WPA Educational Programme on
Cultural Aspects of Depression
M. Kastrup, W. Machleidt, K. Behrens, I. Calliess
Copyright © 2011. World Psychiatric Association
Cultural aspects of depression: Overview
• Background & Epidemiology
• Neurobiological aspects
• Diagnostic considerations
• Symptom manifestation
• Provoking factors
• Comorbidity
• Therapeutic issues
• Prognostic factors and outcome
• Perspectives on training
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BACKGROUND & EPIDEMIOLOGY
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Background & epidemiology
• Globally there are approx. 360 million people with mood disorders
• Depression is the third most important cause of disability in the world
• Depression is responsible for 12% of Years of Life lived with Disability
(YLD)
• Lifetime risk for a severe depression amounts to 12-16%
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Background & epidemiology
The burden of depression depends upon region, having
a relatively smaller burden in poorer regions, e.g.
• 8.9% in high-income countries
• 1.2% of the total burden in Africa
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Background & epidemiology
• Globally, women have a 1.5-2 times as high risk for getting a
depression compared to men
• Depression ranks
– number 4 in the global disease burden in women and
– number 7 in men
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NEUROBIOLOGICAL ASPECTS
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Neurobiological aspects
• No data on neurobiological aspects in the pathogenesis of
depression in migrants
• Acculturative stress can be compared to the general unspecific stress
response which has been described in the aetiology of depression
via HPA axis (Haasen et al. 2008)
• Chronic experience of social defeat in migrants leads to sensitisation
of the mesolimbic dopamine system and puts individual at increased
risk for development of disorder of the brain (Selten & Cantor-Graee 2005)
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DIAGNOSTIC CONSIDERATIONS
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Diagnostic considerations
Challenges of intercultural diagnosis
• Validity of diagnostic categories
• Pathoplasticity of mental disorders
• Existence of culture dependent syndromes
• Cultural variability of symptoms
• Importance of theoretical concepts (cultural relativism vs.
universalism)
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Diagnostic considerations
Classification problems
• Categorization and differentiation of depressive syndromes
(endogeneous vs. reactive, psychotic vs. neurotic, major vs. minor
dysthymic)
• Classification of depression as such is a controversial issue
– Diagnostic terms such as depression or phobia have no
corresponding term in many languages outside Europe
– The concept ’depression’, developed in Western culture, focusses
on mood swings; in many non-Western cultures feeling down is not
necessarily a main symptom of a depressive illness.
• Clinical validity of differentiating between depression and anxiety: over
50% comorbidity concerning WHO Study in General health Care
(Goldberg & Lecrubier 1995)
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Diagnostic considerations
Culture specific aspects in Western classification
systems
• Up to now not included in ICD 10
• Included for the 1st time in DSM-IV (APA 1994)
• ‘cultural formulation’as template for history taking in intercultural
settings to adequately assess the cultural and ethnic background of
the patient
• But: DSM-IV also represents Western concepts and cannot
unequivocally be used in other cultures (Kirmayer 2001)
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Diagnostic considerations
The diagnostic dimension of migration
• Current objective living conditions (e.g. social and legal status,
poverty)
• Differentiation of the heterogeneous groups of migrants
• Analysis of personal history, pre-migratory personalitiy and conditions
that caused migration (e.g. war, torture)
• Consider migration as a long-term process, including different
dynamics in the family
• Consider important psychological variables, such as perceived
control over the decision to migrate (internal vs. external), the
predominant acculturation strategy and the subjective assessment of
the experience of migration (Bhugra 2005)
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Diagnostic considerations
Diagnosing mental disorders in migrants
• 3 most important aspects
– Migration specific aspects
– Culture specific aspects
– Level of integration as predominant style of acculturation
• Function of culture regarding pathogenesis of mental disorders
– The greater the proportion of biological factors, the lower the
pathogenetic effect of culture
– The lower the pathogenetic effect of culture, the higher a
pathoreactive effect of culture
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SYMPTOM MANIFESTATION
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Symptom manifestation
Cultural variations exist in Symptoms of Major
Depressive Episodes
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depressed mood
diminished interest or pleasure
weight loss or gain
insomnia or hypersomnia
psychomoto agitation or retardation
fatigue or loss of energy
feelings of worthlessness or guilt (delusional)
diminished ability to think or concentrate
recurrent thoughts of death, suicidal ideation
psychotic features
somatization
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Symptom manifestation
Experiences of depression in somatic terms in
DSM-IV 1994
• Latino and Mediterranean Cultures
– „Nervios“
– Headaches
• Chinese and Asian Cultures
– Weakness
– Tiredness
– „Imbalance“
• Middle Eastern Cultures
– Problems of the „heart“
• American Indian Cultures (Hopi)
– „Heartbroken“
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Symptom manifestation
Feelings of worthlessness, self-reproaches and guilt:
• Are more frequent in Western than in non-Western cultures e. g.
