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Explanatory models in patients with first episode depression: A study from North India
Asian Journal of Psychiatry 5 (2012) 251–257
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Explanatory models in patients with first episode depression: A study from North India Sandeep Grover *, Vineet Kumar, Subho Chakrabarti, Prabhakar Hollikatti, Pritpal Singh, Shikha Tyagi, Parmanand Kulhara, Ajit Avasthi Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 February 2012 Received in revised form 10 June 2012 Accepted 7 July 2012
The purpose of this work was to study the explanatory models of patients with first episode depression presenting to a tertiary care hospital located in North-western India. One hundred sixty four consecutive patients with diagnosis of first episode depression (except severe depression with psychotic symptoms) according to the International Classification of Diseases-10th Revision (ICD-10) and 18 years of age were evaluated for their explanatory models using the causal models section of Explanatory Model Interview Catalogue (EMIC). The most common explanations given were categorized into Karma-deedheredity category (77.4%), followed by psychological explanations (62.2%), weakness (50%) and social causes (40.2%). Among the various specific causes the commonly reported explanations by at least onefourth of the sample in decreasing order were: will of god (51.2%), fate/chance (40.9%), weakness of nerves (37.8%), general weakness (34.7%), bad deeds (26.2%), evil eye (24.4%) and family problems (21.9%). There was some influence of sociodemographic features on the explanations given by the patients. From the study, it can be concluded that patients with first episode depression have multiple explanatory models for their symptoms of depression which are slightly different than those reported in previous studies done from other parts of India. Understanding the multiple explanatory models for their symptoms of depression can have important treatment implications. ß 2012 Elsevier B.V. All rights reserved.
Keywords: Depression Explanations Culture Treatment
1. Introduction Depression is one of the most prevalent disorders worldwide. It is estimated that, by the year 2020, if current trends for demographic and epidemiological transition continue, the burden of depression will increase further and it would be the second leading cause of disability adjusted life years (DALYs), second only to ischaemic heart disease (Lopez et al., 2006). However, being a psychiatric illness with varied clinical manifestations, associated stigma and different conceptions of this disorder by patients and lay public, many patients do not seek treatment. Understanding how people conceptualize depression within and across cultures is crucial to its effective management. Kleinman used the term ‘‘explanatory model’’ to understand as to how an illness is conceptualized by patients, lay people, and clinicians (Kleinman, 1980). Over the years, many researchers have found differences in the explanatory models of the patients and the clinicians and this has been conceptualized and differentiated as etic and emic perspectives of illness (Littlewood, 1990). Etic models employ physician perspectives and are scientific
* Corresponding author. Tel.: +91 172 2756807; fax: +91 172 2744401/5078. E-mail address: [email protected] (S. Grover). 1876-2018/$ – see front matter ß 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2012.07.003
explanations, whereas emic models elicit patients’ perspectives and conceptualizations about the illness. These include beliefs and behaviours concerning aetiology, course, timing of symptoms, meaning of illness, roles and expectations. There is also evidence to show that explanatory models influence help seeking behaviour (Karasz, 2005), compliance with treatment and patient satisfaction. Studies from various parts of the world suggest many patients with depression and common mental disorders have non-medical causal models of the illness (Dejman et al., 2008; Hammarstro¨m et al., 2009; Niemi et al., 2010; Ying and Miller, 1992; Waite and Killian, 2009; Okello and Neema, 2007). In a study from Iran, most of the patients considered external stressors as the main cause of depression (Dejman et al., 2008). A study from Vietnam evaluated the explanatory models of depression and postnatal depression from nine mothers and nine health workers; it reported that the most common explanatory model is somatosocial in nature (Niemi et al., 2010). In a review of literature which focused on the genderrelated explanatory model for depression, it was seen that a biomedical model (especially gonadal hormones) was the most common model for understanding the symptoms of depression and this was followed by the sociocultural and psychological models (Hammarstro¨m et al., 2009). Further evidence suggests that somatization of emotional problems, differences in the causal
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attribution between patients and their significant others, the nature of the available health care system, and burden of infectious disease complicate access to care (Okello and Neema, 2007). It has also been reported that causal beliefs also influence the type of treatment patients seek out for their condition and the types of lifestyle changes they make to manage their illness (Petrie et al., 2008). Studies done in patients with physical illnesses also suggest that negative illness perception is associated with increased disability and slower recovery (Petrie and Weinman, 2006). There are few studies from India which have evaluated the explanatory models of patients presenting with common mental disorders (Ravi Shankar et al., 2006), depression (Pereira et al., 2007; Kermode et al., 2009, 2010), post-partum depression (Savarimuthu et al., 2010) and these also show that many patients have non-medical causal models of illness. Studies have also shown that many patients with psychological problems prefer to visit local faith healers before seeking help from medical professionals. The reason for the popularity of native healers is that they are easily accessible and available, and they provide culturally sensitive care (Ravi Shankar et al., 2006). Most of these studies are community based and have evaluated rural populations; none of these studies have evaluated the patients attending a psychiatric service. It is important to examine the explanatory models of this group of patients because, although they seek psychiatric treatment, many of them drop out of treatment and are non-adherent to treatment (Chakraborty et al., 2010). Further, many studies from India and other parts of the world are mostly limited to females (Dejman et al., 2008; Niemi et al., 2010; Waite and Killian, 2009; Pereira et al., 2007; Savarimuthu et al., 2010), because of the fact that depression is more common in females. An understanding of local patient perspectives can allow modern medicine to provide culturally sensitive and locally acceptable health care. Although some studies are available from other parts of India (Ravi Shankar et al., 2006; Pereira et al., 2007; Kermode et al., 2009; Chowdhury et al., 2001), no study is available from North India. North Indian culture has its roots from IndoAryan traditions and customs, with assimilation and impact from other cultures. In recent times it is one of the most economically prosperous regions of the country. Many mentally ill patients seek help from non-psychiatric physicians and religious faith healers. With this in mind, the present study aimed to study the explanatory models of patients with first episode depression presenting to a tertiary care hospital located in North-western India. 2. Methodology The purpose of the study was explained to the patients; they were recruited after obtaining written informed consent. The study was approved by the research review committee of the department which also provided ethical clearance. The study was carried out at the Department of Psychiatry of the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, which is a multi-speciality teaching tertiary-care hospital providing services to a major area of North India. This department is a general hospital psychiatric unit with both inpatient and outpatient facilities. The assessment of explanatory models of depression is one of the components of the larger study and these patients are also evaluated for pathways to care, attitude towards psychotropic medications, prevalence and typology of functional somatic symptoms and treatment compliance. In this paper, only data with respect to explanatory attribution of depressive symptoms is presented.
2.1. Sample The sample comprised of consecutive patients attending the Psychiatry outpatient walk-in-clinic. To be included in the study the patients were required to have diagnosis of first episode depression (except severe depression with psychotic symptoms) according to the International Classification of Diseases-10th Revision (ICD-10) and 18 years of age. Patients with comorbid axis-1 psychiatric disorder (except nicotine dependence and any other substance dependence, currently abstaining) were excluded. 2.2. Instruments Using the explanatory model list described as part of the Explanatory Model Interview Catalogue (EMIC), explanatory/ causal models of the patients were assessed. EMIC was designed by Weiss (1997) to elicit patients’ attributions of their presenting complaints, their previous help-seeking behaviour (including visiting a temple, a traditional healer, or a doctor), their causal models (e.g. previous deeds/Karma, evil spirits, punishment by god, black magic, or disease) and perceived consequences (change in the body or mind). It has been used successfully in a variety of countries and cultures, including India (Weiss et al., 1992, 1995). In EMIC the causal models section provides a list of 50 possible causes that are divided into 10 categories. Additionally there are two other categories described as ‘‘others’’ and ‘‘can’t say’’. In the present study the list of causal models described as part of EMIC was used to elicit causal models and data were collected only in quantitative form. Initially an open-ended query as described in EMIC – ‘‘People explain their problems in many different ways, sometimes ways that are different from what their doctors or other family may think. What do you think is the cause of your problem?’’ was stated to the patients to understand their perceived causes for current symptomatology and the responses were noted and appropriately coded according to EMIC categories. The patients were encouraged to describe as many reasons as possible for their symptoms. Later they were asked questions specifically eliciting various aetiological categories described as part of EMIC. At the end, they were asked to specify the most important explanatory model/aetiology for their symptoms. A standard list of questions was made to conduct the initial part of these interviews and to standardized the interview for all patients. Probing was done initially by open ended questions and depending on the responses, further questioning was conducted and closed ended questions were used in the end of the interview. 2.3. Procedure All patients diagnosed with first episode depression (as per ICD-10) were approached and told the purpose of the study. Patients who provided informed consent were evaluated on the inclusion and exclusion criteria and those who fulfilled the inclusion criteria were further evaluated. Socio-demographic data were recorded by Psychiatric Social Worker (PS, ST). The psychiatrist evaluating the patient recorded the clinical data. Patients were interviewed for explanatory/causal models by the Psychiatric Social Workers (PS or ST). 2.4. Statistical analysis Mean and standard deviation were calculated for continuous variables and frequencies and percentages were calculated for discrete variables. Comparisons were done using Chi-square test.
