The Problem with Diagnosing Depression Accross Cultures Part 3: What difficulties arise from applying Western categories of mental illness to Asian societies?

There are many problems that arise due to the importing of the Euro-American psychiatric paradigm and its accompanying categories.  These include decline in the quality of care, and the further unfortunate stigmatisation of those who are suffering from mental illness.  The DSM criteria, as well as the worldviews propagated by the World Health Organisation and the Movement for Global Mental Health (or MGMH, a transnational network of individuals and organisations seeking to improve mental health support worldwide), which often influence the mental health policies and legislations of countries in Asia, conflict with these local idioms found amongst the people living in them.

A national reform of the country’s mental health system was undergone by the Indian government in the name of human rights, after the Erwadi incident on the 6th of August, 2001, in which 28 patients who were bound by ‘divine chains’ were burned alive in a fire in a faith-healing establishment near the village of Erwadi, Tamil Nadu.  However, many Sankatwale in Sood’s study expressed discontent at the Indian government’s attempts to ‘modernise’ the Balaji temple into a generic place of worship in their campaign of promoting the Western psychiatric paradigm, which the Indian government saw as ‘modern’ and ‘evidence-based’.

Likewise, the resulting modernisation of the hospital in Srinagar, Kashmir in Saiba Varma’s (2016) fieldwork, was instead directed towards increasing the prestige of the hospital, resulting in the further neglect of patients in long-term psychiatric wards, who then slipped out of the range of patients with ailments, that before, were curable within the local paradigm, but were now professed to be incurable within Western evidence-based psychiatry.  These include conditions such as schizophrenia, recovery from which was regarded as a miracle rather than a medical breakthrough (Varma 2016).  Moreover, due to a shortage of specialised professionals, the Indian government’s attempts to modernise mental health by discouraging and illegalising traditional methods resulted in the increased stigmatisation of people who turned to traditional healers, who were more accessible, and that too in a society in which medical pluralism is the norm – In India, it is not uncommon to be seeing both a biomedical practitioner and an ayurvedic professional by the same patient, for the same ailment, at the same time.

Interestingly, both Loo and Furnham’s study in Malaysia and Hahn et al’s survey of Hanoi, Vietnam revealed less stigmatisation in rural than in urban parts.  While 32% of the rural participants reported a diagnosis of depression in Malaysia, only 9.2% of urban participants did so.  While this can be due to financial and social problems being more prevalent rurally, it can also insinuate that more participants in rural areas were willing to reveal a previous history with depression.  Kleinman also reported that those living in Chinese villages were more likely to outwardly express distress than their formally-educated middle-class counterparts living in urban areas, who did so only in closed family settings (Kleinman 1986).

These findings attest to how stigma actually accompanies modernisation and the influx of Western psychiatric categories.  Insofar as it concerns the available professions in rural areas, such as farming, mental illness is not considered as much of an impediment to productivity, whereas it has much more of an impact in the industrialised city-centres in which it is perceived to be a hindrance to productivity and workforce performance.  This is consistent with Kleinman’s study in China, a heavily industrialised Communist society that emphasises work ethic and productivity, in which somatisation may actually be a result of stigma towards counter-productive emotional states.

Furthermore, this positive correlation between modernisation and stigmatisation also occurs in Kashmir, in the guise of neglect and prejudice against patients in inpatient wards.  This is likely due to a categorical view, rather than a ‘spectrum view’, so to speak, of the DSM diagnostic criteria in ‘modern’ psychiatric discourse.  The fact that patients in Kashmir were seen as ‘terminally’ mentally ill following the modernisation reforms, attests to this in that it led to the categorisation of some patients as ‘treatable’ and some as ‘untreatable’.

Through the investigation and exploration of various ethnographic data from throughout the Asian continent, which are by no means exhaustive, I have attempted to show that idioms of distress, perceived as the symptoms of major depressive illness in the West, may not correspond to and coincide with those idioms found throughout the East.  Some of these idioms, such as the burning sensations of hwabyung found in Korea, are non-existent in Western culture; others such as somatisation, though present, are infrequent and sporadic, and are never seen as the primary cause of depressive disorder, although they can certainly be seen as effects.

