wpa educational programme on cultural aspects of depression m. kastrup, w. machleidt, k. behrens, i....

WPA Educational Programme on Cultural Aspects of Depression

M. Kastrup, W. Machleidt, K. Behrens, I. Calliess

Copyright © 2011. World Psychiatric Association

Copyright © 2011. World Psychiatric Association 2

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


BACKGROUND & EPIDEMIOLOGY


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%



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



• 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


NEUROBIOLOGICAL ASPECTS


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)


DIAGNOSTIC CONSIDERATIONS


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)



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)



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)



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)



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


SYMPTOM MANIFESTATION


Symptom manifestation

Cultural variations exist in Symptoms of Major Depressive Episodes • 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



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“



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.



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.



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



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


PROVOKING FACTORS


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).


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)


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)


COMORBIDITY


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


Comorbidity

Cross-cultural structure of psychopathologyThe two dimensional model of internalizing and externalizing syndromes

Depression

Anxiety

Neurasthenia

Somatization

Hypochondriasis

Hazardous

use of

alcohol

Culture specific symptom levels

Internalizing syndromes Externalizing syndromes


Comorbidity

Cross-cultural structure of psychopathologyCultural levels of symptoms in primary health care:

• Low: Asians

• Middle: Europeans and Americans

• High: South Americans


THERAPEUTIC ISSUES


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)


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


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).


PROGNOSTIC AND OUTCOME FACTORS


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


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


PERSPECTIVES ON TRAINING


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


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


Perspectives on trainingCultural 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)

wpa educational programme on cultural aspects of depression m. kastrup, w. machleidt, k. behrens, i....

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