Los Angeles when he was five years old. Wilson also suffers from depression. Like Sam, he feels that in his day-to-day life, he is “just going through the motions.” He throws away his packed lunches and often finds himself sleeping in class. Once an avid computer gamer, Wilson now finds himself staring at his computer, only to turn it off a few minutes later, claiming “the games just aren’t fun or stimulating anymore. I seriously would rather do nothing.” While Wilson’s symptoms are analogous to Sam’s, Wilson’s cultural background presents a different twist to his depressive manifestation. To people in his close social circle, Wilson looks every bit like himself. “I don’t want people to be burdened by the things I am going through,” he explains. “They wouldn’t understand it, anyway.” Every day, Wilson fears stigma and ridicule from his peers and family. He struggles with his depression alone.

Clinical depression is a longstanding and highly prevalent mental disorder, characterized by pervasive and persistent low mood, low self-esteem, and loss of interest or pleasure in normally pleasurable daily activities. Over one in ten adults in the United States suffers from depression, and the number of patients diagnosed with it increases by approximately 20% every year (Healthline, 2012). The typical person with depression is inconsolable, unmotivated, and sad; there is very little variation in the illness’s presentation. However, cultural differences in v  alues, beliefs, and practices may contribute to depression’s etiology, eventual manifestation, and maintenance. For instance, variations in cognition, parental expectations, and social behavior play a role in how depression reveals itself and impacts its sufferers’ lives.

Depression manifests dissimilarly in Eastern and Western cultures. In East Asia (i.e., China, Japan, Korea), individuals hold what is known as an “interdependent self-construal.” This cultural self-view places a great importance on relationships in which members of the group are mutually dependent on each other, and emphasis is on goals that are shared by a collective (e.g., a family, a club, or a company). Confucius, a philosopher who shaped early East Asian governing practices, said that “just being filial to your parents and befriending your brothers is carrying out the work of government” (Ames, & Rosemont, Jr., 1999). This contrasts the self-view commonly held by individuals from Western societies (i.e., Europe, Australia, North America), known as an “independent self-construal,” wherein emphasis is on the development of individual attributes and the need for self-actualization. In fact, Western psychologists view the formation of an autonomous identity as one of the primary tasks of adolescence (Erikson, 1968; Blos, 1979). The role of the self in the mind permeates people’s cognitions and behaviors both consciously and unconsciously, and is constantly being generated and reinforced in their respective cultures.

How do these cultural differences affect depression risk? One study found that among Asian Americans, a strong interdependent self-construal (measured by self-reported endorsement of cultural values) would actually attenuate the relationship between anger suppression and depressive symptoms (Cheung, & Park, 2010). In other words, habitually unexpressed feelings of anger, which are normally associated with depressive symptomologies such as rumination and avoidance, have a weaker effect on people who have been culturally conditioned to keep others in mind. Additionally, Brian Trung Lam (2005) found that an interdependent self-construal was associated with high family cohesion, which bolstered adolescents’ self-esteem and, in turn, contributed to less depression. The cultural distinctions in parental expectations between Asian and Caucasian families may have a particular impact on late-adolescent Asian youths. In this case, it appears that interdependent self-construals actually attenuate risk for depression.

However, it is not yet clear whether the cultural self-construal of interdependence actually reduces depression rates, or simply changes its form and makes it harder to detect with our current, Westerner-derived diagnostic tools. To illustrate this point, a depressed person socialized in an independent cultural context typically looks sad all the time, is highly negative, and is low on motivation. Independent individuals with depression LOOK like depressed people, because by doing so, they are exercising a culturally congruent method of communicating their individual states to others. Individuals socialized in an interdependent cultural context may look different. Instead of being motivated to communicate to others, they would be more likely to hide themselves for the sake of not being social burdens; instead of focusing attention on themselves and getting help for their depression, they would choose to suffer silently.

There is some direct empirical evidence for the link between culture and depression. Japanese American college students report lower average positive affect (mood and emotions) than European American college students (Kanazawa, White, & Hampson, 2007) and Korean students showed more negative affect, negative help-seeking behavior, and somatization (the tendency to experience, communicate, and seek medical help for psychological distress in the form of physical symptoms) than European American students (Yoo, & Skovholt, 2001). For instance, a depressed Korean student exhibiting somatization may see her primary care physician for abdominal pain, and may even experience abdominal pain due to her depression. Help-seeking behavior is problem-focused, planned behavior involving interpersonal interaction with a selected healthcare professional (Cornally & McCarthy, 2011). The absence of this behavior is linked to depression. Several studies sound an alarm against the insidious threat of depression among East Asians. A study done by May Kwan Lorenzo, Abbie K. Frost, and Helen Z. Reinherz in 1995 found that although Asian American students performed better academically and reported fewer delinquent behaviors (commonly thought of as protective factors against depression), they also had higher levels of depressive symptomatology, withdrawn behavior, and social problems. Additionally, they perceived themselves more poorly and were more dissatisfied with their social support. Following up on these findings, Sumie Okazaki and Diya Kallivakyalil (2002) found that Asian American college students had significantly higher scores on the Beck Depression Inventory than European American college students. Christine M. Cress and Elaine K. Ikeda conducted a study in 2003 that also found that Asian American college students are more likely to experience depression than their European American peers. Despite these repeated findings, depression among Asian Americans is largely invisible from a societal perspective, and their representation in the mental health care system is almost nonexistent.

So what makes them invisible? The Asian American emphasis on interdependence breeds an associated fear of stigma. As a result, Asian Americans are less likely to report symptoms of depression to family, friends, or those who can help them. Fogel and Ford (2005) found that Asian Americans overall held greater stigma beliefs regarding their depression than European Americans on three outcomes: friends, employers, and most of all, family members. For friends and employers, Asian males had greater stigma levels than Asian females. The stigma of reporting one’s depression may be exacerbated by values of interdependence, whereas sharing psychological difficulty might bring about undue burden onto significant others, since a focus on the self is not condoned.

Hope remains that the relationship between culture and stigma may attenuate among the younger population through the process of acculturation, wherein members of one cultural group adopt the beliefs and behaviors of another group. The cultural cognitions of the younger generation of Asian Americans will gradually differ from the beliefs associated with traditional culture because of this generation’s contact with Western values. Consequently, any ethnic etiological differences in the unfolding of depression will begin to blur. Nonetheless, East Asians remain the fastest growing immigrant population coming to the US, and counselors and therapists should be ever vigilant of the cultural baggage associated with depression. Specifically, they should be aware of the tendency of Asian Americans to under-report their symptoms due to cultural beliefs in order to improve assessment and intervention. Keen understanding of cultural variation in depressive symptoms can help better formulate future research questions and enact effective prevention and intervention efforts across diverse populations.

Sam Davis is now seeing a therapist at CAPS on a weekly basis and is growing to feel comfortable talking about himself and his depression. He is easing back into the basketball court and has recently come back from a fishing trip with his father. His therapist is optimistic about his improvement.

But where is Wilson Chan? All I got was a message that said, “I’m fine. Don’t worry about me. I don’t want to waste your time.”

If you are interested in either psychotherapy or medication for mental illness, schedule an appointment with a psychologist or psychiatrist (medication) to provide you with treatment options. UCLA students have access to Counseling and Psychological Services (CAPS) located in Wooden West, or at (310) 825-0768.

*name changed for privacy

*Special thanks to Alexandra Batzdorf for her assistance in copy-editting this article