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Introduction The question being evaluated in this essay is, “To what extent do depression symptoms differ in collectivist and individualist cultures?” The essay starts off with defining the meaning of depressive disorder and how there is a difference between depressive disorder and being in a depressive mood. Then, the essay will contain an explanation as to how depression is diagnosed and how that can lead to problems when dealing with others from around the world and having a contrast of core beliefs. The essay continues on to talk about how collectivist and individualist cultures vary from one another, which result in the significant contrast in the way individuals from both cultures express symptoms of depression. However, even as the symptoms of depression are usually found to be different with varying cultures, there are times where they share some resemblance. Afterwards, the essay deals with the studies that discuss the ways in which the depressive symptoms are different from each other in both collectivist and individualist cultures most of the time and later on discussing a few instances where the symptoms will be similar to one another. By the end of the essay, the conclusion will be reached and will state that due to such dissimilarities in both collectivist and individualist cultures, to a great extent there will be various depression symptoms from the two. That being said, it is not always the case and even though for the most part the symptoms differ rather greatly, a few studies have shown that there are also correspondence between the two cultures from time to time. Understanding Depression Depression is considered to be a mental illness that has been diagnosed to many people in the world today. It is a mental illness that most often times has the involvement with the mind, body, and thoughts of the person. As depression takes a toll on these aspects of a person’s being, it greatly impacts on the way they can function in their everyday activities and hurting them in the ways they have always normally functioned before. Depression is much more than feeling sad on a bad day and being a little moody; it pains the person that is diagnosed with the illness itself but also those that care for them and are around them that have seen them slowly fall into the realms of the illness. There is a major difference between feeling depressed and going through depression. Everyone can have depressive feelings as they are a normal aspect when one goes through disappointment and grief. However, for depression, it must be a result from symptoms of a mental illness and/or of other mental diseases (Kleinman, 2004).   The mental illness, depression, is increasing by the day, rising from 3.33% to 7.06% between 1991-1992 as well as 2001-2002 within a study based on the community of American adults, and is something that is experienced in all ethnic groups throughout the world (Compton et al., 2006 & Kleinman, 2004). That being said, the contrast between individualist and collectivist cultures is a significant reasoning to why the symptoms of depression can vary tremendously. Individualist cultures mainly emphasize and prioritize more of the characteristics of the individual rather than the entire group, meaning it is a culture that is more likely oriented towards the self and not being dependent on a group. On the other hand, collectivist cultures stress the importance of family, peers, and their work group more than the individual themselves. There is a large emphasis on completing goals and needs of the group as a whole than the wishes of each individual, so the interconnectedness between the lives of the people play a central position in the identity of each person. To what extent do depression symptoms differ in collectivist and individualist cultures? Depression is a mental illness that does not have a simple answer to how each and every symptom is handled; even with manuals that have been created in particular to mental illnesses usually emphasize the symptoms of one culture more than another. Each person has differing symptoms to the illness due to the influence of their culture and environment, so many studies will be demonstrated to the extent in which display that symptoms of depression greatly vary from individualist cultures and collectivist cultures. The symptoms from both perceptions will be examined to support that indications towards depression are not identical. However, there will be such instances where the depression symptoms from each culture share similarities and are not always disparate, showcasing that even as symptoms vary greatly in each culture, there will be times where it is not valid. Diagnosis of DepressionIndividuals of one place will always be unlike other individuals of another place, so why is it that one, who specializes in the field of diagnosing and treating mental illnesses, can diagnose someone with or without major depressive disorder (MDD) when there are so many underlying factors and aspects that are still a mystery even today? Psychiatrists and clinicians still find it difficult when diagnosing a patient with depression as the mental illness itself has a wide range of not only emotional symptoms, but physical symptoms that come along with it; furthermore, these must be explored deeply and carefully in order to present a diagnosis that is accurate and reliable. The Diagnostic and Statistical Manual of Mental Disorders that is now in the fifth edition (DSM-5), is a manual that clinicians and other researchers use on a daily basis in order to aid them in the process of identifying and diagnosing the correct mental illnesses. As it is in its fifth edition, there has been much improvement and adjustment made towards it to enhance the diagnoses, treatments, as well as research (American Psychiatric Association, 2013). The DSM-5 defines major depressive disorder as the deviations from particular cultural norms and ideals; that being said, the DSM-5 is not perfectly done and still contains issues that have yet to be resolved. The DSM-5 