Abstract
Our aim of this study was to explore how authors of medical articles wrote about different symptoms and expressions of depression in men and women from various ethnic groups as well as to analyze the meaning of gender and ethnicity for expressions of depression. A database search was carried out using PubMed. Thirty articles were identified and analyzed using qualitative content analysis. Approaches differ with regard to how depression is described and interpreted in different cultures in relation to illness complaints, illness meaning, and diagnosis of depression. Articles often present issues based on a Western point of view. This may lead to “cultural or gender gaps,” which we refer to as “the Western gaze,” which may in turn influence the diagnosis of depression.
Our article is a qualitative analysis of what the authors wrote regarding expressions of depression in medical research publications about women and men from different ethnic groups. The articles were identified through a database search in PubMed. In our work as family doctors (AL, EJ, UL, AH) we have encountered women and men from different ethnic groups with varying symptoms that may indicate depression. Symptoms serve as the criteria for diagnosing depression. It has been difficult to diagnose if the patients we met had depression or not, however, since their expressions could differ from the symptom criteria in the recommended guidelines for depression. Therefore, the intention of our study was to increase our knowledge about expressions of depression with focus on gender and ethnicity. We studied medical articles, but many of the articles were based on the Western points of view and had cultural and gender “gaps,” referred to as “the Western gaze,” which may influence the diagnosis of depression.
In a medical sense, depression is a syndrome diagnosed according to DSM (CitationAmerican Psychiatric Association, 2000) or ICD-10 (CitationWorld Health Organization [WHO], 1993) criteria. These criteria are based on symptoms, and the core symptoms are depressed moods or loss of interest, present during the last 2-week period. Studies indicate, however, that culture shapes the symptoms and expressions of depression and determines how and where people seek help (CitationHelman, 2007; CitationKleinman & Good, 1985). This could lead to misdiagnosis of depressive symptoms in several ethnic minorities, as diagnostic scales have been developed in the Western world (CitationKirmayer, 2006). It is therefore important for health care professionals to acquire more insight into how depressive symptoms may vary between different ethnic groups (CitationBhugra & Mastrogianni, 2004; CitationKirmayer & Groleau, 2001).
Research also has indicated that there are gender differences relating to how the symptoms of depression are presented (CitationBrownhill, Wilhelm, Barclay, & Schmied, 2005; Danielsson & Johansson, 2005; CitationEmslie, Ridge, Ziebland, & Hunt, 2007). The intersections between gender and ethnicity, cultural and gendered power relations in relation to depression however, has seldom been studied. In a multiethnic study from the United States, depressed men expressed more psychomotor agitation and suicidal ideation than women (CitationMarcus et al., 2005). In addition, symptoms consistent with both alcohol and drug use were more common in depressed men than women, while depressed women reported more anxiety, sleep irregularities, and eating problems.
In the traditional Euro-American model of depression, the focus is on the symptoms of an individual. The individual knowledge, beliefs, attitudes, and meaning of illness, which shape the expressions of mental illness, however, are maintained and formed by external power dimensions of gender, ethnicity, age, class, religion, and their intersections (CitationIyer, 2007).
The aim of our study was to explore how authors of medical articles wrote about different symptoms and expressions of depression among men and women from various ethnic groups as well as to analyze the meaning of gender and ethnicity for expressions of depression.
MATERIAL AND METHODS
For this study we made a PubMed search, based on the following search words: “depression,” “gender” and “ethnicity.” The search was limited to the English language and to the time period 1994–2004. The search was performed in May 2005. In total, 331 abstracts were identified that then carefully were read through. Out of these abstracts, 30 original studies and review articles with focus on symptoms and expressions of depression were included in our study. Exclusion criteria were abstracts focusing solely on depression rates, other psychiatric diagnosis or chronic illnesses, explanations, or pharmaceutical treatments, or in which depression was mentioned only as a secondary illness.
Twenty-three of the included 30 articles were published by authors working in Western countries (USA, UK, Canada, Germany, Switzerland, and Denmark). Five of the articles were published in collaboration between authors in Western countries and authors in other countries (India, Japan, Singapore) and two by authors wholly in other countries (Korea, Argentina). In the included studies depression was diagnosed according to DSM III or DSM IV (CitationAmerican Psychiatric Association, 1994, Citation2000) or ICD-10 (CitationWHO, 1993) with help of several different screening instruments, for example, Centre for Epidemiological Studies-Depression Scale, CES-D.
