Social, Cultural and Ethnic Aspects of Mood Disorders

Dr Imran WaheedConsultant Psychiatrist

Birmingham Central Home Treatment Team

Social, Cultural and Ethnic Aspects of Mood Disorders

Presentation OutlineContextHistory of depressionCulture and depressionSouth Asian women and depression

BirminghamThe 2001 census showed

that 70.4 per cent of the Birmingham population was white and 29.6 per cent were a mixture of various ethnic backgrounds, with British Asians and African-Caribbean dominating.

Research suggests that by 2024 there will be no ethnicity with a majority in Birmingham

History of Depression

“And yet in certain of these cases there is mere anger and grief and sad dejection of mind…those affected with melancholy are not every one of them affected according to one particular form but they are suspicious of poisoning or flee to the desert from misanthropy or turn superstitious or contract a hatred of life. Or if at any time a relaxation takes place, in most cases hilarity supervenes. The patients are dull or stern, dejected or unreasonably torpid…they also become peevish, dispirited and start up from a disturbed sleep.”                                                         Arateus (AD 150)

History of Depression: GreeksMelancholia, meaning “black bile” was used in

Ancient Greece. The Greeks thought it to be due to an imbalance of

the four “humors”.Hippocrates (460-277 BC) described melancholia

as being characterised by “fears and despondencies” due to an “excess of black bile”

Cicero (106-43 BC) rejected Hippocrates’ bile theory, stating that emotional factors could cause mental illness - “perburtations of the mind may proceed from a neglect of reason”. Man could help with his own cure through “philosophy”.

The Old Testament refers to King Saul suffering from “evil spirits” and committing suicide – the future King David played the harp to alleviate his suffering.

History of Depression: ArabsThe Arab psychologist Ishaq bin Imran (d. 908

AD) described “phrenitis” as a type of melancholia – the main clinical features he identified were sudden movement, ‘foolish acts’, fear, delusions and hallucinations

Kitab al-Maliki (980 AD): “Its victim behaves like a rooster and cries like a dog, the patient wanders among the tombs at night, his eyes are dark, his mouth is dry, the patient hardly ever recovers and the disease is hereditary”.

Ibn Sina’s Canon of Medicine (1025 AD): Case described of a prince of Persia who had melancholia and a delusion that he was a cow

Modern History of DepressionRobert Burton’s “The Anatomy of Melancholy”

(1621 AD) was influential - suggested that melancholy could be combated with a healthy diet, sufficient sleep, music, and “meaningful work”

Johann Christian Heinroth (early 19th C) believed that sin was the causal factor in mental illness – “the offending of an individual’s morals by their own thoughts”.

Depression as a term gained currency in the 19th century

From the Latin “deprimere” – to “press down”Some languages where there is no equivalent of

“depression” but there are words meaning sadness, lack of energy, etc.

Treatment through the agesAncient Egyptians: Recreational activities

such as concerts, dances and painting.Medieval times: emetics, laxatives, leeches,

cuppingArab world: 1st psychiatric hospital in

Baghdad (705 AD) – baths, music and activities

17th Century: restraints, chains, whippingModern times: ECT, antidepressants,

psychotherapy

Depression• Characterised by low mood, reduction of

energy and loss of interest.• Anhedonia, appetite change, weight loss,

early morning waking, diurnal variation, reduced libido, poor concentration, reduced self-esteem, guilt, suicidal ideation, psychomotor retardation.

• Common – 15% of people will have an episode at some point

• WHO predict that by 2020 depression will be the 2nd largest cause of disability.

• Women twice as likely to suffer from it than men

Culture and DepressionThe medical model is the dominant model for

understanding and treating depression. ICD and DSM – probably more “Western” than internationalHowever DSM IV states: “Culture can influence the

experience and communications of symptoms of depression.”

“For example, in some cultures, depression may be experienced largely in somatic terms rather than with sadness or guilt. Complaints of nerves and headaches (in Latino and Mediterranean cultures), of weakness, tiredness, or imbalance (in Chinese and Asian cultures) of problems of the heart (in Middle Eastern cultures) or of being “heartbroken” (among the Hopi) may express depressive experiences (1994, 324)”

Emotional symptomsFeelings of guilt

Suicidal

Lack of interest

Sadness

Physical symptoms Lack of energy

Decreased concentration

Change in appetite

Change in sleep

Change in psychomotor skills

Associated symptoms Brooding

Obsessive rumination

Irritability

Excessive worry over physical health

Pain

Tearfulness

Anxiety or phobias

American Psychiatric Association (APA). DSM-IV-TR; 2000:352,356.

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Somatisation•The occurrence of physical symptoms which are not accounted for by demonstrable physical illness. •Earlier theories suggested that somatisation was the cultural equivalent of depression, typically occurring in non-Western cultures. •There is now growing evidence that somatic symptoms are common presenting features of depression throughout the world•Colloquial British expressions such as ‘I feel gutted’ also describe feelings of loss and depression in somatic metaphorical terms.•Simon et al (1999) found that the proportion of patients with depression who reported only somatic symptoms ranged from 45% in Paris to 95% in Ankara (overall prevalence 69%). •However, when somatisation was defined as ‘medically unexplained somatic symptoms’ or ‘denial of psychological distress’, no significant variation between centres was found.

