Depression in Different Cultures: Is it Universal in terms of Emotional Expression?

Charles Darwin, who was himself prone to depression, published The Expression of the Emotions in Animals and Man in 1872, 13 years after Origin of Species. This was the first large-scale attempt by a scientist to demonstrate that certain universals might exist in human emotional expression. Darwin wanted to support his theory of  evolution – that we had all evolved from a common progenitor – by showing not only that certain emotional expressions were universal, and therefore had a common genetic blueprint, but also that there was some continuity between  humans  and  other  mammals  in  the  way  that  we  expressed moods. Some photographs of  his observed expressions are shown on the picture below.

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Darwin  interviewed  people  who  had  lived  or  travelled  in  foreign lands. He pointed to similarities in emotional expression across different cultures. He also recounted striking and poignant descriptions of grief  or sadness in other mammals. On Indian elephants, captured in Ceylon  (now  Malaysia),  he  quoted  an  observer:  ‘[the  elephants]  lay motionless on the ground, with no other indication of  suffering than the tears which suffused their eyes and flowed incessantly’.

Darwin’s  volume  persuasively  suggested  that  the  influence  of natural  selection  is  not  limited  to  mere physical  characteristics but shapes our emotions. However, ever since its publication violent battles have been waged over the interpretation of  its findings. Among the main players in this drama during the twentieth century have been the famous anthropologist Margaret Mead and, later, the experimental psychologist Paul Ekman.

Margaret Mead conducted detailed observations of  many relatively isolated cultures. Her descriptions demonstrated that there were huge variations in behavior – how people lived, hunted, fed, worked, formed intimate partnerships and raised their children – across the different  cultures.  In  1935  Margaret  Mead  published  an  academic work called Sex and Temperament in Three Societies, in which she concluded that  ‘human nature is almost unbelievably malleable,  responding  accurately  and  contrastingly to contrasting cultural conditions. This ‘cultural relativism’ was, at the time, a welcome backlash against racism and eugenics, and it arose in the climate of  radical behaviorism,  which  suggested that we are all entirely products of learning and experience.

This arguably optimistic stance suggested that individual differences could be wiped out if we were all raised in the same environment and with limitless opportunities for self-improvement. It further suggested that there were no genetic limits to our achievements. With regard to our emotional worlds, emotional displays were determined entirely by learnt rules of communication within a culture. There  was no contribution from biology. It followed that some expressions, like a frown, could represent happiness in one culture, and displeasure in another;  and that some facial expressions could be found  in one culture and not in another. The cultural relativists would have strongly resisted any suggestion that the same symptoms of  depression could be detected in every culture of  the world. This would have implied a universal genetic liability, and even continuity with the animal kingdom.

Unfortunately for Margaret Mead, at the time that she was writing other researchers, most notably the  developmental psychologist Florence Goodenough, were coming up with sound evidence to support Darwin’s belief  in emotional universality. More importantly, they provided direct support for the idea that emotional expressions were  innate, not learned. They observed the emotional reactions of children who had not had the opportunity to imitate the emotional expressions of others. In 1932 Goodenough  published her observations of  a ten-year-old girl who had been blind and deaf  from birth. According  to  Goodenough, this young girl showed surprise when something unexpected happened, displayed sadness  when a favorite toy was taken from her, and laughed and smiled when fun or pleasant objects were given to her. Goodenough concluded that children who are born deaf  and blind use the same facial expressions as other children to express the same emotions.

Goodenough blazed a trail for other researchers like Jane Thompson and Irenäus Eibl-Eibesfeldt, a German ethologist. Thompson took photographs of  the emotional reactions of  26 blind children, aged from seven weeks to thirteen years, to certain situations, and had independent  raters  compare  these  reactions to those of sighted children, matched for age in similar emotion-provoking situations. In the 1960s Eibl-Eibesfeldt went further and explored the role of IQ in a small number of  children affected by thalidomide, a drug, launched in the 1960s, which was found to cause major congenital defects to the unborn babies of  pregnant women who took the drug, including eye, ear and brain defects. The children in Eibl-Eibesfeldt’s study were all deaf  and blind from birth and had varying amounts of brain damage. They also had limb malformations. He videotaped the young children and then slowly played the tapes back. He observed a wide spectrum of  spontaneous emotional expressions in each child, including smiling, crying, surprise, and frowning, which were similar to expressions shown by sighted children. This was true even of  one child with an IQ within the severely disabled range. Other researchers produced similar results.

