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Literature Review on Depression
Depression alters one’s mood, making one feel sad and lose interest in people, events, and objects, and thus may cause physical and emotional problems. It may involve treatment in the long run if it persists, which includes medication and psychotherapy. This paper will focus on a detailed summary of other researchers’ work addressing the issue of depression using several databases and carry out a curative study on depression in full text. The following literature review is based on selected articles meeting the criteria of inclusion.
According to Lim et al. (2018), depression in the general population is a common mental health condition. It is highly associated with sadness, low self-esteem, poor concentration, anxiety, interest loss, and a feeling of being a quilt. The study also shows that the World Health Organization (WHO) predicted that depression will be ranked as the second global disease burden by 2020. The research also covered the nomothetic and idiographic measures of depression, which means that the assessed item is common to every person at different degree levels. In contrast, the idiographic measure is based on the distinct features and views of the patient. The study concludes that during the patient assessment on the defined objective of treatment, idiographic measures are preferred due to being more relevant.
An investigation done by Bernaras et al. (2019) states that depression is the main cause of disability-related illness in the world. The research focused on depression among children and adolescents since these two groups are agilely associated with high incidence. It also analyses the theories that construct and explain depression and provides an overview of disorders among children and adolescents. In this study, the authors conclude that depression in terms of the mental distinction between adults and children has no difference, and thus, the theory of explanation is highly taken into account to elaborate a better understanding of depression. The research further stated that treatment and prevention should be multifactorial (Bernaras et al., 2019). Besides, it is estimated that universal programs can be more efficient considering their wide application. The research results are limited in providing a good conclusion and fail to demonstrate any solid long-term efficacy.
Bernaras et al.(2019) in their examination found that biological factors such as tryptophan have a strong influence on the appearance of a depressive disorder. The increase seen in the prevalence of depression is explained by having negative interpersonal relations and the relationship with one’s surroundings accompanied by social-cultural changes. Additionally, the authors conclude that many instruments can be applied in elevating depression, but it is more important to have a continued test to diagnose the condition at the early stages. Regarding the prevention programs, the study suggested that they should be implemented at early initial ages, and finally, most depression treatments are more rigorous and effective.
Additionally, Health Quality Ontario (2017) suggests that the most diagnosed disorders in Canada on depression are major depressive and generalized anxiety disorders that are mostly associated with high disorders and economic hardship. It is important to note that the treatment of the two conditions is known to include pharmacological and psychological preventions. The highly used psychological interventions include cognitive-behavioral therapy (CBT), supportive therapy, and interpersonal therapy.
The study supports the fact that depression is the world’s second-largest health problem based on illness-induced disability. The three most used psychotherapeutic treatments which are well explained in this research include CBT, interpersonal therapy, and supportive therapy. CBT focuses on helping patients understand how automated thoughts on beliefs, expectations, and attitudes have a major contribution to anxiety and sadness. Interpersonal therapy aims to identify and solve problems through the establishment and maintenance of a satisfying relationship. Lastly, supportive therapy is an unstructured approach that relies on the basic interpersonal skills of the therapist.
Research conducted by Lu (2019) on adolescent depression on the topic of national trends, health care disparities, and risk factors shows that in the US, depression is a major cause of suicide among adolescents in aged between 10 and 19. Suicide is marked as the third major cause of death in the US, and research reflects that depression is the major factor in these cases. According to Lu (2019), depression is mostly underdiagnosed among adolescents, although mental health treatment is available. Lu (2019) states that if depression is not treated at the early age of an adolescent, it can have substantial negative effects on health and social results in late adolescence and adulthood.
Findings from the study revealed a growing number of untreated adolescents with major depression from 2011 to 2016 from the National Survey on Drug Use and Health (NSDUH) data. The research outcomes highlighted some of the major causes of depression among young people. Such factors include some sociodemographic, school, and family parameters, and the underutilization of mental health services. The study findings also highlight the importance of family and school in the treatment of depression. Finally, it was proved that adolescents with less family attention were more vulnerable to depression and less likely to receive mental and medical treatment.
The treatment of depression among adults in the United has been covered by a study done by Olfson et al. (2016). Based on the national survey conducted from 2001 to 2003, it was approximated that 49.5 percent of adults with a history of depression had not received any treatment, and about 48.4 percent had not received mental treatment over the past year (Olfson et al., 2016). According to the study, the US Preventive Service Task Force (USPSTF) has recommended adult screening on depression and a follow-up on the treatment that should be provided through a clinical setting arrangement.
The study findings showed that although there is the increased use of antidepressants, there still exists a gap in the treatment of depression. The number of adults who received screening for depression did not receive treatment that year. The research also showed that there was a low hood on receiving treatment to racial /ethnic minority groups. Regarding the application of antidepressants, the patient who had less serious depression had a high likelihood of receiving antidepressants than seriously depressed patients.
Antipsychotics, anxiolytics and mood stabilizers were mostly used to treat patients with higher than lower degrees of distress. Olfson et al. (2016) stated that this type of medication was mostly kept to treat patients with more complicated and resistant to treatment conditions. Antipsychotic treatment is suitable for patients with resistance to the use of antidepressants. Anxiolytics largely aid in managing anxiety problems that do not respond to the use of antidepressants. Finally, mood stabilizers help in the adjustment of agitations related to depression.
Research by Stark et al. (2018) on the issue of depression perspective in older primary care patients, treatment, and depression management opportunities showed that depression in old age is very common and has health-related consequences on the elderly. Research findings showed that symptoms like sadness and withdrawal are associated with older people. The consequences of depression can lead to death through suicide, social isolation, loss of family and work, and low esteem. The causes of the condition, as stated by Stark et al. (2018), are classified based on changing life events and internal factors.
According to Stark et al. (2018), depression does not only occur at young age people but is also a threat to older people. In age-related causes, the increased incidence of deaths among relatives can cause loneliness and boredom. Treatment of depression among older adults is possible. The main obstacles to the successful recovery from depression among the elderly, according to research, include beliefs on there is no treatment for depression among older people as well as fear of stigmatization. Similarly, it is believed that people should only care about their problems.
Research on adolescent depression, in particular, the one conducted by Lu (2019), has greatly contributed to literature work. Vrijen et al. (2016) have concentrated their research on predicting depression through the slow identification of facial happiness during early adolescent stages. As seen from previous research, depression remains a major concern in mental health problems. The study proved how facial emotions in the early ages of depression could predict depressive disorders and symptoms.
Research findings suggested that facial emotion identification prejudice may be a symptom corresponding trait marker for depressive disorder and anhedonia. The associations were found only based on multi-emotional models. The study found that individuals who portray sadness in comparison to happy ones are more likely to develop depression or anhedonia symptoms. The emotion identification effects on depressive disorders are mainly seen as carried by the symptoms of anhedonia but not symptoms of sadness. There is a relationship between symptoms of anhedonia and facial emotion identification (Vrijen et al., 2016). On the elimination of adolescents, the research findings were stronger on the predictive value on the identification of facial reactions for individuals with depressive disorders related to anhedonia and despair and may inversely be connected with facial identification of emotions.
Furthermore, depression and depressive symptoms among outpatients showed that the features are very common in people with mental disorders and gave a considerable number of effects on patient quality of health. The results of previous studies vary from the consideration presented in the research by Wang et al. (2017). In this study, it was found that the number of outpatients from otolaryngology clinics was higher, marking 53.0 %. The research also highlighted that depression was a mediator among conditions in otolaryngology.
