The Cultural Factors in Moderate to Severe Depression and Relevant Interventions

: Depression is resulted from a mixture of hereditary and environmental variables. This article mainly considered biological, genetic, and psychological influences on depression. For environmental aspects, this paper aims to identify the impact of different cultures on depression. The most relevant previous studies were reviewed. The findings suggest that culture does play a role in the development of depression. This review mainly examined studies that compared the effects of individualistic and collectivistic cultures on depression. Traditional filial piety culture and thin culture showed different effects on depression. In addition to the traditional gender roles of certain cultures, caste and other cultural differences can also have an impact on the development of depression. Similarly, prenatal depression is more common in immigrants and poor countries than in non-immigrants and industrialized countries. Resilience and social support are two protective factors for mental health, and these two factors have different degrees of influence depending on the culture. There is still limited amount of research investigated the effects of different cultures on depression. More research on the characteristics of different cultures and their association with depression is needed in the future. This review can provide some guidance for furture research and practice. Prevention and intervention programs for children and families should incorporate cultural factors.


Introduction
Although physical health is important, mental health is equally important.Most countries have begun to focus on the mental health of people, and psychological counseling is set up in high schools, universities, and other major places that are prone to mental health problems.Depression is a very common psychological disorder among the known public health problems.Depression can occur at different ages and in a variety of situations [1].Depression occurs when environmental and genetic factors interact together.The chance of developing depression is determined by genes to some extent, including heredity and genetic mutations.Environmental factors include poor family financial status, negative family relationships, parental divorce, child abuse, childhood trauma, and so on.Prenatal maternal psychological factors or biological factors are likely to cause fetal growth retardation, affect their later growth, and increase the risk of depression.Postpartum social factors may also increase the risk of depression in young children [1].Existing research results have confirmed that the interaction between genes and environment does affect depression [2].However, few studies on environmental (acquired) factors have focused on the effects of different cultures on depression, so this paper aims to fill this gap.
Based on the American Psychological Association's Diagnostic and Statistical Manual of Mental disorders-fifth edition (DSM-5), depression is a significant mental illness that affects many people.Depressed people have a feeling of hopelessness and sadness, and they lose interest in things that they used to enjoy.In addition to the emotional problems produced by depression, people may experience physical symptoms, such as persistent pain or digestive issues.To be diagnosed with depression, patients must show the symptoms for at least 14 days.The individual must show five or more symptoms in the same two-week period, at least one being a low mood, a loss of interest, or pleasure [3].However, the appearance of depression is strongly related to the environment, and the social environment varies from culture to culture.Culture is a factor that must be considered for depression.The purpose of this article is to find out whether different cultures affect the occurrence of depression and to make some recommendations for relevant psychoeducational program.

Biological and Genetic Factors
Early birth, low birth weight, and a short gestational age have all been linked to depression, as shown by previous studies.Su's study mentions that a high level of circulating glucocorticoids may be linked to low birth weight.In other hormonal systems, hypothalamic-pituitary-adrenal axis (HPAA) can work with other hormones, such as the growth hormone-insulin-like growth factor system, to regulate the growth of the fetus and brain development and may have a role in depression pathogenesis [1].Moreover, according to Su's study, small gestational age (SGA) births and preterm were connected to changed HPAA activity, indicating an early learned and persistent neurophysiological susceptibility that later becomes engaged in the development of depression, as a result of heightened sensitivity to adversity.Furthermore, studies also mentioned that the age of parents may lead to the development of depression in their children.Parents under the age of 20 may affect their children's growth due to financial stress, inexperience, and marital discord, etc. Parents over 35 may be unprepared for the life-changing experience related to having children [1].They might put too much hope on the child or spoil the child too much and affect the normal development of the child.
According to research, depression in teens has a heritability between 30% and 80% [2].Research by Dunn and her colleagues included the repetition of 5-HTTLPR variable number tandem, which includes the l/l, s/s, or s/l genotypes.It was the most widely examined variation in 75 percent of studies (n=15).13 studies focused on the biallelic variant (l/l, s/s, or s/l genotype) and three studies focused on the triallelic variant: (1)L′L: LALA, (2) LGS, LGLG, SS, and (3) L′S: LAS, LALG.One researcher merged the s/s and s/l genotypes when examining these 5-HTTLPR genotypes.This would indicate that the 5-HTTLPR polymorphism and s allele are genes associated with depression [2].

