IIJISIPSELF-ATTENTION AS A MEDIATOR OF CULTURAL INFLUENCES

ON DEPRESSION

HONGTU CHEN, PETER J. GUARNACCIA & HENRY CHUNG

ABSTRACTBackground: Despite the widespread recognition of cultural differences indepressive symptoms, it is unclear through what processes culture affectsdepressive symptoms.Aim: This research aims at examining whether self-attention mediates the influ-ence of acculturation on changes in depressive symptoms in an immigrant group.Method: Adults of Asian cultural backgrounds were surveyed. Depressive symp-toms were assessed and divided into three categories: affective, somatic andinterpersonal items of depression. Acculturation experiences were measured.Self-attention to three aspects (i.e. affective, somatic and interpersonal) of theself was also assessed.Results: As acculturation proceeds, Asian immigrants tend to pay increasinglymore attention to the affective aspect of the self and less to the somatic aspectof the self. The changes in the focus of self-attention seem to explain the changesin the experience of depression that include more affective and less somaticsymptoms of depression as the degree of acculturation increases.Conclusion: Self-attention to certain aspects of the self seems to play an impor-tant role mediating the influence of acculturation on changes in subcategories ofdepressive symptoms.

Key words: acculturation, depressive symptom, self-attention

INTRODUCTION

How to explain the cultural variation in depressive symptoms has been a persistently puzzlingissue for both researchers and clinicians who deal with patients with depressive disorders.Research over the last four decades has consistently documented that people of non-westerncultural backgrounds tend to report more somatic symptoms and less affective symptomsthan people in western countries (Singer, 1975; Marsella, 1980; Mezzich & Raab, 1980;Murphy, 1982; Kirmayer, 1984; Kleinman & Good, 1985; Angel & Guarnaccia, 1989;Bhatt el al., 1989; Ebert & Martus, 1994; Al-Issa, 1995; Simon et al., 1999). Recently theissue of cultural differences in depressive symptomatology has become increasingly salient,particularly since mental health clinicians wish to obtain more accurate diagnoses fordepression in ethnic minority patients, and general medicine physicians also wish to identify

International Journal of Social Psychiatry. Copyright C) 2003 Sage Publications (London, Thousand Oaks andNew Delhi) www.sagepublications.com Vol 49(3): 192-203. 10020-7640 (200309)49:3:192-203;035295]

CHEN ET AL.: SELF-ATTENTION AND DEPRESSION

non-neurogenic somatic symptoms associated with depression in primary care patients(Kellner, 1991; Kirmayer & Robbins, 1991; Smith, 1994; Barsky & Borus, 1996). This studyattempts to investigate the processes through which the cultural influences may affect themanifestation of depressive symptomatology.

Over the past century, there have been two general theoretical approaches to the problemof cultural differences in depression: the sociological approach that primarily focuses on influ-ences of a large-scale social context vs. the psychological approach focusing on an indivi-dual's psychological processes. For instance, a historical and sociological perspective holdsthat people from non-western cultures show less depressed affects, possibly due to thenature of a less stressful lifestyle in pre-industrialized societies where traditional family struc-ture, religious beliefs and cultural norms can successfully guide the individual and bufferdepressed moods (Weber, 1978; Kleinman & Kleinman, 1985). Although this view mayaccount for the fact of less manifestation of depressed moods in non-westerners, it cannotfully explain the prevalent somatic depressive symptoms in these people. Another view focus-ing on the influence of the generic linguistic context postulates that languages used by peoplefrom non-western cultures are limited in vocabulary and semantic differentiation with regardto affects or feelings, thus reporting depressed moods becomes more difficult in cross-culturalstudies (Orley, 1970; Leff, 1977). Similarly, this view does not explain non-westerners' preva-lent somatic depressive symptoms either.

