Jefferson Journal of Psychiatry Jefferson Journal of Psychiatry

Volume 9 Issue 1 Article 4

January 1991

Depression and Poverty I. Psychosocial and Cultural Depression and Poverty I. Psychosocial and Cultural

Determinants Determinants

Donald C. Ohuoha, M.D., M.P.H. St. Elizabeth's Hospital, Washington DC

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Recommended Citation Recommended Citation Ohuoha, M.D., M.P.H., Donald C. (1991) "Depression and Poverty I. Psychosocial and Cultural Determinants," Jefferson Journal of Psychiatry: Vol. 9 : Iss. 1 , Article 4. DOI: https://doi.org/10.29046/JJP.009.1.002 Available at: https://jdc.jefferson.edu/jeffjpsychiatry/vol9/iss1/4

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Depression and Poverty I.Psychosocial and Cultural Determinants

Donald C. Ohuoha, M.D. , M.P.H.

Abs t ract

The WorldHealth Organization estimatesthat over 100 millionpeople worldwidesuJferfromdepression, that three times as many may be aJfected (1). While major advances have occurred in ourunderstanding qf the biological aspects of depression, the understanding qfpsychosocial causes ofdepression is still largely sketchy. Thus adequate intervention in dealing with this aspect oftreatment qfdepression is scarce.

This paper, divided into two parts, will review recent findings in psychosocial causes qfdepression and suggest certain strategies.for intervention, speculate on the roles qfpoverty and theissues raisedby povertyon the rates ofdepression and suggest certain strategies.for intervention in thetreatment ofdepression amongst thepoor.

INT RODUCTION

The World H ealth Organization es tima tes th at over 100 million people sufferfrom d epression, th at three times as m any may be a ffec te d (I). It is es t imated to costAmericans a pproxim a te ly 16.3 billion dollars a nn ually (2). Amon gst th e poor , how­eve r, it is not clear how many suffe r from depression as th is population has not beens tudied very well. In not st udying this group, it becomes impossibl e to est ima te th eirnumbers and the human suffering which is oft en reflect ed in th e psych osocial aspectsof th eir illn ess , whi ch includes cultu ra l and sociody nam ic fact ors.

Psychosocial factors have been implicat ed in the developm ent , mai n ten a nce,cou rse, and treatment of d epression (3), how ever their specific fun cti on in th e courseof depressive illn ess remains con t rove rs ia l (2, 3) . The purpose of this paper is tohigh light several psycholog ical a nd socia l variab les th at have been co r re lated withdepress ion among the poor, speculate on their origins, and th en sugges t inte rventionstrategies . In part I of this paper, the psychological ca uses of depression among th epoor is divided in to cult ural determinants, attribut ional style , dysfunctional a ttitudesand sociodynamic ca use s. The issues rais ed by th ese are a lso di scu ssed . In part 2,in te rven t ion st ra tegies will be discussed.

PSYCHOSOCIAL CAUSES OF DEPRESSION IN TH E POOR

Cross Cultural Determinants

Culture may influence the production of illn ess, in this case th e incid ence andprevalence of d epression. This ca n be view ed in terms of th e soc ia l co ns truction of

