Examining Cross Cultural Representation in the DSM-V

Emma Earles

Department of Psychology, Loras College

PSY 490: Senior Seminar & Portfolio

Dr. Grinde

October 5, 2021
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Examining Cross Cultural Representation in the DSM-V

Diversity and cultural representation have been major topics of debate in society, largely

due to recent events such as Black Lives Matter protests, the passing of a bill which restricts

diversity, equity, and inclusion training in schools, and hate crimes against Asian Americans

following the COVID-19 pandemic. In many ways, now more than ever, culture is at the

forefront of society. However, one area which should receive an abundance of cultural

consideration is seriously lacking: the clinical mental health field. In clinical psychology, the

Diagnostic and Statistical Manuel of Mental Disorders, Fifth Edition (DSM-V) is regarded as the

epitome of diagnostic assessment of mental illnesses. However, cultural representation in the

DSM is not as highly developed, and there are significant limitations in the DSM-V’s ability to

sufficiently represent and cater to all cultures. There has been a push for representation of

diverse populations in academia, politics, and the media, however, diverse cultural

representation in the mental health field is not as prevalent. The persisting lack of cultural

representation in the DSM-V is extremely problematic as it fails to adequately serve a

variety of cultures and populations, and results in misdiagnoses. This paper examines

cultural representation in the DSM-V, including the evolution of the portrayal of culture

from previous editions of the DSM to the DSM-V, the ethnocentric nature of the DSM-V,

the role of collectivistic and individualistic cultures on experiences of mental illnesses, and

the risk of misdiagnoses and invalidity of diagnostic criteria across cultures.

Improvements of the DSM-V and Development of the CFI

When analyzing the cultural efficacy of the DSM-V, it is important to begin by reviewing

the evolution from previous editions of the DSM. The DSM-V task force undertook the goal of

improving cultural representation from the previous editions of the DSM by working alongside
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international health organizations, utilizing a cross-cultural study group, and employing cultural

and international experts (Aggarwal et al., 2013). Although all of these efforts contributed to

gaining a variety of cultural perspectives and considerations, the development of the Cultural

Formulation Interview (CFI) was one of the biggest and most concrete changes in implementing

a better assessment of culture in the DSM. In the DSM-IV there was an Outline for Cultural

Formulation (OCF) which was a broad blueprint of cultural topics or concepts related to mental

health and how mental illness may be experienced. The DSM-V cultural subgroup wrote

literature reviews on the OCF to find limitations, facilitated regular conference calls, and

conducted an international field trial to observe the CFI’s feasibility, acceptability, and clinical

utility (Aggarwal et al., 2013). In this way, the development of the CFI was largely based on the

OCF. While the OCF was a broad schema of cultural concepts, the implementation of the CFI

provided a structural format for cultural assessment in the DSM-V, including specific questions

for clinicians to use. The semi-structured interview design in the CFI allows for a more

operational and clinical usage in comparison to the previous OCF (Lewis-Fernández et al.,

2014). This is a crucial improvement from the DSM-IV. The OCF was beneficial as an

informative guide regarding culture, however, the CFI provides clinical utility in understanding

and assessing culture. In order to accurately understand and treat mental illnesses across cultures

it is essential to have a resource that is functional and operational, not simply informative.

Additionally, there is evidence from two separate studies which indicates that the CFI is a

beneficial tool in forming client-patient relationships as well as identifying various cultural

influences that may have impacted the individual’s experience of mental illness. For example, in

the Wallin et al. (2020) article, the CFI was found to be a meaningful tool in Mexican culture by

increasing trust among the patient and clinician, while Jarvis et al. (2020) noted the CFI was
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shown to develop improved clinical communication and client-patient relationships (Jarvis et al.,

2020; Wallin et al., 2020). These findings indicate that, in addition to being a cultural assessment

tool, the CFI also serves as a means to connect clinicians with patients from different cultures,

making them feel comfortable, heard, and validated. This is a substantial improvement in the

DSM-V, as clinician-patient relationships are essential for providing accurate and quality mental

health treatment.