Africa, the Middle East, Asia a.o. (Sartorius et al. 1983).
• Are in non-Western cultures associated with themes like
relationships, family, ancestors, friends and social status rather than
‘God’ like in Western cultures.
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Symptom manifestation
Psychotic symptoms:
• Hallucinations and delusions are less frequent in non-Western
countries (Pfeiffer 1994)
– Acoustic and optic hallucinations
– Themes of delusions are typically somatization, religiosity and
persecution and less frequent guilt, worthlessness and poverty
like in Western countries.
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Symptom manifestation
Relation between somatic Symptoms and Depression
in Urban Areas (Simon et al. 1999) (1)
• Somatic symptoms of depression are ubiquitous
• The frequency varies depending on how somatization is defined
• Somatic symptoms are as „primary“ as psychological symptoms
• No intercultural urban variation of the symptomatic experience
• Somatic symptoms are a core component of depression
• Somatization is a „somatosensory amplification“ of psychological
distress
• Somatization is a psychological defense against psychological
distress
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Symptom manifestation
Relation between Somatic Symptoms and Depression
in Urban Areas (Simon et al. 1999) (2)
• Somatization is an alternative „idiom of distress“ (Kleinman)
• Somatization is a symbolic body language for distress
• Somatization is the „ticket of admission“ to the medical care system (
„facultative somatization“)
• Correlation between close physician/patient relation and somatization
• No correlation between somatization and acculturation
• No mind-body dichotomy
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PROVOKING FACTORS
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Provoking factors
• Concept of personhood or selfhood held by a particular cultural tradition
(e.g., idiocentrism vs. allocentrism; Triandis et al. 1985);
• A persons ethnicity and the degree of identification with cultural heritage;
• Personality factors (e.g., locus of control);
• Degree and mode of acculturation (e.g., role confusion and conflict vs.
bicultural identity);
• Characteristics of the society or community (e.g., individualistic vs.
collectivistic; Hofstede 1980, traditional vs. modern societies);
• Factors related to the status as an ethnic minority (e.g., racism, social
drift, marginalization);
• Factors related to migration (e.g., uprooting due to war or natural
disasters, distance to important persons or family members, alienation,
legal status).
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Provoking factors
• ACCULTURATION includes associated stressors as well as the result
of a successful process
effect on depression can be either positive or negative
• Acculturative stress is associated with high levels of depression and
suicide ideation (Hovey 2000)
• Disconnection from protective culturally mediated social resources
(e.g., strong family networks, role models)
• An acculturating individual has to conform, adapt, meet the demands
and negotiate of two different environments (Hwang & Myers 2007)
• Exposure to culturally incongruent stressors (e.g., shifts in family
dynamics)
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Provoking factors
• The impact of ethnic identity on risk for depression depends on the
nature of the challenges to be handled (e.g., racial discrimination vs.
