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).
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