Beyond the benefits of the CFI in forming relationships between patients and clinicians,

Wallin et al. (2020) also noted that the CFI provides contextual data for the clinician such as

previously utilized coping methods, the influence of family members, and the impact of the

presence or absence of resources on overall treatment (Wallin et al., 2020). Obtaining this

information from the CFI is invaluable, as it allows the clinician to have a more comprehensive

understanding of the patient’s clinical and cultural background, experiences, and values in the

assessment process. The emphasis on creating an exhaustive understanding of culture in the

context of mental health is visible through the DSM-V’s separation between “cultural

syndromes” and “cultural idioms of distress.” While “cultural syndromes” refers to specific

symptoms of a culture or group, “cultural idioms of distress” are associated with collective

experiences and concerns of various cultures (Bredström, 2019). This distinction in the DSM-V

shifted the focus from symptomology to experience. Providing the concept of “cultural idioms of

distress” allows for a more holistic understanding of the role culture plays in the experiences of

mental illness. This terminology moves away from a diagnostic checklist, and allows for

dialogue regarding cultural influences and experiences in relation to mental health.

The feasibility, acceptability, and clinical utility of the CFI was measured in a field trial

including six different countries with 318 patients and 75 clinicians. The results from a mixed
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method analysis concluded the patients and clinicians in the study believe the CFI was feasible,

acceptable, and clinically useful. However, patients responded more positively to the CFI in

comparison to clinicians, and clinicians were most concerned about feasibility (Lewis-Fernández

et al., 2017). In this way, although the CFI proved to be sufficient in clinical utility, acceptability,

and feasibility in this field trial, it also highlighted potential limitations and concerns regarding

the feasibility of the CFI. Clinician concerns about the CFI are not limited to this field trial,

clinicians have also reported concerns regarding the applicability and repetitiveness of the CFI

(Jarvis et al, 2020). It is important to note that although the CFI has provided significant

improvements in the DSM-V in terms of culture, it is not an all-encompassing solution to

cultural representation in the DSM. Gopalkrishnan (2018) highlights the magnitude of continual

changes needed in order to achieve comprehensive cultural understanding and representation in

the DSM, suggesting systemic changes such as the unification of treatment of mental and

physical health, as well as changes in clinical practice (Gopalkrishnan, 2018). There has also

been concern that the latest edition of the DSM has moved even further away from cultural

awareness as medical interventions increase (Ecks, 2016) and that there is a lack of consistency

when contextualizing diagnoses in cultures (Langa & Gone, 2020). Another major limitation of

the CFI that has been noted across studies is its lack of validity and clinical utility among

patients presenting with psychosis (Aggarwal et al., 2013; Jarvis et al., 2020; Lewis-Fernández et

al., 2020). Clinicians feel psychotic patients may not have the ability to produce the coherent

narrative necessary for the CFI due to paranoia and digressive thinking (Aggarwal et al., 2013).

There has also been concern about utilizing the CFI with individuals who are suicidal,

aggressive, or have a cognitive impairment (Jarvis et al., 2020). This creates a serious

shortcoming in the CFI. If the CFI cannot be utilized among a large demographic of patients
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presenting with psychosis or cognitive impairments, or individuals experiencing specific

symptoms, such as aggression or suicidal ideation, then another measure needs to be developed

to account for that population, or the CFI needs to be altered to better assess these specific

diagnoses and symptomologies. While there are both strengths and limitations of the CFI in the

DSM-V, it is only one clinical resource, and cannot account for cultural representation

throughout the DSM-V. This is especially true as the DSM has historically been rooted in

ethnocentrism, and continues to be ethnocentric in nature. This provides a major limitation when

assessing and diagnosing individuals from different cultures.

