Culture-specific psychiatric illness?

It is depressing that an editorial in a major psychiatric journal can still maintain that “there is no solid evidence for a real difference in the prevalence of common psychiatric disorders across cultures” (Cheng, 2001). Cheng collapses the socioculturally determined understandings that patients bring to bear on their active appraisal of their predicament and on their expressions of distress and help-seeking to the term “illness behaviour”. The (Western) psychiatrist is to see through this mere packaging to the psychopathology within, which he knows to be universal and the ‘real’ problem. Cheng goes on to assert that disturbed people in “ less-developed” societies present somatically because of their “ limited knowledge of mental disorders”. There is a distinct echo here of the imperial era, when it was pressed upon indigenous people that there were different types of knowledge and that theirs was second-rate. Sociocultural and sociopolitical phenomena were framed in European terms and the responsible pursuit of traditional values was regarded as evidence of backwardness (Summerfield, 1999).

All of psychiatry is culture-bounded, not just a few syndromes in the DSM or ICD: even presentations by patients with organic disorders are embedded in particular ‘lifeworlds’ and local forms of knowledge. Western psychiatry is but one among many ethnopsychiatries. Cheng commits what Kleinman (1987) called a category fallacy: the assumption that because phenomena can be identified in different social settings, they mean the same thing in those settings.

The World Health Organization is falling into the same trap in its claims that ‘depression’ is a worldwide epidemic that within 20 years will be second only to cardiovascular disease as the world's most debilitating illness. The implication of such medicalisation is to deflect attention away from what millions of people might cite as the basis of their suffering, for example, poverty. In whose interests, apart from the pharmaceutical industry's, can this be?

We need a psychiatry that recognises the limitations of a technical approach and sees acknowledgement of sociocultural and political contexts as an ethical obligation (Bracken & Thomas, 2001). If Cheng were to see this as a challenge to the whole project — to (Western) psychiatry as a global enterprise propagating supposedly universal and morally neutral facts — then so be it.