Psychological Factors
Some studies suggest that prenatal depression, maternal stress, and anxiety can also lead to depression in the offspring.Su's study indicates that elevated levels of maternal glucocorticoids, which were thought to be the fundamental link connecting maternal adversity to the fetus, can be triggered by depression, stress, and anxiety throughout pregnancy.Evidence suggests that maternal glucocorticoids enhance the risk of psychopathology in offspring [1].Prenatal anxiety and maternal stress may be linked to a less optimum development trajectory in offspring.Normal growth and development can be challenged by genetic sensitivities associated with early-life environmental adversity.Studies found that maternal prenatal depression turned into an independent threat element for offspring's depression.Prenatal depression may exert an adverse impact on utero via biological mechanisms.Plenty of physiological altars of depressed mothers at the stage of pregnancy posits unfavorable intrauterine surroundings that could modify fetal developmental programming [1].

Current Review
Although the influences of genetic, biological, and psychological factors on depression are inevitable, it is important to pay attention not only to intrinsic factors but also to extrinsic ones.Environmental factors are also a very important cause.Many studies have so far mentioned the influence of environmental factors on depression, but not many studies have examined the influence of different cultures.Therefore, this review discussed the research findings regarding the relationship between different cultures and depression.This paper analyzed the cultural impact on depression, through the comparison of traditional filial piety, individualism, collectivism, thinness, as well as some traditional cultural norms and biases.This article can provide some guidance for future research and designs of relevant prevention and intervention programs.Psychoeducational programs at school should incorporate students' cultural backgrounds into the curriculum.

