Estadístico de prueba:

Whilst more phenomenological descriptions o f depression, which address the issue of validity

are being produced by the new cross cultural psychiatric approach, they are conspicuously low in comparability component and reliability. Even Kleinman (1977) acknowledges the

current lack of systematic cross cultural comparison of depression. This comparative

component, whether a positive exercise or a negative one, is fundamental to drawing any

conclusions from research and facilitating any pragmatic change in mental health services

diagnosed depression is less frequent in West Indian and South Asian minorities (Burke, 1980; Cochiane, 1977). Earlier, this kind of finding was interpreted as suggesting that these minority groups, simply, did not suffer depression. Which Littlewood and Lipsedge (1982) have connected do the implicitly racist assumptions that Africans and Asians were incapable

of examining their feelings and psychologising: these afflictions being considered the province of the sensitive and the intellectually aware. Research has since showed, however, that this does not reflect the actual occurrence of depression in the community (Cochrane & Stopes-

Roe, 1977; Fenton & Sadiq, 1993). Prince (1968) has argued that black people do get depressed and that with better hospital facilities and less racism they are more likely to seek medical advice and not rely solely on their communities.

In spite of this contradictory and controversial picture, very few comprehensive studies have been conducted on depression in ethnic minorities in Britain. In part, this painfully slow progress has been due to the lack of a suitable approach that, on the one hand, does not impose a Western concept of depression on ethnic minorities and still produces meaningful results. Whilst on the other hand, produces results that are meaningful to a wider medical system, often preoccupied with an empirical approach. Clearly, this requires a combined approach to research and the demarcation of a common ground. Patel (1994), in his review of cross cultural studies on depression, has suggested that an ideal culturally valid assessment method for depression would involve a qualitative starting point. In turn this would elicit the lexicon of idioms of distress and concepts of mental illness from patients, carers, and healers from the culture under investigation, independent of a unified framework (Kleinman, 1977), or in other words, the assumption of a disorder category or structure. Based on this information, Patel then (1994) suggests conducting unstructured and semi-structured interviews to enable an elicitation of emic phenomenology using an etic standardised

approach. The symptom profiles thus elicited he argues, can shed light on the presentation o f common mental disorders in the community, and con be used to develop a screening instrument, which after validation can be used in epidemiological studies. Such an approach of course involves a some-what lengthy and complex process, which few studies have

em barked upon. One example of such an endeavour is the Explanatory Models Interview

Catalogue (EMIC) designed by Weiss et al. (1996). This aims to provide a standardised

approach to the elicitation of explanatory models across cultures. The development of more

indigenous screening instruments also offers further opportunities for this kind of meaningful

comparative research, which has started to accompany the spread of the psychiatry discipline

across the globe, although admittedly rather slowly.

In conclusion, the cross cultural study of depression has been plagued with many difficulties. In a large part this has been due to the nature of the construct and its very close placement

to the centre of the biological / sociological spectrum of mental illness. Geerston (1980), has

also attested to the some-what confused construct of depression, which he argues, remains

an inaccurate and often conflicting diagnosis with no agreed etiology, despite progress in pharmotherapy and psychotherapy. The contradictory cross cultural findings regarding

depression are not surprising given this lack of clarity of the notion of depression, even within

thee cultural context from which it has arisen. Snaith (1993) has claimed that the

measurement of depression in developing countries has often been as confused as the

construct itself. The cross cultural study of depression, however, has had and continues to

have much to contribute to the understanding of emotional distress in all cultures as well as the broader development of the psychiatry discipline. The questions generated by cross

cultural studies have resulted in a fundamental questioning of the aetiology and expression of depression, in fact, the actual clarity of the concept. To therefore produce the kind of valid

and reliable findings required to advance this debate it has been argued that a combined

qualitative and quantitative approach needs to be pursued. By using a combined approach,

which supports one another, we can move away from the basic issues of methodology and progress towards some practically useful findings.

-C H A PTE R 3-

CONCEPTUALLSATION O F MENTAT. D ISTRESS A M O N G ST PA K ISTA N IS

AIM S AND PR O C E D U R E

During the past thirty years, studies on the mental health of South Asian minorities, compared

with the indigenous British population^, have produced a rather confusing picture. Earlier

studies, which predominantly focused on mental hospital admission rates, generally suggested

a higher incidence of psychiatric morbidity in all minority groups (Hashmi, 1968; Bagley,

1969; Pinto, 1974). These studies, however, were open to major criticism for through focus

on hospital admission rates without recourse to demographic differences in populations. For example, they did not address such factors as: sex ratios, age structure, social class, which

are widely known to be associated with mental illness rates. Furthermore, these studies only focused on particular regions of the country, which arguably have different settlement patterns

of minority groups and socioeconomic profiles. Indeed, limitation of this research is evident

in its lack of delineation between minority groups, let alone within the blanket term of 'Asians'.

Cochrane (1977) and Cochrane and Bal (1989) have provided more reliable statistics since then in their nationwide surveys on mental hospital admission rates in England and Wales,

based on 1971 and 1981 censuses. These studies, whilst providing more accurate age and sex

standardised data; also attested to the total higher rates of admissions in minority groups.

Further analysis, however, revealed the more complex nature of the picture. Cochrane (1977) found that Asians, compared with the Irish and Afro-Caribbeans, had markedly less

differential rates to the indigenous population. Further subdivision of 'Asians', by Hitch

^ Most o f this research on the mental health of ethnic minorities has been comparative, therefore, when rates are talked about in terms of 'higher' and 'lower' it is relative to the indigenous British population.

(1981) and Giggs (1986), into Indians and Pakistanis, however, found contradictory results.

For example, whilst Hitch's study in Bradford found higher admission rates in Pakistanis and

lower rates in Indians, Giggs study in Nottingham found higher rates in Indians and lower in

Pakistanis. In terms of diagnoses, Cochrane found that Asians in line with Afro-Caribbeans,

had higher rates of psychosis than the indigenous population, but surprisingly lower rates of

neuroses. The paradox of the higher rates of chronic disorders, yet lower rates of acute disorders in minority groups, in addition to regional differences observed by Hitch and Giggs,

clearly suggested that something was contradictory. The very use of hospital admission rates

as 'absolute' indices o f psychiatric morbidity (as argued in Chapter 1) are to some extent

responsible for this unsatisfactory account (Bhat et al., 1988 ). Cochrane (1981) has also

affirmed that hospital admission statistics conceal more than they reveal. In doing so, he

turned his attention to smaller scale community studies to help clarify the picture.

Despite several such community studies the current picture remains equivocal. Some studies

suggest that South Asians are indeed more psychologically healthy than the indigenous British

population (Cochrane & Stopes-Roe, 1981; Ineichen, 1990), and others suggest that the ‘apparent health' of Asians is a myth and a reflection of a system that is failing minority groups

(Beliappa, 1991; Fenton & Sadiq, 1993; Bowes & Domokos, 1993). The need to address this issue, however, is made all the more urgent by the recent reports of alarmingly high suicide

rates in Asian women (Raleigh, 1990; 1996). This Chapter then, in an attempt to review the current literature and set a context to this research considers the findings of quantitative

(empirical) and qualitative (interpretive) studies on / or relevant to depression in South Asians

in more detail.