Depression is a highly prevalent and disabling mental health condition . Latest estimates from the World Health Organization place depression as the world’s leading cause of disability . Fortunately, there are many efficacious treatments for depression , including cognitive-behavioral therapy [4, 5]. The theoretical underpinnings of treatments such as CBT have seldom been examined among people living in non-Western nations, or among people of non-European decent [6, 7]. Accordingly, the present study examined the validity of central hypotheses related to the cognitive model of depression  among people living on four continents: Asia, Europe, North America, and South America. In the following, we (a) briefly review the literature on the cognitive model of depression, the centrality of cognitions to cognitive therapy for the disorder, and on emotion regulation strategies and their use and consequences across cultures, and (b) present an empirical study examining whether predictions of the cognitive model hold cross-continentally.
Depression is a multifaceted condition, typified by behavioral, affective, cognitive, and somatic symptoms. According to the fifth edition of the Diagnostic and Statistical Manual (DSM-5, ), major depression is a condition wherein symptoms – low-mood, lack of pleasure in otherwise enjoyable activities, disruptions in sleep and appetite, low energy, poor concentration, suicidal thoughts, and feelings of worthlessness and guilt, etc. – have persisted for two or more weeks and have caused significant distress or impairment. Depression is a heterogenous disorder, and several combinations of these symptoms could be placed under the same diagnostic umbrella of depression.
Negative self-referent cognitions have long been theorized to be central to the experience of depression . Beck’s seminal cognitive theory was first to formalize hypotheses regarding the role of cognitions in depression. Beck posited that there are several cognitive layers implicated in the onset and maintenance of depression [4, 10, 11]. Importantly, Beck hypothesized that, at the most accessible or proximate level of the information processing system, negative automatic thoughts about self (“e.g., “I am no good”; “I am unlovable”) are predominant in depression and are central to the experience of the condition . This hypothesis is also known as cognitive triad hypothesis. Strong empirical evidence supports this claim among Western participants: negative self-referent thoughts have been identified as a consistent and defining feature of the disorder [12,13,14].
Many early studies conducted in the West with depressed or dysphoric (i.e., people showing elevated symptoms of depression) participants confirm the validity of the cognitive triad hypothesis during bouts of depression (reviewed in Clark & Beck ). However, there have been surprisingly few examinations of the cognitive triad hypothesis outside of Western regions, although preliminary evidence collected among single non-Western cultures is suggestive (reviewed in Beshai et al. 2012 ). Sami and El-Gawad  found that depressed Arab participants experienced relatively little guilt or self-deprecating cognitions. Similarly,  found that Pakistanis were less likely to present with guilt as a feature of their depression compared with their Austrian counters. In fact, Stompe et al.  specifically suggested that depressive self-reproach and negativity may only be a defining feature of depression among Judeo-Christian sufferers. Despite these inconsistent findings across cultures, negative automatic thoughts have been found to associate with depression symptoms among Chinese [17, 18] Egyptian [6, 7], Turkish , and Japanese  participants. However, none of these studies specifically compared and contrasted cognitive inputs into depression across multiple regions.
Beck’s model also posited more remote cognitive layers that are believed to be implicated in the maintenance of depression. For example, Beck and others hypothesized that people suffering from depression would hold dysfunctional attitudes, or “rules for living”, that are often rigid and negatively skewed (e.g., “If I don’t do everything perfectly, it means I am no good at all”). According to Beck’s cognitive model, people who are vulnerable to depression detect violation of these rules or attitudes (e.g., detect criticism from others), which results in activation of more proximate negative automatic thoughts, finally resulting in an amplified depressive experience. Weissman and Beck  created the Dysfunctional Attitude Scale (DAS) to assess dysfunctional attitudes characteristic of depressive thinking, and in turn, measure the level of activation and access to negative cognitive structures.
Substantial evidence suggests that dysfunctional attitudes lead to depressive symptoms among Western populations of European descent, as well as in non-Western populations. For example, Beshai et al. [7, 22] found that European-Canadian people with elevated depression symptoms reported higher dysfunctional attitudes than those with minimal symptoms. Other researchers have reported similar findings [23, 24]. The association of dysfunctional attitudes with depression symptoms has also been demonstrated across several countries around the world, such as Egypt , Malaysia , Romania , Spain , Iran , and United Arab Emirates . Although these results are suggestive of a generalizable association between dysfunction attitudes and depressive symptoms, many of these studies have employed small, relatively underpowered samples, or were not comparative in their approach (i.e., no control).