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Table 1 Perceived causes/explanatory models of depression. Causes
No explanation reported Reported at least 1 cause Ingestion Health-illness-injury-medical Weakness-nerves Social causes Psychological Victimization-abuse Sexual-reproductive functions Karma-deed-heredity Traditional Environment-sanitation Others Cannot say
Reported spontaneously
Reported on probing
Number (%)
Number (%)
74 90 5 7 9 36 47 0 1 11 0 0 0 74
11 153 18 23 82 66 102 7 10 127 1 32 5 11
(45.1) (54.9) (3) (4.3) (5.5) (22) (28.7) (0.6) (6.7)
(45.1)
(6.7) (93.3) (11.0) (14) (50) (40.2) (62.2) (4.3) (6.1) (77.4) (0.6) (19.5) (3.0) (6.7)
Most important cause reported on probing
98 3 5 8 24 40 0 2 15 0 1
(59.75%) (1.8) (3.0) (4.8) (14.63) (24.39) (1.2) (9.14) (0.6)
3. Results
3.3. Explanatory models
Four hundred twenty-six patients with diagnosis of first episode depression were approached and of these, 187 patients had associated axis-1 psychiatric comorbidity and 13 patients had severe depression with psychotic symptoms and were excluded from the study. Forty patients refused to participate in the study and the data were incomplete for 22 cases as patients did not complete all the assessments for the study. Thus, the final sample comprised 164 patients.
As shown in Table 1, 90 (54.9%) patients spontaneously reported at least one explanation for their depression, whereas 74 (45.1%) of patients did not report any explanation spontaneously. The explanatory models were most commonly categorized into psychological causes (as per EMIC) followed by social causes. Of the 90 patients who spontaneously reported at least one explanation, 68 (41.5%) reported explanation/s that could be categorized into one of the categories, 18 (10.97%) reported explanations belonging to two categories and 4 (2.45%) reported explanations belonging to three categories. However, even on probing, only 11 patients still could not give any explanation for their symptoms. The most frequently reported explanation was categorized to Karma-deed-heredity category, followed by psychological, weakness-nerves related and social causes in descending order. Frequency of other explanations is shown in Table 2. It was further seen that about one-fifth (20.1%) of patients gave two explanatory models and three-fifths (60.4%) gave three or more explanatory models. The mean number of explanations for the study sample was 2.85 (SD – 1.48, range 1–6). When asked to specify the most important cause, only 98 (59.75%) could specify a single most important cause for their symptom. Among the most important explanations, psychological causes were reported most frequently, followed by social causes and Karma-deed and heredity category. Table 2 shows the details of the various explanatory models given by the patients. Among the various specific causes, the commonly reported causes by at least one-fourth of the sample in decreasing order were: will of god, fate/chance, weakness of nerves, general weakness, bad deeds, evil eye and family problems.
3.1. Sociodemographic profile The mean age of the study sample was 41.19 (SD – 14.85) years. In terms of different age groups, 90.9% (N = 149) were aged between 18 and 64 years and the rest of the sample was aged 65 years or more. The mean duration of formal education was 10.44 (SD – 4.59) years. There was a majority of male patients (N = 85; 51.8%) and those who belonged to the Hindu religion (N = 86; 52.4%) and from a urban background (N = 89; 54.3%). Three-forth of the patients were married (N = 128; 78%) and over 80% were residents of neighbouring states (N = 135; 82.31%). A little over half of the sample was not on a paid employment (51.8%; N = 85), most of them were homemakers and student. The mean monthly income of the study sample was about 120 US dollars [6148 Indian rupees (SD – 12,418)]. One-sixth of the sample (N = 29, 17.7%) was of migrant population and the rest were natives of neighbouring states. 3.2. Clinical profile Approximately one-fourth (N = 45; 27.43%) of the patients had comorbid physical illness [18 patients had hypertension, 9 patients had both hypertension and diabetes mellitus, 1 patient had diabetes mellitus, 3 patients had epilepsy, 2 patients hypothyroidism and 12 patients had other physical illnesses]. History of alcohol (N = 6; 3.66%) or opioid dependence (N = 4; 2.44%) was present in very few patients. The mean duration of depression was 12.68 months (SD – 21.94 months; range 0.5–180 months; median = 6 months; mode = 2 months), with only 3 patients having duration more than 60 months. On further analysis, it was seen that mean duration of depression was 6 months or less in 57.7% (N = 94), between 6 months to 12 months in 21.4% (N = 35) and in rest of the patients the mean duration of illness was more than 12 months. Of the total 164 patients, 112 had never been treated with antidepressants and 52 had been prescribed as one of the antidepressants by a physician or a psychiatrist.
3.4. Comparison of explanatory models 3.4.1. Gender Certain differences were found between the two genders with respect to the explanation categories. Significant differences were found between the two genders with males more frequently reporting explanations categorized into ingestion and weakness category of EMIC. As shown in Table 2, when each explanation was compared between males and females, significant differences were found only for alcohol ingestion (male > females), work problems (male > females), evil eye (female > males) and other supernatural causes (female > males). 3.4.2. Locality No significant differences were seen in explanatory model categories between urban and rural population. In terms of specific
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254 Table 2 Perceived causes reported on probing. Causes
Ingestion Food/water Alcohol Smoking Abused drug Prescribed medicines Health-illness-injury-medical Injury-accident Prior illness Prior treatment Pregnancy-childbirth Anatomical-physical problem Weakness General weakness Nerves Social causes Family problem Marital problem Failure to marry Work problems Other interpersonal problems Psychological Bereavement Financial stress Other stress Personality difficulty Mind-thoughts-worry Loneliness Victimization-abuse Physical/sexual abuse-adult Child abuse-sexual/physical/psychological Sexual-reproductive functions Semen-vaginal fluid Masturbation Sexual experience Sexual identity Karma-deed-heredity Fate, chance Bad deeds Heredity Will of God Evil eye Sorcery Possession Neglect vows or rituals Astrology Other supernatural Traditional Heat-cold in body vat-pitt-kaph Environment-sanitation Environmental pollution Climate (hot-cold) Sanitation Personal hygiene Germs-infection Contamination Others Cannot say * ***
Reported on probing in total sample
Reported on probing in males
Reported on probing in females
Number (%)
Number (%)
Number (%)
N = 164
N = 85
N = 79
18 5 9 4 4 4 23 3 12 4 4 7 82 57 62 66 36 10 3 35 17 102 14 28 25 0 13 73 7 7 0 10 1 4 3 2 127 67 43 28 84 40 4 16 4 6 26 1 1 1 32 10 21 8 1 1 1 5 7
14 3 8 3 3 1 12 2 7 1 2 3 49 32 37 40 21 5 0 23 6 56 3 19 6 0 8 41 2 2 0 8 1 3 3 1 63 33 21 18 39 15 1 6 2 3 5 0 0 0 12 6 7 2 1 1 1 2 4
4 2 1 1 1 3 11 1 5 3 2 4 33 25 25 26 15 5 2 9 6 46 11 9 7 0 5 32 5 5 0 2 0 1 0 1 64 34 22 10 45 25 3 10 2 3 21 1 1 1 20 4 14 6 0 0 0 3 3
(11.0) (3.1) (5.5) (2.5) (2.5) (2.5) (14) (1.8) (7.3) (2.4) (2.4) (4.3) (50) (34.7) (37.8) (40.2) (21.9) (6.0) (1.8) (21.3) (10.5) (62.2) (8.5) (17.0) (15.2) (7.9) (44.5) (4.3) (4.3) (6.1) (0.6) (2.4) (1.8) (1.2) (77.4) (40.9) (26.2) (17.0) (51.2) (24.4) (2.4) (9.7) (2.4) (3.7) (15.9) (0.6) (0.6) (0.6) (19.5) (6.1) (12.8) (4.9) (0.6) (0.6) (0.6) (3.0) (4.3)
(16.5) (3.5) (9.4) (3.5) (3.5) (1.2) (14.1) (2.4) (8.2) (1.2) (2.4) (3.5) (57.6) (37.6) (43.5) (47.1) (24.7) (5.9) (27.1) (7.1) (65.9) (3.5) (22.4) (7.1) (9.4) (48.2) (2.4) (2.4) (9.4) (1.2) (3.5) (3.5) (1.2) (74.1) (38.8) (24.7) (21.2) (45.9) (17.6) (1.2) (7.0) (2.4) (3.5) (5.9)
(14.1) (7.1) (8.2) (2.4) (1.2) (1.2) (1.2) (2.4) (4.7)
(5.1) (2.5) (1.3) (1.3) (1.3) (3.8) (13.9) (1.3) (6.3) (3.8) (2.5) (5.1) (41.8) (31.6) (31.6) (32.9) (19.0) (6.3) (2.5) (11.4) (7.6) (58.2) (13.9) (11.4) (8.9)
Chi-square test
5.45* 3.78*
4.12*
6.39*
(6.3) (40.5) (6.3) (6.3) (2.5) (1.3) (1.3) (81.0) (43.0) (27.8) (12.7) (57.0) (31.6) (3.8) (12.7) (2.5) (3.8) (26.6) (1.3) (1.3) (1.3) (25.3) (5.1) (17.7) (7.6)
4.31*
13.15***
(3.8) (3.8)
p < 0.05. p < 0.001.
