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DEPRESSION, WOMEN AND CULTURE: A COMPARATIVE STUDY OF DEPRESSION AMONG MALAWIAN AND UGANDA WOMEN. Dr Joshua Tugumisirize Assumptions 1 Human nature is fundamentally the same regardless of geography, climate, ethnicity, culture, and socioeconomic structure. Therefore mental disorders should be more or less similar across countries and cultures (German, 1987) Assumption 2 Individuals are differentially vulnerable to variations in environments and cultures (German, 1987) Our Task “We are eager to know, certainly, how many people in Uganda suffer from depression (and other ailments) but how can we start to find that out if we do not understand and know the modes in which the local patient expresses depressive symptomatology? What words does he use? What do his gestures mean? What fear is being expressed by the patient from Buganda when he complains of dizziness?” Prof Allan German (1972) in a forward to Orley’s book on “Culture and Mental Illness” Burden of Depression1 Depression is the fourth leading cause of burden of disease in women Data from primary care studies across countries and cultures show gender ratio of female : male of 2:1 In spite of this, there is a wide variation in prevalence rates of depression in women across countries and cultures The WHO study of depression in primary care found a 15 fold variation in prevalence rate of current depression e g Nagasaki (Japan) 2.8%, Ibadan (Nigeria) 3.8%, Santiago (Chile) 36.8%; mean prevalence 12.5% Burden due to Depression 2 A WHO primary health care study involving 14 countries found a mean prevalence of depression in women of 12.5%, with lowest rates of 2.8% in Nagasaki, 3.8% Ibadan, Nigeria, Japan and highest rate of 36.8% in Santiago Chile . Burden of Depression 3 Most of the women with depression in primary care studies are not recognised, are not diagnosed and miss out on appropriate treatment Untreated depression has serious consequences for the health of the women, their families, their offspring. Burden of Depression 4 Depression in women is associates with marital dysfunction, marital violence, divorces, death by suicide, infanticide; developmental disorders and depression in offspring, and inadequate functioning ain all areas of life Burden of Depression 5 If left untreated depression becomes a chronic recurrent disorder In a study in Ethiopia: depression increased standardized mortality (3 times) Depression in patients with physical disease is responsible for poor compliance to treatment and premature death The Problem Although depression is a common and disabling disorder, it is poorly understood and is often unrecognised and untreated The extent to which cultural factors influence the nature, the experience ,the extent, recognition and treatment of depression remain to be resolved. Historical Perspective 1 In the pre-independence Africa,it was generally accepted that Black Africans rarely suffered from depression (Prince, 1968) According to Judaeo-Christian cultures, mental disorder was part of the price paid for civilization, for being responsible and for opposing the devil and his works (German 1987) and Rousseau ‘s idea ‘noble savage’ prejudiced their views about the African. Historical Perspective 2 Some believed that the brains of the black Africans were less developed; that Africans behaved in a childish manner, and that they lacked a sense of responsibility (German, 1987) By implication, depression only occurred among the intellectually gifted. Historical Perspective 3 The African was irresponsible, therefore, he was devoid of a sense right and wrong and could not feel guilt. It was further argued that suicide was rare in Black Africans. Historical Perspective 4 From the 1960s, the story changed. Africans were found to have high rates of depression. It was argued that phenomenology of depression in Black Africans was different from that of the Europeans and Americans Historical Perspective 5 It was claimed that depression in Black Africans manifested with numerous physical symptoms. Depressed black Africans rarely showed feelings of guilt , worthlessness and rarely committed suicide The issue of Language German 1972: Reported on 50 Ugandan depressed patients. All of them presented with weakness, lack of energy, , insomnia, anorexia, ; some presented with loss of sexual and social interests and signs of psychomotor retardation. Regarding the language of presentation, German found two distinct groups of Ugandans: Those with University and College Education – the acculturated The uneducated or lowly educated – the nonacculturated Psychological Idiom The acculturated spontaneously complained of being depressed. The admitted to feeling ‘sad’ and ‘unhappy’ when specifically asked. However they denied primary depressive illness. They were sad because they were ill. Only four admitted to guilty worthless feelings. These were the acculturated group Somatic idiom The acculturated almost invariably complained of weakness and feeling ill. Subsequenty, Muhangi and German were to argue that Ugandan patients lacked the words and phrases to communicate psychiatric symptoms (Muhangi and German,1975) No Guilt, No Suicide In summary: German concurred with other expatriate psychiatrists, that