Anxiety, Depression and Ethnicity

Chapter 8
Anxiety, Depression and Ethnicity

Waquas Waheed¹, Carolyn Chew-Graham² and Linda Gask³

¹ National School for Primary Care Research, University of Manchester, Manchester, UK

² Research Institute, Primary Care and Health Sciences and National School for Primary Care Research, Keele University, Keele, UK

³ University of Manchester, Manchester, UK

This chapter considers the influence of ethnicity on the presentation and management of anxiety and depression, and explores the challenges clinicians face in responding to people of different ethnic groups with these common mental health problems, using the South Asian cultures as an exemplar group. Later we discuss the opportunities and innovations that need to be created within the health services to meet the culture-specific needs of minority groups.

Anxiety and depression in people from ethnic minority groups

Anxiety and depression are the most common psychiatric illnesses amongst all ethnic groups. A high prevalence of depression has been reported amongst ethnic minorities living in developed countries. Research evidence for this high prevalence and associated risk factors mainly derives from people of South Asian origin residing in the UK and those of Spanish and Afro-Caribbean ancestry in the USA. This high prevalence of depression is also associated with reportedly higher episodes of self-harm and completed suicide amongst specific age groups amongst these ethnic minorities.

Among Afro-Caribbean people, rates of anxiety and depression appear to be lower in comparison with the general population, possibly because they seek help from alternative sources, such as herbalists or the church.

Depression in these groups is often reported along with additional symptoms of anxiety. As in any other ethnic group, it is observed that both conditions present with similar core symptoms but usually there are also culturally specific symptoms: south Asians in particular often describe ‘sinking of the heart’ or ‘gas in the abdomen’.

Research shows that depression often follows a comparatively long-term chronic course among these ethnic groups. This may be attributed to complex intertwined psychosocial maintaining factors, poor recognition and lack of treatment-seeking behaviour leading to lack of restitution of symptoms.

Culturally specific psychosocial risk factors

Ethnic density

Geographical areas where ethnic minorities are densely populated have lower prevalences of depression whilst ethnic minority people living in low-density areas have reported a high prevalence of depression. This phenomenon may be due to the fact that people living in low-density areas feel isolated and there is more of a cultural gap between them and people living in their neighbourhoods. On the contrary, those who are living in high-density areas may find their neighbours more supportive, and there is a greater match between their cultural norms and those people living around them.

Life events and difficulties

Research has demonstrated that life events and difficulties specific to ethnic minorities resident in the UK tend to persist over a longer period of time, are difficult to resolve, and are mainly related to interpersonal issues and physical health-related problems. The complexity of difficulties, and interplay between physical and mental health and social circumstances, is illustrated by the case of Robina in Box 8.1.

Disclosure of symptoms

People from some ethnic minority groups may not recognise their distress as depression – for example, this has been shown in Black Caribbean women with postnatal depression – or do not even have the vocabulary to describe their feelings in terms of labels such as ‘anxiety’ or ‘depression’.

People from some ethnic groups may be unwilling to disclose their problems to their GP. This may be because of stigma, but it has also been suggested that confidentiality is an issue, with some people fearing what they have disclosed to their GP might permeate into their community. Also it may be that GPs are less able to explore mood with people of some ethnic groups, and thus reluctant or unwilling to use labels of anxiety and depression. Robina (Box 8.1) illustrates the tendency to seek healthcare on return ‘home’, and GPs need to be aware that when patients return to the UK they may be taking alternative (or conventional) medicines.

Health service-related factors

Health services utilisation

Data from attendance of primary care reveals that people from ethnic minority groups, such as south Asians, tend to visit their GPs more frequently. However, these visits are more often for their physical health conditions and they consult their GP less frequently for, or are unable to disclose, psychological distress. People from other cultures may seek alternative care and support from within their community; fpr example, Chinese people may seek alternative care from Eastern healers, and south Asian people from imams.

Pathways to care

South Asian depressed patients, particularly females, may consult non-health professionals because of low mood, and it may take longer for them to eventually seek help from the NHS. Self-referral to IAPT (Improving Access to Psychological Therapy) services has been shown to facilitate access for people from south Asian groups.

Services within the NHS are provided at different tiers and accessed via multiple and often complex pathways. Thus the barriers that can negatively affect the provision of services are encountered at different locations within the health service. The NICE guideline ‘Common mental health disorders’ outlines approaches that may be used to reduce the barriers and facilitate access to care for people from under-served groups.

Clinical implications

It is important to consider the culturally specific psychosocial risk factors responsible for the higher prevalence of depression and anxiety in people from ethnic minority groups. It is also essential to note that this higher prevalence leads to poorer outcomes, not only for the mental health condition but for the associated physical conditions, which are also observed to be highly prevalent among ethnic groups, particularly diabetes and ischaemic heart conditions. Postnatal depression amongst South Asian groups has also been associated with poor physical health outcome and failure to thrive amongst children.

The UK Department of Health and the National Health Service (NHS) have recently emphasised the importance of meeting the needs of under-served groups. The document Inside Outside (see ‘Further reading’) calls for early recognition of symptoms, training of multidisciplinary staff to work with ethnic groups, and the requirement to tailor interventions to the specific needs of these groups to make them both more accessible and effective.

Management of depression and anxiety

Primary care clinicians should take the opportunity to explore mood when a patient with any long-term condition consults, and can use the case-finding questions (see Chapter 4). The clinician needs to be aware that words such as ‘anxiety’ and ‘depression’ may not be familiar to patients of some ethnic groups, and so finding a common language is important. Thus for Robina (Boxes 8.1 and 8.2), an awareness of her social and family circumstances, and sources of information and understanding about ‘mental health’ are vital when she does attend the practice.