From categories to contexts: a decade of the 'new cross-cultural psychiatry'

Human rights and the trauma model: genuine partners or uneasy allies?

Since World War II, a comprehensive body of international law has developed to protect and promote human rights. Three generations of rights can be delineated: civil and political; economic, social and cultural; and collective rights. The convergence of a medical rights-based campaign in the late 1970s with the emergence of the new trauma model resulted in mental health professionals playing a prominent role in documenting and protecting civil and political rights. Economic, social, and cultural rights also emerged as being pivotal, particularly in the Australian context as mental health professionals began to work with excluded populations such as asylum seekers. Consideration of third-generation rights raises important questions about the responsibilities facing mental health professionals applying the trauma model to non-Western settings.

Is it always the same? Variability of depressive symptoms across six European countries

Using common diagnostic systems together with structured interviews to assess mental disorders has made it possible to compare diagnostic groups of mental disorders across countries. The implicit assumption is that the symptomatology of a particular disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) will not vary between different countries. However, it is conceivable that there will be some variability in the symptom patterns. The present study examines if differences in depressive symptom patterns across European countries can be found and if there are different associations between symptoms and the latent construct depression. Data from 4025 individuals of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project were analysed. Individuals were interviewed using the Composite International Diagnostic Interview (CIDI 3.0). Confirmatory factor analysis was used to examine the associations between depressive symptoms and the latent construct of depression in each country. The proportions of endorsed symptoms of depression showed only slight variation across European countries and only minor to moderate differences in the associations between depressive symptoms and the latent construct depression. The results demonstrated that in European countries using a fully structured and standardized interview based on European-American diagnostic concepts leads to similar results with regard to depressive symptom patterns.

Negotiating candidacy: ethnic minority seniors' access to care

The 'Barriers to Access to Care for Ethnic Minority Seniors ' (BACEMS) study in Vancouver, British Columbia, found that immigrant families torn between changing values and the economic realities that accompany immigration cannot always provide optimal care for their elders. Ethnic minority seniors further identified language barriers, immigration status, and limited awareness of the roles of the health authority and of specific service providers as barriers to health care. The configuration and delivery of health services, and health-care providers' limited knowledge of the seniors' needs and confounded these problems. To explore the barriers to access, the BACEMS study relied primarily on focus group data collected from ethnic minority seniors and their families and from health and multicultural service providers. The applicability of the recently developed model of 'candidacy', which emphasises the dynamic, multi-dimensional and contingent character of health-care access to ethnic minority seniors, was assessed. The candidacy framework increased sensitivity to ethnic minority seniors' issues and enabled organisation of the data into manageable conceptual units, which facilitated translation into recommendations for action, and revealed gaps that pose questions for future research. It has the potential to make Canadian research on the topic more co-ordinated.

Postmodernity and mental health

Contemporary Western societies are characterized by rapid social transformations, the scope and pace of which are unprecedented in comparison to previous eras. This new era is often referred to as "postmodern." Social theory suggests that such transformations influence multifarious processes related to psychiatry, including risk factors, help-seeking behavior, the clinical encounter, and clinical outcomes. I introduce and critically discuss five key themes that arise out of sociological analysis of postmodernity and that may have special relevance to psychiatry: (1) individualization; (2) social roles and self-identity; (3) the culture of expertise; (4) the transformation of intimacy; and (5) future orientation. Although extant work implicitly corroborates the importance of the identified themes as influences relevant to psychiatry, little work in psychiatry has explicitly applied these themes or investigated their impact. Further integration of these themes into research may give a fresh perspective on important issues pertinent to contemporary psychiatry.

Pills that swallow policy: clinical ethnography of a Community Mental Health Program in northern India

India's National Mental Health Program (NMHP) was initiated in 1982 with the objective of promoting community participation and accessible mental health services. A key component involves central government calculation and funding for psychotropic medication. Based on clinical ethnography of a community psychiatry program in north India, this article traces the biosocial journey of psychotropic pills from the centre to the periphery. As the pill journeys from the Ministry of Health to the clinic, its symbolic meaning transforms from an emphasis on accessibility and participation to the administration of a discrete ;treatment.' Instead of embodying participation and access, the pill achieves the opposite: silencing community voices, re-enforcing existing barriers to care, and relying on pharmacological solutions for psychosocial problems. The symbolic inscription of NMHP policies on the pill fail because they are undercut by more powerful meanings generated from local cultural contexts. An understanding of this process is critical for the development of training and policy that can more effectively address local mental health concerns in rural India.

The Health and Well-being of Jewish People Aged 65 to 85 Years Living at Home in the East End of London

Relatively little is known about what has been termed cultural gerontology, or the experience of ageing among members of particular ethnic minority groups. One of the greatest gaps in current knowledge relates to the subjective health status and use of health services among elderly people in ethnic minorities, particularly those who are Jewish. The research results reported here are from a survey of elderly people in City and Hackney, London, of whom 16% were Jewish. They show that Jewish respondents were more likely than other elderly people to report problems with emotional well-being, with mental and physical health and with functional ability (tasks of daily living). Jewish respondents were also more likely to use services, particularly health services, than other respondents. The associations with service use generally remained after health status had been controlled for.

Health seeking for ambiguous symptoms in two cultural groups: a comparative study

This study examined cultural differences in health seeking for medically ambiguous symptoms in women from two culturally diverse communities. Thirty-five South Asian immigrants and 36 European Americans participated in a health history interview. Though the types and relative frequencies of practices were similar across the two groups, the goals and underlying logic supporting practices differed sharply. Among European Americans, practices were focused on the need to increase energy, creativity, and output; among South Asians, practices emphasized storing up strength through increased consumption or reduced expenditure. We conclude that the relationship between conceptual models of cause and cure depends on the ;match' of both to broader, unarticulated cultural models of health and illness.

Are there 'casual users' of cocaine?