depressed Ugandan rarely felt a sense of guilt or worthlessness; that suicide was rare. And yet The rate of suicide in Busoga Uganda, was reported to be 8.5 per 100,000 population at risk (Fallars and Fallars, 1960), similar to rate in England (German 1987). In Phenomenology of Depression However, the facts on the ground were different. In a seminal study Orley determined the psychiatric morbidity of the adult population in Kyadondo. He found that 22.6% of women suffered from depression compared to 9.3% of women from London. More importantly he found that the depressed Ugandan were four times more likely than the subjects in London to admit pathological guilt (Orley and Wing 1979). What had changed? Orley, a psychiatrist and a trained anthropologist applied a semi structured psychiatric interview, used supplementary information, understood the local language It was now clear that culturally sensitive methods must be applied in all crosscultural studies. Orley 1979 The myth that guilt was only among the privileged, highly individualistic and brought to belief in personal responsibility was challenged by Orley’s findings Explanatory models of Depression In fact, subsequent research and discourse on depression, reflected the views expressed of local people. A new cross- cultural psychiatry was developed in which emphasis was on the local understanding of illness and a culturally relevant phenomenolgy (Kleinman 1987, Patel 2001) Local idioms of Distress Sometimes the experience of depressive illness can be ‘incoate and ineffable’ Therefore translation of personal experience into symptoms is very difficult Even when professionals and lay people use the same words and expressions may not share the same meaning. However, the language rendering of psychopathology is key to accurate clinical assessment, diagnosis and treatment Idioms of Distress We should remember that professional language is defined by commissions or committees of experts. These change from time to time when new knowledge and understanding has accumulated It the duty and responsibility of clinicians to acquaint themselves with lay language, lay terminology for psychological problems and distress Epidemiology: 1 Cultural Influences on Depression Rate of depression in women varies widely between countries and ethnic groups. Eg Maori compared to non-Maori (MaGIPIe Research Group (2005) Tongan women more than Samoans (Abbott et al 2006) USA > Israel > Japan (Froom et al 1995) South America > Europe and Africa > Asia/Japan (WHO, Ustun and Sartorius, 1995) Risk Factors for Depression 1 Depression is a consequence of interaction of multiple factors including 1 biological factors: depressive symptoms are increase around menstruation and after childbirth 2 Psychosocial: a) in some cultures failure to give birth to a male child is associated with depressive illness b) Marais et al in a primary care study in South Africa: found high rate of depression in women who reported marital violence compared to women who did not report marital violence Risk factors 2 There is a link between reproductive processes and depression. This may partly responsible for preponderance of depression in women There are two peaks depression in women. In late pregnancy and at around 5 years after childbirth. However, there are new episodes of depression within two to six weeks after childbirth. Risk Factors 3 Women are more vulnerable to a wide range of adverse conditions and situation: poor relationship with significant others, poor relationship with mother, motherin-law. Inadequate material and emotional support. Culture and postnatal depression Postnatal depression has been found in all cultures, including in cultures that have preserved rituals and customs surrounding birth. Contrary to the views of some anthropologists in Asia, Kenya, cultural practices do not protect women from postnatal depression Depression and Motherhood The burden of childrearing is associated with increased risk of depression (Najman et al Muhwezi et al, 2007). This is the explanation for a peak prevalence of depression in mothers. Protective Factors Women who accept traditional roles: as mothers, as careers Women who enjoy employment outside the home. Women who are respected in the community, whose opinions are respected Women who enjoy material and emotional support Case study 1 Cheng and Hsu 1983: measured the risk of psychiatric disorders among women from three different family structures in Taiwan: Patrilineal Matrilineal And mixed The prevalence of psychiatric morbidity was lower in the communities which had preserved the traditional social roles and responsibilities of women in matrilineal culture. For the women in communities which had transformed from the matrilineal to the patrilineal social roles, the women were more vulnerable to psychiatric morbidity. Case study 2 Carstairs 1979 Studied the prevalence of depression among the ethnic groups in Southern India, the Brahmins (prosperous), the Bants (farmers) and the Mogers (underprevilaged fishermen). The Bants and Mogers previously follwed the matrilineal system of family location and inheritance. At the time of Carstairs study, the Bants and Mogers had largely adopted the patriarchal system. Case study 2 cont’d Case rate Brahmins (%) Bants (%) Mogers (%) Males 29 39 32 Females 33 43 42 Case Study 2 cont’d Residence pattern and case rates among formerly matrilineal spouses Cases Males Traditional residence 113 (32%) Changed residence 93 (38%) Females 222 (36%) 115 (55%) Hypothesis Women who enjoy high status and self esteem, women who show a positive attitude to motherhood and women who accept the traditional roles are less vulnerable to depression The cultures which respect the role of women and provide opportunities for personal development are less vulnerable to depression Objectives The objectives were a) to explore the lexica of emotion, cultural idioms and metaphors of distress in selected lay people in Uganda Malawi b) to validate the Tumbuka, Chichewa and Luganda versions of Edinburgh Depression Scale (EDS) and General Health Questionnaire (GHQ 12) and c) to determine and compare the prevalence of depression in women attending primary health care facilities in Mzuzu, northern Malawi (patlineal culture) and Wakiso Uganda (patrilineal culture), Mulanje, southern Malawi (matrilineal culture) To determine the local concepts and lexica of depression and idioms of psychological distress among informants from Malawi and Uganda y Definitions Culture Culture: meanings, values, and behavioural norms , that are learned and transmitted in the dominant society and within its social groups. Culture influences cognition, feelings and self-concepts as well as the diagnostic process and treatment Culture influences: experience, clinical presentation, decisions about treatment Definition Depressive Disorders -Major Depressive Disorder : criteria A of DSM IV -Subthreshold disorder: symptoms count 3-4 and 2-4 symptoms. Note: did not apply the clinical significance criteria (See MADRS) (Bolton et al, 2004; Gouldney et al 2004; Williams et al 2002) Methods: Comparative cross –sectional surveys Used mixed methods: qualitative and quantitative METHODOLOGY Study Site Malawi Matrilineal site: Mulanje Hospital Out-patient Clinic Patrilineal site: Mapale Health Centre in Mzuzu Uganda Patrilineal Sites: Wakiso Health Centre Entebbe Hospital Out-Patient Clinic Local Lexicon Qualitative Interviews of key informants in three languages: Chichewa, Tumbuka, Luganda Convenient sample Listing and sorting: the K I were asked to list words, expressions and metaphors used in each language to express or describe emotions and feelings that arise in the following context a) after the death of a loved one b) after loss of a valued object c) after discovery that a spouse was unfaithful d) if one was to win a thousand dollars e) if one’s marriage has ended. The lists of the words generated were sorted with the help of mental health care workers to identify the words, phrases and metaphors used by patients with depression. Results Data was obtained from 127 key informants in Chichewa, 40 KI in Luganda and 106 KI in Tumbuka Chichewa Lesion Key word/ relative frequency English Equivalent Kusauka mtima 30 Ndikusauka nazo mu mtima 29 Guilt conscious Unsettled in the mind; heartache Ndivutika nazo maganizo 28 To be troubled in the mind; to think alot Worry, anxiety Nkhawa (kudandaula) 24 Kukhumudwa 22 Chisoni Chikumbumtima 13 Maganizo otaya mtima 20 depressed Grief, pity guilty Feeling hopeless and suicidal Luganda Lexicon Key word/ relative frequency English equivalent Okukaaba 44 To cry Okweyawula 44 Okunakuwala 44 Okwekubagiza 44 To isolate oneself To be sad To feel sorry or sad for oneself; self-pity Okweralikirira 42 Enyiike 41 Okulowooza 39 Okwenyamira 38 To worry Angst To think alot To cause to be sad Okwejjusa 34 To regret Tumbuka Lexicon Key words/relative frequency English equivalent Kusweka mtima 16 Kuwa na chitima 13 Kugongowa chitima 13 Broken heart Sad, depressed Become very sad and hopeless Kudandaula 11 Kuwa maghanoghano 9 Mtima ukuwawa 7 Wakusugzika m’mtima worried To have too many thoughts Broken heart In problems Wakuoneka wakusuzgika 2 Wakuba na nthumazi 2 To look troubled Feel guilty Discussion 1 Our results are consistent with those of Bolton et al (2004) e g the key words okwekyawa, okwetamwa, okwekubagiza were identified as equivalent expressions for depression Our results contradict views expressed by Prince, 1968; German, 1972, 1979. Local people have the vocabulary for emotions Implications Lay people are able to describe in detail psychological manifestations of depression and anxiety if they are given time and opportunity to do so (Tomlinson et al 2007; Halbreich et al, 2007) Health care professionals must acquire adequate knowledge of folk concepts and expressions of distress Psychiatric assessment should be culturally sensitive Conclusion The lay people in Malawi and Uganda have a rich vocabulary of emotional words and phrases that accurately describe the experience of depression Giving the patients opportunity to narrate their experience of distress is a more appropriate method of eliciting psychopathology of depression. Having vocabulary for discrete symptoms of depression is a necessary but not a sufficient condition for recognition of depressive syndromes Quantitative Survey Sample Adult women, 18 – 65 years old (systematically selected samples: Mulanje 200, Mzuzu 211, Wakiso 213) Sample size determination Power calculation for comparison of