Severe mental illness across cultures

Introduction

A proportion of patients with psychiatric illnessesare likely to become chronic. The chronicity ofillness implies that there may be a risk of relapseover a long time or that the illness may continuewith varying levels of psychopathology and, withinthis setup, acute exacerbations may occur inresponse to stressors. This exacerbation may wellbe related to partial or incomplete treatment. Inaddition, with chronic severe mental illness, denialand 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 themanagement. However, it must be emphasizedthat diagnosis itself must be seen in the context ofculture at a broader level and individual and familyneeds at a personal level. This allows the cliniciansto be aware of the interaction of culture ingenerating or protecting the individual pathology.

Literature review

The disability following a severe mental illness maybe primary, i.e. resulting from continuation ofsymptoms or ongoing deficits in cognitive proces-

ses because of the illness, secondary, because oflack of motivation or demoralization because ofpersistence of symptoms and/or tertiary, becauseof social rejection or stigma as a result of exhibitingillness-related behaviours (1).Culture is best defined as a common heritage or

set of beliefs, norms and values (2), which areshared among a large group of people. Culturerefers to these attributes as shared meanings, whichcan be acquired at different levels through differentmethods 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 commonheritage (including similarhistory, language and beliefs; (4) but it is also self-ascribed. Culture can be fluid whereas ethnicity orethnic identity is more likely to remain the same. Incontrast, race overlaps with ethnicity but has a verysocial meaning (1) and also has a biological compo-nent. Culture structures the way people define whatis abnormal and deviant, how illness is defined andhow and where help is sought, as it is the culturethat determines what resources are available for

Bhugra D. Severe mental illness across cultures.Acta Psychiatra Scand 2006: 113 (Suppl. 429): 17–23. � 2006 BlackwellMunksgaard.

Objective: International studies have shown that the outcome ofillnesses like schizophrenia vary across cultures. Thegood outcome in developing countries depends upon a number offactors.Method: Using both primary and secondary sources, existing literaturewas reviewed. Using terms severe mental illness, culture andschizophrenia, Medline, Psychinfo and Embase were searched. Furthersearches were conducted using secondary searches.Results: The impact of culture and its components on the individualand their families influences compliance, engagement with services andexpectations of treatment. Cultures also impact upon identity andexplanatory models of individuals.Conclusion: Severe mental illness is as likely to be affected by culture asother illnesses. Clinicians need to use multi-model assessment andmanagement techniques.

D. BhugraHSRD, Institute of Psychiatry, De Crespigny Park,London, UK

Key words: severe mental illness; culture;schizophrenia; chronic depression

Dinesh Bhugra, PO Box 25, HSRD, Institute of Psychiatry,De Crespigny Park, London SE5 5AF, UK.E-mail: d.bhugra@iop.kcl.ac.uk

This paper was read in a preliminary version at the 3rdInternational Zurich Conference on Clinical and SocialPsychiatry, Zurich, September 25–27, 2003. The con-ference and publication of this supplement wereexclusively sponsored by Eli Lilly, Suisse.

Acta Psychiatr Scand 2006: 113: (Suppl. 429): 17–23All rights reservedDOI: 10.1111/j.1600-0447.2005.00712.x

Copyright � 2006 Blackwell Munksgaard

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managing what kind of distress. The understandingof culture allows us to identify the precise roleculture may play in individual’s lifespan of illness.For example, culture can precipitate illness, con-tinue to define something as abnormal therebyperpetuating it, may act as the protector by provi-ding structures which allow the individual to dealwith the distress. Tseng (5) has highlighted functionsof culture as pathogenic, pathoplastic, pathoselec-tive, pathoelaborating pathofacilitative and patho-reactive. Each type of impact has differentimplications for the individual.

Aims of this study

The variation in rates of chronic severe mentalillness across different ethnic groups and cultures isof great interest to both clinicians and researchers.The present paper describes some of the findingsacross different cultures.

Material and methods

Using key words culture, chronic mental illness,severe mental illness, schizophrenia and chronicdepression, literature searches were carried outin major data bases such as Embase, Medline, Psy-chinfo and subsequent searches were secondary totrace all papers in English which fulfilled thesecriteria. The present paper provides a selectivereview, as not enough information could be gath-ered using these strategies.