Medical and public opinion about cocaine use have shifted dramatically over the past decade. New research methodologies and definitions to evaluate the impact of cocaine are needed. This paper presents a theoretical definition and empirical analysis of the 'casual user' of cocaine. Data have been drawn from a subsample of 58 cocaine users and their cocaine-using contacts in Rotterdam. The methodology of the study presents a novel approach to patterns of cocaine use involving the integration of social network variables with 'snowball' sampling data collection techniques. The theoretical definition is systematically related to two social context variables: (1) the scope of settings where contacts use cocaine; (2) the degree of involvement in social network relations of actual cocaine use. Scope of settings has been defined in terms of the number of cocaine-using social circuits contacts are drawn from: i.e. 'narrow' setting where all contacts originate from one circuit while a 'wide' setting indicates contacts come from two or more circuits. Involvement has been defined in terms of the percentage of contacts where the relation with study participants is characterized by cocaine use most or all of the time. Additional social network variables measuring the mean duration (in years) of contacts' cocaine use and the use of cocaine with contacts in the last six months are subsequently related to the scope and involvement variables. The implications of the analysis for a new cross-classification of cocaine use patterns are discussed with special reference to public health policy issues.

Stigma and explanatory models among people with schizophrenia and their relatives in Vellore, south India

BACKGROUND

Stigma associated with mental illness affects patients and their families. Diverse beliefs about the cause and treatment of schizophrenia are common among patients and their relatives.

AIM

To study the association between stigma and beliefs about illness in patients and their relatives.

METHOD

Standard instruments were used to assess beliefs about illness and about stigma among patients with schizophrenia and relatives in Vellore, south India.

RESULTS

The majority of the patients and their relatives simultaneously held multiple and contradictory models of illness and its treatment. Stigma among patients with schizophrenia and their relatives is associated with specific beliefs about causes of mental illness.

CONCLUSIONS

Beliefs may play a role in mitigating or may aggravate the effects of stigma. The cross-sectional study design precludes definitive conclusions on direction of the causal association.

A cross-national study of the stigmatization of severe psychiatric illness: historical review, methodological considerations and development of the questionnaire

Despite their potential significance for public policy and health provision in different societies, popular conceptualizations of and social responses to severe psychiatric illness remain relatively unexamined. Two general research procedures may be identified: (1) the anthropological approach uses ethnographic methods to look at explicit categorizations, and (2) the sociological approach employs quantitative survey methods to examine the public ;stigma' of psychiatric illness. This article reviews methodological and conceptual approaches to the study of stigma and describes the development of an ethnographically grounded questionnaire to examine ;stigmatization' from data in different cultures. The difficulties of achieving cross-cultural comparability of meaning are discussed and the psychometric properties of the instrument are presented.

Seeking help for attention deficit hyperactivity disorder in developing countries: A study of parental explanatory models in Goa, India

This qualitative study analyzes the explanatory models employed by parents whose children have been diagnosed with attention deficit hyperactivity disorder (ADHD) and the ways in which these explanatory models change as they seek help for their child's problem. In-depth interviews were conducted with 24 parents recruited from a list of children who had been diagnosed with ADHD at a community-based child development center (CDC) in Goa, India. The most frequent reasons for consulting the CDC were educational difficulties. Despite having received an ADHD diagnosis and reporting significant adverse impact of the child's behavior, most parents were reluctant to accept the biomedical explanatory model or even consider their child's difficulties as an illness. Instead, parents most commonly attributed causality to psychological models, learning and memory difficulties, and to models which emphasized either the volitional or non-volitional nature of the problem, or to attribute blame of self or spouse. Interventions most commonly used were educational and religious; consultation with the CDC was the last resort for many parents. We conclude that cultural attitudes towards mental illness significantly affect parental perception and behavior in response to interventions by biomedical practitioners for child mental health problems in developing countries.

The performance of the Edinburgh Postnatal Depression Scale in English speaking and non-English speaking populations in Australia

BACKGROUND

The Edinburgh Postnatal Depression Scale (EPDS) has been widely used to assess maternal depression following childbirth in a range of English speaking countries, and increasingly also in translation in non-English speaking ones. It has performed satisfactorily in most validation studies, has proved easy to administer, is acceptable to women, and rates of depression in the range of 10-20% have been consistently found.

METHODS

The performance of the EPDS was compared across different population samples in Australia: (i) Women born in Australia or in another English speaking country who completed the EPDS in English as part of the 1994 postal Survey of Recent Mothers (SRM) 6-7 months after birth (n = 1166); (ii) Women born in non-English speaking countries who also completed the EPDS in English in the same survey (n = 142); and (iii) Women born in Vietnam (n = 103), Turkey (n = 104) and the Philippines (n = 106) who completed the EPDS 6-9 months after birth in translation in the Mothers in a New Country Study (MINC) study (total n = 313). The pattern of item responses on the EPDS was assessed in various ways across the samples and internal reliability coefficients were calculated. Exploratory factor analyses were also conducted to assess the similarity in the factor solutions across the samples.

RESULTS

The EPDS had good construct validity and item endorsement by women was similar across the samples. Internal reliability of the scale was also very satisfactory with Cronbach's alpha for each sample being > or = 8. Between 39 and 46% of the variance in each of the three main samples was accounted for by one principal factor 'depression' (6-7 items loading), with two supplementary factors 'loss of enjoyment' (2 items loading) and 'despair/self-harm' (2-3 items loading) accounting for a further 20-25% of the variance. Alternative one and two factor solutions also showed a great deal of consistency between the samples.

CONCLUSIONS

The good item consistency of the EPDS and the relative stability of the factor patterns across the samples are indicative that the scale is understood and completed in similar ways by women in these different English speaking and non-English speaking population groups. With the proviso that careful translation processes and extensive piloting of translations are always needed, these findings lend further support to the use of the EPDS in cross-cultural research on depression following childbirth.

