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This article summarizes current knowledge about social and ethnocultural variations in the prevalence of anxiety disorders as well as in their symptomatology and course. Some of the substantial differences in rates found in clinical epidemiologic studies probably are related to differential patterns of help-seeking among different ethnic groups. Cultural factors play an important role in the interpretation of behaviors, that is, whether there are reasons in family or social dynamics to make biased judgments about others. Substantial differences also have been found in the symptomatology of culture-related forms of anxiety disorders with variations in content and focus, and in accompanying somatic manifestations as well. Through the case study of a woman with post-traumatic stress disorder, the social embedding and cultural meaning of anxiety in clinical practice are described, and culturally responsive strategies for diagnosis and treatment are outlined. Clinicians should be encouraged to think of innovative ways of approaching anxiety in its social and cultural context.
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Introduction
The World Mental Health Surveys [WMHS, Kessler and Ustun, 2008] and the Global Burden of Disease Study [Whiteford et al., 2013] revealed that the prevalence of mental disorders worldwide is substantial, and prevalence rates vary considerably between countries. Common mental disorders [CMDs, National Collaborating Centre for Mental Health, 2011] include depression, generalised anxiety disorder, panic disorder, phobias, social anxiety disorder, obsessive-compulsive disorder and post-traumatic stress disorder [PTSD].
In the WMHS, the highest lifetime prevalence rates of depression were found in France, the Netherlands, New Zealand, USA and Brazil [18%–21%], and the lowest rates [below 10%] were found in India, Mexico, China, and South Africa. High-income countries [HIC] achieved a higher estimated lifetime prevalence [15%] than low- and middle-income countries [LMIC, 11%]; this difference was statistically significant [Bromet et al., 2011]. With regard to anxiety disorders, the highest prevalence rates were found in the USA [31%], Colombia [25%], New Zealand [25%] and France [22%], whereas the lowest rates were reported in Israel, China, Japan, and Nigeria [5%–7%] [Kessler et al., 2007].
The fact that the highest prevalence rates for CMDs were found among the wealthiest countries seems counterintuitive. In LMIC, a high percentage of people are exposed to extreme stress caused by poverty, natural hazards, or violence. In HIC, most people are protected against these adversities. The higher prevalence rates of CMDs in wealthy countries most likely reflect both the actual underlying prevalence rates as well as the measurement model that was used for assessing CMDs across cultures. The present paper explores the potential role of culture in both these aspects. With regard to the actual underlying prevalence rates, the question arises whether it is wealth per se that fosters higher rates of CMDs, or other environmental-societal factors such as social inequalities or cultural values. Regarding the measurement aspect, the relevant question is how cultural values might affect the way CMDs are expressed across cultures.
Some scholars argue that depression and anxiety are illnesses of affluence [Koplewicz et al., 2009]. According to the ‘hedonic treadmill’ theory, people's expectations rise parallel to their wealth, leading to stagnation in happiness or even frustration [Brickman and Campbell, 1971]. This implies that an increase in wealth for countries currently listed as LMIC by the World Bank would lead to an increase in prevalence rates of mental disorders overtime.
A different perspective arises from evidence on social inequalities. In the WMHS, Kessler and Bromet [2013] found a stronger negative association between income and depression in HIC than in LMIC. In HIC [but not in LMIC], the poorest respondents had about a twofold increased odds of depression compared to those in the highest income group. Thus high prevalence rates of depression in HIC might be explained by social inequalities rather than by wealth per se. Evidence supports this assumption: Pickett and Wilkinson [2010] further analysed WMHS data in HIC and found a positive correlation between the prevalence rate of ‘any mental disorder’ and income inequality. van Hemert et al. [2002] conducted a meta-analysis of 28 studies from 19 countries that had used a depression symptom scale. In affluent countries, the relationship between income inequality and depression was positive, whereas in less affluent countries the opposite relationship was found.