The outcomes also have shown that there is a psychoneuroimmunology link between medical illness and depression. Besides, stroke burdens were found to cause depression among patients and their caregivers. For patience with stroke, it was found that novel rehabilitation interventions might reduce depression. A medical professional often overlooks depression or depressive symptoms due to not having been offered specific mental health training. In this research, it was found that outpatients between the age of 30 and 40 had related depression prevalence as compared to outpatients between the age of 80 and 90 years old. The result contradicts research done by Benaras et al. (2019) on depression among children and adolescents, which focused on the rise of the incidence of suicide cases caused by depression. Yang’s study showed that depression levels declined with age. The author presents different results as he stresses that there was no pattern on depression centering his argument on age.
Depression has been a global problem that has raised concerns among employees and employers. According to McCart and Nesbit (2020), the number of days of absenteeism in jobs results from depression is higher than those related to diseases like heart attack and hypertension all put together. According to the study, billions of dollars are spent on medical care, mortality due to suicide, and the loss of productivity as a result of depression. McCart and Nesbit (2020) have discussed a connection between disorders caused by depression and such chronic conditions as the unemployment period and the total income.
In the employment setting, research has shown that some reasons make it difficult to diagnose depression. In the workplace, employees can avoid diagnosis because of the lack of skills by physicians, stigma, unavailability of treatment and providers, restrictions on drugs, psychotherapeutic care, and limitations due to third-party coverage. The study results from most organizations lack a way of huddling the employee’s depression. Education institutions were found to be having programs that help depressed personnel. Other organizations stated that depression is a personal issue, and unless an employee asks for help, the services are not openly offered.
Among pregnant women, depression has been found to affect both the mother and the unborn child. Looking at both depression and anxiety during the period of antenatal and post-natal, there is a notable effect of depression among these groups. According to Smith et al. (2019), there is a preference in pregnant women for non-pharmacological treatment options; instead, they prefer the use of therapies and complementary medicines to manage the symptoms.
Martínez-Paredes and Jácome-Pérez (2019) conducted a similar study on depression among pregnant women, which confirmed that depression in this group is common psychiatric mobility. Diagnosis of depression is based on guidelines by the DSM-5 to validate scales like the Edinburgh Postnatal Depression Scale. According to medical professionals, the research also shows negative effects on the treatment, diagnosis, and recognition of the fetus. The study concluded that depression is a common condition among pregnant women, though it is underlooked as its symptoms are linked to pregnancy.
Several personal and mental effects are caused by depression among patients of total knee arthroplasty. Findings of the research have indicated that patients with higher education levels have less depression and are happier before surgery. Results have also illustrated that people with depression and anxiety were found to improve at a low rate than other groups. It also stated that patients with greater health were seen to have a considerable improvement in mental health. The conclusion of the research showed that the main determinant of physical, mental, and functional outcomes was depression.
Depression remains to be among the top five illnesses in the world, and research works have reflected that age does not matter, with everyone being at risk of developing the condition. In most studies, it is indicated as the main cause of suicide and death among children and adolescents. There are ways to help individuals suffering from despair such as the use of antidepressants among people with low depression levels. Likewise, early detection and treatment of the disorder can help individuals in their late adolescent stages and adulthood. Families can offer their support instead of contributing and worsening this condition.
Bernaras, E., Jaureguizar, J., & Garaigordobil, M. (2019). Child and adolescent depression: A review of theories, evaluation instruments, prevention programs, and treatments . Frontiers in Psychology, 10 (543), 1-24. Web.
Health Quality Ontario. (2017). Psychotherapy for major depressive disorder and generalized anxiety disorder: A health technology assessment. Ontario Health Technology Assessment Series, 17 (15), 1-167.
Lim, G. Y., Tam, W. W., Lu, Y., Ho, C. S., Zhang, M. W., & Ho, R. C. (2018). Prevalence of depression in the community from 30 countries between 1994 and 2014 . Scientific reports , 8 (1), 1-10. Web.
Lu, W. (2019). Adolescent depression: National trends, risk factors, and healthcare disparities . American Journal of Health Behavior, 43 (1), 181-194. Web.
McCart A, & Nesbit, J. (2020). S trategies to support employees with depression: Applying the Centers for Disease Control health scorecard . Journal of Depression and Anxiety, 9 (5), 1-4. Web.
Martínez-Paredes, J. F., & Jácome-Pérez, N. (2019). Depression in pregnancy . Revista Colombiana de Psiquiatría (English ed.) , 48 (1), 58-65. Web.
Moghtadaei, M., Yeganeh, A., Hosseinzadeh, N., Khazanchin, A., Moaiedfar, M., Jolfaei, A. G., & Nasiri, S. (2020). The Impact of depression, personality, and mental health on outcomes of total knee arthroplasty . Clinics in Orthopedic Surgery, 12 (4), 456-463. Web.
Olfson, M., Blanco, C., & Marcus, S. C. (2016). Treatment of adult depression in the United States . JAMA Internal Medicine, 176 (10), 1482-1491. Web.
Smith, C. A., Shewamene, Z., Galbally, M., Schmied, V., & Dahlen, H. (2019). The effect of complementary medicines and therapies on maternal anxiety and depression in pregnancy: A systematic review and meta-analysis . Journal of Affective Disorders , 245 , 428-439. Web.
Stark, A., Kaduszkiewicz, H., Stein, J., Maier, W., Heser, K., Weyerer, S., Werle, J., Wiese, B., Mamone, S., König, H., & Bock, J. O. (2018). A qualitative study on older primary care patients’ perspectives on depression and its treatments-potential barriers to and opportunities for managing depression . BMC Family Practice, 19 (1), 1-10. Web.
Vrijen, C., Hartman, C. A., & Oldehinkel, A. J. (2016). Slow identification of facial happiness in early adolescence predicts the onset of depression during eight years of follow-up. European Child & Adolescent Psychiatry, 25 (11), 1255-1266. Web.
Wang, J., Wu, X., Lai, W., Long, E., Zhang, X., Li, W.,… & Wang, D. (2017). Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis . BMJ Open , 7 (8). Web.
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A Literature Review of Studies of Depression and Treatment Outcomes Among U.S. College Students Since 1990
- Elissa J. Miller M.D., M.P.H.
- Henry Chung M.D.
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According to the fall 2007 American College Health Association-National College Health Assessment ( 1 ), a national survey of approximately 20,500 college students on 39 campuses, 43.2% of the students reported "feeling so depressed it was difficult to function" at least once in the past 12 months. More than 3,200 university students reported being diagnosed as having depression, with 39.2% of those students diagnosed in the past 12 months, 24.2% currently in therapy for depression, and 35.8% taking antidepressant medication. Among the students surveyed, 10.3% admitted "seriously considering attempting suicide" within the past 12 months and 1.9% actually attempted suicide during that period.
Although the above data may seem surprising to some, it is not to most mental health clinicians and administrators at U.S. colleges. According to the 2008 National Survey of Counseling Center Directors, 95% of respondents believe that there has been a trend in recent years of an increase in the number of students with serious psychological problems. In 2008 an estimated 26% of counseling center clients were taking psychiatric medication, up from 20% in 2003, 17% in 2000, and 9% in 1994 ( 2 ). And although the rate of suicide among college students may have decreased in recent decades ( 3 ), suicide remains the third leading cause of death among adolescents and young adults ( 4 ).
Many college administrators have begun to appreciate the effect that a student's depression can have on overall functioning in the college community. Depression has been linked to academic difficulties as well as interpersonal problems at school, with more severe depression correlated with higher levels of impairment ( 5 ). The treatment of depression among college students has been associated with a protective effect on these students' grade point averages ( 6 ). In an effort to diagnose and treat early and effectively, and thus decrease the excess morbidity and risk of suicide associated with depression, some U.S. colleges have even begun to screen students for depression in the primary care setting ( 7 ).
