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Central Questions Regarding Culture and Psychopathology

Central Questions Regarding Culture and Psychopathology

Researchers have used the methods described previously to answer some of the central questions about culture and psychopathology: Are mental disorders observed in Western contexts seen in other cultural contexts? Does culture influence the expression and meaning of symptoms? Do ‘‘culturally bound’’ syndromes exist? Does the social and psychological impact of mental illness vary across cultural contexts? And how should clinicians treat individuals of cultural backgrounds different from their own? Significantly more empirical research has been conducted on the occurrence and presentation of mental illness (the first four questions) than on the impact and treatment of mental illness (the last two questions).

Are Mental Disorders Observed in Western Contexts Seen in Other Cultural Contexts? Emil Kraeplin, the principal founder of psychiatric nosology, was one of the first scholars interested in the occurrence and expression of mental illness across cultures. He hypothesized that cultural differences in incidence and prevalence rates of mental disorders across cultures existed and were related to differences in social conditions and ethnocultural characteristics (e.g., values). Furthermore, he believed that examining such differences would advance our understanding of pathological processes: If the characteristics of a people are manifested in its religion and its customs, in its intellectual and artistic achievements, in its political acts and its historical development, then they will also find expression in the frequency and clinical formation of its mental disorders, especially those that emerge from internal conditions. Kraeplin journeyed to Java to collect data to support his hypothesis. He concluded that several disorders that were prevalent in Europe were absent in Java and that the expressions of affective and schizophrenic disorders were somewhat different in Java from those in the United States. Although he was unable to test this hypothesis directly or in other cultures, investigators since his time have. Most of the existing research on psychopathology across cultures has focused on schizophrenia (and related psychotic disorders), depression (and related affective disorders), anxiety, and substance abuse and dependence. Investigations of the occurrence of specific mental disorders across cultures are epidemiological. Typically, they use Western classification systems to diagnose mental disorders and then compare the total number of cases of a particular disorder within a specific period (i.e., prevalence) across cultures. A few studies examine the number of new cases of a particular disorder within a specific period (i.e., incidence) across cultures, but these studies are relatively rare. Schizophrenia.The term ‘‘schizophrenia’’ has been used to describe a cluster of symptoms that include delusions; hallucinations; disorganized thought, speech, and/or behavior; restrictions in emotional experience and expression; and lack of goal-directed behavior. There is strong evidence of a genetic and biological component in schizophrenia. However, this genetic vulnerability is expressed only under stressful environmental conditions. Most of the empirical findings suggest that schizophrenia occurs across cultural contexts at similar annual incidence and lifetime prevalence rates. The WHO Program of Cross-Cultural Research on Schizophrenia is the most comprehensive of cross-cultural studies of schizophrenia. Conducted from 1967–1986, this research program was comprised of three studies that sampled more than eighteen psychiatric centers in Africa, Asia, Europe, and Latin and North America. More than 3,000 patients were assessed using a standard clinical interview (Present State Examination) and then were reassessed 1, 2, and/or 5 years after the initial screening. The psychiatric centers included were divided into those that represented ‘‘developing’’ (e.g., Nigeria, India, Taiwan) and those that represented ‘‘developed’’ (e.g., United States, United Kingdom) countries. Across cultural contexts, the lifetime prevalence rate of schizophrenia was a little more than 1% of the population. Moreover, when schizophrenia was conservatively defined, its an nual incidence rates did not statistically differ among the cultures sampled and ranged from 0.7 to 1.4 per 10,000 persons across cultures. The external correlates of schizophrenia were also similar across cultural groups. Males showed an earlier onset of symptoms than females across the cultural groups; Cetingok, Chu, & Park found similar sex differences in their study of schizophrenia in Turkish and European-American samples. Schizophrenia was also associated with other cerebral and physical diseases across cultures. These f indings suggest that the core aspects of schizophrenia are minimally shaped by culture. Exceptions to the WHO findings, however, have been observed. For example, higher incidence rates of schizophrenia were found among British Afro-Caribbean immigrant groups.