If the above sociological and linguistic approaches are inclined to address the root of theproblem, psychological approaches put more emphasis on how individual's experience playsa role in mediating the cultural and societal influences on depressive symptom manifestation.One typical example is Freud's original psychoanalytic theory. Based on this theory, an indi-vidual's conscious mind may repress an affect (e.g. a depressive affect) if it contradicts toexternal cultural values or social cohesion, thus generating somatic symptoms as an alterna-tive expression of the repressed affect (Freud, 1915/1957; Nemiah, 1982). The repression viewvoffers a rather satisfactory account for the findings of less depressive affect and more somaticsymptoms in the depressed non-westerners. However, this view fails to explain the wide-spread variation in somatic symptoms of depression across non-western cultures. Forinstance, a depressed Vietnamese tends to report more gastrointestinal complaints (Shweder,

1985), the Chinese report more fatigue and insomnia (Kleinman, 1982; Ots, 1990) and anIndian reports more back and limb pains (Al-Issa, 1995). The cross-cultural variation insomatic depressive symptoms cannot be explained simply by the concept of conscious orcultural repression. Even if we assume that there might be variation in the ways repressionoccurs in different cultures, the theoretical gap between differential repression and variationin somatic complaints remains to be a challenge.

Another psychological view, which seems to have potential to explain the cross-culturalvariation of depressive symptoms, is the suggestion perspective. The origin of this view canbe traced back to a century ago when it was first proposed by Berheim (see Shorter, 1994).According to this view, a culture defines certain behavior and experience as legitimate ormeaningful, and the conscious mind would selectively enhance those affective and somaticsymptoms that are in congruence with the external, culturally fashioned suggestion or expec-tation. However, it is still unclear that through what specific processes a culturally legitimateor meaningful form can be transferred into an individual. The present study attempts to sub-stantiate the suggestion view with a particular psychological process named self-attention.

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Research over the last four decades seems to support the idea that culture may affect thepresentation of depressive symptoms via self-attention, and such a process can occur intwo steps. First, self-attention can regulate somatic and affective processes. For instance,studies on biofeedback demonstrated that consciousness, which is often indexed by self-attention to one's own sensation, was able to alter the physiological processes (Yates, 1980).Research on psychosomatics also suggests that individuals have remarkable ability to attendto and amplify certain somatic sensation and turn it into a pathological disease (Barsky,1992). In studies of cognitive processes of psychopathology, heightened self-attention hasbeen found to enhance or amplify the depressed mood (Carve & Scheier, 1981). Self-attentionalso has been considered a major contributor to panic disorder (Arnal & Arbona, 1993) andother psychological disorders (Ingram, 1990). Second, the conscious mind of an individualin general, and self-attention and self-perception in particular, can be regulated by culture.Cultural psychologists have pointed out that cultural influences can clearly manifest in thesignificant aspect of an individual's self. People of the western cultural background paymore attention to the ego and emotional aspects of the self, whereas people from non-westerncultures tend to pay more attention to the interpersonal and somatic aspects of the self (Cole,1989; Shweder, 1991; Markus el al., 1996).

Taken together, these lines of research suggest that a culture may influence depressivesymptoms through an individual's self-attention: that is an individual can be sensitized tocertain aspects of the self that are valued, or considered legitimate, by the surroundingculture, and the enhanced self-attention to these aspects of the self- such as somatic, affectiveor interpersonal aspects - will affect the expression of corresponding subgroup of depressivesymptoms. If cultural experience is measured as the degree of acculturation in an ethnicallyhomogeneous immigrant group, we can hypothesize that the more acculturated an immigrantis, the more likely he or she will pay attention to the aspects of the self that correspond to theadmitting culture, and the level of the attention to these aspects of the self will be linked to thelevel of depressive symptoms in the same aspects.

The main goal of the present study is to examine the role of self-attention as a mediatingprocess of cultural influences on individuals' presentation of depressive symptoms. Asianimmigrant groups, composed of Chinese- and Japanese-Americans, are selected, since theyreportedly tend to have more somatic symptoms as compared with the westerners (Cheng,1989; Hsu & Folstein, 1997; Yen, 1998; Waza et al., 1999). We expect to see that as accul-turation into the western culture increases, these immigrants would pay more attention tothe affective aspects of the self, thus leading to more affective and less somatic depressivesymptoms.