Results

Several epidemiological studies, which have inclu-ded several cultures, nations and societies demon-strated that rates of psychiatric disorders varyacross cultures.The concept of chronic severe mental illness is

generally employed to denote chronic schizophre-nia or bipolar disorders. However, there are majormethodological 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) mediatingcultural and social factors, economic conditions,employment, social support available and varyingfollow-up strategies.

Schizophrenia

Bearing in mind the problems in defining schizo-phrenia in early studies, the epidemiological andfollow-up studies have to be seen in that context.The concept of schizophrenia is Western European

and has raised several problems in diagnoses inother cultures.

Bipolar disorders

The symptoms of disinhibition will vary inhypomania according to cultures. The dataon chronicity of bipolar disorders across culturesare not robust enough to draw any firmconclusions.

Discussion

There are some clear factors in identifying riskfactors. For example, males develop schizophreniaat a slightly earlier age when compared withfemales. In the International Pilot study of Schi-zophrenia (6) and Determinants of Outcome ofSevere Mental Disorders (7), it emerged that therates of narrow definition schizophrenia werebroadly similar across nations but broader defini-tion schizophrenia varied nearly twofold. Theincident rates in the second study (7) were identi-fied by including patients who contacted any helpgiving agency for the first time ever in theirlifetime. They were then interviewed by trainedresearchers using standardized instruments andpathways of care were determined. Both clinicaland research diagnoses were used and incidencerates obtained. Narrow definition schizophrenia,which corresponds very closely with Schneiderianfirst rank symptoms showed no difference acrossdifferent centres.However, in spite of the variation in broad

category schizophrenia, no consistent differenceswere reported between cases meeting the broadcategory only and those with narrow definition ineither the course or outcome or onset of the illness.However, Cohen (8) has very cogently argued thatthe researcher’s focus on narrow definition ofschizophrenia and ignoring broad definitions doesnot deal with the relativist position of symptoms.In 2-year follow-up data, Jablensky et al. (7)

observed that in developed countries 39.8% hadsevere outcome compared with 24% in developingcountries. Thus, sociocultural setting, i.e. develop-ing or developed country, was the best predictor of2- and 5-year outcome in both WHO studies (6, 7).These short-term differences may indicate morefamily support, less expressed emotion, low stigmato mental illness or some other mediating factors.However, it is also likely that prevalence ofdifferent symptoms may well vary. Acute transientpsychoses are more likely in developing countries,which may also be related to organic infectivefactors, which will have better outcome. It is also

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entirely possible that stressors may influence thecourse and outcome of the illness and the stressorsmay have specific cultural impact.Thus, there is evidence to indicate that the

outcome of schizophrenia is better in developingcountries. The possibility that the observed differ-ences in outcome can simply be explained bydifferent composition of patient samples cannot becompletely ruled out although it is possible thatsymptoms and their response to management maywell differ.Jablensky (9) proposes that as outcome of other

psychoses such as paranoid psychoses was better indeveloping countries the impact of culture onoutcome may well be non-specific and general.This impact may be a result of effects of beliefs andexpectations about mental illness, strong socialsupport networks and a non-stigmatizing sick roleespecially in the early stages of onset.This better outcome has been shown in migrant

groups in some studies but not consistently and notin all migrant groups, and the rates and outcome ofschizophrenia in migrant communities in the UKhave illustrated varying patterns (10). Markeddifferences in family setups, ethnic density andsocial structures, which can be demonstratedbetween the Asian and the African Caribbeancommunities suggest that the likelihood of betterpatterns of outcome in a new setting will rely onhow the migrant groups have maintained theirtraditional cultural ways and values. This alongwith ethnic density and group cohesion may wellexplain 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 maycontribute to differences in outcome. Externallocus 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 psychosocialadjustment, social isolation, adjustment problemsin 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 athome and treated at home and there were moreolder females in this sample (10) although AfricanCaribbeans were more likely to have been livingalone and being unemployed. In addition, AfricanCaribbean males were shown to have been separ-ated from their fathers for longer than 4 years intheir childhood. This may indicate poor, insecurepatterns of attachment which if replicated in

