Wednesday, October 15, 2008

Presentaion of Depression in Iraq

I am in my final year of my study. To fulfill the criteria of fellowship to the Iraqi board of psychiatry, I should do a research. I have chosen I subject I found myself fond of, cross-cultural psychiatry. "presentation of depression in Iraq" or "symptom profile of major depressive disorder in Iraqi patients" is the title of my thesis. I have gathered till today about 65 patients. It is time to start writing the introduction. It is not easy at all. I have changed it many times since I have started writing it before 2 days. This is my introduction as I chose to make it today. Please I would feel grateful if any got an idea to make it better. I started before two days only and I want my introduction to be much longer than this, but this will stay, as I think, the main skeleton on which I will add.


"Depression is one of today’s most common, and most commonly misdiagnosed, psychological illnesses."

Gorden Parker, Dealing With Depression

"90% of DSM-IV categories are culture-bound to North America and Western Europe"(1)
A drowning shirt in Al Rashad hospital:

Depressive illness is common, painful, and dangerous. Untreated depressive illness can lead to personal, familial, and social disasters. Depression can be lethal. The ability to recognize depression may be a matter of life or death. Failure to recognize depression is a global problem.

Depression involves a different combination of symptoms and reveals itself in slightly different ways. Different authors have commented on different aspects of these disorders, and variations in their incidence, symptomatology and course have aroused widespread speculation regarding possible cultural influences on aetiology and clinical picture.

Socio-cultural aspects

A rosy neglected jacket in Al Rashad hospital

Mental illness is called generally as "Jinoon" in Arabic. A word that is derived from the word "Jin" which refers to supranatural beings believed to have the ability to possess a human.
Cases of "possession" are said to be less common in western countries. It seems that there is a negative relationship between civilization and reported cases of "possession". If you work as a psychiatrist in Iraq these days, you will still be able to see some of those "possession" cases. Unfortunately there is no recorded prevalence rate of such cases. More commonly you will encounter different cases of various mental illnesses that will attribute their illness to a "possession".
There is a belief that a man or a woman who unwittingly steps on a Jinni (Bazzouiand Al-Issa,1966) or across his path is seized by this particular spirit in act of revenge manifesting itself in manic or depressive states, depending on the nature of this Jinni. Is this believe still existing, and to what degree? This is one aim of this study as patients will be asked about what they think is the cause of their illness.

The fast strides of change in the new millennium are affecting people's beliefs and values. How many cases of depression in Iraq are still believed that their illness is due to a "possession"? Internet and satellite channels are invading our homes with their various contents. People in Iraq usually use these media resources for entertainment. But recently a more and more percentage is trying to open a window to see the world through it. Educational satellite channels are succeeding in attracting more viewers. Educational websites in Arabic are still not that much developed but still they do make some change. Many patients are aware these days of the names of mental illnesses. Depression, Schizophrenia, Obsessions, Autism, Hyperkinetic child, and some more terms are used by people more than before.

Traditional healers, on the other side, are still visited very often by those who feel psychologically upset or abnormal. Visiting a holy shrine is still a commonly used way to treat the mentally ill by people of Iraq.
Are the average Iraqis still psychologically naïve like Dr Widad Bazoui had stated in his studies on psychiatry in Iraq between 1966 and 1970? This is another aim of this study as the patients will be given time to express themselves, and to comment on what they think had caused they state they are in, and what do they call the state they are in, and what treatment they believe can help.

Affective Illness Across Time

Runing trousers, lost in time in Al Rashad hospital

Affective illness is not a new entity in the medical history of this land. Although sometimes its description is primitive. The Sumerians had mentioned mental illness in their writings. Avicenna, in his Canon of Medicine, described cases that share many aspects with the modern concept of depressive disorders a thousand years ago.

The black bile theory of Hippocrates was the explanation for this phenomenon for those doctors who lived in Baghdad since one thousand years ago.

A strongly held belief, that may still exist so strong, is that depression is due to weakness, and specifically, being a "not enough" believer in God.

Biological causes of depression is not that understood, if wellcomed, by people other than the psychiatrists. Even doctors from other branches of medicine do not seem to believe in "Biological" cause of depression. This maybe due to that basic sciences researches are not functioning at all in the field of psychiatry. We never did a cerebrospinal fluid chemical analysis for those who got a mental illness for example. Evidences of biological causes of depression, and other mental illnesses, came just with textbooks from the "west". Some doctors find it easier for them to feel emotionally detached from those biological theories.

So the spiritual east is refusing the biological theories strongly and till now.

Iraq the multi-ethnic

Multi-colored blues

Iraq has a heritage of diverse cultures. Since 7000 years and civilizations are flourishing one time, and then fading again. Multiple ethnicities and religions shared this land. But they share some common values. It is not rare to see a Christian patient visiting a Muslim traditional healer who may use the holy Quran verses while trying to offer therapy. And you can see a Muslim woman in a church asking for being healed from a disease.