explanations, patients from urban locality significantly more often attributed depression to loneliness (rural – 27, urban – 46; Chi-square value – 4.05*; p = 0.04). 3.4.3. Marital status In terms of explanatory model categories, married subjects more frequently reported Karma-deed-heredity (single – 23,
married – 104; Chi-square value – 4.84*; p = 0.028) as an explanation for their symptoms. With regard to specific explanation, married subjects more frequently reported general weakness (single – 7, married – 50; Chi-square value – 4.76*; p = 0.029), loneliness (single – 22, married – 51; Chi-square value – 5.14*; p = 0.023), and bad deeds (single – 14, married – 29; Chi-square value – 3.82*; p = 0.05) as explanations for their depression.
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3.4.4. Education status The study sample was divided into two groups depending on the level of education (those with less than 10 years and those with 10 or more years of formal education). Significant differences were seen in terms of general weakness as an explanation, with those less educated more frequently reporting general weakness [less than 10 years of education – 21 (46.66%), 10 or more years of education – 36 (30.22%); Chi-square value – 3.88*; p = 0.049]. On the other hand, more educated patients explained their symptoms more frequently on the basis of pollution (less than 10 years of education – 0, 10 or more years of education – 10; Chi-square value – 4.02*; p = 0.045) and other supernatural causes (less than 10 years of education – 3 (6.66%), 10 or more years of education – 23 (19.32%); Chi-square value – 3.92*; p = 0.048). 3.4.5. Migrant status Compared to the native population (who originally belonged to the neighbouring states), migrant patients (who shifted to the catchment area from other states of India) more frequently gave family problems [migrant – 11 (37.93%), native population – 25 (18.52%); Chi-square value – 5.25*; p = 0.022] or other stress [migrant – 5 (17.24%), native population – 8 (5.92%); Chi-square value – 4.18*; p = 0.041] as an explanation for their symptoms. In terms of explanatory models categories as per EMIC, migrant populations less frequently reported health-illness-injury-medical (migrant – 0, native population – 23; Chi-square value with Yate’s correction – 4.42*; p = 0.036) explanations. 4. Discussion This study attempted to evaluate the explanatory models/ perceived causes held by patients with first episode depression attending a tertiary care hospital. The study included 164 consecutive patients who were assessed at their first contact with the outpatient services. With open ended query, nearly threefourth of the sample reported at least one explanation for their depression, of which psychological factors were the most commonly reported followed by social factors. However, on probing, the most frequently reported explanations were categorized to Karma-deed-heredity category, followed by psychological, weakness-nerves related and social causes in descending order. Further, most patients had more than one explanatory model for their symptoms and the mean number of explanations were 2.85 (SD – 1.48, range 1–6). When the patients were asked to specify the most important cause, the most frequently reported causal models were psychological in nature, followed by social causes and Karma-deed and heredity category. Sociodemographic factors had minimal influence on the explanatory models given by the patients. The beliefs and perspectives of illness held by patients, their families and the local culture are often subsumed in terms of the explanatory model. Cultural beliefs and practices affect nearly all aspects of psychiatry, especially assessments and diagnoses, illness behaviour and help seeking, mutual expectation of interaction between patients and practitioners and perceived quality of care (Weiss, 1997). Previous studies, which have evaluated the explanatory models of patients with depression and other common mental disorders and those of traditional healers, have been limited to the community dwelling rural sample (Dejman et al., 2008; Ravi Shankar et al., 2006; Pereira et al., 2007; Kermode et al., 2010; Savarimuthu et al., 2010; Patel et al., 1998; Nambi et al., 2002), most of whom do not seek psychiatric help. However, at present, the psychiatric services in India are better organized in the towns and cities. Although some of the patients do consult psychiatrists for their symptoms, many of them drop out of followup within a few months (Chakraborty et al., 2010). Among various
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determinants of treatment adherence, one is the belief held by patients about their illness. Hence, it is important to understand the explanatory model of patients seeking psychiatric help and then shortly dropping out of follow-up, so that interventions aiming to improve treatment adherence can be planned. Further, the previous studies from India and other parts of the world have mostly focused on women, based on the fact that depression is more common in women. However, previous studies from our centre suggest that there is nearly equal gender distribution with respect to help seeking in patients of depression (Chakraborty et al., 2010). Hence, it is important to understand the explanatory models of subjects of either gender. A large proportion of the sample (77.4%) reported ‘‘Karmadeed-heredity’’ to be an explanation for their symptoms. This higher occurrence of ‘‘Karma-deed-heredity’’ explanatory model in the present study’s findings reflects the influence of ancient Indian beliefs in Karma theory and Indian Personality. According to ‘‘Karma theory’’, one’s actions and deeds are automatic and mechanical, determined by fundamental law of nature that is automatic and mechanical. It is not something that is imposed by God or a god as a system of punishment or reward, nor something that the gods can interfere with (Varma, 2009a,b). Indian personality is understood as dependence-prone, traditional and religious (Varma, 2009a,b). Higher reporting of ‘‘Karma-deed-heredity’’ explanations in the present study is in contrast to earlier studies from other parts of India (Ravi Shankar et al., 2006; Pereira et al., 2007; Patel et al., 1998). This difference in explanatory model could be a true finding or may be due to differences in the study samples, for example, some of the earlier studies have been limited to women (Pereira et al., 2007), to those with common mental disorders (Patel et al., 1998), to those presenting with somatic symptoms alone (Nambi et al., 2002) or those limited to rural populations (Pereira et al., 2007). Another possible reason for the higher percentage of ‘‘Karma-deed-heredity’’ explanatory models could be higher coverage of the possible explanations held by the patients in the present study compared to the previous studies. As subcategories of ‘‘Karma-deed-heredity’’ explanatory models, about one-fourth of the patients attributed their depression to ‘‘baddeeds’’, which clearly explains the higher prevalence of ideas of guilt (Teja et al., 1971), especially in patients from North India (Gupta et al., 1982). Further, as sub-categories of ‘‘Karma-deedheredity’’ explanatory models, more than half of the patients attributed their symptoms to causes like evil eye, sorcery, possession, neglected vows or rituals, astrology and other supernatural causes. Higher prevalence of these explanations along with psycho-social models possibly explains the helpseeking behaviour of our patients, many of whom, although they continue to take treatment from medical practitioners/ psychiatrists, still keep on performing religious rituals and seek help from the faith healers (Kulhara et al., 2000). Previous studies from other parts of India, which evaluated explanatory models for common mental disorders and depression, have also reported psychological models (Ravi Shankar et al., 2006; Patel et al., 1998) or social explanations (Pereira et al., 2007) to be the most common explanations expressed by the patients (Ravi Shankar et al., 2006; Pereira et al., 2007; Patel et al., 1998). Findings of the present study are in line with these studies in as much that psychological and social explanations were among the most common explanations given by the patients for their symptoms. Higher prevalence of psychosocial explanatory models is also in concordance with the findings reported in non-western cultures. In a review of the literature on explanatory models of mental illness in sub-Saharan Africa, Patel (1995) reported that the understanding of psychotic illness closely resembled that of Western societies, but