adulthood will also indicate that attachment fortherapeutic interactions is likely to be poor andinsecure as well.Thus several candidates for future research in

trying to understand the factors in course andoutcome of schizophrenia across cultures emerge.These include stigma, patterns of childhood attach-ment, ethnic density but going beyond simplenumbers and trying to understand whether indi-viduals who may be egocentric but come fromsociocentric societies who migrate to egocentricsocieties may cope and adjust well when comparedwith sociocentric individuals from sociocentricsocieties who migrate to egocentric societies whomay feel alienated if adequate social supportstructures are not available to them, therebyincreasing their isolation and alienation, thusreducing the likelihood of engagement andchange in outcome of the illness.

Bipolar disorders

There have been fewer studies of bipolar disordersacross cultures. However, there has been at leastone well-designed study looking at patterns ofdepression across cultures. Sartorius et al. (13)reported on symptoms of depression from Basel,Montreal, Nagasaki, Tokyo and Teheran. By usingspecific inclusion criteria and using an open-endedquestionnaire to obtain culture specific items theyfound that the two commonest symptoms ofdepression were sadness and joylessness. Interest-ingly, suicidal ideas were less likely in the samplesin Teheran and Tokyo. In Basel and Montrealfeelings of guilt and self-reproach were observed.Unusually, no case of psychotic depression wasreported from Teheran. The variations in symp-toms within the same country have been reportedas well (14).The rates of depression and symptoms of

depression do not vary dramatically amongWhite population and Black and ethnic minoritypopulations. Interestingly, among South Asians inthe UK, length of time since migration, speakingEnglish language, experience of racial prejudiceand presence of children at home all influence ratesof depression (15).

Assessment of the chronically severely mentally ill patients

The key aim of the assessment is to understand theexperience of illness and not focus simply ondisease. The disease is literally dise-ase, indicatingan underlying pathology, whereas illness is broad-ening of this experience into psychosocial entityinvolving those around the individual. It is here in

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this development of disease into illness experiencethat culture starts to play a significant role. It is theculture which determines what illness is, how sickrole is defined and what help is sought. Thus inassessment, in addition to assessing the general riskfactors of schizophrenia or chronic severe mentalillness, it is essential that an element of assessmentof world view of the patient and their carers andalso the cultural aspects of definition of abnormalbehaviour are understood. The clinician needs toassess the core of the illness by peeling away thelayers of illness behaviour and discovering thetreatable centre. These are, of course, multiplelayers and highly variable across cultures. Theunderstanding 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 mutuallyexclusive but a convenient way of dividing theprocesses involved in the assessment of thepatient.

Individual factors

Individual factors have to be seen in the context ofboth the clinician and the patient. Therapistswhose cultural background differ from that oftheir patients also need to be aware of differencesaccording to age and gender and their professionalstatus. It is quite likely that under these circum-stances, there is an imbalance of power, whichmight work against the patient. Patients especiallyfrom migrant or minority communities will have tobe assessed regarding their cultural and ethnicidentity. It is worth emphasizing that identity is notstatic and will change according to acculturation.Use of verbal and non-verbal communication isalso quite likely to shift accordingly. Additionalfactors such as experiences of alienation, racismand altered expectations of achievement play somerole in the presentation and help seeking by thepatient and their carers (see Table 1). Carers are afruitful source of not only corroborating thehistory but also providing information on cultureand cultural norms.The world view of the patient may well differ

from that of the therapist. The world view isdefined as the means of understanding events andsituations and is a direct result of cultural factors.For example, western views in many countries areindividualistic rather than kinship-based and theseact on self-actualization and a linear interpretationof events. Such generalization provides useful hintsto the therapist in trying to understand their ownassumptions and world view (16). The world view

