DEPRESSION, WOMEN AND DEPRESSION, WOMEN AND CULTURECULTURE: : A COMPARATIVE STUDY OF A COMPARATIVE STUDY OF DEPRESSION AMONG DEPRESSION AMONG MALAWIAN AND UGANDA MALAWIAN AND UGANDA WOMENWOMEN. . Dr Joshua TugumisirizeDr Joshua Tugumisirize

Assumptions 1Assumptions 1

Human nature is fundamentally the Human nature is fundamentally the same regardless of geography, same regardless of geography, climate, ethnicity, culture, and climate, ethnicity, culture, and socio-economic structure.socio-economic structure.

Therefore mental disorders should Therefore mental disorders should be more or less similar across be more or less similar across countries and cultures (German, countries and cultures (German, 1987) 1987)

Assumption 2Assumption 2

Individuals are differentially Individuals are differentially vulnerable to variations in vulnerable to variations in environments and cultures environments and cultures (German, 1987)(German, 1987)

Our TaskOur Task

““We are eager to know, certainly, how many people We are eager to know, certainly, how many people in Uganda suffer from depression (and other in Uganda suffer from depression (and other ailments) but how can we start to find that out if ailments) but how can we start to find that out if we do not we do not understandunderstand and know the and know the modesmodes in in which the local patient expresses depressive which the local patient expresses depressive symptomatology? What words does he use? What symptomatology? What words does he use? What do his gestures mean? What fear is being do his gestures mean? What fear is being expressed by the patient from Buganda when he expressed by the patient from Buganda when he complains of dizziness?”complains of dizziness?”

Prof Allan German (1972) in a forward to Orley’s book on “Culture and Prof Allan German (1972) in a forward to Orley’s book on “Culture and Mental Illness”Mental Illness”

Burden of Depression1Burden of Depression1  Depression is the fourth leading cause of burden of Depression is the fourth leading cause of burden of

disease in womendisease in women

Data from primary care studies across countries and Data from primary care studies across countries and cultures show gender ratio of female : male of 2:1 cultures show gender ratio of female : male of 2:1

In spite of this, there is a wide variation in prevalence In spite of this, there is a wide variation in prevalence rates of depression in women across countries and rates of depression in women across countries and culturescultures

The WHO study of depression in primary care found a 15 The WHO study of depression in primary care found a 15 fold variation in prevalence rate of current depressionfold variation in prevalence rate of current depression

e g e g Nagasaki (Japan) 2.8%, Ibadan (Nigeria) 3.8%, Nagasaki (Japan) 2.8%, Ibadan (Nigeria) 3.8%, Santiago (Chile) 36.8%; mean prevalence 12.5%Santiago (Chile) 36.8%; mean prevalence 12.5%

Burden due to Depression 2Burden due to Depression 2

A WHO primary health care study involving 14 A WHO primary health care study involving 14 countries found a mean prevalence of countries found a mean prevalence of depression in women of 12.5%, with lowest depression in women of 12.5%, with lowest rates of 2.8% in Nagasaki, 3.8% Ibadan, rates of 2.8% in Nagasaki, 3.8% Ibadan, Nigeria, Japan and highest rate of 36.8% in Nigeria, Japan and highest rate of 36.8% in Santiago Chile .Santiago Chile .

Burden of Depression 3Burden of Depression 3

Most of the women with depression in primary Most of the women with depression in primary care studies are not recognised, are not care studies are not recognised, are not diagnosed and miss out on appropriate diagnosed and miss out on appropriate treatmenttreatment

Untreated depression has serious Untreated depression has serious consequences for the health of the women, consequences for the health of the women, their families, their offspring.their families, their offspring.

Burden of Depression Burden of Depression 44

Depression in women is associates Depression in women is associates with marital dysfunction, marital with marital dysfunction, marital violence, divorces, death by violence, divorces, death by suicide, infanticide; developmental suicide, infanticide; developmental disorders and depression in disorders and depression in offspring, and inadequate offspring, and inadequate functioning ain all areas of lifefunctioning ain all areas of life

Burden of Depression Burden of Depression 55 If left untreated depression becomes a If left untreated depression becomes a

chronic recurrent disorder chronic recurrent disorder In a study in Ethiopia: depression In a study in Ethiopia: depression

increased standardized mortality (3 increased standardized mortality (3 times) times)

Depression in patients with physical Depression in patients with physical disease is responsible for poor disease is responsible for poor compliance to treatment and compliance to treatment and premature death premature death

The ProblemThe Problem

Although depression is a common and Although depression is a common and disabling disorder, it is poorly disabling disorder, it is poorly understood and is often unrecognised understood and is often unrecognised and untreated and untreated

The extent to which cultural factors The extent to which cultural factors influence the nature, the experience ,the influence the nature, the experience ,the extent, recognition and treatment of extent, recognition and treatment of depression remain to be resolved. depression remain to be resolved.

