2.4 cultural influences on depression & therapy

Question 1

3 sets of risk factors for depression

(Bailey et al, 2022)

Racial and ethnic differences in depression: current perspectives

Answer 1

internalizing factors - e.g. genetics

externalizing factors - e.g. medication side effects/secondary to illnesses and substance abuse

adversity due to trauma and psychosocial stressors - e.g. low SES

Question 2

race and ethnicity disparities in depression

(Bailey et al, 2022)

Racial and ethnic differences in depression: current perspectives

Answer 2

When considering disparities in depression in the context of race and ethnicity it is important to consider:
- the differences in predisposing factors - e.g. genetic factors and adverse childhood events
- the presentation of disease
- the boundaries to sustained and successful treatment

lifetime prevalence:
- among caucasians: 17.9%
- among african americans: 10.4%
- the difference lies in the fact that the chronicity of depression was higher for African Americans (56%) than for caucasians (38.6%)

Question 3

risk factors for depression in african americans

(Bailey et al, 2022)

Racial and ethnic differences in depression: current perspectives

Answer 3

the role of discrimination: self-perceived racial discrimination has been strongly associated w/worsening mental and physical health, especially in black women

the role of ethnic identity: in contrast, a strong sense of ethnic identity is a protective factor against mental illness

Question 4

SES and depression

(Bailey et al, 2022)

Racial and ethnic differences in depression: current perspectives

Answer 4

in addition to ethnicity and gender, risk factors such as lower yearly income, SES status, poverty status, and employment are recognized as key factors

household income and unemployment predicted MDD among black ppl

african american males were the only group not to exhibit a net protective effect of education on the development of chronic medical conditions (including depression)

Question 5

undoing hypothesis

(Bailey et al, 2022)

Racial and ethnic differences in depression: current perspectives

Answer 5

undoing hypothesis: asserts that positive emotions act as a buffer to undo the harmful effects of negative emotions

African Americans are less likely to exhibit depressive symptoms than Caucasians

depressive symptoms are associated with hopelessness in Caucasians more than in African Americans

black ppl with depression have a tendency to maintain positive attitudes in the face of adversity and foster hope

Question 6

Boundaries to successful treatment

racism in the medical community

(Bailey et al, 2022)

Racial and ethnic differences in depression: current perspectives

Answer 6

many Black ppl have restricted access to adequate care and resources due to racialised framing on the part of the provider

perceived discrimination among Black youth: increased anxiety due to increased negative psychological stress response to discrimination

lack of health insurance and access to proper resources among minorities is a barrier to treatment

treatment discontinuation: black patients are more likely to quit receiving treatment for mental health disorders than other ethnicities

Question 7

black-white depression paradox

(Pamplin & Bates, 2021)

Evaluating hypothesized explanations for the Black-white depression paradox: A critical review of the extant evidence

Answer 7

Black-White depression paradox = despite greater exposure to major life stressors, Black people in the US relative to white people, experience comparable or lower prevalence of unipolar major depression

valid or invalid estimates?
- invalid estimates: suggest that the burden of depression within Black communities is being systematically underestimated
- valid estimates: if true, then the paradox would be the product of etiological mechanisms producing a true lower burden of depression for Black people

Question 8

black-white depression paradox

what drives the observed racial patterns

(Pamplin & Bates, 2021)

Evaluating hypothesized explanations for the Black-white depression paradox: A critical review of the extant evidence

Answer 8

inconsistent operationalization of depression - despite having a lower burden of diagnosed depression, Black people often have higher levels of depressive symptoms and non-specific psychological distress

lack of synthesis within the available empirical evidence - it is difficult to draw conclusions about the degree of empirical support for the proposed mechanisms

Question 9

Artefactual mechanisms

selection based on institutionalised or residential status

(Pamplin & Bates, 2021)

Evaluating hypothesized explanations for the Black-white depression paradox: A critical review of the extant evidence

Answer 9

a form of selection bias

a limitation of the epidemiologic studies is that they are all comprised of samples of non-institutionalized and stably housed populations - implies that the depression paradox could be a product of selection based on institutionalized or residential status

People who are homeless, living on military bases or incarcerated are all absent from community-based studies

Question 10

Artefactual mechanisms

differential misclassification by diagnostic instrument

(Pamplin & Bates, 2021)

Evaluating hypothesized explanations for the Black-white depression paradox: A critical review of the extant evidence

Answer 10

a form of measurement error

some suggest that the paradox may be produced by differentially performing structured assessment tools

black and white individuals could systematically respond differently to items in structured diagnostic instruments

black ppl w/depression would be misclassified as not having depression, such that the prevalence would be artificially low

Question 11

Artefactual mechanisms

somatisation

(Pamplin & Bates, 2021)

Evaluating hypothesized explanations for the Black-white depression paradox: A critical review of the extant evidence

Answer 11

a form of measurement error

some evidence suggest that Black people are more likely to report depression in terms of somatic rather than psychological symptoms

this would result in a lower depression prevalence as the DSM is preferentially weighted towards psychological symptoms

Question 12

Artefactual mechanisms

clinician diagnostic bias

(Pamplin & Bates, 2021)

Evaluating hypothesized explanations for the Black-white depression paradox: A critical review of the extant evidence

Answer 12

when evaluating black patients, clinicians are more likely to misdiagnose depression as a psychotic spectrum disorder than when evaluating white patients

this could lower depression prevalence among Black ppl

not supported by evidence

Question 13

etiologic mechanisms

racial socialisation

(Pamplin & Bates, 2021)

Evaluating hypothesized explanations for the Black-white depression paradox: A critical review of the extant evidence

Answer 13

racial socialisation: the process in which people of diff racial groups are primed for the realities that they will face as a result of their place society

for black ppl: this is hypothesised to lessen the impact of adverse life events on mental health and depression

