Cultural explanatory model of depression among Iranian women in three ethnic groups (Fars, Kurds and Turks)

Abstract: Background: As one of the most prevalent diseases globally and as an important cause of disability, depressive disorders are responsible for as many as one in every five visits to primary care. However, the true figures are unknown, as many do not seek help or know how to access help. Women suffer more than men according to surveys in Iran and other countries. Cultural variations in clinical presentation sometimes make it difficult to recognize the disorder, resulting in patients not being diagnosed and not receiving appropriate treatment and follow up. Purpose: This thesis explores how women s depression is conceptualized among Iranian people in three cities located in north-west (Tabriz), west (Ilam) and central (Tehran, capital city) Iran, representative of three major ethnic groups (Fars, Kurds, and Turks) and how this conceptualization may contribute to the help-seeking behaviour of depressed women. Methods: The thesis consists of four exploratory papers employing qualitative methods including individual interviews and focus group discussions (FGDs). Paper 1 reports a pilot study using a case vignette and explanatory interview guides on Iranian people (including depressed women, clinicians and lay people). Forty three adults participated in three focus group discussions (25 participants) and 18 individual interviews in the three ethnic groups. Paper II presents an explanatory model of the community (lay people) in the three ethnic groups in Iran concerning women's depression. Thirty eight men and thirty eight women from the general population, classified by level of education participated in twelve FGDs in the aforementioned cities by using a case vignette describing a woman with major depression without psychotic features. Paper III reports interview results (25 depressed women and 14 relatives) regarding how these women and their families conceptualize the patients conditions and how their conceptualization shaped the patients help-seeking process. Paper IV reports individual interview results from 24 clinicians (six general practitioners [using case vignette], 14 psychiatrists and four psychologists [interview guide, both]) exploring the explanatory model of depressed women. Results : There were more similarities than differences in the models proposed by Iranian people in the three ethnic groups. Among most of the study participants depressive symptoms were perceived as a transient reaction to external stressors. Most participants named the depressive symptoms as distress of nerve/ soul narahati asabi/narahati rohi , problem of nerve/soul moshkel asabi/rohi , sadness and depression afsordegi . Other names were darikhma (deep sadness with anxiety, Turkish participants only), and tarjoman (sadness and nerve problems due to external events, Kurdish participants only). All connected the illness with an external stressor caused by loss (death of relatives, job loss, etc.), environmental causes (including family conflict), gender-linked stressors and internal factors caused by emotional factors, cognition distortion and hormonal factors. Coping mechanisms involved two strategies: (1) solving problems by seeking help from family and friends, especially ones husband and neighbours, religious practice, and engaging in pleasurable activities, and (2) seeking professional support mostly from general practitioners, psychologists, family counsellors, and traditional support from herbalists and amulets (written prayer notes). The choice of medical treatment depended on the type of somatic or psychological complaints. The important barriers to seeking help from professional (psychiatrists or psychologists) were stigma and fear of dependency on medication. Conclusion and implications: Rather than having a biological model, in this study participants tended to have a psychosocial explanatory model linked with preferred seeking help from informal healers (family and friends, religious practices and traditional healers) as the first treatment step. The inter-ethnic similarities could stem from common cultural and social elements, such as a common official language, legal, structural, educational and political structures, mass media, and religion in the three major ethnic groups in Iran. This finding could be useful for integrating a gender approach to health service delivery and linking gender and culture sensitivity to training of health workers, and also for education society to reduction of the stigma related to depression.