A cross-cultural study of depressive symptomology

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WEINING C. CHANG

A CROSS-CULTURAL DEPRESSIVE

STUDY

OF

SYMPTOMOLOGY

ABSTRACT. Black (N = 26), white (N = 26) and Overseas Chinese (N = 32) college students were surveyed with Zung's Self-rating Depression Scale (SDS). With the exception of two items where marginally significant differences were found, there were no quantitative differences in the results across these ethinc groups. Inter-item analyses, factor analyses and comparison of factor profiles indicated that the items clustered in different configurations for the three groups. The factors contributing the most variances differed in their item contents across the ethnic groups: a mixture of affective and somatic complaints characterizes the black group; existential and cognitive concerns characterize the white group and somatic complaints characterize the Overseas Chinese group. Discussion was focused on issues concerning cultural conception of psychological difficulties, communication styles used to communicate these difficulties and situational variables affecting performances on psychological diagnostic tests. INTRODUCTION In the United States, depression is considered a serious mental health problem. Cross-cultural studies o f mental health, however, have revealed a very different situation a b o u t depression in people o f non-Western cultures (e.g., Al-Issa 1970; Benedict and Jacks 1954; Fabrega 1974; Marsella 1980; Pfeiffer 1968). Many o f these reports observed that the cluster o f symptoms characterizing depression in the West seemed to be rare or absent in non-Western cultures. As a matter of fact, some o f the reports have indicated that the incidences o f depression in some o f these societies were related to the degree of "Westernization" o f the culture groups in question. These observations have p r o m p t e d some researchers to conclude that "depression" is perhaps a "Western" problem (see Marsella 1980 for a review o f cross-cultural studies o f depression). Aside from the absence o f emotional uproar (there is certainly no pride to be taken in being more or less depressed), the situation is reminiscent o f the controversy over intelligence testing in different cultural groups. F o r a while it was considered that many o f the non-Western populations, including some o f the ethnic minorities in the United States, were deficient in mental capacities because o f the lower mean test scores these groups typically obtained in standard intelligence tests. Only recently have researchers looked into the validity o f these standard measurements and at the situational variables involved in psychological testing to provide alternative interpretations o f the performance differences in the standard intelligence tests (e.g., Cole and Brunet 1971 ; Cole and Scribner 1974). These scholars questioned the adequacy o f using the same psychological tests on subjects o f different cultures and contended that before any quantitative

Culture, Medicine and Psychiatry 9 (1985), 295-317. 0165-005X/85.10 © 1985 by D. Reidel Publishing Company.

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WEINING C. CHANG

comparison can be undertaken, it is mosf important to look into the possible cultural differences in the structure and content o f the psychological trait in question (Cole and Scribner 1974). Though studies on culture and human cognition are still inconclusive, important questions have been generated by these studies about psychological testing on people of different cultures (Irvine and Carroll 1980). Some of the basic problems in testing subjects of different cultures were summarized by Florence Goodenough (1936) almost forty years ago: Examination of the literature in the past twenty years shows that approximately two thirds of the publications dealing with racial differences in mental traits have been conducted with measurements of intelligence by means of tests designed for use with American and European whites . . . . Now the fact cannot be too strongly emphasized that neither intelligence tests or the so-called tests of personality and character are measuring devices properly speaking, ... They are sampling devices. . . . The tests items from which the total trait is to be judged are representative and valid samples of the ability (or trait-author) in question as it is displayed within the particular culture with which we are concerned (pp. 5-6). In psychology, emotions are regarded as hypothetical constructs and have to be operationally defined. The operational definitions of an emotion include observations o f behavior, measurements o f physiological concomitants and subjective reports o f subjective feelings o f emotion (Plutchik 1980). Self-report rating scales such as the Self-rating Depression Scale (Zung 1965), Beck's Depression Inventory (Beck et al. 1961) and the Depression Scale in Minnesota Multiphasic Personality Inventory (MMPI-D Scale) Dalstrom et al. 1960) are commonly used to measure the depression state of an individual. These scales are used widely for research and clinical purposes and thus have played an important role in the practice of psychology and psychiatry. Most of these depression measurements were constructed on the basis of clinical observations of patients diagnosed as depressed by means other than the test in question. The items included in such depression measurements are thus empirically derived. However, the observations and validations of these tests were carried out in Western hospitals with patients o f Western culture. The items or symptoms included in the tests are thus not unlike Goodenough's conclusion: samples of the trait in question, in this case depression, as it is displayed in a particular culture context. This sampling problem was evident even when the tests were applied to people o f the same culture. Lack of consistency o f diagnosis of depression has been reported by researchers using different depression measuring instruments on the same subjects (e.g., Akiskal et al. 1979; Depue and Monroe 1978; and Hesselbrock et al. 1983). For instance, the D scale of the MMPI tends to "overdiagnose" subjects for depression (Depue and Monroe 1978; Hesselbrock et al. 1983). The

A CROSS-CULTURAL STUDY OF DEPRESSIVE SYMPTOMOLOGY 297 problem is amplified when the subjects are of different culture and ethnic backgrounds (Dohrenwend and Dohrenwend 1965, 1967, and 1974). Faced with the sampling problem, Zung (1977) has emphasized the concept of core symptoms contained in his Self-rating Depression Scale (SDS) (Zung 1965) which taps a group of symptoms commonly shared by people of different cultures. The list of twenty items in the SDS does not include religion-related items (see MMPI-D Scale for a comparison) and guilt related items (see BDI for a comparison). Cross-cultural studies have been conducted by Zung (1969, 1972) with the SDS; it was found that the twenty items on the list are symptoms experienced by people of a variety of cultures. This group of symptoms is perhaps a better sampling of depressive symptoms in a cross-cultural sense. This makes the SDS a useful tool with which to explore relations between symptoms and cultural variation in the configurations of symptoms. It is agreed by most researchers that depression is a phenomenon of a multidimensional constellation of symptoms. The description of depression given by the Diagnostic and Statistical Manual-Third Edition (DSM-III) (American Psychiatric Association 1980) states the following: The essential feature is either a disphoric mood, usually depression, or loss of interest or pleasure in all or almost all usual activities and past times. This disturbance is prominent, relatively persistent and associated with other symptoms, including appetite disturbance, change in weight, sleep disturbance psychomotor agitation or retardation, decreased energy, feeling of worthlessness or guilt, difficulty in concentration or thinking and thoughts of death or suicidal attempts. This description not only fists the symptoms of depression but also the relationships between the symptoms, that is, the affective complaints are major symptoms; somatic symptoms and feeling of loss and self-worth concerns are secondary concomitants which accompany the primary affective complaints. This description of depression with its emphasis on affective complaints represents a consensus of the operational definitions of depression as it is viewed in the United States (Eysenck, Wakefield, and Friedman 1983). When this cluster of symptoms was used as criteria for depression in cross-cultural studies, incidences of depression seem to be rare in non-Western cultures. Noticeably absent in the case reports were affective complaints (Marsella 1980). Crosscultural surveys, however, indicated strong presences of somatic complaints, physiological symptoms, that usually accompany affective symptoms. Some of the researchers noted the presence of affective symptoms; but the symptoms were often de-emphasized during reporting or interviewing (Kleinman 1977, 1982a, 1982b). Since there are many theories and studies that explain the biological mechanisms of depression, which seem to be universally applied, it seems that a more productive approach is not to argue for the presence or absence of certain symptoms but to search for the configurations and the underlying