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Of  course, all these studies had some weaknesses  of  method,  but taken together they seem to imply that no social learning of emotional expression is required. This seems to be in direct contradiction to the findings of  Margaret Mead, who had carefully observed differences in emotion expression across cultures.  Both theories could not be right as absolutes.

However, the most useful theory of  human emotional expression came along later, in the 1970s. This theory, developed by the eminent experimental  psychologist Paul Ekman, inhabited the middle ground.  Ekman used culture-sensitive observation techniques to demonstrate  that the basic expressions of  sadness, fear, disgust, anger and surprise could be found in many different cultures of  the world, if  one only took care to separate the innate behavior from the learned.  In other words, he showed that all cultures had the fundamental capacity to instinctively express these emotions in the same way, but that certain culture-specific display rules affected when they would be expressed.

For example, in the 1970s Ekman challenged the prevailing view that  the  Japanese did  not express  emotions in the same way as Americans. He did this by asking both Japanese and American people to watch an emotive film on two occasions – once in the presence of a ‘scientist’, dressed in a white coat, and once on their own. On both occasions their external expressions were recorded with a hidden camera. During the viewings with the ‘scientist’ present the Japanese did not express emotion as much as the Americans. However, when both Japanese and American people viewed the same film on their own they reacted in very similar ways. The suppression of  emotional expression witnessed in the Japanese when the ‘scientist’ was present reflected  a  learned  response  to  the  presence  of   authority  figures, defined by the Japanese culture. Without knowledge of  this Japanese display rule one  might have concluded, on the basis of crude observation, that the Japanese did not have the same innate range of emotional  expressions  as  the  Americans. This would  have  been  a mistake.

These issues demonstrate the difficulties that can be anticipated in trying to detect a common collection of  depressive symptoms in many different cultures. We are not merely considering the outward expressions of  sadness, or lack of  animation, we must also gain access to the inner thoughts and feelings, the communication of  which is surely even more  amenable  to  cultural  variation. The  cultural  relativists,  like Margaret Mead, would argue that it is impossible to find core features of depression that are present in all cultures of  the world because there are  more  differences  in  the  way  that  people  express  mental  distress between cultures than there are similarities.  They would suggest that the presentation of  mental distress in each culture is unique. It would be meaningless to look for universal features of depression across cultures if a person’s psychiatric symptoms were entirely determined by the relationship he had with his society.

Differences exist, for example, in the physical location of sadness in different cultures – some feel sadness in the heart (the western concept), others in the stomach (like the Japanese). If  Europe, which is the parent of  modern psychiatry, devises a test for depression, it will use for its template the symptoms suffered by depressed people in Europe. Exaggerated guilt, which is unreasonable in context, is a common feature of  depression  in  European  and American  cultures. However,  it  may be a rare feature of  depression in India. Guilt may be particularly western. Many reasons for this have been postulated, including the contribution of the work ethic, and, in the older generation, the need to ration one’s desires during the two World Wars. There may have been religious contributions too – from Lutheran Protestant and Catholic confessional traditions.

It is possible, however, that while some symptoms may be culture-bound, and so will be missed entirely  in some cultures, other core symptoms may be universal. The development of  the WHO’s Standardized Assessment of Depressive Disorders (SADD) was the first large-scale attempt at producing a culturally unbiased interview for the diagnosis of  depression. It was used in the psychiatric populations of Basle, Montreal, Nagasaki, Teheran and Tokyo and was conducted by people from the host culture. Evidence could be gleaned from the local psychiatrist who had been treating the patient.

It  was discovered that there were certain core symptoms of depression that were present in all cultures, and in at least 79 per cent of the total sample of patients. These symptoms included sadness, joylessness, hopelessness, anxiety, tension, lack of energy, loss of interest, poor concentration, and feelings of insufficiency, inadequacy and worthlessness. The WHO  study  confirmed  that  excessive,  often delusional, feelings of guilt or impoverishment and low self-esteem were particularly western expressions of depression. Delusions of  guilt were completely absent in Teheran, and delusions of  impoverishment absent in Tokyo.

