By Rowena Kong
The difference in rates of depression between East Asians and North Americans has long attracted research leading to explanations for such findings. According to a summary study by Weissman et al. (1996) which analyzed the rates of major depressive disorder in different countries based on community surveys, depression’s prevalence rate in Taiwan stood low at 1.5% for every 100 people while that of Korea was a close 2.9%. Another study indicated China’s 1-year incidence rate for unipolar depression at 2.3%, which was much lower than that of the United States at 10.3% (Kessler et al., 1994; Murray, & Lopez, 1996). Along with their lower lifetime prevalence, the Chinese also tended to report more somatic than psychological depressive symptoms (Parker, Gladstone, & Chee, 2001; Ryder, & Chentsova-Dutton, 2012). A study which compared depressed Malaysian Chinese and Euro-Australians found that the former were more likely to express somatic complaints than were the latter (Parker, Cheah, & Roy, 2001).
Although many interpretations writing off the physical symptoms of depression as a means of masking the psychological symptoms have been put forth by researchers, it is not entirely certain whether this is the case. However, it is clear that there is remarkable cultural variability in the reporting of emotional symptoms between people of Asian and European descent. In consideration of this, while it is possible that there is less openness during discussions of negative emotion-related issues with Asian healthcare providers, Leu, Wang, and Koo (2011) found that East Asians who reported having many positive emotions were not at a lower risk for depression than those who reported having very few positive emotions. The relationship between positive feelings and protection against depression for East Asians is therefore questionable, which may extend to weaken the link between negative emotions and the disorder. On the other hand, when we do not rule out the possibility that East Asians are less inclined to verbalize their emotion, there are explanations that benefit our understanding of the social implication of being diagnosed with a psychological disorder for Chinese and similar East Asian collectivistic populations.
While it has been the interest and challenge of researchers to explain the differences in rates of depression and categories of reported symptoms between Asian Chinese and Americans or Western Europeans, it is of the utmost importance to understand the greater degree of social awareness experienced and practiced on a daily basis by members of interdependent (collectivistic) societies. In a study conducted by Uchida, Townsend, Markus and Bergsleker (2009), the authors analyzed television interviews of Japanese and American Olympic athletes and studied participants’ descriptions these athletes and their reactions to winning. The results showed that both the athletes and participants of Japanese descent, as compared with the Americans, associated more emotions with relationships; for example, including others when they described the athletes’ emotional reaction to their victory and group pictures with teammates. The authors concluded that the Japanese perceived emotion as relational in nature and jointly shared with others while the Americans saw emotion as originating from within them and being distinctly separated from others. Thus, under such a context, the Japanese may not be less emotional in their expression than their American counterparts, as these findings suggest that emotions can carry a more holistic meaning and significance for Asians than previously assumed. This relational component of emotion offers a possible explanation of the different nature of depressive symptoms reported by the Chinese. In addition, this may result in emotions being regarded as less autonomous by the individual, which could suggest the reluctance and lack of spontaneity felt in regards to its experience and expression. Thus, if one’s emotions are seen as more externally interconnected rather than residing within a unique self that is distinct and separated from others, the inward focus of personal symptomatic experience and the process of bringing them to attention may cause Chinese patients to be less aware of the psychological aspects of depression. This tendency could be non-deliberate or implicit.
When we view emotion as a component of self that is shared with others, this may increase the degree of implicitness and presumption in communication since the boundary between one’s internal feelings and those of ingroup members is less solid and more permeable to influence. An American who has just encountered the Japanese language would be surprised to find the extent to which it allows for omission of nouns and/or pronouns in conversations and its greater dependence on implicit communication such as emotional vocal tone (Heine, 2012; Ishii & Kitayama, 2002). As emotion can be positive or negative in nature, the degree of implicity can impact the communication process. In regards to the Chinese somatisation of depressive symptoms, the connection between emotions, implicit communication and relationships with ingroup and outgroup members may have hindered their explicit description of emotional symptoms. A more immediate effect which implicit communication has on symptom reporting is the lower degree of self-disclosure by Chinese compared to Americans, as explained by the East Asian culture and the discouragement of excessive speech over useful actions, according to Confucian and Taoist philosophies (Chen, 1995).
The stigma of depression or mental illness, termed psychiatric stigma, is felt to a greater degree by the Chinese, and one reason could be that the disorder carries heavy social significance for them (Ryder, & Chentsova-Dutton, 2012). Psychiatric care, as compared with conventional medicine, which takes precedence, may be perceived as a deviation from the normally and generally accepted form of treatment for illness. Whereas having been diagnosed with an illness is more of a personal matter for individualistic societies, this is not the case for the collectivistic culture. To people with interdependent self-construals, the illness may be perceived as a shared burden among members of their immediate families and even extended social networks. An indirect illustration is the Japanese culture-specific variation of the social anxiety disorder, taijin kyoufushou (TKS) (Morita, 1917). The diagnostic criteria for this disorder is that individuals, who are already suffering from social anxiety symptoms, are certain that their symptoms will negatively affect others. Such experiences can contradict the ideals of the interdependent society, which may generate additional distressing feelings of guilt and fear for the patient.
From the perspective of one’s status in society, there is also the tendency of Asian people to avoid “losing face” or failure to meet up to the implied “social standard” and roles expected of a competent member of society (Heine, 2012). When the esteemed norm of mental soundness is not attainable by an individual, the weight of personal inadequacy and fear of being ostracized can be a predictive factor in seeking medical and/or psychiatric care. The social costs of being labeled with a mental illness diagnosis may outweigh the benefits of available mutual support and thus make it reasonable not to risk disrupting one’s positive standing in the society. However, when the reverse situation is true, social support may serve as a buffer against depression both prior to and after diagnosis.
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About the author:
Rowena Kong is a fourth year Psychology major who is interested in writing about a diverse range of topics. The brain’s mirror neurons and dopaminergic reward system fascinate her just as much as cultural universals and implicit social communication. During her spare time, she enjoys photography, fanfiction, and working with Photoshop to improve her amateurish skills.