There are unique challenges of providing treatment to college students. These challenges include significant academic pressure in semester-based cycles, extensive semester breaks that result in discontinuities of care, and heavy reliance on community supports that can be inconsistent. Given the prevalence and impact of depression on college campuses and the varying services offered by university mental health centers throughout the United States, there is a significant need to evaluate successful models of treatment and their related outcomes.
The databases PsycINFO, MEDLINE, and CINAHL were searched for studies related to depression among U.S. college students and treatment outcome by using the following terms: "depression," "college or university or graduate or junior college or community college students," "colleges," "community colleges," "treatment and prevention," "empirical study," and "peer reviewed journal." Initially, no limitation was placed on years included in the search. Eighteen relevant publications were read and analyzed closely for method and content, with particular focus on location and inclusion criteria of study participants. Studies were eliminated if participants were students at colleges outside of the United States, if the studies did not have specific depression criteria for inclusion, or if the students included were at risk of depression but did not meet criteria for having depression. Nine remaining articles were reviewed further, and it was decided that the five studies published before 1990 had decreased relevance and would be excluded from this review in light of the growing availability of selective serotonin reuptake inhibitor medications since 1990, which substantially changed the treatment of depression among college students. In addition, the demographic characteristics of U.S. college students may have changed since the early 1990s, with many college counseling center directors noting a trend in recent years of an increase in students with serious psychological problems ( 2 ). Only four articles ( 8 , 9 , 10 , 11 ) remained for this review of depression and treatment outcomes of U.S. college students.
In 2007 Kelly and colleagues ( 8 ) conducted a nonexperimental study that recruited from introductory psychology classes university students with depression who were not currently in treatment, offering both financial compensation and class credit for research involvement. Sixty college students (66% Caucasian, 57% female) with major depression were followed for nine weeks without any treatment to assess for sudden gains (that is, precipitous improvements in depressive symptomatology), remission of depressive symptoms, and reversal of improvements. The authors found that 60% of the college students with major depression experienced sudden gains over the nine weeks of not receiving treatment. However, before the end of the nine-week observation period, more than half of these sudden gains reversed. At the end of the period of not receiving treatment, depression was in remission for 20% of the students. The authors concluded that sudden gains may be part of the natural course of depression for some college students, irrespective of treatment, and that self-evaluation processes may play an important role in recovery.
In 2000 Lara and colleagues ( 9 ) conducted a nonexperimental study in which undergraduate students taking psychology classes who had a recent-onset major depressive episode were paid or received course credit for their research participation. Eighty-four students (51% Caucasian, 86% female) were followed for 26 weeks to assess whether various psychosocial factors predicted the short-term course of major depression. The authors found that within the 26-week period of no treatment, 68% of the college students who were initially depressed recovered. Among those who recovered, 21% relapsed by the end of the 26-week period into another major depressive episode. Lara and colleagues concluded that college students with depression may sometimes spontaneously recover and relapse and that harsh discipline in childhood was significantly associated with higher mean levels of depression at follow-up and relapse but not with recovery.
In 2006 Geisner and colleagues ( 10 ) conducted a four-week randomized controlled trial of depression treatment and recruited undergraduates with depression who were enrolled in psychology courses to participate for course credit. The study enrolled 177 students with depression (49% Caucasian and 48% Asian, 70% female) who were randomly assigned either to an intervention group that received personalized mailed feedback or to a control group. The authors found that depressive symptoms improved for both the intervention and control groups, but in the intervention condition there was a significantly greater improvement of depressive symptoms, as measured by the DSM-IV-Based Depression Scale. There was no significant difference between the intervention and control groups on symptoms measured by the Beck Depression Inventory (BDI). Geisner and colleagues concluded that an intervention using personalized mailed feedback may be useful for reducing depressive symptoms among college students.
In 1993 Pace and Dixon ( 11 ) conducted a four- to seven-week randomized controlled trial to assess the treatment effectiveness of individual cognitive therapy for college students with depressive symptoms. Participating undergraduate students earned course credit for their research involvement. Seventy-four students (100% Caucasian, 81% female) who met strict criteria for study inclusion were randomly assigned to either a group that received individual cognitive therapy or a control condition where participants did not receive treatment and were put on a waiting list for cognitive therapy. Pace and Dixon found that 74% of participants in the cognitive therapy group (versus 33% in control group) were classified as nondepressed with BDI scores of less than 10 after four to seven weeks of treatment. At the one-month follow-up, 81% of participants in the cognitive therapy group (versus 64% of control group) were classified as nondepressed. Outcomes at both time points were statistically significant in favor of cognitive therapy. The authors concluded that brief individual cognitive therapy may effectively reduce mild to moderate depressive symptoms as well as depressive self-schemata among college students.
The current body of literature on depression and treatment outcomes among U.S. college students is sparse, and for the four studies we found, varying inclusion and exclusion criteria, assessment methods, and lengths of treatment make the interpretation of results difficult. Whereas Kelly and colleagues ( 8 ) and Lara and colleagues ( 9 ) used the Structured Clinical Interview for DSM-IV to diagnose participants with major depressive disorder, Geisner and colleagues ( 10 ) and Pace and Dixon ( 11 ) used self-report scales to measure depressive symptoms for study inclusion and Pace and Dixon excluded students with severe levels of depressive symptoms. All four studies recruited students who were not seeking treatment and who were offered course credit for participating, a reward that might have influenced the degree of improvement in outcomes. There was no consistent standard used across studies to define a student with depression, even when using the same assessment tool. In terms of length of treatment, only two of the four reviewed studies followed students for more than nine weeks. The length of time over which students are assessed is especially critical for the college population, where time is defined by a semester calendar, moods are often influenced by exam schedules, and treatments are adjusted to accommodate upcoming vacations ( 12 ). Today's college mental health services tend to employ short-term models of care (eight to 16 sessions), with referral to outside clinicians if longer-term treatment is necessary ( 13 ). Given these dynamics, future research in college mental health will need to establish quality standards for ongoing monitoring and follow-up of students' treatment outcomes.
Unfortunately, the results from these four studies may not be fully applicable to college students today or in the future, particularly in light of the changing demographic characteristics of those attending universities as well as the rapidly evolving role of pharmacology in the treatment of depression. Only two of the four studies reviewed offered any active treatment for depression, and none of the studies included any form of pharmacological treatment. Consistent with current medical literature and best practices, many treatment-seeking college students diagnosed as having depression currently receive psychotherapy and psychopharmacological treatment ( 1 ). Because major depression can be a chronic recurring condition, future research needs to evaluate the effectiveness of the various treatment modalities used to treat college students with depression. This is particularly important in light of the recent addition of a black-box warning for the use of antidepressant medications among young adults aged 18 to 24 years, which recommends the close monitoring of patients taking antidepressant medication for clinical worsening, suicidality, or unusual changes in behavior.
In light of the high prevalence of depression among college students today and the risks and sequelae this illness poses if not diagnosed and treated early and effectively, it is imperative that research funding be increased for both naturalistic and intervention studies of depression and treatment outcomes in the college health setting. First, research documenting depression and treatment outcomes in this cohort should be identified in order to evaluate the adequacy of current care. Second, research should be directed to assessing specific short-term or semester-based interventions for students with depression. Models that explore the effectiveness of integration with primary care, care management, medication, and short-term psychotherapy are all important targets for future study. By conducting such research, effective treatment models and benchmarks of treatment outcome in the college population can be developed and integrated into college mental health practice.
Acknowledgments and disclosures
The authors thank Michael Klein, Ph.D., for his assistance in the development of this brief report.
Dr. Chung has served on advisory boards for Takeda Pharmaceuticals and Lundbeck Pharmaceuticals and has served as a speaker for Pfizer and Jazz Pharmaceuticals. Dr. Miller reports no competing interests.