298

WEINING C. CHANG

dimensions of phenomenological manifestations of depression and to identify dimensions of symptoms that are better indicators of depression for people of different cultures. Aimed at that goal, recent cross-cultural studies have employed multivariate techniques. For instance, Marsella, Kinzi, and Gordon (1973) using a sixty item symptom check list composed of a spectrum of symptoms on clinically depressed college students of white, Japanese and Chinese American backgrounds, found that subjects of different ethnic groups demonstrated qualitatively different symptomology of depression. Irvine and Carroll (1980) suggested that a combination of multivariate psychometric methods with ethnographic studies can provide an effective tool to attack the complicated problem of testing subjects of different cultures. Analyses of patterns of correlations and factor profiles can generate information about the nature of the process being studied; comparing the correlation matrices and factor profiles obtained from the test results of different cultural groups can provide an answer to the question whether the tests are measuring the same construct or underlying processes across different cultural groups. Information gathered with ethnographic studies can provide background contextual information, especially the "knowledge system" of a culture which "shapes" the experience and the culturally conditioned ways of expressing underlying psychological processes. Marsella (1980) suggested that the construct of depression: "is perhaps conceptualized differently in different cultures." A theoretical framework is proposed to explain culture variations in surveys of psychological symptoms (see Marsella and White 1982) that the cultural milieu in which the individual is brought up and has to interact with others provides an "epistemological framework" with which the individual perceives, interprets and categorizes his personal conditions. This epistemological framework also gives rise to culturally conditioned ways in which the individual communicates with others about his personal conditions including psychological symptoms. This appeal to cognitive intervention seems particularly applicable to self-report measures of depressive symptoms. A self-report measure of psychological symptoms does not directly tap the symptoms; it fneasures the symptoms through a subjective report of the perception of symptoms. Cognitive processes involved in perceiving, categorizing and interpreting the symptoms and the culturally conditioned ways of communication are all potential factors that might influence the outcome of a self-report measure of symptoms. Studies in individual cognitive function and perceptual development have suggested perception is a much more subjective process than it was once envisioned. Gibson (1969), based on empirical observations of child development, proclaimed that perception is a process of "filtering and selection" of relevant

A CROSS-CULTURAL STUDY OF DEPRESSIVE SYMPTOMOLOGY 299 information out of an array of information afforded by the environment. Neisser (1976) went a step further and proposed that perception is a process of"reconstruction of reality" based on a set of "schemata" formed, validated, and modified by the individual's interaction with the environment. The new ethnoscience which adopted linguistic models for the study of culture systems and focused largely on the semantic organization of terminological domains is concerned specifically with the task of discovering and representing cultural knowledge as a cognitive system (Ricoeur 1981). Researchers with backgrounds in ethnoscience have been engaged in the search for epistemological frameworks in different cultures (e.g., D'Adrade 1976, 1981). These separate but overlapping lines of research all point to the process in which an individual utilizes an internalized cognitive model to select, categorize and to interpret information from the environment in which he is embedded. Objective validation of subjective feelings about emotions is very difficult if not impossible. When faced with such illusive targets for perception, the perceiver of the subjective experiences of emotions has to rely on a set of cognitive references to "make sense of", to label and to categorize the experiences. In other words, it is proposed that emotional experiences are perceived differently in different cultures because they are selected, labeled and categorized through different cognitive filters. Self-reporting of psychological symptoms is essentially a communicative behavior. In a broad sense, all psychological testings are communicative behaviors. During the process of communication, to achieve the purpose of communication, the communicator has to use symbols and gestures that have been proven effective in the past. These symbols, gestures and display rules constitute a "language." In addition to studying cultural differences in tools used for communication, scholars of sociolinguistics (Bernstein 1970) are particularly concerned with the social contexts in which communications take place (Henderson 1973). Since communication styles vary with the contexts and the contexts are perceived differently by people of different cultures, Cole and Scfibner (1974) contended that the use of standard testing procedures is not really "standard" for people of different cultures and that field studies of the culture have to be conducted prior to the administration of tests or psychological experiments in order to identify situational settings that are culturally equivalent subjects of different cultures. Psychologists are thus faced with a situation in which the psychological test results are end products of at least the following kinds of variables: (1) perceiving, categorizing and interpreting of the psychological traits, (2) communicative tools and styles used by the subjects and (3) situational and contextual variables involved during the administration of the test in addition to the trait being measured. The situation is quite complicated and can be attacked from many

300

WEINING C. CHANG

different angles. Analyses of the final product, the test scores, represent one of the approaches to the problem. By analyzing differences in configurations and underlying dimensions of the scores, information can be obtained to serve as basis to chart directions for future approaches to help formulate better questions and hypotheses which will lead to a more comprehensive undersanding of the problem. The present study used Zung's SDS (Zung 1965) as a tool to explore different dimensions and configurations of depressive symptomology in Black, White and Overseas Chinese college students. Through factor analyses, the present study sought to (1) identify the basic categories or dimensions of depressive symptoms for each culture group, (2) to compare the factor profiles and study the pattern of culture variations in depressive symptomology and (3) to identify culturally salient dimensions of symptoms for diagnosis of depression in different cultures. METHOD

