Acta Psychiatr Scand 2006: 113: (Suppl. 429): 17–23 All rights reserved
Copyright © 2006 Blackwell Munksgaard
ACTA PSYCHIATRICA SCANDINAVICA
Objective: International studies have shown that the outcome of illnesses like schizophrenia vary across cultures. The good outcome in developing countries depends upon a number of factors.
Method: Using both primary and secondary sources, existing literature was reviewed. Using terms severe mental illness, culture and schizophrenia, Medline, Psychinfo and Embase were searched. Further searches were conducted using secondary searches.
Results: The impact of culture and its components on the individual and their families inﬂuences compliance, engagement with services and expectations of treatment. Cultures also impact upon identity and explanatory models of individuals.
Conclusion: Severe mental illness is as likely to be aﬀected by culture as other illnesses. Clinicians need to use multi-model assessment and management techniques.
HSRD, Institute of Psychiatry, De Crespigny Park, London, UK
Dinesh Bhugra, PO Box 25, HSRD, Institute of Psychiatry, De Crespigny Park, London SE5 5AF, UK.
This paper was read in a preliminary version at the 3rd International Zurich Conference on Clinical and Social Psychiatry, Zurich, September 25–27, 2003. The con- ference and publication of this supplement were exclusively sponsored by Eli Lilly, Suisse.
A proportion of patients with psychiatric illnesses are likely to become chronic. The chronicity of illness implies that there may be a risk of relapse over a long time or that the illness may continue with varying levels of psychopathology and, within this setup, acute exacerbations may occur in response to stressors. This exacerbation may well be related to partial or incomplete treatment. In addition, with chronic severe mental illness, denial and disability may occur.
The biological model indicates that the chronic disease is a result of biological vulnerability. Making the correct diagnosis as a result of thor- ough assessment is helpful in setting up the management. However, it must be emphasized that diagnosis itself must be seen in the context of culture at a broader level and individual and family needs at a personal level. This allows the clinicians to be aware of the interaction of culture in generating or protecting the individual pathology.
The disability following a severe mental illness may be primary, i.e. resulting from continuation of symptoms or ongoing deﬁcits in cognitive processes because of the illness, secondary, because of lack of motivation or demoralization because of persistence of symptoms and/or tertiary, because of social rejection or stigma as a result of exhibiting illness-related behaviours (1).
Culture is best deﬁned as a common heritage or set of beliefs, norms and values (2), which are shared among a large group of people. Culture refers to these attributes as shared meanings, which can be acquired at diﬀerent levels through diﬀerent methods of learning, e.g. from child rearing, peers, schools, other institutions.
The role of culture in helping clinicians reached diagnoses and setup management plans is para- mount (3).
This becomes even more urgent if patient and a clinician came from diﬀerent cultural backgrounds. Culture needs to be diﬀerentiated from ethnicity, which refers to a common heritage (including similar history, language and beliefs; (4) but it is also self- ascribed. Culture can be ﬂuid whereas ethnicity or ethnic identity is more likely to remain the same. In contrast, race overlaps with ethnicity but has a very social meaning (1) and also has a biological compo- nent. Culture structures the way people deﬁne what is abnormal and deviant, how illness is deﬁned and how and where help is sought, as it is the culture that determines what resources are available for managing what kind of distress. The understanding of culture allows us to identify the precise role culture may play in individual’s lifespan of illness. For example, culture can precipitate illness, con- tinue to deﬁne something as abnormal thereby perpetuating it, may act as the protector by provi- ding structures which allow the individual to deal with the distress. Tseng (5) has highlighted functions of culture as pathogenic, pathoplastic, pathoselec- tive, pathoelaborating pathofacilitative and patho- reactive. Each type of impact has diﬀerent implications for the individual.
Aims of this study
The variation in rates of chronic severe mental illness across diﬀerent ethnic groups and cultures is of great interest to both clinicians and researchers. The present paper describes some of the ﬁndings across diﬀerent cultures.