At the time of this report, Dr. Miller was a Public Psychiatry Fellow at New York State Psychiatric Institute and Columbia University, New York City. Dr. Chung is associate vice-president of student health at New York University Student Heath Center, New York City. Send correspondence to Dr. Miller at the New York State Psychiatric Institute, Columbia University, 1051 Riverside Dr., Box 111, New York, NY 10032 (e-mail: [email protected] ).
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How is depression experienced around the world? A systematic review of qualitative literature
a Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, United States
b Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD 21205, United States
c Duke University, Duke Global Health Institute & Department of Psychiatry and Behavioral Sciences, Durham, NC 27710, United States
d School of Social Work, Columbia University, 1255 Amsterdam Avenue, New York, NY 10027, United States
e Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, United States
f Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, United States
To date global research on depression has used assessment tools based on research and clinical experience drawn from Western populations (i.e., in North American, European and Australian). There may be features of depression in non-Western populations which are not captured in current diagnostic criteria or measurement tools, as well as criteria for depression that are not relevant in other regions. We investigated this possibility through a systematic review of qualitative studies of depression worldwide. Nine online databases were searched for records that used qualitative methods to study depression. Initial searches were conducted between August 2012 and December 2012; an updated search was repeated in June of 2015 to include relevant literature published between December 30, 2012 and May 30, 2015. No date limits were set for inclusion of articles. A total of 16,130 records were identified and 138 met full inclusion criteria. Included studies were published between 1976 and 2015. These 138 studies represented data on 170 different study populations (some reported on multiple samples) and 77 different nationalities/ethnicities. Variation in results by geographical region, gender, and study context were examined to determine the consistency of descriptions across populations. Fisher’s exact tests were used to compare frequencies of features across region, gender and context. Seven of the 15 features with the highest relative frequency form part of the DSM-5 diagnosis of Major Depressive Disorder (MDD). However, many of the other features with relatively high frequencies across the studies are associated features in the DSM, but are not prioritized as diagnostic criteria and therefore not included in standard instruments. The DSM-5 diagnostic criteria of problems with concentration and psychomotor agitation or slowing were infrequently mentioned. This research suggests that the DSM model and standard instruments currently based on the DSM may not adequately reflect the experience of depression at the worldwide or regional levels.
Depression is a major global public health problem. It is the leading cause of disability, with an estimated global point prevalence of 4.7% and is the eleventh leading cause of global disease burden ( Ferrari et al., 2012 ). While the majority of the world’s population lives in non-Western countries, much of the research used to describe the clinical presentation of depression has been done among populations in Western contexts (e.g., North American, European and Australian). Research and clinical work, particularly in North America, has informed the diagnostic criteria for depressive disorders in the Diagnostic and Statistical Manual, Fifth Edition (DSM-5; American Psychiatric Association, 2013 ) and in the International Classification of Disease, Tenth Edition (ICD-10; World Health Organization, 1992 ).
The DSM has its origins in attempts to track and classify mentally ill persons in institutions. The first edition of the DSM was released in 1952, largely based on psychodynamic theory, and contained 102 diagnostic categories roughly divided into conditions caused by organic brain dysfunction and conditions that resulted from the effects of the socio-cultural environment. The second edition (DSM-II) broadened the scope of the types of conditions that were included. The third edition (DSM-III) was a major turning point in American psychiatry. In response to growing criticism about what constituted true illnesses, as well as low reliability of ratings across evaluators and settings, a criteria-based classification system was developed based on the medical model of psychiatric illness. The system drew extensively from the Feighner criteria ( Feighner et al., 1972 ) developed by research psychiatrists at Washington University in St. Louis based on the clinical experience and research of their group and others within the USA. Other criteria were agreed upon during committee meetings held by the American Psychiatric Association. Criteria for Major Depressive Disorder have remained largely unchanged since the introduction of the DSM-III. They are now nearly ubiquitous in Western psychiatric practice and research ( Kawa and Giordano, 2012 ).
Criteria from the DSM and ICD have been widely used in psychiatric research among very different populations. In their review of 183 published studies on the mental health of refugees, Hollifield et al. (2002) found that 80% of the findings were based on instruments reflecting DSM or ICD criteria for common mental health disorders (Western instruments). Some workers in cross-cultural psychiatry and medical anthropology have criticized the accepted understanding of the construct and symptoms of depression as likely biased towards Western (i.e., North American, European and Australian) clinical populations ( Bass et al., 2007 ; Kleinman, 2004 ; Summerfield, 2012 ). Summerfield (2012) argues that repeatedly measuring the presence of “Western psychiatric templates [of disorders] cannot generate a universally valid knowledge base” because they may not represent the “nature of reality for the individuals under study,” (p. 5). In a meta-analysis of 20 studies, only 61% of participants endorsing culturally meaningful concepts of distress met criteria for depression ( Kohrt et al., 2014 ), suggesting that depression criteria may miss salient features of distress cross-culturally. Taken together, this suggests that the lack of information from non-Western populations may be a significant structural barrier to a worldwide understanding of depression.
If standard instruments based on Western psychiatric nosology are biased they cannot provide an accurate picture of depression worldwide. Their use for global research and practice assumes that Western symptoms of depression are reliable and valid indicators of depression for people in other contexts (i.e. etic approach). This contrasts with an emic approach that is primarily based on local data. Some researchers have combined etic and emic approaches in their study of depression, for example to inform existing (i.e. Western) scale adaptation (e.g., Applied Mental Health Research Group (AMHR), 2013 ; Haroz et al., 2014 ; Rasmussen et al., 2014a ; Rasmussen et al., 2014b ). These studies began with Western-developed instruments considered to have the best face validity based on local qualitative data, then augmented with context specific symptoms using the same qualitative data. However, instruments originally developed in Western populations, even if locally adapted and tested, may still retain a substantial Western bias. There may be symptoms that are important in other parts of the world but are not emphasized or even included in the Western model, and vice versa. Systematically identifying if there are any “missed symptoms” ( Summerfield, 2012 , p.5) and what they are, remains an area where research is needed.
What is needed is a broader, bottom-up, open-ended approach to better understand the applicability of DSM depression diagnostic criteria and whether there are other symptoms/features that represent the common experience of depression in populations worldwide. Some researchers have done this already -- used a grounded-theory approach in which “depression” is not the starting point. Instead, they have used open-ended qualitative methods without reference to Western diagnostic criteria to better understand mental illness in the local context ( Bolton, 2001 ; Bolton et al., 2012 ). However, a few isolated studies of specific populations, taken separately, are not sufficient to identify important cultural similarities and differences. A truly open ended approach covering a wide range of populations, is not feasible in a single study. Therefore, we sought to consolidate the information gathered from decades of open-ended qualitative research, in order to begin to characterize how depression is expressed and experienced in a wide variety of populations.
To the best of the authors’ knowledge there have been no systematic reviews of qualitative studies of depression features across cultures. Most previous research in this area has used quantitative data to compare differing patterns of symptom endorsement (e.g., Dere et al., 2013 ; Haroz et al., 2016 ). The reviews of qualitative studies that do exist have evaluated related topics, including perceived causes and preferred treatments for depression ( Hagmayer and Engelmann, 2014 ), perceived barriers to accessing treatment for postpartum depression ( Dennis and Chung-Lee, 2006 ), and perceived risk factors for postpartum depression in Sub-Saharan Africa ( Wittkowski et al., 2014 ). Other primary research studies have compared the expression of depression in multiple ethnic groups in a single country (c.f. Lawrence et al., 2006 ) and attributions and expressions of postpartum depression across sites in multiple countries ( Oates et al., 2004 ). One of the most comprehensive cross-cultural explorations of depression is the edited book by Kleinman and Good ( Kleinman, 1985 ) that includes chapters from clinical and anthropological perspectives examining the influences of culture in shaping depression. However, there remains no comparison of qualitative studies of depression features across cultural settings.
