The public perception of major depressive disorder in South Asia: a literature review

Review article

Marisse Sonido

 

Abstract

Aims: To understand: the perception of depression as an illness in South Asia and the language used to describe it, its perceived aetiology, how individuals with depression are perceived by the community and the beliefs in the community surrounding the treatment of depression.

Methods: Articles were found through a database search of MedLine, PSYCINFO, and GoogleScholar. They were included if they discussed depression within the context of a South Asian culture.

Results: Depression is widely understood in South Asia as a disease with primarily somatic presentations stemming from stresses associated with difficult socioeconomic circumstances. Those with depression are often stigmatised but they are generally not excluded from the community. Alongside medical intervention, assistance from family and the community are the most accepted methods of addressing depression.

Conclusions: South Asian perceptions of depression accord with a psychosocial model of illness. Incorporating these perceptions is essential to the success of interventions and educational programs hoping to resonate with a general population and improve communication with health professionals.

 

Introduction
Depression, suffered by more than 300 million people worldwide, represents the single greatest contributor to global non-fatal health loss.[1, 2, 3] Its impacts are not limited to the Western world. While developed countries draw much of the research focus, the South Asian prevalence of depression was calculated at 26.3% based on primary care presentations.[1] In India in 2004 it accounted for a greater number of disability adjusted life years per 100,000 people than both cancer and diabetes mellitus combined.[1] Depression is particularly under-recognised and undertreated in rural areas.[4] The presentations, sequelae and understandings of depression are known to depend on culture, a relationship maintained in the South Asian context. [5, 6, 7, 8] Existing research highlights significant differences between developed and developing world perspectives on the disease—the extent to which depression is seen as somatic, the role of socioeconomic factors in its aetiology and community responsibilities in addressing it.[4] The strict biomedical conception of depression favoured by some health professionals may translate poorly across cultures and pose obstacles to improving recognition, treatment and education.[9] This paper aims to discuss general perceptions of depression in developing countries in South Asia. It will identify community views on: (1) depression as an illness, including the way it is described and presents; (2) its aetiology; (3) opinions about individuals with depression; and (4) beliefs about treatment. In synthesising the trends and repeating themes revealed by research, it hopes to provide a foundation for tailoring clinical and public health interventions to a South Asian cultural context.

Methods
Articles were found through a database search of MedLine, PSYCINFO, and GoogleScholar using the following keywords and MESH terms: Mental Disorders OR Depression; Developing Countries OR Asia OR Afghanistan OR India OR Sri Lanka OR Nepal OR Bhutan OR Maldives OR Pakistan; and Stigma, Public Perception, Understanding, OR Health Literacy. Studies were excluded if they were not published English language articles relating to depression in South Asian cultures.

Results

Relevant studies were found about samples in India (n = 3), Pakistan (n = 1), Afghanistan (n = 1), Bangladesh (n = 1) and Sri Lanka (n = 1). The Afghan sample reflected a migrant Afghan population. No depression-specific articles were found about the Maldives, Bhutan and Nepal.

Understanding of depression as a disease

Participants generally professed a poor medical understanding of depression and other mental illnesses. Many in the Liu et al. study (42.77%) could not answer what the word ‘depression’ meant to them.[4] In the Indian state of Maharashtra, 87.5% of community members did not acknowledge depression as a real medical illness.[10] However, participant groups frequently employed locally appropriate terminology when presented with a depression case study or vignette. Bangladeshi respondents referred to chinta rog or “worry illness”. [5] The Dari language speaks of asfurgdadi, the low mood and grief associated with hardships.[11] Using tailored vocabulary greatly improved communication between researchers and participants.[5] Both participants with depression and communities in general stressed the physical manifestations of the disease.[4, 5, 6, 9] The most commonly identified somatic symptoms associated with depression included fatigue, pain, numbness, sleeplessness, headache, breathlessness, and shaking.[5, 6, 9, 11] While several psychological symptoms were also listed,[5, 11] the physical aspects of the disease dominated and were often the main reasons to seek help.[6]

