Professional Documents
Culture Documents
Original Article
Masoumeh Dejman MD MPH PhD *,**, Solvig Ekblad PhD*, Ameneh-Setareh Forouzan PhD***,
Monir Baradaran-Eftekhari MD, Hossein Malekafzali MD PhD
Background: As one of the most prevalent diseases globally and as an important cause of
disability, depressive disorders are responsible for as many as one in every five visits to primary
care doctors. Cultural variations in clinical presentation, sometimes make it difficult to recognize
the disorder resulting in patients not being diagnosed and not receiving appropriate treatment. To
address this issue, we conducted a qualitative pilot study on three ethnic groups including Fars,
Kurdish, and Turkish in Iran to test the use of qualitative methods in exploring the explanatory
models of help-seeking and coping with depression (without psychotic feature) among Iranian
women.
Methods: A qualitative study design was used based on an explanatory model of illness
framework. Individual interviews were conducted with key informant (n=6), and depressed female
patients (n=6). A hypothetical case vignette was also used in focus group discussions and
individual interviews with lay people (three focus groups including 25 participants and six
individual interviews; n=31).
Results: There were a few differences regarding help-seeking and coping mechanisms among
the three ethnic groups studied. The most striking differences were in the area of treatment. Nonpsychotic depressive disorder in all ethnicities was related to an external stressor, and symptoms
of illness were viewed as a response to an event in the social world. Coping mechanisms involved
two strategies: (1) solving problems by seeking social support from family and neighbors, religious
practice, and engaging in pleasurable activities, and (2) seeking medical support from
psychologists and family counselors. The Fars group was far more likely to recommend
professional treatment and visiting psychiatrists whereas the other two ethnic groups (i.e., Turks
and Kurds) preferred to consult family counselors, psychologists or other alternative care
providers, and traditional healers.
Conclusion: The study has educational and clinical implications. Cultural reframing of the
patients and familys perceptions about mental illness and depression may require community
education. Family counseling, family therapy, and also religious practices can be used to empower
the patient.
Archives of Iranian Medicine, Volume 11, Number 4, 2008: 397 406.
Introduction
Box 1
Case 1: Major depression without psychotic features
A 30-year-old woman who had been feeling unhappy
and no longer enjoyed her usual activities during the past
four weeks. She said that her mind was closed and
described herself as feeling empty and thought that she
was unable to continue her life. Furthermore, she had
difficulty in sleeping and had not been eating well. She
complained of lack of energy and no longer enjoyed sex.
She said that life was not worth living. She had difficulty
with concentration and had become forgetful. During the
previous weeks she had been almost always thinking
about death and dead relatives of hers and wished she had
been dead too or could have killed herself.
Results
In this study, we considered different age
ranges and education levels in each ethnic group of
lay people. The groups of patients and key
informants were almost similar in age in the three
ethnic groups, but key informants differed
regarding years of work experience. The mean
work experience was about eight, 17, and 12 years
for Kurdish, Turkish, and Fars key informants,
respectively.
In this article, although major depression
without psychotic features was considered an
illness and most of the lay people called it
depression, they mentioned it in connection with
an external stressor caused by loss (such as death
of relatives, job loss, etc.), environmental, family
pressure, and marital problems. Help-seeking and
coping behaviors concerned the following themes:
medical support, social support, environmental
support, and religious and traditional spiritual
support. These concepts have emerged from the
replies of patients, lay people, and key informants
to question on the cause and help-seeking based on
the interview guide questions and case vignette.
Medical support
Patients were referred to a doctor or hospital,
persuaded by family members such as mother,
sister, or husband.
One Turkish female patient expressed that I
have done nothing, because there is nothing that I
can do about it. I visited doctors .
Female Kurdish and Fars patients said for
example my parents just told me to visit a
doctor. I was very depressed; my sister found out
about it and referred me to a psychiatrist.
This view was also voiced by lay people in the
three ethnic groups. They believed that family had
an important role in referring patients to physicians
and had to support the patients by providing
medicine and advise them taking medication
regularly.
This is shown in the following citation from lay
persons in Tabriz: advised her visiting a doctor
or psychologist because the family could not cope
with the problems.
Patients in Tabriz and Ilam mentioned that they
were referred to psychiatrists during advanced
stages of the illness when somatic symptoms had
become aggravated. Usually, they had visited
various physicians before hospitalization or
Social support
Self care
Patients and lay people in the three ethnic
groups believed that the first step on the road of
improvement was the acceptance of the illness by
the patient. Such acceptance led to the patient
being able to help herself/himself or seek support.
One patient with Fars background said that ... I
must treat myself and accept my depression.
A Kurdish female patient said that I am
helping myself to improve.
All participants in the three ethnic groups
remarked that patients need assistance and that
others must help, comprehend, and listen.
Considering the importance of family and the
role of the husband in particular, these aspects will
be described separately.
Family
Turkish and Fars female patients said nothing
about social support from the family or others. On
the other hand, Kurdish female patients thought
that family members could play an important role
in encouraging patients to come into contact with
physicians and continue with medication. This was
regarded as an important duty of the father or
brother in case of single female patients. Kurdish
key informants, female patients, and key
informants with Fars background mentioned
nothing about the impact of family regarding to
seeking medical help.
According to lay people in the three ethnic
groups, family members are considered to support
the woman and pay attention to her needs and
maintain social contact with her. Their roles are to
take care of children and support the patient during
hospitalization. In this setting, lay people indicated
that the familys behavior, manner, and probable
limitations may be important components in
triggering the illness. A Turkish lay person
reported that some of the families are very
restrictive, especially toward their daughters; these
problems are going to become exaggerated when a
girl marry to a man who puts the same limits on
her.
Furthermore, Turkish lay people stated that
family members must understand the patients
feelings, look for the reason for the illness, and
solve the problems. They voiced the opinion that
family can have a vital role to play in the patients
improvement by changing the environment
through being amiable and giving advice. Young
Discussion
Few studies have been carried out to identify
health belief held by people on mental health
problems.27,32,33 The findings are typically
consistent with biomedical model, indicating that
up to 20% believe depression to have biologic
origins (genetic or chemical change) and 80%
believe it to be primarily social (stress,
bereavement, or childhood experience). However,
studies that have focused on eliciting the meaning
of the subjects experience of illness using
qualitative methods27,34 have shown considerable
variation between lay explanations and explanations offered by biomedicine.
The findings reported in this article, though
preliminary, suggested that the cause of major
depression (without psychotic feature) is
conceptualized as an external stressor. All the three
ethnic groups studied presented a model in which
the symptoms and causes of illness were viewed as
a response to an event in the social world. This
model of causality impacts on their help-seeking
behavior. The seeking help from family and
religious practice were important sources of
Acknowledgment
The authors thank the participants who agreed
to share their experience and knowledge. Thanks
to Undersecretary for Research and Technology,
Ministry of Health and Medical Education and the
University of Welfare and Rehabilitation in Iran
for funding the study, the Iran National Ethical
Committee and Regional Ethics Committee in the
University of Welfare and Rehabilitation, Tabriz,
Ilam, and Iran Universities of Medical Sciences
and the Regional Research Ethics Committee at
Karolinska Institute, for approving the study.
Thanks to the research team from the Psychiatric
Department at Tabriz, Ilam, and Iran Universities
References
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42