Material and methods
Using key words culture, chronic mental illness, severe mental illness, schizophrenia and chronic depression, literature searches were carried out in major data bases such as Embase, Medline, Psy- chinfo and subsequent searches were secondary to trace all papers in English which fulﬁlled these criteria. The present paper provides a selective review, as not enough information could be gath- ered using these strategies.
Several epidemiological studies, which have inclu- ded several cultures, nations and societies demon- strated that rates of psychiatric disorders vary across cultures.
The concept of chronic severe mental illness is generally employed to denote chronic schizophre- nia or bipolar disorders. However, there are major methodological problems in outcome research. These include varying periods of follow-up, vary- ing methods of patient selection, varying consider- ations given to (or completely ignored) mediating cultural and social factors, economic conditions, employment, social support available and varying follow-up strategies.
Bearing in mind the problems in deﬁning schizo- phrenia in early studies, the epidemiological and follow-up studies have to be seen in that context. The concept of schizophrenia is Western European
and has raised several problems in diagnoses in other cultures.
The symptoms of disinhibition will vary in hypomania according to cultures. The data on chronicity of bipolar disorders across cultures are not robust enough to draw any ﬁrm conclusions.
There are some clear factors in identifying risk factors. For example, males develop schizophrenia at a slightly earlier age when compared with females. In the International Pilot study of Schi- zophrenia (6) and Determinants of Outcome of Severe Mental Disorders (7), it emerged that the rates of narrow deﬁnition schizophrenia were broadly similar across nations but broader deﬁni- tion schizophrenia varied nearly twofold. The incident rates in the second study (7) were identi- ﬁed by including patients who contacted any help giving agency for the ﬁrst time ever in their lifetime. They were then interviewed by trained researchers using standardized instruments and pathways of care were determined. Both clinical and research diagnoses were used and incidence rates obtained. Narrow deﬁnition schizophrenia, which corresponds very closely with Schneiderian ﬁrst rank symptoms showed no diﬀerence across diﬀerent centres.
However, in spite of the variation in broad category schizophrenia, no consistent diﬀerences were reported between cases meeting the broad category only and those with narrow deﬁnition in either the course or outcome or onset of the illness. However, Cohen (8) has very cogently argued that the researcher’s focus on narrow deﬁnition of schizophrenia and ignoring broad deﬁnitions does not deal with the relativist position of symptoms.
In 2-year follow-up data, Jablensky et al. (7) observed that in developed countries 39.8% had severe outcome compared with 24% in developing countries. Thus, sociocultural setting, i.e. develop- ing or developed country, was the best predictor of 2- and 5-year outcome in both WHO studies (6, 7). These short-term diﬀerences may indicate more family support, less expressed emotion, low stigma to mental illness or some other mediating factors. However, it is also likely that prevalence of diﬀerent symptoms may well vary. Acute transient psychoses are more likely in developing countries, which may also be related to organic infective factors, which will have better outcome. It is also entirely possible that stressors may inﬂuence the course and outcome of the illness and the stressors may have speciﬁc cultural impact.
Thus, there is evidence to indicate that the outcome of schizophrenia is better in developing countries. The possibility that the observed diﬀer- ences in outcome can simply be explained by diﬀerent composition of patient samples cannot be completely ruled out although it is possible that symptoms and their response to management may well diﬀer.
Jablensky (9) proposes that as outcome of other psychoses such as paranoid psychoses was better in developing countries the impact of culture on outcome may well be non-speciﬁc and general. This impact may be a result of eﬀects of beliefs and expectations about mental illness, strong social support networks and a non-stigmatizing sick role especially in the early stages of onset.
This better outcome has been shown in migrant groups in some studies but not consistently and not in all migrant groups, and the rates and outcome of schizophrenia in migrant communities in the UK have illustrated varying patterns (10). Marked diﬀerences in family setups, ethnic density and social structures, which can be demonstrated between the Asian and the African Caribbean communities suggest that the likelihood of better patterns of outcome in a new setting will rely on how the migrant groups have maintained their traditional cultural ways and values. This along with ethnic density and group cohesion may well explain some of the discrepancies in outcome (11). Another possibility is cultural congruity and cul- tural identity (12). The patterns of engagement, compliance and varying explanatory models may contribute to diﬀerences in outcome. External locus of control and biomedical models of explan- ation may be meditating factors in engagement.