2.
General Cultural Factors in Moderate to Severe Depression

Different Effects of Collectivistic and Individualistic Cultures on Depression
The definition of culture is very broad.It includes norms, institutions, as well as social behaviors, arts, customs, knowledge, beliefs, habits, and so forth.Cultures can be distinguished from different regions of origin which is why each culture is unique.Some studies do show that cultural differences can have an impact on depression.A survey by Khaled and Gray on the relationship between immigrants and nonimmigrants and depression mentioned that immigration seems to affect people from different cultures in different ways.Culture clashes can lead to psychological maladjustment; this is often described as "culture shock," the stress of adapting to culture due to a lack of congruence between the culture acquired by the migrating group and the local culture, which may be a risk factor for depression and anxiety disorders.However, the stress of acculturation and potential depressive symptoms are also related to the length of stay.The perception of quality of life across cultures is also an essential factor influencing acculturation.Thereby, the study concluded that immigrants were significantly more likely to experience depression compared to nonimmigrants.The prevalence of depression was higher among immigrants with gross household income below $1,100 per month, and the occupational nature of the jobs held by immigrants was also an influencing factor [4].A study from OKRAY indicates that sadness, disgust, anger, etc. are universally recognized emotions but their expression and recognition depend on the individual's different cultures.Their findings noticed that Asian students have higher levels of sadness and suicidal ideation than African students [5].
Because of cultural differences, collectivism does not encourage people to express their feelings or personalities too much and are more prone to depressive symptoms while others are more accepting of different individuals and are less prone to depressive symptoms.Individualistic and collectivistic societies are frequently contrasted.Individualism is focused on each individual's rights and interests, whereas collectivism emphasizes the value of the group.Individualism and selfidentity are prized in individualistic nations over cohesion, altruism, and compassion, which are encouraged in collectivist civilizations.Individualism and collectivism have different effects on depression.Chen's study of American and Hong Kong adolescents indicated that cultural differences in individualism and collectivism might make adolescents of a particular culture more sensitive to interpersonal relationships [6].Between these two cultural groups, they discovered a considerable difference in self-efficacy.The greater importance of self-efficacy for Americans suggests that for individualism personal factors have a more prominent impact on depression symptoms.Since self-efficacy is a sense of control and competence, individualism, which views the self as independent and autonomous, would give more consideration to individual goals than to collective goals.In the same way, a close-knit culture would place more emphasis on cultural homogeneity with less deviation from group norms while a loose-knit culture would be more tolerant of deviant behavior.The high variability of American self-efficacy also reflects the variety of individual characteristics in different situations in a loose-knit culture [6].
Meanwhile, interpersonal interpretation is largely related to depression in Nepalese adolescents.Studies on adolescents also noted that the impact of depression varies by country.In Rose-Clarke's study, argument, sadness, role transition, and social isolation were the four interpersonal problem areas related to stressors.Adolescents with depression associated their problems with disputes.Many of these disputes were attributed to unfair household chores, work mishaps, etc.Still, other adolescents described issues related to role transitions.The inability of one or both parents to earn money to meet the family's basic needs due to ill health or other reasons resulted in adolescents having to take on more household chores and/or paid work.They worry about how to give up their studies to earn money to pay for their parents and younger siblings.Additionally, this also increases the social isolation of adolescents when they feel uncomfortable living with friends from other castes who exclude them because of their skin condition because they are "sad belonging to a low caste".Adolescents also associate depression with battering and verbal abuse by teachers and parents [7].This is why adolescents in a collectivist culture are more restrained, afraid to express themselves too much, and under more pressure from their parents, and they will be more depressed because of this.In summary, the causes of depression in Nepalese adolescents are somewhat different from those in other countries.Most teenagers are not bothered by dropping out of school to earn money in other countries.In some countries, it is even illegal to hire teenagers to work.They are also not discriminated against because of their caste.Instead, they received the effects for some of their reasons or other more common reasons, such as interpersonal relationships.Thus, different cultures and policies in different countries can have different reasons for depression.
Moreover, the slimming culture that is popular in some countries also impacts depression.Han's research into the relationship between depression and poor self-esteem in female college students from the United States and Korea found that cultural background can influence the development of eating disorders [8].And there is an inextricable relationship between eating disorders and depression due to lowered self-esteem.Their research noticed that in the United States, women who lack secure attachments are more likely to have poor self-esteem and maladaptive perfectionism, which raises the risk of developing bulimia and depression.However, among Korean women, this indirect effect pathway was not significant.This study noticed that in recent years, Korean culture has placed too much emphasis on female youthful appearance and beauty, and the slim ideal is prevalent among many Korean college women.According to certain data, Korean college women had higher eating disorder symptoms, such as binge eating behaviors, than women in the United States [8].Depending on the influence of cultural indoctrination and peer pressure to produce a negative body image leads to a decline in self-esteem and obsesses with a slimmer body, which leads to attempting poor weight loss methods such as dieting, diet pills, etc. Eating disorder symptoms and depression begin to develop.Both physical and mental health problems have arisen.To conclude, although depression is associated with eating disorders in American and Korean college students, Korean female college students are more likely to develop this problem due to cultural influences.

The Impacts of Traditional Cultural Values or Biases on Depression
The difference between the traditional culture of filial piety and the culture of individualism is also related to depression.In a study of older adults in the UK and Japan, social-isolation was found to be a factor in increasing the risk of death and was also associated with depression.However, there's a loss of consensus on the fitness outcomes of social relationships primarily based on cultural differences.Since there is a traditional filial culture in East Asian families, including in Japan, this is often in contrast to the individualism of the West.A study comparing older adults in the United States and Japan found that relationships with children were associated with depression in Japan.While the presence of a spouse was important in both countries, it was more important in the United States.In addition, there is a study notice that contact with friends is good for women's mental health in the UK but it doesn't seem to work in Japan.Besides, studies say poor interactions with children are slightly associated with depression in the UK, while poor interactions and lack of social engagement with children are significantly associated with depression in Japan [9].
Culture forms the acceptance of different behaviors by different genders and the perception of appropriate behavior among them.Gender identities are also part of the culture and they affect everyday life not only within the family but also in the workplace and other daily life.Different cultures have different levels of acceptance of women's involvement in their lives for example some cultures consider women to be inferior so women in this culture are more likely to have prenatal depression.Prenatal depression is more common in Mexico than in Spain because of the different policies of social support and gender discrimination in different countries.A cross-cultural study by Marcos-Nájera that analyzed the incidence and prevalence of prenatal depression indicated that prenatal depression affected significantly fewer Spanish than Mexican pregnant women.Spanish women are more likely to be working, orderly, more educated, and will plan their pregnancies more than having an unplanned pregnancy compared to Mexican women.Seven more risk factors were associated with a social background in Mexico than in Spain with only three risk factors.Loss of emotional support from others was revealed as a significant risk factor for pregnant depression in Mexico.On the one hand, for everyday survival in Latin American countries, aid from friends, neighbors, and family is essential.In Europe, on the other hand, these are alternate possibilities for primary support provided by the country's services.Because traditional gender roles play a key influence on marital satisfaction, as well as lower educational attainment and occupation rates, pregnant women in Mexico appear to have a high level of marital discontent and stress over marriage/partnership issues.In Mexico, the more rigid gender function culture inhibits women's ability to develop sources and fosters more identical and autonomous partnerships.The study also found that due to economics, the prevalence of prenatal depression is greater in underdeveloped nations than in industrialized countries [10].