Subjects Students from two neighboring state universities in Houston, Texas were recruited for the study. Black students were enrolled in an introductory psychology class at Texas Southern University, a predominantly Black university; White and Overseas Chinese students were enrolled in introductory classes at the University of Houston/University Park. There were 26 Black students, 26 White students and 31 Overseas Chinese students. The gender distribution between male and female was 13:13 in the White group; 16:10 in Black group and 22:9 in the Overseas Chinese group. The average age for all three groups was 21. Background information was obtained from the Overseas Chinese subjects. Their average length of study in the United States was two years. A majority of the students were from Hong Kong, where they had several years of high school education in English as a Second Language (ESL). In accordance with the admission policy of the University of Houston, no foreign students can be admitted into the University without having achieved a score on the Test of English as a Foreign Language (TOFEL) above 550. Therefore it is confident to assume that the Overseas Chinese subjects had no difficulty reading the items in the measurement of depressive sympt~3ms. Answers to questions added to the measurement confirmed this assumption.

Instruments The Self-rating Depression Scales (SDS) developed by Zung (1965) was used. The SDS is a short list of twenty items which describe four categories of depressive

A CROSS-CULTURAL STUDY OF DEPRESSIVE SYMPTOMOLOGY 301 symptoms: pervasive psychic disturbance, physiological disturbance, psychomotor disturbance and psychological disturbance. Each item in the scale contains a short statement reflecting one of the symptoms. The subject is asked to respond to the statement by checking one of the following ratings: (a) a little of the time, (b) some of the time, (c) good part of the time and (d) most of the time. Items are rated on a four point scale, half positively beyed and half negatively keyed. In scoring the result, a response of (a) was given a 1 ; (b) was given a 2; (c) was given a 3; and (d) was given a 4, for the positively keyed items. For the negatively keyed items, a response of (a) was given a 4; (b), a 3; (c) a 2; and (d), al. Two additional questions were added to the instrument for the Overseas Chinese subjects: (1) Did you have any difficulty reading the questions? and (2) What do you think this questionnaire measures?

Procedure The instrument was administered by the instructor of each of the classes. The subjects were instructed to do the rating as part of the course requirements. Anonymity was assured by instructing the subjects to put down only their age, gender and ethnic identity on the scale. The Overseas Chinese students were asked to give their length of stay in the United States. The scale was given without a title to avoid the subjects' interpretation of the term: "depression."

Data Analyses One way analyses of variance were performed across the ethnic groups for each of the items in the scale. Inter-item correlation coefficients were calculated for each of the ethnic groups separately. Factor analyses via principal component analyses were conducted for each of the groups separately. The resulting factor matrices were rotated against each other. Item cosines were calculated for each of the items after the rotation; means of cosines were obtained as indicators of the extent to which the matrics were similar to each other. RESULTS The results of analyses of variances are presented in Table I. With the exception of two items, item 8 and item 13, there were no significant differences of depressive symptoms across these three ethnic groups.

302

W E I N N I N G C. C H A N G TABLE I Ethnic differences in item responses

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

I feel downhearted and blue. Morning is when I feel the best. I have crying spells or feellike it. I have trouble sleeping at night. I eat as much as I used to. I still enjoy sex. I notice that I am loosing weight. I have trouble with constipation. My heart beats faster than usual. I got tired for no reason. My mind is as clear as it used to be. I find it easy to do the things I used to. I am restless and can't keep still. I feel hopeful about the future. I am more irritable than usual. I find it easy to make decisions. I feel that I am useful and needed. My life is pretty full. I feel that others would be better off if I were dead. I still enjoy the things I used to.

White (N = 26) a b

Black (N = 26) a b

Chinese (N = 31) a b

df

1.30-0.63 2.76-1.14 1.10-0.40 1.42-0.75 2.19-1.20 1.46-0.90

1.16-0.57 2.34-1.27 1.27-0.53 1.35-0.29 2.69-1.08 1.38-0.64

1.77-0.88 2.35-1.05 1.71-1.03 1.68-0.98 2.16-1.00 1.84-1.00

2/80 2/80 2/80 2/80 2/80 2/80

2.08 1.30 1.82 0.60 1.62 2.34

1.35-0.63 1.12-0.32 1.50-0.86 1.58-0.58

1.42-0.75 1.07-0.27 1.38-0.69 1.50-0.70

1.64-0.91 1.52-0.77 1.32-0.47 1.93-0.85

2/80 2/80 2/80 2/80

0.50 4.34* 0.57 1.77

1.57-0.54

1.96-1.11

1.67-0.74

2/80

1.40

1.81-0.98 2.08-0.74 1.57-0.81 1.62-0.75 2.11-0.10

2.11-1.17 1.50-0.90 2.04-1.15 1.69-0.74 1.84-1.08

1.87-0.92 2.26-1.15 1.97-1.14 1.94-0.89 2.42-1.11

2/80 2/80 2/80 2/80 2/80

1.06 4.14" 0.82 0.43 1.69

1.88-0.86 1.73-0.78

1.65-0.93 1.54-0.86

1.90-0.91 2.23-0.99

2/80 2/80

0.57 2.66

1.12-0.43 1.42-0.58

1.27-0.72 1.88-1.14

1.35-0.84 2.03-1.05

2/80 2/80

0.50 1.98

* p < 0.05 a. mean b. standard deviation Table II, III, a n d I V p r e s e n t t h e i n t e r - i t e m c o r r e l a t i o n c o e f f i c i e n t s for e a c h o f t h e e t h n i c groups. A close i n s p e c t i o n o f these c o r r e l a t i o n c o e f f i c i e n t s reveals t h r e e d i f f e r e n t p a t t e r n s o f clustering o f t h e items. F o r t h e W h i t e group, a cluster o f significant c o r r e l a t i o n s is f o u n d b e t w e e n t h e i t e m s t h a t c o n t a i n e x i s t e n t i a l c o n c e r n s a n d c o n c e r n s f o r cognitive f u n c t i o n i n g ; for t h e Black g r o u p , a cluster o f significant c o r r e l a t i o n c o e f f i c i e n t s is f o u n d b e t w e e n t h e i t e m s c o n t a i n i n g s o m a t i c c o m p l a i n t s a n d affective c o m p l a i n t s , a n o t h e r cluster is f o u n d b e t w e e n t h e cognitive a n d e x i s t e n t i a l c o n c e r n s . F o r t h e Overseas Chinese g r o u p , it is o b s e r v e d t h a t t h e self-esteem i t e m s a n d cognitive c o n c e r n i t e m s are related. H o w e v e r , h i g h e r c o r r e l a t i o n s are f o u n d b e t w e e n t h e i t e m s c o n t a i n i n g s o m a t i c c o m p l a i n t s . This l a t t e r p a t t e r n seems t o b e c h a r a c t e r i s t i c o f t h e Overseas Chinese group.