A biomedical educational intervention to change explanatory models of psychosis among community health workers in South India

BACKGROUND

Community health workers in developing countries commonly hold indigenous beliefs about mental illness which differ markedly from biomedical models.

AIM

To test the effect of a biomedical intervention on explanatory models (EMs) of community health workers.

METHODS

Indigenous beliefs about chronic psychosis were elicited from community health workers. The Short Explanatory Model Interview formed the basis of the interview. Half the workers were taught about the biomedical model after discussing their EMs of chronic psychosis. The others did not receive education. The beliefs of all community health workers were reassessed 2 weeks after the initial assessment.

RESULTS

A variety of indigenous beliefs, which contradicted the biomedical model, were elicited at the baseline evaluation. Seeking biomedical help at follow up was significantly related to receiving education about the biomedical aspects of chronic psychosis (OR 17.2; 95% CI: 18.75, 15.65; p<0.001). This remained statistically significant (OR 9.7; 95% CI: 82.28, 1.14; p<0.04) after using logistic regression to adjust for baseline variables.

CONCLUSION

The high prevalence of non-medical beliefs among community health workers suggests the need to elicit and discuss beliefs before imparting knowledge about biomedical models of mental disorders. Biomedical educational intervention can change EMs of mental illness among health workers.

Group counseling and psychotherapy across the cultural divide: the case of Ethiopian Jewish immigrants in Israel

Effective counseling across a cultural divide depends on adaptations or changes of technique to suit the particular intercultural circumstances. The concept of mutual creative space provides a guiding principle for therapists who wish to make such changes. This space is 'negotiated' between the therapist/counselor coming from the 'dominant/mainstream' group within society, and the group participants who arrive from another culture. Mutual creative space consists of the negotiation of power and a process of mutual invention, incorporating the creation, by therapist and participants, of something new that did not exist in either of their cultures of origin. A meaningful encounter and effective group counseling can take place following the negotiation of such a creative space. This is illustrated by the example of intercultural group work with Ethiopian Jewish immigrants in Israel, including an analysis of cultural characteristics of the Ethiopian group and specific ways of negotiating mutual creative space in this case. Issues discussed include: establishing trust in the cross cultural context; the use of body language and its interpretation; the psychologist as an authority figure; active participation vs. hidden learning; and working with dreams in such groups.

Explanatory models of common mental disorders among traditional healers and their patients in rural south India

OBJECTIVE

To delineate concepts, categories, causes of common mental disorders (CMD) and their treatment as understood by traditional healers practicing in rural South India.

METHODS

Key informant interviews, focus group discussions and in-depth interviews with traditional and faith healers were conducted to identify concepts, causes, presentations and treatments for CMD. Patients attending clinics conducted by these healers were interviewed using the Tamil versions of the Revised Clinical Interview Schedule (CIS-R) and the Short Explanatory Model Interview (SEMI) in order to identify CMD and understand their explanatory models of illness respectively.

RESULTS

Different terms, concepts and treatments were used by traditional and faith healers. A total of 72 patients were interviewed using the CIS-R and the SEMI. Thirty (42.3%) satisfied the International Classification of Diseases-10 Primary Care Version criteria for CMD. Mixed anxiety depression was the most common diagnosis (40%).

CONCLUSIONS

An understanding of local patient perspectives of common mental disorders will allow modern medicine to provide culturally sensitive and locally acceptable health care.

Beyond the 'new cross-cultural psychiatry': cultural biology, discursive psychology and the ironies of globalization

The 'new cross-cultural psychiatry' heralded by Kleinman in 1977 promised a revitalized tradition that gave due respect to cultural difference and did not export psychiatric theories that were themselves culture bound. In the ensuing years, the view of culture within anthropology has continued to change, along with our understanding of the relationship of biological processes to cultural diversity, and the global political economic contexts in which mental health care is delivered. This article considers the implications of these new notions of culture, biology and the context of practice for theory in cultural psychiatry. The future of cultural psychiatry lies in advancing a broad perspective that: (a) is inherently multidisciplinary (involving psychiatric epidemiology, medical anthropology and sociology, cognitive science and social psychology), breaking down the nature/culture dichotomy with an integrative view of culture as a core feature of human biology, while remaining alert to cultural constructions of biological theory; (b) attends to psychological processes but understands these as not exclusively located within the individual but as including discursive processes that are fundamentally social; and (c) critically examines the interaction of both local and global systems of knowledge and power. Globalization has brought with it many ironies for cultural psychiatry: Transnational migrations have resulted in cultural hybridization at the same time as ethnicity has become more salient; the call for evidence-based medicine has been used to limit the impact of cultural research; and cultural psychiatry itself has been co-opted by pharmaceutical companies to inform marketing campaigns to promote conventional treatments for new populations. Cultural psychiatry must address these ironies to develop the self-critical awareness and flexibility needed to deliver humane care in shifting contexts.

Grappling with affliction: autism in the Jewish ultraorthodox community in Israel

In this essay we seek to examine the cultural tool kit employed in the Jewish ultraorthodox community to cope with autism, a predicament deemed resistant to massive cultural molding. Through 30 open-ended interviews with ultraorthodox mothers of children with autism we portray the mothers' emerging recognition of the disorder, their care seeking activities, and their construction of explanatory models. The health care system on which the ultraorthodox mothers rely is extremely diverse, including mainstream medical and educational services, various alternative therapies, therapies specific to autism, and spiritual and mystical interventions. The outcome of these endeavors is a dual system of illness perception in which bio-medical and spiritual-religious frames of references coexist. This duality cuts across all the facets of the explanatory system: etiology, pathophysiology, treatment, and prognosis. Metaphysical accounts, and especially the notion of the transmigration of souls, serve as meta-accounts, bridging the epistemological gap between God's mysterious intention and the specific bodily mechanisms underlying the disorder. The religious and moral theme of suffering is highlighted in the narratives as a salient constituent of the ultraorthodox mothers' attempts to understand and come to terms with their plight.