•Bhui reported that Punjabi patients visiting their general practitioner more often had depressive ideas, but were no more likely to have somatic symptoms than English patients (Bhui, 2001). •Pain was the most common physical symptom. This, in an Asian culture, could reflect ‘suffering’and dependency needs, while disguising the affective aspects of common mental disorder. •Punjabi women in London (Bhugra et al, 1997b) recognised the English word ‘depression’, but the older ones used terms such as ‘weight on my heart/mind’, or ‘pressure on the mind’. •Symptoms of ‘gas’ and ‘feelings of heat’ were identified, which is in accordance with traditional and ayurvedic models of hot and cold.

Somatisation

Physical Symptoms in Psychiatric Patients

Data from Kellner R, Sheffield BF. The one-week prevalence of symptoms in neurotic patients and normals. Am J Psychiatry 1973;130:102–105

Psychiatric Healthy Symptom Patients % Subjects %

Tiredness, lack of energy 85 40Headache, head pains 64 48Dizziness or faintness 60 14Feeling of weakness in parts of body 57 23Muscle pains, aches, rheumatism 53 27Stomach pains 51 20Chest pains 46 14

Prevalence of Associated Painful Symptoms in Patients with Depression

Studies addressed both depression and painful symptoms, including:Headaches

Back pain

Neck pain

Extremity/joint pain

Chest pain

Pelvic pain

Abdominal pain

General pain

Mean prevalence data from 14 studies focusing on painful symptoms

in patients with depression

MDD withoutpainful

symptoms35%

MDD withpainful

symptoms65%

Prevalence was not influenced by psychiatric versus primary care settings

Depressed patients

Bair MJ, et al. Arch Intern Med. 2003;163:2433–2445.

MDD=major depressive disorder.

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•Early studies showed that South Asian women in the UK had lower rates of depression compared to White British women.

•More recent research suggests that the prevalence is much higher in South Asian women than previously thought.

•Issues of stigma and access to mental health services are important.

•A recent study (Weich et al., 2004) found that South Asian women had higher rates of anxiety and depression compared to the White British population.

•Some studies have shown that Asians less likely to consult for fear of bringing shame on themselves or others.

South Asian women in Britain

South Asian women in Britain

•Less likely to have their symptoms recognised by their GP.

•One study found that only half of South Asian participants had disclosed their psychological distress to their GP.

•It has been thought that they are more likely to present with psychosomatic symptoms which may be more difficult for GP to recognise.

•Asian GPs have been found to be poor detectors of mental distress in Asian patients.

South Asian women in Britain – self harm

•Deliberate self-harm accounts for more than 170,000 hospital attendances in the UK every year.

•One of the first studies to investigate self-harm in South Asians was a retrospective study of Asian Immigrants in Birmingham by Burke

•The study reported that the rates of self-harm among females were twice that of males. However the overall rates were low when compared to the rates among the general population.

•A decade later, a study by Merrill & Owens showed that rates of attempted suicide were beginning to change in Birmingham. In the South Asian cases studied over a two-year period, it was found that females were three times more likely to present. It was also found that the overall rates for South Asian-born females were significantly higher than that for UK-born females.

South Asian women in Britain – self harm

•In a study carried out in London, Bhugra et al reported that of all the deliberate self-harm cases studied, Asian women had the highest overall rates; 1.6 times those of white women and 2.5 times the rate among Asian men. In young Asian females (i.e. under 30 years of age) the rates were 2.5 times those of white women and 7 times those of Asian men.

•As South Asian female adolescents grow older, the rates of self-harm increase; particularly the rates of self-harm for Asian females aged 18–24 are significantly higher.

•This suggests that they come under more stress. The stress may relate to gender role expectations, pressure for arranged marriage, individualisation and cultural conflict, which may precipitate attempts of self-harm.

•A qualitative study of South Asian women in Manchester found that issues such as racism, stereotyping of Asian women, Asian communities, and the concept of "izzat" (honour) in Asian family life all led to increased mental distress. The women in this study saw self-harm as a way to cope with their mental distress.

South Asian women – newer evidence

•Literature - Low rates of suicide in older men of the South Asian diaspora and high rates in young women have been reported across the world.

•Recent study by McKenzie et al. (BJPsych 2008) found that men of South Asian origin in England and Wales have a relatively low age-standardised suicide rate and women of South Asian origin have marginally raised suicide rates.

•The suicide rates for people of South Asian origin in England and Wales decreased between 1993–1998 and 1999–2003

•“only a modestly elevated suicide rate in women of South

Asian origin under 35 years of age. Contrary to the previous

literature, in more recent years young women of South Asian

origin were not at increased risk of suicide.”

•“All previous studies report rates of suicide for older women

of South Asian origin that are similar to or lower than England

and Wales, or White comparison groups. Our study reports a marked increase in suicide rates particularly in people aged over 65 years.”