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Culture defines how people view the world and certain phenomena.^[1] Culture also appears to influence the way people experiencedepression. An individual'sexperience with depression can vary from country to country.^[2] For example, aqualitative study revealed that some countries did not recognizepost-natal depression as an illness; rather, it was viewed as a state of unhappiness that did not require any health interventions.^[2]

In contrast to theindividualistic views of theWestern culture, which emphasize individual thought, achievement, and well-being,Eastern cultures operate oncollectivism, which focuses on the group and the interdependency of its members rather than any one person.^[3] The collectivistic view of theself is that it can only be understood through one's social relationships and affiliations.^[4] These relationships and affiliations make up a network where thenuclear family shares the closest bonds, followed by theextended family andclose friends.^[5][6]

Although the collectivism ofEastern cultures creates a strong support system for the group, it produces many stressors that can lead todepression andanxiety.^[6][7] For example, the overwhelming focus on the group rather than the individual can result in feelings of lost individual identity and sense of self.^[4] Identity issues such as these are historically linked with depression. Moreover, many rules and social norms exist in collective cultures than in individual cultures to maintain the harmony of the group. This combined with the cohesiveness of the group can make social mistakes very public and result in feelings of shame and embarrassment by the individual at fault. Research indicates that these feelings are associated withsocial anxiety within collectivistic societies.^[3] A bigger mistake that affects an individual'sreputation or results in the loss of honor has more severe consequences because of thestress associated with maintaining that honor.^[5]

Symptoms of depression are often expressed differently incollectivistic societies thanindividualistic ones. Overarchingpsychological pain and guilt are often a result of depression.^[8] Guilt and distress are symptoms of depression; yet they may be experienced differently across cultures. A study by Pewzner-Apeloig and colleagues (1994) found that differences in the way depression was experienced in terms of guilt betweenAfrican andWestern cultures existed.^[9] This serves as an example to demonstrate how differences in collectivistic societies in comparison to individualistic societies matter. The expression of symptoms of depression changed in these countries.^[9]

The way communities combatdepression varies on the basis of whether it is within a collectivistic society or not. It has been shown that a better support system is in place for those who are susceptible to depression in collectivistic societies.^[10] On the other hand, in individualized societies, depression is primarily combated through solo work in therapy.Cognitive behavioral therapy (CBT) is used bypsychologists to change one's thoughts and behavioral patterns. CBT has been shown to be quite effective.^[11] Both ways of approaching and treating depression can be effective. Less emphasis on the individual can help minimize rumination andself loathing which are both linked to or direct symptoms of depression.^[12] Yet, more focus on the individuals thought patterns and intervention ofnegative thoughts and behaviors can be effective.

The process ofacculturation involves adjusting one's values, attitudes, and cultural practices in to order to effectively adapt to a new culture.^[13] Acculturation is difficult for mostimmigrants, but especially so for Eastern immigrants since the Western and Eastern cultures differ greatly. The biggest challenges Eastern immigrants must face when they travel toAmerica are the sudden loss of a support system, child rearing, and limited knowledge about the American way of life.^[14] Coming from a collectivist culture that places great emphasis on relationships, immigrants may mourn the loss of their friends and family. The likelihood of suicide and depression tends to increase as acculturation stress, such as this loss, increases.^[15] Tensions within the nuclear family may also arise aschildren assimilate to the mainstream culture and language and identify less with their immigrant parents.Adolescents whose families strictly followtraditional culture are at a high risk for depression andsuicide. A lack of knowledge about theAmerican culture can increase the cultural gap between parents and children.

Research shows that the level of distress and the likelihood that one will develop depression is higher infirst generation immigrants than subsequent ones. This is likely due to increasepsychological stress related to acculturation.^[16] A study by Tibubos states: "mean score patterns were similar for all groups, analyses of item loading among first‐generation migrants yielded some variance in patterns pointing out that certain items have a distinct impact on depression for specific groups."^[16]

The many stressors an individual or family faces by moving to a different country can explain the growing prevalence ofdepression. White R.M.B. et al. demonstrated that environmental stressors can disrupt key parenting processes.^[17] This disrupter increase the prevalence of depression and aggression. Culture differs across countries; hence, the way things are done varies and parents must learn these differences. These changes become very stressful and can in turn lead to depression in both mothers and fathers.^[17] In White's study: "Family models andparenting styles/environmental worries which are often a result of culture could explain increased depression symptoms in parents who live in dangerous neighbors." Adapting to a new culture is stressful and this increase in stress leads to higher prevalence for depression.^[17]

As is true inWestern societies, depression is more prevalent in women than in men in collective cultures. Some have hypothesized that this is due to their inferior positions in the culture, in which they may experiencedomestic violence,poverty, and inequality that can greatly contribute to depression.^[4][6] Moreover, research conducted in theUnited States,Chile andSpain found that cultural differences on the expectations of individuals based on gender varied across cultures and that resulted in different levels of depression across individuals^[18] Changes ingender roles across countries and cultures in this study served to explain varying levels of stress and responsibility that changed on the basis of gender. These ever changing expectations and these additional responsibilities on the basis of gender increased levels of depression.^[18] A study by Ngcobo and Pillay reports a high level of depression in blackSouth African women (83.34%) and a gender difference ratio of four to one.^[19] Depression inSouth Africa is often linked back to low socioeconomic factors and loss through death and abuse.^[19] Despite its prevalence, little is understood about depression in South African women.^[19] This is a result of the laws ofapartheid and the inadequate psychological services that followed, as well as factors such as under-reporting, misdiagnosis, language barriers and cultural differences.^[19]