Race, culture and psychiatry: a history of transcultural psychiatry

The term 'transcultural psychiatry' has encompassed changing notions of race, culture and psychiatry and, as a result, it is a difficult concept to define. For a long time psychiatrists and social scientists have been commenting on how the psyches and psychiatric illnesses differ in non-White populations. However, transcultural psychiatry was not created as a distinct discipline until after World War II. This article will attempt to tell the story of transcultural psychiatry, charting its genesis in the aftermath of World War II, and then go on to describe how it has taken different forms in response to developments within psychiatry and wider sociocultural changes.

Insight in people with psychosis: the influence of culture

The assessment of insight is a part of the routine clinical examination for people with mental illness. Such assessment, by psychiatrists, is based on the current definitions of insight, which rely on western notions of health and illness. This paper discusses the recent findings of explanatory models of people with a variety of physical diseases in Vellore, India. It also summaries the results of studies on insight in schizophrenia, which examined explanatory models of illness among patients, relatives, and the general population, in Vellore. The findings argue for the fact that the assessment of insight should be against the local cultural standards rather than universal yardsticks.

A comparative study of diagnostic practice in psychiatry in Northern Norway and Northwest Russia

BACKGROUND

The co-operation between psychiatrists in Norway and Russia is increasing. The object of this study was to find out whether there were differences in diagnostic practice of psychiatrists in both countries, to look at the nature of the differences and to examine whether these differences affected diagnostic quality.

METHOD

Thirty medical doctors working at psychiatric hospitals in both countries diagnosed 12 clinical case vignettes selected from a wide spectre of psychiatric disorders.

RESULTS

The Russian clinicians used a larger range of diagnoses than the Norwegians. The Russians tended to diagnose schizophrenia and schizophrenia-like disorders in cases that presented psychotic syndromes, and somatoform disorders in cases that presented agoraphobia. The Norwegians tended to evaluate affective aspects in preference to psychotic symptoms in the case of schizoaffective disorder and overestimate the degree of depression. In general, the Russians had lower total score of correct answers than the Norwegians.

CONCLUSION

In spite of the limitations due to minor differences in the data collection phase in the two countries, the study clearly demonstrates differences in diagnostic practice between the countries.

Explanatory models of psychosis among community health workers in South India

OBJECTIVE

To examine commonly held indigenous beliefs about mental illness, which often differ markedly from the biomedical models, among community health workers in rural South India.

METHOD

Indigenous beliefs about chronic psychosis were elicited from community health workers. The Short Explanatory Model Interview formed the basis of the interview.

RESULTS

A variety of indigenous beliefs, which contradicted the biomedical model, were elicited. A significant proportion of health workers did not recognize chronic psychosis as a disease condition, believing that it was caused by black magic, evil spirits and poverty, and felt that doctors could not help.

CONCLUSION

The results of the study suggest that training programmes should elicit and discuss local beliefs prior to the teaching of the biomedical model of mental disorders.

Cross-cultural encounters between careproviders: rabbis' referral letters to a psychiatric clinic in Israel

This paper explores the meaning and social functions of referral letters sent to a mental health clinic in Israel by Haredi (ultra-orthodox) rabbis. The letters exemplify social mechanisms by which various institutions and individuals (careproviders, therapists, and other social actors) negotiate different therapies, advice, and interventions in cross-cultural encounters. We argue that beyond the practical functions of the letters, the rabbis-representatives of a "popular" and religious social sphere-use them to negotiate their position in relation to the psychiatric clinic as a representative of a professional and secular sphere. We show that the rabbis "submit" to the professional and secular therapists by using a local adaptation of Western psychological and psychiatric discourses (instead of a religious or mystical discourse), but also that by choosing a letter as their preferred medium of communication (instead of a personal visit to the clinic), they distance themselves from it. We suggest that the rabbis reconstitute, via the letters, social boundaries within their religious community and between their community and secular society. Hence, through analysis of discourses of mental illness in a cross-cultural encounter we examine ways in which illness is practically managed among diverse groups in society. Specifically, we analyze such discourses as part of a power relationship between careproviders who belong to different therapeutic social spheres, using a phenomenological exploration of how mental illness is perceived and constructed as both "a medical problem" and as "social deviance".

[The competent cell - the immune system as a metaphor, sign, language and culture]

We investigated how the progressive function of the metaphor, the model world of signs, language and culture, link the cell's immunological knowledge with a perceivable concept of the body. Using ethnomethodologically oriented, partly interpretative text analysis, we examined the lymphocyte stimulation test, word clusters in immunology and other medical specialties, the linguistic presentation of the body in German, American and the internet, the presentation of the "self" of the cell in biology and immunology, and protocols of oncological out-patient interviews and chatrooms. When an abstract sign model is created, then the existence of a "negotiable", "competent" and "tolerant" immune cell is predominated by the concept of a cell and much less by elements of the body. Thus, the passive, spatial-anatomical concept of the body can be overcome and the position of the microscopically describable inner observer achieved. This is related to the American concept of a body that can be formed at will from animated individual parts. This model immune system impresses upon physical life and also provides a new metaphor for human interaction in accordance with the pattern of immunocompetent cells.

[Health concepts in current science-oriented discourse]

This article analyzes health as a concept in some science-oriented discourses by representative authors of functional sociology, anthropology and epistemology, by focusing their notions of illness and procedures. In the field of sociology, the ideas of normality, labeling, and deviation from labeling patterns stand out. Additionally, we present the main health models in North American health anthropology and evaluate the proposition of a new perspective that intends to overcome the duality between culture and society - the theory of signal, meaning and practice systems. We also analyze the Canguilhemian difference between normality and health, as well as the notion of health as normative capacity. Finally, we propose the distinctive concepts of primary, secondary and tertiary health as the first step of a theoretical construction that can guide health policies and social procedures based on a positive notion of health.