Historical Perspective 1Historical Perspective 1

In the pre-independence Africa,it was In the pre-independence Africa,it was generally accepted that Black Africans generally accepted that Black Africans rarely suffered from depression (Prince, rarely suffered from depression (Prince, 1968)1968)

According to Judaeo-Christian cultures, According to Judaeo-Christian cultures, mental disorder was part of the price paid mental disorder was part of the price paid for civilization, for being responsible and for for civilization, for being responsible and for opposing the devil and his works (German opposing the devil and his works (German 1987) and Rousseau ‘s idea ‘noble savage’ 1987) and Rousseau ‘s idea ‘noble savage’ prejudiced their views about the African.prejudiced their views about the African.

Historical Perspective 2Historical Perspective 2

Some believed that the brains of the black Some believed that the brains of the black

Africans were less developed; that Africans Africans were less developed; that Africans behaved in a childish manner, and that they behaved in a childish manner, and that they lacked a sense of responsibility (German, lacked a sense of responsibility (German, 1987)1987)

By implication, depression only occurred By implication, depression only occurred among the intellectually gifted.among the intellectually gifted.

Historical Perspective 3Historical Perspective 3

The African was irresponsible, therefore, he The African was irresponsible, therefore, he was devoid of a sense right and wrong and was devoid of a sense right and wrong and could not feel guilt.could not feel guilt.

It was further argued that suicide was rare in It was further argued that suicide was rare in Black Africans. Black Africans.

Historical Perspective 4Historical Perspective 4

From the 1960s, the story changed. Africans From the 1960s, the story changed. Africans were found to have high rates of depression. were found to have high rates of depression. It was argued that phenomenology of It was argued that phenomenology of depression in Black Africans was different depression in Black Africans was different from that of the Europeans and Americansfrom that of the Europeans and Americans

Historical Perspective 5Historical Perspective 5

It was claimed that depression in Black Africans It was claimed that depression in Black Africans manifested with numerous physical symptoms.manifested with numerous physical symptoms.

Depressed black Africans rarely showed feelings of Depressed black Africans rarely showed feelings of guilt , worthlessness and rarely committed guilt , worthlessness and rarely committed suicidesuicide

The issue of Language The issue of Language

German 1972: Reported on 50 Ugandan depressed German 1972: Reported on 50 Ugandan depressed patients. All of them presented with weakness, lack patients. All of them presented with weakness, lack of energy, , insomnia, anorexia, ; some presented of energy, , insomnia, anorexia, ; some presented with loss of sexual and social interests and signs of with loss of sexual and social interests and signs of psychomotor retardation.psychomotor retardation.

Regarding the language of presentation, German Regarding the language of presentation, German found two distinct groups of Ugandans:found two distinct groups of Ugandans:

Those with University and College Education – the Those with University and College Education – the acculturatedacculturated

The uneducated or lowly educated – the non-The uneducated or lowly educated – the non-acculturatedacculturated

Psychological IdiomPsychological Idiom

The acculturated spontaneously The acculturated spontaneously complained of being depressed. The complained of being depressed. The admitted to feeling ‘sad’ and admitted to feeling ‘sad’ and ‘unhappy’ when specifically asked. ‘unhappy’ when specifically asked. However they denied primary However they denied primary depressive illness. They were sad depressive illness. They were sad because they were ill. Only four because they were ill. Only four admitted to guilty worthless feelings. admitted to guilty worthless feelings. These were the acculturated group These were the acculturated group

Somatic idiomSomatic idiom

The acculturated almost invariably The acculturated almost invariably complained of weakness and feeling complained of weakness and feeling ill.ill.

Subsequenty, Muhangi and German Subsequenty, Muhangi and German were to argue that Ugandan patients were to argue that Ugandan patients lacked the words and phrases to lacked the words and phrases to communicate psychiatric symptoms communicate psychiatric symptoms (Muhangi and German,1975) (Muhangi and German,1975)

No Guilt, No SuicideNo Guilt, No Suicide

In summary: German concurred with In summary: German concurred with other expatriate psychiatrists, that other expatriate psychiatrists, that depressed Ugandan rarely felt a sense depressed Ugandan rarely felt a sense of guilt or worthlessness; that suicide of guilt or worthlessness; that suicide was rare.was rare.