METHOD

SampleAn Asian-American sample consisting of both Chinese and Japanese first-generation immi-grants was surveyed. The participants of the Chinese background were recruited througha local church in New Jersey. The Japanese participants were recruited through a localAmerican-Japanese club in New York City. Both groups were adults, ranging from 33 to88 years of age. Of them, 28% had high-school education, 44% had college degrees and

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28% had graduate or above levels of education. Surveys were hand delivered to the churchand the club organizers who distributed them during their regular gatherings. Fifty-seven per-cent of the distributed surveys were returned from the Chinese group, and 84% were returnedfrom the Japanese group. Among returned questionnaires, 91% were completed and attachedwith signed consent forms. The final sample consisted of 102 participants, with 55 ChineseAmericans and 65 Japanese Americans.

MeasuresAcculturation was assessed by a five-item questionnaire adapted from the Suinn-Lew AsianSelf-Identity Acculturation Scale (Suinn et al., 1992). The scale measures culturally relevantactivities such as language usage at home, music listened to, types of foods prepared, withan assumption that the activities of original cultural relevance will decrease as acculturationproceeds. Some items (e.g. 'types of foods eaten at home', 'values about marriage, family,education and career') were dropped from the original scale based on the factor analysis,and the Alpha value of the internal consistency for the five-item acculturation scale was0.84. Each item was rated on a scale of I to 5 (1: Asian only; 2: Asian mostly; 3: EquallyAsian/English; 4: English mostly; 5: English only). The acculturation score for each indivi-dual was the average of the scores across these five items.

Three aspects of self-attention (i.e. affective, somatic and interpersonal) were measured bya modified version of the Introspectiveness Scale (Hansell & Mechanic, 1985). Attention toaffective aspects of the self focuses on the emotional and global situation of the individual.Attention to somatic aspects focuses on specific bodily or physiological functions. Attentionto interpersonal aspects focuses on the individual in relation to others. Based on the factoranalysis, a 10-item scale was used to measure the affective aspect of self-attention, a nine-item scale was used for the social self-attention measure and a nine-item scale for the somaticself-attention. Factor loadings for all these items ranged from 0.45 to 0.82, and the alphavalues for these three self-attention scales were 0.90, 0.83 and 0.91, respectively. Each itemwas rated on a five-point Likert scale ('very little', 'a little', 'some', 'much' and 'verymuch'). Each aspect of the self-attention was calculated with the sum of the scores foritems included in the subcategory of self-attention.

The depressive symptoms were measured by items selected from the Center for Epidemio-logical Study Depression (CES-D) scale. The scale has been widely applied in the healthresearch field, since it was originally developed with satisfactory psychometric properties(Radloff, 1977). These items were divided into three subcategories: 1) the affective itemswere assessed by a six-item scale, with alpha = 0.86, and factor loadings ranging from 0.54to 0.83; 2) two somatic items (i.e. fatigue, no interest in sex) were added to the somaticitems in the CES-D, forming a five-item scale to measure the somatic symptoms of depres-sion, with alpha = 0.81, and factor loadings from 0.43 to 0.91; 3) the interpersonal itemswere assessed by a four-item scale, with alpha = 0.83 and factor loadings from 0.59 to0.88. Each item was rated on the scale of 0 to 3, with 0 being 'Rarely or none of the time',I being 'Some or a little', 2 being 'Occasionally or moderately' and 3 being 'Most or allof the time'. The measure of each subcategory was calculated with the sum of the symp-toms scores divided by the total number of items included in the subcategory of depressivesymptoms.

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All questionnaires were translated into both Chinese and Japanese by professional trans-lators at the Eastern Language Department at the Rutgers University. Back translation wasperformed independently by two different bilingual translators. When the original Englishversion and the second English version from the back-translation were compared witheach other, the discrepancies were resolved through group discussions to ensure linguisticaccuracy and cultural appropriateness (see Appendix for all items in English).

