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Mental health and diversity


  • Chapter 10. Cross-cultural psychiatry. (Helman, 2000).
  • The World Health Report (2001).Mental Health: New Understanding New Hope. Overview.  (World Health Organization, 2002). Full text available for download at
  • For an account of personal experience of illness, read Kleinman (2000).
  • For an all-in-review of advances in transcultural psychiatry since Kleinman’s ground-breaking work, see Cultural Psychopathology, Uncovering the Social World of Mental Illness (Steven Regeser Lopez). The review covers conceptual contributions, disorder related research, and emerging trends. In Annual Review of Psychology. Available at  
  • See Kleinman (1987) on the contribution anthropology can make to cross- cultural and international research in psychiatry: (1) the extent to which psychiatric disorders differ in different societies, (2) the usefulness of the tacit model of pathogenicity/pathoplasticity, (3) the place of translation in cross-cultural studies, and (4) whether the standard format for conducting cross-cultural studies in psychiatry creates a category fallacy. Cross-cultural validity should be given the same attention as the question of reliability, the concept of culture should be operationalized as a research variable, and cultural analysis should be applied to psychiatry's own taxonomies and methods rather than just to indigenous illness beliefs of native populations.o   For a monograph on social suffering, read Kleinman, Das and Lock (1997). Social suffering includes the human consequences of war, famine, depression, disease, torture – human problems that result from what political, economic, and institutional power does to people – and human responses to social problems as they are influenced by those forms of power. The chapters investigate the cultural representations, collective experiences, and professional and popular appropriations of human suffering in the world today. Moral, political, and medical issues cannot be kept separate.
  • The French approach to ethnopsychiatry is embraced on the ethnopsychiatry website
  • For an example of a simple culturally informed measure of distress, read Eisenbruch (1990a).


Indigenous mental health

  • Stolen generation and homeless children (Human Rights and Equal Opportunity Commission, 1993b; Inthirat & Thonglith, 1999).

Human rights and mental illness

  •  National Inquiry into human rights and mental illness (Human Rights and Equal Opportunity Commission, 1993a).


  • Mental health for multicultural Australia: a national strategy (Minas, Silove, & Kunst, 1993).

Classification – taxonomy – nosology

  • For an update on culture and the DSM, written by those involved in the drafting, read Mezzich et al. (1999). This paper critically reviews the process and outcome of an effort to enhance the cultural validity of DSM-IV. An ordered presentation of the antecedents and the main phases of this developmental effort is followed by a content analysis of what was proposed and what was actually incorporated, and a conceptual analysis of underlying biases and their implications. The cultural effort for DSM-IV, spearheaded by a scholarly independent NIMH workgroup, resulted in significant innovations including an introductory cultural statement, cultural considerations for the use of diagnostic categories and criteria, a glossary of culture-bound syndromes and idioms of distress, and an outline for a cultural formulation. However, proposals that challenged universalistic nosological assumptions and argued for the contextualization of illness, diagnosis, and care were minimally incorporated and marginally placed.


  •  Research ethics in psychology (Gil & Bob, 1999);


  • o   Child and adolescent psychiatric residency training (Kim, 1995);

Clinical and public health applications


  • o   Increasing the therapeutic alliance and patient compliance (Langer, 1999);

  • o   The ethnic and cognitive match between therapist and patient in psychotherapy and counselling (Sue, 1998).

Social ‘pathology’

  • o   Antisocial behaviour (Coatsworth et al., 1997); treatment programs for partner abuse (Williams & Becker, 1994); treatment programs for drug abusing (Hewitt, 1993) people including adolescents (Kurtines & Szapocznik, 1995).

