Cultural Aspects of Major Mental Disorders: A Critical Review from an Indian Perspective

Article excerpt

Byline: Biju. Viswanath, Santosh. Chaturvedi

Major mental disorders such as schizophrenia and affective disorders are highly disabling illnesses. The cultural factors that influence the diagnosis and treatment of these disorders are of paramount clinical significance. We attempted to critically review the cultural factors in relation to the epidemiology, phenomenology, treatment, and outcome of major mental disorders from an Indian perspective, and tried to compare these with the cultural factors identified in major international studies. The clinical expression of major mental disorders was noted to vary across cultures in the review. In addition, the outcome of major mental disorders is reported to be better in developing nations than in the developed countries. Transcultural variations are also noted to exist in pharmacokinetics, pharmacodynamics, traditional healing practices, and psychotherapeutic approaches. The role of cultural factors in severe mental illnesses needs adequate attention from mental health professionals. Continued research on the cultural aspects is required to understand the interplay of all social, cultural, and biological factors. It is important to consider other cultural, traditional, and folk methods for understanding and management of mental illnesses.

Culture and Major Mental Disorders

The phenomenology of major mental disorders (schizophrenia and affective disorders) is recognized in all parts of the world. It was previously assumed that culture merely plays a patho-plastic effect on the strong central biological pathogenesis of these disorders. [sup][1] However, current understanding is that culture has multiple roles to play in the expressions of psychopathology. These are as follows: [sup][2]

*Pathogenic effects - Culture is a direct causative factor in forming or generating illness *Patho-selective effects - Tendency to select culturally influenced reaction patterns that result in psychopathology *Patho-plastic effect - Culture contributes to modeling or shaping of symptoms *Patho-elaborating effects - Behavioral reactions become exaggerated through cultural reinforcements *Patho-facilitative effects - Cultural factors contribute to frequent occurrence *Patho-reactive effects - Culture influences perception and reaction.

Culture influences the epidemiology, phenomenology, outcome, and treatment of schizophrenia and affective disorders. We review the effects of culture in each of these parameters.

Cultural Influence on Epidemiology

Schizophrenia

Prevalence

A large number of studies [Table 1] have estimated the prevalence of schizophrenia. Although there are methodological differences, most have found a point prevalence of between 1.5 and 7 per thousand populations at risk. There were pockets of high (e.g., Ireland) and low (e.g., New Guinea) prevalence. Much of the evidence points toward equal prevalence in Asia and the West, although inconclusive. A meta-analysis of 188 studies from 46 countries calculated median lifetime prevalence as 4.0 (1.6-12.1). [sup][3] The prevalence of schizophrenia in "least developed" countries was significantly lower than in the "emerging" and "developed" countries. Indian studies have suggested that the prevalence of schizophrenia is lower in India than in the West. [sup][4] One reason for this difference could be underreporting. [sup][5]{Table 1}

Incidence

The incidence of schizophrenia is comparable across cultures. There are differences based on whether a "narrow" or "broad" definition of schizophrenia is used [Table 2]. Studies that have used broad definition (International Classification of Diseases (ICD)-8, ICD-9) have found incidence rates between 0.17 and 0.54 per thousand populations, whereas studies that have used narrow criteria (ICD-10, Diagnostic and Statistical manual of Mental disorders (DSM)-III) have found incidence rates to be much lower. …