We undertook this review to address several gaps in the literature. First, this review marks an early attempt to consolidate the information on how depressive-like illness is expressed and experienced by people worldwide. Our hope is that by consolidating this information we will be able to better inform our understanding of how depression manifests across cultures. Second, we wanted to determine if concerns (e.g., potential missed symptoms/features) with cross-cultural instrument adaptation and testing were warranted, based on existing data. Findings from this review may help to improve cross-cultural measurement of depression. We intentionally used a neo-Kraepelinian approach ( Compton and Guze, 1995 ; Rasmussen et al., 2014b ) focusing solely on symptoms/features, in an effort to have our results inform self-report measurement instruments, as well as, Western psychiatric nosology as represented by the diagnostic criteria in the DSM. We intend that this review will encourage further relevant research contributing to a comprehensive picture of how depression presents and should be measured worldwide.
2.1. Literature search
Qualitative literature related to depression was examined through a search of peer-reviewed academic journals and solicitation of non-peer-reviewed programmatic reports related to mental health programs. The literature review followed PRISMA guidelines ( Moher et al., 2009 ) (See Supplemental Material for PRISMA checklist). The first search was done between August 2012 and December 2012. The search strategy involved using a multi-step search of nine databases including Pubmed, Web of Science, PsycInfo, Scopus, Embase, Anthrosource, Anthropology Plus, Global Health, and Sociological Abstracts. The first step in the search used the following terms: “depression,” “depressive disorder,” “melancholia,” and “depressive disorder, major.” Once those results were returned, the second step involved reviewing this subset of records for the terms “anthropology,” “qualitative,” “ethnography,” “cross-cultural comparison,” “ethnopsychology,” cultural characteristics,” “cross cultur*,” “phenomenology,” “cultural concepts of distress” “culture-bound” and “idioms of distress.” Study titles, abstracts, and subjects were searched and MeSH terms were used when possible. After this initial search, Google Scholar (up to the first 10,000 hits) was used to find additional references that were not identified during the initial search. Finally, the bibliography of any identified review article was searched for potentially relevant citations, and if any records not already identified were listed in the bibliography, these were included for full-text review. The process was repeated in June 2015 in order to update the search and include all records published between December 30, 2012 and May 30, 2015. No date limits were set for inclusion of articles.
Our search terms were chosen for practical reasons in an effort to efficiently identify highly relevant records. Using depression and related terms as a starting point, rather than a broader more open ended search, was done to limit the number of hits to those thought to be most relevant. However, by taking this approach, our results may be biased towards Western psychiatric nosology because we are reviewing research that has already been defined in this way.
The titles and abstracts of all records that arose during the search process were reviewed to determine if they met inclusion criteria. Authors EH and MR screened all abstracts and full texts for eligibility. Random selections of approximately 5% of abstracts and 20% of full-texts were double screened to evaluate consistency of inclusion determination. Inter-rater reliability was calculated for record eligibility determination during abstract and full-text reviews, using a Kappa statistic. A Kappa of 0 indicates less than chance agreement; 0.01–0.20 slight agreement; 0.21–0.40 fair agreement; 0.41–0.60 moderate agreement; 0.61–0.80 substantial agreement; and 0.81–0.99 indicates almost perfect agreement ( Viera and Garrett, 2005 ).
2.2. Inclusion criteria
Inclusion criteria were: 1) record utilized qualitative methods; 2) record had depression as the main focus; 3) record included information on features of depression; 4) record was written in English; and 5) record reported on a study population of adults between the ages of 18–65. Any records that reported data on only one individual or on a small series of case studies (i.e. less than eight people) were excluded, given the possibility that data from these studies might only reflect personal experience.
2.3. Review and data extraction
After title and abstract review, each article that met inclusion criteria was reviewed in full and the following data were extracted, if available: a) sex of the study population; b) region of the world; c) nationality and/or ethnicity; d) religious distinction; e) class distinction; f) whether the study took place in the context of peri- and post-natal, or in the context of war, trauma or displacement; g) whether the study took place in an urban or rural location; h) which qualitative research methods were used; and i) the features of depression that were mentioned in the text. The extracted features were either mentioned in direct quotes from study participants, or in summaries provided by the authors. Extracted features were classified as related to depression explicitly by authors or participants, or represented distinct descriptions of personal experience by participants in each study.
We also reviewed the methodological rigor of included studies by using criteria set out by Lincoln and Guba (1985) , as well as, more specifically, the degree to which each article used a non-leading approach to data collection and the degree to which the original analysis was guided by an a priori theory. Articles were rated by four different authors independently. Each article was rated on the degree of credibility, transferability, dependability, confirmability, non-leading approach to data collection, and use of a priori theory in analysis. We used a 1- to 5-point scale for ratings; with 1 indicating very little evidence to support the criterion and 5 indicating strong evidence to support the criterion. As there are no standard guidelines for the appraisal of the rigor of qualitative research ( Thomas and Magilvy, 2011 ; Tobin and Begley, 2004 ) we did not exclude on the basis of rigor alone.
Once data were extracted from all studies, features of depression were coded based on content. We started with the diagnostic criteria for Major Depressive Disorder included in the DSM-5 ( APA, 2013 ). Subsequent codes were added as features from each study were reviewed. Features with the same or similar meaning were grouped together. A single code representing the grouping of features was then generated. In some cases these groups contained a single symptom only (e.g., headaches). In other cases, similar concepts were grouped together and assigned a code representing the range of similar content. For example “isolation” ( Bolton et al., 2012 ) and “social withdrawal” ( Okello et al., 2012 ) and “lonely” ( Abdur-Kadir and Bifulco, 2010 ) were all grouped together under the social isolation/loneliness code. Similarly, any symptom that mentioned a problem related to the heart (e.g., palpitations, weakness, heavy heart, heart pain) was grouped under “issues with the heart.” “General aches and pains” was used as a content code for any symptom that related to aches and pains beyond stomach aches and headaches. Table 1 displays examples of the codes applied and their corresponding features for the top 10 most frequent codes.
Most frequently applied codes and examples of corresponding features.
Coding of depression features was done by authors EH and JA using MaxQDA ( Kuckartz, 2007 ) and Microsoft Excel. Any disagreements (e.g., different code used; disagreement with where features fit) within the coding process were discussed. If one of the coders was unsure about how to group a symptom, the symptom was not coded until discussed and agreement was reached about how to group it with others. For example, if study participants mentioned both being nervous and having nerves, it was discussed whether these should be lumped together or kept separate. As a reliability check, a third author (author MB) independently coded a random selection of approximately 10% of the articles. Inter-rater reliability between author MB and the other two coding authors was measured using percent agreement for each symptom code and an average percent agreement was calculated across all features codes. Kappa was not calculated for symptom codes due to the infrequency with which some codes occurred since Kappa may not be reliable for rare observations ( Viera and Garrett, 2005 ).
After all studies had been reviewed and relevant features coded, a dataset was compiled. The dataset included rows for each study population and columns with the name of each of the content codes. As some studies reported on multiple study populations, the number of rows in the dataset was greater than the number of studies included in the review. For each study population (row), whether or not the symptom was reported was marked as present or not present (dichotomous).
2.5. Quantitative analysis
Exploratory and descriptive analyses of identified features for all study populations included in the review were performed to identify the relatively frequently mentioned features and variation by gender, study context, and geographic region. We used Fisher’s exact tests ( Fisher, 1922 ) to examine whether frequencies of features were significantly different across regions, by gender (male only study populations vs. female only study populations) and context (peri- and post-natal vs. all other; trauma vs. all other). Although we reported on differences in features at the p < 0.05 level, statistical significance was set at 0.005 after using a conservative Bonferroni correction to account for the multiple comparisons across symptom codes. Fisher’s exact tests were used on a strictly exploratory basis, as sampling methods within the individual studies were not appropriate for use with inferential statistics.