And yet The rate of suicide in Busoga And yet The rate of suicide in Busoga Uganda, was reported to be 8.5 per Uganda, was reported to be 8.5 per 100,000 population at risk (Fallars 100,000 population at risk (Fallars and Fallars, 1960), similar to rate in and Fallars, 1960), similar to rate in England (German 1987). In England (German 1987). In

Phenomenology of Phenomenology of DepressionDepressionHowever, the facts on the ground were However, the facts on the ground were

different.different.

In a seminal study Orley determined the In a seminal study Orley determined the psychiatric morbidity of the adult population psychiatric morbidity of the adult population in Kyadondo. He found that 22.6% of women in Kyadondo. He found that 22.6% of women suffered from depression compared to 9.3% of suffered from depression compared to 9.3% of women from London. More importantly he women from London. More importantly he found that the depressed Ugandan were four found that the depressed Ugandan were four times more likely than the subjects in London times more likely than the subjects in London to admit pathological guilt (Orley and Wing to admit pathological guilt (Orley and Wing 1979). 1979).

What had changed?What had changed?

Orley, a psychiatrist and a trained Orley, a psychiatrist and a trained anthropologist applied a semi anthropologist applied a semi structured psychiatric interview, used structured psychiatric interview, used supplementary information, supplementary information, understood the local languageunderstood the local language

It was now clear that culturally sensitive It was now clear that culturally sensitive methods must be applied in all cross-methods must be applied in all cross-cultural studies. cultural studies.

Orley 1979Orley 1979

The myth that guilt was only The myth that guilt was only among the privileged, highly among the privileged, highly individualistic and brought to individualistic and brought to belief in personal responsibility belief in personal responsibility was challenged by Orley’s was challenged by Orley’s findings findings

Explanatory models of Explanatory models of DepressionDepression

In fact, subsequent research and In fact, subsequent research and discourse on depression, reflected discourse on depression, reflected the views expressed of local people.the views expressed of local people.

A new cross- cultural psychiatry was A new cross- cultural psychiatry was developed in which emphasis was on developed in which emphasis was on the local understanding of illness and the local understanding of illness and a culturally relevant phenomenolgy a culturally relevant phenomenolgy (Kleinman 1987, Patel 2001) (Kleinman 1987, Patel 2001)

Local idioms of Local idioms of DistressDistressSometimes the experience of depressive Sometimes the experience of depressive

illness can be ‘incoate and ineffable’illness can be ‘incoate and ineffable’Therefore translation of personal Therefore translation of personal

experience into symptoms is very difficultexperience into symptoms is very difficultEven when professionals and lay people Even when professionals and lay people

use the same words and expressions may use the same words and expressions may not share the same meaning.not share the same meaning.

However, the language rendering of However, the language rendering of

psychopathology is key to accurate psychopathology is key to accurate clinical assessment, diagnosis and clinical assessment, diagnosis and treatmenttreatment

Idioms of DistressIdioms of Distress

We should remember that professional We should remember that professional language is defined by commissions or language is defined by commissions or committees of experts. These change committees of experts. These change from time to time when new knowledge from time to time when new knowledge and understanding has accumulated and understanding has accumulated

It the duty and responsibility of clinicians It the duty and responsibility of clinicians to acquaint themselves with lay to acquaint themselves with lay language, lay terminology for language, lay terminology for psychological problems and distress psychological problems and distress

Epidemiology: 1 Cultural Epidemiology: 1 Cultural Influences on DepressionInfluences on Depression

Rate of depression in women varies widely Rate of depression in women varies widely between countries and ethnic groups.between countries and ethnic groups.

Eg Maori compared to non-Maori (MaGIPIe Eg Maori compared to non-Maori (MaGIPIe Research Group (2005)Research Group (2005)

Tongan women more than Samoans (Abbott Tongan women more than Samoans (Abbott et al 2006)et al 2006)

USA > Israel > Japan (Froom et al 1995)USA > Israel > Japan (Froom et al 1995)

South America > Europe and Africa > South America > Europe and Africa > Asia/Japan (WHO, Ustun and Sartorius, Asia/Japan (WHO, Ustun and Sartorius, 1995)1995)

Risk Factors for Depression 1Risk Factors for Depression 1

Depression is a consequence of interaction of Depression is a consequence of interaction of multiple factors including multiple factors including

1 biological factors: depressive symptoms are 1 biological factors: depressive symptoms are increase around menstruation and after childbirthincrease around menstruation and after childbirth

2 Psychosocial: a) in some cultures failure to give 2 Psychosocial: a) in some cultures failure to give birth to a male child is associated with depressive birth to a male child is associated with depressive illnessillness

b) Marais et al in a primary care study in South b) Marais et al in a primary care study in South Africa: found high rate of depression in women Africa: found high rate of depression in women who reported marital violence compared to women who reported marital violence compared to women who did not report marital violence who did not report marital violence

Risk factors 2Risk factors 2

There is a link between reproductive There is a link between reproductive processes and depression. This may processes and depression. This may partly responsible for preponderance partly responsible for preponderance of depression in womenof depression in women

There are two peaks depression in There are two peaks depression in women. In late pregnancy and at women. In late pregnancy and at around 5 years after childbirth. around 5 years after childbirth. However, there are new episodes of However, there are new episodes of depression within two to six weeks depression within two to six weeks after childbirth. after childbirth.

