IIJISIP

SELF-ATTENTION AS A MEDIATOR OF CULTURAL INFLUENCES

ON DEPRESSION

HONGTU CHEN, PETER J. GUARNACCIA & HENRY CHUNG

ABSTRACT
recognition of cultural differences in
widespread
the
Background: Despite
depressive symptoms, it is unclear through what processes culture affects
depressive symptoms.
Aim: This research aims at examining whether self-attention mediates the influence of acculturation on changes in depressive symptoms in an immigrant group.
Method: Adults of Asian cultural backgrounds were surveyed. Depressive symptoms were assessed and divided into three categories: affective, somatic and
interpersonal items of depression. Acculturation experiences were measured.
Self-attention to three aspects (i.e. affective, somatic and interpersonal) of the
self was also assessed.
Results: As acculturation proceeds, Asian immigrants tend to pay increasingly
more attention to the affective aspect of the self and less to the somatic aspect
of the self. The changes in the focus of self-attention seem to explain the changes
in the experience of depression that include more affective and less somatic
symptoms of depression as the degree of acculturation increases.
Conclusion: Self-attention to certain aspects of the self seems to play an important role mediating the influence of acculturation on changes in subcategories of
depressive symptoms.
Key words: acculturation, depressive symptom, self-attention
INTRODUCTION
How to explain the cultural variation in depressive symptoms has been a persistently puzzling
issue 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-western
cultural backgrounds tend to report more somatic symptoms and less affective symptoms
than 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 the
issue of cultural differences in depressive symptomatology has become increasingly salient,
particularly since mental health clinicians wish to obtain more accurate diagnoses for
depression 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 and
New Delhi) www.sagepublications.com Vol 49(3): 192-203. 10020-7640 (200309)49:3:192-203;035295]

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non-neurogenic somatic symptoms associated with depression in primary care patients

(Kellner, 1991; Kirmayer & Robbins, 1991; Smith, 1994; Barsky & Borus, 1996). This study
attempts to investigate the processes through which the cultural influences may affect the
manifestation of depressive symptomatology.
Over the past century, there have been two general theoretical approaches to the problem
of cultural differences in depression: the sociological approach that primarily focuses on influences of a large-scale social context vs. the psychological approach focusing on an individual's psychological processes. For instance, a historical and sociological perspective holds
that people from non-western cultures show less depressed affects, possibly due to the
nature of a less stressful lifestyle in pre-industrialized societies where traditional family structure, religious beliefs and cultural norms can successfully guide the individual and buffer
depressed moods (Weber, 1978; Kleinman & Kleinman, 1985). Although this view may
account for the fact of less manifestation of depressed moods in non-westerners, it cannot
fully explain the prevalent somatic depressive symptoms in these people. Another view focusing on the influence of the generic linguistic context postulates that languages used by people
from non-western cultures are limited in vocabulary and semantic differentiation with regard
to affects or feelings, thus reporting depressed moods becomes more difficult in cross-cultural
studies (Orley, 1970; Leff, 1977). Similarly, this view does not explain non-westerners' prevalent somatic depressive symptoms either.
If the above sociological and linguistic approaches are inclined to address the root of the
problem, psychological approaches put more emphasis on how individual's experience plays
a 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 individual's conscious mind may repress an affect (e.g. a depressive affect) if it contradicts to
external cultural values or social cohesion, thus generating somatic symptoms as an alternative expression of the repressed affect (Freud, 1915/1957; Nemiah, 1982). The repression viewv
offers a rather satisfactory account for the findings of less depressive affect and more somatic
symptoms in the depressed non-westerners. However, this view fails to explain the widespread variation in somatic symptoms of depression across non-western cultures. For
instance, a depressed Vietnamese tends to report more gastrointestinal complaints (Shweder,
1985), the Chinese report more fatigue and insomnia (Kleinman, 1982; Ots, 1990) and an
Indian reports more back and limb pains (Al-Issa, 1995). The cross-cultural variation in
somatic depressive symptoms cannot be explained simply by the concept of conscious or
cultural repression. Even if we assume that there might be variation in the ways repression
occurs in different cultures, the theoretical gap between differential repression and variation
in somatic complaints remains to be a challenge.
Another psychological view, which seems to have potential to explain the cross-cultural
variation of depressive symptoms, is the suggestion perspective. The origin of this view can
be 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 or
meaningful, and the conscious mind would selectively enhance those affective and somatic
symptoms that are in congruence with the external, culturally fashioned suggestion or expectation. However, it is still unclear that through what specific processes a culturally legitimate
or meaningful form can be transferred into an individual. The present study attempts to substantiate 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 the
presentation of depressive symptoms via self-attention, and such a process can occur in
two steps. First, self-attention can regulate somatic and affective processes. For instance,
studies on biofeedback demonstrated that consciousness, which is often indexed by selfattention 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 attend
to and amplify certain somatic sensation and turn it into a pathological disease (Barsky,
1992). In studies of cognitive processes of psychopathology, heightened self-attention has
been found to enhance or amplify the depressed mood (Carve & Scheier, 1981). Self-attention
also has been considered a major contributor to panic disorder (Arnal & Arbona, 1993) and
other psychological disorders (Ingram, 1990). Second, the conscious mind of an individual
in 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 the
significant aspect of an individual's self. People of the western cultural background pay
more attention to the ego and emotional aspects of the self, whereas people from non-western
cultures 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 depressive
symptoms through an individual's self-attention: that is an individual can be sensitized to
certain aspects of the self that are valued, or considered legitimate, by the surrounding
culture, and the enhanced self-attention to these aspects of the self- such as somatic, affective
or interpersonal aspects - will affect the expression of corresponding subgroup of depressive
symptoms. If cultural experience is measured as the degree of acculturation in an ethnically
homogeneous immigrant group, we can hypothesize that the more acculturated an immigrant
is, the more likely he or she will pay attention to the aspects of the self that correspond to the
admitting culture, and the level of the attention to these aspects of the self will be linked to the
level of depressive symptoms in the same aspects.
The main goal of the present study is to examine the role of self-attention as a mediating
process of cultural influences on individuals' presentation of depressive symptoms. Asian
immigrant groups, composed of Chinese- and Japanese-Americans, are selected, since they
reportedly 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 acculturation into the western culture increases, these immigrants would pay more attention to
the affective aspects of the self, thus leading to more affective and less somatic depressive
symptoms.
METHOD
Sample
An Asian-American sample consisting of both Chinese and Japanese first-generation immigrants was surveyed. The participants of the Chinese background were recruited through
a local church in New Jersey. The Japanese participants were recruited through a local
American-Japanese club in New York City. Both groups were adults, ranging from 33 to
88 years of age. Of them, 28% had high-school education, 44% had college degrees and