means: an alpha of 5%, expected difference of 10% between highest and lowest expected prevalence (10- 20%) and at power of 80%: Screening The study subjects were initially screened for depressive symptoms and psychological distress respectively, by translated versions of Edinburgh depression Scale (EDS) and General Health Questionnaire (GHQ 12) in Tumbuka (north Malawi) Chichewa (south Malawi ) and Luganda (Wakiso, Uganda). Ethical Considerations The study was approved in Malawi and Uganda. Informed consent was obtained from all participants Psychiatric Interview Most of the subjects who scored at and above threshold and 20% of those who scored below threshold were interviewed using the MINI International Neuropsychaitric Interview (MINI) to identified those with depressive disorder. The intensity of depressive disorder was determined using the Montgomery –Asberg Depression Rating Scale (MADRS). Analysis of Data The SSPS programme version 11 was used to calculate validity indices for EDS and GHQ 12 and the prevalence rates were calculated using the STATA programs. Relationship between depressive symptoms and depressive disorder and socio-demographic and cultural factors was explored by bivariate and logistic regression RESULTS Data was collected from 200 women at Mulanje, 209 women from Mzuzu and 209 women from Wakiso. RESULTS 1 Depressive symptoms Mulanje38%, Mzuzu 60.3% Wakiso, 45.2%. Rates of Depressive Disorders Prevalence of depression Wakiso 27.8% Mzuzu 16.6% Mulanje (9.9%) . Factors Associated with Depression The main factors associated with depressive illness coercive sex (for women in Mulanje, and Mzuzu) debt burden and marital conflict for women in Mzuzu and domineering spouse for women in Wakiso) Discussion1 The lay people have rich language for expression of distress. Clinicians need adequate understanding of local cultures. Discussion 2 In Luganda- there were more key words for the cognitive expression of distress e g to be fed up (okwetamwa), to be disgusted with self (okwekyawa), regret (okwejjusa), self pity (okwekubagiza) Discussion 3 Depression in Malawi women linked to the social role and social status of women Matrilineal women have the most unstable marriages. Divorce is easy. Remarriage is equally easy. In spite of more poverty among Mulanje women they have lowest rates of major depression Discussion 4 The women in the patrilineal malawi are constrained by difficulty of securing divorce. They relatives are unlikely to condon divorce because they may not be able or willing to refund the bride price. dowry Discussion 5 There was no difference in the level of instability of marriage in Wakiso women in Mulanje.Yet, the women in Uganda have more severe depressive illness. It is likely that the Mulanje women have more access to support. Single parenthood and divorce are not a source of stigma. Discussion 6 The burden of depression is higher in the patrilineal women The rates however are comparable to the rates of depression in other centres in Africa. South Africa 40.5% (Carey et al 2003) The research in Tanzania found severe depression in 2.2% of primary care attenders. More that 17% had either mild depression or anxiety and depression (Ngoma et al, 2003) Discussion 7 It was suggested that women in Tanzania have, through NGOs been economically empowered. Limitations The study was limited to a few sites. The results cannot be generalised to the rest of the countries The samples were not randomly selected Strength of the Study It was a compararative study It address almost homogenous groups – less variation was expected in the local area The results are within the range of studies with similar socio-economic conditions Conclusion1 There are wide variations in the rates of depression among Malawian and Ugandan women. The role of culture remains unclear. Psychosocial factors which may be cultural basis are more significantly associated with depression. Conclusison 2 The research instruments developed in western cultures can be adopted for use in African settings The must be attention to local idioms of distress and the explanatory models IMPLICATIONS Implications for Policy and service: There is need for strategies to address the high levels of depression at primary care level. There is need for further studies in different cultural groups Health care workers need training in skills to manage marital and sexual violence among patients who seek care at primary care Recommendation1 Glossaries of local idioms of distress and psychological terms should be developedy. Strategies for increasing public awareness and to create demand for mental health care service should be considers. Lastly, all curricular for health care providers should include gender and Acknowledgements This work was part of my Ph D research I wish to acknowledge SIDA/SAREC and School of Graduate Studies, Makerere University for the support they provided I wish also to acknowledge my supervisors: Prof Hans Agren, formerly of Karolinska Institutet, Dr Stella Neema and Dr Seggane Musisi of Makerere University College of Medicine, University of Malawi St John of God Community Mental Services, Malawi Dr Joshua Tugumisirize, Formally at Department of Psychiatry, Makerere College of Health Science [email protected] Phone: 0772929741