5. -0.263

0.143

0.324

0.380

0.264

0.105

8. -0.059

0.688"*

0.099

0.039

0.084

10.

11.

12. - 0 . I t 0

0.077

9.

13.

14.

15.

0.454*

0.358

19.

20.

=* p < 0.01

p < 0.05

0.602**

18.

*

0.285

0.115

17.

0.529"*

0.318

0.647**

0.389

0.219

0.469*

16. -0.417"

0.154

0.223

0.156

-0.260

0.093

7. -0.071

6.

-0.201

0.091

0.199

3.

4.

0.255

0.087

1.00

0.434_.____* 1.00

2

1.

No.1

2.

Item

1.00

0.204

0.512"*

0.322

0.282

-0.046

0.005

0.118

0.113

0.124

0.076

0.220

0.159

-0.074

-0.149

0.202

0.271

-0.127

3

0.257

1.00 1.00

0.312

0.460"

0.305

0278

0.232

6

1.00

0.054

0.191

0.266

0.104

0.163

0.283

0.262 -0.067

0:099 -0.101

0.206 -0.304

0.205

-0.079

0.170 -0.130

0.264

7

1.00 1.00

-0.094

-0;077

-0.013

-0.265

-0.009

0.076 -0.109

-0.116

0.000

1.00

0139

-0.032

9

11

0.231 0.034

-0.271 0.001

0.091 0.025

0.409

0.223 0.374

.0,:,579" 0.039 0.113

0.575"* 0.132 0.190

0.396"

1.00

12

0.030

0.154

0.024

0.516"* 0.097

0.431"

0.331

0.219

1.00

14

1.00

15

0.221

1.00

16

0.560

18

0.379

19

0.514"* 0£22**

0.657** 1.00

0.390* 1.00

1.00

17

0.217 0r479" 0.631"* 0.186

0.179 0.312

0.019 0.589**0.264

0.050 0.188

0.133 0.289

0.480"*-0.I27

0.019

1.00

13

0.422*-0.081

0.043

0.026

0.156 0.298 -0.206

0.168 0.370

0.076 1.00

1.00

10

0.505** 0.104 0.028

0.474*

-0.119

0.163 -0.063

0.096

0.142

0.000

0.049

-0.138

$

0.102 -0.408*

-0.356

-0.331

-0.065

-0.087

-0.057

0.020

-0.037

-0,245

0,515"* -0.164

0.284 -0.069

0273

0.122

-0.260

0.004

0.219

-0.224 -0.268

-0.111

5

0.563**-0.023

0.014

0322

0.078

-0.054

-0.222

0.416

-0.051

0.048

-0.i06

4

TABLE II Inter-item correlation matrix of the black data

LO0

20

0

0

0

<

r~

0

>

C

C

> C~ ~0 O ~n o'2

0.123

0.357

0.484"*

0.571"*

0.331

0,520*

0.459"*

0.560**

0,627"*

12.

13.

14.

15.

16.

17.

18.

19.

20.

" p < 0.05 ** p < 0.01

0.281

ii.

8. -0.222

0.025

0.154

7.

10.

0.235

6.

0.000

0,182

0.056

5.

9.

-0.107

0.147

4.

0.336

0.056

0.062

-0,150

0.054

0.172

01193

-0.214

0.173

0,276

-0.093

-0.163

0.185

0.004

-0.160

0.275

0.168

3.

1.000

1.000

0.237

2

i.

No.l

2.

lttm

1.000

1.000

0.215

-0.194

0.435*

0.152

0.328

0.032

-0.155

--0.003

--0,279 -0.045

0.044

1.000 1.000

0.120 -0.001

0.283

6

-0.171

-0,102

-0.224

0,014

0.237

0,006

-0.213 -0.257

-0.336 -0.188

5

--0.122

0.033

-0.071

0.215

0.045

-0.048

-0.036

-0.059

-0.082

0.256

0,199

0.037

-0.008

1.000

7

0.224

0.473*

0.354

0.224

0.304

0.330

1.000

0.025

-0.111

-0.038

-0.178

-0.095

0,057

-0.071

8

0.131

--0,057

-0.048

1,000

10

0.000

0.081

0.189

0.185

0.040

--0.054

0.212

0.123

0,321

0.(~2

0,134

--0.041 0.268

0.043

0.271

0,299

0.392* 0.087

0.071

0.030

12

0,291

-0.040

-0.018

0.020

--0,126

0.275

0.347

0.076

0.729"* 1.000

1,000

11

0.079 -0.009

0,166 -0,149

0.025

0.121

1.000

-0.144

9

--0.303 -0.030

0,437"--0.098

0.280

0.518" --0.235

0.457* --0.038

-0.130

0 . 2 2 3 -0.172

0.649"* -0.017 -0.233

0,114

-0.075

-0.123

0.092

-0.206

-0.152

-0.196

4

--0.052 -0,013

-0.010

0.014

-0.051

-0.004

0.117

0.020

0.174

0.129

-0.116

0.186

0.086

-0.015

3

TABLE III inter-item correlation matrix of the white data

1.000

14

15

0.107

0.096

0.383

0.263

0,183

0.343

0.265

0.295

0.421"

17

18

0.473*

0,422"

0.466"

1.000

19

20

0.531** 0.438* 1,000

0,454*

0.688** 0.667 ~* 1.000

0.684 =* 1,000

1.000

16

(k570"* 0,573"* 0,421"

0.260

0.257

0,156

0.235

0.126 .0..44.~* 1.000

0.322

1.000

13

> Z C3

¢3

C3

Z

0 "~

-0.119

0.183

0.144

0.268

4.

5.