Therefore, there were certain core symptoms of depression, sufficient for making a reliable diagnosis,  present in all cultures studied. In addition, there were culturally specific symptoms, but these were less important than the universal ones.

The WHO study could be criticized for focusing on urban populations only. Its conclusions would not necessarily apply to a traditional African agricultural village. However, other studies have added to our knowledge of  universal symptoms. Patients defined as depressed by local psychiatrists in Ghana had the same pattern of core symptoms, in roughly the same proportion (76 per cent  or more of patients). In  China, a Western psychiatrist Kleinman found that the main core symptoms of  depression were present in 87 per cent of patients presenting to Chinese psychiatrists with neurasthenia (or nervous exhaustion).The label was different but the phenomenon was just the same, and many improved when given antidepressants.

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The WHO study could also be criticized for using preconceived notions of  how symptoms might aggregate together to form the depressive syndrome. An anthropologist Morton Beiser and his colleagues attempted to show how similar psychological symptoms might occur frequently together in different cultures without using any preconceived European notion of  the nature of  depressive symptoms. The aim was to see which generic symptoms of  psychological distress tended to group together most often in different parts of  the world. It was only later that these groupings were compared with our Western concepts of  diagnostic syndromes, including depression.

Beiser et al. studied the Serer, a community of  settled agriculturalists who have inhabited Senegal for at least the past seven hundred years. They focused on the region of Niakur, where, at the time of  the survey in  1970, the 35,000 inhabitants lived one of  the most traditional lifestyles  in  Senegal,  or  possibly in the whole of West Africa. Four hundred  and  forty-six  adults,  who  were  indigenously  defined as probable psychiatric cases, were interviewed in their local tongue, Serer, about their distress. Over 100 different symptoms were described by this  community, and they were compared with symptoms volunteered by communities in the Brooklyn and Queens suburbs of New York, and by a community of  refugees from Vietnam, Laos and Cambodia who had resettled in Vancouver, British Columbia, during 1979 and 1980.

The over 100 items were a ‘distillation of decades, if not centuries, of clinical lore’ about  the ways  people  report  distress.  All  three communities were rated on all the symptoms, although symptoms that recorded a less than 10 per cent positive response across all three centers  were  excluded. No  predetermined  ideas were formed about which  of  these psychological symptoms might constitute the syndrome of  depression. Instead, the researchers determined which symptoms seemed to occur most frequently together in each affected person, using a statistical technique called factor analysis. The  ingenuity of  the design enabled the researchers to explore a wide range of psychological and psychosomatic symptoms, including items that had originally been regarded as culture specific.

The factor analysis revealed many clusters of  symptoms, and one of these clusters contained the constellation of symptoms that western psychiatry would use to define depression. In all centers, a significant proportion of all the symptoms reported were  psychic  descriptions  of   the  depressive  experience.  The six symptoms presenting in all three cultures were hopelessness, indecisiveness, feelings of  futility, hypersensitivity to the feelings of others, and anergia (lack of energy).  Another  group,  called ‘somatization’ (that is, describing distress in physical terms), could be separated out from these symptoms. The ‘somatization factor’ included complaints about shortness of breath, palpitations,  dizziness and persistent poor health. The ‘depression dimension’ was independent of  scores on the somatization dimension.

This latter finding was thought to be important because it challenged the prevailing view that non-western communities were unable to express depression in psychic terms, tending to perceive their distress in physical terms.

The WHO and Beiser et al. surveys challenge the extreme social–anthropological view that mental  distress expresses itself  in such radically different forms in different cultures as to make meaningless trans-cultural comparisons of the prevalence of  a concept such as depression. If  depression has many core features that are evident across different continents it becomes meaningful to compare the prevalence of depression across cultures.

