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Pankhuri Aggarwal

Misfit pieces in a puzzle: What textbooks might not tell you about depression

4 minutes read

November 12,2020

There are many different reasons as to why people around the world pursue a career in mental health. Some are fascinated by the mystery of the human brain, some have a zest for helping people with psychological struggles, and some aspire to shape the future of the field. Whatever the reason may be, most individuals begin their training with obtaining a formal education in psychiatry, psychology or other mental health allied fields. It is likely that their training in mental health will introduce them to diagnostic manuals such as the DSM (Diagnostic and Statistical Manual of Mental Disorders, authored by the American Psychological Association) and the ICD (International Classification of Diseases, authored by the World Health Organization). Although these diagnostic tools provide a helpful template for diagnosing different mental health disorders, over the past few decades, the universality of some of these categories has been questioned.

The DSM is currently in its fifth edition and provides literature, tools, and descriptions that allow healthcare professionals to diagnose mental health disorders accurately. In the 1950s, its content was heavily influenced to appropriately capture the clinical presentation of World War II veterans and service members. Given that normality was defined in terms of social deviance and infrequency, it is not surprising that homosexuality continued to be classified as a mental health disorder until 1987. Even then, studies included in the DSM were representative of a small section of the global population (i.e., those who lived in North America and Europe) with little to no research conducted in low and middle-income countries and with individuals with stigmatized identities. While the series of changes with every new edition of the DSM reflected the latest research conducted in the field, it also began to question the stability of these diagnoses, especially across time and different cultural groups.

Specifically focusing on depression, the term depression itself has Latin roots, meaning "to press down" (Kress et al., 2005). In high-income countries, primarily in the West, individuals with depression may approach clinicians and report feeling 'blue' or 'down'. However, in many other cultures, people experiencing depression might not relate to this vocabulary, and may instead report feeling "empty" (Kleinman, 2004). When you use a questionnaire heavily based on language that is not a part of the inherent cultural experience, many respondents would not 'check' the box that asks if they're feeling 'down', as there is no other box that can effectively capture what they are experiencing. It is like someone trying to forcefully fit a puzzle piece in a spot where it does not belong…

In addition to differences in language, variations may also exist in the way depression is conceptualized across cultural groups. According to the DSM (American Psychological Association, 2013), depression can be best captured using three symptom clusters: affective symptoms (e.g., feeling low, crying), cognitive symptoms (e.g., lack of concentration, suicidal ideation), and somatic symptoms (e.g., fatigue, loss/gain of appetite). The DSM further states that these symptom clusters can lead to interpersonal and occupational difficulties, including social withdrawal, poor performance at work and so on. While such an explanation may hold true for individuals who define themselves relatively independent from others, more and more research studies are indicating that for individuals who define themselves in relation to others, interpersonal and occupational concerns might be primarily in the understanding of depression rather than secondary, as conceptualized in the DSM (Aggarwal et al., 2020; Chentsova-Dutton, Ryder, & Tsai, 2014; Koh et al., 2007). 

If we don't consider these social, academic, and occupational impairments as primary markers of depression, not only do we run the risk of missing out on accurately diagnosing depression, but also jeopardize the chances of successfully treating it.

In all, one must not forget to question the applicability of different concepts and phenomena to diverse contexts and not feel afraid of creating a system that truly acknowledges the cultural diversity we observe on a day-to-day basis. If we continue to force that piece of the puzzle to fit where it does not belong, we are likely to frustrate ourself or break the puzzle in the process, and neither of the options sounds good to a puzzle lover. 

  1. Aggarwal, P., Raval, V. V., Chari, U., Raman, V., Kadnur Sreenivas, K., Krishnamurthy, S., & Viswesweriah, A. M. (2020). Clinicians' perspectives of diagnostic markers for depression among adolescents in India: An embedded mixed-methods study. Culture, Medicine, & Psychiatry, 1-30. doi:10.1007/s1101302009680-8
  2. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, DC: American Psychiatric Association.
  3. Chentsova-Dutton, Y. E., Ryder, A. G., & Tsai, J. (2014). Understanding depression across cultural contexts. In I. Gotlib and C. Hammen (Eds.), Handbook of depression (3rd ed.) (pp. 337-354). New York: Guilford Press
  4. Kleinman, A. (2004). Culture and depression. New England Journal of Medicine, 351(10), 951-953. doi:10.1056/NEJMp048078
  5. Koh, J. B. K., Chang, W. C., Fung, D. S. S., & Kee, C. H. Y. (2007). Conceptualization and manifestation of depression in an Asian context: Formal construction and validation of a children's depression scale in Singapore. Culture, Medicine and Psychiatry, 31(2), 225-249. doi:10.1007/s11013-007-9048-0
  6. Kress, V. E. W., Eriksen, K. P., Rayle, A. D., & Ford, S. J. W. (2005). The DSM-IV-TR and Culture: Considerations for Counselors. Journal of Counseling and Development, 83(1), 97-104. doi:10.1002/j.1556-6678.2005.tb00584.x
Written By
Pankhuri Aggarwal

Pankhuri Aggarwal is a fourth-year doctoral candidate in the clinical psychology program at Miami University, Ohio. She received her bachelor's degree in psychology from Lady Shri Ram College for Women, Delhi University, and a master's degree in clinical psychology from Tata Institute of Social Sciences, Mumbai. She is a recipient of prestigious national and international awards including the PEO International Peace Scholarship, Patrick J. Capretta Memorial Scholarship, Marian K. Hume Named Scholar Award, Sir Dorabji Tata Trust Scholarship for Academic Excellence, and Gold Medal and Prize of Best Student in M.A. Applied Clinical Psychology.

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