Special topicS

Diagnosis and management of depression across culturesKamran ahmed

Dinesh Bhugra

Abstractthe prevalence of depression in ethnic minority populations across the

world varies, and these differences may be due partly to culture-specific

pathoprotective and pathogenic factors. Depression is under-diagnosed

in primary care all over the world, particularly in ethnic minority popula-

tions. Various explanations have been offered for this, including different

explanatory models between patient and doctor, linguistic barriers and

variations in presentation. Such problems may also exist in secondary

mental healthcare services. Help-seeking behaviour remains a problem

in the management of depression in ethnic minority populations, due

in part to stigma associated with mental illness, and differing illness

beliefs. Depression may present with somatic symptoms and cultural

idioms of distress in any culture, including ethnic minority groups. ethnic

variations in response to medication and issues related to compliance

are obstacles in the pharmacological treatment of depression. a novel

approach to psychotherapy is also required. Strategies such as the use

of trained interpreters, raising awareness, improved communication, a

culturally sensitive approach to clinical practice, and various tools and

models can help in the diagnosis and management of depression across

cultures.

Keywords cultural identity; culture; depression; management

In the multicultural climate that we live in, clinicians have the task of recognizing and treating psychiatric disorders such as depression in the context of a patient’s culture. Culture is reflected in the learned, shared beliefs, values, attitudes and behaviours characteristic of a society or population (see pages 379–382). Culture also influences the sources, symptoms and idioms of distress, the individuals’ explanatory models, their

Kamran Ahmed MBBS BSc is a Senior House Officer in Psychiatry and

Honorary Researcher in the Section of Cultural Psychiatry at the

Institute of Psychiatry, London, UK. He qualified from Guy’s, King’s &

St. Thomas’ Medical School and is currently training on the St. Mary’s

psychiatric scheme. His research interests include cultural psychiatry,

self-harm and suicide, depression, and religion. Conflict of interest:

none declared.

Dinesh Bhugra MBBS FRCPsych is Dean of the Royal College of

Psychiatrists, UK, and Head of the Section of Cultural Psychiatry at

the Institute of Psychiatry, London, UK. His research interests include

social and cultural psychiatry, spirituality, sexual dysfunction and

diversity. Conflict of interest: none declared.

pSYcHiatRY 5:11 41

coping mechanisms and their help-seeking behaviour, as well as the social responses. Culture can influence depression in a variety of ways, and cultural differences will translate into dis-tinct manifestations and treatment expectations of the illness. Discrepancies in the understanding and conceptual beliefs of depressive illness between patient and doctor, the complicated effects of acculturation, and various culture-specific psychoso-cial factors result in confusion in the understanding of the illness (see pages 379–382).

The differences between the prevalence of depression in majority and minority communities in various countries are inconsistent and difficult to explain. It is possible that they rep-resent a complex interplay between pathoprotective and patho-genic sociocultural factors. For example, social disadvantage and poverty are common stressors in minority communities and could predispose to depression. Recent migration can cause psy-chological distress as a result of traumatic experiences prior to migration, separation from parents and friends, and difficulties adjusting to a new, alien environment.1 On the other hand, cer-tain cultures have family-oriented cultural values, which could be pathoprotective. For example, socioeconomic adversity and interpersonal and family problems were found to be major risk factors for depressive disorders in Pakistan, whereas supportive family and friends may protect against development of these disorders.2 Similar trends have been seen in south-Asian com-munities in England.3 The effect of acculturation adds another dimension to the influence of cultural factors on the development of mental illnesses, including depression.

Diagnostic difficulties

UnderdetectionThere is evidence that depression is under-recognized and under-treated throughout the world, especially in primary care.4,5 In a World Health Organization study that examined depression prev-alence in primary care across 14 countries, clinicians detected only half of the cases of depression and marked variations between centres were recorded.6 The reasons for this include differing explanatory models between patient and clinician, lan-guage barriers, and somatic presentations which may urge the clinicians to look for medical causation. Similar problems may arise in secondary services providing mental healthcare.

Help-seekingMembers of some ethnic minority groups are less likely to seek professional treatment for depression. It has been proposed that members of ethnic minority groups conceptualize depressive symptoms as social problems or emotional reactions to situa-tions.7 Combined with the stigma of mental illness, this leads to problems in help-seeking.

PresentationAs noted above, depression in some cultural groups may present with somatic symptoms. The recognition of somatic symptoms of depression, and understanding somatic metaphors used to describe distress are important in treating patients from ethnic minorities, who may well present this way. Culturally determined idioms of distress are linguistic and bodily styles of expressing and experiencing illness,8,9 i.e. cultural ways of talking about

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Special topicS

distress. In the case of depression, these often take the form of somatic metaphors. A working knowledge of these cultural idioms can facilitate diagnosis of depression, establish rapport and minimize the risk of misdiagnosis.

