Cultural aspects of depression as a diagnostic entity: historical perspective

Marianne C. KASTRUP, MD, PhD
Head, Center of Transcultural Psychiatry, Psychiatric Center Copenhagen
Copenhagen, DENMARK

Cultural aspects of depression as a diagnostic entity: historical perspective

by M. C. Kastrup, Denmark

Globalization and increasing pluralism require psychiatrists to evaluate the impact of cultural factors on depressive disorders. Modern classification systems should pay due attention to culture-specific factors, and systematic, operationalized appraisals are needed in order to assess cultural elements. In the Diagnostic and Statistical Manual of Mental Disorders IVth Edition (DSM-IV), the Cultural Formulation was introduced, in order to provide an operational approach of the cultural perspective and allow patients to reflect cultural elements in their narratives. Prevailing classification systems are still criticized as reflecting Western concepts and not paying sufficient attention to the symptomatology of patients of non-Western backgrounds. Depression has a multifaceted etiology, and migrants run a particular risk, in part due to the migratory process itself. One should therefore distinguish culture-specific issues and migration-specific issues. The lifetime risk for a major depression is as high as 12% to 16%. The World Health Organization has predicted that in 2020 depression will be the second most important cause of disability. Culture influences depressive symptomatology, explanatory models, help-seeking behavior, and societal response. Furthermore, treatment tends to differ according to culture and so does the treatment gap.

Medicographia. 2011;33:119-124 (see French abstract on page 124)

With increasing globalization, mental health professionals are being confronted with decisions related to culture-specific aspects of diagnosis, validity of diagnostic entities, and variability of symptoms.1 It is important to be able to evaluate the role of culture in explaining differences in symptom manifestation and to be aware of the interaction between culture and depressive symptomatology when assessing a depressed patient.2 Assessing depressive disorders in persons from a variety of cultural backgrounds is becoming part of routine clinical work in many mental health settings. This paper examines issues related to cultural aspects of depression, with particular focus on diagnosis.

Table I
Table I. “Cultural Formulation” and depression.

Reproduced from reference 8: American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders (4th ed). Washington, DC: APA,
1994. © 1994, APA.

Diagnostic considerations

Classification systems are affected by changes in our professional knowledge and orientation, by the actual situation in society, and even by political ideologies.3 Tseng further points out that hitherto it has been easier for Western psychiatrists to adapt to classification systems developed in the West than it is for non-Western psychiatrists, who experience a disparity between their actual practice of psychiatry and international classification systems. The diagnosis of depression has undergone major changes over time. In spite of the fact that melancholia and depression have been described for many centuries, the classification of depression has given rise to extensive debate. The very concept of depression is not universally accepted and, historically, many non-Western societies have consistently reported lower prevalences of depression than Western societies.3 Variations in diagnostic categories over time—including entities like endogenous versus reactive depression; psychotic versus neurotic depression; depression versus dysthymia—have also made comparisons across cultures or time difficult. From the point of view of research, the classification of depression is controversial. In many non-Western languages, there is no corresponding word for “depression” in spite of the fact that lowered mood is a universally encountered phenomenon.4 Furthermore, methodological differences, such as variations in study samples; differences in methodologies in clinical assessments, or lack of culturally validated assessment instruments, contribute to transcultural variability in depression.5

Confronted with a depressive patient of similar cultural background as their own, many clinicians may fail to recognize the prominent role of the cultural element and tend to underestimate its importance. In contrast, when dealing with a depressed patient from another cultural background, cultural differences may become obstacles for the clinician and thus mask the depressive process.6

The concept “category fallacy”7 was introduced to illustrate a fundamental error in transcultural diagnostics. When psychiatrists reject “non-Western” disease categories as being culture-specific, they so-to-speak impose their own cultural categories on the “non-Western” categories in the false conviction that these are neutral and culture-independent.

Several proposals have been made to overcome these diagnostic difficulties. One would be to introduce an independent cultural axis in the diagnostic systems; another would be to include culture-bound syndromes as part of the nosological entities.