These 30 articles were analyzed using Qualitative Content Analysis (CitationGraneheim & Lundman, 2004) by the first author (AL). The entire contents of all articles carefully were read through to get an overview of the content and to obtain a sense of the whole. Afterward, the results and discussion of each article was read through several times in order to grasp the original view of the authors. The text was then broken up into “meaning units” (i.e., words or sentences containing aspects associated through content and context), and the meaning units subsequently were coded. Codes were summarized and classified into subcategories, which in turn were sorted and summarized into three main categories. contains an example of codes, subcategories, and a main category.
TABLE 1 An Example of Meaning Units, Codes, Subcategories, and a Category According to Qualitative Content Analysis
To improve the credibility of the study, a second investigator (AH) of the study also coded 20 of the articles independently and the preliminary codes were compared. Only minor disagreements were found between the researchers, and in that case the coding was discussed until agreement was reached. All involved authors continuously discussed subcategories, categories, and the developing manuscript.
FINDINGS
Three main categories in our analysis “illness complaints,” “illness meaning,” and “depression diagnosis” illustrate how expressions and meaning of illness may differ by culture and gender and influence the diagnosis of depression. Below, these three categories are described in relation to the various subcategories. In order to illustrate findings, citations and references are used from some of the articles included in the study. These references are marked with an asterisk in the reference list.
Illness Complaints
Illness complaints are what patients tell the practitioner when attending health care. The subcategories “cultural expressions” and “gendered expressions” described symptoms of depression shaped by culture and gender.
Cultural Expressions
CitationPatel and colleagues (2001) stated that in many non-European languages there are no direct equivalents for the term “depression,” but cultural expressions, such as “thinking too much,” “heart too much,” “nerves,” or “heartache,” have affective meaning and are symptomatically similar to what in Western countries is labeled “depression.” These cultural expressions are both a local illness category and a cultural explanation of depression. In studies on Chinese and Latvian populations, CitationParker and colleagues (2001) as well as CitationSkultans (2003) described that neurasthenia could be seen as a language of emotions, a somatoform illness manifesting from depression, which includes somatic, cognitive, and emotional symptoms.
The expressions of depression may change following, for example, migration or Westernization and exposure to the dominant culture (CitationBhui, Bhugra, & Goldberg, 2000; CitationSkultans, 2003). CitationSkultans (2003) wrote that in Latvia, for example, since the collapse of Communism several terms of distress have been changed and people emphasize more individual shame and guilt than social dimensions of distress as in neurasthenia.
According to CitationPiccinelli and Simon (1997) and CitationHarris (2004), depression quite often is experienced and communicated through bodily symptoms. Culture plays an important role with regard to the area of the body that is used for the somatic expressions of depression, for example, headaches in Zimbabwe (CitationPatel, 2001), abdominal symptoms in Japan (CitationWasa, Graham, Zyzansk, & Inoue, 1999), and pain or fatigue in India (CitationGanguli et al., 1999). The studies indicate that “somatisation” is a common way to present depressive symptoms worldwide, both among women and men; however, rates and severity of depressive symptoms may vary by ethnicity and gender (CitationFacio & Batistuta, 2001; CitationJackson-Triche et al., 2000; CitationKistner, David, & White, 2003; CitationMaeng, Jung, & Guk, 1998; CitationMeyers et al., 2002; CitationRickert, Wiemann, & Berenson, 2000; CitationZunzunegui, Beland, Llacer, & Leon, 1998).
Gendered Expressions
Some Western articles in our study distinguish gender differences in clinical manifestation of symptoms of depression. CitationAngst and colleagues (2002) found that emotional symptoms and crying were more frequent among women than men, and women had less energy and sleep than men but men were “needing more alcohol.” Möller-Leimkuhler (2002) stated in a study that there is a threshold for men in expressing emotions and weakness related to the dominant masculinity in society. This implies that needing help is not a masculine trait. Therefore, to seek help for depressive symptoms may be considered stigmatizing and lead to loss of status, control, and autonomy, and thus result in underdiagnosis of depression in men (CitationMöller-Leimkuhler, 2002).
Illness Meaning
The subcategories “beliefs” and “collective control” in our analysis illustrate that symptoms of depression have different meaning in different societies, which determines if people seek professional help or not as well as how much stigma is attached to depression.
Beliefs
Different beliefs relating to depressive symptoms determine if people view themselves as ill, as CitationBurr (2002) observed in a study of professionals in London: “Some would see it as a medical problem. Some would see it as a non-medical problem. Beliefs make a difference” (p. 839).
CitationMarwaha and Livingston (2002) found in a study of White British and Black African Caribbean elderly people that the majority of old people did not consider depression to be a mental illness and therefore saw no reason to seek psychiatric help.
