Culture and Depression
http://www.100md.com
《新英格兰医药杂志》
In many parts of Chinese society, the experience of depression is physical rather than psychological. Many depressed Chinese people do not report feeling sad, but rather express boredom, discomfort, feelings of inner pressure, and symptoms of pain, dizziness, and fatigue. These culturally coded symptoms may confound diagnosis among Chinese immigrants in the United States, many of whom find the diagnosis of depression morally unacceptable and experientially meaningless; this cultural pattern changes over time but continues to diverge significantly from the experiences of other groups. The pattern of somatization may be unfamiliar to U.S. clinicians and may further complicate the concept of depression, which, according to biomedicine, can be an emotion, a symptom, or a disease.
(Figure)
The Chinese characters for "depression" are employed in medical settings but are not in popular usage.
Depressive feelings are experienced by all people and are a normal component of disappointment and grief. Depression may be a symptom of a mental disorder (such as bipolar disorder, an anxiety disorder, or schizophrenia) or of other medical diseases, ranging from diabetes and thyroid disorders to postviral syndromes. As one of the most prevalent diseases globally and an important cause of disability, depressive disorder is responsible for as many as one of every five visits to primary care doctors; it occurs everywhere and affects members of all ethnic groups. The rates of depression are increasing, and the disorder is nearly twice as common among the poor as among the wealthy.
But the way in which depression is confronted, discussed, and managed varies among social worlds, and cultural meanings and practices shape its course. Culture influences the experience of symptoms, the idioms used to report them, decisions about treatment, doctor–patient interactions, the likelihood of outcomes such as suicide, and the practices of professionals. As a result, some conditions are universal and some culturally distinct, but all are meaningful within particular contexts.
Among refugees, depressive affect and disorder are common aspects of collective and personal experiences of loss and trauma. Various patterns of somatization are found among depressed patients from many ethnic groups, and even among Latinos, for example, Mexican Americans, Puerto Ricans, and Cuban Americans may report different symptoms. Add differences in sex, age, social class, education, and degree of biculturalism, and the question of cultural influence becomes murky enough to discourage any form of ethnic stereotyping. Inasmuch as black women have lower rates of depression and suicide than white women, and immigrants lower rates of depression than their descendants, some cultural effects may be protective factors rather than risk factors. In a complex, postmodern society like that of the United States — where it is often hard to determine the cultural norm or how experience differs among or within communities — cultural differences can affect any patient–doctor interaction.
The culture of biomedicine is also responsible for some of the uncertainty surrounding depression. Symptoms that represent a depressive disorder for the practitioner (say, sadness and hopelessness in a patient dying from cancer) may not denote a medical problem to the patient, his or her family, or their clergy, for whom depression may be a sign of the moral experience of suffering. What is seen by a particular social network as a normal emotional response — say, grief lasting for years — may count as a depressive disorder for the psychiatrist, since the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), defines normal bereavement as lasting for two months. In this area, the professional culture, driven by the political economy of the pharmaceutical industry, may represent the leading edge of a worldwide shift in norms.
Yet many people with clinical depression — at least 50 percent among immigrants and minority groups in the United States — still receive neither a diagnosis nor treatment from a biomedical practitioner. Lack of access to appropriate services is a major reason for this failure, but cultural causes of misdiagnosis also contribute. Culture confounds diagnosis and management by influencing not only the experience of depression, but also the seeking of help, patient–practitioner communication, and professional practice. Culture also affects the interaction of risk factors with social supports and protective psychological factors that contributes to depression in the first place. Culture may even turn out to create distinctive environments for gene expression and physiological reaction, resulting in a local biology of depression: research already shows that persons from various ethnic backgrounds metabolize antidepressant drugs in distinct ways.
