Dr Joshua Tugumisirize

1. DEPRESSION, WOMEN AND CULTURE: A COMPARATIVE STUDY OF DEPRESSION AMONG MALAWIAN AND UGANDA WOMEN. • Dr Joshua Tugumisirize

2. Assumptions 1 Human nature is fundamentally the same regardless of geography, climate, ethnicity, culture, and socio-economic structure. Therefore mental disorders should be more or less similar across countries and cultures (German, 1987)

3. Assumption 2 Individuals are differentially vulnerable to variations in environments and cultures (German, 1987)

4. 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”

5. 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%

6. 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 .

7. 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.

8. 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

9. 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

10. 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.

11. 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.

12. 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.

13. 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.

14. 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

15. 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

16. 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 non-acculturated

17. 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

18. 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)

19. 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

20. 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).

21. 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 cross-cultural studies.

22. 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

23. 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)

24. 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

25. 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

26. 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)

27. 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

28. 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.

29. 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, mother-in-law. Inadequate material and emotional support.

30. 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

31. 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.

32. 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

33. 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.

34. 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.

35. Case study 2 cont’d

36. Case Study 2 cont’d Residence pattern and case rates among formerly matrilineal spouses

37. 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

38. Objectives The objectives were • to explore the lexica of emotion, cultural idioms and metaphors of distress in selected lay people in Uganda Malawi • to validate the Tumbuka, Chichewa and Luganda versions of Edinburgh Depression Scale (EDS) and General Health Questionnaire (GHQ 12) and • 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

40. 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

41. 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)

42. Methods: Comparative cross –sectional surveys Used mixed methods: qualitative and quantitative

43. 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

45. 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.

48. Results Data was obtained from 127 key informants in Chichewa, 40 KI in Luganda and 106 KI in Tumbuka

49. Chichewa Lesion

50. Luganda Lexicon