Is there a difference in the presentation of depression among different ethnicities and religions in Iraq like Dr. Widad Bazzoui had stated in his study "Affective Disorders in Iraq" in 1970? Dr. Widad Bazzoui had found that Iraqis who are not muslim presents with higher rates of "Guilty feeling" while depressed than the musilms. It is one of the aims of this study to find out wether this is stronly evident.

Somatizing depression/ idiom of distress

The main aim of this study is to find out how Iraqi patients with depression present themselves. It is much stated between psychiatrists in Iraq that Iraqi patients somatise their symptoms. That they do not present with the congitive symptoms as they do more with the physical ones. The aim in this study is to meansure the frequency of each of the Diagnostic and Statistical Manual - forth edition (DSM IV) criteria in Iraqi patients. And to compare the results to studies done on the United States and some other studies done in Asia.

That was the main aim at the start. But as it was found that in Dr Widad Bazzoui study in the 1970s, found that many Iraqi patients with depression presents with other symptoms not mentioned in the DSM IV, other questions were added to the questionnaire.

Questions about: "headache (100% positive answers till now); pain anywhere in the body (100% positive till now); Gastrointestinal symptoms; Respiratory symptoms; Cardiovascular; Neurological; and others)

Questions have been added on paranoia: "ideas of reference, ideas of persecution, ideas of infidility, suspicions and wether they are delusional".

Another question was added on violence and aggressive tendencies and wether it is verbally or physically expressed mainly.

All these were added because they were found to be common in Dr Widad Bazzoui's study.

The prevalence of depression in asia has been reported to be lower than in the west. This has been attributed to somatization. That is to say, that people from asia with depression tend to present themselves with somatic symptoms rather than psychological symptoms. Another explanation was the concept of alexythemia. That is to say, people from non western countries, are less aware of their psychological status, maybe due to ignorance.

Another explanation for presenting depression with physical symptoms is that the diagnosis of depression, and mental illness as a while, is regarded as morally unaccepted and as a weakness a good person must not suffer from.

Arthur Kleinman, a professor of cross-cultural psychiatry, has pointed in his paper "culture and depression" to the experience of depression in the Chinese society where the expression is rather physical than psychological and had stated that: "Culture confounds diagnosis and management by influencing not only the experience of depression, but also the seeking of help, patient-practitioner, communication, and professional practice"(3)
Kleinman, has described somatic symptoms as an “idiom of distress” that is prevalent in culture where psychiatric disorders carry great stigma.
Somatization can be viewed also as a defense mechanism against the awareness of the psychological distress.

Facultative somatization/ a ticket of admission

Patients may feel that reporting a physical complaint is more acceptable as a complaint to a doctor. Many doctors may have answered patients with psychological distress with the answer: "you have nothing wrong; it is all in your head". A commonly used answer in the face of somatization rendering people over time not to complain to doctors about their psychological distress. This has been called "facultative somatization", in which the patient is not in denial, but thinks that physical symptoms is a ticket of admission to the care clinic.
It is a common story to admit a patient with physical symptoms in a hospital in Iraq, then the patient will tell the nurse about a psychological distress. They tell the nurse because they feel him or her more culturally close to them. Doctors are more physical, they are called "physicians", aren't they?
A psychiatrist is a doctor after all and a patient may use facultative somatization with psychiatrists too.
Widad Bazzoui had stated in 1970 that: "In general, the average Iraqi patient describes his depression as a sense of oppression in the chest, a feeling of being hemmed in, or in other cases, a hunger for air. On being asked if he feels sad, downcast or depressed, one is struck in many cases by the unawareness of the patient of his mood. The disorders, especially depression are usually conceptualized not as emotional disturbances but as physical abnormalities affecting various organs of the body. The chest, head and abdomen are frequently considered to be the core of the troubles. Very often the patient describes his complaints in metaphors and similies in an effort to bring his strange experiences within his grasp." (2)

To what degree this is still valid nowadays?

See how this Iraqi patient with schizophrenia expresses himself

On the teared peice of paper he wrote: "the name: unknown, THE IDENTITY". I don't think he is psychologically naive.

NOTE: these pictures won't be used in the thesis paper, nor the comments on them.

(1) Kleinman A. (1997) Triumph or pyrrhic victory? The inclusion of culture in DSM-IV. Harv Rev Psychiatry. 1997 Mar-Apr;4(6):343-4

(2) BAZZOUI, W. (1970). Affective disorders in Iraq. British Journal of psychiatry, 117, 195-203.

(3) Kleinman A. (2004) Culture and depression. N ENGL J MED 2004 September 2, 31;10


adifferentvoice said...

OK, Sami, you asked for comments!

First, it sounds like a fascinating subject.

Couple of things strike me straightaway :

Isn't it the case that if your study is going to be "cross-cultural" that you are going to have to have some comparisons with another culture? You don't mention this in your introduction.