14

DEPRESSIO N AND POVERTY I. 15

illn ess that is the patt ern of distress , interpretation of that distress as illness, and theresponse to it. The social network can affect not only th e production of depression butit also responds to it. A particular cult ure may favor ce r ta in patt erns of illness idiomsof distress; th e identification by which th e distress is known; th e local models personstypically construct to expla in it; and typical patterns of help seeking, which ma yinflu ence th e course and outcome of disease. Some a u tho rs have em phasized th edifferent pathogenic factors which may affect rates of depression in d ifferent cult uresand the factors affecting its particular manifestation (4,5). The lit erature on cross­cult u ra l psychiatry is full of studies that have addressed differences in th e ra tes ofdepression across cultures (6-10). However mo st of th ese a re incon clu sive. Theproblems involved in epidemiological as sessme n t with regards to research in West ern­developed coun t r ies lik e uniformity of methods a nd instruments, and case crite riabecome eve n more com plica te d in cross cult u ral research . Stud ies in th e epide miol­ogy of depression, though numerous, have yield ed onl y few conclusions aboute thnocuItura l variations in th e fr equency and distribution of depressive di sord er s.Until recently most of the information has been an ecdotal on syste matica lly co llectedclini cal expe riences . Historically, studies of rates of depression in poor com m unit iesof west ern coun t r ies and in developing coun t r ies have been rare. A review by Pr ince(II ) of depressive illn ess in Africa divided th e lit erature int o rep ort s prior to 1958,whi ch indicat e a low incid ence, a nd reports since 1958, whi ch ind icat es rat escom pa rable to those in th e West. Prince postulated four reason s why th ere was areported high er incid en ce of depression in mu ch of post-Colonial Afri ca a fte r 1958:

I. Depression was a relatively "prestigious" disease beli eved to a fflict on ly thosewho are "especia lly se ns it ive or intell ectually awa re ." Prince expla ined tha t" in th e co lonia l era depression s should not be seen a nd na med becau seAfricans were not responsibl e; in th e era of ind ep enden ce, depression shouldbe see n because Afri cans are responsibl e a nd awa re."

2. Id entification of ce r ta in clini cal pr esentations as mask ed depression , espe­cially somatization and neurasthenia whi ch were com mon, may hav e led to amore frequent diagnosis of depression. This may have represented a shift incase identification.

3. Patients and families may have viewed m ent al hospitals as inappropriat eplaces to seek help for th e kind of distress that would have been diagnosed asdepression. They were more likely to have seen tradition al healers, if th edepression became too troublesome to be dealt with in th e com m unity.Consequently, because of a sel ection bia s against hospital-based treatmentfor depression, psychi atrists may have underestimat ed th e rates of depres­sion. It should be noted that th e attitude not ed here is preval ent in Westerncult ures al so and not indigenous only with th e under-develop ed coun tries ofth e world.

4. With West ernization and socia l transformation th e re may have be en a trueris e in th e rates of depression.

Prince 's formulation of th e prestige factor to expla in th e Incr ease, In th e

16 JE FFERSON JOURNAL OF PSYCHIATRY

post-indep endence era, of the di agnosis of depression recognizes t he relationshipbetween the pr evailing conceptualization of depression , its interacti on with fact orsarising from th e cultural and historical concepts in whi ch it is em bede d, and th eclini cal practi ces. All of th ese indirectly put th e fing er on th e effec ts of illi teracy andpoverty. It should be pointed out that in Britain, th e definition of melan ch oly, a nd it sevolu t ion into current conce pts of depression, explains in part why there was arelu ctance of British colonia l psychiatrists to diagnose melan ch olia (12) . Thus peopl elike Robert Burton, who wrote in his work , The English Mala dy, sta ted "fools wea k orstupid persons, heavy and dull souls are se ldom troubled with vap ors or lown ess of th espirits . .. th ese nervous disorders being com pute d to make a lmost 1/3 of th ecom pla in ts of th e peopl e of condit ion in England" (13). The poor a nd di sin fran chisedhave al so been called weak. Thus Prince's suggestion of th e prestige facto r mayindicate that during colonial periods th e di agnosis of depression amongst th einhabitants of th e colonies might have be en conside re d tan tamount to ac knowledg­ing that African and Asian natives or even poor people in ge nera l had more incom mon with th e Englishmen a nd th e rich th an th e colonia l ration al izat ion wou ldadmit. Thus th e prestige factor might not onl y have pr edi sposed colonia l psych ia­trists to diagnose depression more frequ ently, but it may a lso have left p reindepen­den ce colonial psychiatrists ill di sposed to recognize it as su ch.