CHEN ET AL.: SELF-ATrENTION AND DEPRESSION

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

Measures
Acculturation was assessed by a five-item questionnaire adapted from the Suinn-Lew Asian
Self-Identity Acculturation Scale (Suinn et al., 1992). The scale measures culturally relevant
activities such as language usage at home, music listened to, types of foods prepared, with
an assumption that the activities of original cultural relevance will decrease as acculturation
proceeds. 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 was
0.84. Each item was rated on a scale of I to 5 (1: Asian only; 2: Asian mostly; 3: Equally
Asian/English; 4: English mostly; 5: English only). The acculturation score for each individual was the average of the scores across these five items.
Three aspects of self-attention (i.e. affective, somatic and interpersonal) were measured by
a modified version of the Introspectiveness Scale (Hansell & Mechanic, 1985). Attention to
affective 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. Attention
to interpersonal aspects focuses on the individual in relation to others. Based on the factor
analysis, a 10-item scale was used to measure the affective aspect of self-attention, a nineitem scale was used for the social self-attention measure and a nine-item scale for the somatic
self-attention. Factor loadings for all these items ranged from 0.45 to 0.82, and the alpha
values for these three self-attention scales were 0.90, 0.83 and 0.91, respectively. Each item
was rated on a five-point Likert scale ('very little', 'a little', 'some', 'much' and 'very
much'). Each aspect of the self-attention was calculated with the sum of the scores for
items included in the subcategory of self-attention.
The depressive symptoms were measured by items selected from the Center for Epidemiological Study Depression (CES-D) scale. The scale has been widely applied in the health
research field, since it was originally developed with satisfactory psychometric properties
(Radloff, 1977). These items were divided into three subcategories: 1) the affective items
were assessed by a six-item scale, with alpha = 0.86, and factor loadings ranging from 0.54
to 0.83; 2) two somatic items (i.e. fatigue, no interest in sex) were added to the somatic
items in the CES-D, forming a five-item scale to measure the somatic symptoms of depression, with alpha = 0.81, and factor loadings from 0.43 to 0.91; 3) the interpersonal items
were assessed by a four-item scale, with alpha = 0.83 and factor loadings from 0.59 to
0.88. 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 all
of the time'. The measure of each subcategory was calculated with the sum of the symptoms scores divided by the total number of items included in the subcategory of depressive
symptoms.

