Conceptualization Of Depression And Treatment For Ethnic Minorities

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We often think that major depression and other disorders look the same for all groups of people; however, several researchers have questioned the assumption of universality with regard to psychological distress and symptomatology (Johnson, Danko, Andrade, & Markoff, 1997), arguing that universal diagnostic criteria cannot adequately capture cultural or race-based aspects of emotional distress (Trierweiler & Stricker, 1998). Efforts to enhance the cultural validity of DSM-IV resulted in the inclusion of cultural considerations for diagnostic criteria, an appendicized glossary of culture-

bound syndromes, and an outline for cultural formulations (Mezzich et al., 1999). However, these innovations have been criticized as a political compromise rather than a challenge to universalistic, nosological assumptions or true recognition of the importance of contextualizing illness (Mezzich et al., 1999). Therefore, some researchers have concluded that the conceptualization, measurement, and treatment for psychological illness should be culture specific (Mezzich et al., 1999), and that important phenomenological aspects of illness are obscured when mental disorders are considered universal constructs (Kohn & Hudson, 2002).

Unfortunately, the majority of psychopathology literature indicates that symptoms and syndromes of mental illnesses represent universal phenomena, and that measurement and diagnostic criteria are applied broadly, regardless of ethnicity or race (Gotlib & Hammen, 2002). In addition to the use of universal diagnostic criteria, a vast amount of research on psychopathology supports the universality of mental disorders, regardless of race or ethnicity. Much of this research, however, has neither included ethnically diverse samples nor conducted adequate comparisons of psychopathological phenomena across ethnically distinct groups; therefore, it cannot answer the question of whether depression is experienced or expressed similarly.

There are some indications that in comparison to whites, ethnic/ minority individuals may present with different symptom profiles or comor-bid conditions prior to treatment. These differences could contribute to less accuracy in diagnosis among African Americans and Latinos (Borowsky, et al., 2000). For example, in comparison to European American patients with depression, depressed African American patients may exhibit more severe somatic symptoms, increased psychiatric comorbidity, greater life stress, and differences in perceived physical functioning and health beliefs (Brown, Schulberg, & Madonia, 1996). Compared to European Americans, African Americans with unipolar depression have reported more depressive symptoms relating to worry, muscular tension, general anxiety, and autonomic symptoms (Fabrega, Merrich, & Ulrich, 1988). In another study, Jackson-Triche et al. (2000), found that in comparison to European Americans, Latinos, and Asian Americans, African Americans with depression were less likely to report suicidal ideation and melancholia but more likely to report poor health-related quality of life and greater adverse life events, likely due to greater reported economic disadvantage. In conducting depression treatment groups with African American women (see Kohn et al., 2002) we found that our patients were more likely to report experiencing increased mood irritability (as opposed to melancholia), increased appetite (as opposed to decreased appetite), and hypersomnia (as opposed to insomnia) than non-African American patients. Though systematic investigations of symptom differences in depression are rare, the limited available evidence suggests that clinicians may need to adjust their conceptualization of depression when working with ethnic/minority individuals.

Ethnic differences in worldview or perspective may contribute to differences in how people understand or experience psychological distress. Compared to whites, Latinos are more likely to endorse a more external locus of control, and to believe that their future is fatalistic and dependent upon external natural and supernatural forces. This orientation may explain some Latinos' view that mental illnesses is caused by external factors and express symptoms in physical terms. Thus, Latino patients may report their depression in terms of dizziness, fatigue, headaches, and other physical symptoms (Arce & Torres-Matrullo, 1982). Therefore, clinicians should assess differences in pretreatment presentations for African Americans and Latinos, and take premorbid functioning and life context into account when planning treatment.

Acculturation, history, and migration differences may also be important in the conceptualization of depression among Latinos. Guarnaccia, Angel, and Worobey (1989) found evidence for a pattern of depressive symptom expression among Latinos that emphasizes a combined somatic and affective dimension rather than differentiated factors, suggesting that physical and emotional aspects may be unified. Guarnaccia et al. believe that Latinos may strategically choose to highlight somatic symptoms in clinical settings due to the stigma of being loca, or crazy. Furthermore, among three groups of Latinos—Puerto Ricans, Mexican Americans, and Cuban Americans— interesting cultural and gender differences emerged. Specifically, level of acculturation influenced the conceptualization of depression for Mexican American men such that those who were English-speaking differentiated between primarily affective and primarily physical symptoms. English-speaking Mexican American women, however, appeared similar to Spanish-speaking women in expressing combined affective and somatic problems. Puerto Ricans expressed a greater level of symptoms of loneliness and demoralization, perhaps related to their long history of social dislocation in the United States. A predominant theme for symptom expression among Cuban Americans was isolation, perhaps as a community characterized by homeland migration and an insulated language and culture. These differences indicate that clinicians should include acculturation, gender, and social history in the conceptualization of distress among ethnic/minority patients. Another study of acculturation and depression diagnoses found that physicians were more likely to classify Latinos with higher acculturation status as depressed in comparison to classification based on a self-report measure of depressive symptoms (Chung et al., 2003). To avoid diagnostic bias, careful assessment of depression for ethnic/minority patients is warranted.

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