A variet y of cultu ra lly specific presentations of depression and rela ted localidioms of distress have been report ed throughout th e world . It has been report ed th a tdepress ed patients in Afghanistan may com pla in of wea kne ss a nd a feeling of a handsq ueezing th eir heart. Obsessiv e-compulsive patterns have been report ed a mo ngstth e Japanese, and Indian depressives may be preoccupied with family issu es, loss oflibido and religion (14) . Reports of cult u re -bound synd romes such as hea r tbrea ksynd ro me among elde rly Mohave Indian men (hiwaitck ), ge nita l retracti on syndromein Southeast Asia (Koro), susto in Latin Am erica , different form s of soul lossworldwide (15,16) and other locall y const ructe d idioms of distress (7) seem to addressim porta nt aspect s of the depression expe r ience.

West ern patients have been report ed to report guilt a nd self reproach asfeatures of depression. This has been touted as distinguishing th em from pat ien tselsewhe re. Murphy (17) suggested th at t his as sociation of guilt with depression mayreflect th e influ en ce of theJud eo-Christian heritage. Others have, however, indi catedthat guilt is not so rare amongst Africans or Asians as on ce believed (18,19,20,21).

AlTRIBUTIONAL STYLE

Attributions are the a nswers people give to th e qu estion " why"? A nega t ive orbiased attributional styl e ha s been implicat ed in persons expe riencing dep ressivesym ptoms. Abramson e t al (22) posited a relationship between expect ing even ts to beun controllabl e a nd expe r iencing depression. Th ey described th e role of a t tr ibutionsin depression after learned helpl essn ess th eory fail ed to account for the losses ofself- est eem or chro nic symptoms noted in human depression . They argue d th a tdepress ed patients will explain negative even ts appealing to internal globa l and

DEPRESSIO N AND POVERTY I. 17

stable ca uses. This ofte n t imes is th e case among th e depress ed poor. T o explai npositive eve n ts th ey will a tt r ibu te ca use to exte rnal, spec ific and unstable fact or s andare thus lured to th ese factors in th eir searc h for pos itive events.

Att ributional styles ca n be assesse d by th e At tribution al Styl e Questionnaire(23) . In th e so call ed Hopelessness Theory, Alloy (24) expla ins th at biased thinkingpla ys a ce n tral rol e in depression. There is so me ag ree me nt that poor depressedpatient s a re more likely than rich depressed patient s to a ttribute th e ca use ofnegat ive eve n ts to internal globa l a nd stable ca uses a nd view themselves, th e wor lda nd th e future, negatively. There is st ill so me controversy with th e sp eculation th atpoor depressed peopl e (de pressed people in genera l) th ink ing is less "realisti c" th anth e th inking of non-depressed peopl e. The ro le poverty plays in this is not underst ooda nd will be a topic of so me specula tion lat er in this pa per.

DYSFUNCTIONAL ATrITUDES

Beck (25,26) maintains th at biases in thinking plays a centra l ro le in depression.H e expla ins th at thi s includes a negative view of th e se lf, world , and future. Ifdysfuncti on al attitudes have develop ed during ea rly life expe rie nce s that result ininflexible a nd negative views of oneself the world a nd future, particularly if this ispr ecipitated by poverty, one ca n ass ume th at thi s follows one throughout life.Dysfuncti on al a tt itudes may be sta te dependen t (27), ma king their role as avulnerability or e t iolog ic fact or qu estion abl e. However, it is im port a nt to not e th atpatient s with high Dysfuncti on al Attitude Scores (DAS) have be en shown to be mor evulnerable to negative even ts (28,29).

Abnormal int erpersonal relationships con t ribute to chron ic dysfun ctional alti­tude. Int erpersonal relationships amon gst depressed person s is often a bnormal.These person s' difficulty in socia l int eraction s is no t lim it ed to th e fami ly. Tongrena nd Levin sohn (30) demon strat ed th at depressed persons com pared with non­depressed con t ro ls rep orted deficit s in soc ia l fu nctio ning in groups , which includeddecr eased fre q ue ncy a nd comfort in soc ial act ivity. Coyne (3 1) suggest s th at de­pr essed people engende r hostility a nd guilt to th eir listen ers an d a re therefore a t riskfor being reject ed . It is not clear again how poverty contribu tes to t his and is an a reath at need s more research.