And even where modes of expressing despair do coincide with the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, they are often expressed through normative rather than deviant cultural scripts, and are therefore not considered to be symptomatic of a biological disease.  In Iran, suffering is seen as indicative of a person’s depth and understanding.  Such is not only the case in Iran, but also in Buddhism, in which the acceptance of the eternal suffering of mankind is an important step in the path to overcoming that suffering, and achieving enlightenment.

The argument I’ve presented is only a small part of a much more extensive and eclectic dialogue between cultural relativism and universalism.  Does it mean that the Western psychiatric paradigm is completely ineffective at treating mental illness?  Absolutely not.  It too is an equally culturally valid paradigm affiliated with a culturally dictated set of idioms, which can provide amelioration of mental health practices both in Western societies and even in many societies beyond.  However, it does suggest that clinicians worldwide should be mindful of local idioms of distress, in order to best deal with a problem that plagues and has plagued both individuals and societies from all cultures, throughout all parts of the world, for many millennia since the dawn of the human species:  the problem of unhappiness and suffering.

 

References

Image Source:  http://www.rajasthanonline.in/About/tourism/religious-spots/index.html

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Healy, D. (2004). Shaping the Intimate: Influences on the Experience of Everyday Nerves. Social Studies of Science 34(2) (April 2004).  Pp. 219-245

Horowitz, A. (2014). The Social Function of Natural Kinds. The Case of Major Depression.  in Kincaid, H. & Sullivan J.  (eds.) (2014).  Classifying Pychopathology: Mental Kinds and Natural Kinds. Cambridge Massachusetts:  MIT Press.  Pp. 209-227

Kleinman, A. & Good, B.  (1985). Culture and depression: Studies in the Anthropology of Cross-Culture Psychiatry of Affect and Disorder. Berkeley: University of California Press.

Jain, S., & Orr, D. M. (2016). Ethnographic perspectives on global mental health. Transcultural Psychiatry.  53(6).  Pp. 685-695. doi:10.1177/1363461516679322

Jenkins, H.  Kleinman, A.  Good, B. (1991). Cross-Cultural Studies of Depression. in Becker, J. & Kleinman A. (eds.) (1991). Psychosocial Aspects of Depression.  London:  Lawrence Erlbaum Associates, Publishers. Pp.67-99

Kirmayer, L.  (2001). Cultural Variations in the Clinical Presentation of Depression and Anxiety: Implications for Diagnosis and Treatment. Journal of Clinical Psychiatry 62 (suppl. 13): Pp. 22-30

Kleinman, A.  & Kleinman J. (1985).  Somatization: The Interconnections in Chinese Society among Culture, Depressive Experiences and Meaning of Pain. in Kleinman, A & Good B. (eds). (1985). Culture and depression: studies in the anthropology of cross-culture psychiatry of affect and disorder. Berkeley, California: University of California Press.

Kleinman A. (1986).  Social Origins of Distress and Disease: Depression, Neurasthnia and Pain in Modern China. New Haven, Connecticut:  Yale University Press.

Loo, P., & Furnham, A. (2013). Knowledge and Beliefs about Depression among Urban and Rural Indian MalaysiansMental Health, Religion & Culture,16(10), Pp. 1009-1029. doi:10.1080/13674676.2012.728579

Sood, A. (2016). The Global Mental Health Movement and its Impact on Traditional Healing in India: A Case Study of the Balaji Temple in Rajasthan. Transcultural Psychiatry,53(6), 766-782. doi:10.1177/1363461516679352

Summerfield, D.  (2006). Depression: Epidemic or Pseudo-epidemic? Journal of the Royal Society of Medicine 99 (March):  Pp. 161-162

Ta, T. M.  Zieger, A., Schomerus, G., Cao, T. D., Dettling, M., Do, X. T…. Hahn, E. (2016). Influence of Urbanity on Perception of Mental Illness Stigma: a Population Based Study in Urban and Rural Hanoi, Vietnam. International Journal of Social Psychiatry, 62(8).  Pp. 685-695. doi:10.1177/0020764016670430

Varma, S. (2016). Disappearing the Asylum: Modernizing Psychiatry and Generating Manpower in IndiaTranscultural Psychiatry,53(6), 783-803. doi:10.1177/1363461516663437

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