Aetiology of depression

An overwhelming majority of study participants described depression through a psychosocial understanding of its origins, emphasising the suffering individual’s social context. In rural Indian villages, depression is seen as an accumulation and escalation of grief or stress.[4] Many studies identified poverty and unemployment as major contributors to these pressures.[5, 6, 9] In Bangladesh it is believed that all tension rogs or “anxiety illnesses” are due to obhab, a (typically material) need of some kind caused by poverty.[5] Culturally specific financial stressors included an inability to provide dowry and education for all of one’s daughters.[5] Other stressors ranged from female reproductive problems and domestic violence to social inequality, injustice, and trauma.[4, 6, 9, 11] Refugees interviewed by Alemi et al. described language difficulties, family separations and cultural clashes.[11] A number of participants attributed depression to religious, supernatural or spiritual factors. A vignette about a woman with depression in Liu et al.’s study prompted participant theories about divine punishment and black magic.[4] Many raised the possibility of spiritual possession.[4] The Liu et al. study was an outlier in terms of biological explanations for aetiology— 54% of respondents linked depression to a disease of the brain and 33.8% believed it was inheritable.[4] The presentation of these options in a questionnaire, as opposed to the open-ended interviews of other studies, may have contributed to this divergence. But some of the external causative factors identified by participants, like “problems in the environment”[6] and polluted air,[4] also hint at a biological understanding of depression’s causes.

Perception of individuals with depression

Expressions of stigma were common. In two of the Indian studies the majority of individuals believed depression is a sign of weakness.[4, 10] In the Kermode et al. study,[10] 40% of community members concurred that people with depression are dangerous, 52.1% said they are erratic and 42.5% believed they should be avoided. Similarly, a large minority of respondents in the Liu et al. study described those with depression as unpredictable (43.8%), hard to talk with (40.5%), and a cause of familial shame (45.1%).[4] Despite this, most individuals expressed a willingness to remain the neighbours, friends and co-workers of someone with depression.[4, 10] These opinions were more likely in respondents who regarded depression as a “sign of weakness” instead of a genetic or biological disease. However, only 60.8% of participants were willing to accept someone with depression marrying into their family.[10] Bangladeshi respondents echoed these doubts about the marriage prospects of people with depression.[5]

Understandings of treatment

Most participants across the studies thought depression would be difficult—if not impossible—to remedy without assistance.[4, 10, 11] Pharmaceutical treatments were often poorly understood and warily regarded. Medication was restricted to treating the physical symptoms of depression.[9] Some participants were concerned about the addictive potential of using drugs to treat depression.[4] In Bangladesh, tablets were the option of last resort, partly due to cost.[5] Bangladeshi respondents instead prioritised poverty alleviation, good health and positive family relations.[5] Opinions of medical practitioners were generally positive. The patients in the Naeem et al. study professed a strong faith in doctors despite minimal awareness of their role in depression management and limited familiarity with non-pharmacological treatments like psychotherapy.[6] Sri Lankan undergraduate students who saw depression as a mental illness had confidence in medical experts[12] and refugees in Afghanistan also expressed faith in psychiatrists.[11] Opinions about traditional and religious healing modalities were mixed across the studies. In India, some respondents reported using herbal medicine to treat depression’s somatic symptoms,[9] and participants from Afghanistan sometimes consulted a tabib or herbal specialist.[11] A minority in the Indian, Bangladeshi, and Afghan samples identified religious practices, mantras and amulets as possible remedies.[5, 9, 11] Conversely, in another study, 63% of participants doubted traditional healers could successfully remedy depression, with more enthusiasm for their effectiveness only in conjunction with medical treatment.[4] None of the participants in the Pakistan study had visited a traditional healer, though one participant did recite passages from the Quran and perform the practice of do dum (or blowing air) on themselves as a form of self-help.[6] Several studies highlighted familial or social support as a particularly popular treatment option.[4, 5, 9] Bangladeshi respondents typically approached family members and close relatives before seeking help from other sources. Many of these individuals believed a community-based program would be the ideal way to address depression.[5] Other suggested treatments included involvement in communal activities,[5, 9] internal dialogue[9] and lifestyle changes such as eating right and exercising.[11] In Alemi et al., cultural activities, such as listening to Afghan music and visiting Afghanistan, were also named.[11]