6. -0.080

0.118

0.209

0.390

0.277

0.133

0.471"*

0.441"

15.

16.

17.

18.

p < 0.05

*'* p < 0.01

*

-0.292

20.

0.008

-0.034

19. -0.068

0.217

0.530"*

1.000

4

0.040

0.194

0.195

-0.121

0.259

0.064

0.047

0.204

0.128

0.277

0.293

-0.023

0.390* -0.140

-0.026

0.189

0.158

-0.063

0.050

0.017

0.506"*

0.126

0.413"

0.303

-0.126

0.484"* 0.091

0.018

0.110

0.200

1.000

3

0.497"*-0.129

0.107

0.096

0.025

0.197

0.233

13. -0.104

14.

-0.274

0.189

11.

12.

-0.048

0.201

0.013

-0.237

0A23"

8.

9. -0.059

10.

0 . 3 1 0 -0.246

7.

-0.015

-0.055

0.253

3.

1.000

1.000

0.161

2

1.

No.1

2.

Item

1.000

6

0.143

0.043

0.049

0.403*

0.070

0.004

0.056

0.240

0.354* 0.267

-0.229

0.130

0.31i

0.413"

-0.025 -0.049

0.209

-0.095 --0.078

0.456*

0.161 -0.338

0.324

0.307

0.061 -0.105

0.173 -0.064

0.192

1.000

5

0.077

1.000

8

0.362*

0.183

0.003

0.531

0.443

0.213

-0.093

0.238

0.313

-0.065

0.275

10

0.071

0.229

0.301

0.129

0.266

0.323

0.310

0.289-0.060

-0.205

0.081

0.162

1.000

14

0.162

1.000

15

0.111-0.121

0.178

0.362"-0.053

0.116

0.152

0.002

0.244

0.420* 0.055

0.024 -0.517"* 0.384" 0.116

0.248 -0.397* 0.220

0.135 -0.241

-0.033

1.000

13

0.313 -0.044

0.118 -0.092

0.222

0.508"* 0.100 0.215

1.000

12

0.061 -0.030

0.179

1.000

11

0.483"*-0.032

0.213

0.169

-0.096 -0.186

0 . 3 2 7 0.455"

0.209

0.382* 1.000

1.000

9

0.192 -0.018

0.074

0.282

0.461"* 0.147

0.212

0.058

0.221

0.022

0,439"-0.151

0.272

0.174

1.000

7

TABLE IV Inter-item correlation matrix of the Chinese data

17

0.322

1.000

18

0.428*

0.220-0.074

0.085 -0.085-0.140

0.213

0.567"* 1.000

1,000

16

0.103

1.000

19

1.000

20

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WEINING C. CHANG

Principal component analyses with Varimax rotation (Harmon 1960)were separately performed for each of the ethnic groups. Orthogonal factors which reflect the underlying dimensions of the construct measured are obtained through these analyses. Seven factors were obtained from the Overseas Chinese sample. The items with relatively high loadings (> 0.40) on each of the factor do not overlap with items with high loadings on other factors. Seven factors were obtained from the White sample, with some overlapping of high loading items. Eight factors were obtained from the Black sample, also with some overlapping of items. Table V presents the results of factor analyses and item loadings. The factor which contributes the most variance in the Black sample is characterized by a mixture of affective and somatic complaints; the factor which contributes the most variance in the White group is characterized by cognitive and existential concerns; the factor which contributes the most variance in the Overseas Chinese group is characterized by somatic complaints. Tables VI, VII, and VIII present the three major factors for each of the ethnic groups. Table IX, presents the item consines after rotating the factor matrices against each other. The means of cosines were calculated for each pair of the matrices and are used as indicators for the extent of similarity between these matrices. The mean of cosines between Black and White samples is 0.6489; between Chinese and Black sample is 0.5921; between White and Chinese samples is 0.6070. None of these values reached the value of 0.85 suggested by Kaiser (1958). These values indicated that the factor matrices were sufficiently different to warrant the conclusion that there are different dimensions underlying the self-reported symptoms for the ethnic groups. CONCLUSION AND DISCUSSION The present study used Zung's SDS as a tool to explore cultural differences in configurations of depressive symptomology. The results indicated that the three college student groups, Black, White, and Overseas Chinese, evidenced different configurations as well as different underlying dimensions of the symptoms of depression. Item analyses revealed that two of the items showed marginally significant differences across the cultural groups. The two items, constipation and psychomotor agitation, perhaps reflect cultural differences in reporting such symptoms; it is socially inappropriate to report problems of constipation for American subjects; however, it is not socially inappropriate to report such a symptom for the Chinese, because constipation is a part of the somatic functionhag of a person and the Chinese have less inhibitions about reporting bodily symptoms than affective symptoms (Lin 1953; Tseng and Hsu 1969). Psychomotor agitation or restlessness is considered more pathological than psychomotor retardation by the Chinese (Lin 1953). The higher mean score and larger variance

Loadings larger than 0.40 are underlined.

I feel downhearted and blue. Morning is when I feel the best. Ihave crying spells or feellikeit. I have toruble sleeping at night. I eat asmuchas Iused to. I stillenjoy sex. Inotice that I am losing weight. I have trouble with constipation. Myheart beats faster than usual. Iget tiredfor no reason. My mindis as clear as it used to be. I find it easy to do the things I used to do. I am restless and can't keep still. I feelhopefulabout the future. I am more irritable than usual. I fired it easy to make decisions. I feel that I am useful and needed. My life is pretty full. I feel that others would be better off if I were dead. 20. I still enjoy the things I used to do.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11, 12. 13. 14. 15. 16. 17. 18. 19.