Risk Factors 3Risk Factors 3

Women are more vulnerable to a Women are more vulnerable to a wide range of adverse conditions wide range of adverse conditions and situation:and situation:

poor relationship with significant poor relationship with significant others, poor relationship with others, poor relationship with mother, mother-in-law. mother, mother-in-law. Inadequate material and Inadequate material and emotional support. emotional support.

Culture and postnatal Culture and postnatal depressiondepression

Postnatal depression has been found Postnatal depression has been found in all cultures, including in cultures in all cultures, including in cultures that have preserved rituals and that have preserved rituals and customs surrounding birth.customs surrounding birth.

Contrary to the views of some Contrary to the views of some anthropologists in Asia, Kenya, anthropologists in Asia, Kenya, cultural practices do not protect cultural practices do not protect women from postnatal depressionwomen from postnatal depression

Depression and Depression and MotherhoodMotherhood

The burden of childrearing is The burden of childrearing is associated with increased risk of associated with increased risk of depression (Najman et al depression (Najman et al Muhwezi et al, 2007).Muhwezi et al, 2007).

This is the explanation for a peak This is the explanation for a peak prevalence of depression in prevalence of depression in mothers.mothers.

Protective FactorsProtective Factors

Women who accept traditional roles: as Women who accept traditional roles: as mothers, as careersmothers, as careers

Women who enjoy employment outside Women who enjoy employment outside the home.the home.

Women who are respected in the Women who are respected in the community, whose opinions are community, whose opinions are respectedrespected

Women who enjoy material and Women who enjoy material and emotional support emotional support

Case study 1Case study 1

Cheng and Hsu 1983: measured the risk of psychiatric Cheng and Hsu 1983: measured the risk of psychiatric disorders among women from three different family disorders among women from three different family structures in Taiwan:structures in Taiwan:

PatrilinealPatrilinealMatrilinealMatrilinealAnd mixedAnd mixedThe prevalence of psychiatric morbidity was lower in The prevalence of psychiatric morbidity was lower in

the communities which had preserved the the communities which had preserved the traditional social roles and responsibilities of traditional social roles and responsibilities of women in matrilineal culture. For the women in women in matrilineal culture. For the women in communities which had transformed from the communities which had transformed from the matrilineal to the patrilineal social roles, the women matrilineal to the patrilineal social roles, the women were more vulnerable to psychiatric morbidity. were more vulnerable to psychiatric morbidity.

Case study 2Case study 2

Carstairs 1979Carstairs 1979Studied the prevalence of depression among Studied the prevalence of depression among

the ethnic groups in Southern India, the the ethnic groups in Southern India, the Brahmins (prosperous), the Bants Brahmins (prosperous), the Bants (farmers) and the Mogers (farmers) and the Mogers (underprevilaged fishermen).(underprevilaged fishermen).

The Bants and Mogers previously follwed the The Bants and Mogers previously follwed the matrilineal system of family location and matrilineal system of family location and inheritance. At the time of Carstairs study, inheritance. At the time of Carstairs study, the Bants and Mogers had largely adopted the Bants and Mogers had largely adopted the patriarchal system. the patriarchal system.

Case study 2 cont’d Case study 2 cont’d

Case rateCase rate Brahmins Brahmins (%)(%)

Bants Bants (%)(%)

Mogers Mogers (%)(%)

MalesMales 2929 3939 3232

FemalesFemales 3333 4343 4242

Case Study 2 cont’dCase Study 2 cont’dResidence pattern and case rates among Residence pattern and case rates among

formerly matrilineal spousesformerly matrilineal spouses

CasesCases Traditional Traditional residenceresidence

Changed Changed residenceresidence

MalesMales 113 (32%)113 (32%) 93 (38%)93 (38%)

Females Females 222 (36%)222 (36%) 115 (55%)115 (55%)

HypothesisHypothesis

Women who enjoy high status and self Women who enjoy high status and self esteem, women who show a positive esteem, women who show a positive attitude to motherhood and women attitude to motherhood and women who accept the traditional roles are who accept the traditional roles are less vulnerable to depressionless vulnerable to depression

The cultures which respect the role of The cultures which respect the role of women and provide opportunities for women and provide opportunities for personal development are less personal development are less vulnerable to depression vulnerable to depression

