Cross-cultural aspects of depression in general practice.

Abstract

It was previously thought that black Africans from traditional cultures rarely suffered from what in the West is classified as depression. The word ‘fatalistic’ was often used to describe what was assumed to be a lack of emotion or feeling. It is being increasingly discovered by psycholinguistic and psychological research that depression in black Africans is underdiagnosed as it presents in different ways of living and interacting as well as from a different existential dimension and world view. From a constellation of symptoms and signs, the West has developed a concept and label of depression that fits and suits Western culture. Traditional African culture has not concretised or labelled this concept yet so that it remains diffuse and undifferentiated. It may present with different linguistic phrases, metaphors of life and symbolic language and often as a story that attempts to express the complex realities of life. An exploration into these stories (and other mediums such as song, theatre, poetry and literature) may reveal that depression is as common among black Africans as it is in the West, but that it is unrecognised and underdiagnosed. How does one diagnose depression in a Zulu patient who comes down from the villages of Hlatikhulu or Ntabamhlophe in the mountains, or from Msinga and Nkandla in the low bushveld? It is a meeting between two worlds of different experience, meaning, language and culture. The patient works within the experience of his or her social and cultural life whereas the doctor works within the criteria laid down by the Diagnostic and Statistical Manual-IV (DSM-IV) 1 and has a list of symptoms that have to be fulfilled before the diagnosis can be made. These symptoms and references are derived from both a biomedical perspective and the doctor’s own experience of living in the Western world. The doctor’s language and even grammar are technologically based. We have now classified almost every activity that human beings are capable of and are busy with subsets and smaller boxes, into which human behaviour can be fitted. When we encounter a traditional African culture that is not informed in this way and that experiences illness differently, we are often at a loss as how to assess, diagnose and treat such patients. For instance, traditional rural Africans may not differentiate their cognitive functions from their bodily functions and symptoms. Their dreams, visions, feelings and inner thoughts are not separated from their bodily symptoms of illness. There is no dichotomy between the spirit or soul and the body. 2