Associated risk factors for poor outcome have been shown to be single, divorced, separated, males, high expressed emotion, poor psychosocial adjustment, social isolation, adjustment problems in adolescence, prolonged duration of the pre- index illness, insidious onset, negative symptoms, abnormal MRI scan and social withdrawal (9).
In the UK, it has been shown that Asians with psychosis are more likely to be married, living at home and treated at home and there were more older females in this sample (10) although African Caribbeans were more likely to have been living alone and being unemployed. In addition, African Caribbean males were shown to have been separ- ated from their fathers for longer than 4 years in their childhood. This may indicate poor, insecure patterns of attachment which if replicated in
adulthood will also indicate that attachment for therapeutic interactions is likely to be poor and insecure as well.
Thus several candidates for future research in trying to understand the factors in course and outcome of schizophrenia across cultures emerge. These include stigma, patterns of childhood attach- ment, ethnic density but going beyond simple numbers and trying to understand whether indi- viduals who may be egocentric but come from sociocentric societies who migrate to egocentric societies may cope and adjust well when compared with sociocentric individuals from sociocentric societies who migrate to egocentric societies who may feel alienated if adequate social support structures are not available to them, thereby increasing their isolation and alienation, thus reducing the likelihood of engagement and change in outcome of the illness.
There have been fewer studies of bipolar disorders across cultures. However, there has been at least one well-designed study looking at patterns of depression across cultures. Sartorius et al. (13) reported on symptoms of depression from Basel, Montreal, Nagasaki, Tokyo and Teheran. By using speciﬁc inclusion criteria and using an open-ended questionnaire to obtain culture speciﬁc items they found that the two commonest symptoms of depression were sadness and joylessness. Interest- ingly, suicidal ideas were less likely in the samples in Teheran and Tokyo. In Basel and Montreal feelings of guilt and self-reproach were observed. Unusually, no case of psychotic depression was reported from Teheran. The variations in symp- toms within the same country have been reported as well (14).
The rates of depression and symptoms of depression do not vary dramatically among White population and Black and ethnic minority populations. Interestingly, among South Asians in the UK, length of time since migration, speaking English language, experience of racial prejudice and presence of children at home all inﬂuence rates of depression (15).
Assessment of the chronically severely mentally ill patients
The key aim of the assessment is to understand the experience of illness and not focus simply on disease. The disease is literally dise-ase, indicating an underlying pathology, whereas illness is broad- ening of this experience into psychosocial entity involving those around the individual. It is here in this development of disease into illness experience that culture starts to play a signiﬁcant role. It is the culture which determines what illness is, how sick role is deﬁned and what help is sought. Thus in assessment, in addition to assessing the general risk factors of schizophrenia or chronic severe mental illness, it is essential that an element of assessment of world view of the patient and their carers and also the cultural aspects of deﬁnition of abnormal behaviour are understood. The clinician needs to assess the core of the illness by peeling away the layers of illness behaviour and discovering the treatable centre. These are, of course, multiple layers and highly variable across cultures. The understanding of these depends upon the therap- ist–patient interaction.
The assessment therefore must be at both individual and general cultural levels. It is neces- sary to emphasize that these are not mutually exclusive but a convenient way of dividing the processes involved in the assessment of the patient.
Individual factors have to be seen in the context of both the clinician and the patient. Therapists whose cultural background diﬀer from that of their patients also need to be aware of diﬀerences according to age and gender and their professional status. It is quite likely that under these circum- stances, there is an imbalance of power, which might work against the patient. Patients especially from migrant or minority communities will have to be assessed regarding their cultural and ethnic identity. It is worth emphasizing that identity is not static and will change according to acculturation. Use of verbal and non-verbal communication is also quite likely to shift accordingly. Additional factors such as experiences of alienation, racism and altered expectations of achievement play some role in the presentation and help seeking by the patient and their carers (see Table 1). Carers are a fruitful source of not only corroborating the history but also providing information on culture and cultural norms.