is mainly used by the clinicians in the United States rather than used by the clinicians from other parts of the world as every culture varies from each other. Moreover, depression standard includes both the physiological and psychological symptoms, but the DSM-5 focuses on the emotional symptoms of depressed moods, indicating the way Western countries emphasize mental states. As the DSM-5 is the basis for which patients are diagnosed with depression, it does not allow for those that display different symptoms from the manual to be correctly and accurately identified. Cultural Differences in Symptoms of Depression A mental illness, such as depression, is complicated to diagnose due to differences amongst each individual. Not only so, but it is a mental illness that is handled in various ways from around the world since each nation has certain cultural meanings and practices that shape the course of which a psychiatrist takes in order to appropriately assist the patient (Kleinman, 2004). The DSM-5 is a reliable source to be utilized by clinicians in the United States, but to be used in non-Western countries would prevent the patients from being accurately diagnosed, displaying a great extent to which culture differences affect depression symptoms. As the inaccuracy of diagnosis causes questioning, the key question would be cross-cultural validity. Bolton (1999) carried out an emic approach of study to investigate the reasoning behind why the DSM, a universal manual, would give results in disorders that were often times under-diagnosed in particular sub-cultures within a society and over-diagnosed in others. Leading with an emic approach meant that he emphasized the necessity of viewing a culture by looking at it from the inside perspective and understanding it by learning in order to see the difference of each and every culture. He teamed up with a non-profit organization called World Vision, setting up a program that addresses the Rwandan genocide and the psychological aftermath of it. He used this program as a way to explore whether there was any local validity of the western mental illness concepts, to see if the Western methods of diagnosing depression would be acknowledged by the local community and viewed as a justifiable explanation to their retaliation to the trauma. Bolton outlined six basic steps that must be followed for an emic approach to the diagnosis and by using these six steps, he hoped that it would allow him to determine the degree of which the local people were experiencing depression due to trauma. The results showed that the interviewees were describing the diagnostic symptoms of depression due to the genocide, but they were also describing the associated “local” symptoms that were not included as a part of the diagnostic criteria. The two symptoms were divided into a “mental trauma” syndrome (Guhahamuka), which had posttraumatic stress disorder and a few depression symptoms along with local symptoms, while the other syndrome was grief, which included additional depression as well as local symptoms (Agahinda gakabije). As they were interviewed, Bolton found that 70 were diagnosed as having Agahinda gakabije symptoms, and 30 of those were tested positive for showcasing signs of depression. As the test was distributed to an extensive community, out of the 368 adults that were interviewed, 17.9% met the depression criteria in the DSM and 41.8% were described as having Agahinda gakebije (Crane & Hannibal, 1999). Bolton’s way of approaching his study emically assists clinicians in the future to understand that before diagnosing a patient with an illness, they must consider a variety of components of culture in order for them to establish a proper treatment for the patient. As can see in the study, the patients were diagnosed with depression based on a local definition of their symptoms and then those were compared to the symptoms that are defined in the DSM. As this does not have any outside confirmability to a diagnosis of depression, the symptoms are being compared to the West, which can be flawed as the West considers different symptoms as depressive symptoms and could lead to misdiagnoses. Bolton’s results showcased that even when he interviewed 368 adults, the majority were described as having depression and local symptoms rather than meeting the depression criteria in the DSM. That being said, depression symptoms vary from the West and in this case, Rwanda, showed much dissimilarity as Bolton’s results display that only about 17% of a community of 368 adults met the DSM depression criteria. In 1993, Ananth and a few other researchers worked on a study to further investigate between depression and the symptoms of guilt in Indian and North American patients. There has been previous research done, that showed the significance in correlation between depression and guilt (Beck, 1967). The researchers interviewed the patients and used the criteria of the DSM-III in order to diagnose a major affective disorder. As the interview went on, the method called the Hamilton Rating Scale for Depression (HAMD) was utilized and made into an entire data sheet including all the demographic variables that were involved. The investigators that were a part of the study were all trained in psychiatry so they were to evaluate and rate the patients on the HAMD together up to the point when they saw that inter-rater reliability was fulfilled. The investigators evoked guilt from the patients by questioning the two groups with the same particular question. As the researchers compared the results that they were able to obtain, they found that the HAMD scores were higher for the Indian population than the North American population, 25.8 to 24.4. There was an 84% of guilt that was shown as evidence that the North Americans felt and the same was said for the Indian patients, as they had a 62% of feelings of guilt. Both groups were compared in order to assess the variance in scores of the HAMD. The American group held more prominence in items like, middle insomnia, anxiety somatic, and anxiety psychic; whereas, the Indian group displayed items such as, delayed insomnia, loss of appetite, and psychomotor retardation. The researchers then analyzed their data and saw that the feeling of guilt was more of the beliefs that God was the one responsible for depression and reincarnation in the Indian sample. These results allowed them to conclude that depression symptoms are different amongst Indian and North American patients (Ananth et al, 1993).  