Discussion

The reviewed literature suggests depression in South Asia is widely understood as a stress-related disease that emerges out of difficult socioeconomic circumstances and has primarily somatic manifestations. While those with depression are still subject to stigma, communal exclusion is rare.[4, 10] Familial and community assistance are the most accepted treatments for depression with medical intervention reserved for physical symptoms. [4, 5] South Asian respondents overwhelmingly favoured a psychosocial model of depression’s aetiology with minimal emphasis on biology. Empathy and understanding seemed highest when causal explanations of depression were linked to relatable hardships. Education campaigns and anti-stigma efforts may have more success if framed through this understanding of the disease compared to approaches rooted in biomedicine. In Kermode et al., individuals who related depression to a personal flaw (“weakness”) or extrinsic factors (e.g., family and financial problems) were less likely to socially distance themselves from people with depression compared to those who believed in a biological cause.[10] Biology may be seen to imply a lack of agency and the possibility of hereditary transmission, both of which negatively impact marriage prospects. This aetiological understanding of depression affects the acceptance of pharmacological interventions. While Indian respondents used pharmacological treatments for somatic symptoms, and drugs are seen as a valid last resort in Bangladesh,[5] the expense and arcane mechanisms of action of antidepressants may compromise adherence when they are prescribed. Nonpharmacological methods might be more acceptable despite remaining mostly unheard of in more rural areas. A study on university students in Pakistan, for example, found that cognitive behavioural therapy could be successful in that population provided interventions are tailored to South Asian cultural and religious values.[13] As depression is commonly attributed to external socioeconomic factors, programs addressing these wider social issues may reduce its prevalence. Studies investigating poverty alleviation as an intervention for depression have reported conflicting results in Uganda and Mexico.[14, 15] The evidence suggests depression interventions demand a multi-faceted approach. The importance of family and the community support for individuals with depression was a motif across the reviewed studies. South Asian countries are characterised by collectivistic cultures emphasising close family ties.[16] While family and the community participation in interventions can be extremely beneficial, the isolation and interpersonal conflict associated with stigma can be especially damaging. Community-based interventions were the ideal approach for participants in the Selim et al. study.[5] Education campaigns targeting the family and communities around individuals with depression may be fruitful.

Limitations

Due to the limited body of research on this topic as it relates to this region, not every South Asian country could be represented in this review. The included studies cannot be interpreted as reflecting universally held beliefs within their respective countries. The review also only included English-language studies, narrowing its scope further and perhaps excluding significant contributions from local research. It is possible participants were reluctant to openly share their traditional and religious beliefs with medical professionals or as part of a scientific study, resulting in their underrepresentation.[6]

Conclusion

This review aimed to present a general overview of how depression is perceived in the developing countries of South Asia. Considering these synthesised findings may help shape future public health efforts seeking greater success in improving education about depression and its treatment and prevention—in South Asia, and potentially in other developing countries where depression is similarly understood.

 

Acknowledgments
None

Conflicts of Interest
None declared

Correspondence
marisse.sonido@gmail.com

References
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2. World Health Organisation. Depression: World Health Organisation; 2018 [cited 2018 Aug 16]. Available from: http:// www.who.int/news-room/fact-sheets/detail/depression
3. World Health Organisation. Depression and other common mental disorders: global health estimates [Internet]. Geneva: World Health Organisation; 2017 [cited 2018 Aug 16]. Available from: http://apps.who.int/iris/bitstream/handle/10665/254610/ WHO-MSD-MER-2017.2-eng.pdf?sequence=1
4. Liu MC, Tirth S, Appasani R, Shah S, Katz CL. Knowledge and attitudes toward depression among community members in rural Gujarat, India. J Nerv Ment Dis. 2014;202(11):813–21.
5. Selim N. Cultural dimensions of depression in Bangladesh: a qualitative study in two villages of Matlab. J Health, Popul Nutr. 2010;28(1):95–106.
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9. Pereira B, Andrew G, Pednekar S, Pai R, Pelto P, Patel V.The explanatory models of depression in low income countries: listening to women in India. J Affect Disord. 2007;102(1):209–18.
10. Kermode M, Bowen K, Arole S, Pathare S, Jorm AF. Attitudes to people with mental disorders: a mental health literacy survey in a rural area of Maharashtra, India. Soc Psychiatry Psychiatr Epidemiol. 2009;44(12):1087–96.
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13. Naeem F, Gobbi M, Ayub M, Kingdon D. University students’ views about compatibility of cognitive behaviour therapy (CBT) with their personal, social and religious values (a study from Pakistan). Ment Health Relig Cult. 2009;12(8):847–55.
14. Ozer EJ, Fernald LCH, Weber A, Flynn EP, VanderWeele TJ. Does alleviating poverty affect mothers’ depressive symptoms? A quasi-experimental investigation of Mexico’s Oportunidades programme. Int J Epidemiol. 2011;40(6):1565–76.
15. Green EP, Blattman C, Jamison J, Annan J. Does poverty alleviation decrease depression symptoms in post-conflict settings? A cluster-randomized trial of microenterprise assistance in Northern Uganda. Glob Ment Health. 2016;3:e7.
16. Chadda RK, Deb KS. Indian family systems, collectivistic society and psychotherapy. Indian J Psychiatry. 2013;55(Suppl 2):S299–S309

Pornography: the psychological and neurological effects of a $97 billion industry

Review article

Bridie H Peters

 

Abstract

Aims: This review aims to summarise the research exploring the health effects of internet pornography

on its users. It focuses on pornography’s addictive potential, impact on sexual behaviours and mental

health.