A total of 16,130 records were identified through databases searches. After initial screening, 14,960 records did not meet the inclusion criteria (i.e. were focused on children, older adults, or other disorders). One hundred ninety-seven unique records were added from the Google Scholar search, resulting in a total of 1357 records for abstract review. Fifty abstracts were double screened for eligibility by authors EH and MR. Inter-rater reliability for abstract screening was moderate (kappa = 0.72; % agreement = 86%). Discrepancies in determination of article eligibility were resolved through discussion between raters.
Nine-hundred, fifty-one records were determined to be ineligible after abstract review leaving 406 articles identified for full-text review. During full-text review, 270 articles were excluded for the following reasons: not qualitative research ( n = 115); review articles ( n = 47); no symptom level information ( n = 43); single case or a small case series ( n = 20); not primarily focused on depression ( n = 25); not published in English ( n = 10); data reported on in another article ( n = 2); articles could not be found through library searches ( n = 8). In addition, two programmatic reports that had not been published in peer-reviewed literature were included in the review. Determination of inclusion from full text review was done for n = 20 records by authors EH and MR. Inter-rater reliability was again moderate (kappa = 0.79; % agreement = 90%). Records with disagreement between raters were subsequently reviewed collaboratively and discussed to arrive at consensus about inclusion. This resulted in a total of 138 studies that met all inclusion criteria and were included in the full review ( Fig. 1 ) ( Table S1 ).
The authors of included studies specified a number of methods to identify features of depression and many used multiple methods ( n = 82). According to the authors of the studies, the most common method used was in-depth and/or semi-structured interviews ( n = 95). Other methods included focus groups ( n = 50), key-informant interviewing ( n = 23), ethnography ( n = 6), the use of the Explanatory Model Interview Catalogue (EMIC) ( n = 5), participant observation ( n = 3), pile sort activities ( n = 3), case vignettes ( n = 3), illness narratives ( n = 2), analysis of case histories ( n = 2), photo elicitation ( n = 2), and participatory diagramming ( n = 1).
Studies on average used a mix of leading and non-leading approaches to data collection. The average rating for the degree to which a non-leading approach to data collection was used was 3.5 or between a mix of open-ended and leading approaches and mostly open ended approach to data collection (overall range: 1–5; average range between raters: 3.1–3.7). Only eight studies were given the lowest possible rating indicating the authors used a very leading approach to data collection. These studies represented data across regions, gender and context and mainly focused on qualitative inquiry to help with conceptual translation of scales (e.g. Kay and Portillo, 1989 ; Nakimuli-Mpungu et al., 2012 ). Many articles were rated as being more leading because the authors purposively sampled participants based on their depressed status. For example, in a study by Okello et al. (2012) , participants were identified by clinicians as having depression and then asked about their experiences. Sixty-four articles were rated as utilizing a non-leading approach to data collection.
Ratings for the degree to which a priori theory was used in analysis averaged 3.9 or mostly no a priori theory was used in analysis (overall range: 1–5; average range between raters: 3.4–4.4). Very few studies ( n = 3) were rated with a 1, indicating a priori theory guided the analysis (i.e. use pre-specified codes). Studies that were rated with a 3, often used a mix of a priori and emergent coding. The majority of studies approached analysis without a pre-specified theory, instead utilizing techniques such as thematic analysis or content coding with emergent codes to identify features associated with depression.
Overall, it was challenging to rate articles on rigor as methodological reporting varied widely across studies. Most articles were rated as slightly above a moderate degree on credibility (average = 3.1; average range between raters: 2.9–3.8); transferability (average = 3.3; average range between raters: 2.7–3.7); and confirmability (average = 3.3; average range between raters: 3.0–3.7). The degree to which studies were dependable was lower with an average rating across studies of 2.9 (average range between raters: 2.4–3.4). Many of the articles that received low ratings provided little detail or did not report on techniques such as member-checking, reflexivity or auditing that would have enhanced the rigor of the studies.
The 138 studies represented 170 different study populations and data from 76 different nationalities/ethnicities ( Fig. 2 ). Study populations were from North American/European/Australian non-native populations (55 study populations), Sub-Saharan Africa (38 study populations), South Asia (25 study populations), Latin America (21 study population), East Asia (7 study populations), Southeast Asia (10 study populations), the Middle East/North Africa (11 study populations), and North American/European/Australian native populations (3 study populations). No studies were identified from Russia or Central Asia. Refugee and immigrant populations were grouped together by region of origin. Sixty-five studies included data on female only samples (38.2%), eleven included data on all male only samples (6.5%), and 94 (55.3%) included data on study samples with both males and females. Twenty-seven studies focused specifically on the peri- and post-natal context (15.8%), while 25 took place in the context of war, trauma or displacement (14.7%).
Geographic variation of study populations*.
Content codes based on the nine diagnostic criteria for major depression described in the DSM-5, with the addition of irritability and impaired function (i.e. eleven codes), were applied ( Table 1 ). A total of 89 additional codes were identified during coding. There was an average of 1.5 ( SD = 2.4; Range: 0–16) features that did not fit into any of the content codes (i.e. represented a unique concept) in each study population. Inter-rater reliability for the symptom content codes was calculated for n = 15 records. Percent agreement between raters was high (88.0%). For a full list of all codes and their frequencies see the supplemental material (Table S1) .
Table 3 shows relative frequencies of depression features among all study populations ( N = 170). Depressed mood/sadness ( n = 117; 68.8%), fatigue/loss of energy ( n = 100; 58.8%) and problems with sleep ( n = 99; 58.2%) had the three highest relative frequencies. Depressed mood/sadness was described similarly across studies (see Table 2 for qualitative descriptions among select studies). Features with the highest relative frequencies across all populations (N = 170) were either DSM-5 diagnostic criteria or described as associated features of Major Depressive Disorder in the DSM-5. The same was true for non-Western populations only (N = 115). Features of depression with the highest relative frequencies that are not part of DSM-5 diagnostic criteria included social isolation/loneliness ( n = 92; 54.1%), crying a lot ( n = 77; 43.5%), anger ( n = 64; 37.6%), general pain ( n = 58; 34.1%), and headaches ( n = 60; 35.3%). This was also true for non-Western populations only (i.e., excluding Northern American/European/Australian non-native populations) although the order by frequency was different ( Table 3 ).
Features commonly associated with depressed mood/sadness from select studies.
Most frequently mentioned features across populations (N = 170) and in non-Western populations.
3.1. Results by region
As with the overall results, the features with the highest relative frequencies across regions were either DSM-5 diagnostic criteria or described as associated features of Major Depression in the DSM-5. Depressed mood/sadness had the highest relative frequency in Western non-indigenous, Middle Eastern/North African, and Sub-Saharan African populations ( n = 40, 72.7%; n = 9, 81.8%; n = 38, 73.7% respectively). In Latin America and East Asia fatigue/loss of energy had the highest relative frequency ( n = 15; 71.4% and n = 6; 85.7% respectively), while in South Asia it was problems with sleep ( n = 19; 76.0%), and in Southeast Asia depressed mood/sadness ( n = 8; 80.0%). Non-diagnostic features with the highest relative frequencies included: social isolation/loneliness in Western non-indigenous, Middle Eastern/North African and Sub-Saharan African populations ( n = 33; 60.0%; n = 7, 63.6%; n = 23, 60.5% respectively); crying ( n = 13; 61.9%) in Latin America; general pain, anger, and anxiety ( n = 3; 42.9%) in East Asia; headaches and issues with the heart ( n = 13; 52.0%) in South Asia; and issues with the heart ( n = 8; 80.0%) in Southeast Asia ( Table 3 ).
