With most medical conditions it could be expected that, regardless of what country or culture the person affected was living in, the experience of illness would be very similar and that there would be common agreement, for instance, about who was experiencing measles and who was suffering from asthma.
But what if an individual said they could hear the voices of their dead ancestors or reported that they had been temporarily abducted by aliens? Would they be considered ‘mad’ or believed? The answer to that question might depend on whether they lived in Europe, Africa or America.
As there are no physical tests available, the diagnosis of psychiatric disorders depends on assessing what the person concerned says and does, or on what other people report about an individual who is causing them concern.
There are at least two aspects of this process that can be problematic in relation to cultural differences. Firstly, the diagnostic manuals that are used tend to be developed within the North American and European traditions of psychiatry and are likely to be affected by the cultural norms that prevail in those parts of the world.
Secondly, when the mental health practitioner and their patient come from different cultural backgrounds it may be difficult for the practitioner to know if what they are seeing is a symptom of a mental illness or simply a different way of thinking, feeling or behaving linked to the patient’s background.
Cultural differences affect aspects of behaviour significant for making a diagnosis. Behaving in a loud and extroverted fashion could be taken as a sign of mania. Similarly engaging in a prolonged period of mourning following a close bereavement could be interpreted as grief that has spilled over into clinical depression.
But both of these behaviours could be culturally determined. In the UK, psychiatric admissions to hospital of men from African and Caribbean origins are roughly twice as high as for white British men and there has been much concern that this group is being over-diagnosed with psychotic conditions.
In his book Mental health, race and culture (Palgrave, 2002) psychiatrist Suman Fernando makes a plea for mental health practitioners to recognise the underlying humanity of all people who are distressed, but at the same time to also take into account the impact of race and culture when assessing and treating the people who use their services.
In his book, Recovery from Schizophrenia: Psychiatry and Political Economy (Routledge 2004) Psychiatrist and anthropologist Richard Warner has compared rates of recovery from schizophrenia in different parts of the world and, perhaps surprisingly, has concluded that outcomes are better in the less industrialised nations compared to Western societies.
Possible reasons for this include the use of healing rituals to promote hope and to support integration with person’s community, close ties with family members which provide on-going support, and the nature of the work available which makes it easier for someone recovering from psychosis to engage in productive activities.
The other side of the coin is that there are concerns that, as developing countries lack the mental health infrastructure of industrialised countries, there are many people who are not receiving appropriate treatment, or who may even being treated with cruelty or being forced into isolation.
It is quite striking that when human rights are mentioned in connection with mental health in developing countries, the key issue is about the right to receive treatment from mental health services, whereas in Western societies the main issue seems to be about the right not to be given psychiatric treatment.