As CitationSchreiber and colleagues (1998) wrote in another study among West Indian women in Canada, depression also may be written off as madness and to seek help could lead to social isolation and sanctions: “The women felt strongly that they would be labelled as crazy if they would seek professional help and the consequence would be shunning which caused reluctance to seek help” (CitationSchreiber, Stern, & Wilson, 1998).
Collective Control
The analysis of articles showed that in studies of Asian and African societies mental illness is viewed as a collective loss of face for the family, a cause of family shame, and a sign of weakness. Thus, according to CitationParker and colleagues (2001), in order to avoid stigma and discrimination, depressed persons do not seek help.
In a Chinese study of women with psychiatric symptoms, CitationPearson (1995) found that it is not the patients’ own but their families’ opinions about what is wrong, that matters. Thus, the family decides if and when help is sought.
Diagnosing Depression
Health care practitioners translate patients’ symptoms of illness into disease entities. The subcategories “cultural norms” as well as “clinician–patient encounter” influence the process of diagnosing depression in different ways.
Cultural Norms
The analyzed articles show that cultural norms are important when it comes to how people express their affects. For instance, CitationIwata and Buka (2002) found that verbal expressions of emotional distress are not sanctioned in Asian cultures: “In traditional Japanese society, the inhibition of positive affects seems to represent a moral distinction and socially desirable behaviour in Japanese society” (p. 2252). The above study of the Japanese society shows that responses to positive affect questions in Western depression-screening instruments, for example CES-D, including both negative items, such as “I felt depressed” and positive items, such as “I was happy,” could be biased for particularly elderly, Asians or immigrant Hispanics and African Americans in the United States (CitationIwata, Turner, & Lloyd, 2002).
According to traditional Hindu scriptures, the last phase of a human being's life should be characterized by disengagement, peacefulness, and contentment. Thus, CitationGanguli and colleagues (1999) mean that these socially desirable qualities may lead to false responses on a standard depression scale.
Clinician-Patient Encounter
CitationBurr (2002) observed that health care professionals also may be influenced by cultural stereotypes and their own cultural filters and depression consequently may go undiagnosed. CitationBhui and colleagues (2001) found in another study of primary health care in London that general practitioners of Asian origin were more likely to identify psychiatric illness in English than in Punjabi patients, although Punjabi patients were more likely to suffer from hopelessness and depressive ideas. The general practitioners’ own cultural beliefs included a view of life in which hopelessness might be accepted and not labeled as illness. Thus, the general practitioners might not diagnose patients from their own culture as depressed.
The gender of both patients and professionals may affect the process of diagnosing depression. CitationSleath and Rubin (2002) showed in a study from New Mexico that physicians asked male patients significantly more questions about anxiety and depression than female patients, and female patients brought up depression before their physicians more frequently than male patients. The educational level of the patients could also influence the symptom communication, so highly educated patients were more likely to bring up depression during medical visits compared with less educated patients (CitationSleath & Rubin, 2002).
DISCUSSION
Our text analysis of PubMed articles indicates cultural and gendered variations in illness expressions, meanings of depression, and diagnosing depression. Illness complaints, depression-related beliefs, norms, and behavior, and clinician–patient encounter, in our analysis, can be seen to be formed by different sociocultural, gendered, or religious power dimensions, which all influence diagnosing depression. The findings, however, were quite rarely analyzed with intersectional theory. Thus, “cultural and gender gaps,” which we refer to as “the Western gaze,” may arise when researchers from a dominating culture write about depression in other cultures.
The Western “Gaze”
Our study shows that some countries outside the Western world do not use depression as a concept of sadness and suffering. Instead, other expressions were used, such as “neurasthenia” and “nerves,” which contain symptoms similar to the Western psychiatric construct of depression. These other expressions, similar to depression, link an individual case of illness with wider concerns, for example, the sufferers’ family or community (CitationSkultans, 2003). These non-Western expressions can be seen as culture-specific dimensions of experiences, where the mental and physical dimensions are not always separated. Each society has its own threshold for the translation of troubling experiences into illness and help-seeking, and the threshold may change over time (Kleinman, 1998). Our study indicates that diagnostic instruments are not universal and must be contextualised (CitationInternational Guidelines for Diagnosis Assessment [IGDA] Workgroup, 2003; CitationIwata & Buka, 2002). Further, it is important for health care professionals to identify local concepts of depression, “situated narratives” (CitationKirmayer, 2006, p. 132), in order to provide cultural adapted health care and in order to avoid Western bias.
