Cultural differences in conceptual models of depression
Introduction
Though depressive illness is common in many societies and has been defined in recent years as a major global public health problem, professional treatment seeking is relatively rare in many non-western societies and among immigrant and minority groups in the west. Recent studies of African Americans (Sussman, Robins, & Earls, 1987; Swartz et al., 1998), Latinos (Padgett, Patrick, Burns, & Schlesinger, 1994; Wells, Katon, Rogers, & Camp, 1994), and Asian Americans (Sue, Nakamura, Chung, & Yee-Bradbury, 1994; Ying & Miller, 1992) confirm that members of these ethnic groups are less likely than whites to utilize voluntary specialty mental health treatment.
Several hypotheses have been proposed to account for ethnic/cultural differences in treatment seeking. One of these is the somatization hypothesis (Ryder, Yang, & Heine, 2002). This hypothesis proposes that people from traditional cultural backgrounds either deny psychological distress, interpret such distress as somatic illness, or present distress as physical illness in medical settings. Recent research, however, suggests that somatic symptoms are strongly associated with psychological stress in western as well as traditional societies (Gureje, Simon, Ustun, & Goldberg, 1997), and that depressed patients from ethnic minority groups are no more likely than European Americans to deny emotional distress (Kirmayer, Robbins, Dworkind, & Yaffe, 1993). A second hypothesis focuses on stigma, suggesting that cultural or ethnic differences in treatment seeking are accounted for by the greater stigma with which non-western and non-middle class people regard mental illness (Durvasula & Mylvaganam, 1994; Tsai, Teng, & Sue, 1980). Again, some recent data raise the question of whether traditional interpretations of psychiatric illness are less stigmatizing than psychiatric models (Jenkins, 1988) and whether concerns over stigma constitute a significant barrier to health seeking among ethnic minority groups (Sussman et al., 1987).
A third hypothesis frames a broader argument, attributing cultural differences in treatment seeking to differences in conceptual models of depressive symptoms across cultures. Evidence suggests that while members of white middle class communities in western societies may be uniquely apt to view depression as a medical problem requiring professional treatment, more traditional groups conceptualize depressive symptoms as social problems or as emotional reactions to situations (Jacob, Bhugra, Lloyd, & Mann, 1998). Yet this hypothesis has rarely been explored explicitly through cross-cultural comparisons. The present study uses a vignette methodology and a multi-dimensional model of illness representation from the health psychology literature to compare conceptual models of depressive symptoms in two groups of New Yorkers: a white, middle class group and a traditional immigrant group.
Section snippets
Background: culture and the disease model of depression
The biopsychiatric model of depression, a disease model which emphasizes the roots of the disorder in anatomy, heredity, and disease processes, is more common in western societies than elsewhere (Keyes, 1985). Conversely, a “situational” model that describes psychological distress in the context of social and interpersonal situations may be a more common explanatory strategy in traditional societies and minority communities in the west (Patel, 1995).
On the other hand, studies carried out under
The present study
We used a model from the health psychology literature called the illness representation model (IRM) (Leventhal, Nerenz, & Steele, 1984) to explore multiple dimensions of participants’ illness representations. The model proposes a five-dimensional structure of illness representation, which includes symptom label, the cause of symptoms, consequences, timeline, and management. Most studies based on the IRM have employed quantitative methods (Meyer, Leventhal, & Gutmann, 1985; Baumann & Leventhal,
Sample
The goal of the study was to examine differences in illness representation in two cultural groups that would be expected to vary along the variable of interest: in this case, exposure to the biopsychiatric model of depression. To this end, a purposive sampling strategy was employed to select two theoretically diverse cultural groups. Married, upper middle class EA women from two affluent New York City neighborhoods were sampled to represent the “high exposure” group, while a group of mostly
Procedures
The analyses presented here were part of a larger study examining vignette responses, health history, and symptom questionnaire data. Subjects were presented with a vignette describing a woman with emotional symptoms of depression (see Table 1). Subjects were asked to generate a representational model of the depressive symptoms utilizing a semi-structured query that focused on each of the five IRM dimensions, including: (1) identity of the illness, (2) antecedents or causes, (3) consequences
Analyses
Hypothesis testing: The goal of this phase of the analysis was to test hypotheses about conceptual differences in models of depression across the two groups. It was hypothesized that EAs would report a more biopsychiatric model of depressive symptoms than SAs. “Biopsychiatrism” was defined as the degree to which participants’ conceptual representations shared features of the western psychiatric disease model of depression. Conversely, it was hypothesized that SAs would report a more situational
Results
Demographics (see Table 2): Though the groups were similar in age, they differed significantly on education and income. The EAs reported high levels of income and education. EAs were twice as likely as SAs to work outside the home. Acculturation and immigration data for the SA group suggest low levels of acculturation. Though many spoke English, only a small number preferred English as their language of interview, and all but one reported socializing exclusively with members of her SA community.
Descriptive study
The interview generated a series of structured narratives punctuated by interviewer questions. In general, participants in both groups responded readily to the vignette, and no one seemed to find it uninterpretable. A major difference across groups was that EA responses were much longer. In general, SAs were usually content to generate a single explanatory model for the vignette, while EAs were more likely to generate multiple, often conflicting, models.
Discussion
The use of the IRM as a basis for query and analysis permitted a detailed examination of the ways in which culture shapes illness representations. Conceptual models of depressive symptoms described by the two groups differed sharply. Even when SAs actually used the label depression, which they did with some frequency, they viewed this condition quite differently from European Americans. Among EAs, the symptoms of sadness described in the vignette are symptoms of a medical disorder; while SAs
Illness representation as a mirror of culture
Results of the study suggest that illness representations, in addition to being constitutive of culture—of shaping experience through symbols and categories reflecting larger scale disease taxonomies and categories—also act as a mirror reflecting cultural realities. When European Americans talked about social contexts, as they usually did in their mixed models, they refer to a sharply different social reality from that of SAs.
SAs’ narratives focused almost exclusively on the world of the
Becoming a patient
Our data offer insight into the question asked at the beginning of this paper: “Why do SAs (and by implication, persons from other traditional societies and ethnic minority groups) rarely seek treatment for depression?” The data suggest that depressive emotional symptoms do not constitute depression-as-disease in the SA context. For the majority of SAs in the study, depressive symptoms reflect painful and threatening real-life problems. “Treatment” involves one of two strategies: solving the
Acknowledgments
This study was supported by a grant from the National Institute of Mental Health 5R03MH062914-02.
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2021, Social Science and MedicineCitation Excerpt :Despite some differences, the condition of the character in both vignettes [PTSD and depression] was explained in terms of situational explanatory models that describe psychological distress in the context of social and interpersonal situations and externally caused stress. These are central EMs for depression in many cultural groups (e.g. Hagmayer and Engelmann, 2014; Karasz, 2005). Concerning PTSD, Grupp et al. (2018) found that refugees from Eritrea, Cameroon, and Somalia interpreted a PTSD-vignette in light of their own (traumatic) life experiences before and during their migration trajectories, post-migration stressors, and social problems such as loneliness and isolation.