Methods: The relevant literature concerning the health effects of internet pornography was reviewed.

Resources were sourced from databases such as PubMed and JSTOR.

Results: This review finds significant evidence for the addictive potential of pornography, validating

the consideration of pornography addiction as a clinical diagnosis. Pornography may also cultivate

misogynistic beliefs, affect the sexual functioning of its users and have some role in promoting sexually

aggressive behaviours. Poor mental health and pornography appear to have a bi-directional association.

Conclusions: The potential health effects of pornography are extensive and well-established. Given

the ubiquitous nature of this media, there may be significant clinical implications for these findings.

 

Background

The proliferation of the Internet has fostered a wild-fire growth of the pornography industry.[1] Pornography is more accessible and widely disseminated than ever before, accounting for a quarter of all internet searches and 1.5% of all websites.[2] However, this growth doesn’t come without concern. The cultivation of sexual abuse, misogyny and poor mental health are among some of the startling accusations made against this industry. [1,3,4] Given that 84% of Australian males and 23% of females aged 16-25 years use this media daily or weekly,[5] if these accusations hold water, they may have significant and widespread impacts. The following review aims to summarise the research on the health effects of pornography on its users.

Compulsive pornography use and addiction

There is considerable debate as to whether pornography has addictive potential and if it does, whether it is comparable to those of other addiction disorders (e.g. alcoholism, compulsive gambling). [6] These well-established addiction disorders are characterised by several common thought and behavioural patterns. These include but are not limited to: (a) perceived lack of control over the substance/ object of abuse; (b) adverse consequences from is use (e.g. relationship, social, work or school problems); (c) an inability to stop its use despite these negative consequences; and (d) preoccupation with the substance/ object of abuse.[7] These symptoms are being increasingly reported in patients who complain of pornography overuse. [6]

Pornography addiction is not at present a formally recognised clinical disorder in the DSM-V or ICD-10, however, the prevalence of these findings has led to the widespread use of Compulsive Pornography Use as a working clinical diagnosis. Many of the studies mentioned in this paper have recruited patients suspected to have this disorder. There is no consensus on the definition of this disorder, but as with other addictions, the aforementioned thought patterns are characteristic[7]. The prevailing argument contesting the recognition of Compulsive Pornography Use as a clinical disorder is the thought that these symptoms reflect a high sex drive in certain populations and are not suggestive of a pathological addiction.[8] Due to this debate, researchers have attempted to draw direct comparisons between those with suspected Compulsive Pornography Use and those with addiction to substances where the disorder is better defined and established (e.g. alcohol). One of the hallmarks of a substance use disorder is an increased desire for a substance without proportional pleasure from its use.[6] On fMRI neuroimaging this can be visualised as decreased striatal responsiveness to dopamine as the brain becomes tolerant to its effects.[9] Very similar findings have been found in patients with suspected pornography addiction. Their desire for this media far exceeds the pleasurable effects it has on them[10] and fMRI changes resemble those in patients with other substance use disorders.[11] Studies have found reduced grey matter volume in the right caudate and dampened putamen activation in those who compulsively use pornography.[12] These patients are also likely to have escalating levels of pornography usage, which supports the theory that a tolerance to pornography can develop.[13]

A predominant counter to these findings is that reduced striatal volume is a precondition for, not a result of increased pornography use.[12] This model argues that people with naturally lowered striatal volume require additional stimuli for dopaminergic responses. They are therefore more likely to consume large amounts of pornography. With this model, those with decreased striatal volume should be able to achieve the full pleasurable effects of pornography, even if more of it is needed.[12] However, there does not seem to be this expected positive dose-effect relationship between pornography use and pleasure.[10] Additionally, laboratory fMRI studies have shown that repeated viewing of sexual images can cause a down-regulation of the brain’s reward pathways.[14] This suggests pornography can play an active role in down-regulating the striatum. The dose-response relationship of this finding is yet to be established, and it remains unclear whether these findings are exclusive to high-volume users or those with other risk factors for addiction.

Gender roles and sexual behaviour

Another charge made against pornography is its potential to promote misogynistic attitudes and behaviours, particularly in males. In a review of 135 studies on the topic, it was found that sexualised media, of which pornography was included, was directly associated with “sexist beliefs … and greater tolerance of sexual violence toward women” in males. [15] This media may play a role in cultivating views that support female objectification, patriarchal ideologies and permissiveness towards female harassment. [1] This association is greatest when pornography is accessed during early adolescence (12-14 years). [16] Longitudinal research in this area is lacking, therefore these findings may simply suggest that people with these views consume greater amounts of pornography as it reaffirms their beliefs. Additionally, if pornography is to have a role in promoting sexist attitudes, the extent to which these opinions go on to influence interactions with others is unclear and difficult to determine.