Cultural Factors in Interventions for Depression
Pharmacotherapy, psychotherapy, and supportive measures have been used to treat depression so far.Monotherapy, i.e., employing a single medicine or psychotherapy, should be used as the initial method of treatment for moderate or severe depression, based on the patient's preference and availability.The main integration of the two treatment modalities may be useful in individuals with severe, relapsing, or chronic depression, as well as elderly depressed patients [11].According to Brailovskaia's study, social support and resilience can be utilized as mental health protective factors.Social support has a powerful correlation with anxiety, stress, and depression symptoms throughout the German sample, while resilience has a higher correlation with worse mental health symptoms in the Chinese and Russian populations.China is generally classified as a strongly collectivistic country.Germany is frequently considered a very individualistic society.The following is one possible reason for these findings.Students in large universities in Russia, China, and Germany were studied in this study.Many German students receive financial support from their parents to live at home during their studies.Young people in Russia and China, particularly those from small towns and villages, frequently relocate to greater cities for their studies.Because their families are unable to financially support them, they typically live alone and work in addition to schooling.Resilience is the ability to cope with adversity by drawing on personal resources.Self-esteem, interpersonal skills, and problem-solving abilities are all traits of resilient people.They are selfassured, upbeat, and emotionally stable.Early childhood interactions with the environment and positive family interactions contribute to the growth of resilience and healthy self-perception.Social support is provided through a person's social relationships with others, such as coworkers, neighbors, governments, friends, society, and family.This assistance can be practical or emotional.It improves a person's ability to deal with stressful events and also increases their resilience.Individuals who lack social support are more likely to develop mental illnesses.Resilience and social support are mutually beneficial processes [12].

Conclusions
This review set out to examine whether different cultures have different factors that contribute to depression.This paper found that the differences among traditional filial culture, collectivism, Western individualism, and thin culture can lead to depression symptoms in different ways.For example, Korean is very concerned about age and seniority, so their people will have great respect for people, who are older than themselves whether it is a few months or a few years older.Such small cultural traits may also increase the chance of depression.Besides this, some countries have specific cultural norms that may cause depression.For example, adolescents in Nepal may be discriminated against because of caste, but some countries do not have this cultural rule.And traditional gender roles in Mexico may cause prenatal depression.Apart from this, prenatal depression is more common in developing countries than in developed countries.Social support for depression is likely to be different across cultures and have a significant impact on the effectiveness of interventions for depression.
There is limited research on the relationship between the characteristics of different cultures and depression.There should be a more professional assessment solution for different cultures.Based on the current review, although some cultural factors in depression were instigated, intervention incorporated cultural factors for depression is still scarce.For example, when treating a patient with an eating disorder, it should be considered whether she is culturally influenced to develop symptoms of eating disorder and depression.If it is mainly due to cultural factors, then the intervention should aim to change her culturally based negative thoughts.This review is also a valuable resource for the development of relevant psychoeducational programs at school.