We know that major depression is common in the western world. However, for many decades, psychiatrists from the white western Christian culture such as Frederick Kraupl-Taylor, a professor of psychiatry during the first half of the twentieth century, have believed that the prevalence of  depression in the ‘undeveloped’ cultures of Asia, Africa and South America is much lower than the  western prevalence.  Some  have  even  concluded  that  depression  is  nonexistent in the traditional, ‘undeveloped’ communities.

These early researchers have mostly attributed this discrepancy to ‘cultural  differences’.  Some, like  Kraupl-Taylor, blamed the discrepancy on the less developed use of  language in pre-literate societies. However, the most predominant explanation was that there were fewer stresses  in the seemingly less  complicated lives of  the tribes of, say, traditional Africa, or Papua New Guinea. Carrothers, in his 1953 monograph The African Mind in Health and Disease, concluded that Africans did not suffer depression because of  the ‘lack of  responsibility’ they enjoyed within a ‘primitive paradise’.

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This ‘happy savage’ idea persists to this day, despite the fact that people all over the world have had to  deal with personal and interpersonal  difficulties and tragedies  –  death of  loved ones, separation from loved ones, status battles, childcare, ill-health and old age.  As social animals we all have the potential  to hurt each other, psychologically and emotionally, wherever we live, and extraneous stressors, acts of  God and so on, can never be ruled out. In the modern world these stressors might be redundancy and crime; our ancestors would have had to endure famine and drought. Some psychiatrists have suggested that the minds of the members of traditional communities are more primitive, and that this makes them  less susceptible to depression. Kraepelin visited Java at the beginning of  the twentieth century and concluded that depression was seldom  experienced  there. He believed that the Indonesians were incapable of experiencing such a condition because they lacked the mental capacity to experience it. The underlying assumption was that their brains were less developed than the modern European brain – and  consequently  they  had  not  evolved  the  capacity  to  experience depressed mood to the same degree. Forty years later, when biological explanations for mental illness and physical treatments such as lobotomy  (making lesions in the frontal lobes of the brain) were all the rage, some psychiatrists even ventured to suggest that the African tribesman had an emotional life akin to the lobotomized European patient.

Early observations by European researchers in Africa and India often supported such beliefs by reporting low hospital admission rates for depression compared to Europe. For example Shaw, in his book entitled Clinical Handbook of  Mental Diseases (published in 1925), reported that Indians in the Berhampore asylum suffered less frequently from depression than in-patients in European asylums. However,  there  were many reasons for these comparatively low estimates that had nothing to do with the true prevalence in the communities  observed.  First, little consideration was given to the possibility that many people with depression were not being admitted to hospital. This was indeed the case in many instances due to the very real barriers to hospital admission. Hospitals were often geographically remote, there was frequently a shortage of  beds and there were limited primary care facilities for referral of  patients to hospital. Second, few depressed people attended  local doctors, preferring instead to visit religious healers. Spiritual explanations for depression are common around the world. Such explanations can prevent people with the illness from coming forward for treatment. In  India, the suffering that occurs during a depressive illness is often thought to be a punishment for sins in a past life. The self-prescribed treatment is to cry silently, work hard and pray. People living in India are willing to go to their doctor with physical complaints, but prefer to visit a spiritual healer for help with the mental distress caused by depression.

Sudhir  Kakar, a psychoanalyst working in India, conducted an anthropological study of  the various ways  in which mental health problems are treated there. He identified three main kinds of  care –the exorcism tradition, the Ayurvedic tradition and the Guru tradition. In the exorcism tradition there is a hierarchy of  treatment: from the healer in the village up to the priest in the temple. The more intractable problems are treated in the temple. In the Ayurvedic tradition, treatments  include  herbs  with tranquillizing properties or shock treatment – using irritants placed up the nose, for example. The Guru tradition was the mainstay of treatment for depression.

So,  in  order  to  obtain  an  estimate  of   the  true  prevalence  of depression in different countries, attempts have been made to conduct community surveys. Surveys can be fraught with difficulties. One major difficulty is observer bias. Some early researchers, who, due to various preconceived notions (perhaps with their roots in the happy savage idea), were expecting low rates of  depression, were not exactly painstaking in their attempts to detect the condition. Similar mistakes continue to be made in assessing contemporary immigrant communities in the western world. 


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