SOCIODYNAMIC FACTO RS AND DEPRESSIO N

Several work ers have hypothesized th at psychosocial st ress es adversely affect aperson 's emotiona l health . This to a large exte n t depend s on on es abi lity to cope withva rious st ressors (co ping styles) . This is a lso in flue nce d by th e ava ilability of ad equat esoc ia l suppor t, by ones age , sex, socio-economic sta tus, me ntal status and religion.Ap art fro m depressi on , life st ress (includi ng poverty) has bee n im plica ted withph ysical illn esses, lik e dysfuncti on al ut erine bleeding, end stage rena l di sease,dermatological disorders, st ro ke (26), a nd myocardial in farcti on (27).

III JEFFERSON JOURNAL OF PSYCHIATRY

ISSUES RAISED BY PSYCHOSOCIAL AND SOCIODYNAMIC CAUSES OFDEPRESSION

The issu e of poverty and its interrelations to depression is th e main focus of thispaper. Earlier we dis cu ssed th e cult ural attitudes and soc ia l dyna mic influences in th epr oducti on of illn ess. The perception of poverty is va ried in differen t cultures. Aperson might be poor in one cult ure but may be perceived rich in a no the r. If povertyis related to depression, th e interpret ation of depression a nd respon se to it may bedifferen t among different socioec ono mic cla sses, as well as cult u res. This may a lso betrue eve n in intra-cultural persp ecti ve. By this I mean th e percept ion of depressi ona nd interpretation of it may not be th e same in a fflue n t a nd poor a reas of sayWashington, D.C . or in simila r areas in developing coun t r ies. This raises significantqu estions th at must be understood prior to stra tegies for int ervention . If pove rty do esin teract wit h depression-and if it s perception a nd understa nd ing varies amongs tculture s and classes:

I . Does poverty int eract wit h the biologi ca l an teced ents a nd effects of depres­sio n? In th is q ues tion the sp ecu lation (mine) is th at it does. The ro le of th ege ne ro le, nu tri tional sta tus and othe r loca l eco log ica l and biological mi lieudo effect th e rat e of dep ression, eve nt houg h it has not bee n stu d ied properl y.Poor nutritional sta tus, substanda rd housing, high ra tes of illn ess, substanceabuse pr eval ent a mong t th e poor may con t r ibu te to abnormal it ies in th ebioch emical ca uses of depression , eve n from child hoo d.

It might be th at th e chro nicity of th ese cond it ions a nd th eir con t r ibu­tion s to depression , eve n th ou gh not perceived as suc h wit hin th ese popu la­tion s, cre a tes a biological environmen t devoid of clear t hinking an d planning.There is not mu ch kn own abo u t th e effec ts of pe rsistent neural dischargesa nd th e cog nitive adj us t me n t poor peopl e mak e to live wit h these conditions,a nd th eir con t ribu t ion to a tt r ibutiona l styles a nd dysfu nctional attitudesfound in depressed patients. On th e ot her hand , docs cult ura l bel iefs a ndpracti ces within a population , even th ou gh poor, affect th e ph ysical enviro n toexpose and to det er one from th e effec ts of th ese biological an teceden ts (32)?I also sp eculate th at this is true but is a n area th at need s more study.