The differences between the two groups of patients is related to the cultural factors, being in this case, the sick role and the feeling of guilt. Depression is not viewed as a sickness in India, so when they reported having more physical symptoms (loss of appetite), it provided the researchers a pathway towards assumptions of a sick role and then establishing treatments. Guilt was a feeling that the North Americans felt more often than the Indian patients, which relates back to how individualistic cultures emphasize the self and independence rather than the group so they are more inclined to feel that when things go wrong it is more likely their fault than anyone else’s around them. Anthony J. Marsella, is another researcher, that worked on figuring out depressive experiences as well as disorders through the cultural aspects in 2003. He explains the cultural concept as being the learned behaviors and meanings which transmit inside a society in many contexts, promoting the individual along with adjustments of growth, society, and development.  He believes that cultures all have external and internal representations which change due to the circumstances, leading to the shared behaviors and meanings to be subjected to modify as a response to these factors. Marsella found that among many of the Asian countries, losing personal control is not a large consequence as it is in the Western countries due to the fact that Asian cultures are greatly emphasized to be selfless subordinate towards their family as well as valuing non-personal control that is not emphasized in Western cultures. He noted that those from non-Western cultures do not express their feelings along with the existing problems, that are found in the West, as they have been taught to construct as well as experience the disorder in a different type of domain, that being somatic and interpersonal. The Western cultures tend to have more complaints on personal responsibility, the individual’s power, and their strength of character that is usually not seen or reduced in non-Western cultures. Marsella concludes that Western psychology usually retains their individual stance on mental illnesses, in this case depression, and in the end ignoring the other possibilities that come from various cultures. He states that it is important for researchers to understand how essential it is to contain diversity, using it as a leverage to build more knowledge within the cultural context and see that viewing depressive disorder in only one perspective will lead to limitations towards the comprehension levels of depression symptoms (Marsella, 2003). Marsella clearly expresses that depression cannot simply be diagnosed using the DSM in every single culture due to the consideration that each culture varies from one another, so the symptoms from each individual will be different. He says that more of the somatic symptoms, signs, and complaints are often what is reported and seen in those with depressive experiences in non-Western cultures; whereas, in Western cultures, more cases of existential complaints, guilt, self-deprecation, as well as suicidal thoughts and gestures are presented in society (Marsella, 2003). Through his study, there is an establishment of individualist and collectivist cultures varying each other in the way that the population of those who suffer from depression do not share the same symptoms and that for the most part, individuals in non-Western countries showcase more physiological symptoms and Western countries display more psychological symptoms. Cultural Resemblance in Symptoms of Depression Depression symptoms for the most part can be seen as having various aspects due to the differences in culture. However, that is not always the case for MDD. Even though the majority of the research studies that have been done exhibit that both individualist and collectivist cultures have individuals reporting a variety of expressions and symptoms, there are still such instances and studies that display how symptoms from both cultures do not differ in every aspect. The World Health Organization, is one example, in which looked at investigating depressive disorder in different cultural contexts in order to further evaluate the social consequences that come along with it as well as discuss the diverse approaches towards treatment and management. The organization chose to look closely at four specific areas that showed much variety in demographic, cultural, and sociable features: Iran, Canada, Switzerland, and Japan. In the way they recruited the participants, they had a criteria that was applied onto the screening procedure and that was assessed by the facility to select the patients that would be the best fit for the conditions of the study. The researchers in this large study collected data of the environment where certain types of depression usually occur and the way in which those disorders are distinguished amongst the different settings. This allowed them to get a better grasp on understanding the relations between cultural and social factors as well as the manifestations of the disorder, such as depression. Each of the investigators were to collect as much data as they could to describe the social, economic, and cultural attributes of the study itself in order to explicate the patients’ backgrounds. What they found as an end result from their experiment was that the patients from all of the centers shared the “main” aspect of depression symptoms, showcasing a percentage of 76 to 100 in the two diagnostic groups. Those “main” depressive symptoms being: joylessness, sadness, anxiety, lack of energy, tension, loss of interest and ability to concentrate, and