Spirituality, depression and suicide: a cross-cultural perspective.

No discussion of depression and spirituality can be complete without a discussion of depression and culture, for culture and religion/spirituality are so intertwined. The negotiation between religion and culture ranges from ongoing discussions by mainline Christian theologians about the proper stance of religion within culture (1) to commentaries on the dramatic revolts against culture by fundamentalist groups in virtually every religion around the globe. (2) Perhaps of greatest importance for any discussion of depression and spirituality is a discussion of those cultural forces that augment, shape, and perpetuate depression. In many cases, a culturally shaped depression may be manifested as a spiritual crisis or as a challenge.

Nussbaum (3) goes so far as to suggest that emotions are socially constructed. Emotions are not feelings that well up in some natural and untutored way from our natural selves; they are contrived, social constructs. We learn how to feel. They are taught to us through stories. If they can be learned, then they also can be unlearned (cognitive therapy). Lutz (4) proposes a theory and examples of emotion as aspects of cultural meaning systems people use in attempting to understand the situations in which they find themselves. (5) Emotions are socially negotiated. The social context surrounding the person gives meaning to feeling and to behavior and provides criteria for judging one's own emotions and the emotions of others.

Margaret Field, (6) in her ethnographic study of Ghana, explored the close connection between culture and religion. She found that women who were depressed around the age of menopause (they had completed their childbearing years) visited a shrine to gain relief from that depression. The depression arose out of the fear of sorcery and evil spirits that made them barren. They felt that they had become useless because they no longer could bear children and therefore had become witches. In many cases the depressed women were not considered mentally ill, for if they believed they had caused harm to others, they were taken at their word. If the woman was restless, agitated, unable to sleep, a spirit had overtaken her. She would rarely seek help for her illness.

Eaton and Weil (7,8) studied the Hutterites (from 1950-1955), a small group of people who isolated themselves for cultural and religious reasons in the northern great plains of the United States and Canada. They prized the simple life and had a reputation for mental health (namely because the members of the group had similar lifestyles and shared the same sentiments leading to group cohesion). This sheltered lifestyle was thought to shield them from social risks for mental disorders. Yet the Hutterites' protective social structure was associated with feelings of guilt among those who feared that they might not live up to group expectations and a high frequency of symptoms of depression.

Karp, (9) in reflecting upon his own chronic depressive illness, emphasizes the "socially generated meanings of illness." Though the core syndrome of depression may be observed universally across cultures, there are widely varying experiences of depression. All too often the physician leaves out the "illness narrative," as suggested by Kleinman, (10) uninterested in hearing the patient's experience of illness. Rather, the physician listens only to gather the data necessary to make a diagnosis. Though not religious himself, Karp notes that, in today's society, depression may be a "gift" that helps one gain a greater meaning of the mystery of human suffering. He goes on to maintain that the social disconnection generated by an ethic of individualism in America is an important element in the proliferation of mood disorders.

In summary, though the biologic substrate of depression is universal, cultural factors shape the expression and meaning of the emotions as they emerge. In addition, the social press of certain cultures, such at the Hutterite culture, may very well increase the biologic vulnerability to depression. Spirituality is so tightly interwoven with many prevailing cultures (such as the cultures in Ghana and among the Hutterites) that no exploration of the frequency and symptoms of depression can be divorced from the context of the prevailing religious orientation of the culture.

Yet these isolated cultures may appear on the surface to have very little influence upon a diverse culture such as found in North America. The psychiatrist must recognize that, despite the multilayered and intersecting cultural influences that virtually everyone encounters daily, unique cultural influences continue to shape thoughts and behaviors. People retreat into their subcultures, often as an escape from the confusion of such a diverse environment. Indeed, retreat into a religious subculture may be one of the most common means of retreat.

References

1. Niebuhr HR. Christ and Culture. New York, Harper and Row, 1951.

2. Lawrence BB, Denny F. Defenders of God: The Fundamentalist Revolt Against the Modern Age. Columbia, University of South Carolina Press, 1995.

3. Nussbaum MC. Upheavals of Thought: The Intelligence of Emotions. New York, Cambridge University Press. 2001.

4. Lutz C. Depression and the translation of emotional worlds. In: Kleinman AK, Good BJ, eds. Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder. Berkeley, University of California Press, 1985.

5. Blazer DG. The Age of Melancholy: Major Depression and Its Social Origins. New York, Routledge, 2005.

6. Field M. Search for Security: An Ethnographic Study of Rural Ghana. New York, WW Norton, 1960.

7. Schwab JJ, Schwab ME. Sociocultural Roots of Mental Illness: An Epidemiologic Survey. New York, Plenum Medical Book Company, 1978.

8. Eaton J, Weil R. Culture and Mental Disorders: A Comparative Study of the Hutterites and Other Populations. New York, The Free Press, 1976.

9. Karp DA. Speaking of Sadness: Depression, Disconnection, and the Meanings of Illness. New York, Oxford University Press, 1996.

10. Kleinman A. The Illness Narratives: Ssuffering, Healing, and the Human Condition. New York, Basic Books, 1988.

Anger makes you smaller, while forgiveness forcess you to grow beyond
what you were.
--Cherie Carter-Scott

Dan Blazer, MD, PhD

From Duke University Medical Center, Durham, NC.

Reprint requests to Dan G. Blazer, MD, PhD, Duke University Medical Center, Durham, NC 27710. Email: [e-mail]