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Transcultural Psychiatry and Depression
P. SIKLAFIDOU*, D. ZELENI*, M. LIVADITIS**
*Psychologist, Master of Science in Social Psychiatry, Faculty of Medicine, Democritus University of Thrace
**Professor of Social Psychiatry,
Abstract
Depression is a mental disorder that has been described since the ancient times and there seems to be in almost every society in which it has been searched. Ethological studies show that a syndrome with many similarities to that of human depression exists in the animal kingdom. Based on these observations it has been noticed, that depression, apart from being a disorder is also a psychological condition which serves evolutionary purposes.
Depression is associated, by many researchers, with loss. This may involve the loss of a relationship (eg, separation, death), or the loss of social status of the individual (eg social degradation). In all the societies there are mechanisms and institutions that encourage the expression of depressive feelings and tend to smooth out and put under social control the depressive reaction. The most important of the above mentioned institutions is grief and mourning. In traditional societies, grief is externalized through an intense, dramatic way. On the other hand in modern societies, the mourning is more standardized and those who mourn have to control the expression of their feelings.
According to a prevalent view of Transcultural Psychiatry, depression and many other mental disorders as well, have a universal patho-physiological substrate on which different symptoms are constructed, depending on the cultural-ideological environment. For example, in Jewish and Christian communities depression prevails with guilt and the need for redemption. In other traditional societies depression is combined with dramatic reactions of externalized anger and a variety of body symptoms. There is a suspicion that in modern societies there is an increase with regard to the consequences of depression, but this may partly be due to an increase of its recognisability.
Traditionally, depression was treated with exorcism and redemption rituals. The therapeutic result was due to the placebo effect.
In the modern world the antidepressants and certain psychotherapies (e.g. cognitive) have a more specific action. However, at least in Greek society, many cases remain undiagnosed or undertreated, so that this disorder results in being a major cause of social, economic, interpersonal problems and misery. A more complete information of the population and of the doctors and the other stuff that are involved in primary care about depression is needed, in order to make them competent to offer better prevention with regard to this disorder and its consequences. Encephalos 2011, 48(4):146-150.
Key words: Depression, transcultural psychiatry, evolutionary psychology.
The depressive experience and disorder have been a source of concern for Western culture. Depression is a psychiatric disorder which has been described since ancient times and there seems to be in almost every society in which it has been searched. The etymological origin of the term depression is reduced in the Roman term de primere, which means pushing down. Earlier the word was used in the literal sense (e.g. in astronomy and architecture) and later with the metaphor sense (E.g. in theology and ethics). From the 17th century since nowadays, the metaphor sense of the word extended the field of psychology1.
Originally, the term depression was used as a subcategory of "melancholy", then as a synonym, and later replaced the term. The term "melancholy" was introduced by Hippocrates (5th and 4th centuries BC) who connected it to natural causes, namely hyper secretion of black bile from the spleen, and described a disorder with the main features of an aversion to food , insomnia, irritation, anxiety and discouragement. The term melancholy was used extensively in Europe until the 17th century when the term depression began to replace it2.
The term depression indicates the inability to raise satisfaction and the presence of mental stress (distress), the expression of which varies in quality (eg sadness, feelings of helplessness, loss of emotional reactivity, anhedonia) and in intensity ( from slight discomfort as the deep pain and suffering). Often other events associated with physical-biological and psychological functions coexist, such as fatigue, decreased vigor and activity, disturbed appetite, sleep and sexuality, anxiety, irritability, slowing or transient reduction of certain cognitive abilities, pessimistic and negative thoughts, suicidal thoughts, psychotic symptoms like delusions and hallucinations3.
According to modern classification systems, to characterize a pathological depressive state, it is required some of the events reported, to be occurred with such intensity, frequency or duration in order to cause significant distress or dysfunction to the person2.
Ethological studies show that a syndrome with many similarities to this of human depression, which was described above, exists in the animal kingdom. It is also found the theory, that depression except of a disorder is a psychological condition which serves evolutionary considerations and needs of social groups. It is suggested that depression is a useful adaptation to group welfare when there is competition that gives reproductive advantage over others. The symptoms associated with depression include altered behavior patterns, reduced sociability, reduced appetite and increased submission. The above combination that supports depression, functions in order to reduce the possibility of the animal to go through further attacks. From the moment it has lost its social position the chances of survival are increased. The successful transition from a higher to a lower position may provide more opportunities for reproduction. Therefore, the animal that develops depression during this critical period, gains a reproductive advantage over others, as the other animals will either be killed or be banished from the group4.
Depression is associated by many researchers with loss. This may involve the loss of a relationship (separation, death) or the social status of the individual (e.g. social degradation). In all societies there are mechanisms and institutions that allow the expression of grief and tend to smooth out and put under social control the depressive reaction. The most important of the above mentioned institutions is grief and mourning. The grief is manifested by stress (stress, anxiety, nervousness) depressive reactions (crying, grief, withdrawal, constant preoccupation with the lost person or the fact of loss) and standardized social activities and rituals (e.g. . religious ceremonies, mourners black wearing)2,5.
