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Correspondence |
National Institute of Mental Health & Neurosciences, Bangalore 560 029, India
Department of Public Health & Epidemiology, Swiss Tropical Institute, Socinstrasse 49, Basel, Switzerland
In their exhaustive review of the impact of globalisation and culture on depression, Bhugra & Mastrogianni (2004) highlight the role of somatisation in many parts of the world, where it often accounts for ‘common presenting features of depression’ (p. 16). Emphasising both the ubiquity and cultural aspects of somatisation, they cite an earlier characterisation of common mental disorders that refers to the ‘black box of somatisation’ (Bhui, 1999). In doing so, however, they miss an important explanatory feature of this process with substantial practical and clinical significance - that is, the role of stigma. Despite increasing availability of effective treatments, many people with depression (perhaps even a majority) do not seek professional help because of the stigma associated with the illness. Efforts to clarify the impact of stigma are crucial for explaining cultural aspects of illness-related experience and meaning, and highly relevant for planning interventions that are culturally appropriate and locally effective.
As one effort towards elucidating the experience of depression, in a study in Bangalore, India, we examined the role of self-perceived stigma (Raguram et al, 1996). We found that greater severity of depression was associated with higher stigma scores, but more somatisation was associated with less stigma. Through qualitative analysis of patients' narratives, we also demonstrated that patients viewed depressive, but not somatic, symptoms as socially disadvantageous. Somatic symptoms were considered to be less stigmatising since they resembled illness experiences that most people could expect to have from time to time. Consequently, studying the work of culture clarifies the nature of somatisation. From a Western vantage point, somatisation may appear enigmatic, but attention to stigma helps to illuminate the internal structure of the black box.
REFERENCES
Bhugra, D. & Mastrogianni, A. (2004)
Globalisation and mental disorders. Overview with relation to depression.
British Journal of Psychiatry,
184, 10-20.
Bhui, K. (1999) Common mental disorders among people with origins in or immigrant from India and Pakistan. International Review of Psychiatry, 11, 136 -144.[CrossRef]
Raguram, R., Weiss, M. W. & Channabasavanna, S. M.
(1996) Stigma, somatisation and depression - a report from
South India. American Journal of Psychiatry,
153, 1043
-1049.
Section of Cultural Psychiatry, Institute of Psychiatry, PO25, De Crespigny Park, Denmark Hill, London SE5 8AF, UK
Drs Raguram and Weiss are right to point out the role stigma plays in help-seeking. We agree that many people with depression will not seek help from Western medical sources. The problem is more complex than that. In search of making sense of symptoms by the health professionals, we believe that the first step is by understanding the symptoms and the distress experienced by the individuals themselves through their identification that something has gone wrong; then their search for a possible explanation for their distress will lead to identifying possible sources of help and then finding a way to seek relief. However, in this process of help-seeking there are numerous culturally determined barriers. Stigma will indeed be a potential barrier but it is also likely that other factors may help modify the idioms of distress. In an earlier study of middle-aged Punjabi women, we found that they were able to identify symptoms of depression, and life events causing it, but they also felt that these symptoms were part of life's ups and downs and not a medical condition; hence, they preferred to seek solace in religious places (Bhugra et al, 1997). They identified both psychic and somatic symptoms but were also clear in their discussion that sources of help were not medical. Similar observations were made in Dubai (Sulaiman et al, 2001). Our conjecture is that globalisation will influence the way individuals see their distress because media influences may affect their cognitive schema. Cognitive schema determine the meanings we impart to ongoing experience and give an expectation of the future (Strauss & Quinn, 1997). We do not hold the view that somatisation is enigmatic. It is a perfectly understandable representation of the distress which is a reflection of the explanatory models held by the individual.
REFERENCES
Bhugra, D., Baldwin, D. & Desai, M. (1997) Focus groups: implications for primary and cross-cultural psychiatry. Primary Care Psychiatry, 3, 45-50.
Strauss, C. & Quinn, N. (1997) A Cognitive Theory of Cultural Meaning. Cambridge: Cambridge University Press.
Sulaiman, S., Bhugra, D. & De Silva, P.
(2001) Perceptions of depression in a community sample in
Dubai. Transcultural Psychiatry,
38, 201
-218.
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