The world view of the patient may well diﬀer from that of the therapist. The world view is deﬁned as the means of understanding events and situations and is a direct result of cultural factors. For example, western views in many countries are individualistic rather than kinship-based and these act on self-actualization and a linear interpretation of events. Such generalization provides useful hints to the therapist in trying to understand their own assumptions and world view (16). The world view
Table 1. Assessment of risk factors
General Differential rates across cultures
Differential outcomes across cultures
Biological – PBC, neuro development, genetic Psychological – schizoid, schizotypal
Social – unemployment, poor housing, ethnic density
does not remain static and shifts with accultur- ation. Individual identity and world view often go hand-in-hand. With chronicity of mental illness the identity may well shift too. In an interesting study, Bhugra (17) showed that ethnic identity of patients with schizophrenia led them to see themselves as belonging to a diﬀerent ethnicity under the inﬂu- ence of their psychopathology. For example, some Black patients either thought they were White or wanted to be White, where some White patients saw themselves as Chinese. In the context of severe mental illness, this phenomenon has been under- estimated.
As mentioned earlier, cultures stigmatize or destigmatize mental illness. This may be one reason why some cultures use physical symptoms in preference to psychological symptoms. These developments also direct the patient to diﬀerent help seeking agencies. For example, Wang et al.
(18) demonstrated that 23% of their sample were more likely to approach the clergy even when they were suﬀering from seriously impairing mental disorders. Thus the clinicians must attempt to formulate pathways their patients have chosen in seeking help.
Certain behaviours and experiences may be seen as abnormal in some cultures but completely normal in others. The clinician therefore must employ verbal and non-verbal skills in observing and interviews. Crying, aggression, and loud speech are behaviours which are inﬂuenced by cultural mores, and the clinician must be sensitive in not reading too much into these. The use of external locus of control, i.e. patient stating that the fault is in their stars or in their fate must not be interpreted as ideas of reference or delusions of control. By deﬁnition, in order to understand the beliefs as delusional, a degree of knowledge of cultural background is indicated in order to embed these ideas in their proper context. In order to under- stand these ideas the clinician can draw from the wealth of information available from those around the patient including family, friends, user groups, voluntary groups and support groups. These beliefs may be recorded and explored with these experts in the patient’s culture to avoid misclassi- ﬁcation (19).
A clear conceptual framework, which includes biological, psychological and social factors must be put in place. Cultural factors will inﬂuence all these spheres to a varying degree. The clinician must also be aware of chronicity, potential for deterioration, denial and disability. Both short- term and long-term interventions in rehabilitation are necessary. The strategy for managing chronic severely mentally ill patients across cultures is no diﬀerent except for a few additional factors.
In managing patients with chronic severe mental illness several cultural factors need to be remem- bered. Pharmacokinetics of drugs vary across ethnic groups. Asians and Black patients showed higher blood levels of neuroleptics and also more side-eﬀects at lower dosages. Asians also have a lesser need for high dosages of tricyclic antidepres- sants as blood and peak levels are reached earlier. Even within the same ethnic group lithium levels display highly variable serum levels (20).
Some ethnic groups are more likely to be treated with diﬀerent medications – for example, African– Americans have been shown to be treated with conventional neuroleptics compared with White Americans who get atypical neuroleptics (21). Thus it is not entirely surprising that levels of compliance in certain ethnic groups are poor.