Items 0.741 0.463 0.071 0.546 -0.027 -0.064 -0.019 -0.015 0.885 -0.052 -0.055 0.178 -0.047 -0.047 0.543 0.433 0.574 0.755 0.715 0.415

0.706 0.766

Black

0.785 0.199 0.101 0.026 0.047 0.465 0.353 -0.184 0.043 0.209 0.380 0.230 0.309 0.549 0.637 0.722 0.755 0.749

White

Factor I

-0.266 0.097

0.116 -0.044 0.094 0.820 0.653 0.108 0.175 -0.132 0.484 0.581 0.244 0.824 0.057 0.185 -0.091 0.183 0.129 0.153

Chinese

-0.112 0.300

0.189 0.488 0.285 0.185 -0.128 0.059 -0.543 -0.008 -0.045 -0.447 0.452 0.664 -0.014 0.456 0.269 -0.450 -0.467 -0.307

White

Black

0.328 0.279

-0.427 -0.139 -0.058, 0.250 0.794 -0.119 -0.014 0.113 -0.010 -0.092 0.257 0.757 0.018 -0.001 -0.089 0.322 0.362 0.063

Factor II Chinese

-0.192 0.368

0.314 -0.162 -0.169 -0.045 0.275 0.035 0.222 -0.017 0.204 0.454 -0.009 0.025 -0.814 0.235 0.096 0.634 0.826 0.232

TABLE V Result of factor analyses performed separately for each ethnic group

-0,272 -0.027

0.129 -0.416 -0,287 0.858. 0.060 -0.476 -0.192 -0.255 0.141 -0.016 -0.252 0.080 0.776 0.355 -0.064 -0.078 0.111 0.066

White

Black

-0.057 0.442

0.216 0.178 -0.175 -0.096 0.161 0.305 -0.838 -0.024 0.237 0.186 -0.078 0.134 0.011 0.216 0.320 0.657 -0.233 0.039

Factor III

-0.137 -0.319

0.518 0.832 -0.074 -0.017 -0.062 0.140 -0.084 0.147 -0.315 0.084 -0.188 0,215 0.135 0,430 0.191 0,072 0.237 0.773

Chinese

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308

W E I N I N G C. C H A N G TABLE VI The first three prominent factors of the black data

Rank order of factor loading self-rating depression scale - the black group Facrot I Eigenvatue 5.1480, % of variance 19.8% Rank order of loading 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

My heart bea~s faster than usual. My life is pret~y full. 1 feel down~earted and blue. I feel that others would be better off if I were dead. I feel that I am useful and needed. I have trouble sleeping at night, I am more irritable than usual. Morning is when I feet the best. I find it easy to make decisions. I still enjoy the things I used to do.

0.885 0.755 0.741 0.715 0.575 0.594 0.534 0.463 0.433 0.415

Factor II Eigenvahie 2.2635, % of variance 10.0% Rank order of loading 1. 2. 3. 4. 5. 6.

I eat as much as I used to. I find it easy to do the things I used to. I feel down hearted and blue. I feel that I am losing weight. I feel that others would be better off if I were dead. I find it easy to make decisions.

0.794 0.757 -0.427 0.362 0.382 0.322

Factor III Eigenvalue 1.9885, % of variance 9.5% Rank order of factor loading 1. 2. 3. 4. 5.

I I I I I

noticed that I am losing weight. find it easy to make decisions. still enjoy the things that I used to do. am more irritable than usual. feel that others would be better off if I were dead.

-0.838 0.657 0.442 0.320 0.305

There are eight factors; five of the factors have eigenvalue less than 2. o f p s y c h o m o t o r a g i t a t i o n r e p o r t e d b y t h e Overseas Chinese s u b j e c t s in this s t u d y p e r h a p s i n d i c a t e s salience o f this s y m p t o m as a n i n d i c a t o r o f p s y c h o l o g i c a l wellbeing of a person. I n t e r - i t e m c o r r e l a t i o n s a n d s u b s e q u e n t f a c t o r analyses revealed c u l t u r a l variat i o n s i n p a t t e r n s o f self-report s y m p t o m s . F a c t o r analyses o f results yielded t h r e e d i f f e r e n t f a c t o r profiles. It is p e r h a p s n o t surprising to find d i f f e r e n t f a c t o r p a t t e r n s b e t w e e n t h e Chinese s u b j e c t s a n d t h e A m e r i c a n s u b j e c t s ; it is surprising to f i n d d i f f e r e n t f a c t o r p a t t e r n s b e t w e e n t h e A m e r i c a n groups. T h e d a t a obt a i n e d f r o m t h e Black s a m p l e c o r r e s p o n d s w i t h a n earlier s t u d y b y S i m o n et al. ( 1 9 7 3 ) in t h a t q u a l i t a t i v e d i f f e r e n c e s i n s y m p t o m o l o g y were f o u n d b e t w e e n

A CROSS-CULTURAL STUDY OF DEPRESSIVE SYMPTOMOLOGY

309

TABLE VII The first three prominent factors in the white data Rank order of factor loading on SDS - The white group Factor I, Eigenvalue 4.829, % of total variance 17.9% Rank order of item loading 1. 2. 3. 4. 5. 6. 7. 8.

I feel that I am useful and needed. I find it easy to make decisions. I have crying spells or feel like it. My life is pretty full. I feel that others would be better off if I were dead. I get tired for no reason. I feel down hearted and blue. I still enjoy the things I used to do.

0.820 0.801 0.774 0.722 0.657 0.435 0.423 0.325

Factor II, Eigenvalue 2.4489, % of total variance 14.8% Rank order of item loading 1, 2, 3, 4, 5. 6. 7. 8.

I am more irritable than usual. I feel hopeful about the future. I still enjoy the things I used to do. I feel down hearted and blue. I still enjoy sex. I notice that I am loosing weight. My life is pretty full. Morning is when I feel the best.

0.833 0.716 0.695 0.589 0.415 -0.406 0.396 0.336

Factor III, Eigenvalue 2,2543, % of total variance 10.6% Rank order of item loading 1. 2. 3. 4.

I I I I

have trouble sleeping at night. am restless and can't keep still. still enjoy sex. feel hopeful about the future.