ideas of inadequacy, insufficiency, and worthlessness. Also they saw that there was an absence of any striking symptoms that were to be categorized as culture-specific, indications that usually do not suit the traditional descriptive phenomenology of depression (Sartorius et al., 1983). The World Health Organization did this study in 1983 and shared a compatibility with the findings of Murphy et al. (1967) (Crane & Hannibal, 155). As the study was done in a large context, with the involvement of many nations from around the world, it allowed for future researchers to comprehend that not all symptoms of depressive disorders are identical but not all are different. The study found that both Western and non-Western nations were sharing some specific types of symptoms, even if not all, that are commonly established as collectivist or individualist symptoms. The patients from the four nations, all experienced some sort of physiological symptoms along with psychological symptoms, that are usually only seen as its own category of symptoms in collectivist or individualist cultures. Even though, two of the nations that took part in the study were considered to be collectivists (Canada and Japan) and the other two being individualists (Iran and Switzerland), the symptoms that the patients expressed were a mix of symptoms of Western and non-Western countries. That being said, it is not always the case in which symptoms of depressive disorder differ in both cultures. ‘A cross-cultural comparative study of depressive symptoms in British and Turkish clinical samples’ is a study done by Ulusahin, Basoglu, and Paykel. For this study, they aimed to compare the different symptoms between patient groups in Great Britain as well as Turkey. They hoped to find that there will be differences in intensity and frequency of individual symptoms, along with dissimilarities among symptom clusters that are generated by the principal components of analysis. The sample that was collected for Turkish was in Istanbul and for the British sample, they obtained data from the patients in psychiatric out-patient clinics at a hospital in Tooting, London, called St. George’s Hospital. They utilized The Clinical Interview for Depression (CID) as it is a semi-structured interview, the Hamilton Depression Rating Scale for another interview, and the Raskin Three Area Score as it tells the severity score of depression. They found that the duration mean in the British sample of the index depressive episode was not much longer and that when they closely compared the two groups, they saw that the mean scores from the Hamilton Depression Scale was very close to each other, 21 and 22 in the Turkish as well as British samples, subsequently. As they examined the symptoms that seemed to be present in both samples, they found that the most common symptoms were a mixture of psychological and physiological ones, meaning they are a common core of depressive disorder in the two cultures. The British and Turkish sample also displayed some similarities in the aspect of weight and sleep changes, even though they found some differences (Ulusahin et. al, 1994). In this study, even though they found differences in the symptoms that arose from the two samples, they also found many similarities that they did not expect. Both the Turkish as well as the British sample expressed symptoms somatically and psychologically: fatigue, feeling depressed, anxiety, impairment of work along with interests, somatic anxiety, self-pity, and suicide (Ulusahin et. al, 1994). Similarly to the World Health Organization’s study, Ulusahin exhibits through his findings and results that two completely different nations, with different core beliefs can also be similar in the particular side of depressive disorder. Though the Turkish sample is seen as more of a collectivist culture and the British sample more of an individualist culture, not all of the symptoms that they expressed were uncommon in either cultures. Symptoms of depression are often viewed as different in every culture around the world, but there are still such instances where they share a resemblance that is often not taken into consideration. Conclusion The symptoms of depressive disorder are for the most part very different when comparing one culture with another; however, there are a few instances where that claim does not fit into play, meaning there are similarities that are shared cross culturally. That being said, researchers still have a difficult time diagnosing people with depression due to the Diagnostic and Statistical Manual of Mental Disorders (DSM). As it is more of a Western manual, it does not provide all of the symptoms that are present in other nations across the world, such as collectivist cultures. Also, it cannot be forgotten that as it is a more Western manual, utilizing it as the main resource to diagnose people from other ethnic backgrounds and those from other countries will not give an accurate reading as every individual is different, meaning in a larger context, cultures vary each other immensely. As individualist and collectivist cultures vary each other in so many ways, it increases the amounts of variation and differences of symptoms in depression. They both emphasize different core beliefs, which result in few research studies that display the similarities that are shared amongst the two cultures. That being said, depression is more complicated than feeling sad and having a bad day. It is a mental illness that involves every aspect of a person’s body and mind, which can eventually lead them towards isolating from the world and even hurting those that are around them who care. The key importance is that depression is not a simple mental illness that can be diagnosed with a simple manual. It is a process that takes learning and understanding of the person to fully grasp onto whether or not they have depression and that will eventually lead towards the difficulty of diagnosing the correct illness as a person from any culture can vary from another to a great extent.

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