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 Table of Contents  
EDITORIAL
Year : 2017  |  Volume : 33  |  Issue : 4  |  Page : 285-287

Cultural diversity and mental health


1 Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, Government Medical College, Kottayam, Kerala, India

Date of Web Publication17-Nov-2017

Correspondence Address:
Siddharth Sarkar
Department of Psychiatry and NDDTC, Room No 4096, Teaching Block, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_94_17

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How to cite this article:
Sarkar S, Punnoose VP. Cultural diversity and mental health. Indian J Soc Psychiatry 2017;33:285-7

How to cite this URL:
Sarkar S, Punnoose VP. Cultural diversity and mental health. Indian J Soc Psychiatry [serial online] 2017 [cited 2017 Dec 12];33:285-7. Available from: http://www.indjsp.org/text.asp?2017/33/4/285/218606

We live in a rapidly changing world. The social structures, institutions of discourse, and outlook of the general public have witnessed evolution over the course of the past few decades. The changes have been hastened by the mobility of individuals and availability of instant means of communication. The rapidly changing world brings various cultures in contact, facilitating exchanges and influences. The inter-mingling and amalgamation of cultures make their understanding important from the perspective of mental health. Hence, the theme of the 24th National Conference of Indian Association of Social Psychiatry “Cultural diversity and mental health” is pertinent in the present day social and cultural milieu.

Cultural diversity shares a complex relationship with mental health. [Figure 1] schematically depicts the various facets of this relationship. The figure should be interpreted with the caveat that relationship of cultural diversity with the mental health can be conceptualized in multiple ways, and this representation may be just one of the possible elucidations. The figure simplistically presents the overview of how mental health intersects with cultural diversity.
Figure 1: Interaction of cultural diversity and mental health

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Cultural diversity affects the manner in which psychiatric illnesses manifest in the clinical or community settings. Psychiatric symptoms are expressed through the verbal and nonverbal language. The “idioms of distress” convey the tumultuous experiences of an individual to other members of the community.[1] Such idioms of distress are not culturally invariant. While depression is expressed more in cognitive terms in the western societies, somatic presentations have been recorded frequently among patients from the Indian subcontinent.[2] Similar differences in the presence of somatic symptoms have been reported for generalized anxiety disorder, where the co-occurrence of somatic symptoms with anxiety was higher in the Orient than the United States.[3] Thus, culture influences the manner in which psychiatric disorders are expressed to the treating team, and variability may occur in the symptom profile of common mental disorders. Cultural factors have also been reported to influence the prevalence of psychiatric disorders. Postpartum depression is a case in point in this context. The prevalence rate of postpartum depression has varied across the globe.[4] Although such variability can be ascribed to multiple possibilities including differences in biological vulnerability, cross-cultural variation in expression of complaints has been touted as an important reason for the observed differences in prevalence rates.

Cultural diversities not only affect the expression of illnesses, but they also contribute to the vulnerability factors for such illnesses. While Jewish culture endorses social and controlled drinking of alcohol, Indian culture has conventionally been abhorrent towards alcohol use. The growing consumption of alcohol in India does not have cultural precedence of a socially curbed and regulated usage. This leads to a situation where though the number of alcohol users is small, the proportion of heavy drinkers among those who drink is high in India. Furthermore, diverse cultures have their own etiological conceptualizations for illnesses. Examples include magicoreligious beliefs being considered the cause of schizophrenia or “wind” being the cause of anxiety.[5],[6] Although the etiological understanding of psychiatric illnesses has progressed over time, the cultural explanations need not be ignored so that knowledge gaps in the community can be addressed and illnesses conceptualizations can be corrected during psychoeducation sessions.

A unique facet of cultural diversity in mental illness is the concept of “cultural bound syndromes.” These syndromes are considered to be limited to a specific cultural context. Among the culture-bound syndromes, Dhat syndrome is probably the most well-studied in India. This syndrome was described by Malhotra and Wig [7] and has spurred theoretical and research exploration for further understanding about this condition. Dhat syndrome has been described in the Indian subcontinent and individuals who have migrated from here. The understanding and expression of this illness have been rooted in the cultural explanation of the functioning of reproductive organs.[8] The disorder has merited attention for searching the best ways to address the anxieties and concerns of young males suffering from this disorder. Similar to Dhat syndrome, “Hikikomori syndrome” from Japan and “brain fag” from Nigeria are examples of other culture-bound syndromes that have received attention in different parts of the world. The need for focusing on culture-bound syndrome lies in the fact that modern psychiatric classifications have largely originated from European–American conceptualization of mental illnesses, and has been applied elsewhere. Such an approach might have omitted manifestations of psychiatric distress from other areas. Thus, culture-bound syndromes can be considered as niche diagnoses, which are pertinent to selected geographical and cultural areas. Systematic efforts to understand these syndromes have been subpar compared to other “cross-cultural” and common diagnoses, and they deserve further concerted attention.

