Cultural aspects of depression in the arab world

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1. WALID SARHAN Consultant Psychiatrist Amman-Jordan 2. Culture influences the sources, the symptoms and the idioms of distress; the individuals’ explanatory models,…
  • 1. WALID SARHAN Consultant Psychiatrist Amman-Jordan
  • 2. Culture influences the sources, the symptoms and the idioms of distress; the individuals’ explanatory models, their coping mechanisms and their help-seeking behavior; as well as the social response to distress and to disability. (Kirmayer, 2001).
  • 3.  Depression will be the second most important cause of disability after ischemic heart disease worldwide (WHO, 2002).  The problem of depression crosses cultural, international and socioeconomic boundaries, and is one of the great challenges of mental health care today.
  • 4.  Although depression is considered to be the most common disorder in Western cultures. Some scholars regard depression as a disorder of the Western world, which lacks universal applicability .  Depression in the Arab population is prevalent with classical or modified clinical presentation. (Marsella, 1978 ,Fernando, 1988).
  • 5.  As the world is being gripped by economic depression, international psychological epidemiologists have amassed evidence to suggest that psychological depression and its variants are becoming leading contributors to the global burden of disease with the Middle East and North Africa (MENA) region being no exception. Sultan Qaboos Univ Med J. 2009 April; 9(1): 5–15. Published online 2009 March 16.
  • 6.  The value of individual independence is often balanced or outweighed by that interdependence within the family unit.  While the structural extended family, in which several generations reside in a single household, is no longer as common in these communities as it was a few decades ago  Functional extended faqmily M. Fakhr El-Islam Transcultural Psychiatry 2008 45: 671
  • 7.  Cultural factors may condition the development of depression in women who cannot fulfil their culturally-prescribed - monorole of marriage and motherhood. Having no husband or children or living under a threat thereof, may be a 'potent factor in the genesis of depressive symptoms in women.  In the Arabian Gulf area, especially among the illiterate. They ultimately develop' a chronic culture conditioned form of neurosis, where neurasthenic and hypochondriacal symptoms dominate the clinical picture.
  • 8.  Loss of a mate and love failure, which figure prominently among depressed western patients, are uncommon precipitating factors among Arab depressives.  Culturally-shared religious beliefs and prescribed ritual practices reduce the pathogenic effect of grief.  Responsibility for failure in arranging marriage is shared by the whole family so its impact on the individual' is greatly reduced.
  • 9.  Many Arab/Muslims believe that way to seek help would be from healers, or Shekhes, to exorcise the Jinn or to undo the influence of the evil eye or black magic through amulets or certain rituals.  Depressed patients seek help of medical practitioners late.  Psychiatric help will only be reached very late in the majority of cases.  Very small percentage will start by psychiatric consultation but this is on the rise .
  • 10.  The only responsibility the patient has is to avoid sinning, and, after such an illness, to submit herself to religious healers (Shekhes) in order to exorcize the Jinn.  These beliefs, of course, prevent the patient from playing an active role in psychotherapy based on self-responsibility and on “working on the self.”
  • 11.  This disorder is reactive and involves a variety of symptoms such as anxiety, depression, dissociation, psychosis, and also somatic symptoms  Mixed rather than distinct syndromes seem to be a very common clinical picture among Arab/Muslims.  It creates a lot of sympathy from the community.
  • 12.  Patients develop patterns of symptoms in keeping with what medical practitioners consider illness.  A somatic concept of illness that concerns the medical profession is entertained by most Arab patients and medical practitioners alike.  Therefore, presentation of patients with somatic symptoms is the rule.
  • 13.  Depressed patients complain of pains, aches or symptoms of autonomic dysfunction rather than psychological symptoms that are differentiated from associated bodily symptoms.  The majority of medical practitioners in the Arab world, who have been biometrically trained to think of the human being as an assemblage of parts and particles, resort to a multitude of physical investigations for their patients' bodily symptoms in their search for an organic etiology  Commonly reassurance and psychotropic prescription at times and rarely referral.
  • 14.  The term somatization is therefore misleading, because in these cultures there are no distinct and pure psychological distresses in the first place, and therefore there is no place for somatization.  Arab/Muslims, are somatizing therefore a diagnosis of somatoform disorder is almost useless in relation to Arab/Muslims.
