Mood Disorders - Cultural Aspects of Psychiatric Disorders

Mood Disorders

Contemporary cross-cultural research on mood disorders has focused on unipolar depression syndromes, revealing extensive cultural patterning as well as significant similarities. For ex-ample, the World Health Organization Collaborative Study on Depression found a core depressive syndrome in the five coun-tries studied, but it also revealed substantial cross-cultural dif-ferences in symptom presentation, affect conceptualization, level of severity, and influence of acculturation, despite a methodology that tended to accentuate similarities at the expense of local dif-ferences (Marsella et al., 1985).

Culture and other social factors, such as class and gen-der, influence the interpretation of and exposure to stressors that predispose to depression (Brown and Harris, 1978). The specific characteristics of the dysphoria of depressive illness also vary cross-culturally. For example, among the Hopi in North Amer-ica, feelings of guilt, shame and sinfulness are separate experi-ences displaying distinct relationships to subtypes of depression (Manson et al., 1985). Whereas reports of irritability, rage and “nervousness’’ are prominent descriptors of depressive affect among the Puerto Ricans and other Latinos (Lewis-Fernández, 2002). The frequent combination of depression and anxiety noted around the world, particularly in primary care settings, has fueled the DSM-IV-TR proposal for a mixed anxiety–depression disorder (Katon and Roy-Byrne, 1991).

In addition, most cross-cultural studies have found a sig-nificantly higher rate of somatic complaints associated with de-pression (and anxiety) among the nonWestern groups than in the Western settings, including the presence of unique symptoms (e.g., “heat or water in the head’’ and “crawling sensation of worms and ants’’ in the Nigerian cultures) (Marsella et al., 1985; Ebigbo, 1982). Emotional complaints are often present as well but may not be considered the source of distress or impairment. The mix of emotional and somatic symptoms has also been found to vary by sex in some studies (Clark et al., 1981; Guarnaccia et al., 1989). For example, a study comparing the Puerto Ricans, Mexican-Americans and Cuban-Americans on the Center for Epidemiologic Studies Depression Scale of depressive symptoms found that the women in all three groups tended to endorse de-pressive and somatic scale items together as a single factor. This happened significantly more often amongst women than men (Guarnaccia et al., 1989).

Finally, the threshold at which dysphoria becomes disor-der is affected by cultural factors. The two-week duration cri-terion for major depression, an important proxy for pathological intensity, may vary among some nonWestern groups. Manson and colleagues (1985) found that the Hopi identify five distinct indigenous syndromes related to depression, only one of which shares significant parameters with Western depressive disorder. This folk syndrome, however, differed from major depression in its average duration of 1 week, not 2, although still causing comparable morbidity. On the basis of this, duration criterion for major depressive disorder when it is used with the Hopi patients should be shortened (Manson et al., 1985). Conversely, in a study of the Bambui community in Brazil, researchers were surprised to find depressive episodes averaging 1 month, higher than that observed in similar studies in many other societies (Vorcaro et al., 2001).

The substantial overlap of depression with anxiety, so-matoform and dissociative disorders implies a higher probability of under-recognition or misidentification of affective disorders in many ethnocultural groups (Kirmayer and Groleau, 2001). These findings raise serious issues about the universality of the proto-typical representation of depression in the North American psy-chiatry and the operational criteria of the depressive disorders, and tend to support the phenomenological expansion of the de-pression categories (Manson and Good, in press; Kirmayer and Groleau, 2001).