I appreciate that you may not have access to patients with depression in another culture, but I get the impression that depression was probably somatised in Europe, too, in earlier times - we don't see many cases of the kind of hysteria that Freud studied. Is it the case that depression in Europe, or North America, for example, has moved inwards (as opposed to having outward manifestations) in the same way as you see it moving in Iraq? If so, what were the trends in Europe that led to that interiorisation of depression - and are they the same now in Iraq?

I would have liked you to set out in your introduction what you hope your report to show, so that I could anticipate or bear in mind themes as I am reading on, and so that there is a bit more structure to your writing. As it is, I am not sure how you are going to use your case studies to mount an argument (which is what I presume you are asked to do). I am not sure where you are going ... (easily put right with a few sentences of explanation - as basic as "In this paper I intend to show/investigate (whatever) ..., First by considering ... and thereafter).

I also wondered if you were going to make a distinction between situational depression (where a cause can be identified with some certainty) and other depression which has no identifiable cause - or is all depression situational, if only you can uncover the situation that causes it?

Is "depression" just a name we, particularly in the West, give to an inability resolve the Id and the Superego, where the Superego is winning? Does that inability present itself differently in different cultures because of factors specific to those cultures? If so, what are the factors in Iraqi culture that determine the presentation of that inability in patients?

That last image, painted by a patient, is quite wonderful.

I've often wondered whether "vices" are cultural, which is probably why I find your proposed study so interesting. You know, how people say that a certain vice is absent in their country, ... but you kind of imagine that they have another vice that makes up for the absence of the other one. I'm thinking, for example, of the prevalence of alcoholism in the West, and a higher toleration of domestic violence in some other countries, or frightening outbreaks of horrific violence such as in Burundi...

I hope your report goes well - I remember very clearly the pain that precedes the breakthrough writing academic contributions. There doesn't seem to be any way to avoid the pain - if you want your work to be good, that is!

Good luck! I'd love to read the whole thing one day!

saminkie said...

Dear Margaret, you were up to the point, how could I not mentioned how my study will be croo cultural? Margaret, I will not have a samlpe of non-iraqi patients but I will compare my sample results to the results of other studies done in Korea, Chinese in the US, and US population. I should have said that in the introduction didn't I.

In Iraq we have a fixed order of presenting our thesis and that would be:
summary, intoduction, aims, methods, results, discussion and conclusion, and finally references.

Maybe I was waiting the AIMS part to make my AIMS more clear, but thank you for your comment very much Margaret, I think now about making them appear more clear in the inroduction too.

Regarding making a diagnosis, I would write that in the method part. But I will tell you here that I am using a structured psychiatric interview based on the DSM IV to diagnose Major Depressive Disorder. I will not make distinction between types of depression, although it seems a good idea and I may end up studying the atypical features in our patients (in my sample there are some patients who have hypersomnia rather than insomnia, for example).

Margaret can I use that thing you said about "superego winning" in my discussion? it is the firrst time i heard of that. I will search for other references on it.

Your comment will make me work on my introduction dark tunnel again with some light in my hand right now. I will rewrite this post and makes my additions appear in fanit orange color.

Thank you very much for your time Margaret I will never forget this favor you done for me.

Don Cox said...

Very interesting. You mentioned in a previous entry that Iraq is a paella - so even a study done within Iraq will be cross-cultural. ______ Besides "somatisation" there is the interesting case of the converse: stoach ulcers were for a long time thought to be symptoms of psychological problems, and finally turned out to be caused by bacterial infection.

sami said...

You have all the right Don Cox, a study in Iraq is cross cultural by itself. Thank you for that remark which I may use during my discussion of the thesis.
The convers of somatization always remembers me of that case of szhiophrenia who presents to the emergency unit complaining of an "Ectopus in my stomach" and was neglected and refereed to the psychiatric ward to inter into a state of shock and found to have rigid abdomen. Investigations reavled perforated deudenal ulcer.

Thank you Don Cox for your care and advice.

sami said...

Thank you John P. Murtha for your care and nice comment. sami

Ala Ali said...

Hi Sami
Firstly its a great idea to have this nice, well prepared blog.
I would like to ask if you have any idea about the prevalence of Depression in Iraq , or still the figure is not available.
Many thanks

saminkie said...

Hi Ala, thank you for your nice encouraging words. There was a study in 2007 done by the ministry of health with the aid of WHO about the prevalence of mental illnesses apart from schizophrenia and drug abuse and suicide, as far as I can remember and I remember the cross-sectional prevalence of major depressive disorder to be as low as less than 1 per cent. I am not sure of the figure since I dont have my laptop with me right now. I think you can find the study published in a free journal of psychiatry named WORLD PSYCHIATRY that belongs to the WHO. Regards.

Anonymous said...

Many many thanks Sami,
Very informative paper.
By the way, r u still in Iraq?
Best Regards

saminkie said...

Hi again Ala, the link of the study is this

I was wrong about it. It includes the lifetime prevalence and it is about 7 percent in iraq. I am still working in Iraq although I am now in a family visit outside Iraq. My email is and you are welcome as a friend Ala. Regards. Sami.