Cultural diversity also has a bearing on the manner in which treatment services are developed and provided. Psychotherapy as a treatment modality is more commonly used among Caucasians than other ethnicities.[9] The reasons for the differential rates of use of psychotherapy across the ethnicities can be many, though culture might play a role in influencing what is considered as an acceptable form of treatment for a given ailment. It has been commented that culturally accepted conventional practices like temple healing can reduce psychopathology and distress,[10] and thus can play a constructive complementary role in the treatment of psychiatric disorders. Such temple healing may be quite acceptable in some parts of India, yet they may not be considered acceptable in other places and other countries. Hence, the treatment services offered needs to take cognizance of the cultural values and outlook. The current paradigm of offering autonomy to the patient needs to include (or at least be open to the idea of inclusion) choices that the cultural influences predicate, though such options might not have been vehemently endorsed by the Western systems of medicine. Built in this paradigm is the idea of offering culturally-sensitive and culturally-competent services.[11],[12] Such services aim to sensitize the treatment providers about the nuances of identifying the needs of the clients based on their cultural backgrounds, and about culture-related issues that can hamper or facilitate the treatment process. A “one size fits all” approach is unlikely to work in the present fast-paced world with diverse cultures mingling together. Rather, respect for the choices based on cultural proclivities and using culturally endorsed social supports may help distressed individuals in their recovery.

It would be interesting to speculate whether cultures influence the course and prognoses of illnesses. Sometimes, cultural influences like stigma deter individuals from seeking help.[13] Hence, the progression of the illness may be concealed from others. This would make the illness progress to a point where the endured distress bursts out, thus manifesting a severe form of the illness. On the other hand, cultural attributes such as collectivism and enmeshment may provide implicit social supports which can be helpful in reducing the distress associated with the illness, and provide means of rehabilitation. This has been exemplified in the outcome of schizophrenia being better in developing countries as compared to developed ones.[14] Thus, the attributes of the culture can be a boon or bane for the illness prognosis depending on the situation.

As discussed above, culture interacts with mental health is a variety of ways. In the future, mental health professionals need to delve deeper into how cultural diversity impacts the presentation, remediation, and prognostication of mental illnesses. Collaborative efforts are required to deliberate and discourse on understanding culture-based needs of the treatment-seeking individuals and enforce policies that do not exclude patients based on specific cultural affiliations.

 
  References Top

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Nichter M. Idioms of distress revisited. Cult Med Psychiatry 2010;34:401-16.  Back to cited text no. 1
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2.
Mumford DB, Bavington JT, Bhatnagar KS, Hussain Y, Mirza S, Naraghi MM, et al. The Bradford somatic inventory. A multi-ethnic inventory of somatic symptoms reported by anxious and depressed patients in Britain and the Indo-Pakistan subcontinent. Br J Psychiatry 1991;158:379-86.  Back to cited text no. 2
    
3.
Hoge EA, Tamrakar SM, Christian KM, Mahara N, Nepal MK, Pollack MH, et al. Cross-cultural differences in somatic presentation in patients with generalized anxiety disorder. J Nerv Ment Dis 2006;194:962-6.  Back to cited text no. 3
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Halbreich U, Karkun S. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord 2006;91:97-111.  Back to cited text no. 4
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Kulhara P, Avasthi A, Sharma A. Magico-religious beliefs in schizophrenia: A study from North India. Psychopathology 2000;33:62-8.  Back to cited text no. 5
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Hinton DE, Park L, Hsia C, Hofmann S, Pollack MH. Anxiety disorder presentations in Asian populations: A review. CNS Neurosci Ther 2009;15:295-303.  Back to cited text no. 6
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Malhotra HK, Wig NN. Dhat syndrome: A culture-bound sex neurosis of the orient. Arch Sex Behav 1975;4:519-28.  Back to cited text no. 7
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8.
Kar SK, Sarkar S. Dhat syndrome: Evolution of concept, current understanding, and need of an integrated approach. J Hum Reprod Sci 2015;8:130-4.  Back to cited text no. 8
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9.
Olfson M, Marcus SC, Druss B, Pincus HA. National trends in the use of outpatient psychotherapy. Am J Psychiatry 2002;159:1914-20.  Back to cited text no. 9
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Raguram R, Venkateswaran A, Ramakrishna J, Weiss MG. Traditional community resources for mental health: A report of temple healing from India. BMJ 2002;325:38-40.  Back to cited text no. 10
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11.
Kirmayer LJ, Groleau D, Guzder J, Blake C, Jarvis E. Cultural consultation: A model of mental health service for multicultural societies. Can J Psychiatry 2003;48:145-53.  Back to cited text no. 11
    
12.
Park M, Chesla CA, Rehm RS, Chun KM. Working with culture: Culturally appropriate mental health care for Asian Americans. J Adv Nurs 2011;67:2373-82.  Back to cited text no. 12
    
13.
Gary FA. Stigma: Barrier to mental health care among ethnic minorities. Issues Ment Health Nurs 2005;26:979-99.  Back to cited text no. 13
    
14.
Hopper K, Wanderling J. Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: Results from ISoS, the WHO collaborative followup project. International study of schizophrenia. Schizophr Bull 2000;26:835-46.  Back to cited text no. 14
    


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