Cultural Notion of Depression in Nepal by Dr Usha Kiran
Culture refers to the shared patterns of life that define social groups. Cultural processes
include physiological reactions, understanding demand of particular situations, the
development of interpersonal connections, religious practices, and the cultivation of
collective and individual identity. Culture is inextricably caught up with economic,
political, psychological, and biological conditions. Treating culture as a fixed variable
seriously impedes our ability to understand and respond to disease states such as
depression. The concept of a depressive disorder that focuses on mood change as the
primary or core feature of the disorder has evolved from a Western context and may not
be universally applicable (Bebbington, 1993). Tanaka-Matsumi and Marsella (1976)
investigated the subjective experience of depression among Japanese nationals, through
the use of word associations to the terms “depression” and “yuutsu” between Japanese
Americans and Caucasian Americans. Such constructs have been identified in several
cultures, such as the construct of thinking too much or kufungisisa in the shona language of
Zimbabwe (Patel et al 1996) and neurasthenia in China (Kleinman and Kleinman 1985).
In the present study, ‘depression’ influenced by socio-cultural considerations, denotes a
mood, a symptom, and various syndromes of disorder and disease. It simultaneously
connotes a broad spectrum of affective experiences and social consequences in which
they are shaped, experienced, communicated, and responded by others. Culture can
influence the experience and communication of symptoms of depression. The American
Psychiatric Association yielded to the pressures from ethnic minority mental health
professionals and others who had studied depressive experience and disorder across
cultures and agreed to include cultural commentaries on depression in the section on
major depressive disorders stated in the DSM-IV-TR (2000). Psychiatrists are alert to the
ethnic and cultural specificities in the presenting complaints of a Major Depression
Episode (Unipolar). For examples, in some cultures, depression may be experienced
largely in somatic terms rather than with sadness or guilt. Complaints of nerves and
headaches (in Latino and Mediterranean cultures), of weakness, tiredness, or imbalance
(in Chinese and Asian cultures), of problems of the “heart” (in Middle Eastern cultures),
or of being ‘heartbroken’ (among the Hopi) may express depressive experiences (1994,
324).
Marsella (1980) suggested the experience and expression of depressive disorders are not
identical in all cultures, but vary according to the degree a society is “westernized”. He
also contended that the presence of a “psychological representation” – symptoms
including depressed mood, feeling of guilt, and self-deprecation-may affect the response
to treatment as well as the course and outcome of depressive disorders, when the
psychological dimension is added to the somatic dimension, the experience of depression
assumes new implications: it is now exacerbated.
Marsella (1998) points out that Western mental health professionals and scientists have
been guided by assumptions that stand in direct opposition to the post-modernist views
that currently characterize and inform the study of culture and mental health
relationships. These views emphasize the importance of the sociocultural context of
psychological problems (i.e., powerlessness, poverty, underprivileged, marginalization,
and inequality) in understanding the etiology and expression of psychopathology, and in
understanding its assessment, diagnosis and treatment. In brief, problems of depressive
experience and disorder must be understood within the cultural context that socializes,
interprets, and responds to them. This requires that we proceed from different values,
perspectives, and practices, especially those that emphasize context, ecology, and
qualitative and naturalistic methods (e.g., Marsella, Purcell, & Carr, in press).
Asian people in general are reluctant to talk about mental health issues because there is
disgrace associated with revealing mental health problems. Thus it may be difficult to
detect depression in Nepal because of the extreme social stigma it carries. It is for this
reason that measures of mental health may not translate well in the Nepalese context.
There are known difficulties in applying western diagnostic criteria or symptoms scales
to both minority populations and cross culture populations (Kleinman & Good, 1985).
With the help of above mentioned literature review, the present study attempted to
understand, how did people perceive and experience depression? What are the styles of
coping? The behavior of people in the health care system would be influenced by their
socio-cultural context. Cultural beliefs and social values and norms will influences their
conceptualization and response to depression. Transmission of these shared notions is
expected to be reflected in their explanation of illness, its causes, and treatment as well as
in their health seeking behavior. In order to achieve this objective, a qualitative approach
was adopted using Focus Group Discussion (FGD).
