Depressive disorders
There are many forms of depressive disorders, including major depressive disorder and postpartum depression. The common feature of all of these disorders is the presence of a sad or irritable mood, which is accompanied by somatic and cognitive changes that significantly affect the individual's capacity to function. The types of depressive disorders differ in terms of the duration, timing and associated factors.
The most common symptoms of depressive disorders include:
-
Depressed mood or hopelessness most of the day
-
Decreased interest or pleasure in most activities
-
Significant weight change or change in appetite
-
Change in sleep patterns
-
Fatigue or loss of energy
-
Feelings of guilt/worthlessness
-
Diminished ability to think or concentrate
-
Thoughts of suicide
When considering signs or symptoms of depression, it may be helpful to keep in mind the possibility of manifestations through cultural idioms. The chart below outlines some common cultural idioms associated with depression as identified by the American Psychiatric Association's DSM-5. Of course, these somatic complaints are not universal to clients identifying with the ethnic groups noted; they are presented simply as examples.
-
Culture
Somatic complaints
-
Chinese and Asian:
Weakness, tiredness, “imbalance”
-
Latino and Mediterranean:
“Nerves,” headaches
-
Middle Eastern:
Problems of the “heart”
Some cultural groups report higher rates of somatic symptoms than others, leading to discussion on whether North American or European-trained psychiatrists may miss diagnoses in groups less likely to report more classic symptoms of depression. It is important to keep in mind that the symptoms of depression can be quite variable. Although sadness may be clearly present, the possibility of depression should be considered when there is a change an individual's level of functioning for no apparent reason.
Rates: Similarities and differences
Rates of reported depression differ widely across countries and ethnocultural groups. The rate of depression in an individual's country of origin is not a reliable predictor of whether an immigrant will suffer from depression in the host country. Rates vary significantly among immigrant groups. Immigrants generally have lower rates of depression than the general population; however, with a longer stay in Canada, the rate tends to match that of the general population.
Refugees have higher rates of depression compared to the general population, although this can depend on the specific refugee group in question (Turrini et al., 2017; Blackmore et al., 2020).
Assessment
Conventional approaches to screening for and treatment of depression are effective for different ethnocultural groups, although these screening tools should be conducted in the language that the client is most comfortable with (Kirmayer et al., 2011b). It is important to keep in mind that “cultural variations in symptom presentation, ways of coping and the stigma” associated with depression can complicate screening (Ibid., p.7).
The Patient Health Questionnaire, a commonly used screening tool for depression in primary care, is particularly useful for working with immigrants and refugees because it is available in multiple languages.
See a sample of the questionnaire.
After a positive screen, physicians should conduct a clinical assessment.
The best approach to screening for depressive disorders in newcomers is a comprehensive assessment that incorporates information on broader factors, such as the client's cultural, social, familial and community situation. The following tools may be helpful:
- DSM-5 Cultural Formulation Interview (CFI): Used to help clinicians think about culture when doing a full assessment and treatment plan; not to be used as a diagnostic tool (American Psychiatric Association, 2013).
- General Health Questionnaire (GHQ-12) (Goldberg & Hillier, 1979): Has been used in many different cultures; cross-cultural validation shows the different cut-off points for the prediction of depression (Goldberg, User's guide to the General Health Questionnaire, 1988) (Werneke, Goldberg, Yalcin, & Üstün, 2000) (G, Bonetto, Van Bortel, & Brayne, 2020) (El-Metwally, et al., 2018).