As a result of expanding migratory population movements, it is increasingly recognized that culture-specific factors related to modern societal realities should be taken into account by international classification systems. Yet, culture does not have a prominent explicit place in the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10), even though the development of ICD-10 did include field trials in a number of countries worldwide.

In the Diagnostic and Statistical Manual of Mental Disorders IVth Edition (DSM-IV),Cultural Formulation was introduced to apply a cultural perspective to the clinical evaluation and to allow an operational approach and an individual assessment. This can be seen as a significant step toward a cultural-competent and cultural-sensitive assessment of mental disorders Table I.8 Using the Cultural Formulation to assess a depressive episode enables the patient to provide a narrative of all components reflecting cultural elements. It offers a larger scope than purely diagnostic evaluation by encompassing aspects of the patients’ social universe, personal interpretations, explanatory reflections, and attitudes toward help-seeking.9 A comprehensive biographical history, taking into account the patient’s cultural reference group and identity, as well as stressors related to migration and acculturation, enables better understanding of the depressive disease process and of its impact on patients and their relatives. Yet despite this innovation, objections are raised that classification systems nevertheless continue to reflect Western concepts and values and cannot be used uncritically in patients of other cultural backgrounds.10

Table II
Table II. Guidelines for diagnosis of depression by a clinician from
another culture than the patient’s.

Modified from reference 11: Bhugra and Mastrogianni. Br J Psychiatry. 2004;
184:10-20. © 2004, The Royal College of Psychiatrists.

Clinicians and researchers must find ways to carry out transcultural comparisons. Bhugra and Mastrogianni11 suggest that when categorizing depression across cultures, the prevailing psychiatric model, the cultural context, and indigenous beliefs should be considered. It should be kept in mind that the pathogenetic and pathoreactive influence of culture may result in different clinical pictures, making differential diagnosis difficult for clinicians from other cultures Table II.11,12


Historically, it has been a frequently held belief that depression, in developing countries, in particular in Africa and Asia, is an infrequent illness compared withWestern countries, and suicides due to depressive illness were thought to be extremely rare in non-Western countries.2 Investigations carried out by the World Health Organization (WHO) have demonstrated today that depressive disorders occur in all cultures.13 Cross-cultural comparisons of depressive disorders, eg, the WHO study following a cohort with standardized assessments in 5 different countries, show similarities in symptoms, such as lowered mood, sleep disorders, lack of energy, and concentration difficulties.13,14 Depression today is a huge and increasing public health concern on a global level. Neuropsychiatric disorders contribute 31.7% of all YLDs (years lived with disability) according to WHO,15 with unipolar depression ranking highest (11.8%). Among the ten most important diseases measured by YLDs, psychiatric conditions make up four, among which unipolar depression.16

Around 360 million persons throughout the world suffer from mood disorders.16 Furthermore, depressive disorders are the fourth most important contributor to the global burden of disease, and in adults aged 15 to 44 years, they are the leading cause of DALYs (disability-adjusted life years) lost worldwide. As persons under 45 years run a greater risk of depression, persons are affected during their most productive years of life, in all cultural settings. About 5% to 10% of persons at any given time are suffering from identifiable depression that requires psychiatric/psychosocial intervention, while the lifetime risk for major depression is 12% to 16 %. WHO has predicted that in 2020 depression will be the second most important cause of disability. In the European Region, the prevalence of major depression and bipolar disorders totals 21 million.17

It is well documented that women run a greater risk in most cultures: overall, women have a 1.5- to 2-times higher risk of suffering from depression compared with men. In the Cross- National Collaborative Group, women in all countries had a higher prevalence with a female:male ratio varying from 1.6 in Lebanon to 3.1 in West Germany.18 Possible explanations for these differences include the multiple roles women have as homemakers, professionals, wives, and mothers.