Foster (29) noted that th e Am eri can Indian views time in a mu chdifferent manner than th e Anglo Am eri can , perceives tim e a nd space as ameasurable and ordered en t ity. H e not es that India ns have a focus on th epresent m uch like t he poor, whose condit ions for ce them to , witho ut anyori entation as to fut ure t im e . This may inva riab ly lead to not planning a head ,not knowing wh ere on e is going. It is a lso some times a pr elude to at rophy ofcoping sk ills, self-medi cation , a nd thus leads to di sease a nd abno rmaliti es inneural dis charges. On the other hand, th ese beliefs may also help one to copewith th ese abnormal dis charges wh en th ey occ ur th rough ot he r mechanismsth at are not related to poverty.

2. Does poverty int eract with th e psych ological a n tecede n ts a nd effec ts ofdepression? Con sid er th e role of th e conce pt of se lf among poor people, th e

DEPRESSION At'\lD POVERTY I. 19

intense affe ct brought on by poverty, pr eferred coping styles a nd locallydefin ed principl es organizing intrapsychi c expe riences. These a ll affect th eeve n ts that ca use depression.

In a community wh ere eve ryone is poor, th e effec ts of poverty and itsconsequences may not be perceived, and thus may not present a poor conceptof self a mong individuals living in that com m unity. The affect s br ou ght on bypoverty may not be intense and pr eferred coping styles may be adaptive andintrapsychic expe riences may be on e th at do es not pr ecipi ta te depression.However, wh en a poor community is su rro unde d by an affluent one, th eperception of poverty may cha nge and pr eferred coping styles may bemaladaptive and con t r ibu te immen sely in pr ecipitat ing depression and mayalso playa rol e in th e conse q ue n t seq ue llae of th e di sease. For example, th econ cept of self a mongst people in McLean, Virginia may be th e sa me as thosein rural Idaho because th ese com m unit ies are essen tia lly far from each otherand day to day int eractions amongst th e peoples do not occur, eve n t houghth e cult ure is th e same. What is conside re d poor in Mel .can , may becons ide re d rich in Idaho, but because people do not expe rie nce th a t dai ly,th eir expe riences and thus psychological mak e-up as it rela tes to suchcond it ions, is invariabl y stable. If, how ever, th ese two comm unities tha t shareth e sa me cult ural basis are in close proximity, th e psych ological understand­ing of se lf a mo ngs t people of th ese two com m unit ies will become a ltered.Local beli efs a nd practi ces th en impact in th e psych ological mak e-up of th eindividual and fun ctions as anteced ents, eithe r crea t ing vulnerability or affe ctsymptom formation of depression. As a not he r exam ple, No bles (34,35 ,36) ha sem phasized th e conce pt of strong group identification or " we- ness" as apositive Black Am erican trait. Cook and Rono (37) a nd White (38) have alsoarg ue d that growth-promoting aspect s ofAfro Am eri can cultu re a nd conscious­ness ca n positively organize th e intrapsychi c expe rience of the ind ividual.These in turn could be used by th e individual to cope with th e ravages ofpoverty a nd depression .

3. Does cultu re a nd poverty int eract with th e soc ia l anteceden ts an d effec t ofdepression ? The answer to this qu estion is yes. The ex ternal a nd int ernalsocia l for ces on th e cultu re, mor es, a t t itudes a nd beli efs, a lso impact on th eincid ents and manifestations of different rates of depression . Wh a t is th e rol eof s te re otypes, int erpersonal and instutitional (Governments) percept ions,and principles of organizing social relationships on th e cult ure a nd th us itsrelationship to depression? The individual wh om soc iety by it s ste reo type isexpec te d to behave a ce r ta in way is for ced oft en to live up to th at expecta tioneithe r to maintain an identity, a se lf-image, or to be accep ted. T his is true no tonly in th at individuals interacti on with th e ou ts ide or withi n his or her owngro up. Do Gov ernment 's perception of a gro up or comm uni ty and does it inturn affec t th e rate of poverty a nd thus depression ? My spec ula t ion is tha t itdo es. When Gov ernments acce pt sq ua lid cond itions a nd fa il to im prove SocialServi ces, or improve opportunities for em ployme nt, this in turn reinforces

