The cultural origins of western depression

Decolonising the medical curriculum: psychiatry faces particular challenges

Colonial thinking runs deep in psychiatry. Recent anti-racist statements from the APA and RCPsych are to be welcomed. However, we argue that if it is to really tackle deep-seated racism and decolonise its curriculum, the discipline will need to critically interrogate the origins of some of its fundamental assumptions, values and priorities. This will not be an easy task. By its very nature, the quest to decolonise is fraught with contradictions and difficulties. However, we make the case that this moment presents an opportunity for psychiatry to engage positively with other forms of critical reflection on structures of power/knowledge in the field of mental health. We propose a number of paths along which progress might be made.

History, violence and collective memory: Implications for mental health in Ecuador

National histories of violence shape experiences of suffering and the ways that mental health professionals respond to them. In Ecuador, mental health literature addressing this crucial issue is scarce and little debated. In contrast, local psychiatrists and psychologists within the country face contemporary challenges that are deeply rooted in a violent colonial past and the perpetuation of its fundamental ethos. This paper critically reviews relevant literature on collective memory and historical trauma, and focuses on Ecuador as a case study on how to incorporate history into modern mental health challenges. The discussion poses key questions and outlines possible ways for Ecuador to address the link between history and mental health, including insights from countries that have struggled with their violent pasts. This paper contributes to ongoing international debate on the role of cultural history in mental health with implications for social scientists and practising clinicians in former colonised nations.

How ‘culture bound’ is ‘cultural psychiatry’?

Cultural psychiatry as a clinical specialty sprung mainly from Europe and North America, in order to respond to growing concerns of ethnic minorities in high-income countries. Academic psychiatrists pursuing comparative international studies on mental health, together with medical anthropologists conducting clinical ethnographies, contributed to its theoretical basis (Kleinman, 1987; Littlewood, 1990). What at first appeared to be a marginal specialty is no longer so. For example, the UK alone has witnessed a steady growth of the field, as evidenced by its mandatory inclusion in mental health training curricula, and the existence of several taught masters courses, academic positions in universities and three dedicated journals, as well as, more recently, lead papers in mainstream publications that have debated the cultural position of ‘biology’ itself (Timimi & Taylor, 2004). Additionally, with a proliferation of clinical jobs for ‘ethnic minority’ services in hospital trusts across the country, there is ample scope for employment. The overall evidence indicates that ‘cultural psychiatry’ in the UK is now a specialty in its own right.

Modifying Cognitive-Behavioral Therapy for a Depressed Older Adult With Partial Sight: A Case Report

Depression is a common mental health problem in older adults, especially among those suffering from visual impairment. A clinical case of an Indonesian older adult with retinal detachment (75% blindness) suffering from Major Depressive Disorder, based on Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) criteria, was reported. Her principal motivation to seek help was her depressive symptoms, as well as her husband’s discomfort with her change. A modified standardized cognitive-behavioral therapy was delivered in eight sessions, and a clinically significant reduction of depressive symptoms was observed at the middle of the treatment (Session 5); symptoms were further reduced at follow-up. This case report showed that conventional evidence-based psychological treatment can be modified to handle mental health problems in people with visual impairments.

Ethnic and migrational impact on the clinical manifestation of depression

PURPOSE

Depressive disorders are still underdiagnosed. Ethnic and cultural factors may influence the way depression is presented and therefore contribute to problems in assessing these disorders in different ethnic populations appropriately. In this investigation, the impact of both ethnicity and migration on the manifestation of depression was studied.

METHODS

Three groups of depressed female patients (n = 136) were included in this investigation on the variation in depressive symptomatology by ethnic groups. Group 1 consisted of Austrian patients living in Austria, group 2 were Turkish patients who had migrated to Austria and group 3 were Turkish patients living in Turkey. Participants were rated using the Montgomery-Åsberg Depression Rating Scale (MADRS), the Beck Depression Inventory (BDI), the Bradford Somatic Inventory (BSI) and an additional list of physical symptoms.

RESULTS

Both Turkish groups had significantly higher BSI scores and more somatic symptom severity. Migrated Turkish patients scored significantly higher in the items headache, backache and dry mouth than Turkish patients in Turkey. In addition, there were between-group differences in non-physical symptoms.

CONCLUSIONS

Depressive symptomatology varies between ethnic groups. These differences are mainly due to ethnicity as such but migration may play an additional role. It is essential for physicians to be aware of atypical presentation forms of depression in minority groups.

