Expats and Depression: The Research

July 14, 2014 Kristance Harlow
Lightning Storm

My last blog post on depression and expats sparked some interesting discussions on LinkedIn. Unfortunately, I accidentally deleted the thread when I got pissed at my non-responding mouse and started clicking it like a madwoman. In my fury of clicks it responded, just to delete a very productive conversation. Thanks technology. I’m going to follow through on the promise I made to the conversation prior to its deletion and write a follow up about the research surrounding depression and expatriates. I would also like to apologize for using the term “weakness” in my last post. I was addressing just myself with that terminology in an attempt to reclaim the idea of my weaknesses, I was not saying clinical depression is a weakness. To be clear, mental illness is not a weakness and it is nothing to be ashamed of.

Mental illness is serious and just as pervasive as the common cold and just as real as diabetes. They are complex and have biological, psychological, and social factors. In reality, mental illnesses are much more complex than normal medical diseases which can be treated (basically) in one way for everyone. Mental disorders require individualized holistic treatment. Mental illness is not simple and it is nearly impossible to point to one factor and place all the blame on that situation for causing an illness.

There are many kinds of depression and each one has its own unique set of symptoms and causes. Situational depression, also known as adjustment disorder, is a short term reaction to a major change or source of stress. It is not major depression, because it is caused by an outside factor and often fades with time and adjustment. However, it can persist longer. Symptoms are similar to clinical depression and situational depression can turn into a long term problem. It can be caused by the place or where you are.

A pervasive myth is that depression is just in your head. For the present moment, I’m going to assume that my readers can handle the fact that depression is not something someone can just get over. I want to delve into myths that are even more pervasive than ones spread by people who “don’t believe in it.” Depression is not all in the mind, literally. Depression has a slew of physical symptoms including low energy, fatigue, headaches, body pain, and stomach issues.

And it could be you. Clinical depression can be triggered at any point for any reason, or for no reason at all.  At any point in our lives, 5 to 10 percent of people will need help for this issue and an estimated 8 to 20 percent of people risk developing it at any point. You can get a mental disorder at any time in your life, with or without warning. At the same time, if you belong to a subset of people (ie; expatriates) and that subset is more likely to suffer higher levels of mental illness than another group of people that does not mean you will or that you do suffer from that same issue.

Since depression can happen to anyone at any time, someone may be suited to being an expat but then depression happens. Depression isn’t the same as culture shock or homesickness, however issues like culture shock or feeling extremely homesick can contribute to someone developing depression. Psychologists are getting closer to understanding the various factors that may be able to predict whether or not someone is ideally suited for expatriate life. It will never be an exact science and outliers will always exist.

You have met an expat suffering from depression, you just didn’t know it. There are an estimated 350 million people worldwide who suffer from depression. Around the world, depression is the top cause of disability. It is a very common illness. Every year in the United States, over 26 percent of people over the age of 18 are experiencing a mental disorder. Depression and other mental illnesses can be shockingly easy to hide.

Depression isn’t visible, you won’t know that someone is depressed by looking at them or even by talking to them. Many people with depression don’t cry persistently or act particularly sad. Instead many people have trouble feeling a wide range of emotions. Even family members can go on oblivious to the disease, even if they notice a change in personality. Admitting you need help is not easy. Mental illness carries an excessive amount of stigma. No one should be ashamed of having depression or of having any other mental health issue. The truth is, sadly, that people are ashamed.

The primary reason people don’t seek help is because of the shame, stigma, and discrimination associated with depression and other mental disorders. According to the National Alliance on Mental Illness, an estimated 66 percent of people with diagnosable mental disorders do not try and get help. Worldwide people with mental health issues face discrimination on a daily basis. The World Health Organization even states, “There are many who would argue that the most disadvantaged in any society are the stigmatized mentally ill.” Health professionals, like Melissa Pinto, PHD, RN, and a professor at Case Western Reserve University’s School of Nursing, say that stigma associated with “mental illness is a national health problem.”

Discrimination is a very real thing that people fear when admitting a mental illness. One of the three main issues for mental health in the work place, according to WHO, is “creating a positive work environment free from discrimination.” Depending on the country and its specific laws (or lack of laws) relating to mental health discrimination, disclosing a mental disorder to a potential employer or landlord can prevent someone from obtaining employment or housing.