Alongside wealth and social inequality, countries can also be described in terms of their cultural values. Cultural values and socio-economic factors such as wealth and social inequality are strongly intertwined [Schwartz, 2007]. However, cultural values contribute elements that are possibly more relevant to mental health than the socioeconomic factors alone, e.g. the acceptance vs. rejection of unequal distribution of wealth in society, or the importance given to individual vs. collective interests. The influence of these factors on mental health outcomes is described below.
Different value theories exist and have been studied extensively in the last few decades. Hofstede [1980] described societies according to their degree of collectivism vs. individualism, along with the value dimensions of power distance, uncertainty avoidance, and masculinity/femininity. Inglehart [1997] suggested a distinction between materialist and postmaterialist values and explained the prevalence of these values in terms of historical shifts in society and economy. Finally, Schwartz, 1994, Schwartz, 2006 developed a theory of cultural values, which is used in the present study.
When compared to other value theories, Schwartz, 1994, Schwartz, 2006 value theory offers an important advantage for empirical research on mental health in that it does not conceptualise cultural values as separate entities, but as constructs that are related to one another in a circular structure. This theoretical aspect [explained more in detail below] is most relevant for the present study. If the relationship between values and mental health is systematic [i.e., follows the circular structure], a more holistic empirical insight can be gained than would be achieved from finding correlations between mental health and single values.
According to Schwartz, 1994, Schwartz, 2006, cultural values reflect the shared standards and beliefs in societies and are formed through the process of adapting to three major challenges [Schwartz, 1994, Schwartz, 2006]. The first dimension, embeddedness vs. autonomy, describes how relationships [or boundaries] between the individual and society are shaped. Embeddedness refers to the importance of social relationships and encompasses values such as preserving public image, being obedient, and moderate. By contrast, autonomy gives high importance to individual interests and experiences, which includes intellectual autonomy [pursuing one's own ideas] and affective autonomy [striving for emotionally positive experiences].
The second dimension defines the social order, which is reflected in the contraposition of hierarchy vs. egalitarianism. Hierarchy legitimises the unequal distribution of power and resources. By contrast, egalitarianism emphasises equality and social justice. And the third dimension describes people's relationship to the natural and social world, which is reflected in the conflict between harmony vs. mastery. Harmony is defined as ‘fitting into the world as it is, trying to understand and appreciate rather than to change, direct, or to exploit’ [Schwartz, 2006, p. 141]. Mastery expresses the opposite values such as being successful and ambitious.
Evidence on the relationship between cultural values and mental health is scarce. Maercker [2001] analysed data from eleven countries which had been included in both a multi-centre study on cultural values [Schwartz, 1994] and the WHO Collaborative Study on Psychological Problems in General Health Care [Üstün and Sartorius, 1995], the predecessor of the WMHS. He found higher prevalence rates of current depression and generalised anxiety disorder in countries where autonomy, egalitarianism, and harmony were more important. By contrast, negative correlations emerged for the same mental disorders with embeddedness, hierarchy, and mastery.
van Hemert et al. [2002] compiled data from studies that had applied the Beck Depression Inventory [Beck et al., 1961] in normal populations. Using Schwartz' [1994] data on cultural values from 19 countries, they found a negative correlation between autonomy and depression, after controlling for gross national income [GNI]. The correlation between depression and hierarchy was not significant, and the other cultural values were not analysed.
Fischer and Boer [2011] conducted a comprehensive meta-analysis including 63 countries worldwide. All studies had used the General Health Questionnaire [Goldberg, 1972], a measure of psychological distress. As an indicator of the importance given to autonomy in each country, three scores were averaged in this study: Inglehart's survival vs. well-being dimension, Hofstede's individualism index, and Schwartz' autonomy vs. embeddedness score. The authors found diverging patterns of relationships across countries: among the more traditional and collectivistic societies, autonomy was associated with negative affect. Among more individualistic European societies, autonomy was associated with positive affect. This association, however, levelled off toward the extreme ends of autonomy. Anxiety was inversely related with both wealth and autonomy when entered individually into the multilevel analysis [i.e., higher wealth and autonomy were associated with lower anxiety]. When entered together, only autonomy remained significant.