The term "culture" is often misused. In its early anthropologic usage, culture referred to the shared patterns of life that define social groups. This usage tended to portray cultures as bounded, fixed entities, neglecting crucial differences among and within groups, and it risked reducing culture to an autonomous variable among others. But culture is not a thing; it is a process by which ordinary activities acquire emotional and moral meaning for participants. Cultural processes include the embodiment of meaning in habitus and physiological reactions, the understanding of what is at stake in particular situations, the development of interpersonal connections, religious practices, and the cultivation of collective and individual identity. Culture is inextricably caught up with economic, political, psychological, and biologic conditions. Treating culture as a fixed variable seriously impedes our ability to understand and respond to disease states such as depression.
For all the talk of training practitioners to be culturally competent, there is little agreement on what this means for treatment, and there is surprisingly little research demonstrating that culturally informed approaches affect outcomes. Nonetheless, the DSM-IV offers a sensitive method of cultural formulation. It stipulates steps in the evaluation of patients, beginning with the respectful affirmation of and inquiry into their ethnic identity and continuing with the determination of whether ethnic factors seem pertinent in the particular case.
Clinicians must then consider what is chiefly at stake for patients as they face a particular illness; mental illness, for example, may be so stigmatized in a given culture that a diagnosis of depression is unacceptable and a euphemism is required. Next, the patient's explanatory models of causality, disease, and desired treatment must be assessed. Patients may attribute their depressive disorder, for instance, to culturally salient family conflicts, such as those between parents' patriarchal attitudes and children's modern perspectives. In addition, patients may have engaged in self-care or alternative and complementary treatments that can affect the biomedical regimen; practitioners need to know about and respond to these treatments.
Clinicians must then evaluate the culturally relevant aspects of the stresses and support in the life of a depressed patient. For instance, poverty and joblessness frequently intensify cultural issues. Moreover, the conventional belief that minority groups have strong extended-family ties may not be accurate, but cultural forms of resilience should be considered.
Attention should also be paid to the ways in which culture can influence the clinical relationship. Some recent immigrants, for example, may expect a directed, hierarchical relationship and be uncomfortable with a more egalitarian, consumer-oriented model. Physicians must be sensitive to institutional racism and be aware that health care providers can unwittingly convey a sense of stigma to patients.
Probably the most essential clinical task is not to do harm by stereotyping patients. There is enough evidence showing that culture and ethnic background are associated with health disparities and poor outcomes that the application of this approach to the treatment of depression, and probably most other disorders, seems warranted.
Source Information
From the Department of Anthropology, Harvard University, Cambridge, Mass., and the Departments of Social Medicine and Psychiatry, Harvard Medical School, Boston.(Arthur Kleinman, M.D.)
(Figure)
The Chinese characters for "depression" are employed in medical settings but are not in popular usage.
Depressive feelings are experienced by all people and are a normal component of disappointment and grief. Depression may be a symptom of a mental disorder (such as bipolar disorder, an anxiety disorder, or schizophrenia) or of other medical diseases, ranging from diabetes and thyroid disorders to postviral syndromes. As one of the most prevalent diseases globally and an important cause of disability, depressive disorder is responsible for as many as one of every five visits to primary care doctors; it occurs everywhere and affects members of all ethnic groups. The rates of depression are increasing, and the disorder is nearly twice as common among the poor as among the wealthy.
But the way in which depression is confronted, discussed, and managed varies among social worlds, and cultural meanings and practices shape its course. Culture influences the experience of symptoms, the idioms used to report them, decisions about treatment, doctor–patient interactions, the likelihood of outcomes such as suicide, and the practices of professionals. As a result, some conditions are universal and some culturally distinct, but all are meaningful within particular contexts.
Among refugees, depressive affect and disorder are common aspects of collective and personal experiences of loss and trauma. Various patterns of somatization are found among depressed patients from many ethnic groups, and even among Latinos, for example, Mexican Americans, Puerto Ricans, and Cuban Americans may report different symptoms. Add differences in sex, age, social class, education, and degree of biculturalism, and the question of cultural influence becomes murky enough to discourage any form of ethnic stereotyping. Inasmuch as black women have lower rates of depression and suicide than white women, and immigrants lower rates of depression than their descendants, some cultural effects may be protective factors rather than risk factors. In a complex, postmodern society like that of the United States — where it is often hard to determine the cultural norm or how experience differs among or within communities — cultural differences can affect any patient–doctor interaction.
