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Social, Cultural and Ethnic Aspects of Mood Disorders


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A lecture by Dr Imran Waheed, Consultant Psychiatrist, delivered in Birmingham, UK on February 7th 2012. The audience was medical students in Birmingham

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Social, Cultural and Ethnic Aspects of Mood Disorders

  1. 1. Dr Imran Waheed Consultant Psychiatrist Birmingham Central Home Treatment Team Social, Cultural and Ethnic Aspects of Mood Disorders
  2. 2. Presentation Outline <ul><li>Context </li></ul><ul><li>History of depression </li></ul><ul><li>Culture and depression </li></ul><ul><li>South Asian women and depression </li></ul>
  3. 3. Birmingham <ul><li>The 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. </li></ul><ul><li>Research suggests that by 2024 there will be no ethnicity with a majority in Birmingham </li></ul>
  4. 4. History of Depression
  5. 5. “ 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)
  6. 7. History of Depression: Greeks <ul><li>Melancholia, meaning “ black bile ” was used in Ancient Greece. </li></ul><ul><li>The Greeks thought it to be due to an imbalance of the four “ humors ” . </li></ul><ul><li>Hippocrates (460-277 BC) described melancholia as being characterised by “ fears and despondencies ” due to an “ excess of black bile ” </li></ul><ul><li>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 ” . </li></ul><ul><li>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. </li></ul>
  7. 8. History of Depression: Arabs <ul><li>The 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 </li></ul><ul><li>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 ” . </li></ul><ul><li>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 </li></ul>
  8. 10. Modern History of Depression <ul><li>Robert 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 ” </li></ul><ul><li>Johann Christian Heinroth (early 19 th C) believed that sin was the causal factor in mental illness – “ the offending of an individual ’ s morals by their own thoughts ” . </li></ul><ul><li>Depression as a term gained currency in the 19 th century </li></ul><ul><li>From the Latin “ deprimere ” – to “ press down ” </li></ul><ul><li>Some languages where there is no equivalent of “ depression ” but there are words meaning sadness, lack of energy, etc. </li></ul>
  9. 11. Treatment through the ages <ul><li>Ancient Egyptians: Recreational activities such as concerts, dances and painting. </li></ul><ul><li>Medieval times: emetics, laxatives, leeches, cupping </li></ul><ul><li>Arab world: 1 st psychiatric hospital in Baghdad (705 AD) – baths, music and activities </li></ul><ul><li>17 th Century: restraints, chains, whipping </li></ul><ul><li>Modern times: ECT, antidepressants, psychotherapy </li></ul>
  10. 12. Depression <ul><li>Characterised by low mood, reduction of energy and loss of interest. </li></ul><ul><li>Anhedonia, appetite change, weight loss, early morning waking, diurnal variation, reduced libido, poor concentration, reduced self-esteem, guilt, suicidal ideation, psychomotor retardation. </li></ul><ul><li>Common – 15% of people will have an episode at some point </li></ul><ul><li>WHO predict that by 2020 depression will be the 2 nd largest cause of disability. </li></ul><ul><li>Women twice as likely to suffer from it than men </li></ul>
  11. 14. Culture and Depression <ul><li>The medical model is the dominant model for understanding and treating depression. </li></ul><ul><li>ICD and DSM – probably more “ Western ” than international </li></ul><ul><li>However DSM IV states: “ Culture can influence the experience and communications of symptoms of depression. ” </li></ul><ul><li>“ 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) ” </li></ul>
  12. 15. <ul><li>Emotional symptoms </li></ul><ul><li>Feelings of guilt </li></ul><ul><li>Suicidal </li></ul><ul><li>Lack of interest </li></ul><ul><li>Sadness </li></ul><ul><li>Physical symptoms </li></ul><ul><li>Lack of energy </li></ul><ul><li>Decreased concentration </li></ul><ul><li>Change in appetite </li></ul><ul><li>Change in sleep </li></ul><ul><li>Change in psychomotor skills </li></ul><ul><li>Associated symptoms </li></ul><ul><li>Brooding </li></ul><ul><li>Obsessive rumination </li></ul><ul><li>Irritability </li></ul><ul><li>Excessive worry over physical health </li></ul><ul><li>Pain </li></ul><ul><li>Tearfulness </li></ul><ul><li>Anxiety or phobias </li></ul>American Psychiatric Association (APA). DSM-IV-TR; 2000:352,356. UKCYB00200