Our analysis of studied articles highlighted cultural differences in the interpretation of depression as an illness or as a normal response to life events as well as religious differences in the meaning of depressive symptoms (CitationKleinman, 1988). According to the Hindu attitude, for example, suffering may be a good thing that provides profound insight into reality (CitationGanguli et al., 1999). It may be impossible, however, to isolate “pure” cultural behaviors and norms from the social, economic, and religious context and their different power dimensions that form the individual, lived experiences (CitationHelman, 2007). Cultural differences in interpretation of depression rarely were problemized in relation to different power relations in the analyzed articles. This may lead to blaming of the culture instead of visualizing the importance of social disadvantages, generalizations, stereotypes, and misunderstanding of depressed patients (CitationNazroo, 2003). The Western way of explaining illness in an individualized manner differs from the more nonindividualised non-Western explanations that illness has a collective meaning (CitationParker et al., 2001; CitationPearson, 1995). A focus on the collective meaning of depression and on collective social control could lead to other forms of stigma related to family shame and social isolation, which interfere with help-seeking behavior. Thus, both the extended family and the patient could be affected by stigma and shame. Therefore, awareness of the patients’, their families’ as well as the professionals’ context-bound value systems and culturally sanctioned illness behavior is necessary in order to avoid stereotypes and misdiagnosis when meeting depressed patients from different cultures (CitationHelman, 2007).
Our analysis also showed that a common clinical presentation of depression worldwide is through bodily symptoms. Symptoms from a particular organ, such as head or stomach pain, have not only focused on physical abnormalities but also may be more culturally accepted ways to communicate underlying depression. The area or the organ in the body as a site for somatic expressions of depression may vary by culture. Thus, the “embodiment” of distress is not only an expression of individual suffering, it also includes “social embodiment,” a cultural, context-bound, emotional message that may be problematic when diagnosing depression. Thus, it is important to bear in mind that somatic symptoms, as a language of distress, may have both an individual and a social meaning and represent not only individual pathology (CitationHelman, 2007; CitationKirmayer, 2006).
Gender
The dominating or hegemonic form of masculinity in the Western world could be viewed as an idealized form of masculinity that emphasizes among other things that men should be rational rather than emotional and strong rather than weak (CitationConnell, 1995; CitationCourtney, 2000). A consequence of this might be that men hide their feelings in difficult situations, and also that men express their symptoms of depression differently and often seek less help than women. Gendered expressions of depression seem to exist everywhere but seldom are problemized in a cultural perspective in the studies we have analyzed. On the contrary, the articles in our study showed that the patterns of communication differ by gender as well as by cultural and social circumstances. Thus, it may be necessary to reflect on gender and dominating gender norms in the studies of depression.
On the Methods
In this study we have analyzed cultural and gendered expressions of depression by examining all relevant PubMed publications over a long time period. In order to obtain knowledge about a more global context, we decided to include all published articles in our analysis rather than to use inclusion criteria related to the scientific quality of the articles. Selection of high-quality publications would increase the risk of excluding small-scale studies from low-income countries. Furthermore, in order to analyze different aspects of what the authors wrote about expressions of depression, we decided to perform a qualitative content analysis of the text rather than to make a systematic review of the field.
Text analysis often is used in the areas of humanities and social science. The method is important also in medicine in order to acquire a broader understanding of contents (CitationMorse, 2002).
The selection of articles in our study was based on analysis of abstracts. It is possible that selection based on analysis of complete articles would have resulted in more articles being included. The key findings of an article should be presented in the abstract however, and we have no reason to believe that the selection of articles for this study is not representative for our purpose. Our results might have been different if other databases had been used (e.g., Psychlit or Sociological abstracts), but the focus of this study was the area of medicine.
CONCLUSION
The expressions and interpretation of depression is related to sociocultural and gender norms and cannot be fully understood without taking the wider context in which they appear into account. In order to avoid Western hegemony and research bias, it is important to regard depression as a situated, context-bound illness. Knowledge about the local context in which depressed patients live, also is essential in order to avoid that depression, formed by gendered social and cultural life circumstances, is not treated only as an individual mental health problem. Consequently, it is necessary for clinicians when meeting depressed patients to include questions about both the patient's social and cultural context as well as about their illness beliefs related to depression. To identify patient's “situated narratives” is basic not only to avoid misdiagnosis and cultural stereotyping, but also to ensure better communication and more equity in health care (CitationWachtler, 2006).
The study was supported by grants from the Swedish Research Council and from the County Council of Västerbotten, Sweden.
Notes
∗References from the articles included in the study are marked with an asterisk.
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