Childhood Depression: International Views and Treatment Practices

F. NESLIHAN INAL-EMIROGLU

RASIM SOMER DILER

KEY POINTS

An understanding of the complex role that cultural background, national medical traditions, and diverse experiences play in mental disorders is crucial for early diagnosis, treatment, and prevention.
Only a small proportion of children and adolescents affected by mental disorders receive adequate care.
The gap in meeting child mental health training needs worldwide is staggering.
The lack of epidemiologic data related to child and adolescent mental disorders in the developing world is well documented.
Reported prevalence rates of childhood depression across the world vary considerably.
Depression in children is considered in many countries to be a “temporary reaction to a stressor” or a “spiritual problem.”
Despite suggestions that a higher incidence of guilt feelings in Western cultures is related to the influence of the Judeo-Christian religious tradition, religion is largely reported as protective against suicide. When different religions are compared, the presence or absence of guilt feelings is associated with the level of education and the degree of depression but not with religious background.
In most countries, suicide in children and adolescents is considered to be “moderately” associated with depression.
Although the Classification of Mental and Behavioral Disorders by the World Health Organization (WHO) and the U.S. Diagnostic and Statistical Manual of Mental Disorders are widely accepted as the standard for statistical reporting, clinical use, and research, local diagnostic systems remain in some regions.
In nondeveloped countries, traditional healers, alternative medicine practitioners, and religious figures are consulted more readily than mental health professionals.
Psychotherapies that have been found useful for the treatment of depression in youth, such as cognitive behavioral therapy and interpersonal psychotherapy, are largely unavailable, but most clinicians provide counseling as well as supportive therapy and sometimes play therapy for the child and family.
Selective serotonin reuptake inhibitors (mostly fluoxetine), tricyclic antidepressants (such as imipramine and amitriptyline), and benzodiazepines (for comorbid anxiety and depression) are the most commonly used medications worldwide.

Introduction

An understanding of the complex role that cultural background, national medical traditions, and diverse experiences play in mental disorders is crucial for early diagnosis, treatment, and prevention. Children and adolescents younger than 18 years represent about half of the world’s population, although this varies widely from country to country. For example, the proportion of people younger than 15 years is 14% in Japan, 20% in the United States, 30% in Colombia, and 42% in Nigeria.1
Current epidemiologic data indicate that one in five has a mental health problem, and 3% to 4% have a serious mental disorder requiring treatment, with depression one of the most frequent.2 Only a small proportion of children and adolescents affected by mental disorders receive adequate care. The gap in meeting child mental health needs worldwide is staggering, with between a half and two-thirds of the need going unmet, with higher proportions in low- and middle-income countries.2

A cross-national examination of depression raises many issues, including the following: Do all youth, regardless of their culture, experience emotions in similar ways? Does the description of the experience of an emotion and its response to treatment change from culture to culture, or is it similar? This chapter describes the available literature regarding differences regarding the diagnosis and treatment of childhood depression across the world. To this end, we reviewed the few studies published and briefly present the results of a survey among psychiatrists/child psychiatrists carried out to gather information about practices to diagnose and treat depression in different countries (unpublished results). It is acknowledged that “country” and “culture” are not synonymous (e.g., several countries may share a similar culture, whereas several cultures often coexist in one country), but separating country and culture is difficult and both terms are used. Irrespective of culture, within-country differences are minimized because of homogeneous health delivery systems, health funding, and so on, and are more meaningful because of the availability of statistical data. Child is used to mean both children and adolescents unless specified otherwise.

EPIDEMIOLOGY

The absence of epidemiologic data related to childhood mental disorders in the developing world is well documented and confirmed by the World Health Organization’s ATLAS survey.2 Among high-income countries, 8 out of 20 (40%) have some form of epidemiologic data available, compared with 1 in 16 (6%) in low-income countries.2 Accordingly, research on cross-national aspects of depression in children is limited. Some of the difficulties in the cross-cultural study of depression stem from diagnostic conceptualization. Historically, psychiatrists in different countries have used different diagnostic concepts such as endogenous depression, reactive depression, depressive psychosis, neurotic depression, major depression, and dysthymic disorder, making it difficult to compare cross-cultural data. Standardized methods and uniform diagnostic criteria are crucial for cross-country epidemiologic study.

