Discuss cultural and gender variations in prevalence of disorders

Major Depression

More common in individualistic than collectivistic cultures
Seattle, Washington: 6.3 %
China: 4 %
Verona, Italy: 4.7 %
Groningen, Germany: 15.9 %
Manchester, United Kingdom: 16.9 %
Ankara, Turkey: 11.6 %
Nagasaki, Japan: 2.6 %

Possible cause: Collectivistic cultures may share their feelings and since group interest is important, people may help each other get through personal issues. Also, there might be a lower rate of depression in collectivistic cultures because of somatization. They report other bodily symptoms instead of feeling depressed.

Anorexia Nervosa

More common in western societies but is increasing in eastern societies because of globalization
Possible cause: There are more expectations of how you look in the west. Women are sometimes pressured to look thin and model-like. Eastern societies are starting to experience anorexia nervosa due to globalization from the west.

Major Depression

Life time prevalence for the disorder: Women – 10-25% Men – 5-12%

Possible cause: violence and abuse against women could make them more prone to depression than men. Another possible cause is that, although men and women may have similar rates of depression, more women are diagnosed correctly as having the depression due to gender bias.

Anorexia Nervosa

10 times more likely in females than in males
Possible cause: Females are more aware about their body weight, while men are less afraid of gaining weight. Females are usually more expected to have a thin body shape, since female models must be thin but this is not always the case for males.

Major Depression (Weissman et al. (1996)):
AIM: To estimate the rates and patterns of major depression and bipolar disorder based on cross-national epidemiologic surveys.
DESIGN AND SETTING: Population-based epidemiologic studies using similar methods from 10 countries: the United States, Canada, Puerto Rico, France, West Germany, Italy, Lebanon, Taiwan, Korea, and New Zealand.
PARTICIPANTS: Approximately 38000 community subjects.
OUTCOME MEASURES: Rates, demographics, and age at onset of major depression and bipolar disorder. Symptom profiles, comorbidity, and marital status with major depression.
RESULTS: The lifetime rates for major depression vary widely across countries, ranging from 1.5 cases per 100 adults in the sample in Taiwan to 19.0 cases per 100 adults in Beirut. The annual rates ranged from 0.8 cases per 100 adults in Taiwan to 5.8 cases per 100 adults in New Zealand. The mean age at onset shows less variation (range, 24.8-34.8 years). In every country, the rates of major depression were higher for women than men. By contrast, the lifetime rates of bipolar disorder are more consistent across countries (0.3/100 in Taiwan to 1.5/100 in New Zealand); the sex ratios are nearly equal; and the age at first onset is earlier (average, 6 years) than the onset of major depression. Insomnia and loss of energy occurred in most persons with major depression at each site. Persons with major depression were also at increased risk for comorbidity with substance abuse and anxiety disorders at all sites. Persons who were separated or divorced had significantly higher rates of major depression than married persons in most of the countries, and the risk was somewhat greater for divorced or separated men than women in most countries.
CONCLUSIONS: There are striking similarities across countries in patterns of major depression and of bipolar disorder. The differences in rates for major depression across countries suggest that cultural differences or different risk factors affect the expression of the disorder.
EVALUATION: The findings do not necessarily demonstrate a cause (Validity low). This was a natural experiment during which the investigators had no control over extraneous variables (Credibility low). Can people of all cultures be diagnosed with major depression as defined by Western psychiatric manuals? There are ethical and cultural concerns for diagnosis (Credibility low). Large sample size is good. Lots of countries is a good representative of differing cultural factors (questionable Asian sample though).

Anorexia Nervosa (Becker Study (1993-1995)):
AIM: to investigate the influence of cultural factors on the incidence of anorexia nervosa by taking advantage of cultural change when television was first introduced to the island of Fiji to see what effects western TV would have on attitudes towards eating and the incidence of anorexia nervosa
PROCEDURE: In 1993 when TV was first introduced to the island of Fiji, 63 native Fijian girls were asked to complete a questionnaire on attitudes towards eating and were questioned about their TV viewing habits. 2/3 years later, a further sample of 65 girls aged 17 years on average were re-questioned to assess the impact of TV on their eating habits. Girls were also interviewed about their views on eating and television.
FINDING: % of girls who reported vomiting in order to control weight changed from 3% in 1993 to 15% in 1995. Girls with a high score on the eating questionnaire (indicating a risk of disordered eating) changed from 13% in 1993 to 29% in 1995
CONCLUSION: The findings indicate a strong link between exposure to western ideals of thinness and changed attitudes towards eating.
Such changed attitudes are likely to lead to the development of eating disorders such as anorexia nervosa
EVALUATION: The findings do not necessarily demonstrate a cause (Validity low). This was a natural experiment during which the investigators had no control over extraneous variables (Credibility low). Changed attitudes may not lead to eating disorders - we do not all show signs of eating disorders even if we are all exposed to the same cultural influences, there may well be a biological vulnerability. Low generalizability, as study was conducted in only country.

Two studies of gender variations in prevalence of major depression and anorexia nervosa

Name of study and year: The National Comorbidity Study
Procedure: A large survey of adult in the United States released, followed by other countries such as Canada, Brazil, Germany and Japan, with the same procedures. Questions such as social life leading to depression
Findings: 1.7 women for every man had experienced at least one episode of depression. Roughly the same ratio has been found in recent studies in nine other countries, including Canada, Brazil, Germany and Japan
Sample: adults (both male and female)
Methodological strength/limitation: strength: generalizability & credible / weakness: possible response bias

Name of study and year: Dr. George Zubenko
Aim: Identification on 19 regions of chromosomes that were especially common and, therefore, likely to contain genes that promote depression.
Procedure: scanning the genomes of people with major depression in 81 family.
Findings: four of these regions showed up only in women and one only in men. For example CREB1 which has an unknown affect on estrogen receptor, but still might have affect on the reproductive hormone itself, therefore might lead to a certain level of depression.
Conclusion: the sex difference in depression is most pronounced in women during their reproductive years, when sex hormone levels are highest. Before puberty, boys and girls have roughly equal rates of depression. The incidence of depression climbs in both sexes during puberty, but the climb is steepest for girls.
Sample: 81 family
Methodological strength/limitation: strength: reliable, scientific, controlled / weakness: generalizability, disregards other influences on depression

Explanation on cultural variations in prevalence of major depression; differences in symptoms

Centre for Addiction and Mental Health (CAMH)

Aim: to test the following hypotheses

East-Asian participants will emphasize somatic or physical symptoms of depression more than North American participants

North American participants would emphasize psychological symptoms of depression (e.g. report feeling sad, crying spells, or a loss of self-confidence) more than East-Asian participants

wanted to examine the role stigma and alexithymia (difficulty using words to describe emotions) play in how each culture presented and expressed depression symptoms

Participants: 100 Chinese out-patients and 100 North American patients

Method: spontaneous report of problems during unstructured discussion with doctor; clinician-rated symptoms in a structured clinical interview; and a symptom rating scale in questionnaire Findings:

1. East-Asian participants did report a significantly higher level of somatic symptoms

2. Western cultures emphasize psychological symptoms of depression

Conclusion: people who do not frequently focus on their internal emotional state are more likely to notice somatic symptoms.


+ Application: help clinicians be more aware of how culture can impact how people talk about their illness

- Data might not be representative: all east-asian participants are from China