Schizophrenia occurs six to eight times more frequently among British Afro-Caribbean immigrant groups than in the native White British population. Several studies suggest that these differences are not due to misdiagnosis. Therefore, Jarvis argues that schizophrenia is not biologically based and, instead, results from environmental stresses such as migration, broken family structure, socioeconomic disadvantage, and racism. Future research must assess whether this is the case. Affective Disorders.There are several types of affective disorders, but unipolar and bipolar depression are the most distinct. Unipolar depression refers to a constellation of affective and vegetative symptoms that include depressed mood, loss of interest and pleasure in activities, fatigue, agitated movement, sleep problems, and changes in appetite and weight. Other symptoms associated with unipolar depression in Western contexts include feelings of worthlessness and thoughts of death. Bipolar depression describes manic symptoms such as grandiosity, flight of ideas, pressured speech, and irritability; often these manic states are interrupted by episodes of unipolar depression. Unlike unipolar depression, there is evidence that bipolar disorder has a strong genetic component. The bulk of the research findings suggest that unipolar and bipolar depression occur across cultures, but at varying prevalence rates. Bipolar Depression.Epidemiological studies conducted in the United States did not find ethnic differences in lifetime prevalence rates of bipolar depression. For example, in the Epidemiological Catchment Area Study (ECA) of 18,000 adults in five U.S. communities, lifetime prevalence rates of one type of bipolar disorder for White American, African-American, and Hispanic groups were 0.8, 1.0, and 0.7%, respectively.

Moreover, there were no significant sex differences in lifetime prevalence rates of bipolar depression across the three ethnic groups. More recently, findings from the National Comorbidity Survey (NCS), a study of psychiatric disorders in a national probability sample of 8,090 respondents including AfricanAmerican, White American, and Hispanic groups, also suggest that prevalence rates of bipolar depression do not differ by ethnicity or sex. Unipolar Depression.Lifetime prevalence rates of unipolar depression, however, differ among ethnic and cultural groups. For example, in the ECA study, lifetime prevalence rates of unipolar depression were higher for White Americans (5.1%) than for African-Americans (3.1%) and Hispanics (4.4%). Moreover, prevalence rates were higher for women than for men  across the three ethnic groups. Findings from the NCS also suggest that African-Americans have significantly lower prevalence rates of depressive disorders than White Americans, even after controlling for differences in income and education. Contrary to the ECA findings, Hispanic groups in the NCS study had significantly higher rates of unipolar depression than non-Hispanic White Americans and African-Americans. There are a variety of possible explanations for the discrepancy in findings between the ECA and NCS studies. For instance, the stresses and life circumstances encountered by Hispanic groups may have increased during the two periods. It is also possible that the studies included Hispanic samples that varied in their generational status, acculturation levels, and specific Hispanic heritage (e.g., Cuban vs. Puerto Rican). In fact, differences in prevalence rates have been found among specific Hispanic groups. For instance, Moscicki et al. analyzed the Hispanic Health and Nutrition Examination Survey (H-HANES) data and found that the prevalence rates for unipolar depression (in parentheses) varied for Cuban males (1.4%), Cuban females (2.9%), Mexican males (1.0%), Mexican females (3.6%), Puerto Rican males (3.4%), and Puerto Rican females (7.4%). Within the same subgroup, differences were reported based on the length of the stay in the United States and the generational level. In a study of Mexican immigrants and Mexican-Americans in California, Vega and colleagues (1998) found that unipolar depression levels were lowest for recent immigrants (3.2%), were higher for those who had been in the United States thirteen years or more (7.9%), and were highest for those born in the United States (14.4%). The rates of the last group did not differ significantly from those reported for the entire NCS sample (17.2%). Although the NCS and ECA studies did not include a significant number of Asian-Americans to allow for statistically powerful analyses, findings from other studies demonstrate differences between White and Asian-American prevalence rates of depression. In a study of 1,747 ChineseAmericans in Los Angeles, Takeuchi and colleagues found that the lifetime prevalence of depression was 6.9%, which was higher than that for White Americans in the ECA study.

Other studies also found higher levels of depressive symptomatology among Asian-Americans compared to White Americans. In a San Francisco community sample, Ying  found that ChineseAmericans had higher levels of depressive symptoms as measured by the Center for Epidemiological Studies-Depression Scale (CES-D) than White American community samples. Asian-American college students also reported higher levels of depressive symptoms than their White American counterparts (as measured by the Zung SelfRating Depression Scale  and the Beck Depression Inventory.

However, because these studies examined reported levels of depressive symptomatology as measured by rating scales, it is unclear whether the groups would have differed in rates of diagnosable clinical depression. Prevalence rates of unipolar depression also differ across cultures . For instance, lifetime prevalence rates of unipolar depression are lower in Asian countries than in Western countries. The Taiwan Psychiatric Epidemiological Project found that prevalence rates of depression in Taiwanese samples were significantly lower than those of White Americans in the ECA study (1.14% in Taiwan, compared with 4.9% in ECA).

Recent evidence, however, suggests that the magnitude of this Western-Asian cultural difference may be decreasing. A variety of explanations have been proposed to explain these cultural differences in prevalence rates of depression. For instance, some propose that because Asian cultures place a greater emphasis on family and other social relationships than Western cultures, the occurrence of depression is rare. Others, however, argue that depressive symptoms occur at similar rates in Asian and Western cultures, but because mental illness is severely stigmatized in Asian cultures, depressive symptoms are rarely diagnosed as such.

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