20 J EFFERSON JOURt'JAL OF PSYCHIATRY

povert y, poor se lf-es teem and thus leads to greater depression, even though itis not perceived as suc h amon g members of such gro ups. T his area has notbeen stud ied greatly eit he r a nd it s rol e to dysfunction ality needs to bestud ied . The rol e of socie tal disruptions, migrations, mod ernizat ion s, natu ra ldis ast ers and wars as determinant of poverty and th eir effec ts on th e rates ofdepression have also not been studied . The effec t of wa r on post-t rauma t icst ress synd ro me how ever is well kn own. Consid er th e term "T he Good O ldDays." What do es it mean? That cond it ions before were bet ter in terms ofint erperson al rel ationships, peopl es perception of th emselves, or is it a trueindictment of modernization? I don 't kn ow, but I specu la te it 's all of th eabove.

4. Do cult ure and poverty influen ce th e way peopl e thi nk of depression andrelat ed patterns of distress a nd how does it in turn influen ce what peoplethink? The answe r to this qu estion was a llude d to earlie r. It add resses th erelationship between cosmopolitan (afflu ent) a nd local (low soc ioeco nom ic)factors of depression.

C ult ure and poverty do influ en ce th e way peopl e think of depr ession. Itaffects th e way people deal with life eve nts whi ch is kn own to playa key rol e indepressive illn ess (39) . In speaking of life even ts, each cult u re deal s witheve n ts differently a nd thus modulates it s impact (increasing or de cr easing)on depression. It is clear however that poverty in itse lf, regardless of cultura lbeli ef modulation s, is corre la te d to depression a nd se lf-es te em (39,40 ).Brown, in th eir sa m ple, found th at working class wom en were more likelyth an middle class wom en to becom e depressed if th ey ex pe rie nced a stressfuleve n t or major difficulty. If thi s is so, do es it th en mean th at poor dep ressedpeople's thinking is " unrealist ic" in th e face of con sist ent stresses andunfavorable life eve n ts. This is an area worth studying .

5. Do religious ideologies con t r ibu te to or prot ect from depression ? T he answerhere is ag ain yes, even a mongs t th e poor. The relation shi p be tween normalsuffe r ing a nd clin ical depression may va ry be tween socia l classes and cultur es.In Buddhist soc ie ty whe re no rmal suffer ing is ofte n cons ide red intrinsicfea tu re of human cond it ion rathe r th an indication of di sorder, the features ofdepression as defin ed in standa rd diagn ostic syste ms, may not ap ply. T here­for e it is imperative th at standa rd di agnosti c sys te ms be refin ed to take int oaccount su ch local idioms of distress so as to avoid a n incorrect d iagnosiswh en su ch religious beliefs do occur.

SU MMARY

In th e first part of this paper, I have t r ied to rai se significa n t q ues t ions tha t haveyet found very few a nswe rs . Depression a mo ngs t th e poor present s a perplexingqu estion regarding th e ca use, how it is perceived and th e cult ura l underp innings tha tdrive or prot ect individuals from th e disease. The ph en om ena of lived experiencesvary across cult u res a nd soc ia l st ra ta. There are specific differen ces in th e significance

DEPRESSION AND POVERTY I. 21

of guilt soma t iza t ion and neurasthenia , one must cons ider th e cult u ra l and hist ori calfactors th at shape th e conce p ts of depression in a pa rticul a r culture or socioecon omicgro up, prior to planning st ra tegies for int ervention. These m us t a lso be underst oodso as to prep are e thnog ra phies of th e expe rience of depression among local classes,especia lly th e poor to com pleme nt findings from other quatitative met hods. Wh enth ese a re understood th ey will help to cre a te st ra tegies for men tal healt h delivery forth is population . The qu estion s rai sed were don e to provok e debat e and research inth e a rea with the hop e th at significa nt a nswe rs will be fou nd that will he lp improvepoli cy a nd treatment of this popula tion . In Part II , I will review suggest ed strat egiesfor intervention.

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