DSM-V Ethnocentrism and Western Understanding of Mental Health Pathology

Ethnocentric thinking is harmful in any context; however, it can be detrimental in relation

to mental health. The disproportionate influences of the western culture in mental health has

resulted in the DSM being written through an ethnocentric lens, not accounting for other cultural

influences. Although there have been efforts to eradicate the lack of cultural representation in the

DSM-V, the diagnoses, symptoms, and contexts in the DSM-V are in accordance with a western

understanding of mental health pathology. Gopalkrishnan (2018) explained that the majority of

both the theory and practice of mental health is based on western experiences and perception of

mental illness (Gopalkrishnan, 2018). This disparity is further emphasized by the language used

in the DSM-V. The use of terminology such as “cultural considerations” and “culture-bound

syndromes” imply these symptoms and experiences are “exotic” and that they are outside of the

norm. It also perpetuates the notion that cultures outside of the western world are “other”

cultures (Ogundare, 2020). This language draws a clear line between a cultural “us” and “them,”

further contributing to the ethnocentric design of the DSM.

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Beyond the language of the DSM, there is also a clear imbalance of cultural

representation in the qualifications of diagnostic criteria. For example, shortness of breath

qualifies as one of the four symptoms necessary for a PTSD diagnosis, signifying shortness of

breath is a universal, accepted symptom of PTSD. However, uncontrollable crying is listed as an

additional, culturally specific symptom (Bredström, 2019). Uncontrollable crying being listed as

a “culturally-specific” symptom of PTSD maintains the idea that there is one main culture, and

then there are other cultural specifications. This is evident as shortness of breath is listed as a

core symptom of PTSD, while uncontrollable crying does not carry the same weight, simply

because it is a symptom more commonly experienced outside of the western world. Moreover,

while the DSM-V recognizes Anorexia Nervosa is a culture-bound syndrome specific to western

cultures, Anorexia Nervosa is not listed in the appendix with the rest of the culture-bound

syndromes (Ogundare, 2020). Acknowledging that Anorexia Nervosa is a culturally specific

disorder in western cultures, but not including it among the other culture-bound syndromes

creates an inconsistency in the DSM, and promotes the idea that western cultures reflect the

standard, while other cultures are the “exception to the rule.”

In addition to the westernization of diagnoses, there is also a lack of sociocultural

considerations among diagnoses, which is evident in the removal of the bereavement exclusion.

The removal of the bereavement exclusion, which prevented individuals from being diagnosed

with major depressive disorder after the recent death of a loved one, has been largely debated in

the context of culture. Eradicating the bereavement exclusion from the DSM-V communicates

the message that the sociocultural context is not valued, and discounts the different ways in

which grief is experienced among various cultures (Bredström, 2019; Langa & Gone, 2020). The

bereavement exclusion allowed space for various cultures to experience grief in different ways,
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over different periods of time; therefore, the removal of the bereavement exclusion disregards

cultural traditions and processes of grieving, further contributing to the DSM-V’s ethnocentrism

by aligning with the western understanding and practices of mourning.

Shehab and Al-Hroub (2019) highlight the negative effects of the DSM-V’s western

ideation in their study of the clinical utility of the DSM-V criteria for ADHD in Lebanon. The

study reported that the DSM-V is constructed to fit western symptomology and experience of

mental illness, not accounting for different cultures. The researchers emphasized the lack of

cultural transferability of DSM-V criteria by stating, “…it is unfair to diagnose a student with

ADHD when almost all people raised in Lebanon could be diagnosed with the condition

according to these criteria” (Shehab & Al-Hroub, 2019). This statement, and the entirety of the

study, emphasizes the vast difference in what is defined as normal versus abnormal based on

cultural differences. This study also calls attention to a significant issue in clinical psychology,

which is, although the DSM-V may not be a culturally relevant diagnostic tool in non-western

cultures, there is no alternative manual which represents cultural expressions of symptoms and

disorders, therefore many cultures will continue to use the DSM-V despite its limitations

(Shehab & Al-Hroub, 2019). There is a serious lack of diagnostic resources available for non-

western cultures. This lack of culture specific diagnostic resources makes the DSM-V the best

option for a diagnostic reference, however, it is not adequately equipped to accurately assess and

diagnose all other cultures. This is a major limitation of the DSM-V, which can result in

misdiagnoses. The insufficient representation of cultures in the DSM, as well its lack of cross-

cultural utility, once again reinforces the ethnocentric conceptualization of the DSM. Cultural

context must be considered across diagnoses and cultures, starting at the macro level, with
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understanding the differences between collectivistic and individualistic cultures in how their

experiences, understanding, and attitudes of mental illnesses vary.