Cross-cultural aspects of social anxiety disorder

Cross-cultural perspectives have much to teach about psychopathology in general and about SAD in particular. The authors accept that the construct of SAD (like that of other anxiety disorders) cannot simply be interpreted as a category fallacy. Universal psychobiological mechanisms are likely important in determining the onset of SAD; empiric, epidemiologic, and neurobiological data provide some support for this argument, and clinical data confirm that patients can experience onset of anxiety disorders in the absence of exposure to cultural narratives about their symptoms. Nevertheless, culture may exert important influences on the experience and expression of anxiety disorders. In the clinic, the authors believe that it is often useful to ask patients about their view of disorders such as SAD and about their opinion of the etiology and optimal treatment of their symptoms. Subsequent negotiation can take place between the clinician's model of the disorder and that of the patient. A shared view of the etiology and treatment is likely to result in the patient feeling more understood and in greater compliance with prescribed treatment. There is an important clinical lesson in the observation that Western scales of anxiety are not always cross-culturally valid. It is also important to recognize that anxiety disorders are not simply the result of culturally influenced interpretations of an underlying disease but rather that anxiety disorders are also disorders of the interpretive process. From the perspective of research, cross-cultural differences in social anxiety disorder suggest a number of interesting leads for further work. Neurobiological and psychopharmacologic investigation of overlap and differences between Western SAD and Eastern TKS may provide helpful new insights. The possible existence of a group of Western SAD patients with poor insight, for example, deserves further scrutiny and research. Women and people with lower socioeconomic status are at greater risk for developing SAD; the mechanisms underlying these associations require further study. Future investigation of the contribution of sociocultural mechanisms to the course of SAD may provide an important avenue toward understanding this complex disorder.

Re-examining the psychology of spinal cord injury: a meaning centered approach from a cultural perspective

OBJECTIVES

To examine the impact of SCI from a non-Western cultural perspective.

SETTING

India.

METHODS

A philosophical approach.

CONCLUSION

Management of the individual with spinal cord injury needs to take in to account the individual's beliefs and cultural context.

Depression and social change. From transcultural psychiatry to a constructivist model

Based on the findings of previous studies carried out by our group, which will be briefly summarised, the present paper puts forward several hypotheses to account for the evolution of depressive symptoms and the possible increase observed in risk of depression subsequent to social changes. The particular mood disorders presented by Senegalese emigrants and several protective factors which appear to determine a low risk in these populations, such as a strong social support, will be examined. Based on a previous investigation carried out by our group, which seems to indicate the presence of depressive pictures among poorly westernised populations such as the Peul nomads or Dogon farmers from the Sub-Saharian regions, the hypothesis that "westernalisation" (considered as the loss at an individual level of traditional ways of life, working habits, cultural patterns and languages in favour of different attitudes influenced by western culture) may represent a risk factor for depressive illness, in its clinical expressions commonly observed in western contexts, has been considered. In these populations, with the exception of educated individuals, the albeit rare depressive symptoms appear to be secondary to serious somatic disorders. Research performed identified two well-defined means of clinical expression, which has been termed, respectively, "western style" or "guilty" and "traditional" or "dislocation from the group". Further studies carried out in rapidly changing areas seem to indicate how environmental factors are able to influence the evolution of depressive symptoms from the first form to the latter and to modify the threshold of onset of emotive, behavioural and depressive patterns. It has been hypothesised that rapid changes in the social organisation tend to exacerbate attitudes of "compulsive hyper-responsibilisation", a cognitive set of basic assumptions which may be considered at the same time both as a product of "westernalization" at an individual level and a risk factor for depression. Individuals who possess these basic characteristics, subsequent to the opportunities afforded by the social changes, tend to develop new complex systems of interpreting reality, causality, controlling of events and ways of expressing emotions. Accordingly, we herewith propose a reviewal of the entire threshold concept and provide a means of interpreting the transformation in depressive phenomena in view of the fact that, although the new levels of knowledge and learning better equip subjects to face the new situations, they also render them more vulnerable to depression.

Cultural factors and international epidemiology

The debate on the role of culture on psychiatric epidemiology has evolved considerably in the past two decades. There is now a general consensus that the integration of the universalist and culturally relativist approaches, and their methodologies, is required to generate a truly international psychiatric epidemiology. The large body of research investigating the influence of culture on the epidemiology of depression has produced a number of key findings: the clinical presentation of depression in all cultures is associated with multiple somatic symptoms of chronic duration; psychological symptoms, however, are important for diagnosis and can be easily elicited. The diagnostic differentiation between depression and anxiety in general health care settings is not clinically valid. Culturally appropriate terminology for depression can be identified and their use may improve levels of recognition and treatment compliance. It is also evident that culture is only one factor in the difference between, and within, human societies which has a bearing on the epidemiology of depression. Other factors, which may interact with culture, such as gender and income inequality, are major risk factors for depression. Future international research must focus on two themes: (i) intervention studies including cost-effectiveness outcomes; and (ii) research aiming to bridge the gap between regional public health priorities and the concern that psychiatrists have about depression.

Against over-interpretation: the understanding of pain amongst Turkish and Kurdish speakers in London

The understanding of experienced pain has recently moved from the biological to the metaphorical. Detailed interviews with twelve Turkish and Kurdish patients in London who had been unsuccessfully investigated medically for chronic pain showed that their understanding reflected local, typically humoural, conceptions of self and body. However there was little to suggest interpretation of the illness as a more specific and grounded idiom for social or political experience. It is suggested that the current vogue for 'interpretation' in medical anthropology and social psychiatry may occasionally be, as Umberto Eco puts it, 'over-interpretation'.