RESULTS

The data were first analyzed to examine the degree of acculturation and the distribution of thedepressive symptoms in this group of subjects. Based on the means and standard deviationsof the responses to each acculturation item (Table 1), it seemed that the preferences formovies and music were among the first to be acculturated, the use of language changed rela-tively slower and establishment of social network with people from different origins was theslowest. Overall, the averaged acculturation scores ranged from 1.45 to 2.53, suggesting thatthese subjects, being first-generation immigrants, have been moderately acculturated into theAmerican society. Those of Japanese cultural background were slightly, but not significantly,more acculturated than the Chinese immigrants.

To examine the general distribution of the responses to the depressive symptoms items, themeans and deviations of scores for each item of the depressive symptoms are summarized inTable 2. Overall, the affective symptoms of depression were moderately, but not significantly,higher than other two subcategories of the depressive symptoms. There were no signifi-cant differences between somatic symptoms and interpersonal symptoms of depression. Toexamine the effect of ethnicity on types of depressive symptoms, an analysis of variancewas performed and revealed no significant differences between Chinese and JapaneseAmericans in the levels of all three subcategories of depressive symptoms. Due to the similarpatterns of behavior between the two ethnic groups, the data were pooled together in thefollowing analyses.

To examine the mediating role of self-attention in the influence of acculturation on changesof depressive symptoms, logistic regression models were employed. As shown in Table 3, in

Table 1Means and standard deviations of acculturation items

M SD

Acculturation items'Speak English 1.75 1.20Prefer American music 1.93 1.06Prefer English movie 2.53 1.38Associate with non-Chinese 1.45 0.96Read in English 1.76 1.09

1: Asian only; 2: Asian mostly; 3: Equally Asian/English;4: English mostly; 5: English only

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Table 2Means and standard deviations of three subcategories of

depressive symptoms items

M SD

Affective itemsaFelt sad 1.02 1.03Was depressed 0.96 1.14Trouble concentrating 1.15 1.02Everything was an effort 1.11 1.35Could not get going 0.74 1.09Life had been a failure 0.52 1.12

Somatic itemsaNot feel like eating 0.78 0.86Restless sleep 1.15 1.03Had crying spells 0.37 1.51Felt tired 1.28 1.05No interest in sex 0.58 0.78

Interpersonal itemsaTalked less than usual 0.57 0.97Felt lonely 0.92 0.86Couldn't shake off blues 0.54 1.02Felt people dislike me 0.42 0.79

a 0: Rarely or none of the time; 1: Some or a little;2: Occasionally or moderately; 3: Most or all of the time

the first step of regression analysis (Model I), four predictors (i.e. gender, age, ethnicity andacculturation) were included. Self-attention was added into the second step of regressionanalysis (Model II) to predict the variance of depressive symptoms. To test the hypothesisthat attention to a particular aspect of the self may intensify that particular aspect of thedepressive symptoms, regression analyses were performed for each of the three subcategoriesof depressive symptoms respectively. According to the regression analysis on affective symp-toms, acculturation was first found to be significantly associated with the total sum of thescores for affective items. The results suggest that the more acculturated into the westernculture, the more likely that the Asian immigrant would report affective symptoms of depres-sion. As self-attention was entered into the regression model, self-attention replacing theacculturation factor became the only significant predictor of affective symptoms, suggestingthat paying attention to the affective aspect of the self may mediate the influence of accultura-tion on these Asian immigrants who become increasingly likely to experience affective symp-toms of depression.

The regression analyses on somatic symptoms generated slightly different results. Both ageand acculturation were significant predictors accounting for the variance in the somaticdepressive symptoms. Particularly, the older the subject, the more somatic symptoms werepresent. But as the person became more acculturated into the American society, the lesssomatic symptoms they would report. When adding self-attention (to the somatic aspect ofthe self) into the regression model, self-attention becomes the only significant predictor of

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Table 3Regression beta coefticients of gender, age, ethnicity, acculturation and self-attention as predicting threce

subcategories of depressive symptoms

Predictors Affective symptoms Somatic symptoms Interpersonal symptoms

Model I Model II Model I Model II Model I Model 11

Gender 0.08 0.06 0.01 0.03 0.17 0.01Age 0.08 0.01 0.21* 0.11 0.04 0.03Ethnicity 0.17 0.14 -0.10 -0.07 0.16 0.15Acculturation 0.24* 0.05 -0.22* -0.06 0.15 0.11

Self-attention 0.45** -0.48*** 0.24*

R2 0.16 0.43 0.23 0.59 0.12 0.39

*p < .05; **p < .01; ***p < .001

the somatic symptoms. These results suggest that during the acculturation process, the Asian-American adults tend to pay increasingly less attention to the somatic aspects of the self andalso report less somatic depressive symptoms.