Objectives Objectives The objectives were The objectives were

a)a) to explore the lexica of emotion, cultural idioms and to explore the lexica of emotion, cultural idioms and metaphors of distress in selected lay people in Uganda metaphors of distress in selected lay people in Uganda Malawi Malawi

b)b) to validate the Tumbuka, Chichewa and Luganda to validate the Tumbuka, Chichewa and Luganda versions of Edinburgh Depression Scale (EDS) and versions of Edinburgh Depression Scale (EDS) and General Health Questionnaire (GHQ 12) and General Health Questionnaire (GHQ 12) and

c)c) to determine and compare the prevalence of to determine and compare the prevalence of depression in women attending primary health care depression in women attending primary health care facilities in Mzuzu, northern Malawi (patlineal culture) facilities in Mzuzu, northern Malawi (patlineal culture) and Wakiso Uganda (patrilineal culture), Mulanje, and Wakiso Uganda (patrilineal culture), Mulanje, southern Malawi (matrilineal culture) To determine the southern Malawi (matrilineal culture) To determine the local concepts and lexica of depression and idioms of local concepts and lexica of depression and idioms of psychological distress among informants from Malawi psychological distress among informants from Malawi and Uganda yand Uganda y

DefinitionsDefinitions

CultureCulture Culture: meanings, values, and behavioural norms , Culture: meanings, values, and behavioural norms ,

that are learned and transmitted in the dominant that are learned and transmitted in the dominant society and within its social groups. society and within its social groups.

Culture influences cognition, feelings and self-concepts Culture influences cognition, feelings and self-concepts as well as the diagnostic process and treatmentas well as the diagnostic process and treatment

Culture influences: experience, clinical presentation, Culture influences: experience, clinical presentation, decisions about treatmentdecisions about treatment

DefinitionDefinition

Depressive DisordersDepressive Disorders

-Major Depressive Disorder : criteria A of DSM IV-Major Depressive Disorder : criteria A of DSM IV

-Subthreshold disorder: symptoms count 3-4 and 2-4 symptoms.-Subthreshold disorder: symptoms count 3-4 and 2-4 symptoms.

Note: did not apply the clinical significance criteria (See MADRS)Note: did not apply the clinical significance criteria (See MADRS)

(Bolton et al, 2004; Gouldney et al 2004; Williams et al 2002)(Bolton et al, 2004; Gouldney et al 2004; Williams et al 2002)

Methods:Methods:

Comparative cross –sectional Comparative cross –sectional surveyssurveys

Used mixed methods: qualitative Used mixed methods: qualitative and quantitative and quantitative

METHODOLOGYMETHODOLOGY

Study SiteStudy SiteMalawiMalawi Matrilineal site: Mulanje Hospital Out-patient Matrilineal site: Mulanje Hospital Out-patient

ClinicClinic Patrilineal site: Mapale Health Centre in Mzuzu Patrilineal site: Mapale Health Centre in Mzuzu Uganda Uganda Patrilineal Sites: Patrilineal Sites: Wakiso Health CentreWakiso Health Centre Entebbe Hospital Out-Patient ClinicEntebbe Hospital Out-Patient Clinic

Local LexiconLocal Lexicon

Qualitative Interviews of key informants in three Qualitative Interviews of key informants in three languages: Chichewa, Tumbuka, Lugandalanguages: Chichewa, Tumbuka, Luganda

Convenient sample Convenient sample Listing and sorting: the K I were asked to list words, Listing and sorting: the K I were asked to list words,

expressions and metaphors used in each language expressions and metaphors used in each language to express or describe emotions and feelings that to express or describe emotions and feelings that arise in the following context a) after the death of a arise in the following context a) after the death of a loved one b) after loss of a valued object c) after loved one b) after loss of a valued object c) after discovery that a spouse was unfaithful d) if one was discovery that a spouse was unfaithful d) if one was to win a thousand dollars e) if one’s marriage has to win a thousand dollars e) if one’s marriage has ended. The lists of the words generated were sorted ended. The lists of the words generated were sorted with the help of mental health care workers to with the help of mental health care workers to identify the words, phrases and metaphors used by identify the words, phrases and metaphors used by patients with depression. patients with depression.