Focus Group Discussions were conducted in four geographical regions – mountain, hill,
valley, and plain to gather information about people’s perception and knowledge of
depression and its consequences, cultural notions and ways of coping with depression.
Focus group was a carefully planned discussion designed to obtain views on specific area
of interest conducted with 6-8 participants using a skilled moderator. Questions asked
during a focus group are referred to as a ‘question route’. It is a carefully predetermined
set of open-ended questions. The participants of focus groups were carefully recruited
using systematic recruitment procedures. Each group included 12 key informants such as
psychologists, social workers, counselors, traditional healers, lawyers, teachers, medical
doctors and officials from GO/NGO/INGO who were active in the mental health sector
within the community. The participants of each group shared similar characteristics so
that they were more comfortable and had a sense of belonging to the group.
Key issue questions focused during the session

How do you perceive Depression?

What are the terms used to refer to ‘depression’ and ‘depressed person’?

What are the symptoms of depression?

What according to you are the causes of depression?

In your opinion, what coping styles do you use when you face a stressful situation?

What are the health seeking behaviors of the depressed person?

What are the different ways in which depressed people can be treated or cure?
Focus group participants were encouraged to discuss the questions with each other. The
discussions were digitally recorded and later transcribed. A Transcriber (researcher)
listened to the recording and made a verbatim transcript of the spoken dialogue. The
transcripts were then analyzed by first sorting the transcripts by segment and then reading
them keeping the objectives of the study in mind and examining the opinions and
attitudes that were expressed by the groups. During the analysis major themes and topics
were identified, notations made regarding the linkage between topics, and significant
quotes were highlighted. This process was repeated for each segment, and similarities/
differences between the segments were noted, describing major themes and giving quotes
for each theme. A written report was analyzed separately region-wise using content
analysis. After content analysis of major opinions and attitudes elicited in the FGDs,
some notable themes were identified. These themes are discussed below.
Super natural affects on health or ill-health, depression are the consequence of
possession by ghosts, devil, and evil spirits.
Mental illness is often explained as the consequence of incurring the wrath of gods and
goddess, unfavorable planetary effects, evil spirits, sorcery, witchcraft and evil eye,
breach of taboo and bad luck. Rituals are often undertaken to propitiate the evil spirits.
Rituals vary depending upon the nature of spirit that has possessed the patient.
Rural Nepal has a rich traditional beliefs system regarding health, illness and treatment.
Traditional health care systems were found to be closely linked with the larger cultural
system. The naming, causes, diagnosis, and treatment were depended on cultural setting
and cultural explanation.
The second theme, which emerged, was that depression is the result of deeds of one’s
past life or “Karm ko phal”.
Karma is also responsible for dokh ‘bhabi le chhaithi ma yestai lekhko raichh, aaja
bhognu paryo’ loosely translated in English as ‘God has decided my destiny on the sixth
day of birth’ or ‘mero bhagya nai futekoraich’ (wretched fate) or ‘chori ko janma hareko
karma’ are the common expression used by people to explain the causation of illness.
Related to the karmic view is the idea of ‘bhabi’. The Hindus and some ethnic Nepalese
believe that on the sixth day after the birth of a child, when a special rite is performed, the
bhabi (god) comes down and decides the destiny of the child. Closely related to karma
and this view is the concept of obstruction by stars or the astrological position of stars at
the time of birth. The constellation of stars at the time of birth guides the life of the
individual. Therefore, no person can escape from his or her karma.
The third theme, which emerged, was that depression was conceptualized in
somatic terms and as a social metaphor.
The predominance of somatic symptoms is a basic feature in the construction of illness in
Nepal, as well as in other Asian countries such as, China, India and Japan. Similarly,
Marsella (1977) found that among the Japanese the same affect is cognized and
communicated in an external, naturalistic metaphor – clouds, rain, and mist – that again
appears to produce a distinct difference in the quality of the experience of depression.
The fourth theme focused on the fact that depression was viewed as a brain or nerve
weakness or a neurological problem.
Most of layperson did not consult mental health professionals. They often consulted a
neurologist because they believed that depression was caused by nerve weakness and
vitamins/mineral deficiencies. The stigma associated with mental disorders influenced
their help-seeking behavior. While attempting to make sense of their illness first step is to
understand the symptoms and the distress experienced through their identification that
something has gone wrong. Somatic symptoms are often considered as less stigmatizing
since they resembled illness experiences that most people could expect to have from time
to time.
