Research reportManifestations of affective disturbance in sub-Saharan Africa: Key themes
Introduction
Over the past 50 years, there has been a sea change in how professionals have viewed depression and depressive disorders in Africa. Depression was commonly seen to be linked to sophistication, and Africans, as ‘unsophisticated’ and ‘lacking in responsibility’, were viewed as essentially incapable of suffering from depression. Infamously, Carothers (1951) argued that depression was rare in Africa, and ‘the African seldom uses his cortex’ (cited by Njenga, 2002: 356).
Two very recent thorough and systematic examinations of both formal and grey literature available on mental health issues in sub-Saharan Africa has shown that there is scant empirical information available on mental health issues on the continent (Gureje et al., 2006, Swartz et al., 2005). It remains true to say, however, that since the 1960's, epidemiological research has begun to show that depression is at least as common in Africa as in the rest of the world; some data in fact suggest that prevalence rates may be higher (Swartz, 1998). As McCulloch (1995) puts it:
During the 1960's there was a flood of publications on depressive illness in Africa, and Western-trained psychiatrists who for two generations had been unable to find any evidence of depression now found it in abundance… The symptoms presented by patients had not changed, nor had the nosology; what had changed was the capacity of clinicians to recognise them. (McCulloch, 1995: 113)
In spite of the sea change, and the increasing (though still scant) evidence of high prevalence rates of depression in Africa, there is a persistent focus on how depression is different in Africa, how there are no terms for ‘depression’ in many African languages, and on how depression in Africa does not present with cognitive and affective symptoms but rather is characterised by somatic presentation (to name a few examples). In this paper we will firstly provide a brief outline of the existing evidence regarding prevalence rates of depression in Africa, including a brief discussion of the gender differences in prevalence rates. Secondly, we will discuss the idioms of distress and the manner in which depressive symptomatology may be expressed in Africa, and the implications of this presentation for the diagnosis of affective disturbance in sub-Saharan Africa. We will also argue that while symptoms often present in a somatic form and that there is frequently a lack of a term for depression in many African cultures, careful inquiry and investigation often leads to a rich description of cognitive and emotional symptoms. We discuss issues associated with measurement and instrumentation in this regard. Finally, we will make a case for a possible move away from categorical descriptions of affective disturbance and suggest that a dimensional description such as common mental disorders may better account for the many idioms of distress with which people present throughout the world.
Section snippets
Prevalence rates
Epidemiological studies and data on prevalence rates of psychiatric disorders in Africa are limited. In addition, many of the studies that have been completed have used clinic attendance as a recruitment method (Institute of Medicine, 1996), thus introducing a potential bias. In an early study investigating psychiatric morbidity in pregnancy amongst women in semi-rural Uganda, Cox (1979) found that 16.7% of women had certain psychiatric morbidity, and 14.1% had uncertain psychiatric morbidity,
The question of gender differences
It has been argued that a consistent feature of psychiatric disorder prevalence studies across diverse societies is that there are few gender differences in overall rates of psychiatric disorder (Stewart et al., 2001). Others however, have argued that in fact there are marked differences in the rates of occurrence of mental disorders between the two sexes, with females showing higher incidence and prevalence rates compared with males (Institute of Medicine, 1996). Consistent epidemiological
Presentation of affective disturbance in Africa
Many of the debates about presentation of affective disturbance in Africa echo more general concerns about presentation of disorder in non-dominant cultures world-wide, including those in Asia and Latin America. The discussion which follows therefore applies not exclusively to African issues, but more generally to the context of cross-cultural assessment globally.
The comparison of psychopathology or psychological entities across cultures can be crudely split into two positions. The universalist
Instruments of assessment
When gathering data on manifestations of distress and depressive symptomatology a core consideration is whether or not the instruments are cross-culturally valid (Swartz, 1998). Patel et al. (2001) argue that instruments developed in one culture can be used in another providing careful attention is paid to conceptual translation. One example of the use of an instrument developed in a European context and used in a sub-Saharan African context was the use of the Edinburgh Postnatal Depression
Discussion and conclusions
Depression may be defined in different language by different cultures. In South Africa and many other contexts it may be referred to as ‘the nerves’, in East Timor as ‘wind blowing through one's body’ while in Western countries it may be described as ‘yuppie flu’. Acknowledging the fact that people throughout the world may have variable terminology for depression is not the same as the exoticising of Africa and other countries in the developing world. The danger is that when limitations are
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