The National Mental Health Association conducted a survey that found that a shocking 43 percent of Americans “believe that depression is the result of a weak will or a deficit in one’s character.” Like other forms of discrimination, you may be guilty of illustrating societal mental health stigma without even realizing it. Why would someone want to disclose their mental illness if they fear that everyone around them will just start treating them differently?

There is research that shows what many expatriates have known for years – it isn’t easy being an expat. According to a study by Chestnut Global Partners and the Truman Group, upwards of 50 percent of American expats have a high risk of developing mental health problems including anxiety and depression. That rate is 2.5 times more than people who stay at home. The difficulty adjusting to life as an expatriate is reflected in the 40 percent failure rate that American expats experience when sent abroad.

According to the World Health Organization, “Mental health issues are among the leading causes of ill health among travellers, and ‘psychiatric emergency’ is one of the most common medical reasons for air evacuation.”  The stress brought on by international travel can have significant impact on the psyche. As described by the Center for Disease Control and Prevention, short-term travel causes the least amount of stress while expatriates and frequent travelers experience the highest levels of stress. Even people without known pre-existing conditions can have a mental health disorder emerge during travel.

A lot of this is due to the high levels of stress that expats often face. The study found that expatriates “experience higher levels of stress than their U.S. counterparts.” They are three times as likely as workers based at home in the United States to feel either trapped or depressed. They are also twice as likely to feel anxious or nervous.  Not every expat is the worker, many expatriates are family members who have been brought along on the journey. The 2011 Global Relocation Trends Survey found that for expatriates “the top challenges [are] partner resistance (47%) and family adjustment (32%).”

If you don’t know that someone is suffering from a mental illness, you also wouldn’t know if someone was suffering from excessive stress. Stress is a personal and subjective experience – what you find trivial someone else might find crippling.  Stress causes an increased risk of mental disorders and mental illness episodes. Stress can trigger many serious physical and mental health problems including depression, anxiety, high blood pressure, insomnia, and heart disease. There are some things that can affect someone’s ability to handle stress: having a good support network; feeling confident and in control of your life; being knowledgeable and prepared or a stressful experience.

Stress can be harder to deal with as an expatriate. The nature of expat life usually means becoming disconnected physically from normal support networks that you had back home. Being in a foreign land can be undoubtedly exciting and invigorating, but it can also be confusing and discomforting. Your sense of control will be tested at some point when living abroad, it is not the culture you grew up in and there will be differences and situations which you cannot control. There is also only so much one can do to prepare for a life abroad. Even being an expat in one country does not completely prepare you for life in a different country.

Returning home is not an easy Band-Aid fix. Returning home is not an option for all expats, nor is it something they all want to do. Once a mental illness develops, it requires treatment and moving will not fix the problem. Going home will cure homesicknesses, but this is not about feeling homesick. In fact, repatriation can mean a loss of services, benefits, and support. There are fewer programs for repatriation than there are for expatriation. Feelings of loneliness and isolation are commonplace for many people who return home after a period as an expat. Reverse culture shock is very stress inducing and can have a negative effect on mental health.

Expatriates face a myriad of mental health challenges and the resources for help are not easy to access. Individual businesses may have programs in place to aid in adjustment issues, but for those who have ventured on their own into expat life it is a challenge to find the proper kind of assistance. The expat community needs to acknowledge that fellow expats are at a high risk for developing mental health disorders. Until a unified force challenges the stigma it will continue to be an uphill battle.

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  1. NoMad68 on February 4, 2015 at 1:58 pm

    I suffered with depression prior to leaving my home country. I was divorced and bankrupt and had to take a job overseas to get money and keep a roof over my head (since the job included free accommodation).
    My plan was to make some money and return home once the bankruptcy stigma had passed. It has not turned out that way. Rising house prices and the economic downturn have made it even harder for ex-bankrupts like me to get a mortgage. Instead of returning with a healthy deposit for a home I now have to finance a home without a mortgage.
    My depression has not gone away but the causes have changed. Instead of being depressed about money-worries as before, I now feel rootless, unable to return home. I feel an erosion of who i am. The lack of my own roof and front door contribute to my lack of self-worth. As an expat in the Middle East I have no real rights, no real job security, and limited social options.
    Yes, it was decision to come her, to leave ‘home’ but now that i want to return I cannot, feeling trapped by out of control house prices and lack of jobs in my field at ‘home’. The tragic death of Robin Williams brought home the fact that this is an illness requiring treatment because otherwise the consequences can be fatal and no end of calls to ‘look on the bright side’ do any good at all.