0.858 0.776 0.476 0.407

There were seven factors. Because of low eigenvalue only three of the factors are presented here. Black a n d W h i t e subjects. In a n a t i o n a l survey c o n d u c t e d b y Levitt a n d L u b i n ( 1 9 7 5 ) using t h e Depressive A d j e c t i v e C h e c k List ( D A C L ) , it was f o u n d t h a t Blacks in t h a t sample s c o r e d significantly h i g h e r t h a n t h e Whites o n t h e D A C L w h i c h c o n s i s t s o f a series o f affective descriptive t e r m s (i.e., sad, h a p p y , b l u e , etc.). T h e first f a c t o r o b t a i n e d f r o m t h e Black s a m p l e in t h e p r e s e n t s t u d y s h o w e d m o r e o f t h e p r i m a r y affective s y m p t o m s d e s c r i b e d in DSM-III. In o t h e r words, the symptom

c o n f i g u r a t i o n o b t a i n e d f r o m t h e Black s u b j e c t s s h o w e d

m o r e r e s e m b l a n c e t o a " c l a s s i c a l " s y m p t o m o l o g y o f d e p r e s s i o n t h a n t h a t obt a i n e d f r o m t h e W h i t e or t h e Overseas Chinese samples. Because t h e s u b j e c t s were all college s t u d e n t s , t h e r e is r o o m to argue t h a t t h e

WEINING C. CHANG

310

TABLE VIII The first three prominent factor in the Chinese data Rank order of factor loading on SDS - The overseas Chinese group Factor I Eigenvalue 4.3172, % of total variance 13.5% Rank order of item loading 1. 2. 3. 4. 5.

I t'md it easy to do the things I used to. I have trouble sleeping at night. I eat as much as I used to. I get tired for no reason. My heart beats faster than usual.

0.824 0.820 0.653 0.58 0.48

Factor II Eigenvalue 2.490, % of total variance 12.8% Rank order of item loading 1. 2. 3. 4. 5. 6.

I feel that I am useful and needed. I am restless and can't keep still. I find it easy to make decisions. I get tired for no reason. I still enjoy the things I used to. I feel downhearted and blue.

0.826 -0.814 0.63 0.45 0.36 0.31

Factor III Eigenvalue 2.3259, % of variance 11.1% Rank order of item loading 1. 2. 3. 4. 5. 6.

Morning is when I feel the best. My life is pretty full. I feel downhearted and blue. I feel hopeful about the future. I still enjoy the things I used to. My heart beats faster than usual.

0.83 0.77 0.51 0.43 -0.319 -0.315

There were seven factors. Because of low eigenvalues, only three of the factors are presented here. Black/White differences observed in this study reflects m o r e o f a Black/White college student difference than a Black/White difference in the p o p u l a t i o n at large. Since a large n u m b e r o f the students at Texas S o u t h e r n University are on financial aid and m a n y o f the students are f r o m working class backgrounds, it is unclear w h e t h e r the Black/White difference observed here reflects a class difference or an ethnic difference. F o r this reason, the present study is n o t i m m u n e f r o m the p r o b l e m that plagues m a n y o f the o t h e r studies in Black/ White ethnic differences in the U n i t e d States, that is, ethnic differences are o f t e n masked or c o n f o u n d e d b y significant class differences caused b y the large disparity in e c o n o m i c conditions b e t w e e n Black and White Americans. Studies b y Handerson (1973) comparing language differences b e t w e e n working class mother-child diads and middle class mother-child diads in England n o t e d that

A C R O S S - C U L T U R A L STUDY OF D E P R E S S I V E S Y M P T O M O L O G Y

311

TABLE IX Results of rotating factor matrices Item cosines and mean item cosines of factor matrices after rotated against comparison factor matrices

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

I feel down hearted and blue. Morning is when I feel the best. I have crying spells or feel like it. I have trouble sleeping at night. I eat as much as I used to. I stillenjoy sex. I notice that I am losing wight. I have trouble with constipation. My heart beats faster than usual. I got tired for no reason. My mind is as clear as it used to be. I find it easy to do the things I used to. I am restless and can't keep still. I feel hopeful about the future. I am more irritable than usual. I find it easy to make decisions. I feel that I am useful and needed. My life is pretty full. I feel that others would be better off if I were dead. I still enjoy the things I used to.

White/Black Mean = 0.6489

White/Chinese Mean = 0.6070

Black/Chinese Mean = 0.5921

0.6645 0.6664 0.9014 0.6549 0.5259 0.4805 0.6655 0.4448 0.0465 0.4925 0.8003

0.6068 0.4354 0.7392 0.8173 0.6394 0.8263 0.5813 0.3127 0.7518 0.5594 0.8677

0.3347 0.7455 0.9585 0.3913 0.7097 0.6532 0.5063 0.5063 0.7020 0.4062 0.2617

0.6419 0.7766 0.5832 0.5877 0.4858 0.8953 0.9044

0.4912 0.3248 0.7439 0.4596 0.8575 0.9602 0.6213

0.7138 0.8640 0.3273 0.6517 0.7923 0.6931 0.7153

0.9040 0.8565

0.4018 0.1431

0.3281 0.5810

the w o r k i n g class m o t h e r s used m a n y affective terms while the middle class m o t h e r s used m o r e cognitive terms. This i n f o r m a t i o n reinforces the possibility that the current Black/White differences in depressive s y m p t o m o l o g y is perhaps a class difference in perceiving and interpreting depressive s y m p t o m s . In light o f the fact that the Black s y m p t o m o l o g y resembles m o r e o f a "classical" synd r o m e o f depression, it is logical to assume t h a t the s y m p t o m o l o g y o f the Black college students is m o r e like depression in the general p o p u l a t i o n and it is the White depressive s y m p t o m o l o g y t h a t reflects a " s u b c u l t u r e " o f middle class intellectuals. The inter-item correlation m a t r i x o b t a i n e d f r o m the Chinese sample indicated t h a t the somatic complaints o n l y have low correlations w i t h existential concerns and the affective s y m p t o m s . F a c t o r analysis o f the Chinese data also showed that somatic c o m p l a i n t s c o n s t i t u t e a relatively o r t h o g o n a l dimension. The same d i m e n s i o n was n o t observed in the Black or the White sample. It is interesting to consider this finding w i t h long standing observations that for the Chinese psychiatric patients,

