Cases & Commentaries
Cultural Dimensions of Depression
A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability to breathe and swallow. The patient had been living in the United States for 20 years and currently was unemployed, with a wife and two children. He spoke English reasonably well; nevertheless, the history was obtained with a translation service. The patient was anxious and repeatedly stated that he was "dying" from his physical ailments. Extensive workup showed no evidence of cancer, but revealed reflux disease and Zenker diverticulum (an outpouching) of the esophagus. Psychiatric evaluation ruled out major depression. In the midst of a gastroenterology consult (to obtain an esophagogastroduodenoscopy [EGD]) the patient ran to the bathroom, jumped out of the fifth floor window, and killed himself.
After this event, subsequent discussions with the family revealed some relevant details. The patient had lived through the Vietnam War; he and his family had come to the United States on a boat as part of a mass exodus in the late 1970s; there was strife within the family unit, as the patient felt he was an undue burden to them; and the family was "losing face" in their community due to his unemployment.
The psychiatric team concluded that the evaluation had not been sufficiently sensitive to identify important culture-specific clues related to depression and has since taken steps to incorporate culturally sensitive screening tools.
This complicated case of a 55-year-old Vietnamese man who committed suicide is tragic and probably represents a misdiagnosis. Before I discuss the case in detail I would like to present some background information about Vietnamese who have migrated to the United States. Part of this commentary is based on my experience as a physician in Vietnam in the 1960s and 34 years experience treating Vietnamese refugees.
Vietnam has had a long history of wars, beginning with the Japanese invasion in World War II, a long-term war first against the French, and then a civil war of North Vietnam against South Vietnam with American involvement. After the fall of Saigon in 1975, many refugees—estimated at more than 500,000—came to the United States. The first group tended to be well-educated, well-placed individuals who had Western ideas and fit in very well with the American culture. A second group, the so-called boat people, lived under the Communists and were later able to escape, often by boats, to neighboring countries. These people were often rural and less educated and had endured many hardships, including torture experiences at the hands of pirates and/or deprivation of food and water. Subsequently, many spent years in refugee camps in Thailand, Malaysia, and the Philippines before coming to the United States. Traditional Vietnamese values emphasize maintaining the stability of the culture and primacy of the community over the individual.(1) These values lead to a reverence for both traditions and conformity. Many of the traditional beliefs had been changed because of the effects of war, losses, and migration, and being exposed to a new culture.
Emigration to the United States has put pressure on these traditional values, particularly as the roles of husbands and wives have changed, family members have learned the English language, and young people have Westernized. This has resulted in much family stress.(2) There is also a tendency for many refugees from Southeast Asia and Vietnam to somaticize their psychological distress; many Vietnamese do not make distinctions between mind and body.(1) In reporting somatic symptoms such as headache, backache, poor sleep, or poor appetite, the Vietnamese patient may really be expressing psychological distress. In fact, most Vietnamese patients with mental disorders present with somatic complaints.(3) A related fact is that many Vietnamese have experienced significant trauma; therefore, posttraumatic stress disorder (PTSD) is a frequent diagnosis, usually comorbid with depression. In a systematic review of 7000 refugees, PTSD was found in 9% and major depression in 5%, with considerable comorbidity.(4) In a study in Australia, long-term Vietnamese refugees had a prevalence rate of PTSD of 3.5%, but 50% had a prevalence of any psychiatric diagnosis as opposed to 19% of the Australian population. Trauma contributed the largest role to mental disorders in the Vietnamese group.(5) In our own Vietnamese patient population of more than 400 patients, PTSD and depression are comorbid 80% of the time.
When conducting diagnostic interviews of Vietnamese patients, it is important to inquire about their life in Vietnam before they left, especially war experiences, as well as the escape process and life in the United States. There should be a thorough consideration of multiple diagnoses, including PTSD, which we have found in approximately 50% of Vietnamese patients.(6) PTSD can contribute to suicide.(7) Additionally, brain damage from torture has been found in Vietnamese and corroborated by radiographic studies.(8,9) In our studies, 10% of Vietnamese refugees had had psychotic symptoms.
Depression is a common diagnosis among Vietnamese refugees, and it presents in non-Western ways. Our group developed a Vietnamese Depression Scale that incorporated Vietnamese concepts of depression (10) and specifically cultural-related symptoms including nhuc nahn, shame and dishonor, and muon dien len, going crazy. Feeling shameful and dishonored is very distressing in Vietnamese culture. The Vietnamese Depression Scale has been validated in other studies.(11)
In this particular case, the diagnostic approach seemed inadequate. Going through a DSM-IV checklist for depression is not sufficient to establish a diagnosis of depression for a Vietnamese patient. Other diagnoses that can contribute to suicide, such as PTSD and psychosis, should be considered. Many other questions should have been addressed: Why was the patient not working? Did his symptoms interfere with his job? What was his relationship with his wife and children? The patient believed he was a burden; was this also shared by them? Did the patient feel he was a burden to his family and did they show this feeling? And, more important, did they notice a change in his behavior? What was the patient's concept of what was wrong with him? What needed to change to help him feel better? As mentioned, the Vietnamese Depression Scale may help with the diagnosis of depression. When dealing with a Vietnamese man with unexplained physical symptoms and other signs of distress, the wife should be questioned. When it is impossible to get a clear diagnostic impression by formal interviewing, one needs to observe the nonverbal behavior and body language; particularly signs of psychomotor retardation, agitation, and distress inconsistent with the verbal behavior. Vietnamese are reluctant to seek psychiatric help. In the previous cited Australian study (5), only 1 in 10 Vietnamese with PTSD sought mental health care as opposed to 1 in 3 Australians.
Establishing a foundation that includes an appreciation of the Vietnamese patient's background and cultural heritage can be crucial. Continuing a complicated medical evaluation without such a foundation may signal to the patient that something is seriously wrong, even that his case is hopeless. Referring such a patient to a psychiatrist without adequate preparation may imply to the patient that he or she is crazy, which carries tremendous shame in the culture. Finally, it is important to recognize the signs of severe distress. In the Vietnamese refugee, unexplained medical symptoms or reactions out of proportion to the symptoms need to be taken seriously, and suicidal intent, which may be impulsive and unpredictable, should be considered. Appropriate education and information, including medical and psychiatric possibilities, need to be provided in a sensitive way.
By having good communication with the patient and his family and by ensuring safety, support, and adequate antidepressant medicine, effective treatment can occur. There are several important changes clinics and hospitals can make to address the needs of refugee patients. First is the need to have a counselor/interpreter from that culture (in this case, Vietnamese) to aid in the interpretation of language and culture. Second, there is a need for culturally sensitive physicians, especially psychiatrists, who recognize that depression presents variably in different cultures, and that the evaluation of depression, PTSD, and suicidal potential is a challenging and time consuming process.
- Psychiatric diagnosis and suicidal behavior among Vietnamese is a complicated process and requires information about past experiences and current stressors, as well as current symptoms (including somatic symptoms).
- The symptoms of depression among Vietnamese include unique cultural symptoms such as feeling shameful and dishonored and feeling as though one is "going crazy." PTSD is a common comorbidity.
- A DSM-IV checklist of major depression is not adequate to diagnose depression among Vietnamese patients. Specific scales, such as the Vietnamese Depression Scale, can improve detection of depression.
- Depression among Vietnamese is embedded within cultural and family values. Spouse and family members need to be brought into the diagnostic process.
J. David Kinzie, MD
Professor of Psychiatry
Intercultural Psychiatry Program
Oregon Health and Science University
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