The differences ingender roles within a community also impact one's level of depression.^[20] According to Wichstrøm (1999) women tend to ruminate more and therefore symptoms of depression can be accentuated. Since women are encouraged to talk about and share their feelings, they can get caught talking about and staying in a negative state.^[21] On the other hand, boys are taught not to discuss their feelings with others which then diminishes or even gets rid ofrumination entirely. The way one is socialized to deal with theirnegative emotions will vary across cultures and may lead to different outcomes.

Considering thestigma associated with mental illnesses in theArab culture, it is not surprising that many Easterners express depression and anxiety through somatic complaints. This is especially true with Eastern women, who may feel symptoms of depression as a result of inequality, but are taught not to express personal feelings. Instead, they complain ofheadaches,numbness,breathlessness, and chest pains to receive some form of medical attention.Somatization is also common among individuals with little knowledge ofmental health who have no linguistic way to express their symptoms.^[15][5]

In some parts ofChinese society, depression is expressed as and experienced in terms of a physical experience rather than psychological. According to Kleinman (2004): "Many depressed Chinese people do not report feeling sad, but rather express boredom, discomfort, feelings of inner pressure, and symptoms of pain,dizziness".^[22] This is different from the way depression is perceived in America in which people often report sadness or feeling down.^[23]

Symptoms do not only vary in their expression across cultures but will also greatly vary within cultures and across individuals. Depression is aheterogeneous disorder.^[24] Sometimes depression leads to increased appetite, while other times it leads to decreasedappetite. Similarly, a symptom of depression can be both anincrease in sleep ordecrease in sleep. Symptoms will look different from individual to individual; however, as mentioned above, the expression of these symptoms tend to follow somewhat of a trend from one culture to the next.^[25]

In many other non-Western societies, astigma is associated withmental disorders despite high prevalence of depression and anxiety.^[26] Many Easterners believe that symptoms of depression and anxiety are simply a part of life and do not require medical attention.^[27] Also, individuals fromcollective societies tend to be extremely careful in maintaining their reputations, and mental distress is usually interpreted as a weak faith inGod and/or a weak self. Eastern cultures attribute mental illness to supernatural causes or social behaviors like bad character or unfavorable behavior in a past life.^[28] Therefore, they do not seek treatment for their symptoms in order to avoid shame and gossip. This stigma stems in part from the limited knowledge many Easterners have about depression and anxiety. Multiple studies reveal that the majority Easterners do not know the names of mental illnesses.^[26][29] Instead, they describe their symptoms through series of physical complaints.

Rates of clinical depression are greater in the West than inAsia.^[30] According to this study, Asian cultures think differently about emotions than do Western cultures. Not only do changes in one's understanding ofpsychological disorders change the prevalence of mental health problems it also has an impact on the rate at which these symptoms become problematic. An individual's education on mental health will impact their likelihood of seeking help.^[31]

Research indicates that for psychologists to effectively diagnose and treat patients of an ethnic minority they need to consider cultural differences.^[32][33] Appropriate cultural knowledge may help psychologists appropriately adjust their methods to fit the needs of a diverse population.^[34]

The Arab American Institute Foundation estimates that there are over 3.5 million individuals with Arab-speaking ancestry residing in theUnited States, with thousands more arriving from theMiddle East every year. As these numbers increase, so does the importance of psychologists to understand theArab culture.Arab American immigrants make for an interesting case because they face additional discriminatory stressors associated with the events of the9/11 attacks and political tensions in theMiddle East.^[14]

The causes of depression and anxiety in Arabs andArab Americans are a combination of biological factors and psychological and social factors that are greatly influenced by the Arab culture and immigration. Research indicates that biological markers of depression are consistent between Arab and Western populations,^[35] as are many psychological factors.

Arabs who seek psychological help are more confident about the effectiveness of medication overtherapy.^[36] But since many Arabs either refuse to meet with mental health professionals or do not have any knowledge of them, traditional treatment methods are still commonly used. Islamic therapy, for example, involvesQuran recitation by animam to repel moral deviance from the soul of the individual. The imam may also suggest old Islamic remedies, such asice baths andherbal antidotes. UsingIslam to simply cope with psychological distress is a more widely used method of treatment that is supported by research.^[36] A study completed on depressedPakistani patients also reported that the participants believed that medicine could rid them of their symptoms but had little to no knowledge ofpsychotherapy.

Latino adolescents tend to have higher levels of symptoms of depression than some of theirCaucasian andAfrican American peers.^[37] An explanation for this difference is the increase in cultural stressors that in turn add to this form of cultural disparity. Although the cultural stressors have not yet been identified, the correlation between it and symptoms of and the prevalence of depression is still significant. Within communities, discrimination on the basis of race andethnicity is also a strong contributor to the elevated number of depressive symptoms among Latino youth.^[38]

• Depression (mood)
• Culture

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