Based on the regression analysis on the interpersonal depressive symptom, the effect ofacculturation was not found for this set of depressive symptoms, but self-attention wasstill a significant predictor of the corresponding depressive symptoms. There was no signifi-cant correlation between acculturation and self-attention to the interpersonal aspects of theself.

DISCUSSION

The main findings of the present study suggest two general messages: 1) as Asian adult immi-grants become acculturated into the western society, they tend to increasingly report moreaffective and less somatic depressive symptoms; 2) self-attention or an individual's sensitivityto certain aspects of the self seems to play an important role mediating the influence of accul-turation on changes in subcategories of depressive symptoms.

A number of relevant issues should be discussed in conjunction with these findings. First ofall, the study used community samples with a limited sample size. Therefore, caution needs tobe taken in not generalizing these findings to other populations. Although there is a commonassumption that psychiatric symptoms in a non-clinical population are on a continuum withthose in a clinical sample, it is possible to find differences particularly in somatic expressionof depressive experiences (e.g. Zheng et al., 1986). For the future research, a longitudinalobservation of the impact of acculturation will be methodologically more robust than across-sectional analysis as done in this study. Since only one direction of acculturation wasexamined, a similar study on the reverse direction of acculturation using the western immi-grants becoming acculturated into an Asian society will be an interesting way to confirmthe finding from this study.

The findings that affective symptoms were moderately higher than the somatic symptomswere different from the widely accepted observation that people of non-western cultural back-

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grounds tend to report more somatic symptoms. It is possible that these groups were alreadymore acculturated than the Asians in their native countries, and the symptomatology hadchanged toward a lower level of somatic symptoms as compared with native Asians. It isalso likely that the somatic symptoms were relatively underestimated in this study as com-pared with a normal clinical assessment in a primary care setting or in a typical transculturalstudy of somatization, which usually would include other somatic complaints such as head-ache, dizziness, neck pain, sinking feeling in the chest and abdominal distress that aretypically observed among Japanese and Chinese (Kleinman & Kleinman, 1985; Waza et al.,1999).

Conceptually, this study explores a cognitive mechanism through which cultural influencesare manifest in an individual. As cognitive scientists have recently become increasingly inter-ested in culture, using cognitive processes as an explanatory framework for understandingcultural influences on individuals has provided a new methodological and conceptual direc-tion for research. Culture can be considered as a 'salience-enhancing' process, which 'renderscertain kinds of experience perceptually significant and readily communicable within a com-munity' (Shore, 1996, p. 315). Particularly, 'suggestion' as a cultural model is consistent witha cognitive sciences approach that allows a rather flexible reorganization of the individualexperience under the influence of a cultural environment.

Even if we accept that acculturation to the western society makes an Asian person lesslikely to pay attention to the somatic aspect of the self, the mechanism that links such cultu-rally related attention to the presentation of depressive affect is still unclear. According to thesuggestion theory, both paying attention to the affective self and experiencing depressiveaffect are a result of an acquired behavioral and psychological norm about what is legitimateand meaningful in a given culture. The association between attention and depressive symp-toms does not necessarily indicate a causal relationship. In other words, culture couldaffect an individual's symptom presentation by regulating both attention and symptomreporting; it is also possible that culture affects focus of attention, which further on influencessymptom formation. Research on psychosomatics tackled the possibility of attention being acontributor of only the somatic symptom formation (e.g. Barsky, 1992). The suggestionmodel, in contrast, provides a rather generic perspective that attention paid to affectiveaspects of the self may also enhance the formation of affective pathological symptoms.