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conceptual models of neurotic illness differed sharply from Western models. These neurotic conditions were invariably regarded as life situations. Higher prevalence of psycho-social explanatory models in the present study is also in agreement with the current bio-psychosocial model of depression (Schotte et al., 2006) and suggests that many patients hold appropriate explanations for their depressive symptoms. Another important finding of the present study is that half of the patients gave weakness (either general or weakness of nerves) as an explanation for their symptoms. This finding is similar to that reported in earlier studies which reported that many patients attribute their symptoms of depression, common mental disorders and functional somatic symptoms to physical causes (Ravi Shankar et al., 2006; Pereira et al., 2007; Kermode et al., 2010; Chowdhury et al., 2001; Patel et al., 1998; Nambi et al., 2002). Holding of these explanatory models possibly reflects a mechanism to escape blame and stigmatization associated with mental disorders (Pereira et al., 2007). In the present study, about one-fifth (20.1%) of patients gave two explanatory models and three-fifth (60.4%) gave three or more explanatory models. This finding again emphasizes the Indian model of causality that is described as non-linear and multifactorial, which is understood as ‘‘continuous ongoing interaction of every event with every other, with everything around it, everything before and after it’’ (Varma, 2009a,b). In the present study, certain differences were seen in the explanatory models held by patients of different gender, locality, marital status, level of education and migrant status. Female patients more often held explanatory models like evil eye and other supernatural causes. This finding can have important management implications, because depression as such is more prevalent in females and these explanatory models increase the chance of seeking alternative forms of treatment or help. Compared to patients from rural locality, patients from urban locality significantly more frequently attributed depression to loneliness. Attribution of depression to loneliness possibly reflects that breakdown of traditional joint families to nuclear families and decrease in social interaction in the society in general enhances social distancing and loneliness. Less educated people more frequently held physical illness based explanatory models. The difference in the explanatory models between native population and migrants reflects the difference in the type of stress faced by these different populations in their day-to-day functioning. The present study was limited to a population attending the outpatient clinic of a tertiary care hospital; hence, the findings cannot be generalized to a primary care population per se. Since the explanations/attributions of illness are related to help-seeking behaviour, the current results may not provide a representative picture of the whole population of North Indian people with depression since this study only assessed help-seeking individuals. The present study was also limited by its cross sectional nature and because we did not evaluate the influence/relationship of perceived causes with drug compliance. It is hoped that our study will encourage further research in this area that focuses on developing effective interventions based on the explanatory models held by patients of depression. To conclude, findings of the present study suggest that patients with depression have multiple explanatory models for their symptoms. Among the various explanatory models, Karmadeed-hereditary explanations are reported more frequently closely followed by psychosocial causes. These explanatory models seem to be influenced to a certain extent only by various socio-demographic variables. With respect to gender, the present study also included males and showed that there were significant differences between the two genders for aetiologies like
ingestion and weakness category (male > females), alcohol ingestion (male > females), work problems (male > females), evil eye (female > males) and other supernatural causes (female > males). The physicians and psychiatrists providing help to these patients should be aware of these explanatory models and should tailor the interventions accordingly so as to improve the treatment adherence and outcome of these patients. Future studies should evaluate community dwelling subjects of both genders with in depth interviews to have a better understanding of the explanatory models, help seeking behaviour, and expectations from treating agencies to improve the prognosis and reduce the morbidity and disability associated with depression. Funding None. Conflict of interest None to declare. References Chakraborty, K., Avasthi, A., Grover, S., Kumar, S., 2010. Functional somatic complaints in depression: an overview. Asian Journal of Psychiatry 3, 99–107. Chowdhury, A.N., Chakraborty, A.K., Weiss, M.G., 2001. Community mental health and concepts of mental illness in the Sundarban Delta of West Bengal, India. Anthropology & Medicine 8, 109–129. Dejman, M., Ekblad, S., Forouzan, A.S., Baradaran-Eftekhari, M., Malekafzali, H., 2008. Explanatory model of help-seeking and coping mechanisms among depressed women in three ethnic groups of Fars, Kurdish, and Turkish in Iran. Archives of Iranian Medicine 11, 397–406. Gupta, R., Khandelwal, S.K., Varma, V.K., Wig, N.N., Rao, U., Tripathi, B.M., 1982. Depressive symptoms—an inter-centre comparison. Indian Journal of Psychiatry 24, 380–382. Hammarstro¨m, A., Lehti, A., Danielsson, U., Bengs, C., Johansson, E.E., 2009. Genderrelated explanatory models of depression: a critical evaluation of medical articles. Public Health 123, 689–693. Karasz, A., 2005. Cultural differences in conceptual models of depression. Social Science & Medicine 60, 1625–1635. Kermode, M., Bowen, K., Arole, S., Joag, K., Jorm, A.F., 2009. Community beliefs about treatments and outcomes of mental disorders: a mental health literacy survey in a rural area of Maharashtra, India. Public Health 123, 476–483. Kermode, M., Bowen, K., Arole, S., Joag, K., Jorm, A.F., 2010. Community beliefs about causes and risks for mental disorders: a mental health literacy survey in a rural area of Maharashtra, India. International Journal of Social Psychiatry 56, 606– 622. Kleinman, A., 1980. Patients and Healers in the Context of Culture. University of California Press, Berkeley. Kulhara, P., Avasthi, A., Sharma, A., 2000. Magico-religious beliefs in schizophrenia: a study from north India. Psychopathology 33, 62–68. Littlewood, R., 1990. From categories to contexts: a decade of the ‘new crosscultural psychiatry’. British Journal of Psychiatry 156, 308–327. Lopez, A.D., Mathers, C.D., Ezzati, M., Jamison, D.T., Murray, C.J.L., 2006. Global Burden of Disease and Risk Factors. The World Bank, Washington. Nambi, S.K., Prasad, J., Singh, D., Abraham, V., Kuruvilla, A., Jacob, K.S., 2002. Explanatory models and common mental disorders among patients with unexplained somatic symptoms attending a primary care facility in Tamil Nadu. National Medical Journal of India 15, 331–335. Niemi, M.E., Falkenberg, T., Nguyen, M.T., Nguyen, M.T., Patel, V., Faxelid, E., 2010. The social contexts of depression during motherhood: a study of Explanatory Models in Vietnam. Journal of Affective Disorder 124, 29–37. Okello, E.S., Neema, S., 2007. Explanatory models and help-seeking behavior: pathways to psychiatric care among patients admitted for depression in Mulago Hospital, Kampala, Uganda. Qualitative Health Research 17, 14–25. Patel, V., 1995. Explanatory models of mental illness in sub-Saharan Africa. Social Science & Medicine 40, 1291–1298. Patel, V., Pereira, J., Mann, A.H., 1998. Somatic and psychological models of common mental disorder in primary care in India. Psychological Medicine 28, 135–143. Pereira, B., Andrew, G., Pednekar, S., Pai, R., Pelto, P., Patel, V., 2007. The explanatory models of depression in low income countries: listening to women in India. Journal of Affective Disorder 102, 209–218. Petrie, K.J., Broadbent, E., Kydd, R., 2008. Illness perceptions in mental health: issues and potential applications. Journal of Mental Health 17, 559–564. Petrie, K.J., Weinman, J., 2006. Why illness perceptions matter. Clinical Medicine 6, 536–539. Ravi Shankar, B., Saravanan, B., Jacob, K.S., 2006. Explanatory models of common mental disorders among traditional healers and their patients in rural South India. International Journal of Social Psychiatry 52, 221–233.
S. Grover et al. / Asian Journal of Psychiatry 5 (2012) 251–257 Savarimuthu, R.J., Ezhilarasu, P., Charles, H., Antonisamy, B., Kurian, S., Jacob, K.S., 2010. Post-partum depression in the community: a qualitative study from rural South India. International Journal of Social Psychiatry 56, 94–102. Schotte, C.K., Van Den Bossche, B., De Doncker, D., Claes, S., Cosyns, P., 2006. A biopsychosocial model as a guide for psychoeducation and treatment of depression. Depression & Anxiety 23, 312–324. Teja, J.S., Narang, R.L., Aggarwal, A.K., 1971. Depression across cultures. British Journal of Psychiatry 119, 253–260. Varma, V.K., 2009a. Ancient Indian concepts of reality, causality and cosmology. In: Varma, V.K., Kala, A.K., Gupta, N. (Eds.), Culture, Personality and Mental Illness. Jaypee Brothers, New Delhi, pp. 5–22. Varma, V.K., 2009b. Culture and Indian personality. In: Varma, V.K., Kala, A.K., Gupta, N. (Eds.), Culture, Personality and Mental Illness. Jaypee Brothers, New Delhi, pp. 177–187.