The Role of Collectivistic vs. Individualistic Cultures in Mental Health

Societies provide cultural context for individuals by shaping their beliefs, norms, and

attitudes from a young age. In this way, society is incredibly influential in shaping our

understanding of ourselves, as well as our worldview. Two major types of societies across

cultures are collectivistic and individualistic societies. These two forms of societies function

differently, as their priorities, values, and norms differ from one another. For example,

collectivistic societies value close ties with their families and communities, place an emphasis on

interdependence and a sense of responsibility to the society, and there is little distinction between

the individual self and the larger group. Individualistic culture, in contrast, is characterized by

independence, autonomy, less community reliance, and the individuals are regarded separately

from the community (Tse & Ng, 2014). In this way, collectivistic and individualistic cultures

vary greatly from one another, which can have an impact on how mental illnesses are perceived,

experienced, and treated. In fact, Tse and Ng (2014) note that the “individualistic-collectivistic

orientation” is one of the most critical elements to consider in cultural differences (Tse & Ng,

2014).

Additionally, studies have shown that collectivistic and individualistic cultures may

experience symptoms of the same disorder differently, and may cope or respond to the same

disorder differently. For example, depression is commonly presented through somatic symptoms

in cultures outside of the western world, which aligns with the socio-centric identity of

collectivistic cultures, while western, individualistic cultures typically experience depression

through psychological symptoms such as feelings of worthlessness, which is associated with the
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more individual and isolated society (Ogundare, 2020). In this way, understanding whether the

individual’s culture is individualistic or collectivistic is crucial in the diagnostic process,

specifically in recognizing symptom expression. The same dichotomy can be seen in

collectivistic compared to individualistic cultures in the context of coping. African-American

individuals diagnosed with depression were found to have “higher levels of interpersonal

functioning” in comparison to white individuals who were diagnosed with depression, as a result

of the collectivistic nature of African-Americans culture and the individualistic culture of whites

(Ogundare, 2020). The difference in experiences of symptoms of mental illnesses as well as

ability to cope with mental illnesses is largely impacted by the collectivistic or individualistic

structure of the culture.

In addition to experiences of mental illness, attitudes towards mental health are largely

influenced by whether the society is collectivistic or individualistic, specifically when looking at

stigma. Individuals who belong to a collectivistic culture are more likely to be subject to public

stigmatization of mental illness in comparison to individualistic cultures (Papadopoulos et al.,

2013). Individuals belonging to collectivistic cultures may maintain stronger stigmatizing

attitudes regarding mental health due to the strong association between individuals and families,

as well as the larger community, which may lead to fear of bringing a negative reputation or

shame upon ones’ family or community. Stigmatizing attitudes can result in individuals not

seeking mental health care, or waiting to seek mental health care due to feelings of shame or to

avoid stigmatization (Gopalkrishnan, 2018). In this way, it is important to understand the role of

individualistic and collectivistic cultures in perpetuating stigmatizing attitudes, in order to

provide additional resources for individuals who may be more susceptible to fear of

stigmatization, such as in collectivistic cultures.

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The clear connection between mental illnesses and collectivistic and individualistic

cultures affirms the necessity of accounting for both individualistic and collectivistic cultures in

the DSM-V. However, because the DSM is centered in western culture, which is traditionally

individualistic, the diagnostic criteria is largely reflective of an individualistic culture rather than

a collectivistic culture, resulting in an incomplete understanding of patient experiences. If the

DSM included cultural context for individualistic compared to collectivistic cultures, this would

provide a framework for distinct diagnostic criteria to be contextualized in specific cultures.