Nevertheless, we should also mention an alternative interpretation based on a traditionalstress theory. According to this view, as acculturation proceeds, immigrants may experienceless stress, and therefore the decrease in somatic symptoms only indicates a generic reductionin severity of emotional distress. If severity of distress is defined as the total number of symp-toms, a post-hoc test did not find correlation between acculturation and the total sum of scoreof all depressive items in this study. However, if we use somatic symptoms alone to defineseverity of distress, as done in the classic theory of Hans Selye's General AdaptationSyndrome (Selye, 1956), we will have to rely on further research, such as the aforementionedreverse design (i.e. observing westerners acculturated into an Asian society), to test such ahypothesis. In general, what a cognitive model can potentially offer, while a traditionalstress theory lacks, is the linkage between specificity of symptom presentation and the mean-ing of a particular culture to an adapting individual.

Another relevant issue, which has been constantly challenged by cross-cultural evidence ofvarying depressive symptoms, is whether it is appropriate to have a universal concept of

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depression. One conventional position often assumes that there is a neurobiological invariantbasis beneath all kinds of depressive presentations, whereas cultures will somehow guide indi-viduals toward different ways of experiencing this core biological reality named depression(Fabrega, 1975). The present study certainly cannot repudiate this grand assumption ofthe existence of a biological common ground. The cross-cultural clinical trial research testingthe effects of antidepressants on patients with different clusters of depressive symptoms couldbe a productive way to ultimately disentangle the contribution of culture from the possiblebiological influences to the formation of depression.

ACKNOWLEDGEMENTS

We are grateful to all people who participated in the study. We particularly wish to thankDr David Mechanic and Dr Alan Shwartz for their support for the project.

APPENDIX

Itemiis of Depressive Symnptomiis ScaleA. Affective depressive symptoms:

a. I felt sadb. I was depressedc. I had trouble keeping my mind on what I was doingd. I felt that everything I did was an efforte. I could not get "going"f. I thought my life had been a failure

B. Somatic depressive symptoms:a. I did not feel like eating my appetite was poorb. My sleep was restlessc. I had crying spellsd. I felt tirede. I had no interest in sex

C. Interpersonal depressive symptoms:a. I talked less than usualb. I felt lonelyc. I felt that I could not shake off the blues even with help of my family or friendd. I felt that people disliked me

Items of Acculturationi Scalea. What language do you usually speak?b. What kind of music do you prefer to listen to?

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c. What kind of movies do you usually see?d. Which groups of friends do you usually interact with?e. Types of language you usually read

Items of Self-Attention Scale1. Attention to the affective aspects of the self

How much do you ...a. think about yourself when you are alone?b. think about why your life is the way it is?c. pay attention to your own feeling?d. consider "making yourself happy" as an important thing in life?e. consider "your own opinion" as an important thing in life?f. concern about your competence?g. concern about your intelligence?h. concern about your memory?i. concern about your future?j. concern about your money?

2. Attention to the soniatic aspects of the selfHow much do you ...a. pay attention to your weight or height?b. think about the size of your body parts?c. think about your skin?d. concern about getting physically sick?e. concern about bodily pains?f. concern about your physical appearance?g. concern about insomnia?h. concern about eating unhealthy food?i. concern about your weight?

3. Attention to the interpersonal aspects of the selfHow much do you ...a. pay attention to what others think about you?b. notice that others think differently from you?c. consider "getting along with others" an important thing in life?d. consider "ability to cooperate with others" an important thing in life?e. concern about falling behind others?f. concern about being embarrassed in front of others?g. concern about being considered uncooperative?h. concern about being angry at another person?i. concern about being considered selfish?

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Hongtu Chen, PhD, Department of Psychiatry, Harvard Medical School, USA.Peter J. Guarnaccia, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers: State University ofNew Jersey, USA.Henry Chung, MD, Department of Psychiatry, New York University School of Medicine, USA.Correspondence to Hongtu Chen, PhD, Department of Psychiatry, 75 Francis Street, Boston, MA 02115, USA.Email: htchen@rics.bwh.harvard.edu

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