does not remain static and shifts with accultur-ation. Individual identity and world view often gohand-in-hand. With chronicity of mental illness theidentity may well shift too. In an interesting study,Bhugra (17) showed that ethnic identity of patientswith schizophrenia led them to see themselves asbelonging to a different ethnicity under the influ-ence of their psychopathology. For example, someBlack patients either thought they were White orwanted to be White, where some White patientssaw themselves as Chinese. In the context of severemental illness, this phenomenon has been under-estimated.As mentioned earlier, cultures stigmatize or

destigmatize mental illness. This may be onereason why some cultures use physical symptomsin preference to psychological symptoms. Thesedevelopments also direct the patient to differenthelp seeking agencies. For example, Wang et al.(18) demonstrated that 23% of their sample weremore likely to approach the clergy even when theywere suffering from seriously impairing mentaldisorders. Thus the clinicians must attempt toformulate pathways their patients have chosen inseeking help.Certain behaviours and experiences may be seen

as abnormal in some cultures but completelynormal in others. The clinician therefore mustemploy verbal and non-verbal skills in observingand interviews. Crying, aggression, and loud speechare behaviours which are influenced by culturalmores, and the clinician must be sensitive in notreading too much into these. The use of externallocus of control, i.e. patient stating that the fault isin their stars or in their fate must not be interpretedas ideas of reference or delusions of control. Bydefinition, in order to understand the beliefs asdelusional, a degree of knowledge of culturalbackground is indicated in order to embed theseideas in their proper context. In order to under-stand these ideas the clinician can draw from the

Table 1. Assessment of risk factors

GeneralDifferential rates across culturesDifferential outcomes across cultures

Low EELow stigmaFamily support

IndividualVulnerability

Biological – PBC, neuro development, geneticPsychological – schizoid, schizotypalSocial – unemployment, poor housing, ethnic density

StressorsLife eventsChronic difficulties

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wealth of information available from those aroundthe patient including family, friends, user groups,voluntary groups and support groups. Thesebeliefs may be recorded and explored with theseexperts in the patient’s culture to avoid misclassi-fication (19).

Management

A clear conceptual framework, which includesbiological, psychological and social factors mustbe put in place. Cultural factors will influence allthese spheres to a varying degree. The clinicianmust also be aware of chronicity, potential fordeterioration, denial and disability. Both short-term and long-term interventions in rehabilitationare necessary. The strategy for managing chronicseverely mentally ill patients across cultures is nodifferent except for a few additional factors.

Physical management

In managing patients with chronic severe mentalillness several cultural factors need to be remem-bered. Pharmacokinetics of drugs vary acrossethnic groups. Asians and Black patients showedhigher blood levels of neuroleptics and also moreside-effects at lower dosages. Asians also have alesser need for high dosages of tricyclic antidepres-sants as blood and peak levels are reached earlier.Even within the same ethnic group lithium levelsdisplay 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 withconventional neuroleptics compared with WhiteAmericans who get atypical neuroleptics (21). Thusit is not entirely surprising that levels of compliancein certain ethnic groups are poor.The clinician must explore explanatory models

of patients� illnesses and decide whether thepatients and the clinician’s models can be broughtto work together. Symptoms which may havesignificant personal meaning to the patient must betaken seriously. The patient’s beliefs in traditionaland complementary medicine may take them to usedrugs, which may interact with prescribed medica-tion. The commonest example of this in clinicalpractice is when patients use St John’s Wort whenthey feel low, even when they have been prescribedantidepressants. Treatment compliance is also animportant factor. In order to increase compliancethe clinician must explain the treatment strategiesin culturally meaningful ways, which would facili-tate mutual trust. Educating patients must includecultural explanations and cultural expectations.

Other non-biological factors, which will affectmedication compliance include personality stylessuch as culturally related differences in � normative�personality traits. This has been indicated as theability of some ethnic groups to become moresedated on equivalent dosage of medicationbecause the personality style is less-action oriented.Social support systems will influence compliance

especially if the patient comes from a sociocentricculture where kinship may take part in decision-making. Thus, the explanatory models may wellconflict with those of the patient or the clinicianand lead to conflict and poor compliance.Communication and language will also influence

engagement and compliance. Table 2 illustratessome of the principles which apply equally acrosscultures. It is important to remember that drugmanagement does not work in isolation and willhave to form a part of wider biopsychosocialmanagement.