In all regions three out of the top five most frequently mentioned features are DSM-5 symptom criteria of MDD ( Table 4 ). Associated (non-diagnostic) DSM-5 features had the highest relative frequency only in Southeast Asian populations. Statistically significant differences ( p < 0.005) in relative frequencies across regions were observed for the following features: headaches, worry, thinking too much, heart issues, anxiety, weakness, dizziness, feelings of blackness, trouble breathing, disappointed, pressure in the chest and digestion ( Table S2 ). Other features such as, low self-esteem, feeling scared, confusion, as well as others, were significant at the p < 0.05 level, but were not statistically significantly different across regions after adjusting for multiple comparisons ( Table S2 and S3 ).
Top 5 most frequent features by region. a
3.2. Ubiquitous features
Fig. 3 is a Venn-like diagram, with the rings representing each study region (with the exception of the Western indigenous populations because of the small sample size) and the center circle representing features that arose during the review and present in at least one study population from these regions. Features in the table were ranked by their relative frequency by taking the product of their frequencies in each region. Thirty-six features (out of 100 features) appeared in every region. All eleven DSM-5 diagnostic features were present in every region, while most of the other 25 were included in the DSM-5 as associated features.
Ubiquitous features associated with depression.
3.3. Results by gender
Among female-only study populations ( n = 65) four out of the five features with the highest relative frequencies were DSM-5 diagnostic criteria for MDD and included depressed mood/sadness ( n = 42; 64.6%), fatigue/loss of energy ( n = 39; 60.0%), problems with sleep ( n = 37; 56.9%), and weight/appetite issues ( n = 25; 38.5%). Social isolation/loneliness ( n = 33; 50.8%), general pain ( n = 23; 35.4%), headaches ( n = 22; 33.8%), and crying (n = 23; 35.4%) also had relatively high frequencies. The number of studies involving all-male populations was small ( n = 11). D epressed mood/sadness ( n = 8; 72.7%), anger ( n = 6; 54.5%) social isolation/loneliness n = 6; 54.5%), and weight/appetite problems ( n = 6; 54.5%) had the highest relative frequencies ( Table 5 ). When comparing frequencies of features across genders, no statistically significant differences ( p < 0.005) were detected. However, at the p < 0.05 level, several features emerged as trending towards significantly different between men and women including: substance use/abuse, staying in bed , and aggression which were all higher in all male populations compared to all female populations ( Table S3 ). Despite the small number of male-focused studies this review suggests that subjective experiences of depression are similar across genders.
Top 10 most frequently mentioned features among studies of single-gender populations.
3.4. Results by context
Results by contextual variable are presented in Table 6 . In the context of trauma, most study populations reported problems with sleep ( n = 17; 68.0%), social isolation/loneliness ( n = 16; 64.0%), depressed mood/sadness ( n = 15; 60.00%), and weight/appetite problems ( n = 15; 60.0%). In peri- and post-natal contexts, social isolation/lonelines s ( n = 19; 70.4%) was the most common symptom, followed by depressed mood/sadness ( n = 18; 66.6%), and fatigue/loss of energy ( n = 15; 55.5%).
Top 10 most frequently mentioned features in the peri- and post-natal and trauma contexts.
The frequency of features was not significantly ( p < 0.005 ) different between study populations when comparing peri- and post-natal populations to all others. However, some features appeared to be trending ( p < 0.05 ) towards significance, including general pain, not talking to others, substance use/abuse and homicidal thoughts . These results suggest that features from peri- and post-natal populations are relatively similar to overall populations.
Among trauma-affected populations, the frequencies of hopelessness, rumination, and feeling suspicious were significantly different ( p < 0.005) than the frequencies observed in other populations. A greater proportion of study populations in trauma-affected populations reported feeling these features compared to all other populations. Other features that were trending towards significantly different ( p < 0.05 ) included problems with sleep, weight/appetite problems, crying, impaired functioning, not talking to others, problems with memory, feeling trapped, lack of coping, feeling regretful, nightmares, and feelings of grief . Many of these features overlap with posttraumatic stress and may be particularly salient given this population’s higher risk for this disorder.
Most research on depression conducted among non-Western populations has used measurement instruments and diagnostic criteria based on the DSM and ICD presentations of depression. This assumes that these criteria, developed among Western populations, are applicable across cultures. We reviewed available worldwide qualitative studies on depression in order to explore the evidence for this assumption, as well as to provide a less culturally biased understanding of how depression is experienced across populations.
The DSM-5 diagnostic criteria for MDD were reported across all regions, genders and socio-cultural contexts. Most other frequently described features also appear in the DSM-5 as associated features of MDD. Across all regions, features of depressed mood/sadness, fatigue/loss of energy, problems with sleep, appetite/weight problems, suicidal thoughts, loss of interest, and worthlessness/guilt were commonly reported in qualitative studies of depression, with irritabilit y also frequent to a lesser degree than the other features. Most of the remaining frequently described features also appear in the DSM-5 as associated features of MDD.
Our findings do, however, suggest problems with the cross-cultural use of the DSM-5 Major Depression diagnostic criteria. Four of the most frequently mentioned ubiquitous features across studies were not part of DSM-5 diagnostic criteria: social isolation/loneliness , crying , anger , and general pain . In contrast, other DSM-5 diagnostic features were not frequently reported in the global literature, specifically, problems with concentration and psychomotor agitation or slowing .
Many features overlapped with symptoms of anxiety disorders, such as worry, issues with breathing, irritability, problems with sleep, and restlessness . The DSM-5 currently separates Major Depressive Disorder and Generalized Anxiety Disorder. However, there is a robust evidence showing that depression and anxiety are often co-morbid ( Kessler et al., 2008 ), share similar risk factors ( Almeida et al., 2012 ), exhibit similar neurocognitive processes involving the limbic system ( Ressler and Nemeroff, 2000 ), and respond to similar treatments ( Butler et al., 2006 ). While we limited our search strategy to records with a main focus of depression, we did not exclude records that included anxiety, as long as depression was one of the main foci of the record. Results from our review support previous literature which suggests that the symptoms of depression and anxiety demonstrate substantial overlap and are highly comorbid ( Abas and Broadhead, 1997 ; Bener et al., 2012 ; Das-Munshi et al., 2008 ; Kaaya et al., 2002 ).
Anger was frequently mentioned overall ( n = 61; 36.3%), and was present with comparable frequency in both female-only populations ( n = 16; 25.8%) and male-only populations ( n = 3; 37.5%). There is general consensus that depression in men usually consists of symptoms of anger, impoverished social relationships, emotional numbness, impulse control difficulties, irritability, aggression, substance use, and suicide ( Brownhill et al., 2005 ; Cochran and Rabinowitz, 2003 ; Martin et al., 2013 ; Oliffe and Phillips, 2008 ). However, results from the current review indicate that women around the world also commonly report anger as a symptom of depression, which has been found in other studies ( Rees et al., 2013 ; Williamson et al., 2014 ). Anger may represent a common sign of depression in women that has not been fully acknowledged in psychiatric classification.
Somatic complaints were very common among all study populations, including Western populations. Reviews of other research suggest that somatic complaints related to depression are ubiquitous worldwide ( Draguns and Tanaka-Matsumi, 2003 ; Shidhaye et al., 2013 ) and their expression often functions as a reflection both of the individual and of problems with the broader healthcare system ( Kirmayer, 2001 ). People may express these complaints as a method for getting help with their distress when the overall system does not understand or provide services for more cognitive or behavioral symptoms, as suggested by the literature on idioms of distress which are commonly somatic ( Nichter, 2010 ).
