Transcript Case study 2 - Makerere University News Portal

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
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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

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

Dr Joshua Tugumisirize,
Formally at Department of
Psychiatry, Makerere College of
Health Science
[email protected]
Phone: 0772929741