Investigation of validity of closed questions in a survey of British South Asian and white populations

OBJECTIVES

The paper concerns the validity of closed-format questions in an interview-based population survey and focuses on a comparison of South Asian and white respondents.

METHOD

A two-part interview consisting of open, respondent-centred questions followed by closed questions taken from a large-scale interview-based health survey was carried out with 15 persons from white and 14 from South Asian communities resident in the UK. Interviewees' views of their stays in hospital was the focus.

RESULTS

The two-part interview was found to provide a broadly satisfactory method for the investigation of validity although a limitation was recognised. Twenty-nine per cent of the variation in response to a closed question on 'overall satisfaction' was predictable from views expressed in the open interview. The views of both groups, as expressed in the open interview, were inadequately represented by the closed questions. This appeared to be especially true for the South Asian sample. The validity of the closed question appeared greater for white than for South Asian interviewees.

CONCLUSIONS

It is concluded that when designing and piloting health surveys consideration should be given to members of all communities to be included in the survey.

Attitudes towards mental health in an urban Pakistani community in the United Kingdom

The aim of this study was to investigate the attitudes of Pakistani families living in an urban area of the United Kingdom, towards mental health issues, to identify the emic models used and compare them with the etic model, predominant in Western medicine. This would allow the exploration of some of the inconsistencies in the research literature relating to the incidence of mental illness in this cultural group. The second aim was to explore the needs of this community, particularly women, in relation to mental health services. Due to problems gaining access to females on their own, interviews were held with family groups. Findings suggested that there were differences in the models of mental illness being employed with greater somatisation of symptoms in the Pakistani group and an emphasis on aggressive behaviour as a significant symptom. Treatment expectations also varied with some emphasis on traditional Pakistani treatments such as Faith healers and Hakims as well as General Practitioners and hospital treatments. Language difficulties, religious and cultural practices were also identified as barriers to female treatment in particular. Recommendations were made for improved training for interpreters and more emphasis on cultural factors and emic models of mental illness as part of medical training.

The place of culture in DSM-IV

This paper critically reviews the process and outcome of an effort to enhance the cultural validity of DSM-IV and outlines recommendations to improve future diagnostic systems. An ordered presentation of the antecedents and the main phases of this developmental effort is followed by a content analysis of what was proposed and what was actually incorporated, and a conceptual analysis of underlying biases and their implications. The cultural effort for DSM-IV, spearheaded by a scholarly independent NIMH workgroup, resulted in significant innovations including an introductory cultural statement, cultural considerations for the use of diagnostic categories and criteria, a glossary of culture-bound syndromes and idioms of distress, and an outline for a cultural formulation. However, proposals that challenged universalistic nosological assumptions and argued for the contextualization of illness, diagnosis, and care were minimally incorporated and marginally placed. Although a step forward has been taken to introduce cultural elements in DSM-IV much remains to be done. Further culturally informed research is needed to ensure that future diagnostic systems incorporate a genuinely comprehensive framework, responsive to the complexity of health problems in increasingly multicultural societies.

Clinical relevance of contemporary cultural psychiatry

In recent years, the field of cultural psychiatry has gained recognition and accumulated evidence of its clinical relevance. This article examines the intersections of culture and psychopathology and describes five independent but interrelated clinical dimensions that identify and define culture as: a) an interpretive/explanatory tool, b) a pathogenic/pathoplastic agent, c) a diagnostic/nosological factor, d) a therapeutic/protective element, and e) a service/management instrument. Along these lines, conceptual boundaries, clinical findings, specific applications, and research implications for each of the five dimensions are systematically reviewed. Cultural psychiatry adds significantly to the comprehensiveness of psychiatric evaluation and management and addresses prominent issues regarding understanding, classification, diagnosis, and competent treatment of most psychiatric disorders in every society and region of the world. Based on the strength of these clinical dimensions, and on the related educational and research efforts, cultural psychiatry can also contribute decisively to the design of comprehensive mental health policies.

Social determinants of psychiatric morbidity and well-being in immigrant elders and whites in east London

OBJECTIVES

The social conditions under which migrants to the UK live may be more significant than the experience of migration itself in leading to increased risk of mental illness. We aimed to compare the prevalence of mental, physical and social health problems in elderly Somalis, Bengalis and whites living in a deprived inner London area and examine associations between environmental circumstances, social support, physical health status, mood and life satisfaction in these groups. In addition, we wanted to test the hypothesis that differences in mental health between immigrants and whites are explained by social disadvantages rather than ethnicity.

DESIGN

Cross-sectional survey with participants drawn from age-sex registers of general practices, augmented by other sources.

SETTING

East London--'first-generation' Somali and Bengali immigrants and white British.

SUBJECTS

A total of 274 people aged 60+ years: 72 Somalis, 75 Bengalis and 127 whites.

MAIN OUTCOME MEASURES

Symptoms of Anxiety and Depression Scale (SAD), Life Satisfaction Index (LSI). High SAD scores indicate more anxiety and depression symptoms; high LSI scores indicate greater life satisfaction.

MAIN RESULTS

Highest SAD scores were found among Bengalis; lowest LSI scores were found among Bengalis and Somalis. The prevalences of depression (SAD score 6+) were 25% in Somalis, 77% in Bengalis and 25% in east London whites. Physical health status and SAD scores were associated in Somalis (r = +0.31, p < or = 0.01). Bengalis (r = +0.47, p < or = 0.001) and east London whites (r = +0.27, p < or = 0.01). Physical health problems also related to lower LSI scores in Somalis (r = -0.24, p < or = 0.05) and east London whites (r = -0.24, p < or = 0.01). Social factors (i.e. poor housing conditions, low family support and reported need of community services) were strongly associated with SAD scores among Somalis (r = +0.5, p < or = 0.001) and, to a lesser extent, among Bengalis (r = +0.33, p < or = 0.01). Ethnicity (i.e. being an immigrant as opposed to a non-immigrant) became a statistically non-significant risk factor for high SAD scores after adjusting for the effects of age, weekly income, physical health and social problems (OR = 0.71, 95% CI = 0.5-1.1, p = 0.09). A residual, but much attenuated effect for ethnicity on LSI scores persisted in the estimated model after controlling for the same set of independent risk factors (OR = 0.7, 95% CI = 0.4-1, p = 0.05).