Important methodological considerations have to be taken into account: the meta-analyses by van Hemert et al. [2002] and Fischer and Boer [2011] analysed data based on symptom scales, whereas the data analysed by Maercker [2001] relied on clinical interviews. Symptom scales inflate the prevalence rates of depression when compared to clinical interviews, as revealed in a large meta-analysis of epidemiological studies [Ferrari et al., 2013]. Moreover, the two meta-analyses by van Hemert et al. [2002] and Fischer and Boer [2011] focused on autonomy and hierarchy only, and omitted the other cultural value dimensions. According to Fischer [2013b], this is problematic: ‘Focusing on a single value without considering the overall pattern of correlations of values with each other in that particular sample will yield misleading results’ [p. 237].
On the other hand, at the time of Maercker's [2001] study, epidemiological data and data on Schwartz' cultural values were available only for eleven countries, which is a very small sample size for a cross-cultural analysis. Furthermore, prevalence data from the WHO Collaborative Study did not stem from nationally representative samples but from large cities, which is another shortcoming of this study. And finally, Maercker [2001] had not controlled for wealth, which might have biased the results.
The present study examines how cultural values relate to prevalence rates of CMDs. Important shortcomings of the three previous studies are addressed by using more recent epidemiological data stemming from clinical interviews with nationally representative samples in 25 countries, and by controlling for wealth [i.e., GNI]. For a better understanding of how cultural values relate to mental health, important theoretical considerations have to be taken into account. First, correlations between cultural values and other criteria should follow the circular structure of values, as explained below. Second, when looking at the relationship between cultural values and mental illness, evidence from cultural clinical psychology is relevant.
Schwartz, 1994, Schwartz, 2006 postulated a circular structure of values [Fig. 1] that reflects similarity vs. dissimilarity among values: compatible values are adjacent, whereas incompatible values are distant. The strength of the correlation among values first decreases and then increases again when moving around the circle. This circular structure has very important implications. Correlations between values and any other third variable should show the same systematic pattern of increasing and decreasing correlations when moving around the circle [Fischer, 2013b], a pattern that has been described as ‘sinusoid’. The term sinusoid refers to the approximate sine curve that emerges when correlation coefficients between values and a third variable are graphically displayed. Boer and Fischer [2013] describe statistical properties of this sinusoid pattern.
In accordance with this theoretical assumption, Fischer [2013a] analysed climatic demands [i.e., extreme hot and cold temperatures], population genetic differences in serotonin-transporter genes [5-HTT], and cultural values across 29 countries, including both HIC and LMIC. Data on the 5-HTT genes stemmed from 124 peer reviewed publications. The 5-HTT transporter gene is related to depression and anxiety. Fischer [2013b] showed the sinusoid pattern of relationship between climatic demands, 5-HTT, and values. Climatic demands and 5-HTT had the highest positive correlation with hierarchy and embeddedness. Correlation coefficients decreased when moving around the circle, resulting in negative correlations with autonomy and mastery; thereafter, correlation coefficients increased again.
The evidence outlined above suggests a systematic relationship between cultural values and the prevalence of CMDs. Cultural values most likely relate to both aetiology and phenomenology of mental illness. With regard to aetiology, a causal relationship is assumed between cultural values and mental health. Most evidence on such causal relationships has focused on autonomy, and reveals divergent patterns of correlations [Fischer and Boer, 2011, van Hemert et al., 2002]. On the one hand, autonomy enables people to live in accordance with their individual needs and choices; on the other hand, ‘too much choice’ might not be beneficial, as B. Schwartz [2000] suggested in his seminal work The Tyranny of Freedom.