The research attempting to establish the impact of pornography on sexual encounters is highly conflicted. A prevalent thought is that the violence depicted in its material desensitises viewers to sexual assault, increasing their propensity to commit sexual crimes. [17] This view is supported by findings that porn can increase acceptance of rape and sexual assault in males.[3,18] This influence on sexual violence seems to be greatest and perhaps limited to males with other risk factors for sexually aggressive behaviour. [1] These include: a history of family violence, a cultural upbringing promoting male dominance and toughness, attitudes accepting of violence and impersonal views of sex.[19] Pornography use in these high-risk individuals has been associated with an increased prevalence of forced vaginal, oral and digital penetration, sexually aggressive remarks and sex with animals.[1] This research challenges the argument of a cathartic role for pornography – that its usage can reduce the prevalence of sexual crimes committed in males as these sexual impulses are somewhat acted upon through pornography usage. The active role of pornography usage in promoting sexual assault is well-established in people with other risk factors for sexual assault, however, the causal link between pornography and sexual assault in most users is less strongly established and highly debated.[20] Therefore, pornography may play a role in fostering and validating attitudes that predispose some men to rape women, however, it may have little to no impact in males with no other risk factors for sexually aggressive behaviour.[1] There are many barriers to research into this question, not least the underreporting of sexual assault and the ubiquitous nature of this media.

While pornography may have a limited role in promoting sexually aggressive behaviour in most men, lowered libido and erectile dysfunction are widespread in pornography users.[21] In a study of adolescent males, 16% of those who consumed pornography more than once weekly reported low sexual desire, compared to 0% of those who did not.[22] Other sexual performance problems associated with pornography use include difficulty orgasming, decreased enjoyment of sexual intimacy, less sexual and relationship satisfaction and a preference for pornography over a sexual partner. c [23] Erectile dysfunction is also strongly associated with pornography use and when present, often occurs during intimate sexual relationships, but not to sexually explicit material.[10] Males who use pornography to stimulate sexual desire likely partially account for these findings. However, cessation of pornography use has on numerous accounts been recorded as an effective treatment for patients with sexual dysfunction, suggesting it does also play a causal role in this condition.[24,25] One longitudinal study has also found that pornography usage has a statistically significant role in predicting poor marital quality. Pornography usage was found not only to be a product of marital dissatisfaction, but a causal factor for such dissatisfaction. This media was the second greatest predictor of poor marital quality in the study, following only marital quality at the commencement of the study. These effects increase with frequency of pornography use and seemed to only apply to husbands who use pornography and not to wives. [26]

Mental health

With our society’s increasing interest in mental health, pornography’s impact in this area is beingheavily researched. Pornography usage is strongly associated with mental health disorders, loneliness, poor self-esteem and reduced quality of life. [5,27,28,29] An Australian study of 914 adolescents found that those who reported mental health problems in the last 6 months were 52% more likely to watch pornography at least once weekly than those who did not.[5] Masturbation to internet pornography has also been strongly associated with dissatisfaction in offline life and feelings of poor social support.[29] Pornography may play a causal role in this relationship, but equally, it may be a means by which adolescents aim to aid feelings of loneliness. Exploring the causal nature of this relationship, a study published earlier this year found that intentional exposure to pornography in adolescence was a predictive factor for depression and low self-esteem in later life.[30] On the other hand, a longitudinal study has also found that low self-esteem and depressive feelings in adolescent males are predictive of compulsive pornography use.[31] The extent to which poor mental health and pornography encourage each other is unclear. The increasing ubiquity of this media makes controlled longitudinal trials in this field difficult to conduct. Additional research exploring the therapeutic benefits of pornography cessation in patients with mental health disorders would be of great clinical benefit.

Conclusion

While much of the research exploring the health impacts of pornography is still inconclusive, there is still substantial and warranted concern surrounding this media. This field would greatly benefit from additional longitudinal studies which further clarify the causal role of pornography in promoting the health issues addressed above. The prolific use of this media does serve as a barrier to controlled studies in this field, but also stresses the need for further research, given the extensive clinical implications such findings may have. Additionally, this industry has transformed substantially this century with the proliferation of the internet, and the full impacts of this may yet be apparent.

 

Acknowledgements

Koshy Matthew & Tim Hanna.

Conflicts of interest

None declared.

Correspondence

bpeters7@myune.edu.au

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