    • Kristance Harlow on March 2, 2015 at 2:06 am

      That sounds like a really difficult situation. I’m so sorry. It absolutely is an illness and letting depression go untreated is like thinking cancer will just go away on its own. It won’t. Everyone needs unique attention paid to their specific set of circumstances, emotions, and kind of depression. When it comes to treatment, what works for one person won’t work for all people. At the same time, what works at one time in your life might not work later. That has certainly been the case for me and many people I know. Sending you lots of good vibes and I appreciate you sharing your story.

    • jkjjmattiassi on March 7, 2015 at 5:23 pm

      Thank you for sharing your story. Mine is almost the same. I left the United States three years ago due to the economy. I am afraid to go back and feel stuck in my career. 1 month after I moved here my mother called the night efore to tell me she would have a surgery to have a brain tumor removed. Everything has been a challenge since I moved here. I moved from a challenging situation into a challenging situation..the last 8 months my dog of 10 ywars passed, my mom’s cancer has come back, my dad has medical issues too.I have been home 4 times this year. I feel like I am merely existing..I cry all the time and am fearful about surviving financially in the states when my contract here ends in 3 months.

      • chinacassy on August 24, 2015 at 7:15 am

        I’m in the same boat. I’ve been in Beijing for over two years and constantly looking for a way to get back to the States. I’ve applied for several jobs, but nothing has come of it, and now my teaching license has expired. I feel very ‘stuck’ and find myself going from depression and loneliness to pulling up my big girl panties and dealing with my situation. It’s a constant roller-coaster. I’m 50, so my options are getting more and more limited. I was married for 30 years, but now I’m alone and sometimes just feel like giving up. This summer I started taking Mandarin classes and volunteered at a summer camp so I could meet new people. However, these ‘highs’ only last so long, and when I’m in my apartment alone I get depressed again. It’s the loneliness that hurts the most. I bought a bike and riding has helped me not feel so isolated. Other ways I’m trying to fight this loneliness and depression is I’m looking into investing in a rental house back in the States and/or starting some kind of business. These things give me a vision for the future. I’m also looking at how I can get my teaching license again. I know how it feels to be ‘merely existing’. I hate it, but I think it’s very, very important to get some friends around you. Not that they’ll be with you every minute, but at least they help to relieve some of the isolation, albeit temporary. I wish you the best. 🙂

        • Kristance Harlow on October 13, 2015 at 5:32 pm

          I know what you mean, finding friends and getting a support system is essential to making progress!

  2. Marc d'Entremont on July 16, 2014 at 10:22 pm

    A well thought out article which makes clear that simply becoming an expat does not lead to depression. The studies show that people predisposed to clinical depression may have issues living abroad that would exacerbate their condition, but as your earlier post asked, “Would they be happier anywhere else?” I don’t believe they would. Except there are the other mitigating factors, as the studies pointed out: (1) being an involuntary expat (company assigns employee or being a family member of the employee (2) becoming an expat for economic reasons or (3) willingly becoming an expat for sheer adventure. I’m sure you’ll agree they all are mitigating factors.

    • Kristance Harlow on July 17, 2014 at 6:57 pm

      Thanks for reading and commenting. There are so many factors that go into physical and mental health. Once depression sets in, it requires treatment and just moving wouldn’t make someone happier. I completely agree that there are too many variables that there will never be a bandaid fix that works for everyone.

  3. Alice Lynn on July 15, 2014 at 2:44 pm

    A well researched article that brings to light many of the factors involved in Depression as well as the effects that living abroad can trigger. The mind and brain are just as complex as the physical body, so it shouldn’t be surprising that things can “go wrong.” You have done a great job.

    • Kristance Harlow on July 16, 2014 at 4:25 am

      I might integrate more posts like this into my blog. I often write about my opinion, and often my opinion about many issues is a combination of experience and research. Once in a while you need to just showcase the research and let it speak for itself.

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