Are We Medicalizing Women’s Misery? A Critical Review of Women’s Higher Rates of Reported Depression

Epidemiological research consistently reports that women experience higher rates of depression than men. Competing biomedical, psychological and sociocultural models adopt a realist epistemology and a discourse of medical naturalism to position depression as a naturally occurring pathology within the woman, caused by biology, cognitions or life stress. Feminist critics argue that this medicalizes women’s misery, legitimizes expert intervention, and negates the political, economic and discursive aspects of experience. However, the alternative model of social constructionism may appear to dismiss the ‘real’ of women’s distress, and deny its material and intrapsychic concomitants, as well as negate relevant research findings. A critical review of sociocultural and psychological research on women’s depression is conducted. It is argued that a critical-realist epistemology allows us to acknowledge the material-discursive-intrapsychic concomitants of experiences constructed as depression, without privileging one level of analysis above the other, in order to understand women’s higher rates of reported depression.

Pills that swallow policy: clinical ethnography of a Community Mental Health Program in northern India

India's National Mental Health Program (NMHP) was initiated in 1982 with the objective of promoting community participation and accessible mental health services. A key component involves central government calculation and funding for psychotropic medication. Based on clinical ethnography of a community psychiatry program in north India, this article traces the biosocial journey of psychotropic pills from the centre to the periphery. As the pill journeys from the Ministry of Health to the clinic, its symbolic meaning transforms from an emphasis on accessibility and participation to the administration of a discrete ;treatment.' Instead of embodying participation and access, the pill achieves the opposite: silencing community voices, re-enforcing existing barriers to care, and relying on pharmacological solutions for psychosocial problems. The symbolic inscription of NMHP policies on the pill fail because they are undercut by more powerful meanings generated from local cultural contexts. An understanding of this process is critical for the development of training and policy that can more effectively address local mental health concerns in rural India.

A Cultural Critique of Community Psychiatry in India

This article is the first comprehensive cultural critique of India's official community mental health policy and program. Data are based on a literature review of published papers, conference proceedings, analyses of official policy and popular media, interviews with key Indian mental health professionals, and fieldwork in Kanpur district, Uttar Pradesh (2004–2006). The authors demonstrate how three influences have shaped community psychiatry in India: a cultural asymmetry between health professionals and the wider society, psychiatry's search for both professional and social legitimacy, and WHO policies that have provided the overall direction to the development of services. Taken together, the consequences are that rural community voices have been edited out. The authors hypothesize that community psychiatry in India is a bureaucratic and culturally incongruent endeavor that increases the divide between psychiatry and local rural communities. Such a claim requires sustained ethnographic fieldwork to reveal the dynamics of the gap between community and professional experiences. The development of culturally sensitive psychiatric theory and clinical services is essential to improve the mental health of rural citizens who place their trust in India's biomedical network.

The development of valid subtypes for depression in primary care settings: a preliminary study using an explanatory model approach

A persistent theme in the debate on the classification of depressive disorders is the distinction between biological and environmental depressions. Despite decades of research, there remains little consensus on how to distinguish between depressive subtypes. This preliminary study describes a method that could be useful, if implemented on a larger scale, in the development of valid subtypes of depression in primary care settings, using explanatory models of depressive illness. Seventeen depressed Hispanic patients at an inner city general practice participated in explanatory model interviews. Participants generated illness narratives, which included details about symptoms, cause, course, impact, health seeking, and anticipated outcome. Two distinct subtypes emerged from the analysis. The internal model subtype was characterized by internal attributions, specifically the notion of an "injured self." The external model subtype conceptualized depression as a reaction to life situations. Each subtype was associated with a distinct constellation of clinical features and health seeking experiences. Future directions for research using explanatory models to establish depressive subtypes are explored.

Cultural differences in the experience of everyday symptoms: a comparative study of South Asian and European American women

This paper describes a study of medically ambiguous symptoms in two contrasting cultural groups. The study combined a qualitative, meaning-centered approach with a structured coding system and comparative design. Thirty-six South Asian immigrants and thirty-seven European Americans participated in a semistructured health history interview designed to elicit conceptual models of medically unexplained illness. The groups reported similar symptoms, but the organization of illness episodes and explanatory models associated with these episodes differed sharply. A variety of cultural variables and processes is proposed to account for observed differences, including somatization, the role of local illness categories, and the divergent core conflicts and values associated with gender roles. It is argued that the comparative design of the study provided insights that could not have been achieved through the study of a single group.

Measuring depression in Korean Americans: development of the Kim Depression Scale for Korean Americans

This article discusses issues related to measuring depression in linguistic and cultural minority groups, using Korean Americans as an example. The article details the process of developing and evaluating a depression-screening tool for Korean Americans. A series of focus groups was conducted in the development stage of the study. In the evaluation phase, 154 first-generation Korean Americans participated in the assessment of the psychometric properties of the newly developed depression scale, the Kim Depression Scale for Korean Americans (KDSKA). The KDSKA showed adequate reliability, validity, and potentially high sensitivity as a depression-screening tool for Korean Americans.