The rate of depression does not vary significantly with ethnicity. Socioeconomic or educational differences may contribute to differences between ethnic groups, but the differences disappear to a large extent when controlled for these.19

The burden of depression (Figure 1, page 122)20 is relatively smaller in poorer regions of the world, eg, depression represents 1.2% of the disease burden in Africa compared with 8.9% in high-income countries, but depression is predicted to become a leading cause of disease burden in developing countries as well.21 It has been suggested that differences in the prevalence of depression may reflect dysfunctionality of a changing culture.22

Primary health care

General practitioners often diagnose depressive disorders. A WHO study of 15 primary care centers reported that 11.7% of patients presenting in a primary health care (PHC) setting had depression, but the fact that the psychiatric problem was generally not the presenting complaint meant that the depression risked going unidentified.23

The frequency of depression in the community was measured by the WHO in its General Health Care Study including 14 countries around the world. The prevalence of current depression was found to vary from 2.6% in Nagasaki to 16.9% in Manchester and 29.5%in Santiago.24 The range in frequency was interpreted as: (i) reflecting true differences in prevalence; (ii) cultural variations in disease concept; (iii) differences in help-seeking behavior; (iv) or differences in demographic characteristics.24

Figure 1
Figure 1. The burden of depression.

Reproduced from reference 20: Prince et al. Lancet. 2007;370: 859-877. © 2007, Elsevier Ltd.

Provoking factors

Depression is acknowledged to be a disorder with a multifaceted etiology. Depressive syndromes are very common in migrants, and up to half of all migrants in the US may have clinical depression.25 The very process of migration itself may be partly responsible for the risk of emergence of stress-related disorders. A wide range of provoking factors may contribute to an episode in minority ethnic groups. These include: premigratory stressors; personality; physical health problems; as well as postmigratory stressful living conditions; discrimination; socioeconomic adversities; cultural conflicts; personal losses related to migration, etc (Table III).2,26 In addition, persons coming from traditional, sociocentric, societies, who migrate to a Western country with a more egocentric type of society, may feel alienated, which makes adjustment more difficult and results in an increased risk of mental health problems.27

Table III
Table III. Diagnosis of depression in migrants.

Reproduced from reference 26: Bhugra and Ahmad. World Cult Psychiatry Res Rev. 2007;47-56. © 2007, World Association of Cultural Psychiatry

Migration is thus a highly complex experience comprising a range of processes, influences, and conditions that may affect health and illness.28 At the same time, migration and the cultural change from a traditional, more community-centered, society to a modern, individualistic society, can lead to decompensation of coping mechanisms and emergence of depression. As the above shows, migration can trigger mental disorders when the protective function of the original culture is missing.29

Cultural dimensions

WHO reports indicate considerable cross-cultural similarities in depressive symptomatology, with symptoms such as low mood, lack of joy, anxiety, lack of energy and interest in surroundings evidenced in most cultures.30 However, crosscultural differences do exist: for example, feelings of guilt are one of the major symptoms of depression in Western countries even though they are not specific and can be observed in many other cultures, albeit with far lesser frequency. Thus, a WHO study reported the highest frequency of feelings of guilt in Swiss patients and the lowest in Iranian patients, while somatic complaints were more common in the latter.31

In non-Western patients delusions often have themes like physical health, or religion, and are not, as in Western patients, constructed around guilt and inferiority.2 Due to the absence of the dualistic body-soul distinction prevalent in Western cultures, patients in some non-Western countries often have narratives that contain metaphors of body functions when describing their emotional state rather than psycho- logical terms.2 Nevertheless, somatization as a sense of bodily discomfort, or vegetative symptoms without any demonstrable organic cause, are part of depressive symptomatology in all cultures.

Culture may also influence the expression of depressive thoughts. The question of whether suicide is considered an acceptable strategy for solving conflicts in a seemingly hopeless situation is very culture-dependent, and vast differences in the traditions of suicide exist depending on which culture is considered. Depressive reactions following bereavements or as part of old age are in many cultures not seen as conditions requiring an intervention, but rather as part of normal life. Western psychiatrists should, however, also be aware of the fact that more severe depressive symptoms may be interpreted as normal reactions, thereby preventing the afflicted person from receiving adequate treatment.32

Thus, the interaction between culture and depression should be borne in mind whenever interviewing a patient in whom a depressive episode is suspected.32 When diagnosing depression in persons of another ethnic origin it is important to distinguish culture-specific issues and migration-specific issues, as they may have a different impact on the intrapsychic conflict forming part of the migration process. The literature often fails to distinguish between the two29 and to indicate whether the increased vulnerability to depression is associated with the fact of being a migrant per se or with problems encountered in the host country due to cultural differences, or whether it is due to a combination of both (Table IV).10,28