Cultural values also relate to the social determinants of mental health. As outlined above, the relationship between income inequality and the prevalence of CMDs was stronger in Western countries, where egalitarianism [i.e., social justice and equal rights for all] is held in high regard. In countries with a strong emphasis on hierarchy [i.e., the legitimisation of unequal power and resource distribution], social inequalities might have a different effect on psychological distress.
With regard to phenomenology, critical voices have raised doubt about the cross-cultural invariability of depression. Kleinman [1977] coined the term category fallacy, which refers to the unwarranted application of the same diagnostic categories across different cultural groups. This would mean that with increasing divergence from Western cultural values, the psychopathological categories used in the WMHS would become less meaningful, which might explain differences in prevalence rates to some extent. If measured differently across different cultures, prevalence rates would possibly be more consistent.
As an example, Ryder et al. [2008] compared the expression of depression among US and Chinese patients using both symptom questionnaires and structured clinical interviews. They predicted that the Chinese sample would emphasise somatic symptoms of depression more than the North American sample and vice versa. The cultural difference with regard to the expression of somatic symptoms was strongest in clinical interviews and disappeared entirely when using symptom scales.
And finally, cultural values relate to stigma. Yang et al. [2007] described the far-reaching consequences of losing face due to mental illness in China, which affects not only the individual person but also the entire family. This kind of stigma ‘threatens to break the vital connections [“quanxi wang”] that link the person to a social network of support, resources, and life chances’ [p. 1529]. Thus, people might hesitate to express psychological symptoms, even if they are experienced, due to fear of stigma and discrimination.
In summary, cultural values might affect both the phenomenology and aetiology of mental disorders, but evidence is limited so far. Cultural values provide a meaningful taxonomy to describe ‘culture’ and examine the prevalence of mental disorders against this background.
Section snippets
Aims and hypotheses
The present study examined systematic relationships between cultural values and lifetime prevalence rates of CMDs, controlling for GNI per capita. First, a positive correlation between GNI per capita and the prevalence rates of CMDs was hypothesised [Hypothesis 1]. Second, it was hypothesised that the correlation between cultural values and the prevalence rates of CMDs would follow the sine curve, after controlling for GNI per capita. Different guidelines exist for interpreting the strength of
Data
Three different datasets were compiled in this study. Countries were included if data on cultural values as well as lifetime prevalence rates from either the WMHS or the Global Burden of Disease Study were available for at least one CMD: major depressive disorder, dysthymia [a depressive disorder with less severe but longer lasting symptoms], ‘any anxiety disorder’, generalised anxiety disorder, panic disorder, agoraphobia [fear of public places] without panic, social phobia, specific phobia,
Results
Twenty-five countries were included in the analysis [see Table 1]. Value data were generally older [1988–2002] than prevalence data [1990–2008]. Time between value data and prevalence data ranged from two years [e.g. Chile] to 20 years [e.g. Portugal], with a mean of nine years. In two cases, prevalence data were older than cultural values data [Canada and South Korea]. With regard to prevalence rates, obsessive-compulsive disorder was omitted due to the small sample size [N = 7].
In accordance
Discussion
This study looked at systematic relationships between Schwartz, 1994, Schwartz, 2006 cultural values and the prevalence rates of CMDs in 25 countries. The WMHS showed higher prevalence rates of depression and anxiety disorders in HIC when compared to LMIC [Bromet et al., 2011, Kessler et al., 2007]. Results of this study indicate that some of these differences are associated with cultural values. In accordance with previous findings [Maercker, 2001], lifetime prevalence of affective disorders
Conclusions
This study provided insights into the relationship between cultural values and the prevalence rates of CMDs in 25 countries. Affective disorders showed a clear and consistent relationship with cultural values, after controlling for GNI per capita. For anxiety disorders, correlations were lower but still offered meaningful insights. Our results provide a possible explanation for the variance found in prevalence rates in the WMHS, although more countries and more sophisticated analyses would be
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