Question 14

etiologic mechanisms

social support

(Pamplin & Bates, 2021)

Evaluating hypothesized explanations for the Black-white depression paradox: A critical review of the extant evidence

Answer 14

theorised greater social support in black communities

greater social support serves as a protective factor against mood disorders in general, and among Black Americans specifically

evidence - no support

Question 15

etiologic mechanisms

environmental affordances model

(Pamplin & Bates, 2021)

Evaluating hypothesized explanations for the Black-white depression paradox: A critical review of the extant evidence

Answer 15

posits that Black ppl in response to heightened exposure to major life stressors and discrimination, engage in unhealthy coping behaviors

these simultaneously protect them from negative mental health consequences while increasing their risk for chronic physical illness

this would explain the higher presence of somatic symptoms

Question 16

discussion

(Pamplin & Bates, 2021)

Evaluating hypothesized explanations for the Black-white depression paradox: A critical review of the extant evidence

Answer 16

artefactual mechanism: out of the 4 artifactual mechanisms, for 3 of them the available evidence consisted of only one study each

etiological mechanisms: moderate support for the EA Model and the Racial socialization hypothesis; however, the evidence comes from studies with considerable limitations

ultimately none of the proposed mechanisms included in this review are strongly supported by the available evidence

Question 17

method

(Slobodin et al, 2018)

Developing a culturally sensitive mental health intervention for asylum seekers in the Netherlands: a pilot study

Answer 17

participants were residents of a certain asylum-seekers centre in the Netherlands, with most of them from the Middle East crisis

needs and expectations were identified using therapy expectations questionnaire and two focus groups

Question 18

results

expectations from therapy questionnaires

(Slobodin et al, 2018)

Developing a culturally sensitive mental health intervention for asylum seekers in the Netherlands: a pilot study

Answer 18

most desired outcome was that the therapist will help them to ease their distress and get active

most participants expected that the therapist will assist them in solving everyday problems and organise their daily lives

seeking a safe place were they could explore their difficulties

most patients appreciated help focusing on symptoms associated w/their adverse past

Question 19

results

focus group - 3 themes

(Slobodin et al, 2018)

Developing a culturally sensitive mental health intervention for asylum seekers in the Netherlands: a pilot study

Answer 19

loss of identity:
- a loss of self-resources and assets that once constituted their sense of identity, including relationships, education, profession, belongings and social status
- this identity crisis was associated w/negative self-esteem and feelings of worthlessness

feelings of uncertainty and helplessness:
- described their daily lives as empty from activities and full of waiting, thinking and worrying
- experience of being passive and the lack of control were often described as a major source of psychological distress
- their vague future combined w/the absolute powerlessness in the decision were associated w/feelings of anxiety and anger

negative attitudes towards mental health issues:
- sharing mental health problems was associated with heavy stigmatisation and shame
- psychological distress is associated w/abnormal behaviour and people are overburdened w/their own problems, hence they refuse to help others who are experiencing psychological distress

Question 20

discussion

key finding

(Slobodin et al, 2018)

Developing a culturally sensitive mental health intervention for asylum seekers in the Netherlands: a pilot study

Answer 20

1. mental health problems were more frequently associated with post-migration stressors than with past traumatic experiences
2. mental health problems and the use of mental health services were silenced among refugees due to shame guilt, anxiety and the fear of negative stigma
3. participants expressed their readiness to process adverse experiences in therapy
4. individuals and communities were limited in their ability to support those suffering from psycho distress due to the heavy stigma of such issues and the burden of multiple stressors

Question 21

discussion

risk factors

(Slobodin et al, 2018)

Developing a culturally sensitive mental health intervention for asylum seekers in the Netherlands: a pilot study

Answer 21

duration of the asylum procedure: those who stayed longer than 2yrs in the asylum-seekers centre suffered from higher anxiety, depression and somatoform disorders

stigma and discriminations: stigma hinders help-seeking behaviour and results in social-isolation, low self-esteem and limited opportunity in employment and education

Question 22

cultural adaptations of mental health treatments

(Soto et al, 2018)

Cultural adaptations and therapist multicultural competence: Two meta‐analytic reviews

Answer 22

involve systematic modifications to consider language, culture, and context in such a way that it is compatible w/the client’s cultural patterns, meanings and values

culturally adapted therapy considers multiple factors not typically addressed in traditional psychotherapy

Question 23

Meta-analysis of cultural adaptations to treatments

results

(Soto et al, 2018)

Cultural adaptations and therapist multicultural competence: Two meta‐analytic reviews

Answer 23

overall results:
- moderately strong effect of cultural adaptations to treatment on treatment gains
- high heterogeneity indicating that the results were inconsistent across studies

publication bias:
- the distribution strongly suggest presence of publication bias in the available literature
- after accounting for publication bias the effect size was decreased

overall, the more cultural adaptations reported in the study, the larger the effect size

Question 24

Meta-analysis of therapist multicultural competence

results

(Soto et al, 2018)

Cultural adaptations and therapist multicultural competence: Two meta‐analytic reviews

Answer 24

high heterogeneity of findings - the relation between therapist multicultural competence and client experiences in treatment was highly variable across studies

publication bias: the gap between statistically significant and nonsignificant studies suggested ‘missing studies’

Question 25

conclusion

(Soto et al, 2018)

Cultural adaptations and therapist multicultural competence: Two meta‐analytic reviews

Answer 25

clients engage better in therapy and experience improved outcomes when the treatments align with their culture

consistent with the cultural match model; the more cultural adaptations to treatments, the more clinical improvements the client’s experience

culturally adapted therapy should be performed in the client’s preferred language to optimize treatment gains

client ratings of therapist multicultural competencies strongly predict their engagement and outcomes