In March 2017, the World Health Organization issued what it called “a wake-up call” to mental health professionals across the globe. Depression, the WHO reported, is now the leading cause of disability worldwide and a major contributor to the overall global burden of disease.

Think about that for a moment. Depression — not heart disease, not cancer, not stroke — causes more disability than any other health condition on Earth. And it costs the global economy about $1 trillion — with a T — every year. WHO counts more than 322 million people around the world who suffer from depression, an increase of 18 percent between 2005 and 2015. About 800,000 people die by suicide every year, and suicide is the second leading cause of death in 15- to 29-year-olds.

[See: 9 Things to Do or Say When a Loved One Talks About Taking Their Life.]

“These new figures are a wake-up call for all countries to re-think their approaches to mental health and to treat it with the urgency that it deserves,” said WHO Director-General Dr. Margaret Chan in a recent news release. But depression and other mental illnesses are different from most physical afflictions in that, as with real estate, location plays an enormous role in how the disease is viewed and understood. As Michael D. Yapko, a clinical psychologist who has given workshops on depression in more than 30 countries on six continents, puts it: “The relationship between culture and psychology is a complex one. When I go to a place like China or Japan, it is quite different than when I am in North Carolina.”

Where ‘Depression’ Isn’t Even a Word

One thing most countries have in common is their lack of support for people with mental illness, WHO states. “Even in high-income countries, nearly 50 percent of people with depression do not get treatment. On average, just 3 percent of government health budgets is invested in mental health, varying from less than 1 percent in low-income countries to 5 percent in high-income countries,” the report claims.

But the differences among countries are more telling. One way to look at those is by seeing where depression occurs most frequently. According to a 2013 study in the journal PLOS Medicine, the most depressed country is Afghanistan, where more than 20 percent of the population has the disorder, followed by Honduras and the Palestinian territories as the three most-depressed areas. The Middle East and North Africa comprise the most depressed region, it says. The reasons for this aren’t hard to imagine: war, political conflict and other health epidemics such as HIV/AIDS and malaria, the researchers note.

The least depressed country, according to the report, is Japan, with a diagnosed rate of less than 2.5 percent. Yet, Japan has a seriously high rate of suicide. And that gets to the heart of the problem. Clearly, many more Japanese are depressed — or are what we think of as depressed — than are being counted as depressed. That’s because sociocultural norms are in many cases at least as important as, and often more than, science.

[See: Am I Just Sad — or Actually Depressed?]

There’s even a disconnect between the words used to describe the symptoms and the disease. “Many linguistic communities, for example, in India, Korea and Nigeria, do not even have a word for ‘depression’, and many people from traditional societies with what may be construed as depression instead present with physical complaints such as fatigue, headache, or chest pain,” writes Dr. Neel Burton, author of “Growing from Depression,” in an adaption from his book posted at PsychologyToday.com.

“Punjabi women who have recently immigrated to the UK and given birth find it baffling that a health visitor should pop round to check their mood: it had never crossed their minds that giving birth could be anything but a joyous event,” he writes. “Being much more exposed to the concept of depression, people in modern societies such as the UK and US are far more likely to interpret their distress in terms of depression and to seek out a diagnosis of the illness. At the same time, groups with vested interests actively promote the notion of saccharine happiness as a natural, default state, and of human distress as a mental disorder.”

Where ‘Primitive Treatments’ Can Be Effective

Yapko agrees. “There are cultures where depression is considered a minimal problem because they don’t think of these as mental disorders.” Physical symptoms, like fatigue or insomnia, are the most common reason people seek treatment, he says, and many cultures treat them as physical, not psychological, concerns. “In China, there is a very low likelihood someone will say, ‘I have depression.’ It is more likely they will say, ‘I have back pain’ or some other somatic complaint.”

Treatment is different as well, he says. In many countries, people go to a physician who gives them a physical treatment. Medication most likely is an anti-anxiety drug, not an antidepressant. “The National Health Service in England is doing a better job at treating depression, because they made a very interesting decision no longer to prescribe antidepressants at all, except in the most extreme cases, because they are not much more effective than placebo,” he says. “They decided they would rather get people exercising and learning the basics of cognitive therapy.”

[See: How to Find the Best Mental Health Professional for You.]

Other cultures treat depression with rituals that, “by our standards seem pretty primitive,” he says. In Botswana, for example, Yapko talked to a medicine man about people who seem listless or have given up hope. “He said: ‘We have them stay up all night, then sacrifice a chicken and eat it,'” he recalls. “When I asked, ‘does that work?’ he said, ‘yeah.’ That is enough to help get them out of whatever space they are in. The lesson is, whatever you think will work has a high probability that it will work.”

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A Look at Depression Around the World originally appeared on usnews.com