  13. 16. Somatisation <ul><li>The occurrence of physical symptoms which are not accounted for by demonstrable physical illness. </li></ul><ul><li>Earlier theories suggested that somatisation was the cultural   equivalent of depression, typically occurring in non-Western   cultures. </li></ul><ul><li>There is now growing evidence that somatic symptoms   are common presenting features of depression throughout the   world </li></ul><ul><li>Colloquial British expressions such as ‘ I   feel gutted ’ also describe feelings of loss and depression   in somatic metaphorical terms. </li></ul><ul><li>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%). </li></ul><ul><li>However,   when somatisation was defined as ‘ medically unexplained   somatic symptoms ’ or ‘ denial of psychological distress ’ ,   no significant variation between centres was found. </li></ul>
  14. 17. Somatisation <ul><li>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). </li></ul><ul><li>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. </li></ul><ul><li>Punjabi women in London (Bhugra  et al , 1997 b ) recognised the   English word ‘ depression ’ , but the older ones used   terms such as ‘ weight on my heart/mind ’ , or ‘ pressure   on the mind ’ . </li></ul><ul><li>Symptoms of ‘ gas ’ and ‘ feelings   of heat ’ were identified, which is in accordance with   traditional and ayurvedic models of hot and cold. </li></ul>
  15. 18. 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 40 Headache, head pains 64 48 Dizziness or faintness 60 14 Feeling of weakness in parts of body 57 23 Muscle pains, aches, rheumatism 53 27 Stomach pains 51 20 Chest pains 46 14
  16. 19. Prevalence of Associated Painful Symptoms in Patients with Depression <ul><li>Studies addressed both depression and painful symptoms, including: </li></ul><ul><ul><li>Headaches </li></ul></ul><ul><ul><li>Back pain </li></ul></ul><ul><ul><li>Neck pain </li></ul></ul><ul><ul><li>Extremity/joint pain </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Pelvic pain </li></ul></ul><ul><ul><li>Abdominal pain </li></ul></ul><ul><ul><li>General pain </li></ul></ul>Mean prevalence data from 14 studies focusing on painful symptoms in patients with depression MDD without painful symptoms 35% MDD with painful symptoms 65% <ul><li>Prevalence was not influenced by psychiatric versus primary care settings </li></ul>Depressed patients Bair MJ, et al. Arch Intern Med. 2003; 163 :2433–2445. MDD=major depressive disorder. UKCYB00200
  17. 21. <ul><li>Early studies showed that South Asian women in the UK had lower rates of depression compared to White British women. </li></ul><ul><li>More recent research suggests that the prevalence is much higher in South Asian women than previously thought. </li></ul><ul><li>Issues of stigma and access to mental health services are important. </li></ul><ul><li>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. </li></ul><ul><li>Some studies have shown that Asians less likely to consult for fear of bringing shame on themselves or others. </li></ul>South Asian women in Britain
  18. 22. South Asian women in Britain <ul><li>Less likely to have their symptoms recognised by their GP. </li></ul><ul><li>One study found that only half of South Asian participants had disclosed their psychological distress to their GP. </li></ul><ul><li>It has been thought that they are more likely to present with psychosomatic symptoms which may be more difficult for GP to recognise. </li></ul><ul><li>Asian GPs have been found to be poor detectors of mental distress in Asian patients. </li></ul>
  19. 23. South Asian women in Britain – self harm <ul><li>Deliberate self-harm accounts for more than 170,000 hospital attendances in the UK every year. </li></ul><ul><li>One of the first studies to investigate self-harm in South Asians was a retrospective study of Asian Immigrants in Birmingham by Burke </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  20. 24. South Asian women in Britain – self harm <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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 &quot;izzat&quot; (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. </li></ul>
  21. 25. South Asian women – newer evidence <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>The suicide rates for people of South Asian origin in England and Wales decreased between 1993–1998 and 1999–2003 </li></ul><ul><li>“ 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. ” </li></ul><ul><li>“ 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. ” </li></ul>