Anxiety and depression

  •  For an overview of depression, see Marsella, A. J. Cultural aspects of depressive experience and disorders. In Lonner et al. (2002). As Marsella states: ‘Cultural variations in the nature and meaning of depressive experience and disorder have critical implications for assessment, diagnosis/classification, and treatment because cultural variations imply cultural relativism regarding with regard to such critical variables as epistemology, personhood, self, body, health and disorder, normality, and the spectrum of social and interactive behaviors (e.g., Fabrega, 1989, 1992; Kleinman & Good, 1986;; Marsella & Yamada, 2001; Kirmayer, 2001; Marsella, Kaplan, & Suarez, 2002). In brief, to the extent cultures differ in their constructions of reality, their meaning systems, and their socialization patterns, differences will emerge in psychopathology, including depressive experience and disorder.’ Chaper available at

  • o   Chapter 11. Cultural aspects of stress, pp.206-216 (Helman, 2000).

  • o   For a classic monograph exploring and reconfiguring a Western category of mental disorder – depression – in cultural perspective, read Kleinman (1985).

  • o   See chapter by Jenkins, Kleinman and Good (1991) on cultural variation in dysphoric affect and its importance for universalist definitions of depressive disorder; cross-cultural evidence on somatic components of depression and the concept of somatization in relation to depression and the communication of distress; the role of gender, social class, family relations, migration, political violence, and social change;  the cultural construction of emotion, the ethnopsychology of emotion; depression among refugees and immigrants; depression and social change; and methodological problems in cross-cultural research on depression.

  • o   See Weiss and Kleinman (1988) on an interactionist model of cross-cultural depression combining epidemiological and anthropological considerations

  • o   Correlates of depression and PTSD in Cambodian women with young children (Matthey et al., 1999).

  • o   Ethnic differences in presentation to general practice (Shaw et al., 1999). Full text available at


  • o   'Mental' in 'Southie': individual, family, and community responses to psychosis in South Boston (Scheper-Hughes, 1987). The study indicates that even seriously disturbed individuals are sensitive to cultural meanings and social cues regarding the perception, expression, and content of psychiatric episodes. Scheperhughes emphasises that while madness invariably disenfranchises, it does not necessarily deculturate the individual

  • o   For an early account of the symbolic and social aspects of the use of psychotropic drugs, read Helman (1981).

  • o   For an account of family and community responses to psychosis working class neighbourhood, read Scheper-Hughes (1987).

  • o   The incidence of schizophrenia and the ecology of the environment in London, see Boydell et al., (Boydell et al., 2001). Full text available at

Somatisation; psychosomatic disorders

  • o   See Ware and Kleinman on empirical research on neurasthenia in China and chronic fatigue syndrome (CFS) in the US. Attributions of illness onset to social sources, the symbolic linking of symptoms to life context, and the alleviation of distress with improvement in circumstances point to the sociosomatic mediation of sickness. Transformations occasioned by illness in the lives of neurasthenic and CFS patients confirm the significance of bodily distress as a vehicle for the negotiation of change in interpersonal worlds (Ware & Kleinman, 1992).

  • o   For an overview of the somatization-psychologization idea, read Ryder, A. G., Yang, J., & Heini, S. (2002). Somatization vs. psychologization of emotional distress: A paradigmatic example for cultural psychopathology, in Lonner et al (2002). Paraphrasing from the Introduction, this paper describes the developing area of cultural psychopathology, an interdisciplinary field of study focusing on the ways in which cultural factors contribute to the experience and expression of psychological distress.  The main section of the paper is devoted to a discussion of depression in Chinese culture as an example of the types of questions that can be studied. This starts with a review of the epidemiological literature, suggesting low rates of depression in China, and moves to the most commonly cited explanation, namely that Chinese individuals with depression present this distress in a physical way. Different explanations of this phenomenon, known as somatization, are explored according to an increasingly important model for cross-cultural psychologists: the cultural constitution of the self. Available at

  • o   For a study in general practice of the social construction of psychosomatic disorders, read Helman (1985).

