Author's reply

Drs Raguram and Weiss are right to point out the role stigma plays in help-seeking. We agree that many people with depression will not seek help from Western medical sources. The problem is more complex than that. In search of making sense of symptoms by the health professionals, we believe that the first step is by understanding the symptoms and the distress experienced by the individuals themselves through their identification that something has gone wrong; then their search for a possible explanation for their distress will lead to identifying possible sources of help and then finding a way to seek relief. However, in this process of help-seeking there are numerous culturally determined barriers. Stigma will indeed be a potential barrier but it is also likely that other factors may help modify the idioms of distress. In an earlier study of middle-aged Punjabi women, we found that they were able to identify symptoms of depression, and life events causing it, but they also felt that these symptoms were part of life's ups and downs and not a medical condition; hence, they preferred to seek solace in religious places (Bhugra et al, 1997). They identified both psychic and somatic symptoms but were also clear in their discussion that sources of help were not medical. Similar observations were made in Dubai (Sulaiman et al, 2001). Our conjecture is that globalisation will influence the way individuals see their distress because media influences may affect their cognitive schema. Cognitive schema determine the meanings we impart to ongoing experience and give an expectation of the future (Strauss & Quinn, 1997). We do not hold the view that somatisation is enigmatic. It is a perfectly understandable representation of the distress which is a reflection of the explanatory models held by the individual.