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Waite, R., Killian, P., 2009. Perspectives about depression: explanatory models among African-American women. Archives of Psychiatric Nursing 23 323–233. Weiss, M., 1997. Explanatory Model Interview Catalogue (EMIC): framework for comparative study of illness. Transcultural Psychiatry 34, 235. Weiss, M.G., Doongaji, D.R., Siddhartha, S., Wypij, D., Pathare, S., Bhatawdekar, M., Bhave, A., Sheth, A., Fernandes, R., 1992. The Explanatory Model Interview Catalogue (EMIC). Contribution to cross-cultural research methods from a study of leprosy and mental health. British Journal of Psychiatry 160, 819–830. Weiss, M.G., Raguram, R., Channabasavanna, S.M., 1995. Cultural dimensions of psychiatric diagnosis. A comparison of DSM-III-R and illness explanatory models in south India. British Journal of Psychiatry 166, 353–359. Ying, Y.W., Miller, L.S., 1992. Help-seeking behavior and attitude of Chinese Americans regarding psychological problems. American Journal of Community Psychology 20, 549–556.
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Explanatory models in patients with first episode depression: A study from North India Sandeep Grover *, Vineet Kumar, Subho Chakrabarti, Prabhakar Hollikatti, Pritpal Singh, Shikha Tyagi, Parmanand Kulhara, Ajit Avasthi Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 February 2012 Received in revised form 10 June 2012 Accepted 7 July 2012
The purpose of this work was to study the explanatory models of patients with first episode depression presenting to a tertiary care hospital located in North-western India. One hundred sixty four consecutive patients with diagnosis of first episode depression (except severe depression with psychotic symptoms) according to the International Classification of Diseases-10th Revision (ICD-10) and 18 years of age were evaluated for their explanatory models using the causal models section of Explanatory Model Interview Catalogue (EMIC). The most common explanations given were categorized into Karma-deedheredity category (77.4%), followed by psychological explanations (62.2%), weakness (50%) and social causes (40.2%). Among the various specific causes the commonly reported explanations by at least onefourth of the sample in decreasing order were: will of god (51.2%), fate/chance (40.9%), weakness of nerves (37.8%), general weakness (34.7%), bad deeds (26.2%), evil eye (24.4%) and family problems (21.9%). There was some influence of sociodemographic features on the explanations given by the patients. From the study, it can be concluded that patients with first episode depression have multiple explanatory models for their symptoms of depression which are slightly different than those reported in previous studies done from other parts of India. Understanding the multiple explanatory models for their symptoms of depression can have important treatment implications. ß 2012 Elsevier B.V. All rights reserved.
Keywords: Depression Explanations Culture Treatment
1. Introduction Depression is one of the most prevalent disorders worldwide. It is estimated that, by the year 2020, if current trends for demographic and epidemiological transition continue, the burden of depression will increase further and it would be the second leading cause of disability adjusted life years (DALYs), second only to ischaemic heart disease (Lopez et al., 2006). However, being a psychiatric illness with varied clinical manifestations, associated stigma and different conceptions of this disorder by patients and lay public, many patients do not seek treatment. Understanding how people conceptualize depression within and across cultures is crucial to its effective management. Kleinman used the term ‘‘explanatory model’’ to understand as to how an illness is conceptualized by patients, lay people, and clinicians (Kleinman, 1980). Over the years, many researchers have found differences in the explanatory models of the patients and the clinicians and this has been conceptualized and differentiated as etic and emic perspectives of illness (Littlewood, 1990). Etic models employ physician perspectives and are scientific
* Corresponding author. Tel.: +91 172 2756807; fax: +91 172 2744401/5078. E-mail address: [email protected] (S. Grover). 1876-2018/$ – see front matter ß 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2012.07.003
explanations, whereas emic models elicit patients’ perspectives and conceptualizations about the illness. These include beliefs and behaviours concerning aetiology, course, timing of symptoms, meaning of illness, roles and expectations. There is also evidence to show that explanatory models influence help seeking behaviour (Karasz, 2005), compliance with treatment and patient satisfaction. Studies from various parts of the world suggest many patients with depression and common mental disorders have non-medical causal models of the illness (Dejman et al., 2008; Hammarstro¨m et al., 2009; Niemi et al., 2010; Ying and Miller, 1992; Waite and Killian, 2009; Okello and Neema, 2007). In a study from Iran, most of the patients considered external stressors as the main cause of depression (Dejman et al., 2008). A study from Vietnam evaluated the explanatory models of depression and postnatal depression from nine mothers and nine health workers; it reported that the most common explanatory model is somatosocial in nature (Niemi et al., 2010). In a review of literature which focused on the genderrelated explanatory model for depression, it was seen that a biomedical model (especially gonadal hormones) was the most common model for understanding the symptoms of depression and this was followed by the sociocultural and psychological models (Hammarstro¨m et al., 2009). Further evidence suggests that somatization of emotional problems, differences in the causal
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attribution between patients and their significant others, the nature of the available health care system, and burden of infectious disease complicate access to care (Okello and Neema, 2007). It has also been reported that causal beliefs also influence the type of treatment patients seek out for their condition and the types of lifestyle changes they make to manage their illness (Petrie et al., 2008). Studies done in patients with physical illnesses also suggest that negative illness perception is associated with increased disability and slower recovery (Petrie and Weinman, 2006). There are few studies from India which have evaluated the explanatory models of patients presenting with common mental disorders (Ravi Shankar et al., 2006), depression (Pereira et al., 2007; Kermode et al., 2009, 2010), post-partum depression (Savarimuthu et al., 2010) and these also show that many patients have non-medical causal models of illness. Studies have also shown that many patients with psychological problems prefer to visit local faith healers before seeking help from medical professionals. The reason for the popularity of native healers is that they are easily accessible and available, and they provide culturally sensitive care (Ravi Shankar et al., 2006). Most of these studies are community based and have evaluated rural populations; none of these studies have evaluated the patients attending a psychiatric service. It is important to examine the explanatory models of this group of patients because, although they seek psychiatric treatment, many of them drop out of treatment and are non-adherent to treatment (Chakraborty et al., 2010). Further, many studies from India and other parts of the world are mostly limited to females (Dejman et al., 2008; Niemi et al., 2010; Waite and Killian, 2009; Pereira et al., 2007; Savarimuthu et al., 2010), because of the fact that depression is more common in females. An understanding of local patient perspectives can allow modern medicine to provide culturally sensitive and locally acceptable health care. Although some studies are available from other parts of India (Ravi Shankar et al., 2006; Pereira et al., 2007; Kermode et al., 2009; Chowdhury et al., 2001), no study is available from North India. North Indian culture has its roots from IndoAryan traditions and customs, with assimilation and impact from other cultures. In recent times it is one of the most economically prosperous regions of the country. Many mentally ill patients seek help from non-psychiatric physicians and religious faith healers. With this in mind, the present study aimed to study the explanatory models of patients with first episode depression presenting to a tertiary care hospital located in North-western India. 2. Methodology The purpose of the study was explained to the patients; they were recruited after obtaining written informed consent. The study was approved by the research review committee of the department which also provided ethical clearance. The study was carried out at the Department of Psychiatry of the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, which is a multi-speciality teaching tertiary-care hospital providing services to a major area of North India. This department is a general hospital psychiatric unit with both inpatient and outpatient facilities. The assessment of explanatory models of depression is one of the components of the larger study and these patients are also evaluated for pathways to care, attitude towards psychotropic medications, prevalence and typology of functional somatic symptoms and treatment compliance. In this paper, only data with respect to explanatory attribution of depressive symptoms is presented.