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All questionnaires were translated into both Chinese and Japanese by professional translators at the Eastern Language Department at the Rutgers University. Back translation was
performed independently by two different bilingual translators. When the original English
version and the second English version from the back-translation were compared with
each other, the discrepancies were resolved through group discussions to ensure linguistic
accuracy 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 the
depressive symptoms in this group of subjects. Based on the means and standard deviations
of the responses to each acculturation item (Table 1), it seemed that the preferences for
movies and music were among the first to be acculturated, the use of language changed relatively slower and establishment of social network with people from different origins was the
slowest. Overall, the averaged acculturation scores ranged from 1.45 to 2.53, suggesting that
these subjects, being first-generation immigrants, have been moderately acculturated into the
American 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, the
means and deviations of scores for each item of the depressive symptoms are summarized in
Table 2. Overall, the affective symptoms of depression were moderately, but not significantly,
higher than other two subcategories of the depressive symptoms. There were no significant differences between somatic symptoms and interpersonal symptoms of depression. To
examine the effect of ethnicity on types of depressive symptoms, an analysis of variance
was performed and revealed no significant differences between Chinese and Japanese
Americans in the levels of all three subcategories of depressive symptoms. Due to the similar
patterns of behavior between the two ethnic groups, the data were pooled together in the
following analyses.
To examine the mediating role of self-attention in the influence of acculturation on changes
of depressive symptoms, logistic regression models were employed. As shown in Table 3, in
Table 1
Means and standard deviations of acculturation items

Acculturation items'
Speak English
Prefer American music
Prefer English movie
Associate with non-Chinese
Read in English

SD

1.75
1.93
2.53
1.45
1.76

1.20
1.06
1.38
0.96
1.09

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

4: English mostly; 5: English only

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197

Table 2
Means and standard deviations of three subcategories of
depressive symptoms items
M

SD

Affective itemsa
Felt sad
Was depressed
Trouble concentrating
Everything was an effort
Could not get going
Life had been a failure

1.02
0.96
1.15
1.11
0.74
0.52

1.03
1.14
1.02
1.35
1.09
1.12

Somatic itemsa
Not feel like eating
Restless sleep
Had crying spells
Felt tired
No interest in sex

0.78
1.15
0.37
1.28
0.58

0.86
1.03
1.51
1.05
0.78

Interpersonal itemsa
Talked less than usual
Felt lonely
Couldn't shake off blues
Felt people dislike me

0.57
0.92
0.54
0.42

0.97
0.86
1.02
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 and
acculturation) were included. Self-attention was added into the second step of regression
analysis (Model II) to predict the variance of depressive symptoms. To test the hypothesis
that attention to a particular aspect of the self may intensify that particular aspect of the
depressive symptoms, regression analyses were performed for each of the three subcategories
of depressive symptoms respectively. According to the regression analysis on affective symptoms, acculturation was first found to be significantly associated with the total sum of the
scores for affective items. The results suggest that the more acculturated into the western
culture, the more likely that the Asian immigrant would report affective symptoms of depression. As self-attention was entered into the regression model, self-attention replacing the
acculturation factor became the only significant predictor of affective symptoms, suggesting
that paying attention to the affective aspect of the self may mediate the influence of acculturation on these Asian immigrants who become increasingly likely to experience affective symptoms of depression.
The regression analyses on somatic symptoms generated slightly different results. Both age
and acculturation were significant predictors accounting for the variance in the somatic
depressive symptoms. Particularly, the older the subject, the more somatic symptoms were
present. But as the person became more acculturated into the American society, the less
somatic symptoms they would report. When adding self-attention (to the somatic aspect of
the self) into the regression model, self-attention becomes the only significant predictor of