ResultsResults

Data was obtained from 127 key Data was obtained from 127 key informants in Chichewa, 40 KI in informants in Chichewa, 40 KI in Luganda and 106 KI in TumbukaLuganda and 106 KI in Tumbuka

Chichewa LesionChichewa Lesion

Key word/ relative Key word/ relative frequencyfrequency

English EquivalentEnglish Equivalent

Kusauka mtima 30Kusauka mtima 30 Guilt consciousGuilt conscious

Ndikusauka nazo mu mtima Ndikusauka nazo mu mtima 2929

Unsettled in the mind; Unsettled in the mind; heartacheheartache

Ndivutika nazo maganizo 28Ndivutika nazo maganizo 28 To be troubled in the mind; To be troubled in the mind; to think alotto think alot

Nkhawa (kudandaula) 24Nkhawa (kudandaula) 24 Worry, anxietyWorry, anxiety

Kukhumudwa 22Kukhumudwa 22 depresseddepressed

ChisoniChisoni Grief, pityGrief, pity

Chikumbumtima 13Chikumbumtima 13 guiltyguilty

Maganizo otaya mtima 20Maganizo otaya mtima 20 Feeling hopeless and Feeling hopeless and suicidalsuicidal

Luganda LexiconLuganda Lexicon

Key word/ relative Key word/ relative frequencyfrequency

English equivalentEnglish equivalent

Okukaaba 44Okukaaba 44 To cryTo cry

Okweyawula 44Okweyawula 44 To isolate oneselfTo isolate oneself

Okunakuwala 44Okunakuwala 44 To be sadTo be sad

Okwekubagiza 44Okwekubagiza 44 To feel sorry or sad for To feel sorry or sad for oneself; self-pityoneself; self-pity

Okweralikirira 42Okweralikirira 42 To worryTo worry

Enyiike 41Enyiike 41 AngstAngst

Okulowooza 39Okulowooza 39 To think alotTo think alot

Okwenyamira 38Okwenyamira 38 To cause to be sadTo cause to be sad

Okwejjusa 34Okwejjusa 34 To regretTo regret

Tumbuka LexiconTumbuka Lexicon

Key words/relative Key words/relative frequencyfrequency

English equivalentEnglish equivalent

Kusweka mtima 16Kusweka mtima 16 Broken heartBroken heart

Kuwa na chitima 13Kuwa na chitima 13 Sad, depressedSad, depressed

Kugongowa chitima 13 Kugongowa chitima 13 Become very sad and Become very sad and hopelesshopeless

Kudandaula 11Kudandaula 11 worriedworried

Kuwa maghanoghano 9Kuwa maghanoghano 9 To have too many To have too many thoughtsthoughts

Mtima ukuwawa 7Mtima ukuwawa 7 Broken heartBroken heart

Wakusugzika m’mtimaWakusugzika m’mtima In problemsIn problems

Wakuoneka wakusuzgika Wakuoneka wakusuzgika 22

To look troubledTo look troubled

Wakuba na nthumazi 2Wakuba na nthumazi 2 Feel guiltyFeel guilty

Discussion 1Discussion 1

Our results are consistent with those of Our results are consistent with those of Bolton et al (2004) e g the key words Bolton et al (2004) e g the key words okwekyawa, okwetamwa, okwekyawa, okwetamwa, okwekubagiza were identified as okwekubagiza were identified as equivalent expressions for depressionequivalent expressions for depression

Our results contradict views expressed Our results contradict views expressed by Prince, 1968; German, 1972, 1979. by Prince, 1968; German, 1972, 1979. Local people have the vocabulary for Local people have the vocabulary for emotionsemotions

ImplicationsImplications

Lay people are able to describe in detail Lay people are able to describe in detail psychological manifestations of psychological manifestations of depression and anxiety if they are given depression and anxiety if they are given time and opportunity to do so (Tomlinson time and opportunity to do so (Tomlinson et al 2007; Halbreich et al, 2007) et al 2007; Halbreich et al, 2007)

Health care professionals must acquire Health care professionals must acquire adequate knowledge of folk concepts and adequate knowledge of folk concepts and expressions of distressexpressions of distress

Psychiatric assessment should be culturally Psychiatric assessment should be culturally sensitivesensitive

ConclusionConclusion

The lay people in Malawi and Uganda The lay people in Malawi and Uganda have a rich vocabulary of emotional have a rich vocabulary of emotional words and phrases that accurately words and phrases that accurately describe the experience of depressiondescribe the experience of depression

Giving the patients opportunity to narrate Giving the patients opportunity to narrate their experience of distress is a more their experience of distress is a more appropriate method of eliciting appropriate method of eliciting psychopathology of depression.psychopathology of depression.