Psychosocial management

Different types of psychosocial therapies can beculture specific or certainly culture bound. Psycho-analytical therapy is very much embedded inwestern egocentric tradition and is less likely tobe successful across cultures and has limitedapplication in managing chronic severe mentalillness. Of greater benefit are cognitive and beha-viour therapies. Assessing cognitive deficits andsetting in place cognitive therapies across culturesis not an easy task. Firstly, norms of cognitions arenot universal. The triad of I am a failure, the futureis bleak and the world is a horrible place derivesfrom America, and its application to patients fromother cultures whose concepts of I-ness (or self) aredifferent must be very carefully applied.Behavioural therapy is generally more adaptable

across cultures, which is because of its practicalnature. It requires little interpreter time, thetherapy is specific as is outcome. However, insome societies with the notion of arranging

Table 2. Controlling and managing symptoms

Check the diagnosisEnsure adequate losses of drugs over a specific period at leastto see if these work

Therapeutic levels may be indicatedIf poor response, check complianceIf compliance good consider changing drugsTry and change only one drug at a timeTry and change typicals to atypicals if indicatedDo not try and treat every single symptomCheck diet, dietary taboos, alternative medicationCheck on smoking, alcohol etc.

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marriages is paramount, training in social skills togo out on dates is bound to create resentment.Thus, a careful analysis of cultural norms prior toconsidering behavioural therapy will provide greatdividends.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 andcombining them with culturally sensitive psycho-therapies available elsewhere. Such adaptations arenot necessarily easy but can be very fruitful. Forexample, using yoga as meditation to reduceanxiety rather than relaxation therapy will bemore acceptable to some patients, they will alsowelcome the inherent cultural–religious belief sys-tems. However, a note of caution is necessary. Justbecause the patient originates from India does notmean they will automatically take to yoga. Theclinicians therefore must avoid stereotyping.Some groups will use pluralistic approaches to

healthcare. They may combine Western systemswith Ayurvedic, homoeopathic or Unani systemsand the clinician must ensure that the scope ofinteraction between different models is minimal.That patients from some cultures will also usereligious and non-medical healers shows the needfor clinicians to be aware of these. Some of thesetherapists will provide a degree of psychosocial aswell as social management.

Social management

Using social approaches to identify the socialcausation and putting management in place mayrequire the teams to have members who canprovide such an expertise. Using non-governmen-tal organizations may well provide a more accept-able inroad into engaging patients. However, thequestion of confidentiality and stigma must beremembered. Using interpreters who are nottrained may complicate matters further. Usingsocial services may indicate a failure of the kinshipsystem in the eyes of some ethnic minority groups.They may see social workers as a key to betteraccommodation 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 asthe starting point, which takes the focus away frompsychiatric diagnosis. Such an approach allows theclinician to patch together a treatment packageincluding in-patient, rehabilitation, crisis resolu-tion or home treatment. Engaging user groups andvoluntary organizations may allow them to act asadvocates for patients. The user movement has a

variable influence on psychiatric practice world-wide. It is especially strong in some countries andcultures, but not in all. The voluntary organiza-tions often provide an excellent link between thecommunity and the services but the danger is oftenlack of sustained funding, which may impact ontheir contributions. These agencies meet needs thatmay not be met by statutory agencies. Theirautonomy is their strength, and working togetherwith them without affecting their autonomy needsto be considered very seriously. The grass rootsperspective provided by these agencies can prove tobe extremely helpful in planning out strategies forboth assessment and management.

Conclusions

There is no doubt that culture clothes the diseaseand turns it into illness. This changes acrosscultures as does the experience of disease. Thesecultural differences impinge upon symptoms,planning clinical assessment and planning multi-disciplinary management. Both the clinician andthe patient need to be aware of each other’sexplanatory models and worldview. Changes incultural identity and perceived stigma of mentalillness will influence how symptoms are identifiedand prevented for treatment. An acceptableservice for patients from any culture is acceptableto them only if their needs are understood andclearly identified. This suggests that listening tothe patients, their carers and also community atlarge will enable the clinician to provide help,which will substantially change the clinical out-come.

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