Diagnostic solutions

To improve recognition of depression and poor help-seeking behav-iour in ethnic minority populations, various measures can be taken by healthcare providers. For example, the use of trained medical interpreters can result in a higher quality of patient–physician communication. Reliance on family members as interpreters may lead to serious problems in confidentiality and in evaluating issues such as suicidal ideation and sexual symptoms.8

Multifactorial educational approaches for both the public and general practitioners, such as the Defeat Depression campaign in the UK, and strategies for the detection and management of depres-sion at a local and national level are other measures that could alter practice by increasing awareness and changing illness beliefs.10,11

In order to make accurate diagnoses across cultural bound-aries and formulate treatment plans acceptable to the patient, DSM-IV proposes the use of the ‘cultural formulation’, which is designed to supplement a standard clinical evaluation by high-lighting the effect of culture on the patient’s identity, personality development, symptoms, explanatory models of illness, help-seeking preferences, stressors and supports, therapeutic relation-ships and outcome expectations.12

Somatic symptoms and idioms of distress can be assessed and understood using an approach recommended by Lewis- Fernandez et al., as shown in Table 1.

Difficulties in treatment

PharmacologyEthnic variations in response to psychotropic medication are known to exist as a result of both pharmacokinetic and phar-macodynamic differences and have implications for drug choice and compliance (e.g. African Americans are more sensitive to the side effects of antidepressants13). Possible explanations for such differences include slow hydroxylation and receptor hypersen-sitivity,14 and slow metabolism. Interactions resulting from the use of traditional medication, different levels of stress, and other environmental and social factors may also be important.15

Compliance: studies in general healthcare suggest that patients in transcultural settings are especially likely not to comply with treatment.16 Important factors that may contribute to this include concerns around the stigma of mental health services and fears of the effects of medication,17 poorer physician–patient communica-tion, increased sensitivity to side effects and cultural differences in expectations for treatment between patient and clinician.15,16

PsychotherapyIt is particularly important for psychotherapists to attain ‘cultural competence’ to provide an effective intervention when working with patients of a different cultural background. Cultural com-petence can be divided into generic cultural competence, which includes the knowledge and skill set necessary to work effectively in any cross-cultural therapeutic encounter, and specific cultural

pSYcHiatRY 5:11 41

competence, which enables therapists to work effectively with a specific cultural community.18

Treatment solutions

The difficulties encountered in forming a therapeutic alliance and maintaining adherence can be minimized by negotiating a man-agement plan with the patient, coming to a common understand-ing of the illness, goals and treatment expectations and actively monitoring medication adherence.19 It has been proposed that culturally appropriate educational packages could also improve compliance.15

Diagrams and videos may be helpful adjuncts for patients with low health literacy or poor English proficiency. Family members can be included in the discussion about treatments so that they can assist the patient, with his or her consent.8 Concerns about using antidepressants due to perceived harmfulness or addictive-ness are common and explaining that antidepressants are non-addictive in a culturally sensitive manner may prove beneficial. The use of a model such as the ESFT, which was designed to improve medication adherence through enhanced patient–clini-cian communication may help form a therapeutic alliance. It was initially developed for treating hypertension but can be applied to other illnesses. The model explores explanatory models, barriers to treatment adherence, fears and concerns about medication,

Managing somatic symptoms of depression

• awareness of the possibility of somatic presentations, and

enquiring about the patient’s understanding of the somatic

symptoms

• clarifying the patient’s use of specific cultural idioms of

distress to describe the somatization process and being

familiar with somatic metaphors

• Recognizing that somatic symptoms are real and not

imagined

• exploring physical symptoms in the context of stressors with

open-ended questions such as ‘What are the problems that

you are facing now that create difficulty or distress?’

• Relevant medical investigations should be performed but

over-investigation should be avoided. Not conducting any

tests may be negligent or taken as a sign of lack of caring.

Discussing negative laboratory or imaging tests with the

patient is usually helpful

• Discussing the patient’s physical distress in relation to

their life situation and stressors. Many patients will find a

biopsychosocial interpretation helpful

• Rare possibilities should be considered: somatic

amplification – patients are hypervigilant to irrelevant bodily

stimuli and report their awareness of bodily sensations

as physical distress; alexithymia – an extreme inability to

verbalize feelings or emotional states. Such patients are

likely to express emotions purely or primarily with physical

symptoms

adapted from lewis-Fernandez et al., 2005.8

Table 1

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Special topicS

especially side effects, and dialogue between the clinician and the patient.20

Conclusion

Difficulties in the diagnosis and treatment of depression in ethnic minority populations, including explanatory models, have been described, and some of the practices and skills that clinicians can employ to overcome these boundaries have been identified. The processes of globalization and continuing migration mean that the cultural boundaries to be negotiated in the management of disorders such as depression will change. Psychiatrists will have to become more sensitive to multicultural settings with varying models of explanations and treatment expectations. The key to successful treatment of depression in this multicultural setting is further research into the experience and management of depres-sion across cultures, increasing awareness of cultural differences amongst clinicians, and training in culturally sensitivity and novel strategies that help to overcome these difficulties. ◆

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