Having vocabulary for discrete symptoms Having vocabulary for discrete symptoms of depression is a necessary but not a of depression is a necessary but not a sufficient condition for recognition of sufficient condition for recognition of depressive syndromesdepressive syndromes

Quantitative Survey Quantitative Survey

SampleSample

Adult women, 18 – 65 years old Adult women, 18 – 65 years old (systematically selected samples: Mulanje (systematically selected samples: Mulanje 200, Mzuzu 211, Wakiso 213)200, Mzuzu 211, Wakiso 213)

Sample size determinationSample size determinationPower calculation for comparison of means: Power calculation for comparison of means:

an alpha of 5%, expected difference of an alpha of 5%, expected difference of 10% between highest and lowest expected 10% between highest and lowest expected prevalence (10- 20%) and at power of prevalence (10- 20%) and at power of 80%:80%:

Screening Screening

The study subjects were initially The study subjects were initially screened for depressive symptoms screened for depressive symptoms and psychological distress and psychological distress respectively, by translated versions respectively, by translated versions of Edinburgh depression Scale (EDS) of Edinburgh depression Scale (EDS) and General Health Questionnaire and General Health Questionnaire (GHQ 12) in Tumbuka (north Malawi) (GHQ 12) in Tumbuka (north Malawi) Chichewa (south Malawi ) and Chichewa (south Malawi ) and Luganda (Wakiso, Uganda). Luganda (Wakiso, Uganda).

Ethical Considerations Ethical Considerations

The study was approved in Malawi The study was approved in Malawi and Uganda.and Uganda.

Informed consent was obtained Informed consent was obtained from all participants from all participants

Psychiatric InterviewPsychiatric Interview

Most of the subjects who scored at and Most of the subjects who scored at and above threshold and 20% of those above threshold and 20% of those who scored below threshold were who scored below threshold were interviewed using the MINI interviewed using the MINI International Neuropsychaitric International Neuropsychaitric Interview (MINI) to identified those Interview (MINI) to identified those with depressive disorder. The intensity with depressive disorder. The intensity of depressive disorder was determined of depressive disorder was determined using the Montgomery –Asberg using the Montgomery –Asberg Depression Rating Scale (MADRS). Depression Rating Scale (MADRS).

Analysis of DataAnalysis of Data

The SSPS programme version 11 was The SSPS programme version 11 was used to calculate validity indices for used to calculate validity indices for EDS and GHQ 12 and the prevalence EDS and GHQ 12 and the prevalence rates were calculated using the STATA rates were calculated using the STATA programs. Relationship between programs. Relationship between depressive symptoms and depressive depressive symptoms and depressive disorder and socio-demographic and disorder and socio-demographic and cultural factors was explored by cultural factors was explored by bivariate and logistic regression bivariate and logistic regression

RESULTS RESULTS

Data was collected from 200 Data was collected from 200 women at Mulanje, 209 women women at Mulanje, 209 women from Mzuzu and 209 women from from Mzuzu and 209 women from Wakiso. Wakiso.

RESULTS 1RESULTS 1

Depressive symptoms Depressive symptoms

Mulanje38%, Mulanje38%,

Mzuzu 60.3%Mzuzu 60.3%

Wakiso, 45.2%. Wakiso, 45.2%.

Rates of Depressive DisordersRates of Depressive Disorders

Prevalence of depressionPrevalence of depression

Wakiso 27.8%Wakiso 27.8%

Mzuzu 16.6%Mzuzu 16.6%

Mulanje (9.9%) .Mulanje (9.9%) .

Factors Associated with Factors Associated with DepressionDepression

The main factors associated with depressive The main factors associated with depressive illnessillness

coercive sex (for women in Mulanje, and coercive sex (for women in Mulanje, and Mzuzu)Mzuzu)

debt burden and marital conflict for women in debt burden and marital conflict for women in Mzuzu Mzuzu

and domineering spouse for women in and domineering spouse for women in Wakiso) Wakiso)

Discussion1Discussion1

The lay people have rich language The lay people have rich language for expression of distress.for expression of distress.

Clinicians need adequate Clinicians need adequate understanding of local cultures.understanding of local cultures.

Discussion 2Discussion 2

In Luganda- there were more key In Luganda- there were more key words for the cognitive words for the cognitive expression of distress e g to be expression of distress e g to be fed up (okwetamwa), to be fed up (okwetamwa), to be disgusted with self (okwekyawa), disgusted with self (okwekyawa), regret (okwejjusa), self pity regret (okwejjusa), self pity (okwekubagiza)(okwekubagiza)

Discussion 3Discussion 3

Depression in Malawi women linked to Depression in Malawi women linked to the social role and social status of the social role and social status of womenwomen

Matrilineal women have the most Matrilineal women have the most unstable marriages. Divorce is easy. unstable marriages. Divorce is easy. Remarriage is equally easy.Remarriage is equally easy.