Therapeutic aspects

When assessing the impact of culture on the treatment of depression, attention should be paid to the specific context. Clinicians trained in Western countries tend to focus only on the individual. But in many instances it may be of benefit to consider the depressed patient in a social context and take into account social values and role expectations.2 Clinicians from Western individualistic cultures sometimes falsely assume that cohesive family structures prevent personal growth and do not allow individualization, whereas in fact cohesive social patterns foster the development of a self-contained identity in accordance with one’s role within a social hierarchical structure.33 Attitudes toward treatment tend to differ according to cultural context when comparing persons in their home country with the same ethnic groups having migrated to a Western country.

Table IV
Table IV. Interaction between culture and depression.

Reproduced from reference 10: Kirmayer. J Clin Psychiatry. 2001;62 (suppl 13):
22-28. © 2001, Physicians Postgraduate Press, Inc.

Treatment gap

Overall, the increased focus on depression has failed to translate into a better situation for depressed persons, and there is still a significant lack of correlation between the disease’s extent and the availability of adequate treatment (the so called treatment gap). This gap is highest in low-and middle-income countries,34 but even in Western Europe, the European Ministerial Report35 estimates the treatment gap at 45.4% for severe depression, while in low-income and middle-income countries only a small proportion of treated depressed patients are in fact adequately treated.36 Reasons for this treatment gap in many countries comprise the lack of trained staff, lack of resources, and stigma toward depression. Even in the US, it has been shown that the treatment gap varied considerably between ethnic groups.37

In order to minimize the gap between the consequences of depression and the availability of treatment, research should focus on therapies that are practical and allow for the needs of the population in question.38 With the current focus on prevention, a cost-effective decrease in the current burden of depression is possible. _