Reported prevalence rates of childhood depression across the world vary considerably from 1% to 14% (Australia, 14.2%; China, 13%; Brazil, 1%; Italy, 3.8%; Japan, 2.7%; Russia, 11%; Trinidad and Tobago, 14%; Turkey, 8%; and United Kingdom, 10%).3, 4, 5, 6, 7, 8, 9, 10, 11 However, studies used different samples, methodologies, and diagnostic instruments. A European study that sought to estimate the prevalence of childhood psychiatric disorders in four ethnic groups (Dutch, Moroccan, Turkish, and Surinamese) using best-estimate diagnoses reported an overall prevalence of psychiatric disorder of 11%; externalizing disorders (9%) were more common than mood disorders (2%). They also reported that the prevalence of childhood disorders did not differ between natives and immigrant children of low socioeconomic status from inner-city neighborhoods.12

CHILDHOOD DEPRESSION FROM A CULTURAL PERSPECTIVE

A symptom is a communication, an interpretation, and an experience, which is also a signal and a changing set of expectations and demands.13 Symptoms reveal the culture and its influences, whether they are expressed idiomatically or in conventional Western medical terms.13 Cultural considerations in the assessment, diagnosis, and treatment of childhood disorders are always necessary14 (see also Chapter 23); however, it is very difficult to disentangle what is nature (e.g., genetics, biology) and what is nurture (e.g., environment, society, culture). A universalistic orientation tries to incorporate both biologic or genetic factors and cultural or environmental factors in the understanding of human
behavior. As detailed by Choi,15 this orientation assumes the existence of common features in human development and mental health across ethnocultural groups, and it considers observable behaviors, expressions of emotion, and the manifestations of mental illness as shaped by culture.15 A recent study suggests that people from different cultures may weight facial cues in different parts of the face differently when interpreting emotional expressions: Americans focused on the mouth, whereas Japanese gave more weight to the eyes.16

It has been suggested the reported increase in rates of childhood depression in North America and Europe may reflect a lowering of the threshold for diagnosis.17 A recent meta-analysis reviewed studies between 1965 and 1996 that had used at least one structured diagnostic interview, finding no evidence for an increase in the prevalence of childhood depression over the past 30 years.18 It is possible that public perceptions of an epidemic may be the consequence of heightened awareness of a disorder that was long underdiagnosed, or the availability of better measures, screening programs, and new treatment options, resulting in more depressed children seeking help.18,19

There are many case reports about cross-cultural differences in the manifestation of depression. For example, it was reported that depressive symptoms in Afghanistan are similar to those in other countries, but in Afghanistan the majority of depressed patients express “passive death wishes” rather than active suicidal thoughts. Despite suggestions that a higher incidence of guilt feelings in Western countries is related to the influence of the Judeo-Christian religious traditions, religion is largely reported as protective against suicide.20 When different religions are compared, the presence or absence of guilt feelings is associated with the level of education and the degree of depression but not with religious background.21

The Indian value system is not based on the dichotomous view of the world central to Western thought (such as individual versus collective, humankind versus nature, body versus mind). Characteristics such as interdependence, interpersonal harmony and cooperation, and nonverbal and indirect communication are more valued in India and in other Eastern countries. These cultures are weary, if not critical, of the value placed by Western cultures on individualism and of the priority given to individual needs above those of the group.22

To explore variations in the meaning and subjective experience of depression, Tanaka-Matsumi and Marsella23 asked Japanese, Japanese American, and white American college students to associate a word with “depression.” They reported that Japanese do not describe (mild or ordinary) depression in the same way as Americans, nor do they express feelings in the same way. For the Japanese, concrete images from nature allow personal emotions to be expressed impersonally; as a result, they largely lack a personal reference or connection when expressing emotions.23

Asians generally experience greater family and social connections and support than do people in Western cultures. However, this could also be a result of poverty and need for survival. For example, growing problems in Singapore are associated with development and increasing wealth (e.g., family breakdown, not looking after elders), similar to those in many Western countries.24 It has been suggested that family support is protective against depression; rates of depression in Asian countries such as Japan, China, and Taiwan are reported to be lower than in the Western world.25 It is, however, questionable whether the prevalence of depression is truly lower in Asian countries or simply an artifact of cultural biases.15 Clinicians’ training and practice could also influence the reported rates of depression in those populations. For example, Israeli clinicians tend to give one primary diagnosis, whereas in the United States multiple diagnoses are very common. A study reported a significantly higher percentage of diagnoses of depression in U.S. adolescent psychiatric inpatients compared with Israeli ones (78% versus 24%); depression was mostly assigned as a secondary diagnosis in the U.S. sample but not in the Israeli sample.26

Hispanic cultures also place a greater emphasis on family than other Western cultures. Although support from the family is protective, poverty and lack of resources loom large in some of these countries.27 Rather than as feelings of guilt or low mood, depression is frequently experienced in somatic terms in Hispanic populations. Clinicians must be aware that depressed Hispanic youth may present with headaches, gastrointestinal and cardiovascular symptoms, or complaints of “nerves”28 (see Chapter 23). In this context, the use of “somatic” to refer to melancholic or endogenous aspects of the depressive syndrome can be confusing.28 It should be noted that presentations with somatic symptoms are not limited to Hispanic depressed children but are frequent in adolescents from other countries as well, such as Italians.29

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