CONCLUSION

The marked variation in mental health between ethnic groups in east London might be a reflection of socioeconomic and health differentials acting concomitantly and adversely. Inequalities in housing, social support, income and physical health status accounted for variation in mood observed between immigrants and whites, and may partly explain differences in life satisfaction. These results seem to support a 'multiple jeopardy' theory of ageing in ethnic minorities in east London. Greater efforts are needed to recognize anxiety and depression in immigrant elders. Better social support and housing among 'minority ethnic' elders who live alone might be expected to alleviate social stress and improve mental health and psychological well-being.

Culturally sensitive validation of screening questionnaires for depression in older African-Caribbean people living in south London

BACKGROUND

We tested the validity of two screens for depression in older African-Caribbean adults, the 15-item Geriatric Depression Scale (GDS) and a new Caribbean Culture-Specific Screen for emotional distress (CCSS). Two independent criteria were used for validity: (a) a psychiatric diagnosis derived from GMS-AGECAT, and (b) a culturally sensitive assessment of mental disorder, derived from a tool developed with local African-Caribbean religious healers.

METHOD

One hundred and sixty-four consecutive African-Caribbean primary care users, aged 60 years or older, were screened with the GDS and the CCSS. Diagnostic interviews were carried out on 80% of high scorers and 20% of low scorers.

RESULTS

The number of cases detected by the two separate diagnostic approaches was similar. However, the agreement between who was and who was not a case was only modest. At a cut-off of > or = 5, the GDS was an adequate case detector for psychiatric depression, and, at a cut-off of > or = 4, for 'depressed/lost spirit', as defined by culture-specific criteria. It performed as well as the new CCSS.

CONCLUSIONS

At a cut-off of > or = 4 the 15-item GDS can be recommended as a case detector for significant forms of depression in older African-Caribbean people living in south London.

Culture and classification: the cross-cultural application of the DSM-IV

Changes incorporated into the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) include a number of features designed to enhance its cross-cultural applicability. However, the overt move toward a culture-sensitive nosology is undermined by an implicit assumption of the universality of its primary syndromes. In this review we argue that the DSM-IV's underlying thesis of universality based on Western-delineated mental disorders is problematic and has limited cross-cultural applicability. Research on the cross-cultural manifestation of schizophrenia and depression shows that presentation of these disorders varies significantly across cultures. We conclude by discussing the research and clinical implications of these findings.

The indigenous psychiatry of Ladakh, part II: Narrative and metanarrative in the cultural control of dissociative states in the Himalayas

In traditional Ladakh (NW India, Tibetan) men are less frequently sufferers from dissociative possession by 'witches' than are women, but they may be possessed by spirits of place, plausibly a consequence of their more outward focus on life beyond the household. Where possession leads to authorisation to practice as an oracle healer the 'afflicted' may gain in social status. Male possession is also induced through ritual meditation (visualisation) in monks destined to function as oracles in monastic festivals which have ancient links with traditional government. In these cases the individuals have usually had considerable experience and training in Buddhist mental yoga and have not experienced an initiatory illness. The metanarrative governing these occasions constrains village narratives as an aspect of social control by Buddhist authorities with a long history in the culture of Tibetan-speaking peoples. The functions of shamanic trance and its parallels in the post-modern West are considered.

Common mental disorders, explanatory models and consultation behaviour among Indian women living in the UK

Women of Indian origin are said to have a lower rate of recognized common mental disorders and a higher frequency of consultation in primary care than white British. The aim of this study was to evaluate factors, including explanatory models (patient perspectives) of illness, associated with common mental disorders and with frequency of consultation among women of Indian origin in primary care. The investigation was conducted in a general practice in West London with a large Indian population. Consecutive woman attenders of Indian descent were screened with the General Health Questionnaire-12 to identify probable cases of psychiatric morbidity. 100 patients were interviewed with the Revised Clinical Interview Schedule (CIS-R), a specific tool for the diagnosis of common mental disorders, and the Short Explanatory Model Interview, which elicits the individual's conceptualization of his or her illness. Those patients who satisfied CIS-R criteria were classified as 'cases', the others as 'controls'. Common mental disorders were documented in 30% of patients. The general practitioner's diagnosis of common mental disorders had a sensitivity of 17% and a specificity of 91%. Individuals with common mental disorders had a higher frequency of consultation (P = 0.017), were less likely to see depression as an indication for medical intervention and were more likely to withhold some of their concerns from the general practitioner. Incorrect diagnosis by the GP was most likely to occur when patients did not disclose all their complaints. These associations were all statistically significant after adjustment for possible confounders by multiple linear and logistic regression. Women of Indian origin in this sample had rates of common mental disorders similar to those in other UK populations. Differing conceptualizations of common mental disorders may contribute to their underrecognition in women of Indian origin.