The fifth theme Depression was equated with hysteria and attributed to the evil
eyes, witchcraft and ancestral spirits.
Most of people living in the plains used the word ‘hysteria’ for the experience of
depression and episodic depressive symptoms. As depression and hysteria emerge as
afflictions and carry the connotations of a failure in coping with the present situation,
they are often confused with each other. Blaming others for one’s ill health is a common
feature of many societies, where interpersonal conflicts are frequent. The commonest
forms of those are bokshi (witchcraft) and aankha lagnu (evil eye). Similarly, if gods,
goddesses, Manus deva, Goshai (spirits or ancestral spirits, and deities) cause illness, the
remedies include puja (paying homage) to the deities and the practice of traditional
customs such as manchhaune/panchhaune (toward off) while ill person is in the
possession of bhut/prêt (spirits or ancestral spirits). People belonging to the Newar
(ethnic) caste, mostly do the ritual ‘toward off’ at chhwasa (crossing) or do bato/chau
bato (two road crossing or four road crossing respectively).
Symptoms of depression highlighted during FGD
Most of symptoms reported in the FGD were somatic in nature followed by cognitive,
affective and performance-related changes. There are cultural differences in the
manifestations of distress and the way such manifestations are interpreted. Illnesses (such
as endogenous depression) may have a different presentation in different cultures, or, and
at times the same symptom may have a different meaning in different cultures. Among
African patients, somatic symptoms play a major, predominant role, and they tend to
push psychological symptoms into the background (Adomakoh, 1975). In Nepal, in an
interview taken a foreign Professor of Psychology and Fulbright researcher scholar Dana
Jack stated that often patients would describe depression like 'the blood is running
through my veins really fast and hot' or 'my head feels like it's vibrating.’ She further
stated, "Rather than talking in emotional terms, they talk more in concrete physical
symptoms." (Carlson, 2002),
Causes of Depression
Invisible forces such as ghosts, spirits, dead ancestors, sorcerers, witches and evil
eye can lead to depression.
Mental illness it is commonly believed is due to the wrath of gods, goddess, unfavorable
planetary effects, evil spirits, sorcery, witchcraft and evil eye, breach of taboo and luck
itself. Rituals to propitiate the evil spirits are recommended and these vary depending
upon the nature of spirit possession.
However, they believe that there may be two causes for the same natural or climatic and
supernatural. The first instance, all illnesses and ailments are attributed to supernatural
causes such as the wrath of gods/goddesses, the evil eye, evil effects of malicious spirits
and black magic done by an enemy. The major source of illness being supernatural,
treatment too lies in propitiation of the responsible force through adequate ritualistic
performances and sometimes the promise of animal sacrifice if required.
Even educated people believe that certain diseases are due to the wrath of some god or
goddess, breach of taboo, past sins, spirit and ghost intrusion into the body. Treatment is
generally traditional. In these cases, pujas are made to appease the god. Even if a doctor
diagnoses a serious medical condition, local people believe that unless the evil spirit is
removed, medicine or modern treatment will be ineffective.
The second cause of depression was related to evil deeds done by oneself or
ancestors in the past.
Karma is a deep seated and enduring belief. In addition to Karmphala, people also
attributed their problems to God’s will and fate. They make sense of their illness,
attributing the illness to evil deeds done in the past life. Attributing disease to
metaphysical belief makes sense in a culture where religion has a profound influence on
all life domains. (Joshi, 1995)
The third cause of depression referred to both physical and psychosocial factors.
These included brain injury, tension, financial loss, poor interpersonal relationship,
significant life events, alcohol abuse, conflict, frustration, loss of self-esteem, lack of
education, failure and Love tragedy.
The vast majority of international studies of depression have focused on sociodemographic and life event risk factors for depression. These have conclusively shown
the following findings - women, persons with less education, and persons who are less
economically privileged are at significantly higher risk to suffer depression (Lorant, et
al., 2007).