Misdiagnoses and Lack of Diagnostic Validity Across Cultures

Perhaps the most significant negative implication of a lack of cultural representation in

the DSM-V is the misdiagnosis of individuals because there are not proper assessment tools

available to clinicians which consider culture’s impact on mental illness experiences. This can

result in the overdiagnosis of certain populations. For example, African Americans have

historically been disproportionately diagnosed with schizophrenia, resulting from misdiagnoses

rooted in stereotypes and misinterpretations during assessment (Gopalkrishnan, 2018; Ogundare,

2020). The overdiagnosis of African Americans has resulted in serious consequences for this

demographic, including more frequent hospitalizations, increased dosages of antipsychotic drugs,

regular usage of restraints, and being regarded as more dangerous and mentally ill in comparison

with white individuals (Ogundare, 2020). These repercussions perpetuate existing stereotypes

and prejudice against an already minoritized group. Misdiagnoses also occur due to the variance

in how individuals from different cultures present symptoms of the same disorder. For example,

in the western world, schizophrenic delusions are often focused on themes relating to technology

such as microchips, paranoia about the government watching or listening to them, etc. However,

in the non-western world, schizophrenic delusions are frequently influenced by religious themes,
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demons, and witchcraft (Ogundare, 2020). Additionally, research has shown that in India,

individuals are much more likely to present with somatic symptoms of disorders than individuals

from the western world, who are more likely to present with cognitive symptoms

(Gopalkrishnan, 2018; Watson, 2017). Individuals from different cultures experience symptoms

of the same disorder in very different ways, which means culture needs to be taken into

consideration when assessing the expression of symptoms in order to avoid misdiagnoses.

The prevalence of certain diagnoses also varies across cultures, signifying what is

regarded as normal and abnormal in different cultures is subjective. For example, rates of

diagnosis of ADHD differ greatly from country to country and are largely based on cultural

understandings of the diagnosis and what behaviors are or are not accepted among children in

each country (Ogundare, 2020). The variance of which behaviors constitute as normal or

abnormal in the context of ADHD in different cultures is exemplified in Shehab and Al-Hroub’s

study. The focus of the study was to determine whether or not the DSM-V was an adequate

diagnostic tool for ADHD in Lebanese schools. The study included 20 counselors which were

given the DSM-V diagnostic criteria for ADHD, and were asked to add, delete, or annotate any

of the criteria to align with the culture in Lebanon. Ten of the counselors in the study added,

deleted, or annotated one or more of the criteria, meaning half of the counselors believed there

was diagnostic criterion which was not applicable in the Lebanese culture. While impulsivity,

hyperactivity, and inattention are DSM-V criteria for ADHD, these domains are not reflective of

the culture in Lebanon. For example, Lebanese schools are known to have a lot of stimuli, which

can easily result in inattention. “Talks excessively,” which is listed under hyperactivity, is not a

relevant criterion, as excessive talking is a part of Lebanese culture. Finally, impulsivity was

regarded as overly general, as Lebanon was characterized as a chaotic culture which does not
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value rules in the same way much of the western world does (Shehab & Al-Hroub, 2019). This

study exemplified how easy it is to misdiagnose individuals from different cultures, as the DSM-

V diagnostic criteria for ADHD does not provide cultural considerations, and what may be

considered abnormal in one culture, is encouraged in another culture.

Conclusion

The DSM-V is the most recent, universally utilized, and widely accepted diagnostic tool

in the mental health field. Given the reliance on the DSM-V in clinical psychology, it is essential

that it accurately and adequately serves all populations of people, regardless of demographics,

backgrounds, or cultures. However, after reviewing literature from a variety of studies, it is

apparent that the DSM-V has considerable limitations in cultural representation. Although there

have been efforts to advance cultural representation in the DSM-V, such as the implementation

of the CFI, it remains underqualified in providing the same level of detailed, accurate, and

consistent diagnostic criteria that is available for western cultures, cross-culturally. This is

particularly concerning, as out of the 195 countries, less than half are considered to be a part of

the western world, yet the DSM-V aligns with a western understanding of mental health

pathology. The implications of the lack of cultural representation in the DSM are detrimental.