First-onset schizophrenia in the community: relationship of urbanization with onset, early manifestations and typology

As part of a World Health Organization collaborative study in 12 centres in developing and developed countries within defined urban and rural catchment areas with populations of 348,786 and 103,865, respectively, a total of 155 and 54 cases of first-onset schizophrenia, respectively, were identified over a 24-month period by a comprehensive and active recruitment of all cases. Approximately 50% of the subjects in both cohorts were in the age range of 15-24 years. There was a preponderance of males in the younger age group and of females in the older age group. The majority of cases had no family history and had shown good adjustment in childhood and adolescence. The onset was much more frequently acute and much less often insidious in our samples and (more so in the rural cohort), compared to the figure for all developed countries' sites. With regard to early manifestations of the disorder, there was a much higher incidence of loss of interest in appearance and cleanliness, being irritable and angry without reason, and loss of appetite, sleep or interest in sex in both of our samples, and of being excited or overactive for days or weeks in our rural cohort than in the developed countries' centres as a whole. On the other hand, claiming impossible things, behaving as if hearing voices and feeling persecuted, harmed or bewitched were much less frequent in our rural cohort than in the urban cohort or the developed countries' centres as a whole. With regard to the clinical diagnosis of schizophrenia, paranoid, hebephrenic/disorganized and residual types were under-represented in our samples (more so in the rural sample), and catatonic type and acute schizophrenic episode were over-represented compared to the developed countries' centres. Moreover, the proportion of subjects of CATEGO class S+ was lower in our samples. With regard to onset, early manifestations and clinical subtypes of schizophrenia, our rural cohort deviated most from developed countries' centres as a whole, with our urban sample falling in between, thus indicating the role of socio-cultural factors in general, and urbanization in particular, in these variables in schizophrenia.

The Shona Symptom Questionnaire: the development of an indigenous measure of common mental disorders in Harare

The objective of this study was to develop an indigenous measure of common mental disorders (CMD) in the Shona language in Zimbabwe. Ethnographic and qualitative studies elicited idioms of distress of mental disorder leading to the preliminary Shona Symptom Questionnaire (SSQ), and items from the Self-Report Questionnaire (SRQ) were added to it. The 56-item Preliminary Shona Symptom Questionnaire (PSSQ) was administered to 302 randomly selected primary care attenders, of whom 100 were classified as cases on the basis of agreement between care provider assessment and a psychiatric interview. Discriminant analysis identified 14 items that were the strongest predictors of mental disorder. The 14-item SSQ has a high level of internal consistency (Cronbach's alpha = 0.85). The items are a mixture of emic and etic phenomena. The total score correlates strongly with patients' self-assessment of the emotional nature of their illness. Satisfactory specificity and sensitivity occurred at a cut-off point of 7/8. The SSQ is the first indigenous measure of mental disorder developed in sub-Saharan Africa to have included idioms or distress of primary care attenders and involved patients consulting traditional medical practitioners. It promises to be a useful instrument for epidemiological and clinical research. The methodology used is an innovative way of combining etic and emic methods in the evaluation of CMD.

Mental disorders and health care seeking in Bandiagara: a community survey in the Dogon Plateau

A two-level community study was carried out among the Peul and Dogon populations of the Bandiagara plateau (Mali). For the purpose of the study the Questionnaire pour le depistage en santé mentale (QDSM), a 23-item screening questionnaire derived from the Self-Reporting Questionnaire (SRQ), was adapted and validated; internal consistency and accuracy were evaluated. In the first phase of the study, 466 subjects randomly selected on a residential basis were evaluated by means of the QDSM. In the second phase all subjects who were "positive" at the screening, as well as a sample who were "negative", were examined by means of a semistructured interview. When necessary, clinical and laboratory investigations were performed. The estimated prevalence of psychiatric cases was 6.4%. A significant risk was associated with age and education. Somatic diseases frequently associated with psychiatric disorders were genitourinary tract disorders, tuberculosis and disabling cardiopathies. The main factor determining the seeking of medical help either through traditional of conventional health systems was the presence of a somatic disorder. The presence of a true minor psychiatric disorder, however, was often associated with divining practices.

Etic and emic criteria for non-psychotic mental disorder: a study of the CISR and care provider assessment in Harare

The paper describes the relationships between the Revised Clinical Interview Schedule (CISR) and the assessment of psychiatric status by primary care providers in Harare. Primary care clinic (PHC) and traditional medical practitioner (TMP) clinic attenders (n = 302) were interviewed with the Shona Symptom Questionnaire, the CISR and the Explanatory Model Interview. The PHC nurses and TMP were interviewed to elicit diagnostic formulation using the WHO Health Staff Rating codes. "Etic" cases were those who scored 12 or more on the CISR and "emic" cases were those whom the care provider had assessed as having a mental disorder. In all, 52% of subjects were classified as etic cases and 59% as emic cases. Overall agreement between the two criteria was 55%. Three-quarters of care provider "false-positives" were accounted for by a failure to take into account the varying reasons for consultation, such as social or spiritual problems. Most of the "false-negative" groups were symptomatic subjects, though with fewer symptoms than those who were "definite cases". One etic concept-phobia-was not considered as a mental disorder and appeared to lack concept validity in this setting.

The pathways to primary mental health care in high-density suburbs in Harare, Zimbabwe

The pathways to care for mental illness are diverse and are dependent on sociocultural and economic factors. The objective of this study was to describe the pathways to primary care for patients with common mental disorders in Harare. One hundred and nine consecutive patients with conspicuous psychiatric morbidity identified by general nurses in three primary health care clinics (PHC) and by four traditional medical practitioners were interviewed with the Pathways to Care Schedule. Other than those patients with an acute illness, most patients consulted more than one care provider; three-quarters of those with a history of prior consultations had consulted both traditional and biomedical care providers. Biomedical care providers were the most common first care provider consulted; if this treatment failed, then patients tried other biomedical or traditional care providers. Different factors operated in the decision-making process in choosing between consulting biomedical and traditional care providers. Traditional care providers provided explanations more often than biomedical care providers; explanations given were most often spiritual. Injectable treatments were often prescribed for mental illness, especially by private general practitioners (GPs). Such treatments, and many oral treatments, were non-specific. Dissatisfaction with consultations was most commonly due to lack of symptomatic improvement. The costs of consultation were highest for private GPs, general hospitals and traditional healers; faith-healers, PHCs and hospital psychiatric departments were the cheapest.