2.1. Sample The sample comprised of consecutive patients attending the Psychiatry outpatient walk-in-clinic. To be included in the study the patients were required to have diagnosis of first episode depression (except severe depression with psychotic symptoms) according to the International Classification of Diseases-10th Revision (ICD-10) and 18 years of age. Patients with comorbid axis-1 psychiatric disorder (except nicotine dependence and any other substance dependence, currently abstaining) were excluded. 2.2. Instruments Using the explanatory model list described as part of the Explanatory Model Interview Catalogue (EMIC), explanatory/ causal models of the patients were assessed. EMIC was designed by Weiss (1997) to elicit patients’ attributions of their presenting complaints, their previous help-seeking behaviour (including visiting a temple, a traditional healer, or a doctor), their causal models (e.g. previous deeds/Karma, evil spirits, punishment by god, black magic, or disease) and perceived consequences (change in the body or mind). It has been used successfully in a variety of countries and cultures, including India (Weiss et al., 1992, 1995). In EMIC the causal models section provides a list of 50 possible causes that are divided into 10 categories. Additionally there are two other categories described as ‘‘others’’ and ‘‘can’t say’’. In the present study the list of causal models described as part of EMIC was used to elicit causal models and data were collected only in quantitative form. Initially an open-ended query as described in EMIC – ‘‘People explain their problems in many different ways, sometimes ways that are different from what their doctors or other family may think. What do you think is the cause of your problem?’’ was stated to the patients to understand their perceived causes for current symptomatology and the responses were noted and appropriately coded according to EMIC categories. The patients were encouraged to describe as many reasons as possible for their symptoms. Later they were asked questions specifically eliciting various aetiological categories described as part of EMIC. At the end, they were asked to specify the most important explanatory model/aetiology for their symptoms. A standard list of questions was made to conduct the initial part of these interviews and to standardized the interview for all patients. Probing was done initially by open ended questions and depending on the responses, further questioning was conducted and closed ended questions were used in the end of the interview. 2.3. Procedure All patients diagnosed with first episode depression (as per ICD-10) were approached and told the purpose of the study. Patients who provided informed consent were evaluated on the inclusion and exclusion criteria and those who fulfilled the inclusion criteria were further evaluated. Socio-demographic data were recorded by Psychiatric Social Worker (PS, ST). The psychiatrist evaluating the patient recorded the clinical data. Patients were interviewed for explanatory/causal models by the Psychiatric Social Workers (PS or ST). 2.4. Statistical analysis Mean and standard deviation were calculated for continuous variables and frequencies and percentages were calculated for discrete variables. Comparisons were done using Chi-square test.
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Table 1 Perceived causes/explanatory models of depression. Causes
No explanation reported Reported at least 1 cause Ingestion Health-illness-injury-medical Weakness-nerves Social causes Psychological Victimization-abuse Sexual-reproductive functions Karma-deed-heredity Traditional Environment-sanitation Others Cannot say
Reported spontaneously
Reported on probing
Number (%)
Number (%)
74 90 5 7 9 36 47 0 1 11 0 0 0 74
11 153 18 23 82 66 102 7 10 127 1 32 5 11
(45.1) (54.9) (3) (4.3) (5.5) (22) (28.7) (0.6) (6.7)
(45.1)
(6.7) (93.3) (11.0) (14) (50) (40.2) (62.2) (4.3) (6.1) (77.4) (0.6) (19.5) (3.0) (6.7)
Most important cause reported on probing
98 3 5 8 24 40 0 2 15 0 1
(59.75%) (1.8) (3.0) (4.8) (14.63) (24.39) (1.2) (9.14) (0.6)
3. Results
3.3. Explanatory models
Four hundred twenty-six patients with diagnosis of first episode depression were approached and of these, 187 patients had associated axis-1 psychiatric comorbidity and 13 patients had severe depression with psychotic symptoms and were excluded from the study. Forty patients refused to participate in the study and the data were incomplete for 22 cases as patients did not complete all the assessments for the study. Thus, the final sample comprised 164 patients.
As shown in Table 1, 90 (54.9%) patients spontaneously reported at least one explanation for their depression, whereas 74 (45.1%) of patients did not report any explanation spontaneously. The explanatory models were most commonly categorized into psychological causes (as per EMIC) followed by social causes. Of the 90 patients who spontaneously reported at least one explanation, 68 (41.5%) reported explanation/s that could be categorized into one of the categories, 18 (10.97%) reported explanations belonging to two categories and 4 (2.45%) reported explanations belonging to three categories. However, even on probing, only 11 patients still could not give any explanation for their symptoms. The most frequently reported explanation was categorized to Karma-deed-heredity category, followed by psychological, weakness-nerves related and social causes in descending order. Frequency of other explanations is shown in Table 2. It was further seen that about one-fifth (20.1%) of patients gave two explanatory models and three-fifths (60.4%) gave three or more explanatory models. The mean number of explanations for the study sample was 2.85 (SD – 1.48, range 1–6). When asked to specify the most important cause, only 98 (59.75%) could specify a single most important cause for their symptom. Among the most important explanations, psychological causes were reported most frequently, followed by social causes and Karma-deed and heredity category. Table 2 shows the details of the various explanatory models given by the patients. Among the various specific causes, the commonly reported causes by at least one-fourth of the sample in decreasing order were: will of god, fate/chance, weakness of nerves, general weakness, bad deeds, evil eye and family problems.
3.1. Sociodemographic profile The mean age of the study sample was 41.19 (SD – 14.85) years. In terms of different age groups, 90.9% (N = 149) were aged between 18 and 64 years and the rest of the sample was aged 65 years or more. The mean duration of formal education was 10.44 (SD – 4.59) years. There was a majority of male patients (N = 85; 51.8%) and those who belonged to the Hindu religion (N = 86; 52.4%) and from a urban background (N = 89; 54.3%). Three-forth of the patients were married (N = 128; 78%) and over 80% were residents of neighbouring states (N = 135; 82.31%). A little over half of the sample was not on a paid employment (51.8%; N = 85), most of them were homemakers and student. The mean monthly income of the study sample was about 120 US dollars [6148 Indian rupees (SD – 12,418)]. One-sixth of the sample (N = 29, 17.7%) was of migrant population and the rest were natives of neighbouring states. 3.2. Clinical profile Approximately one-fourth (N = 45; 27.43%) of the patients had comorbid physical illness [18 patients had hypertension, 9 patients had both hypertension and diabetes mellitus, 1 patient had diabetes mellitus, 3 patients had epilepsy, 2 patients hypothyroidism and 12 patients had other physical illnesses]. History of alcohol (N = 6; 3.66%) or opioid dependence (N = 4; 2.44%) was present in very few patients. The mean duration of depression was 12.68 months (SD – 21.94 months; range 0.5–180 months; median = 6 months; mode = 2 months), with only 3 patients having duration more than 60 months. On further analysis, it was seen that mean duration of depression was 6 months or less in 57.7% (N = 94), between 6 months to 12 months in 21.4% (N = 35) and in rest of the patients the mean duration of illness was more than 12 months. Of the total 164 patients, 112 had never been treated with antidepressants and 52 had been prescribed as one of the antidepressants by a physician or a psychiatrist.