  • 15.  Lack of education about depression lack of availability of appropriate therapies, competing clinical demands, social issues, and the lack of patient acceptance of the diagnosis were among the most important barriers to the identification, diagnosis, and treatment of patients with depression in this population Nasir LS, Al-Qutob R. J Am Board Fam Pract. 2005 Mar-Apr;18(2):125-31. PMID: 15798141 [PubMed - indexed for MEDLINE] Barriers to the Diagnosis and Treatment of Depression in Jordan. A Nationwide Qualitative Study
  • 16.  Continuing medical education for providers about depression, provision of counseling services and antidepressant medications at the primary care level.  Efforts to destigmatize depression may result in increased rates of recognition and treatment of depression in this population.  Systematizing traditional social support behaviors may be effective in reducing the numbers of patients referred for medical care. Nasir LS, Al-Qutob R. J Am Board Fam Pract. 2005 Mar-Apr;18(2):125-31. PMID: 15798141 [PubMed - indexed for MEDLINE]
  • 17. The level of awareness of depression was acceptable. However, further efforts are necessary to establish public educational programs related to depression in order to raise awareness regarding the disease. Sayer Al-Azzam et al International Journal of Occupational Medicine and Environmental Health Volume 26, Issue 4 , pp 545-554 -2013
  • 18.  The 'evil eyes' of others Who notice or hear about one's happiness, success or possessions are believed to be capable of causing him to lose them.  Anhedonic depressed patients who have lost their capacity to experience happiness or pleasure attribute the loss to envy, and they easily talk about their emotional loss to ward off the possibility of further envy by others
  • 19.  A comparison between depressive patients in Egypt, India, and Britain revealed that the Egyptian Arab/Muslim and Indian patients displayed more anxiety and somatic symptoms than did the British.  Anxiety was displayed in 99% and somatic symptoms in 87% of the Egyptian sample (Abd El-Gawad, 1995)
  • 20.  Suicide is a major sin, the punishment for which is eternal hell during the afterlife of the person who commits it.  Depressed Muslims, including Arabs, may passively wish they were dead or 'pray to God to take their life away.  Parasuicidal acts of pathological care-eliciting were found to have no relationship to the degree of adherence to Islamic religious practice. (Abd El-Gawad, 1995)
  • 21.  suicidal thoughts in the Egyptian depressives were relatively high compared with the low rates of suicide and attempted suicide.  Guilt feelings among the Egyptian sample were relatively few. (Abd El-Gawad, 1995)
  • 22. Bazzoui and Al-Issall found that Arab depressives in Iraq, rather than expressing guilt feelings, are more likely to be aggressive to others on whom they project responsibility for the illness.
  • 23. Okasha (1999) reported similar findings, He found that Egyptian depressed patients mask their affect with multiple somatic symptoms that occupy the foreground, and the affective component of their illness recedes into the background.
  • 24.  The Islamic religion provides a comprehensive code of conduct and interpersonal relationships, the guilt attached to wrongdoing nearly always has a religious component.  Some Arab depressives combine projection and guilt when they attribute their illness to God's punishment in retribution for their real or imaginary wrongdoing.
  • 25.  According to Islamic culture it is blasphemous to give up hope for relief of suffering because patient endurance is rewarded in the afterlife.  Hopelessness was not a prominent symptom experienced by depressed inpatients (both natives and expatriates) surveyed in Kuwait . (El-Islam, Moussa, Malasi, & Mirza, 1988).
  • 26. The patient may find it impossible to cry. Male depressed patients deliberately prevent themselves from crying because they feel that weeping would undermine their masculinity.
  • 27.  Breathlessness is one of the common somatic complaints in depressed Arab patients. The patient has difficulty in taking in air during inspiration, which is sometimes described as if it were air hunger.  Breathlessness is often attributed to the experience of tightening up of the chest. Repeated sighing, which assures the patient of his ability to take in enough air by deep inspiration now and again, has a temporary comforting effect.
  • 28. The depressed mood is more likely to find expression in dream contents which center around death and the dead for example: A dead relative would call the patient to his side or tell him off for his real or imaginary wrongdoings.
  • 29.  Heartache' is a common complaint among female depressed patients. It usually refers to the loss or inability to achieve or maintain a loving relationship to a key figure.  Depressed men complaining of back pain usually have sexual problems, for the back is believed to be the origin of their virility and procreativity.
  • 30.  In a study about the effect of the evil eye in Lebanon, 81.3% of the mothers reported that they believed that evil eye had had a harmful effect on their infants (Harfouche, 1981).  Arab/Muslims perform several rituals that are intended to protect them from the evil eye, some of which may seem bizarre, such as incantation, and the use of amulets, blue beads, or a horseshoe (Donaldson, 1981; Harfouche, 1981).
  • 31.  Metaphoric descriptions of the experience of an Arab/Muslim patient may add more confusion and misunderstanding to the assessment of the reality testing.  As an example, one expression that is commonly used by Arab/Muslims is “hwo sammelly badani.” This expression literally means “He poisoned my body,” while the intended meaning is “he made me nervous.”  An unaware therapist or translater who hears a woman saying “Yesterday my husband became furious and poisoned my body,” may misinterpret this as delusion or as a homicide attempt.
