On My Mind: Cultural bias and mental health

Two frequent Vineyard visitors, Mass General Brigham neurologist and psychiatrist Barry Fogel and his wife Xiaoling Jiang, who holds a Ph.D. in comparative culture, recently published a remarkable book, “Seeing Depression Through a Cultural Lens.” It has changed the way I think about our evaluation and treatment of psychiatric illness on Martha’s Vineyard and beyond. Through storytelling, an exhaustive review of the literature, and abundant clinical acumen, they demonstrate how our diagnostic system is riddled with cultural bias that impedes our ability to help our patients.

Take, for instance, the Vineyard’s Brazilian population, which now constitutes a large portion of year-rounders. According to the authors, a 2013–14 study of depression in adult Brazilian immigrants in Massachusetts showed depressive symptoms of clinical severity in more than one-third of the sample. This compares with a rate of depression of approximately 5 percent in the U.S. population overall. We don’t know exactly why the rates among Brazilians are so high, but not surprisingly, depressive symptoms were more common in single people, those with low incomes, those with poor English proficiency, those with less education, and those with general health issues. It is easy to imagine that for many, being separated from families and communities in Brazil, the arduous and sometimes traumatic journeys they took to the U.S., the challenges of finding work and housing here, and the experience of prejudice and hostility in a new country would exacerbate depression.

Yet in our experience at Martha’s Vineyard Community Services, where we have good translation services and several Brazilian employees, depressed Brazilian immigrants seek formal help relatively rarely, and they are not often referred by their primary care clinicians for mental health services. Sometimes the issue is one of nonrecognition of depression by the clinician, sometimes one of denial by the patient, and sometimes avoidance of treatment related to stigma or fear of stigma (and now, in some cases, also related to fear of trouble with U.S. Immigration and Customs Enforcement, or ICE).

Fogel and Jiang’s book addresses the issue of underreporting of depression and poor acceptance of treatment in various immigrant populations including immigrants from China, Japan, and Korea, as well as among Spanish-speaking immigrants from Mexico and Central America. In those populations, deterrents to seeking help include stigma, mistrust of medications, incompatibility of treatment options with people’s work schedules, and troubles with communication. 

Here are some practical suggestions for any therapist, medical professional, guidance counselor, or helpers in any form who might be reading this column: To address the problem of underreporting, the authors’ approach to assessing depressed mood would include asking patients to describe their feelings using words from Brazilian Portuguese, and then to explain in English — perhaps with examples — the connotations of the words they used. A patient might say they were triste (sad), baixo (down), experiencing saudade (a wistful desire for something different, and probably unattainable), desprimido (depressed), or devastação (devastated); when combined with the status of such physical symptoms as disturbed sleep and altered appetite, each description would have different implications for the need for treatment, potential risk of self-harm, etc.

Studies in Brazil suggest that depressed Brazilian men are far less likely to take antidepressant drugs than depressed Brazilian women, and Brazilians of both genders are less likely to take antidepressants than most Americans. Before prescribing an antidepressant to a patient in a population often averse to psychotropic medications, a culturally aware prescriber would ask a patient whether they knew someone who had taken antidepressants, and if so, how it went for them. The patient’s response would guide what the prescriber did next. If, for example, the patient didn’t know anyone who had taken antidepressants and seemed averse to trying them themselves, the prescriber might begin by recommending nonmedical interventions such as increased exercise, which is known to help with overall mood. If these interventions proved inadequate over time, the patient might become less averse to taking medication.

The Fogel-Jiang approach would help a non-Brazilian to see Brazilians as a distinct community, rather than as part of a homogeneous population of Latinos or Hispanic people. Many Brazilian immigrants do not regard themselves as “Hispanic,” and would feel misunderstood if seen as such. In the immigrant population, frequent experiences of everyday discrimination are associated with more depression. A cultural-lens approach would encourage a clinician to ask Brazilian immigrants about how they identify themselves, how they think they are seen by others, and the implications of each. Rather than seeing ethnicity as a variable to be ticked off on a checklist in a medical record, the clinician following the book’s approach would engage in a continuing dialogue with Brazilian clients about cultural issues that might affect treatment options. 

The cultural lens described in the book has immediate applicability to many other Vineyard residents — both year-round and seasonal. For example, many Vineyard residents are in creative professions. (Think William Styron, Art Buchwald, and Mike Wallace, all of whom suffered from severe depressive episodes.) In its chapter “The Dark Side of Creative Talent,” the book deals with issues like the relationship of the depressive experience to the content of creative work, the relatively high prevalence of bipolar symptoms in creative people, potential adverse effects of antidepressant drugs on creative work, and the need for clinicians treating creative professionals to recognize that their patients might have unusual schedules. Other examples on the Vineyard include the need to appreciate the relevance of historical trauma to the context of depression in a Wampanoag; understanding how growing up as a child of highly successful parents might make a young adult vulnerable to depression despite being the object of their peers’ envy; and exploring the anger and ambivalence that many multigenerational Vineyarders feel toward washashores and seasonal visitors, upon whom all year-rounders are dependent, but who have dramatically changed the nature of life on the Island. When we are sensitive to these cultural differences, people are more likely to open up to us, to feel understood, and to be willing to accept help.

The book addresses blind spots of depression-screening questionnaires and rating scales, offering examples of how serious depression can be overlooked because the wording of a standard questionnaire is incompatible with a patient’s culture. Men with stereotypically masculine identities, for example, are more likely to acknowledge irritability, anger, physical pain, and alcohol use than to admit to feelings of emotional vulnerability. They are also more likely to commit suicide and other acts of violence than they are to give in to feeling sad, helpless, and weepy, and they are far less likely to seek or accept help, which they might perceive as a sign of weakness. A person with a traditional Chinese background is more likely to admit to feelings of nervousness, physical discomfort, and specific fears (crowds, speaking in public) than to more explicitly psychological symptoms like anxiety and depression. In one example the authors cite, the prevalence of depression in a Nigerian community jumped from 3 percent to 21 percent when the standard screening questionnaire was adjusted for local culture.

Fogel and Jiang suggest giving up our traditional screening tools and replacing them with a nine-item checklist that is effective across cultures. This list emphasizes the fundamental nature of depression (a state of physical and emotional negativity with measurable cognitive and physical changes) by determining, for example, whether respondents have less energy available for useful activity, are less able to access positive thoughts and feelings, or are suffering from sleep disruptions.

Understanding depression in its cultural context can reduce the stigma of depression, help depressed people be heard and understood, and ultimately prevent considerable suffering and lower the instances of deaths by suicide. Even for those of us who spend our lives as mental health professionals, it is easy to assume that others experience the world the way we do, that we see windows into others’ emotions and perspectives as easily as we see our own. The truth is that none of us are fully aware of all of the influences on how we experience existence.

Sometimes, it is hard to remember that each person has their own lens through which they perceive their inner and outer reality, including their experience of wellness and pain. And those lenses are influenced by the legacy and experience of our ancestors, the nature of our work and the culture that we live in, and even by such day-to-day factors as diet, activity level, sleep, and substance use. “Seeing Depression Through a Cultural Lens” is a reminder of how important it is to expand those lenses and to question assumptions about the minds of others. 

Dr. Charles Silberstein is a psychiatrist on staff at Martha’s Vineyard Hospital and at Island Counseling Center, where he is the medical director. He is board-certified in general, addiction, and geriatric psychiatry. He writes regularly about issues Islanders have with mental health.

Laura Roosevelt is a poet, journalist, and editor who writes regularly for Bluedot Living and other local publications.