The case of depression, also known as major depressive disorder, seems to be globally prevalent with substantial data being reported annually. The World Health Organization (WHO) has reported that depression is known to be “a leading cause of disability worldwide… a major contributor to the overall global burden”, affecting more than 264 million people all around the world (WHO, 2019). Whilst the knowledge and information we have about depression as a global health issue, as well as the treatment(s) involved, is significant compared to previous years, it is not completely efficacious due to the presence of social stigmatisation and as a result, the discrimination that individuals suffering with depression face. Social stigma is defined as “a process of social rejection” and contributes towards discrimination against those who are marginalised in society, resulting in low self-esteem and being reluctant in seeking help. This is true especially for low-income and middle-income countries who are at a disadvantage and face inequity, due to the lack of resources attainable and the low funding towards mental health services. A -study shows that the usage of mental health services was lower for low-income countries like Nigeria (1.6%) compared to high-income countries like the United States of America (17.9%) and New Zealand (13.8%), which could reflect upon the countries’ percent of health budget to gross domestic product (GDP), a representation of their budgeting towards health care .
It is also important to acknowledge that in most cases, for the diagnosis procedure of depression, there are concerns over the diagnostic tool used. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) published by the American Psychiatric Association (APA) is a diagnostic tool which requires a minimum of five symptoms for the duration of two weeks and depressed mood or anhedonia (loss of interest)= should be at least one of them along with loss of concentration, changes in sleeping pattern and at extreme, thoughts of suicidality. There is a lack of cross-cultural validity and it is thought to be ethnocentric, with symptoms not fully being “culturally contextualized” despite the influence of the culture on certain factors like stress. The concept of ethnocentrism, in this case, refers to as the “evaluation of other cultures according to the perceptions originating in the standards and customs of one’s own culture”. This is important in the context of diagnosis as it can fail to correctly evaluate an individual’s suffering and experience, leading to misdiagnosis, or even underdiagnosis which prevents the further receival of the correct adequate treatment.
In this essay, I will be exploring the rise of depression as a mental health issue and the transition from conceptions previously held whilst addressing the current differences in different cultures around the world. By culture, I will be specifically comparing and contrasting upon individualism and collectivism cultures. Individualism here can be defined as culture where characteristically, the focus is on the self and the individual itself, whilst collectivism focuses on the needs of the community as a whole. Within culture, socioeconomic factors such as gender, income, race etc are also embellished which can also be considered upon the topic of depression.
How has depression emerged as an object of mental health disease and how does this differ across cultures such as in India compared to the United States?
This research question involves the development of depression into the current object of disease and a global burden and how it differs amongst cultural contexts. The history of depression will be referring to the clinical diagnosis and perceptions by society. I will be specifically referring it back to individualistic and collectivist cultures, by using the example of India and the United States. Firstly, this specific research question is important because from our understanding of the previous conceptions regarding depression, we can transcend to a greater comprehension so that those most vulnerable are not facing marginalisation that they might have previously felt. It is also significantly important for researchers as they can take into account cultural differences and aim for research that is universal. Evolving knowledge of the disorder can then lead to positive outcomes for those suffering with depression, as they have the chance to access resources towards improving their quality of life.
Whilst the epidemiology of depression has continually increased, the current understanding of major depressive disorder is completely different throughout previous centuries. Historically speaking, before the 18th century, ‘melancholia’ was the common term used. The word itself was literally translated to “black bile” and was based upon the humoral theory predominant during that time period where melancholia was believed to be a mental disorder which involved “prolonger fear and sadness” with common symptoms including “sleeplessness, irritability , aversion to food” . The humoral theory accredited the imbalance of the four bodily fluids also known as humors (phlegm, yellow bile, black bile and blood) for the occurrence of disease and disorders, and for which moderate exercise was recommended).
Another concept rising at the time, particularly within the Christians, was the idea of “religious melancholy” where as a result of committing sin leading to abandonment by God to the possession of the devil, where the “body was visited by a malignant spirit”, leading to the assistance of the priest. I believe that the transition from the concept of religious melancholia to prioritising biological and sociopsychological factors is beneficial, as traditional views of suffering as a result of committing sin can be harmful for patients. Studies reveal that a lack of uncertainty arises over being forgiven for their sins, leading to negative interpretations, and alienation from God was shown to be a factor that was determinant of depression (Exline, et al., 2000). If traditional perceptions of mental illness as abnormal and deviant still persist, it could affect sufferers who are religious as they are not provided with social support, and could be scrutinised and alienated by their community as well as their relationship with their faith and God. Treatments during that time period wasn’t also effective or humane, due to the stigma around mental illness,
Recent understandings of the model for the explanation of depression involves the intercalated interaction between biological, social and psychological factors, yet not a single cause has been identified.
In regards to funding towards mental health services, there is still a lack of resources in most parts of the world. The WHO’s 2014 Mental Health Atlas reported that amongst all income groups, mental health funding consisted of less than 5% of overall spending on government health expenditures, with only seven out of fourty one countries contributing more than 5% (WHO, 2014). When vulnerable people are not provided with the correct treatment and are a member of the society that oppresses them, it can lead to severe consequences like suicide.
In India, one of the most densely populated country in the world with a population of over 1.2 billion, “mental health expenditures by the government health department/ministry are 0.06% of the total health budget” (WHO, 2011). The extremely low percentage of funding towards mental health could reflect upon the government’s attitudes towards the need for improving mental health facilities. Due to the lack of resources available, especially in rural areas, individuals in the community might resort to other alternatives including healing temples. Commonly in India, those with mental illnesses often visit religious sites such as the temple of Muthusamy in the rural area of Tamil Nadu, thought to hold healing power, where sufferers typically stay for few weeks free of charge and findings reveal the average psychiatric rating scale score decreased from 52.9 to 42.9 (Raguram, et al., 2002). This management of mental illnesses is another alternative which could be beneficial due to the cultural impact it has whilst habituating in a supportive environment. Not only does it reflect upon the lack of treatment facilities available, it also shows the reluctancy of people to seek help from a professional. Furthermore, evil eye and black magic is believed to be a cause of illness by more than 25% of the patients in one study, and 45% had visited religious healers before meeting with a psychiatrist and primarily resort to religious practitioners “who believe in supernatural explanation of mental illness” 7.
A recent survey conducted in India a by The Live Love Laugh Foundation composing of 3,556 participants reveals the omnipresent social stigma surrounding mental illness. Whilst a majority of responses displayed some awareness about mental illness, 62% also used derogatory terms such as ‘retard’ as well as crazy/stupid to describe someone with mental illness and 60% agreed that “lack of self-discipline and willpower” was one of the main cause, whilst also believing mental illness to be contagious (“healthy people need not to be contaminated by them”) (TLLLF, 2018). TLLLF survey also concluded that 47% of the sample were judgemental, displaying stigma despite coming from a higher socio-economic background with high education level (2018). Conformity towards stigma is detrimental especially in a collectivist society, where group identity is significant. Negative stigma held by the public could lead to the resistance of discussing mental health, so education needs to be prioritised so that the stigma around mental illness is desensitised.
Whilst the West prioritises biological and psychological theories, situational model is embedded upon non-Western societies where they believe symptoms to be “social problems or emotional reaction to situations” and less likely to seek help, “deny psychological distress, interpret distress as somatic illness” .