3.4. Comparison of explanatory models 3.4.1. Gender Certain differences were found between the two genders with respect to the explanation categories. Significant differences were found between the two genders with males more frequently reporting explanations categorized into ingestion and weakness category of EMIC. As shown in Table 2, when each explanation was compared between males and females, significant differences were found only for alcohol ingestion (male > females), work problems (male > females), evil eye (female > males) and other supernatural causes (female > males). 3.4.2. Locality No significant differences were seen in explanatory model categories between urban and rural population. In terms of specific
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254 Table 2 Perceived causes reported on probing. Causes
Ingestion Food/water Alcohol Smoking Abused drug Prescribed medicines Health-illness-injury-medical Injury-accident Prior illness Prior treatment Pregnancy-childbirth Anatomical-physical problem Weakness General weakness Nerves Social causes Family problem Marital problem Failure to marry Work problems Other interpersonal problems Psychological Bereavement Financial stress Other stress Personality difficulty Mind-thoughts-worry Loneliness Victimization-abuse Physical/sexual abuse-adult Child abuse-sexual/physical/psychological Sexual-reproductive functions Semen-vaginal fluid Masturbation Sexual experience Sexual identity Karma-deed-heredity Fate, chance Bad deeds Heredity Will of God Evil eye Sorcery Possession Neglect vows or rituals Astrology Other supernatural Traditional Heat-cold in body vat-pitt-kaph Environment-sanitation Environmental pollution Climate (hot-cold) Sanitation Personal hygiene Germs-infection Contamination Others Cannot say * ***
Reported on probing in total sample
Reported on probing in males
Reported on probing in females
Number (%)
Number (%)
Number (%)
N = 164
N = 85
N = 79
18 5 9 4 4 4 23 3 12 4 4 7 82 57 62 66 36 10 3 35 17 102 14 28 25 0 13 73 7 7 0 10 1 4 3 2 127 67 43 28 84 40 4 16 4 6 26 1 1 1 32 10 21 8 1 1 1 5 7
14 3 8 3 3 1 12 2 7 1 2 3 49 32 37 40 21 5 0 23 6 56 3 19 6 0 8 41 2 2 0 8 1 3 3 1 63 33 21 18 39 15 1 6 2 3 5 0 0 0 12 6 7 2 1 1 1 2 4
4 2 1 1 1 3 11 1 5 3 2 4 33 25 25 26 15 5 2 9 6 46 11 9 7 0 5 32 5 5 0 2 0 1 0 1 64 34 22 10 45 25 3 10 2 3 21 1 1 1 20 4 14 6 0 0 0 3 3
(11.0) (3.1) (5.5) (2.5) (2.5) (2.5) (14) (1.8) (7.3) (2.4) (2.4) (4.3) (50) (34.7) (37.8) (40.2) (21.9) (6.0) (1.8) (21.3) (10.5) (62.2) (8.5) (17.0) (15.2) (7.9) (44.5) (4.3) (4.3) (6.1) (0.6) (2.4) (1.8) (1.2) (77.4) (40.9) (26.2) (17.0) (51.2) (24.4) (2.4) (9.7) (2.4) (3.7) (15.9) (0.6) (0.6) (0.6) (19.5) (6.1) (12.8) (4.9) (0.6) (0.6) (0.6) (3.0) (4.3)
(16.5) (3.5) (9.4) (3.5) (3.5) (1.2) (14.1) (2.4) (8.2) (1.2) (2.4) (3.5) (57.6) (37.6) (43.5) (47.1) (24.7) (5.9) (27.1) (7.1) (65.9) (3.5) (22.4) (7.1) (9.4) (48.2) (2.4) (2.4) (9.4) (1.2) (3.5) (3.5) (1.2) (74.1) (38.8) (24.7) (21.2) (45.9) (17.6) (1.2) (7.0) (2.4) (3.5) (5.9)
(14.1) (7.1) (8.2) (2.4) (1.2) (1.2) (1.2) (2.4) (4.7)
(5.1) (2.5) (1.3) (1.3) (1.3) (3.8) (13.9) (1.3) (6.3) (3.8) (2.5) (5.1) (41.8) (31.6) (31.6) (32.9) (19.0) (6.3) (2.5) (11.4) (7.6) (58.2) (13.9) (11.4) (8.9)
Chi-square test
5.45* 3.78*
4.12*
6.39*
(6.3) (40.5) (6.3) (6.3) (2.5) (1.3) (1.3) (81.0) (43.0) (27.8) (12.7) (57.0) (31.6) (3.8) (12.7) (2.5) (3.8) (26.6) (1.3) (1.3) (1.3) (25.3) (5.1) (17.7) (7.6)
4.31*
13.15***
(3.8) (3.8)
p < 0.05. p < 0.001.
explanations, patients from urban locality significantly more often attributed depression to loneliness (rural – 27, urban – 46; Chi-square value – 4.05*; p = 0.04). 3.4.3. Marital status In terms of explanatory model categories, married subjects more frequently reported Karma-deed-heredity (single – 23,
married – 104; Chi-square value – 4.84*; p = 0.028) as an explanation for their symptoms. With regard to specific explanation, married subjects more frequently reported general weakness (single – 7, married – 50; Chi-square value – 4.76*; p = 0.029), loneliness (single – 22, married – 51; Chi-square value – 5.14*; p = 0.023), and bad deeds (single – 14, married – 29; Chi-square value – 3.82*; p = 0.05) as explanations for their depression.
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3.4.4. Education status The study sample was divided into two groups depending on the level of education (those with less than 10 years and those with 10 or more years of formal education). Significant differences were seen in terms of general weakness as an explanation, with those less educated more frequently reporting general weakness [less than 10 years of education – 21 (46.66%), 10 or more years of education – 36 (30.22%); Chi-square value – 3.88*; p = 0.049]. On the other hand, more educated patients explained their symptoms more frequently on the basis of pollution (less than 10 years of education – 0, 10 or more years of education – 10; Chi-square value – 4.02*; p = 0.045) and other supernatural causes (less than 10 years of education – 3 (6.66%), 10 or more years of education – 23 (19.32%); Chi-square value – 3.92*; p = 0.048). 3.4.5. Migrant status Compared to the native population (who originally belonged to the neighbouring states), migrant patients (who shifted to the catchment area from other states of India) more frequently gave family problems [migrant – 11 (37.93%), native population – 25 (18.52%); Chi-square value – 5.25*; p = 0.022] or other stress [migrant – 5 (17.24%), native population – 8 (5.92%); Chi-square value – 4.18*; p = 0.041] as an explanation for their symptoms. In terms of explanatory models categories as per EMIC, migrant populations less frequently reported health-illness-injury-medical (migrant – 0, native population – 23; Chi-square value with Yate’s correction – 4.42*; p = 0.036) explanations. 4. Discussion This study attempted to evaluate the explanatory models/ perceived causes held by patients with first episode depression attending a tertiary care hospital. The study included 164 consecutive patients who were assessed at their first contact with the outpatient services. With open ended query, nearly threefourth of the sample reported at least one explanation for their depression, of which psychological factors were the most commonly reported followed by social factors. However, on probing, the most frequently reported explanations were categorized to Karma-deed-heredity category, followed by psychological, weakness-nerves related and social causes in descending order. Further, most patients had more than one explanatory model for their symptoms and the mean number of explanations were 2.85 (SD – 1.48, range 1–6). When the patients were asked to specify the most important cause, the most frequently reported causal models were psychological in nature, followed by social causes and Karma-deed and heredity category. Sociodemographic factors had minimal influence on the explanatory models given by the patients. The beliefs and perspectives of illness held by patients, their families and the local culture are often subsumed in terms of the explanatory model. Cultural beliefs and practices affect nearly all aspects of psychiatry, especially assessments and diagnoses, illness behaviour and help seeking, mutual expectation of interaction between patients and practitioners and perceived quality of care (Weiss, 1997). Previous studies, which have evaluated the explanatory models of patients with depression and other common mental disorders and those of traditional healers, have been limited to the community dwelling rural sample (Dejman et al., 2008; Ravi Shankar et al., 2006; Pereira et al., 2007; Kermode et al., 2010; Savarimuthu et al., 2010; Patel et al., 1998; Nambi et al., 2002), most of whom do not seek psychiatric help. However, at present, the psychiatric services in India are better organized in the towns and cities. Although some of the patients do consult psychiatrists for their symptoms, many of them drop out of followup within a few months (Chakraborty et al., 2010). Among various
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determinants of treatment adherence, one is the belief held by patients about their illness. Hence, it is important to understand the explanatory model of patients seeking psychiatric help and then shortly dropping out of follow-up, so that interventions aiming to improve treatment adherence can be planned. Further, the previous studies from India and other parts of the world have mostly focused on women, based on the fact that depression is more common in women. However, previous studies from our centre suggest that there is nearly equal gender distribution with respect to help seeking in patients of depression (Chakraborty et al., 2010). Hence, it is important to understand the explanatory models of subjects of either gender. A large proportion of the sample (77.4%) reported ‘‘Karmadeed-heredity’’ to be an explanation for their symptoms. This higher occurrence of ‘‘Karma-deed-heredity’’ explanatory model in the present study’s findings reflects the influence of ancient Indian beliefs in Karma theory and Indian Personality. According to ‘‘Karma theory’’, one’s actions and deeds are automatic and mechanical, determined by fundamental law of nature that is automatic and mechanical. It is not something that is imposed by God or a god as a system of punishment or reward, nor something that the gods can interfere with (Varma, 2009a,b). Indian personality is understood as dependence-prone, traditional and religious (Varma, 2009a,b). Higher reporting of ‘‘Karma-deed-heredity’’ explanations in the present study is in contrast to earlier studies from other parts of India (Ravi Shankar et al., 2006; Pereira et al., 2007; Patel et al., 1998). This difference in explanatory model could be a true finding or may be due to differences in the study samples, for example, some of the earlier studies have been limited to women (Pereira et al., 2007), to those with common mental disorders (Patel et al., 1998), to those presenting with somatic symptoms alone (Nambi et al., 2002) or those limited to rural populations (Pereira et al., 2007). Another possible reason for the higher percentage of ‘‘Karma-deed-heredity’’ explanatory models could be higher coverage of the possible explanations held by the patients in the present study compared to the previous studies. As subcategories of ‘‘Karma-deed-heredity’’ explanatory models, about one-fourth of the patients attributed their depression to ‘‘baddeeds’’, which clearly explains the higher prevalence of ideas of guilt (Teja et al., 1971), especially in patients from North India (Gupta et al., 1982). Further, as sub-categories of ‘‘Karma-deedheredity’’ explanatory models, more than half of the patients attributed their symptoms to causes like evil eye, sorcery, possession, neglected vows or rituals, astrology and other supernatural causes. Higher prevalence of these explanations along with psycho-social models possibly explains the helpseeking behaviour of our patients, many of whom, although they continue to take treatment from medical practitioners/ psychiatrists, still keep on performing religious rituals and seek help from the faith healers (Kulhara et al., 2000). Previous studies from other parts of India, which evaluated explanatory models for common mental disorders and depression, have also reported psychological models (Ravi Shankar et al., 2006; Patel et al., 1998) or social explanations (Pereira et al., 2007) to be the most common explanations expressed by the patients (Ravi Shankar et al., 2006; Pereira et al., 2007; Patel et al., 1998). Findings of the present study are in line with these studies in as much that psychological and social explanations were among the most common explanations given by the patients for their symptoms. Higher prevalence of psychosocial explanatory models is also in concordance with the findings reported in non-western cultures. In a review of the literature on explanatory models of mental illness in sub-Saharan Africa, Patel (1995) reported that the understanding of psychotic illness closely resembled that of Western societies, but
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conceptual models of neurotic illness differed sharply from Western models. These neurotic conditions were invariably regarded as life situations. Higher prevalence of psycho-social explanatory models in the present study is also in agreement with the current bio-psychosocial model of depression (Schotte et al., 2006) and suggests that many patients hold appropriate explanations for their depressive symptoms. Another important finding of the present study is that half of the patients gave weakness (either general or weakness of nerves) as an explanation for their symptoms. This finding is similar to that reported in earlier studies which reported that many patients attribute their symptoms of depression, common mental disorders and functional somatic symptoms to physical causes (Ravi Shankar et al., 2006; Pereira et al., 2007; Kermode et al., 2010; Chowdhury et al., 2001; Patel et al., 1998; Nambi et al., 2002). Holding of these explanatory models possibly reflects a mechanism to escape blame and stigmatization associated with mental disorders (Pereira et al., 2007). In the present study, about one-fifth (20.1%) of patients gave two explanatory models and three-fifth (60.4%) gave three or more explanatory models. This finding again emphasizes the Indian model of causality that is described as non-linear and multifactorial, which is understood as ‘‘continuous ongoing interaction of every event with every other, with everything around it, everything before and after it’’ (Varma, 2009a,b). In the present study, certain differences were seen in the explanatory models held by patients of different gender, locality, marital status, level of education and migrant status. Female patients more often held explanatory models like evil eye and other supernatural causes. This finding can have important management implications, because depression as such is more prevalent in females and these explanatory models increase the chance of seeking alternative forms of treatment or help. Compared to patients from rural locality, patients from urban locality significantly more frequently attributed depression to loneliness. Attribution of depression to loneliness possibly reflects that breakdown of traditional joint families to nuclear families and decrease in social interaction in the society in general enhances social distancing and loneliness. Less educated people more frequently held physical illness based explanatory models. The difference in the explanatory models between native population and migrants reflects the difference in the type of stress faced by these different populations in their day-to-day functioning. The present study was limited to a population attending the outpatient clinic of a tertiary care hospital; hence, the findings cannot be generalized to a primary care population per se. Since the explanations/attributions of illness are related to help-seeking behaviour, the current results may not provide a representative picture of the whole population of North Indian people with depression since this study only assessed help-seeking individuals. The present study was also limited by its cross sectional nature and because we did not evaluate the influence/relationship of perceived causes with drug compliance. It is hoped that our study will encourage further research in this area that focuses on developing effective interventions based on the explanatory models held by patients of depression. To conclude, findings of the present study suggest that patients with depression have multiple explanatory models for their symptoms. Among the various explanatory models, Karmadeed-hereditary explanations are reported more frequently closely followed by psychosocial causes. These explanatory models seem to be influenced to a certain extent only by various socio-demographic variables. With respect to gender, the present study also included males and showed that there were significant differences between the two genders for aetiologies like
ingestion and weakness category (male > females), alcohol ingestion (male > females), work problems (male > females), evil eye (female > males) and other supernatural causes (female > males). The physicians and psychiatrists providing help to these patients should be aware of these explanatory models and should tailor the interventions accordingly so as to improve the treatment adherence and outcome of these patients. Future studies should evaluate community dwelling subjects of both genders with in depth interviews to have a better understanding of the explanatory models, help seeking behaviour, and expectations from treating agencies to improve the prognosis and reduce the morbidity and disability associated with depression. Funding None. Conflict of interest None to declare. References Chakraborty, K., Avasthi, A., Grover, S., Kumar, S., 2010. Functional somatic complaints in depression: an overview. Asian Journal of Psychiatry 3, 99–107. Chowdhury, A.N., Chakraborty, A.K., Weiss, M.G., 2001. Community mental health and concepts of mental illness in the Sundarban Delta of West Bengal, India. Anthropology & Medicine 8, 109–129. Dejman, M., Ekblad, S., Forouzan, A.S., Baradaran-Eftekhari, M., Malekafzali, H., 2008. Explanatory model of help-seeking and coping mechanisms among depressed women in three ethnic groups of Fars, Kurdish, and Turkish in Iran. Archives of Iranian Medicine 11, 397–406. Gupta, R., Khandelwal, S.K., Varma, V.K., Wig, N.N., Rao, U., Tripathi, B.M., 1982. Depressive symptoms—an inter-centre comparison. Indian Journal of Psychiatry 24, 380–382. Hammarstro¨m, A., Lehti, A., Danielsson, U., Bengs, C., Johansson, E.E., 2009. Genderrelated explanatory models of depression: a critical evaluation of medical articles. Public Health 123, 689–693. Karasz, A., 2005. Cultural differences in conceptual models of depression. Social Science & Medicine 60, 1625–1635. Kermode, M., Bowen, K., Arole, S., Joag, K., Jorm, A.F., 2009. Community beliefs about treatments and outcomes of mental disorders: a mental health literacy survey in a rural area of Maharashtra, India. Public Health 123, 476–483. Kermode, M., Bowen, K., Arole, S., Joag, K., Jorm, A.F., 2010. Community beliefs about causes and risks for mental disorders: a mental health literacy survey in a rural area of Maharashtra, India. International Journal of Social Psychiatry 56, 606– 622. Kleinman, A., 1980. Patients and Healers in the Context of Culture. University of California Press, Berkeley. Kulhara, P., Avasthi, A., Sharma, A., 2000. Magico-religious beliefs in schizophrenia: a study from north India. Psychopathology 33, 62–68. Littlewood, R., 1990. From categories to contexts: a decade of the ‘new crosscultural psychiatry’. British Journal of Psychiatry 156, 308–327. Lopez, A.D., Mathers, C.D., Ezzati, M., Jamison, D.T., Murray, C.J.L., 2006. Global Burden of Disease and Risk Factors. The World Bank, Washington. Nambi, S.K., Prasad, J., Singh, D., Abraham, V., Kuruvilla, A., Jacob, K.S., 2002. Explanatory models and common mental disorders among patients with unexplained somatic symptoms attending a primary care facility in Tamil Nadu. National Medical Journal of India 15, 331–335. Niemi, M.E., Falkenberg, T., Nguyen, M.T., Nguyen, M.T., Patel, V., Faxelid, E., 2010. The social contexts of depression during motherhood: a study of Explanatory Models in Vietnam. Journal of Affective Disorder 124, 29–37. Okello, E.S., Neema, S., 2007. Explanatory models and help-seeking behavior: pathways to psychiatric care among patients admitted for depression in Mulago Hospital, Kampala, Uganda. Qualitative Health Research 17, 14–25. Patel, V., 1995. Explanatory models of mental illness in sub-Saharan Africa. Social Science & Medicine 40, 1291–1298. Patel, V., Pereira, J., Mann, A.H., 1998. Somatic and psychological models of common mental disorder in primary care in India. Psychological Medicine 28, 135–143. Pereira, B., Andrew, G., Pednekar, S., Pai, R., Pelto, P., Patel, V., 2007. The explanatory models of depression in low income countries: listening to women in India. Journal of Affective Disorder 102, 209–218. Petrie, K.J., Broadbent, E., Kydd, R., 2008. Illness perceptions in mental health: issues and potential applications. Journal of Mental Health 17, 559–564. Petrie, K.J., Weinman, J., 2006. Why illness perceptions matter. Clinical Medicine 6, 536–539. Ravi Shankar, B., Saravanan, B., Jacob, K.S., 2006. Explanatory models of common mental disorders among traditional healers and their patients in rural South India. International Journal of Social Psychiatry 52, 221–233.
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