PERSPECTIVE

Culture and Depression
Arthur Kleinman, M.D. In many parts of Chinese society, the experience But the way in which depression is confrontof depression is physical rather than psychologi- ed, discussed, and managed varies among social cal. Many depressed Chinese people do not report worlds, and cultural meanings and practices shape feeling sad, but rather express boredom, discom- its course. Culture influences the experience of fort, feelings of inner pressure, and symptoms of symptoms, the idioms used to report them, decipain, dizziness, and fatigue. These culturally cod- sions about treatment, doctor–patient interaced symptoms may confound diagnosis among tions, the likelihood of outcomes such as suicide, Chinese immigrants in the Unitand the practices of professioned States, many of whom find the als. As a result, some conditions diagnosis of depression morally are universal and some culturally unacceptable and experientially distinct, but all are meaningful meaningless; this cultural pattern within particular contexts. changes over time but continAmong refugees, depressive ues to diverge significantly from affect and disorder are common the experiences of other groups. aspects of collective and personal The pattern of somatization may experiences of loss and trauma. be unfamiliar to U.S. clinicians Various patterns of somatization and may further complicate the are found among depressed paconcept of depression, which, tients from many ethnic groups, according to biomedicine, can and even among Latinos, for exbe an emotion, a symptom, or a ample, Mexican Americans, Puerdisease. to Ricans, and Cuban Americans Depressive feelings are exmay report different symptoms. perienced by all people and are Add differences in sex, age, social a normal component of disapclass, education, and degree of pointment and grief. Depression biculturalism, and the question of may be a symptom of a mental cultural influence becomes murky disorder (such as bipolar disorenough to discourage any form der, an anxiety disorder, or schizoof ethnic stereotyping. Inasmuch phrenia) or of other medical disas black women have lower rates eases, ranging from diabetes and of depression and suicide than thyroid disorders to postviral syn- The Chinese characters for “depreswhite women, and immigrants dromes. As one of the most prev- sion” are employed in medical settings lower rates of depression than alent diseases globally and an but are not in popular usage. their descendants, some cultural important cause of disability, depressive disorder is effects may be protective factors rather than risk facresponsible for as many as one of every five visits to tors. In a complex, postmodern society like that of primary care doctors; it occurs everywhere and af- the United States — where it is often hard to deterfects members of all ethnic groups. The rates of de- mine the cultural norm or how experience differs pression are increasing, and the disorder is nearly among or within communities — cultural differtwice as common among the poor as among the ences can affect any patient–doctor interaction. wealthy. The culture of biomedicine is also responsible

n engl j med 351;10

www.nejm.org

september 2, 2004

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Downloaded from www.nejm.org on May 17, 2010 . Copyright © 2004 Massachusetts Medical Society. All rights reserved.

sadness and hopelessness in a patient dying from cancer) may not denote a medical problem to the patient. defines normal bereavement as lasting for two months. may represent the leading edge of a worldwide shift in norms. Clinicians must then evaluate the culturally relevant aspects of the stresses and support in the life of a depressed patient. Lack of access to appropriate services is a major reason for this failure. It stipulates steps in the evaluation of patients. grief lasting for years — may count as a depressive disorder for the psychiatrist. religious practices. mental illness. Some recent immigrants. disease. may expect a directed. hierarchical relationship and be uncomfortable with a more egalitarian. 4th edition (DSM-IV). Cultural processes include the embodiment of meaning in habitus and physiological reactions. Culture also affects the interaction of risk factors with social supports and protective psychological factors that contributes to depression in the first place. and professional practice. the patient’s explanatory models of causality. For instance. but cultural forms of resilience should be considered. Moreover. Attention should also be paid to the ways in which culture can influence the clinical relationship. but cultural causes of misdiagnosis also contribute. but also the seeking of help. poverty and joblessness frequently intensify cultural issues. consumeroriented model. . patient–practitioner communication. the conventional belief that minority groups have strong extended-family ties may not be accurate. and it risked reducing culture to an autonomous variable among others. beginning with the respectful affirmation of and inquiry into their ethnic identity and continuing with the determination of whether ethnic factors seem pertinent in the particular case.org september 2. In addition. political. psychological. may be so stigmatized in a given culture that a diagnosis of depression is unacceptable and a euphemism is required. The term “culture” is often misused.PERSPECTIVE for some of the uncertainty surrounding depression. the DSM-IV offers a sensitive method of cultural formulation. Yet many people with clinical depression — at least 50 percent among immigrants and minority groups in the United States — still receive neither a diagnosis nor treatment from a biomedical practitioner. for example. 2004 Downloaded from www. culture referred to the shared patterns of life that define social groups. and there is surprisingly little research demonstrating that culturally informed approaches affect outcomes. for instance. In this area. Nonetheless. Patients may attribute their depressive disorder. In its early anthropologic usage. for example. it is a process by which ordinary activities acquire emotional and moral meaning for participants. Culture confounds diagnosis and management by influencing not only the experience of depression. Treating culture as a fixed variable seriously impedes our ability to understand and respond to disease states such as depression. Copyright © 2004 Massachusetts Medical Society. practitioners need to know about and respond to these treatments. Next. and the cultivation of collective and individual identity. and biologic conditions. since the Diagnostic and Statistical Manual of Mental Disorders. All rights reserved. Culture Culture and Depression is inextricably caught up with economic. Physicians must be sensitive to institutional racism and be aware that health care providers can unwittingly convey a sense of stigma to patients. the understanding of what is at stake in particular situations. the professional culture. such as those between parents’ patriarchal attitudes and children’s modern perspectives. there is little agreement on what this means for treatment. neglecting crucial differences among and within groups. Culture may even turn out to create distinctive environments for gene expression and physiological reaction.nejm. resulting in a local biology of depression: research already shows that persons from various ethnic backgrounds metabolize antidepressant drugs in distinct ways. and desired treatment must be assessed. 2010 . There is enough evidence showing that culture and ethnic background are associated with health disparities 952 n engl j med 351. his or her family. or their clergy. driven by the political economy of the pharmaceutical industry. Clinicians must then consider what is chiefly at stake for patients as they face a particular illness.org on May 17. the development of interpersonal connections. For all the talk of training practitioners to be culturally competent. to culturally salient family conflicts. fixed entities. What is seen by a particular social network as a normal emotional response — say. Symptoms that represent a depressive disorder for the practitioner (say. This usage tended to portray cultures as bounded. But culture is not a thing.nejm. Probably the most essential clinical task is not to do harm by stereotyping patients. for whom depression may be a sign of the moral experience of suffering. patients may have engaged in self-care or alternative and complementary treatments that can affect the biomedical regimen.10 www.