There are no additional diagnostic tools which are culturally-specific that other countries can rely

on, meaning the DSM-V is their best option, however, cultures should not have to depend on a

diagnostic tool which is the “best” option out of equally culturally inadequate alternatives. This

lack of culturally representative diagnostic resources in turn leads to misdiagnoses. Misdiagnoses

of individuals from non-western cultures are disproportionately exacerbated, and result in

overdiagnosis, ineffective treatment, confusion, and distress. If the DSM diagnostic criteria for

mental illnesses is not amended to address cross-cultural societies, there will continue to be a
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huge population of individuals from various cultures who are receiving substandard mental

health care, and who are considerably susceptible to misdiagnoses which will not only be

ineffective in providing them with the treatment they require, it may also lead to further distress

and dysfunction. Considering how much cultural representation has evolved in other disciplines,

a comprehensive understanding of culture in the context of clinical psychology, specifically the

DSM, is long overdue.

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References

Aggarwal, N. K., Nicasio, A. V., DeSilva, R., Boiler, M., & Lewis-Fernández, R. (2013).

Barriers to implementing the DSM-5 cultural formulation interview: a qualitative

study. Culture, Medicine, and Psychiatry, 37(3), 505-533.

Bredström, A. (2019). Culture and context in mental health diagnosing: Scrutinizing the DSM-5

revision. Journal of Medical Humanities, 40(3), 347-363.

Ecks, S. (2016). The strange absence of things in the “culture” of the DSM-V. CMAJ, 188(2),

142-143.

Gopalkrishnan, N. (2018). Cultural diversity and mental health: Considerations for policy and

practice. Frontiers in public health, 6, 179.

Jarvis, G. E., Kirmayer, L. J., Gómez-Carrillo, A., Aggarwal, N. K., & Lewis-Fernández, R.

(2020). Update on the Cultural Formulation Interview. Focus, 18(1), 40-46.

Langa, M. E., & Gone, J. P. (2020). Cultural context in DSM diagnosis: An American Indian

case illustration of contradictory trends. Transcultural psychiatry, 57(4), 567-580.

Lewis-Fernández, R., Aggarwal, N. K., Bäärnhielm, S., Rohlof, H., Kirmayer, L. J., Weiss, M.

G., ... & Lu, F. (2014). Culture and psychiatric evaluation: operationalizing cultural

formulation for DSM-5. Psychiatry: Interpersonal and biological processes, 77(2), 130-

154.

Lewis-Fernández, R., Aggarwal, N. K., & Kirmayer, L. J. (2020). The Cultural Formulation

Interview: Progress to date and future directions.

 16
CROSS CULTURAL REPRESENTATION IN THE DSM-V

Lewis-Fernández, R., Aggarwal, N. K., Lam, P. C., Galfalvy, H., Weiss, M. G., Kirmayer, L.

J., ... & Vega-Dienstmaier, J. M. (2017). Feasibility, acceptability and clinical utility of

the Cultural Formulation Interview: mixed-methods results from the DSM-5 international

field trial. The British Journal of Psychiatry, 210(4), 290-297.

Ogundare, T. (2020). Culture and mental health: Towards cultural competence in mental health

delivery. Journal of Health and Social Sciences, 5(1), 023-034.

Papadopoulos, C., Foster, J., & Caldwell, K. (2013). ‘Individualism-collectivism’as an

explanatory device for mental illness stigma. Community mental health journal, 49(3),

270-280.

Shehab, N., & Al-Hroub, A. (2019). Is the DSM-5 a Culturally Appropriate Assessment Tool for

Identifying Learners with ADHD in Lebanese Schools?. International Journal of Special

Education, 34(1), 166-181.

Tse, S., & Ng, R. M. (2014). Applying a mental health recovery approach for people from

diverse backgrounds: the case of collectivism and individualism paradigms. Journal of

Psychosocial Rehabilitation and Mental Health, 1(1), 7-13.

Wallin, M. I., Dahlin, M., Nevonen, L., & Bäärnhielm, S. (2020). Patients’ and clinicians’

experiences of the DSM-5 Cultural Formulation Interview: A mixed method study in a

Swedish outpatient setting. Transcultural psychiatry, 57(4), 542-555.

Watson, E. L. (2017). A critical examination of the DSM as a multicultural diagnostic tool for

depression among Asian Americans and Asian Indians. Journal of Applied Psychology

and Social Science, 3(1), 19-32.