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

Model I
Gender
Age
Ethnicity
Acculturation

0.08
0.08
0.17
0.24*

0.16

Interpersonal symptoms

Model II

Model I

Model II

Model I

Model 11

0.06
0.01
0.14
0.05

0.01
0.21*
-0.10
-0.22*

0.03
0.11
-0.07
-0.06

0.17
0.04
0.16
0.15

0.01
0.03
0.15
0.11

0.43

0.24*

-0.48***

0.45**

Self-attention
R2

Somatic symptoms

Affective symptoms

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 AsianAmerican adults tend to pay increasingly less attention to the somatic aspects of the self and
also report less somatic depressive symptoms.
Based on the regression analysis on the interpersonal depressive symptom, the effect of
acculturation was not found for this set of depressive symptoms, but self-attention was
still a significant predictor of the corresponding depressive symptoms. There was no significant correlation between acculturation and self-attention to the interpersonal aspects of the
self.
DISCUSSION
The main findings of the present study suggest two general messages: 1) as Asian adult immigrants become acculturated into the western society, they tend to increasingly report more
affective and less somatic depressive symptoms; 2) self-attention or an individual's sensitivity
to certain aspects of the self seems to play an important role mediating the influence of acculturation on changes in subcategories of depressive symptoms.
A number of relevant issues should be discussed in conjunction with these findings. First of
all, the study used community samples with a limited sample size. Therefore, caution needs to
be taken in not generalizing these findings to other populations. Although there is a common
assumption that psychiatric symptoms in a non-clinical population are on a continuum with
those in a clinical sample, it is possible to find differences particularly in somatic expression
of depressive experiences (e.g. Zheng et al., 1986). For the future research, a longitudinal
observation of the impact of acculturation will be methodologically more robust than a
cross-sectional analysis as done in this study. Since only one direction of acculturation was
examined, a similar study on the reverse direction of acculturation using the western immigrants becoming acculturated into an Asian society will be an interesting way to confirm
the finding from this study.
The findings that affective symptoms were moderately higher than the somatic symptoms
were 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 already
more acculturated than the Asians in their native countries, and the symptomatology had
changed toward a lower level of somatic symptoms as compared with native Asians. It is
also likely that the somatic symptoms were relatively underestimated in this study as compared with a normal clinical assessment in a primary care setting or in a typical transcultural
study of somatization, which usually would include other somatic complaints such as headache, dizziness, neck pain, sinking feeling in the chest and abdominal distress that are
typically observed among Japanese and Chinese (Kleinman & Kleinman, 1985; Waza et al.,
1999).
Conceptually, this study explores a cognitive mechanism through which cultural influences
are manifest in an individual. As cognitive scientists have recently become increasingly interested in culture, using cognitive processes as an explanatory framework for understanding
cultural influences on individuals has provided a new methodological and conceptual direction for research. Culture can be considered as a 'salience-enhancing' process, which 'renders
certain kinds of experience perceptually significant and readily communicable within a community' (Shore, 1996, p. 315). Particularly, 'suggestion' as a cultural model is consistent with
a cognitive sciences approach that allows a rather flexible reorganization of the individual
experience under the influence of a cultural environment.
Even if we accept that acculturation to the western society makes an Asian person less
likely to pay attention to the somatic aspect of the self, the mechanism that links such culturally related attention to the presentation of depressive affect is still unclear. According to the
suggestion theory, both paying attention to the affective self and experiencing depressive
affect are a result of an acquired behavioral and psychological norm about what is legitimate
and meaningful in a given culture. The association between attention and depressive symptoms does not necessarily indicate a causal relationship. In other words, culture could
affect an individual's symptom presentation by regulating both attention and symptom
reporting; it is also possible that culture affects focus of attention, which further on influences
symptom formation. Research on psychosomatics tackled the possibility of attention being a
contributor of only the somatic symptom formation (e.g. Barsky, 1992). The suggestion
model, in contrast, provides a rather generic perspective that attention paid to affective
aspects of the self may also enhance the formation of affective pathological symptoms.
Nevertheless, we should also mention an alternative interpretation based on a traditional
stress theory. According to this view, as acculturation proceeds, immigrants may experience
less stress, and therefore the decrease in somatic symptoms only indicates a generic reduction
in severity of emotional distress. If severity of distress is defined as the total number of symptoms, a post-hoc test did not find correlation between acculturation and the total sum of score
of all depressive items in this study. However, if we use somatic symptoms alone to define
severity of distress, as done in the classic theory of Hans Selye's General Adaptation
Syndrome (Selye, 1956), we will have to rely on further research, such as the aforementioned
reverse design (i.e. observing westerners acculturated into an Asian society), to test such a
hypothesis. In general, what a cognitive model can potentially offer, while a traditional
stress theory lacks, is the linkage between specificity of symptom presentation and the meaning of a particular culture to an adapting individual.
Another relevant issue, which has been constantly challenged by cross-cultural evidence of
varying 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 invariant
basis beneath all kinds of depressive presentations, whereas cultures will somehow guide individuals toward different ways of experiencing this core biological reality named depression
(Fabrega, 1975). The present study certainly cannot repudiate this grand assumption of
the existence of a biological common ground. The cross-cultural clinical trial research testing
the effects of antidepressants on patients with different clusters of depressive symptoms could
be a productive way to ultimately disentangle the contribution of culture from the possible
biological influences to the formation of depression.

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

APPENDIX
Itemiis of Depressive Symnptomiis Scale
A. Affective depressive symptoms:
a. I felt sad
b. I was depressed
c. I had trouble keeping my mind on what I was doing
d. I felt that everything I did was an effort
e. 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 poor
b. My sleep was restless
c. I had crying spells
d. I felt tired
e. I had no interest in sex
C. Interpersonal depressive symptoms:
a. I talked less than usual
b. I felt lonely
c. I felt that I could not shake off the blues even with help of my family or friend
d. I felt that people disliked me
Items of Acculturationi Scale
a. What language do you usually speak?
b. What kind of music do you prefer to listen to?

CHEN ET AL.: SELF-ATTENTION AND DEPRESSION

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 Scale
1. 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 self
How 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 interpersonalaspects of the self
How 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 of
New 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