language learning) (Beiser & Hou 2006)
• The impact of the ethnic minority status on risk for depression vary
depending on age, gender and social status (Clarke 2007)
• Characteristics of the society (e.g. traditional values) can have a
protective effect (Colla et al. 2006)
• External locus of control can have beneficial effect when coping with
different conditions following migration because of less threatening
cognitions (Bhugra 2004)
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COMORBIDITY
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Comorbidity
Examples for Ethnicity and Comorbidity in Depression
• Diabetes: African Americans, Cubans, Mexicans, Bangladeshi
• Heart disease: Mexicans
• Asthma: Latinos, Puerto Ricans, Mexicans
• Pain: Hispanics, Hongkong Chinese
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Comorbidity
Cross-cultural structure of psychopathology
The two dimensional model of internalizing and externalizing syndromes
Internalizing syndromes
Externalizing syndromes
Depression
Anxiety
Hazardous
Neurasthenia
use of
Somatization
alcohol
Hypochondriasis
Culture specific symptom levels
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Comorbidity
Cross-cultural structure of psychopathology
Cultural levels of symptoms in primary health care:
• Low: Asians
• Middle: Europeans and Americans
• High: South Americans
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THERAPEUTIC ISSUES
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Therapeutic issues
• Basic tool: continuous reflection of one’s own cultural attitudes and
values to facilitate a dialogue on cultural aspects in concepts of
mental illness, treatment strategies and roles of patient and therapist.
(Fox 2005)
• Discussion of diverse explanatory models for the etiology of illnesses
(mirror central cultural values)
• Open intercultural dialogue may help to figure out problems
associated with acculturation in the patient’s everyday life
• Involvement of interpreters –emotional experience is less accessible
in a cognitively learned second language (Marcos & Alpert 1976)
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Therapeutic issues
• Defining therapeutic goals in accordance with the patient’s cultural
background (e.g., a self-organization based on interindividual
relatedness)
• Use of cultural resources (e.g., a traditional role in the family may
provide support and orientation)
• Consideration of both cultural and migration-related influences on the
therapeutic situation (e.g., perception of the psychiatrist as a member
of the formerly repressive state-run authorities)
• Regarding ethnic differences in reactions to psychotropic medication
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Therapeutic issues
• PSYCHOPHARMACOLOGY: Ethnic differences in reactions to
psychotropic medication due to gene differences (Lin 2001, Bhugra 2004)
• Patients from ethnic minority backgrounds, particularly blacks, had a
less robust response to antidepressant treatment (Citalopram)
(Lesser 2007)
• Impact of severe psychosocial stressors (e.g., crime, racial
discrimination, family disruptions, poor housing) on the association
between race/ethnicity and remission remains unclear
• Racial and ethnic minorities preferred counseling for depression
treatment in contrast to medication more than whites (Givens et al. 2007).
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PROGNOSTIC AND OUTCOME FACTORS
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Prognostic and outcome factors
Factors to be considered in relation to prognosis,
outcome and culture:
• Existence of societal stress factors:
– E.g. war, poverty, forced migration, discrimination
• Existence of psycho-social factors:
– E.g. family conflicts, unemployment
Concomitant physical health problems
Role and support of the family
Willingness to disclose suicidal ideations
Medication
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Prognostic and outcome factors
Factors to be considered in relation to prognosis,
outcome and culture:
• Cultural factors influencing compliance
• Cultural factors influencing access to care
• Availability of adequate care
• Cultural barriers in the therapist-patient relationship
– E.g. linguistic, racial
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PERSPECTIVES ON TRAINING
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Perspectives on training
• Training in cultural competence for all mental health professionals
• Training in communication skills
• Awareness of culturally influenced treatment gap
• Awareness of differences in access to care and steps to overcome this
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Perspectives on training
Issues related to identification/diagnosis of depression:
• Further development of cultural interviews
• Validation of standardized assessment instruments
• Awareness of somatic presentations
• Awareness of migratory stressors and traumata
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Perspectives on training
Cultural competence:
• Sharpening cultural sensitivity
• Acquiring cultural knowledge
• Enhancement of cultural empathy
• Adjustment of culturally relevant relations and interactions
• Ability for cultural guidance
• Therapist-patient relations
• Interview and communication (Tseng 2003)
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