Depression

= **Depression** =

Definition
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Depression is described as a form of mental illness in which the primary attribute is mood disruption. It is classified as the most common form of mood disorders. Depression can also be a symptom of other medical conditions such as diabetes, thyroid disorders, or post viral syndromes to name a few. Seen as one of the most prevalent diseases worldwide and an important cause of disability, depression accounts for one of every five primary care physician visits. Depression affects people of all racial and ethnic backgrounds. However, it is more prevalent among the poor than among the well-off.

Depression is understood, discussed, confronted, and managed based upon cultural meanings and practices. Experience of depressive symptoms, how depression is reported, treatment decisions, patient-doctor interactions, and professional practices are all influenced by culture. Some conditions are universal and some are determined culturally. For example, in his work on culture and depression, Arthur Kleinman explains how various patterns of somatization are found among depressed patients from various ethnic groups of Latinos. Mexican Americans, Cuban Americans, and Puerto Ricans may not report the same symptoms. However, adding differences of sex, age, social class, education, and degree of bioculturalism to the equation, makes the population all that more diverse and the questions of cultural influence all the more obscure. In other examples, black women were found to have lower rates of depression and suicide than white women; and immigrants lower rates than their descendants. Hence, we find cultural effects sometimes serve as protective factors rather than risk factors.

History
Depression classified as an illness is a Western construct derived from the word ‘melancholia’ during the time of Hippocrates. However, current understandings of depression as an illness in other cultures are questionable. The culture of biomedicine also contributes to the ambiguity of depression. Symptoms of depression represent different meanings based upon who is defining them (i.e. practitioner vs. patient vs. family and friends vs. clergy vs. social worker). As a result, many immigrants and minorities with clinical depression are undiagnosed, underdiagnosed, and untreated in the United States.

According to the //Diagnostic and Statistical Manuel of Mental Disorders, 4th edition// (DSM-IV), there are nine criteria for major depressive disorder, which can be a single episode or recurrent event. A minimum of five of the nine symptoms are required to have been present during the same two week period for a diagnosis of depressive or major depressive disorder.


 * The criteria for a major depressive episode are:**
 * 1) Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others.
 * 2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
 * 3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
 * 4) Insomnia or hypersomnia nearly every day.
 * 5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
 * 6) Fatigue or loss of energy nearly every day.
 * 7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
 * 8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
 * 9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

The DSM-IV is culturally sensitive and stipulates the evaluation process of patients. This begins with respectful affirmation of ethnic identities and continues with determining how cultural factors may contribute to assessing causality, disease, and treatment of depressed clinically depressed patients. Cultural forms of resilience should also be considered when evaluating depressed patients. For example, black women are often portrayed as strong, resilient, and adaptive in their ability to cope with adversity and still be a support for their families. Accordingly, physicians should be sensitive to the issue of institutional racism and be careful not to stereotype patients because of cultural or ethnic backgrounds.

Symptoms of depression clinically cause feelings of significant distress or some type of impairment, whether it is social, occupational, or some other functioning. However, symptoms should not be a result of physiological effects of alcohol or drug use (including prescription medication) or due to the result of mourning the loss of a loved one. Based on standard diagnostic criteria, the average lifetime rate of major depression is estimated at 10 to 20 percent. It is found most common in primary care settings and has significant effects on the lives of those who experience it.

Case Studies/Examples
Addressing the issue of whether or not there are cross cultural differences in psychiatry, Arthur Kleinman uses data from a study in Taiwan looking at Chinese depressives to see if differences occur and are a function of what he calls “cultural shaping of normative and deviant behavior somatization.” In the National Taiwan University Hospital, 25 patients suffering from depressive symptoms were assessed of somatic complaints. During the course of his research, Kleinman found somatization in the U.S. existing at a smaller degree than in Chinese culture. Although somatization appears more common in the U.S. than in Chinese culture, it is not to the same extent as found among the Chinese. Because of the differences found, Kleinman proceeded with three cases to further explain differences in phenomenology between Chinese and American depressives.

The three cases were:
 * Case 1 – a 32 year old unmarried Taiwanese account suffering from headaches and insomnia.


 * Case 2 – a 60 year old retired Navy Captain, living in China, a widower living alone suffering from weakness in all extremities, tremor of hands, unsteadiness of gait, heart palpitations, easily fatigued, profound weight loss, and insomnia


 * Case 3 – a 33 year old Chinese male with complaints of tiredness, dizziness, general weakness, pains in the upper back described as rheumatism, a sensation of heaviness in the feet, 20 lb. weight loss, and insomnia of 6 months duration Patient denied any emotional complaints.

After thorough assessment of the cases, Kleinman’s conclusions refuted those of Singer, which were “depression has outstanding deviant features in Chinese society.” Conversely, he showed that illness is a personal, interpersonal, and cultural reaction to disease. Hence, we find that we have to approach illness with a cross cultural perspective; because meanings and behaviors for illness that hold true for one culture do not always translate as the same for another culture.

Below are two media examples of individuals sharing their stories about their experience with depression.

[|A woman’s chronicle of her life in therapy.] [|A woman’s journey of living with depression.]

Related Terms/Pages

 * Arthur Kleinman
 * Stress (Health)
 * Stress
 * William Dressler

Online Resources
National Institute of Mental Health - A detailed booklet that describes Depression symptoms, causes, and treatments, with information on getting help and coping: []

Video from the National Institute of Mental Health (NIMH) about the causes, symptoms, and treatments of depression: []

Coping with Postpartum Depression - Family Support: []

Discussion Board/Comments
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