In spite of more poverty among In spite of more poverty among Mulanje women they have lowest Mulanje women they have lowest rates of major depressionrates of major depression

Discussion 4Discussion 4

The women in the patrilineal The women in the patrilineal malawi are constrained by malawi are constrained by difficulty of securing divorce. difficulty of securing divorce. They relatives are unlikely to They relatives are unlikely to condon divorce because they may condon divorce because they may not be able or willing to refund not be able or willing to refund the bride price. dowrythe bride price. dowry

Discussion 5Discussion 5

There was no difference in the level of There was no difference in the level of instability of marriage in Wakiso instability of marriage in Wakiso women in Mulanje.Yet, the women in women in Mulanje.Yet, the women in Uganda have more severe depressive Uganda have more severe depressive illness.illness.

It is likely that the Mulanje women It is likely that the Mulanje women have more access to support. have more access to support.

Single parenthood and divorce are not Single parenthood and divorce are not a source of stigma. a source of stigma.

Discussion 6Discussion 6

The burden of depression is higher in the The burden of depression is higher in the patrilineal womenpatrilineal women

The rates however are comparable to the The rates however are comparable to the rates of depression in other centres in Africa. rates of depression in other centres in Africa. South Africa 40.5% (Carey et al 2003)South Africa 40.5% (Carey et al 2003)

The research in Tanzania found severe The research in Tanzania found severe depression in 2.2% of primary care depression in 2.2% of primary care attenders. More that 17% had either mild attenders. More that 17% had either mild depression or anxiety and depression depression or anxiety and depression (Ngoma et al, 2003) (Ngoma et al, 2003)

Discussion 7Discussion 7

It was suggested that women in It was suggested that women in Tanzania have, through NGOs Tanzania have, through NGOs been economically empowered.been economically empowered.

LimitationsLimitations

The study was limited to a few The study was limited to a few sites. The results cannot be sites. The results cannot be generalised to the rest of the generalised to the rest of the countries countries

The samples were not randomly The samples were not randomly selected selected

Strength of the StudyStrength of the Study

It was a compararative study It was a compararative study

It address almost homogenous It address almost homogenous groups – less variation was groups – less variation was expected in the local area expected in the local area

The results are within the range of The results are within the range of studies with similar socio-studies with similar socio-economic conditionseconomic conditions

Conclusion1Conclusion1

There are wide variations in the There are wide variations in the rates of depression among rates of depression among Malawian and Ugandan women.Malawian and Ugandan women.

The role of culture remains unclear.The role of culture remains unclear.

Psychosocial factors which may be Psychosocial factors which may be cultural basis are more cultural basis are more significantly associated with significantly associated with depression. depression.

Conclusison 2Conclusison 2

The research instruments The research instruments developed in western cultures can developed in western cultures can be adopted for use in African be adopted for use in African settings settings

The must be attention to local The must be attention to local idioms of distress and the idioms of distress and the explanatory models explanatory models

IMPLICATIONSIMPLICATIONS

Implications for Policy and serviceImplications for Policy and service: :

There is need for strategies to address the high There is need for strategies to address the high levels of depression at primary care level.levels of depression at primary care level.

There is need for further studies in different There is need for further studies in different cultural groups cultural groups

Health care workers need training in skills to Health care workers need training in skills to manage marital and sexual violence among manage marital and sexual violence among patients who seek care at primary care patients who seek care at primary care facilities.facilities.

Recommendation1Recommendation1

Glossaries of local idioms of distress and Glossaries of local idioms of distress and psychological terms should be psychological terms should be developedy. developedy.

Strategies for increasing public awareness Strategies for increasing public awareness and to create demand for mental health and to create demand for mental health care service should be considers. care service should be considers.

Lastly, all curricular for health care Lastly, all curricular for health care providers should include gender and providers should include gender and mental health.mental health.

AcknowledgementsAcknowledgements

This work was part of my Ph D research This work was part of my Ph D research I wish to acknowledge SIDA/SAREC and School of I wish to acknowledge SIDA/SAREC and School of

Graduate Studies, Makerere University for the Graduate Studies, Makerere University for the support they providedsupport they provided

I wish also to acknowledge my supervisors: I wish also to acknowledge my supervisors: Prof Hans Agren, formerly of Karolinska Institutet, Prof Hans Agren, formerly of Karolinska Institutet,

Dr Stella Neema and Dr Seggane Musisi of Dr Stella Neema and Dr Seggane Musisi of Makerere UniversityMakerere University

College of Medicine, University of MalawiCollege of Medicine, University of MalawiSt John of God Community Mental Services, MalawiSt John of God Community Mental Services, Malawi

Dr Joshua Tugumisirize, Dr Joshua Tugumisirize, Formally at Department of Formally at Department of

Psychiatry, Makerere College Psychiatry, Makerere College of Health Scienceof Health Science

jtugumisirize@yahoo.com jtugumisirize@yahoo.com Phone: 0772929741Phone: 0772929741