However, these general conclusions need to be tempered by several important considerations. First, 21 of the 25 countries compared were mostly western countries from Europe and the Americas, with only four non-western countries meeting our criteria (three from Asia, and one from the Middle East). We were not able to contact the authors 14 of the 39 eligible studies to obtain standard errors or confidence intervals. It is still possible, that if a larger number of non-western cultures could have been included in our analyses that differences between Western and non-Western countries would have emerged. A larger sample would have increased the internal and external validity of our findings. Second, the cross-cultural equivalence has not been tested directly through multi-group confirmatory factor analysis or other analytic techniques [40]. This is an important area for further research. Third, it is still possible that some cultures may have alternative ways of expressing psychopathology not captured by the DSM classification. By using the DSM symptoms in these studies, investigators may have imposed an appearance of cross cultural homogeneity that would not have appeared
