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Thesis Format

Integrated Article

Degree

Doctor of Philosophy

Program

Health and Rehabilitation Sciences

Supervisor

Dr Nouvet , Elysee

Abstract

Depressive disorder stands as a significant global health challenge and recognized as the primary cause of disability worldwide. Collaborating with the World Health Organization (WHO), Global Mental Health (GMH) initiatives have devised tailored international guidelines and intervention programs for low- and middle-income countries (LMICs) in response to this crisis. Despite concerted efforts, depressive disorder often remains underdiagnosed and undertreated in LMICs. However, our global understanding of depression is predominantly based on Western nosology, potentially limiting its universality. Consequently, existing clinical research and practices may fail to capture culturally relevant and salient aspects of depression.

Utilizing qualitative ethnographic methods, including Foucauldian critical discourse and document analysis, in-depth interviews, field notes, and observations, the study explored the conception(s) of depression among diagnosed individuals and healthcare providers and its cultural shaping in Bahirdar City, Northern Ethiopia. Specifically, it aimed to understand how patients diagnosed with depression conceptualize their condition and whether these local conceptions align with international definitions outlined in DSM-5 (APA, 2013). Additionally, through (re) reading global mental health as a biopolitical discursive practice (Foucault, 2008), the dissertation examined how a specific body of knowledge about depression was constructed and circulated and reshaping the landscape for psychiatric subjects in LMICs (Ethiopia).

Thirty-five in-depth interviews, involving purposively selected patients with depression (n=20) and mental health care workers (n=15) from two major psychiatric units were conducted. Findings revealed that patients perceive depression as a complex syndrome with cognitive, emotional, and physical symptoms. They attribute its origins to psychosocial, economic, and spiritual factors, highlighting the inseparable link between the mental and the social. While many symptoms align with DSM-5 criteria, five frequently mentioned symptoms do not conform, highlighting limitations in global diagnostic paradigms. Healthcare providers describe challenges in defining, diagnosing, and treating depression within a cultural context influenced by local beliefs.

The biopolitical discursive analysis of GMH intervention guidelines revealed power dynamics, operate as part of knowledge-power processes, materializing in certain forms rather than others, and shaping mental health discourse. The analysis identified several resistive discourses and suggested reconceptualizing the treatment gap for common mental disorders. This dissertation contributes to global mental health literature, stressing contextually grounded interventions in LMICs. By targeting social, cultural, and structural determinants of mental health(depression), policymakers, researchers and practitioners can work towards more equitable and effective mental health systems worldwide.

Summary for Lay Audience

Depression has emerged as a global public health concern, often remaining underdiagnosed and undertreated in low- and middle-income countries (LMICs). However, our current global understanding of depression is primarily rooted in Western nosology, which may not universally apply. Consequently, existing clinical research and practices may fail to capture culturally relevant and salient aspects of depression. This dissertation ethnographically explored depression among individuals who are diagnosed with depression and healthcare providers and its cultural shaping in Ethiopia. The study involved two main processes. First, it aimed to understand how patients diagnosed with depression conceptualize their condition. Second, it explored whether these local conceptions of depression align with the international definitions of depression outlined in the DSM-5 (APA, 2013) or ICD-11 (WHO, 2022). Ethnographic methods, including in-depth interviews, field notes, and observations were utilized. We conducted 35 in-depth interviews, involving purposively selected patients with depression (n=20) and mental health care workers (n=15) from two psychiatric units.

Findings reveal depression was often attributed to challenging life circumstances, with local social interactions shaping illness meanings, highlighting the inseparable link between the mental and the social. Spiritual explanations and traditional healing play a significant role in patients' accounts, and the decision to seek medical help was influenced by the severity of symptoms. While there was substantial overlap with DSM-5 diagnostic criteria, certain symptoms mentioned by patients did not align with those criteria, highlighting limitations in global diagnostic paradigms for Ethiopia and beyond. Improved screening, detection and diagnosis requires expanded understanding of local conceptualizations to facilitate interventions acceptable to those affected. Healthcare providers describe challenges in defining, diagnosing, and treating depression within a cultural context influenced by local beliefs. Addressing these complexities requires culturally informed interventions and enhanced screening processes. As we continue to strive for improved mental health on a global scale, it is imperative to elucidate the social context of mental health issues and identify the cultural and structural factors from which suffering arises. This understanding can guide the design of healthcare systems, improving access to care and facilitating the development of culturally relevant and effective intervention programs.

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

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