While depression and anxiety are often considered to be “diseases” of the affluent, new studies find them to be just as common in poorer countries. Can a Western model of interpreting and treating mental distress be applied to other cultures?
An article in the New York Times, Psychotherapy for All, relates a project in Goa, India, in which laypeople are trained to identify and treat depression and anxiety. Almost 2,000 patients have been treated in community health clinics, and a randomised clinical trial is being carried out to see how well the strategy works.
The programme is an attempt to deal, in an appropriate way, with the huge amount of undiagnosed and untreated mental distress in India, whose population of more than one billion is served by fewer than 4,000 psychiatrists, most of whom are concentrated in urban areas. While depression and anxiety are often considered to be “diseases” of the affluent, new studies find them to be just as common in poorer countries. Severe depression is of course disabling wherever it occurs. It may just be a question of definition. Of which, more later.
The programme involves a screening and first consultation which typically take half an hour, and straightforward explanations of depression and anxiety and the offering of a range of treatments. This is a human approach, likely to be more effective than the referral of patients to a state mental hospital. The take-up rate for such appointments under the previous system was lower as patients could not afford to take time from work or pay for transport.
The stigma of mental illness is also considerable in Indian society. Health workers in the project carefully avoid all mention of mental illness, and diagnoses of depression and anxiety, using words like “stress” and “tension” instead. The major troubles they report encountering — financial difficulties, interpersonal conflicts, unemployment and alcoholism — seem very familiar to me from my work in rural Poland. Poverty can lead to a spiral of alcoholism, domestic abuse and stress, to which depression and anxiety might be considered natural responses.
These spirals of poverty, alcoholism and abuse lead, particularly in traditional rural communities, to high levels of individual stress which often do not fit within the tight social model (for example children abused by priests have nowhere to go with the experience in communities in which the priest is the greatest authority). In urban areas there are therapists and there is an understanding of “mental illness” as defined by Western psychiatry, but even here it is a partial and sometimes generational thing. In my own practice, often young clients come to me with a sophisticated understanding of what they are experiencing and how therapy might help, but do not breathe a word of this to their families or friends because “they don’t understand and would think I was crazy”.
Being crazy and being an outcast from the community bites harder in less affluent societies. It may also be associated with deep seated notions of evil and fear of going to hell in some religious societies. Societies which have suffered greatly throughout their history, such as Poland, may find that social cohesion is of primary importance to them, and there is a kind of fear passed on through generations, which now does not seem to be justified, but lingers on, the feeling that outcasts will not survive. We survive injustice and cruel regimes by maintaining an underground society, by our family and community bonds. Maybe it is the “winners” of history who tend to have more individualistic societies and less fear of mobility, of being different, even of being crazy, which can certainly also be taken in some circles as a compliment!
Taking all these factors into account, I can quite understand that people do not want to be seen as mad. Too many individual emotions and needs may threaten the stability of the whole system, so being sad may not be welcomed either. So if we can’t be mad, sad or bad, what can we do with ourselves when internal or external pressures demand some kind of response from us?
We can become ill. The article claims that “people in the developing world often complain of physical symptoms like fatigue, headache and insomnia, rather than emotional problems like sadness or regret”. I would argue that this applies to all societies which are not strongly individualistic. Wherever I go here in my everyday life I come across people who are “having a bad day” because of the air pressure, the wind, an inexplicable lack of sleep, or for no apparent reason. “Having a bad day” involves lack of energy, aches and pains. No defined emotions seem allowed.
Are all these people depressed and/or anxious? Or is this just a social code, a way of keeping up a desired level of contact with each other? Does it matter at the end of the day how we define our distress? At the end of the day it is all a matter of definition. One person’s stress is another’s depression is another’s headache. They can all be understood and treated differently, individually. What matters I think is that people get the help they need.
Here we run into the next problem — talking therapies themselves can be seen as suspicious. Surely we should be talking to our families, friends, or the priest? Why should we need to talk and be listened to by anybody else? Of course the people who come to see me often come precisely because something is lacking in, or impeding, those relationships.
What is more shameful, needing help, or going to get it? This is the internal conflict suffered by many people in cultures in which getting help for states of mental distress is not culturally approved of. More projects such as the one in Goa, could fruitfully be undertaken in many countries, and could probably save health services there a lot of the money and time which they presently spend on sending people from specialist to specialist searching for the origin of mysterious physical symptoms.
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