Poverty, domestic isolation, powerlessness resulting from economic dependence or low
levels of education and patriarchal oppression are all associated with a higher prevalence
of psychiatric morbidity in women. The morbidity is, however, exclusive of substance
abuse. Nepalese women from hilly regions used to take alcohol to reduce tension being
unaware of its negative impact on their health (Patel, 1993).
Another cause of depression was related to heavy workload in the home as well as
outside and no time for leisure activities
Nepalese women are often found to bear a disproportionate burden of work in the home
and outside. The contributions of women is neither recognized nor valued, as they do not
have much control over family property and other resources. The household and farm
related work is classified as economically unproductive. Lack of economic empowerment
and recognition of their intense labor hours they are vulnerable to depression.
Work may moderate stress as it acts as an outlet for the tensions and frustrations. At
work, women socialize and seek an outlet to activities, skills and interest. Somehow, they
have limit time or no time for their own triumph, that can lead to be depressed. Not only
women in poverty are vulnerable to depression: professional women have a higher
incidence of depression and suicide than do women in the general population (McGrath
et al. 1990).
Depression was also attributed to a failure to propitiate the Gods and Goddess
(bhakal pura nagare), which resulted in divine retribution.
In spite of the availability of sophisticated modern medicine, hospitals, doctors and
experts, people often turned to traditional healers, having deeply rooted beliefs in
traditional health practices. They visited jannemanche (astrologer), dhami. Jhankri,
gubhaju, jharphuke, deuma (woman possessed by gods and goddess), and many others.
The different ethnic groups in Nepal use their own method to drive the evil spirit away.
The evil spirit reminds them that they failed to fulfill their promise to sacrifice goats,
chickens, etc to the deities. This failure to propitiate Gods and Goddess results in
affliction. They were advised to offer sacrifices them on certain days according to lunar
calendar.
Another cause of depression was the tendency of women to blame themselves and
Self-silencing
Self-silencing which is commonly found in women leads to feelings of a ‘loss of self’. As
depressed women use the metaphor loss of self, it serves as verbal shorthand for a
complex process that includes, most centrally, a loss of voice. Voice does not mean the
literal act of speaking but refers to the feeling central to one’s identity. Speaking one’s
feelings and thoughts in a relationship is part of creating, maintaining, and recreating
one’s relational identity. Thus, voice refers more to the substance of what is
communicated or hidden in relationship than to speech acts themselves (Jack, 1999). To
understand women’s rates of depression, it is necessary to listen carefully to women’s
inner dialogues and negative self- assessments.
Health seeking behavior
A major factor, which emerged in FGD, was that the health seeking behavior of
women was influenced by their belief in traditional healers and their practices.
People have enormous faith in traditional healers, because their practices are in line with
prevailing beliefs about the causation of illness and because western practices do not
always make much sense to such people. It may be that traditional healers are more
appropriate for rural Nepal, as well as better accepted.
Many patients sought the help of the chemist or pharmacist
Self-treatment of common illness by lay people is common in economically deprived
countries (Choulagai, 1995). Common reasons cited for self-medication are
inaccessibility of health care facilities, economic constraints and previous experience of
illness. Sometimes, city-dwellers used to take medicine, taking the advice of the chemist
and thus avoided the stigma of going to a mental hospital.
Alternative medical practices were often the preferred mode of treatment for
patients.
The traditional system of medicine including naturopathy, homeopathy, ayurved,
shamanism, ethno medicine, meditation, yoga and mantra all are very much alive in
Nepal even today. In fact, they have become part of the culture, and they continue to be
an important source of medical relief to most of the people.
An investigation into cultural notions is predicted on the assumption that culture is the
composite of enduring traditions, practices, institutions, behaviors, ideas, beliefs and
attitudes shared by a large group of people and passed from one generation to the next
(Brislin, 1988). Normal behavior is subject to the greatest cultural influence.
Nevertheless, even when there are severe neurological intrusions, culture still affects the
meaning, experience, and expression of disorder (Fabrega, 1995). The social system was
seen as instrumental in determining the behavior related to illness. The naming, causes,
diagnosis, and treatment were often influenced by cultural factors.