Bereavement as a painful internal process (grief) and externalizing as a ritual (mourning) may help to calm the mental tension and prevent depression. The rituals of mourning are traditional in nature, and are encountered in almost all known societies. In traditional societies grief is externalized through an intense, dramatic way. On the other hand in modern societies, the mourning is more standardized and those who mourn have to control the expression of their feelings2,5.
Transcultural Psychiatry explores the relationship of culture with mental life and behavior with emphasis on the intercultural module in comparative studies, of the psychological and psychopathological manifestations in different environments. Depression, like many other psychiatric disorders has a universal pathophysiological background on which different symptoms are being developed differently, depending on the cultural and ideological environment2,6.
It has been ascertained that the clinical reality is affected by the current cultural context in the following areas: in the expression of subjective symptoms, diagnosis, treatment options and expectation of the result7. The main difference of the symptoms is that, in non-Western societies, the symptoms of the disorder are mainly physical, while some emotions such as guilt, usually absent from the behavioral picture of the individual. For example, in Jewish and Christian communities depression coexists with guilt and the need for redemption. In other traditional societies depression is combined with dramatic reactions of externalized anger and a variety of body symptoms2,8. Kleinman (1980) reached the following conclusions: He claims that emotions as psycho-biological phenomena are universal. What varies from culture to culture is whether and how a feeling is called, what 'label name' is given by the society. Due to the fact that sometimes the name given to a feeling is either absent or less recognizable, it is mistakenly believed that some emotions are absent from specific cultural systems9.
Three cross-cultural directions are distinguished in the metaphysical interpretation of depression: a) Effect of exogenous, spiritual or demonic influences, eg magic, spirit possessions. b) Endogenous laziness, avelteria which infringes moral orders, therefore it implies sin. c) inevitable, karmic consequence of human destiny. The first way of understanding depression is the logical consequence of the animistic belief according to which supernatural wills and forces intervene and have a great impact on everyday life. Although this belief is very old, it is quite widespread even in modern times. According to the second way of understanding the innate laziness is attributed to demonic and evil influences. The imputation of individual responsibility created the conditions for the emergence and maintenance of self-blame ideas, guilt, as well as permanent masochistic tendencies. The third way of understanding is found in Hindu and Buddhist religious ideas that are formed based on the law of karma which determines the retributive price of misery each person pays for his actions having caused suffer or harm to others during this life, but mostly during their preceding reincarnations. Within the framework of this approach, the actual experience of grief constitutes a process of atonement3.
There is a suspicion that in modern societies there is an increase with regard to the consequences of depression, but this may be partly be due to an increase of its recognisability. Often refers to the "age of depression" in which humanity seems to entered into. The following views have been expressed about this issue:
Case 1st.The increase is, at least partially, fictitious, which may either be due to the fact that people forget and adorn the past, (so for example do not remember the depressing expressions which themselves or people around them presented years ago), or due to the experts’ sensitivity as well as the population’s to recognize to others or each for themselves the existence of a depressing pathological situation which has been increased in the past decades. The recognisability of depression may be due to the development of psychiatric services, the improvement of treatment’s options and the better updating of the public.
Case 2nd. There is a temporal variation concerning the morbidity of depression. This disorder shows peaks in some generations, i.e. people born during a certain period of time. According to this hypothesis it is considered that in some countries, those who were born during the decades of ‘40 and ‘50 present more often depression rather than those who were born during the interwar period10,11.
Case 3rd. The increase of the frequency of depression refers to all ages and is consequence of the "modern" lifestyle, as it was formed especially after the decades of 60's and 70's. The contestation or the rejection of traditional ideas and ideologies (political or religious), the loosening of family, kindred and community cohesion, the lifestyle in the cities and especially in the most degraded districts, unemployment, migration are some of the individual risk factors3,12-14.
Regarding the treatments that occasionally have been used for depression, traditionally depression was treated with exorcism and redemption rituals, because of the belief that depression was caused by demonic spirit possessions. The therapeutic result was probably caused by the placebo effect17-19. The therapeutic result was due to the placebo effect17-19.
In the modern world depression is treated with antidepressants and certain psychotherapies, of which the cognitive appears to have a greater effect20. The rational use of the available means leads the vast majority of cases to fast, significant improvement, usually with mild side effects.
Nevertheless there is a high percentage of patients with depressive syndromes, even in countries with highly developed psychiatric and psychological services, that does not use modern therapeutic potentialities.. Many of them fall back on traditional forms of counseling or compassionate assistance (eg by their priest-confessor), while others await passively the symptoms to respond. Several visit to primary care medical services mainly for various physical symptoms, but the -coexisting in clinical picture- depression several times is not, often, diagnosed21-23.
However, at least in Greek society, many cases remain undiagnosed or undertreated, so that this disorder results in being a major cause of social, economic, interpersonal problems and misery. A more complete updating, in terms of depression, of the population, the doctors and the stuff involved in primary care, is needed, in order to make them competent to offer better prevention with regard to this disorder and its consequences24.
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