this approach can lead to stereotyping and oversimplification of culture. and health outcomes. or religious. Harvard Medical School.3 have highlighted the importance of patient-centered care and cultural competence as means of improving communication and thereby improving quality. be social. Harvard University. the concept goes beyond race. educational efforts in “cultural competence” have emerged. M. but when broadly applied. As the United States becomes increasingly diverse. values. nonadherence. Two recent reports by the Institute of Medicine 2. Culturally competent providers expand this repertoire to include skills that are especially useful in cross-cultural interactions. Culture and Depression From the Department of Anthropology. and behavior. Cultural competence has thus evolved from the making of assumptions about patients on the basis of their background to the implementation of the principles of patient-centered care. This field is not new. ethnic background. Cambridge. Previous efforts in cultural competence have aimed to teach about particular groups — the key practice “dos and don’ts” for caring for “the Hispanic patient. Culture is a pattern of learned beliefs. Patients may present their symptoms quite differently from what we learned in our textbooks. In certain situations. and their beliefs will influence whether or not they follow our recommendations. eliminating disparities. and probably most other disorders. Cultural competence has emerged as an important goal for very practical reasons. empathy.nejm. styles of communication. seems warranted. effective provider– patient communication is linked to improved patient satisfaction.D. As the United States becomes more diverse. 2010 . that cultural competence is necessary for the effective practice of medicine.org on May 17. Many point to the lack of empirical evidence linking cultural competence to improvements in health outcomes and question whether it represents a marginal fad or has mainstream clinical applications and a direct correlation with high-quality care. physicians will see patients from a variety of sociocultural backgrounds on a daily basis. adherence to recommendations. clinicians will increasingly see patients with a broad range of perspectives regarding health. including exploration. Although the former remains important. among other organizations. M. becoming a physician Cultural Competence — Marginal or Mainstream Movement? Joseph R. Boston. Culture shapes the way we approach our world and affects interactions between patients and clinicians. and the Departments of Social Medicine and Psychiatry. but it has been reenergized during the past decade as a result of pronouncements by the Institute of Medicine and the American Medical Association. and behavior that are shared within a group. and poorer health outcomes may result.H. and responsiveness to patients’ needs. With the aim of providing physicians with the knowledge and skills to address “cross-cultural” challenges in clinical encounters. the latter is more problematic. Yet the term “cultural competence” elicits varied responses from health care professionals..nejm. practices.” for example. beliefs. it includes language.1 When sociocultural differences between patient and provider are not explored and communicated. Copyright © 2004 Massachusetts Medical Society.10 www. Mass. Culture plays a large role in shaping health-related values. In addition. and achieving equity in health care. ranging from complete acceptance to outright derision. professional. learning about a particular community can be helpful. All rights reserved.PERSPECTIVE and poor outcomes that the application of this approach to the treatment of depression. customs.. which may. and country of origin. and views on roles and relationships.P. Many have thought of cultural competence simply as the skills needed to address language barriers or knowledge about specific cultures. Education in cultural competence has focused in part on methods for eliciting patients’ understanding of illness and their condition (their “ex- n engl j med 351. We all belong to more than one culture. patient dissatisfaction. they may have different expectations or thresholds for seeking care. and preferences. values. . Betancourt. for example.org september 2. 2004 953 Downloaded from www.

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