5.4 Coping Strategies
Second half of FGD was to investigate how people respond when they confront difficult
or stressful events in their lives. There are many ways to deal with stress, but the study
dealt particularly what the participants of FGD articulated during the sessions. In the
present study, the method suggested by Holahan and Moos (1987) was used which is
suitable to the pattern of items generated and refined through FGD. The items were
grouped into the six categories more than the original method’s classification because
some of items are not compatible with them.
From the data analysis, it is found 41.7% of women living in the mountains used
behavior methods than other methods, whereas valley women used cognitive methods
(41.7%), avoidance-substance method (41.7%) as well as avoidance and other methods
(58.3%). This is broadly consistent with US findings (Billings & Moos, 1981; Holahan &
Moos, 1985). It is not possible to assert that coping by avoidance causes depression or
that depression leads one to use avoidance coping methods. The causal relationship
between coping and mental health is likely to bidirectional (Aldwin & Revenson, 1987).
It might also be tempting to try to categorize certain coping methods as ‘good’ or ‘bad’
according to whether they are associated with better or poorer psychological functioning.
However, the adaptiveness of any particular coping strategy probably depends on the
personal and environmental context in which it is used (Folkman & Lazarus, 1988;
Folkman, Lazarus, Gruen & Delongis, 1986). Most studies had have examined the
relationship of coping styles to health outcomes have reported the use of denial and
avoidance coping to be associated with greater psychological distress (Coyne & Downey,
1991).
Majority of women from the plains area used spiritual method (52.1%) to cope with the
stressful situation. Religious beliefs and practices may also have psychological effects,
which inturn bring about somatic changes. Religious beliefs and activities help to reduce
anxiety, stress and depression; they could also help to shield women from their negative
effects on general health and well-being. As Koeing, Larson and Larson (2001) surmise,
when people become physically ill, many rely heavily on religious beliefs and practices
to relieve stress, retain a sense of control, and maintain hope and sense of meaning and
purpose in life. It is suggested that religion (a) acts as a social support system, (b) reduces
the sense of loss of control and helplessness, (c) provides a cognitive framework that
reduces suffering and enhances self-esteem, (d) gives confidence that one, with the help
of God, could influence the health condition, and (e) creates a mindset that enables the
patient to relax and allow the body to heal itself. Again, the values engendered by
religious involvement such as love, compassion, charity, benevolence and altruism may
help to successfully cope with debilitating anxiety, stress, and depression.
37.5% of the respondents used emotional methods of coping. Women from the hilly
region used more emotional focused coping as compared to men. Women tended to
blame the self and reported the use of crying, becoming irritable and confronting their
feelings when depressed. Family and/or friends can affect coping efforts through
provision of actual instrumental and/or informational support and can serve as source of
emotional support (Cohen 1992). Such social resources may be particularly important in
coping with lower SES environment demands. The relationship between lower
occupational status and greater psychological vulnerability to life events disappears for
lower-status women reporting high social support (Turner & Noh 1983). A consistent
finding is that women use more social support seeking strategies than men do (Thoits,
1995).
Although, stable coping styles do exist and are important, coping behavior is contextual
and to be effective, it must change over time and across different stressful conditions.
Coping behavior is an important mediator between stress and health outcomes. Broadly,
coping is divided into two types: problem focused, if it helps to solve the problem and
emotion focused, if it helps in reducing the associated distress (Lazarus & Folkman,
1984).
Researchers have postulated the existence of coping styles that are stable or consistent
across situation (Carver and Scheier, 1994). Studies examining the role of coping in
depression suggest that depressive and non-depressed individuals may be different in
their coping processes. Depressed patients use more of emotion-focused coping in the
form of escape-avoidance, denial, distancing and less of problem-focused coping as
compared to non-depressed individual (Kolence, Hartley and Murdock, 1990; Kuyken
and Brewin, 1994; Marx William and claridge, 1992; Satija, Advani and Nathawat 1998;
Turner, King and Tremblay 1992).
Depressed patients tend to appraise aversive or ambiguous situations as causing more
strain and being less controllable as compared to non-depressive people (Pertz and
Reichartz, 1986). The perception of control has been shown to be more influential in its
relationship to depression than the actual controllability. While researches would like to
believe that problem focused coping is more beneficial to well-being, the evidence is
equivocal (Thoits 1995). Future work is also needed to designing effective programs to
facilitate and improve the coping strategies which already exist in the society or
community.
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