The clinician must explore explanatory models of patients’ illnesses and decide whether the patients and the clinician’s models can be brought to work together. Symptoms which may have signiﬁcant personal meaning to the patient must be taken seriously. The patient’s beliefs in traditional and complementary medicine may take them to use drugs, which may interact with prescribed medica- tion. The commonest example of this in clinical practice is when patients use St John’s Wort when they feel low, even when they have been prescribed antidepressants. Treatment compliance is also an important factor. In order to increase compliance the clinician must explain the treatment strategies in culturally meaningful ways, which would facili- tate mutual trust. Educating patients must include cultural explanations and cultural expectations.
Table 2. Controlling and managing symptoms
Check the diagnosis
Ensure adequate losses of drugs over a specific period at least to see if these work
Therapeutic levels may be indicated If poor response, check compliance
If compliance good consider changing drugs Try and change only one drug at a time
Try and change typicals to atypicals if indicated Do not try and treat every single symptom
Check diet, dietary taboos, alternative medication Check on smoking, alcohol etc.
Other non-biological factors, which will aﬀect medication compliance include personality styles such as culturally related diﬀerences in ‘ normative’ personality traits. This has been indicated as the ability of some ethnic groups to become more sedated on equivalent dosage of medication because the personality style is less-action oriented. Social support systems will inﬂuence compliance especially if the patient comes from a sociocentric culture where kinship may take part in decision- making. Thus, the explanatory models may well conﬂict with those of the patient or the clinician and lead to conﬂict and poor compliance.
Communication and language will also inﬂuence engagement and compliance. Table 2 illustrates some of the principles which apply equally across cultures. It is important to remember that drug management does not work in isolation and will have to form a part of wider biopsychosocial management.
Diﬀerent types of psychosocial therapies can be culture speciﬁc or certainly culture bound. Psycho- analytical therapy is very much embedded in western egocentric tradition and is less likely to be successful across cultures and has limited application in managing chronic severe mental illness. Of greater beneﬁt are cognitive and beha- viour therapies. Assessing cognitive deﬁcits and setting in place cognitive therapies across cultures is not an easy task. Firstly, norms of cognitions are not universal. The triad of I am a failure, the future is bleak and the world is a horrible place derives from America, and its application to patients from other cultures whose concepts of I-ness (or self) are diﬀerent must be very carefully applied.
Behavioural therapy is generally more adaptable across cultures, which is because of its practical nature. It requires little interpreter time, the therapy is speciﬁc as is outcome. However, in some societies with the notion of arranging marriages is paramount, training in social skills to go out on dates is bound to create resentment. Thus, a careful analysis of cultural norms prior to considering behavioural therapy will provide great dividends.
The use of intercultural therapies which bridge European models with traditional indigenous ther- apies can be useful. This means developing psy- chotherapies which are culture-speciﬁc and combining them with culturally sensitive psycho- therapies available elsewhere. Such adaptations are not necessarily easy but can be very fruitful. For example, using yoga as meditation to reduce anxiety rather than relaxation therapy will be more acceptable to some patients, they will also welcome the inherent cultural–religious belief sys- tems. However, a note of caution is necessary. Just because the patient originates from India does not mean they will automatically take to yoga. The clinicians therefore must avoid stereotyping.
Some groups will use pluralistic approaches to healthcare. They may combine Western systems with Ayurvedic, homoeopathic or Unani systems and the clinician must ensure that the scope of interaction between diﬀerent models is minimal. That patients from some cultures will also use religious and non-medical healers shows the need for clinicians to be aware of these. Some of these therapists will provide a degree of psychosocial as well as social management.
Using social approaches to identify the social causation and putting management in place may require the teams to have members who can provide such an expertise. Using non-governmen- tal organizations may well provide a more accept- able inroad into engaging patients. However, the question of conﬁdentiality and stigma must be remembered. Using interpreters who are not trained may complicate matters further. Using social services may indicate a failure of the kinship system in the eyes of some ethnic minority groups. They may see social workers as a key to better accommodation or employment without neces- sarily looking at the possibility of change.