  • 32. ‘Sadri dayeq alayya’ =‘My chest feels tight’ ‘Tabana’ =‘I am tired, fatigued’ ‘Jesmi metkasser’ =‘broken body’ Sulaiman et al (2001)
  • 33.  The usual first stop on the help-seeking route for mental illness is the traditional healer.  In a study of the help-seeking preference for mental health problems in children, Eapen & Ghubash (2004) found that only 37% preferred to consult a mental health specialist.  Alternative remedies are also much sought after,
  • 34.  The effects on mental health of social change associated with the rapid pace of development and Western influences have been the subject of several studies (e.g. Ghubash et al, 1994).  While education, employment and social opportunities have started to improve perceptions of and attitudes to mental illness, the stigma associated with mental disorder is still a major factor that prevents individuals from seeking appropriate treatment. V. EapenInternational Psychiatry Volume 5 Number 2 April 2008
  • 35. ‘The heart is poisoning me’ ‘As if there is hot water over my back’ ‘Something is blocking my throat’ Hamdi et al (1997)
  • 36. Arab populations are also more likely than Westerners to associate depression with aches, pains and weakness, and use a variety of somatic metaphors to describe depression (Hamdi et al., 1997; Sulaiman et al., 2001).
  • 37.  Individual agreement to disclosures to family  Family informed by patient  Joint interviews  Family background as a measure of normality/pathology  Family psycho-education  Family members as co-therapists
  • 38. 1. Awareness of the possibility of somatic presentations, and enquiring about the patients’ understanding of the somatic symptoms. 2. Clarifying the patients’ use of specific cultural idioms of distress to describe the somatisation process and being familiar with somatic metaphors.
  • 39. 3. Recognition that somatic symptoms are real and not imagined. 4. Exploring physical symptoms in the context of stressors with open-ended questions such as: "What are the problems that you are facing now that create difficulty or distress?"
  • 40. 5. Relevant medical investigations should be performed but over-investigation should be avoided. Not conducting any tests may be negligent or taken as a sign of lack of caring. Discussion of negative laboratory or imaging tests with the patient is usually helpful.
  • 41. 6. Discussing the patient’s physical distress in relationship to their life situation and stressors should be discussed. Many patients will find a biopsychosocial interpretation helpful. 7. Rare possibilities should be considered e.g. Somatosensory amplification; patients are hypervigilant to irrelevant bodily stimuli and report their awareness of bodily sensations as physical distress and Alexithymia
  • 42. In keeping with culturally-shared explanations of depressive manifestations, therapy practices among traditionally-oriented Arabs include the prescription of anti-envy amulets, the appeal to shrines of dead Muslim sheikhs, and occasionally the performance of pilgrimage and “omra”. Amulets usually contain verses of the Holy Quran that ward off others evil. Visits to shrines of dead religious sheikhs may help the depressed by imparting a subjective sense of blessing in return for his humble submission to the saintness of the sheikh.
  • 43.  Arab patients and their families transfer onto therapists culturally shared attitudes, especially those related to age and gender.  When dealing with intergenerational conflict in Kuwait, members of both generations would be surprised if a middle-aged therapist did not reject younger peoples’ anti-traditionalist and modern ideas.  A good or effective therapist in Egypt and Arabian Gulf countries is expected to be authoritative rather than to offer choices to patients.  Patients also expect therapists to take their side, rather than remain neutral, in family conflicts and in reports to public authorities (El-Islam, 2005).
  • 44.  As compared to the reductionist Western nosology represented in the DSM IV, the psychological disorders among Arab/Muslims tend to be mixed rather than distinct syndromes. Anxiety, depression, dissociation, and somatic symptoms are highly inter-correlated among Arab/Muslims.  To avoid misdiagnosis, practitioners who are familiar with the Western nosology of mental health are advised to be aware of the uniqueness of each diagnostic category among Arab/Muslims.  Almost all the diagnostic categories are manifested in a unique clinical picture and course that need to be known to practitioners.
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  • 46. • Al-Ansari, E. A., Emara, M. M., Mirza, I. A., & El-Islam, M. F. (1989). Schizophrenia in ICD-10: A field trial of suggested diagnostic guidelines. Comprehensive Psychiatry, 30, 416–419. • Asuni, T. (1990). Nigeria: A report on the care, treatment and rehabilitation of people with mental illness. Psychosocial Rehabilitation Journal, 14, 35–44. • Atallah, S. F., El-Dosoky, A. R., Coker, E. M., Nabil, K. M., & El- Islam, M. F. (2001a). A 22-year retrospective analysis of the changing frequency and patterns of religious symptoms among inpatients with psychotic illness in Egypt. Social Psychiatry and Psychiatric Epidemiology, 36, 407–415. • Bilal, A. M., & El-Islam, M. F. (1985). Some clinical and behavioural aspects of patients with alcohol dependence problems in a Kuwait psychiatric hospital. Alcohol and Alcoholism, 20, 57–62.
  • 47. • El-Islam, M. F. (1982a). Arabic cultural psychiatry. Transcultural Psychiatric Research Review 19, 5–24. • El-Islam, M. F. (1982b). Rehabilitation of schizophrenics by the extended family. Acta Psychiatrica Scandinavica, 65, 112–119. • El-Islam, M. F. (1990). Illness behaviour in mental ill-health in Kuwait. Scandinavian Journal of Social Medicine, 18, 195–201. • El-Islam, M. F. (1994a). Collaboration with families: An alternative to mental
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