WONCA's Culturafly Sensitive Depression Guideline Cultural metaphors in depression

Gabriel Ivbijaro

Depression, a common psychiatric disorder in primary care, is often under-diagnosed and under-treated. The World Health Organisation ( W H O ) predicts that by the year 2020, depression will be the second most im- portant cause of disability worldwide, after ischaemic heart disease.' Epidemiological studies show that the lifetime risk of depression varies from culture to cul- ture.2.3 Looking after patients from different ethnic backgrounds who suffer from depression presents ad- ditional challenges to the primary care practitioner, and requires a different approach.

In recognition of the challenge posed by the impact of culture on ways of working with depressive disorders, and to assist family physicians who treat this group of patients, the World Organisation of Family Doctors Special Interest Group (WONCA SIG) in Psychiatry and Neurology has developed a culturally sensitive de- pression guideline for use in primary care.

The WONCA Culturally Sensitive Depression Guide- line was developed by an international reference group of family physicians and psychiatrists with an interest in primary care, convened by the WONCA SIG in Psychiatry and Neurology. Using evidence from the medical literature, and recognising the importance of the American Diagnostic and Statistical Manual of Mental Disorders (DSM) and the World Health Organisation

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Gabriel Ivbilaro MBBS FRCGP FWACPsych MMedSci DFFP MA, Convenor WONCA Special Interest Group in Psychiatry and Neurology, Visiting Fellow London South Bank University, U K

Correspondence to: Dr Gabriel Ivbijaro The Forest Road Medical Centre P M S Mental Health Pilot, 354-358 Forest Road, Walthamstow, London E l 7 SIC, U K E-mail: gahluc@aol.com

Submitted: 22 September 2004. Accepted: 26 April 2005.

International Classification of Diseases (ICD), the group identified factors they considered important in the management of depre~sion.~. ' Obstacles to early diagnosis were identified and specific attention was paid to the role of culture diversity on diagnosis and treatment. The WONCA Culturally Sensitive Depres- sion Guideline was launched at the WONCA World Scientific Meeting in Orlando, USA in October 2004.

The resulting depression guideline differs from many of those previously developed, as it acknowledges the importance of the classical nosological systems whilst recognising that patients who present to primary care d o not always fulfil the criteria described in such diag- nostic classification systems. It affirms the experience of many general practitioners that depressed patients in primary care often present with multiple somatic symptoms as well as mixed anxiety and depression. The WONCA Culturally Specific Depression Guideline highlights that patients from different ethnic back- grounds may use a rich variety of metaphors, often un- familiar to the treating practitioner who may be from a different ethnic and cultural background, to describe states of depression and psychological distress. Primary care practitioners need to be aware of the verbal and symbolic language used by their patients in order to promote a better quality consultation and so a better understanding of their patient's mental health needs.

Accurate mental state assessment is the key to the re- cognition and management of depression and takes time. In recognition of the time constraints faced by primary care practitioners, the international reference group members support the method of 'look, listen and test' as a useful framework for mental state exami- nation in the busy primary care clinic. Whilst looking at their patient from the moment they enter the room, the primary care practitioner is able to assess and record the style of dressing, mood, the affect and the level of eye contact the person presents, some of which may be culturally determined. Whilst actively listening

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to what the patient has to say, and the way in which they say it, the practitioner should note the volume, rate and character of speech. The content, including the specific metaphor used to describe the state the patient is in, should be noted. The practitioner should test by using specific probes to elicit additional information about the patient’s mental state by asking direct ques- tions about levels of attention, concentration and memory recall and suicidality. Relevant mental health screening tools can be administered if locally available.

The guideline also covers the use of pharmacological agents and strategies for the discontinuation of pharma- cological agents. It highlights that different ethnic groups respond differently to antidepressant medication. It also recognises the importance of non-pharmacological interventions in the primary care setting and cultural dif- ferences in response the different psychological treatment modalities.

The guideline is freely available to primary care physi- cians, patients, their families and health professionals on the WONCA website (www.globalfamilydoctor.com) and is available on a direct link. www.globalfamilydoctor.com/a boutWonca/sig/ FinalguidelinedepressionSIG-Version1 .O.pdf 0

Acknowledgements The WONCA SIG is grateful to all the members of the International Reference Group and Team Leaders for the time and commitment to this project.

References I Murray CLJ, Lopez AD. Alternative projections of mortality and

disability by cause 1990-2020: global burden of disease study. Lancet 1997;349:1498-505. Goldberg DP, Lecrubier Y. Form and frequency of mental disorders across centres. In: Ustun TB, Sartorius N, editors. Mental Illness in General Health Care: An International Study. John Wiley: Chichester,

3 Weissman MM, Bland RC, Canino GJ, et al. Cross-national epidemiology of major depression and bipolar disorder. J Am Med

American Psychiatric Association (1 994) Diagnostic and Statistical Manual of Mental Disorders. (4th ed) (DSMIV). APA: Washington DC.

5 World Health Organisation Tenth Revision of the International Classification of Diseases and Related Health Problems. (ICD- 10) WHO: Geneva, 1992.

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1995:323-34.

ASSOC 1996; 276:293-9. 4

I Notice to ElQP Subscribers ffrom the Chief Editor

We apologise that this issue of the EJGP is arriving much later than scheduled. This is due to difficulties beyond our control

that arose at our former Publisher, Mediselect bv. We have now terminated our relationship with them and are in the

process of selecting and appointing a new publisher. In the meanwhile, the journal will be produced by the combined

efforts of my Department (Department of General Practice, University College Cork), the Dutch College of GPs (Nederlands

Huisartsen Genootschap) and WONCA Europe. We are publishing this issue belatedly and plan on publishing a combined

issue 3 and 4 before the end of the year. We plan to have a new publisher in place for next year (volume 12). Thank you

for bearing with us in this difficult period. The future of the journal has been assured by certain pre-emptive actions and

decisions by WONCA Europe. We have every confidence that with your continued support the journal will go on thriving

and developing to meet the needs of the academic discipline of general practice/ family medicine in Europe and beyond.

Professor Colin P Bradley

Chief Editor

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