somatic complaints are the chief presenting s y m p t o m s

312

WEINING C. CHANG

(Cheung 1982; Kleinman 1977, 1982a, 1982b; Tseng and Hsu 1969). Results in the present study did not indicate that the Chinese had quantitatively less affective complaints, only that the affective complaints were not "grouped" with the somatic complaints. The dimension of somatic complaints contributed to the largest proportion of variance indicating that the somatic complaints are more "indicative" of depression for the Chinese. Finally a convergence is reached, that is both psychiatric reports and psychometric studies (Marsella et al. 1973) indicate a phenomenon of "somatization" by the Chinese (Kleinman 1977, 1982b). Anthropological studies of the belief systems in Asian Cultures have shown that many Asian cultures believe in a close interaction between the mind and the body, and see the mind and the body as an integral whole. Thus, the same problem, be it physical or psychological in origin, will find its expression in both the physical and the psychological domains of a person's life (Kleinman and Lin 1981 ; Sue and Sue 1974; Sue et al. 1976, and Tseng 1975). It should be emphasized that "somatization" in symptom presentation does not mean that the Chinese language does not have terms or concepts that make fine distinctions between different kinds of affective feelings or that the affective symptoms are suppressed or even repressed by the Chinese. The affective symptoms of depression or any other kind of emotion, for that matter, are experienced and communicated differently by the Chinese. A full investigation of the nature of the epistemological framework concerning emotions in the Chinese culture is beyond the scope of the present paper. However, even a cursory reading into Chinese literature would reveal a wealth of terms which describe a large variety of different human emotions. There is certainly no shortage of terms that convey sadness and despair in Chinese language. To fully test the conceptual equivalency of the term depression cross-culturally, a nomological net (Cronbach and Meehl 1955) has to be established for the term. At the present time, such a nomological net has not yet been established. A search into the Chinese language for terms of depression has yielded a term which seems to reflect the affective aspect of depression; YOU-YU (melancholia)(Zhihai 1957, pp. 1171). This term is basically descriptive of mood, and has a connotation of subjective feelings of a prevailing mood of sadness and despair and listlessness combined with a tendency toward crying. This description fits the description of the affective item is SDS: "I feel downhearted and blue." It is therefore argued that the affective aspect of depression does have its counterpart in the Chinese culture. Only this affective aspect of depression is treated and reported differently by the Chinese. For future studies on depression in Chinese, semantic differential techniques (Osgood 1964) shall be used to map out the domain of meaning of the term YOU-YU to test the concept equivalency between YOU-YU and "depression".

A CROSS-CULTURAL STUDY OF DEPRESSIVE SYMPTOMOLOGY 313 Wu (1982) argued that there are different display rules for emotion in Chinese culture and that the difference in display rules is responsible for the absence of affective complaints by the Chinese. The present author would like to propose that more fundamental to the display rules are a set of symbols and gestures which constitute the "language of emotion" for the Chinese. Chinese frequently use metaphor in communication. Somatic concerns are often used by the Chinese to convey affective meanings. Among the Chinese, giving and withdrawal of affection are customarily carried out via giving and withdrawal of goods and services intended for physical comfort. Between parents and children, husbands and wives, material goods and services are exchanged for each other's physical well-being while no words of affection have been uttered. It is understood by the provider and the receiver that the exchange means affection. Thus, a language of emotion is spoken eloquently between the Chinese without having to invoke emotional words or terms. Those terms are usually reserved for literature but not for everyday interaction. Similarly, individual happiness and unhappiness are also expressed in a set of somatic terms. Heartache means sadness; fatigue, tiredness means hurt and despair. The speaker uses this set of somatic metaphors to convey his (her) emotional conditions and the listener understands that these are metaphors which actually convey meanings of emotion. What is needed is longitudinal systematic studies in interpersonal communications between the Chinese to observe the nature and the development of this language of emotion, and the situations or social context in which the language is used. Situational variables involved in psychological research have been systematically studied in a series of studies. Orne (1962) used the term "demand characteristics" to describe the configuration of stimuli present in a psychological study that involves human subjects. The demand characteristics oftentimes confound the experimental results. In a broader sense this concept of demand characteristics can be applied to psychological testing and psychiatric interviewing where human performance is required. Research in cross-cultural studies have identified situation variables which radically change the performances of subjects (Labov 1970; LeVine 1970). Furthermore, Labov (1970) and Cole et al. (1971) suggested that people of different cultures are likely to respond differently to any given situation. The study conducted by Cole et al. (1971) in KpeU farmers illustrated the point clearly. Each culture has its own conception as to the right time and the right place to do the right behavior. Under the broad epistemological framework to which an individual subscribes in orde? to interpret social events, situational variables involved in a testing situation are likely to be perceived differently. The demand characteristics would thus differ for people of different cultures even with standard testing procedures (Cole and Bruner 1971). It is noted that evidence of "somatization" has been mostly obtained in medical settings (Cheung 1982; Kleinman 1977, 1982a, 1982b) where the demand

314

WEINING C. CHANG

characteristics were such that it was more conducive to voice medical (somatic) complaints. The present study was conducted in psychology classes, a relatively formal and impersonal setting. The SDS was given without a title. Answers to the question added to the end of the SDS: "What do you think this questionnaire measures?" indicated that a majority of the Chinese students thought it was a measure of "general health conditions o f the subject". None of the subjects thought it was a measure of depression. If such answers can be used to infer the perceived demand characteristics by the Chinese, it can then be deduced that the Chinese subjects were more oriented to answer the somatic items of the scale. The study was conducted at the wake of the "human potential movement" where the zeitgeist among the college students in the United States was characterized by the "search for the self" or the "search for the meaning o f life" (Lasch 1978). Could it be that the White samples in the present study were using an epistemological framework and a set of languages that are based on existentialist ideas embedded in the culture of the 1960's and 1970's in the United States, much in the same way as the Chinese students used a somatopsychic cognitive system to perceive and to convey emotional conditions? Generalization of conclusions drawn from the results are limited because (1) the subjects were college students attending American universities and (2) the sample sizes were small for multivariate analyses. Given such limitations, the results are encouraging in that they provide information complementary to data obtained in ethnoscience. The factor profile obtained from each ethnic group can provide additional information to help validate the construct validity of existing standard measuring instruments of depression and to help construct new measurements of depression for subjects o f different cultures. The different configurations of symptomology can also be used as a reference for diagnosing depression for subjects of different cultures.

Department of Psychology Texas Southern University Houston, TX 77004, U.S.A.

WEINING C. CHANG

REFERENCES Akiskal, H. S. et al. 1979 Differentiation of Primary Affective Illness from Situational Symptomatic and Secondary Depression. Archives of General Psychiatry 36: 635-643. Al-Issa, I. 1970 Culture and Symptoms. In C. Costello (ed.), Symptoms of Psychopathology: A Handbook. New York: Wiley. American Psychiatric Association 1980 Diagnostic and Statistical Manual, Third Edition. Washington, D.C.: American Psychiatric Association.

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