1. Minas H. Service responses to cultural diversity. In: Thornicroft G, Szmukler G, eds. Textbook of Community Psychiatry. Oxford, UK: Oxford University Press; 2001:192-206.
2. Kastrup M, Machleidt W, Behrens K, Calliess I. Cultural aspects of depression. In: Maj M et al, eds. The WPA Educational Series on Depressive Disorders. Volume 4: Depression in Population Groups. Geneva, Switzerland:WPA; 2009; 4:208-237
3. TsengWS. Handbook of Cultural Psychiatry. San Diego, Calif: Academic Press: 2001:335, 464.
4. Patel V. Cultural factors and international epidemiology. Br Med Bull. 2001; 57:33-45.
5. Ballenger JC, Davidson JRT, Lecrubier Y, et al. Consensus statement on transcultural issues in depression and anxiety from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry. 2001;62:47-55.
6. Littlewood R. From categories to contexts: a decade of “new cross-cultural psychiatry.” Br J Psychiatry. 1990;156:308-327.
7. Kleinman A. Depression, somatization and the ”New cross-cultural psychiatry.” Soc Sci Med. 1977:11:3-10.
8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed.) Washington, DC: APA; 1994.
9. Lewis-Fernandez R, Diaz N. Cultural Formulation: a method for assessing cultural factors affecting the clinical encounter. Psychiatr Quart. 2002;73:271-295.
10. Kirmayer LJ. Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment. J Clin Psychiatry. 2001;62 (suppl 13):22-28.
11. Bhugra D, Mastrogianni A. Globalisation and mental disorders. Overview with relation to depression. Br J Psychiatry. 2004;184:10-20.
12. Pfeiffer W. Transkulturelle Psychiatrie. Stuttgart, Germany: Thieme; 1994.
13. Jablensky A, Sartorius N, Bulbinat W, Ernberg G. Characteristics of depressive patients contacting psychiatric services in four cultures. Acta Psychiatr Scand. 1981;63:367-383.
14. Thornicroft G, Sartorius N. The course and outcome of depressive disorders in different cultures: 10 year follow-up of the WHO collaborative study on the assessment of depressive disorders. Psychol Med. 1993;23:1023-1032.
15. World Health Organization (WHO). World Mental Health Atlas. Geneva, Switzerland: WHO; 2005.
16. World Health Organization (WHO). World Health Report. Geneva, Switzerland: WHO; 2001.
17. Olesen J, Baker M, Freund T, et al. Consensus document on European brain research. J Neurol Neurosurg Psychiatry. 2006;77(suppl 1):1-49.
18. Weismann MM, Bland RC, Canino GJ, et al. Cross-national epidemiology of major depression and bipolar disorder. JAMA. 1996;276:293-299.
19. World Health Organization (WHO). ( Section1199/Section1567/Section1826_8101.htm) 8.1. 2008.
20. Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet. 2007;370:859-877.
21. Murray CJ, Lopez AD Alternative projections of mortality and disability by cause. 1990-2020. Global Burden of Disease Study. Lancet. 1997;349:1498-1504.
22. Bebbington P, Cooper C. Affective disorders. In: Bhugra D, Bhui K, eds. Textbook of Cultural Psychiatry. Cambridge, UK: Cambridge University Press; 2007: 224-241.
23. Wittchen HU, Lieb R, Wunderlich U, Schuster P. Comorbidity in primary care: presentation and consequences. Clin Psychiatry. 1999;60(suppl 7):29-36.
24. Goldberg D, Lecrubier Y. Form and frequency of mental disorders across centres. In: Ûstun TB, Sartorius N, eds. Mental Illness in General Health Care. Chichester, UK: Wiley; 1995.
25. Kleinman A. Culture and depression. N Engl J Med. 2004;351:951-953.
26. Bhugra D Ahmad K. Depression across ethnic minority cultures: diagnostic issues. World Cult Psychiatry Res Rev. 2007;2:47-56.
27. Bhugra D, Becker M. Migration, cultural bereavement and cultural identity. World Psychiatry. 2005;4:18-24.
28. Bhugra D. Cultural identities and cultural congruency: a new model for evaluating mental distress in immigrants. Acta Psychiatr Scand. 2005;111:84-93.
29. Cantor-Graae E, Selten J. Schizophrenia and migration: a meta-analysis and review. Am J Psychiatry. 2005;162:12-24.
30. Jablensky A, Sartorius N, Ernberg G, et al. Schizophrenia: manifestations, incidence and course in different cultures. A WHO ten-country study. Psychol Med. 1992; Monograph suppl 20.
31. Sartorius N, Davidian H, Ehrenberg G, et al. Depressive Disorders in Different Cultures: Report on the WHO-Collaborative-Study on Standardized Assessment of Depressive Disorders. Geneva, Switzerland: WHO; 1983.
32. Kastrup M. Global burden of mental health. In: Preedy VR, Watson RR, eds. Handbook of Disease Burdens and Quality of Life Measurements. New Yoirk, NY: Springer; 2009:1474-1491.
33. Fisek GO. Cultural Context. Migration and health risks—A multilevel analysis. In:Marschalck P,Wiedl KH , eds. Migration und Krankheit. IMIS-Schriften, Vol 10. Osnabrück, Germany: Universitätsverlag Rasch; 2001:113-122.
34. WHO; Mental Health Consortium. Prevalence, severity and unmet need for treatment of mental disorders in the World Health Organization. JAMA. 2004;291: 2581-2590.
35. WHO. Mental Health: Facing the challenges, Building Solutions. Report From the WHO European Ministerial Conference. Copenhagen Denmark: WHO Regional Office; 2005.
36. Lancet Global Mental Health Group. Scale up services for mental disorders: a call for action. Lancet. 2007;370:2241-2252.
37. Williams DR, Gonzales HM, Neighbors H, et al. Prevalence and distribution of major depressive disorder in African American, Caribbean Blacks, and non-Hispanic whites: results from the National Survey of American life. Arch Gen Psychiatry. 2007;64:305-315.
38. Desjarlais R, Eisenberg L, Good B, Kleinman A. World Mental Health. Problems and Priorities in Low-Income Countries. New York, NY: Oxford University Press; 1995.

Keywords: diagnosis; depression; culture; epidemiology; migration; globalization; gender