Some features appear to be contextually specific and may warrant inclusion in measurement instruments used among specific populations. For example, in trauma-affected study populations, features that overlap with PTSD, such as guilt, rumination, and feeling suspicious occur more frequently compared to all populations combined. Consistent with other research, there is high overlap with depression and PTSD symptomology in populations affected by collective trauma ( Momartin et al., 2004 ; O’Donnell et al., 2004 ). Other features that arose more frequently in some populations such as worry (more common in South Asian and Southeast Asian populations) or thinking too much (more common in Southeast Asian and Sub-Saharan African populations), may be important to include in measurement instruments for use in these particular regions.
Our review was limited to studies published in the English language literature so we have likely missed relevant studies. Features extracted in this review were also already translated into English by the authors of the studies and it is possible that during translation nuances of the literal expressions of the features were not captured. Limiting records to those in English may have biased the results in favor of DSM features since English speakers seeking to better understand depression in other cultures may be primed to look specifically for people who fit their conceptualization of depression.
While our goal was to avoid this bias by selecting open-ended, qualitative literature the degree to which studies achieved this varied. All studies utilized qualitative methods, and most involved data collection and analysis using open-ended approaches. However, there were a small number of studies included that used qualitative methods to confirm a priori assumptions. Moreover, assessing the rigor of methods was challenging as the adequacy of methodological reporting varied significantly across studies. Many studies did not report clearly on aspects of credibility, transferability, dependability, or confirmability, which reduced our ability to assess their rigor and that of the studies overall.
We did not include grey literature in our search strategy but did solicit reports of studies from researchers working in the field that had not been published in peer-reviewed literature. Only two records from the non-peer reviewed grey literature were found and included. Our search strategy did not explicitly include “mixed-methods” perhaps resulting in missed features as well. While a proportion of the included studies represented mixed-methods studies, future research should explicitly examine this body of literature more thoroughly. Another limitation is in our exclusion of case studies. Some case studies may reflect a rich description of depression that would not have otherwise been captured in broader qualitative work. However, since case studies include data on such a limited number of participants, that they may not represent the experiences of the more general population. The results from the Fisher exact tests are suggestive only, due to the likelihood of sampling bias within the individual studies.
There is a potential tautological error that the search for depression features across global populations will result with confirmation of the diagnosis because most studies are influenced by psychiatric categorizations ( Kleinman, 1988 ). Thus, DSM/ICD features will typically be more thoroughly evaluated through qualitative interview prompts and more likely to be reported than features not associated with the psychiatric diagnosis of depression. Limiting our review to studies explicitly focused on depression increases this bias. Search terms were selected for practical reasons in order to limit the number of potential hits to articles that would be relevant to our research question. We acknowledge this bias and the subsequent over-emphasis on existing diagnostic criteria in the results extracted. Given this bias, we do find it striking that some features, though nearly ubiquitous across populations, are not part of current DSM diagnostic criteria: loneliness, anger, crying , and somatic complaints. Their absence from instruments based on the DSM criteria may constitute a gap in the assessment of depression symptomatology generally while the absence of regionally or locally important features may constitute a bias in cross-national studies.
A second conceptual limitation is that the current study does not address the personal and cultural significance of the features we have extracted. This could lead to “category fallacies”, i.e., assumptions that a symptom or group of symptoms will have comparable personal and cultural meaning across social groups ( Kleinman, 1977 ). Potential mislabeling of features associated with disorder in one culture as also being a ‘disorder’ in another culture (in the absence of evidence of prolonged impairment) is a major concern in anthropology and cross-cultural psychiatry in terms of the potential for pathologizing normative non-disabling behavior, i.e., medicalization ( de Jong and Reis, 2013 ; Kleinman, 2008 ; Nichter, 2010 ).
One way to reduce the risk of this category fallacy is to examine if features are associated with expected life impact. In this study, we evaluated the relationship between features and impaired functioning as an indicator of comparable impact across cultural groups. Unfortunately, problems with daily functioning were only mentioned explicitly in one quarter of the study populations included in this review. The majority of study populations did not raise problems with daily functioning as part of their subjective experiences of depression. To the extent possible, future studies and literature synthesis should not only focus on the presence of features but also the meaning of these experiences and the association with functional impairment (c.f., Bolton and Tang, 2002 ). This focus would help to distinguish between depression, conceived as a psychiatric disorder, and culturally-normative displays of sadness and grief that do not lead to prolonged impairment ( Horwitz and Wakefield, 2007 ). Use of specific probes during data collection or more reporting on findings related to impairment would help to make this distinction.
Multiple approaches can be used to understand cross-cultural and cross-population commonalities in expression of distress. A complimentary strategy to our symptom-based approach is to examine cultural concepts of distress, that are shared across groups. A recent review on cultural concepts of distress related to “thinking too much” identified 138 publications on this manifestation of distress across more than 20 countries covering Asia, Africa, Europe, North and South America, and Australia/Pacific Islands ( Kaiser et al., 2015 ). Thinking too much was associated with low mood, anhedonia, poor concentration, social withdrawal, sleep disruptions, and somatic complaints across most populations. Moreover, manifestations of thinking too much were related to functional impairment and often perceived to result in more severe mental health problems if not formally or informally treated. This approach started with locally salient categories then explored potential overlap with psychiatric categories such as depression, anxiety, and PTSD. Ultimately, both approaches (i.e., reviewing both the literature on depression and cultural concepts of distress) are necessary and complimentary to fully understand commonalities and diversity in experiencing psychological distress.
We undertook this review to determine whether the current practice of using standard depression instruments based on Western models (specifically the DSM) may represent a significant bias in global mental health research, even after local adaptation and testing. We found that the diagnostic and associated features described in the DSM-5 are consistent with the frequently mentioned features in our review at both the regional and worldwide levels. However, worldwide and at the regional level, some DSM non-diagnostic features were mentioned by more study populations than were some diagnostic features, while several diagnostic features were not prominent in some regions. These findings suggest a need for review of the content of standard instruments beyond their current focus on DSM diagnostic criteria, in order to accurately reflect the experience of depression worldwide and particularly for non-Western populations. Our findings also support the need for regional variation in instruments in accord with local variation in presentation.
While we have confidence in our approach, the robustness of our findings is limited by the small number of studies we could find and the limited information available on how they were conducted. We propose to repeat this process as more qualitative studies become available. We therefore advocate for a coordinated effort to conduct relevant and high quality qualitative research on how depression manifests across cultures. Meanwhile, this paper describes the first attempt to review the available qualitative literature to better understand how depression manifests worldwide, in order to develop more appropriate instruments for both worldwide and regional use. Based on this review, we believe instruments that only include DSM-5 diagnostic criteria are inadequate for use in populations world-wide. These, instruments should not only include features representing diagnostic criteria but also incorporate highly relevant associated features such as social isolation or loneliness , excessive crying , anger , and general aches and pain . Patterns of regional variation documented here can help guide researchers and clinicians to features relevant for specific populations and settings.
- Reviews qualitative literature to identify features of depression worldwide.
- Emphasizes importance of qualitative data to enhance understanding of depression.
- Investigates potential biases in Western instruments that measure depression.
- Argues that Western diagnostic criteria do not represent depression globally.
All supplemental tables (s1, s2, s3), supplemental material for prisma checklist, acknowledgments.
United States Agency for International Development/Victims of Torture FundAID-DFD-A-00-08-00308.
National Institute of Mental Health: T32 MH014592-38. NIMH grant number: K01MH104310
The authors would like to thank Dr. Wietse Tol for help with development of the search strategy.
Appendix A. Supplementary data
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