Bhugra (19) recommends that the client’s explanation of their symptoms should be seen as the starting point, which takes the focus away from psychiatric diagnosis. Such an approach allows the clinician to patch together a treatment package including in-patient, rehabilitation, crisis resolu- tion or home treatment. Engaging user groups and voluntary organizations may allow them to act as advocates for patients. The user movement has a
variable inﬂuence on psychiatric practice world- wide. It is especially strong in some countries and cultures, but not in all. The voluntary organiza- tions often provide an excellent link between the community and the services but the danger is often lack of sustained funding, which may impact on their contributions. These agencies meet needs that may not be met by statutory agencies. Their autonomy is their strength, and working together with them without aﬀecting their autonomy needs to be considered very seriously. The grass roots perspective provided by these agencies can prove to be extremely helpful in planning out strategies for both assessment and management.
There is no doubt that culture clothes the disease and turns it into illness. This changes across cultures as does the experience of disease. These cultural diﬀerences impinge upon symptoms, planning clinical assessment and planning multi- disciplinary management. Both the clinician and the patient need to be aware of each other’s explanatory models and worldview. Changes in cultural identity and perceived stigma of mental illness will inﬂuence how symptoms are identiﬁed and prevented for treatment. An acceptable service for patients from any culture is acceptable to them only if their needs are understood and clearly identiﬁed. This suggests that listening to the patients, their carers and also community at large will enable the clinician to provide help, which will substantially change the clinical out- come.
- GAP: Resident’s guide to treatment of people with chronic mental illness. Washington DC: APA,
- DHHS: Mental Health. Culture, race and ethnicity. Rockville, MD: DHHS,
- Bhugra D, Bhui K. Cross cultural psychiatric assessment. APT 1997;3:103–110.
- Zimmer E, Ethnicity. In: Levison D, Ember M, eds. Ency- clopaedia of cultural anthropology. New York: Holt, 1996:393–395.
- Tseng W-T. Handbook of cultural psychiatry. San Diego: Academic Press,
- WHO: International pilot study of Geneva: WHO, 1973.
- Jablensky A, Sartorious N, Ernberg G et al. Schizophrenia: manifestations, incidence and course in diﬀerent Psychol Med 1992;5(suppl. 20):1–75.
- Cohen A. Prognosis for schizophrenia in the third world. Cult Med Psychiatry 1992;16, 53–75.
- Jablensky A. The epidemiological horizon. In: Hirsch S Weinberger D Schizophrenia. Oxford: Blackwell, 1995:26–252.
- Bhugra D, Leff J, Mallelt R, Der G et al. Incidence and outcome of schizophrenia in whites, African Caribbean’s and Asians in London. Psychol Med 1997;27, 791–798.
- Bhugra Migration and mental health. Acta Psych Scand 2004;109:243–258.
- Bhugra Cultural congruity & cultural identities and cultural congruency: a new model for evaluating mental distress in immigrants. Acta Psych Scand; 111:84–93.
- Sartonius N, Davidson H, Ernberg G et al. Depressive dis- orders in different Geneva: WHO, 1983.
- Bhugra D, Gupta KR, Wright Depression in North India. Int J Psychiatry Clin Pract 1 1997;1:83–87.
- Furnham A, Li Gender, generational and social support correlates of mental health in Asian migrants. Int J Soc Psychiatry 1993;39, 22–33.
- Sue DW. Counselling the culturally different. New York: Wiley,
- Bhugra D. Distorted ethnic identity, a report of 43 cases. Int J Soc Psychiatry 2001;47, 1–7.
- Wang PS, Bergland P, Kessler R. Patient’s and correlates of contacting clergy for mental disorder in the United Health Serv Res 2003;38, 647–673.
- Bhugra D. Setting up services: cross cultural issues. Int J Soc Psychiatry 1997;43:16–28.
- Bhugra D, Bhui Psychopharmacology and ethnic minorities: Adv Psych Treat 1999;5, 89–95.
- Opolka J, Rascati K, Brown C, Banner J, Johnsrud M, Gibson
- Ethnic diﬀerences in uses of antipsychotic medication among Texan medical clients with schizophrenia. J Clin Psychiatry 2003;34:635–669.