The culture of biomedicine is also responsible for some of the uncertainty surrounding depression. Symptoms that represent a depressive disorder for the practitioner (say, sadness and hopelessness in a patient dying from cancer) may not denote a medical problem to the patient, his or her family, or their clergy, for whom depression may be a sign of the moral experience of suffering. What is seen by a particular social network as a normal emotional response — say, grief lasting for years — may count as a depressive disorder for the psychiatrist, since the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), defines normal bereavement as lasting for two months. In this area, the professional culture, driven by the political economy of the pharmaceutical industry, may represent the leading edge of a worldwide shift in norms.
Yet many people with clinical depression — at least 50 percent among immigrants and minority groups in the United States — still receive neither a diagnosis nor treatment from a biomedical practitioner. Lack of access to appropriate services is a major reason for this failure, but cultural causes of misdiagnosis also contribute. Culture confounds diagnosis and management by influencing not only the experience of depression, but also the seeking of help, patient–practitioner communication, and professional practice. Culture also affects the interaction of risk factors with social supports and protective psychological factors that contributes to depression in the first place. Culture may even turn out to create distinctive environments for gene expression and physiological reaction, resulting in a local biology of depression: research already shows that persons from various ethnic backgrounds metabolize antidepressant drugs in distinct ways.
The term "culture" is often misused. In its early anthropologic usage, culture referred to the shared patterns of life that define social groups. This usage tended to portray cultures as bounded, fixed entities, neglecting crucial differences among and within groups, and it risked reducing culture to an autonomous variable among others. But culture is not a thing; it is a process by which ordinary activities acquire emotional and moral meaning for participants. Cultural processes include the embodiment of meaning in habitus and physiological reactions, the understanding of what is at stake in particular situations, the development of interpersonal connections, religious practices, and the cultivation of collective and individual identity. Culture is inextricably caught up with economic, political, psychological, and biologic conditions. Treating culture as a fixed variable seriously impedes our ability to understand and respond to disease states such as depression.
For all the talk of training practitioners to be culturally competent, there is little agreement on what this means for treatment, and there is surprisingly little research demonstrating that culturally informed approaches affect outcomes. Nonetheless, the DSM-IV offers a sensitive method of cultural formulation. It stipulates steps in the evaluation of patients, beginning with the respectful affirmation of and inquiry into their ethnic identity and continuing with the determination of whether ethnic factors seem pertinent in the particular case.
Clinicians must then consider what is chiefly at stake for patients as they face a particular illness; mental illness, for example, may be so stigmatized in a given culture that a diagnosis of depression is unacceptable and a euphemism is required. Next, the patient's explanatory models of causality, disease, and desired treatment must be assessed. Patients may attribute their depressive disorder, for instance, to culturally salient family conflicts, such as those between parents' patriarchal attitudes and children's modern perspectives. In addition, patients may have engaged in self-care or alternative and complementary treatments that can affect the biomedical regimen; practitioners need to know about and respond to these treatments.
Clinicians must then evaluate the culturally relevant aspects of the stresses and support in the life of a depressed patient. For instance, poverty and joblessness frequently intensify cultural issues. Moreover, the conventional belief that minority groups have strong extended-family ties may not be accurate, but cultural forms of resilience should be considered.
Attention should also be paid to the ways in which culture can influence the clinical relationship. Some recent immigrants, for example, may expect a directed, hierarchical relationship and be uncomfortable with a more egalitarian, consumer-oriented model. Physicians must be sensitive to institutional racism and be aware that health care providers can unwittingly convey a sense of stigma to patients.
Probably the most essential clinical task is not to do harm by stereotyping patients. There is enough evidence showing that culture and ethnic background are associated with health disparities and poor outcomes that the application of this approach to the treatment of depression, and probably most other disorders, seems warranted.
Source Information
From the Department of Anthropology, Harvard University, Cambridge, Mass., and the Departments of Social Medicine and Psychiatry, Harvard Medical School, Boston.(Arthur Kleinman, M.D.)