Another foundational hypothesis of cognitive models of depression is that desired emotional and behavioral changes result from cognitive modification . Accordingly, the skill of cognitive reappraisal – the reinterpretation of emotionally eliciting materials or events in a way that alters the emotional response  – is considered to be an adaptive and effective strategy to manage negative emotions. For example, in using reappraisal to regulate sadness in response to losing one’s job, someone might start to reinterpret the event of losing their employment as an opportunity to travel. By contrast, the regulation strategy of emotional suppression – defined as a person’s attempt to decrease emotional expression of a certain emotion and/or their attempt to decrease or eliminate thoughts or outward expression of this said emotion  – is considered to be maladaptive and ineffective in regulating negative emotions. For example, an individual who experiences sadness in reaction to losing their job might suppress this sadness by attempting to hide any discernible signs (i.e., facial expressions) of their sadness to their family and friends, or by externally expressing an opposite emotional reaction (e.g., “putting on a smile”).
Recent research among participants of European descent shows that cognitive reappraisal and emotional suppression have dramatically divergent affective, social, and cognitive consequences . Suppression does not effectively lead to reduced negative affect, but paradoxically may increase sympathetic nervous system response. Cognitive reappraisal, by contrast, has the opposite effect in that it leads to decreases in negative emotions and decreased systemic activity . Further, it appears that cognitive reappraisal is associated with decreased anxiety and depression symptoms, while suppression is associated with increases in symptoms of depression and anxiety [35,36,37]. However, the divergent effects of suppression versus cognitive appraisal have not been extensively investigated in diverse regional contexts.
Several studies suggest that culture moderates the emotional outcomes of emotion regulation. Soto, Perez, Kim, Lee and Minnick  found that adverse effects of suppression of emotion were observed among European students but not Asian students, suggesting that the maladaptiveness of this approach is culture specific. Similarly, Butler, Lee and Gross  found that, for participants with Western values (e.g., independence of self and individualism), suppression was associated with increase in negative emotion. However, this adverse emotional effect of suppression was not found for participants holding Asian values (e.g., interdependence of self and collective values). These findings were replicated by Kwon, Yoon, Joormann, and Kwon  among a sample of Korean participants. Taken together, the evidence suggests that identification of cultural heritage and level of assimilation into mainstream culture (and disengagement from one’s heritage culture) both moderate the adaptiveness different emotion regulation strategies.
The evidence reviewed above suggests that (a) there are core cognitive processes that are central to depressive symptoms (i.e., negative self-referent thoughts; dysfunctional attitudes); (b) cognitive modification leads to amelioration of depressive symptoms; and (c) different cognitive modification strategies have divergent effects across cultures. In the present study, we examined the relationships of depression symptoms, negative automatic thoughts, dysfunctional attitudes, and emotional suppression and cognitive reappraisal in a large cross-continental sample of participants living on four continents and in several countries (Table 1). We used a state-of-the-art analysis to minimize measurement bias in examining such relationships. Specifically, we used the alignment method  to reduce invariance of the measures used across the four continents. This research replicates and extends extant literature in several important ways. First, this study is the first large scale cross-continental examination of central hypotheses of the cognitive model of depression. The cognitive model is the foundation upon which CBT and other cognitive therapeutic approaches rest, and previous cross-national investigations have examined either single populations (e.g., ) or pairs of populations (e.g., ). Unfortunately, the majority of depression interventions and their theoretical foundations have almost exclusively been developed by or with individuals of the majority culture (White; middle class; Judeo-Christian). Second, this is the first study to employ the alignment method for optimal scale performance across several continents. Potential measurement bias is an inherent problem in any study, but is particularly salient in cross-national investigations given diversity in interpretation of scale items. Finally, our sample size was large, and therefore, sufficiently statistically powered to test even small effects.
In accordance with the cognitive model of depression, we predicted that depression symptoms would be significantly and positively correlated with negative automatic thoughts and dysfunctional attitudes among people across cultures and continents. Further, we predicted that, among people living in North America and Europe, use of cognitive reappraisal strategies would be significantly and negatively associated with depression symptoms, and use of suppression as a strategy for emotion regulation would be positively associated with depression symptoms. This is a first step to understand the assumptions underlying CBT and its cross-continental adaptation.