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How do we know when someone is clinically depressed, the type in which we seek out the help of doctors who intervene with medication and therapy? This is to be distinguished from the occasional feeling of sadness common to all people when we experience disappointment or grief. How we know someone is clinically depressed may have everything to do with our cultural differences.
Feelings of depression are experienced by all people and are a normal component of disappointment and grief. Clinical depression, however, may be a symptom of a mental disorder (such as bipolar disorder, an anxiety disorder, or schizophrenia) or of other medical diseases (diabetes and thyroid disorders) that require treatment and attention. As one of the most prevalent diseases globally and an important cause of disability, depressive disorder is responsible for as many as one of every five visits to primary care doctors; it occurs everywhere and affects members of all ethnic groups. The rates of depression are increasing, and the disorder is nearly twice as common among the poor as among the wealthy.
The way clinical depression is diagnosed in Western culture is based on the Diagnostic and Statistical Manual (DSM-IV TR) definition and includes the presence of depressed mood, markedly diminished interest or pleasure in almost all activities, significant weight loss or weight gain or decrease or increase in appetite, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, diminished ability to think or concentrate, recurrent thoughts of death including suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
However, the way in which depression is confronted, discussed, and managed varies among cultures, and cultural meanings and practices shape its course. Culture influences the experience of symptoms, the idioms used to report them, decisions about treatment, doctor-patient interactions, the likelihood of outcomes such as suicide, and the practices of professionals.
Psychiatric anthropologists have studied the interpretation of depressive illness and dysphoric affect (sadness) among Iranians. Dysphoria, defined as sadness, grief, and despair, is fundamental to the Iranian culture because it is an emotion that is full of symbolic meaning. Sadness for Iranians is linked to personal depth and often a sad person is considered a thoughtful person. Dysphoria has immense religious, secular, political, and personal connotations and significance in the Iranian culture.
Grief, despair, and tragedy can be found laid into the underpinnings of Iranian Shiism, secular traditions of writing and film, and political philosophy. Iranian Shiism, for example, includes a vision of tragedy and grief as a religiously provoked emotion signified by ritualized mourning ceremonies. For example, in bereavement there is no stigma attached to deep and demonstrative expressions of sadness. In fact, individuals are sometimes called upon to simulate sadness if others are monitoring their behavior as an indication of their level of grief and affection for the person they have lost. Secular Iranian literature, in the form of classic poetry and modern novels and film, often focus on melancholy and despair as their central themes. Iranian political philosophy, as well, has tragedy, injustice, and martyrdom central to it and the historical experience of the nation. It appears that Iranians have a well developed affective dialogue related to sadness, loss, and grieving.
There is a culturally shaped perception of self, in a ritualized tradition of religious grieving, and in a tragic view of history and society that is shared both in religious and secular sectors of Iranian culture. This is separate from the experience of clinical depression for Iranians. What is considered clinically significant depression or its equivalent takes a more diffuse form and is often referred to as narahati which means “discomfort” or “distress” and includes a wide range of mixed and undifferentiated anxiety and depression symptoms. Common forms of discourse that relate to narahati include: sadness and grief, anger, mistrust, and sensitivity.
It appears that due to the value placed on sadness and dysphoria in Iranian culture and the highly developed discourse around sadness, loss and grief that is essential to Iranian culture, the expression and the experience of depression may differ from the traditional Western conception of clinical depression which includes: poor morale, lack of hope in the future, and a general dissatisfaction with ones life situation. What does this mean for Iranians in America who seek help from mental health professionals? One thing to keep in mind is that the symptomology used by Western physicians, psychiatrists, and psychologists to define clinical depression may pathologize Iranian patients. Iranian patients may more often be seen as experiencing a significant level of depression than they actually are due to cultural differences. This could translate into Iranians being more often diagnosed with clinical depression and prescribed medication that they may not need. Both mental health professionals and consumers of mental health services should be aware of the impact of culture and how it shapes and influences our lives in immeasurable ways.
For further reading:
Culture and Depression: studies in the anthropology and cross-cultural psychiatry of affect and disorder. By Good, Good, & Moradi (1985) Berkeley, CA: University Press.
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