The young

  • o   Eisenbruch (2000) has reviewed the cultural issues in perinatal disorder. Cox and his colleagues developed the Edinburgh Postnatal Depression Scale  (EPDS) for use in Scotland (Cox, Holden, & Sagovsky, 1987). The EPDS is the best available benchmark for a ‘cross-cultural psychiatric’ measuring scale for postnatal depression, although caution should be exercised in applying it to non-Western societies (Bashiri & Spielvogel, 1999; Yoshida et al., 1997). Stewart and Jambunathan (1996), in their study of postpartum depression among Hmong women living in the United States, have found that traditional beliefs and practices helped the women to adjust to the postpartum period. In a comparative study of the significance of social supports to Western depression, the social support network and postnatal mood of Anglo-Celtic women (having mothers and partners, and uninhibited in expression of feelings), Vietnamese refugees (lacking mothers and even partners, and suppressing the expression of personal difficulties), and Arabic migrant women (high in expressing desire for more help) were compared (Stuchbery, Matthey, & Barnett, 1998). While most cross-cultural studies of perinatal disorder have focused on postnatal depression, postpartum psychosis has also been described in various countries e.g. in Uganda (1979) and South Africa (Cheetham, Rzadkowolski, & Rataemane, 1981)

The elderly

  • o   Some research is carried out with the intention to reveal information about the cultural validity of the tool. Cultural differences in the reporting of depressive symptoms among older people were examined using the Center for Epidemiological Studies Depression (CES-D) scale in five Southeast Asian countries: Indonesia, Korea, Myanmar, Sri Lanka, and Thailand. The behaviour of the CES-D in older Asian populations was found to be comparable to results obtained in North American and European cultures, suggesting that the scale is culturally valid (Mackinnon et al., 1998).

  • o   Henderson (Henderson, 1989) argues that epidemiological research has implications for the cross-cultural research on the prevalence of dementias and for the comparative study of depression in the elderly. Even in the case of dementia, which is universal, it may vary across cultures and between social and ethnic groupings. This variation needs to be taken into account in screening (Lam et al., 1997) and diagnosis (Rait, Burns, & Chew, 1996), for example, of dementia. The instruments used for screening also have to be culturally validated (Tsai & Gao, 1989). (Pollitt, 1996) makes the case that the sociocultural context in which dementia occurs and the meaning to the sufferers and caregivers need to be included in anthropologically informed studies. Fabrega (1994) found that, comparing African-American and Anglo-European geriatric patients, on diagnosis, symptomatology, psychotic diagnoses, and variability in the ratings on the Brief Psychiatric Rating Scale and Hamilton Depression Scale were significantly associated with ethnicity. African- Americans appeared to obtain comparatively higher therapeutic benefits from hospitalization. The social conditions of the elderly may play no less a role in determining the mental health of the elderly. Silveira and Abraham (Silveira & Ebrahim, 1998) tested this hypothesis among East London Somali and Bengali immigrants and white British, and found that inequalities in housing, social support, income and physical health status accounted for variation in mood between immigrants and whites, supporting a theory of ‘multiple jeopardy’ of ageing among ethnic minorities. It is not all bad news – Kua (Kua, 1998), for example, showed that 94 per cent elderly Chinese in Singapore were able to live independently, 78 per cent had good social resources, and only 9 per cent had mental disorders.


  • o   Some international data suggest that immigrants have lower rates of suicide compared with the population of the host country. See, for example, among Caucasian, African Americans, Asians, Hispanics, and Native Americans in San Francisco (Shiang, 1998). A survey of depression and suicide rates among ethnically diverse groups in the United States showed that Mexican American and Puerto Rican males had lower relative suicide rates than white males (Oquendo et al., 2001).

  • o   The situation, however, is more complex, as noted by Baume and Clinton (1997), in examining the social and cultural patterns of suicide in young people in rural Australia. . Many studies have shown that culture and ethnicity does make a difference to suicide patterns, but that it is not simply a matter of comparison of the raw rates by ethnicity. According to Stack’s 15 year review of the sociological literature, there is continued stability in suicide research findings in terms of racial differences (Stack, 2000). Lester (1998) examined suicide rates in Singapore and found as association with measures of domestic integration for Indians and ‘others’ but not for Chinese and Malays. Neeleman and Wesseley (1999) examined the effect of the size of an ethnic community on the suicide rate among White, Afro-Caribbean and Asian communities in South London, and found that minority suicide rates are higher in areas where minority groups are smaller. Dependent on address, a suicide risk factor for a White individual may protect an ethnic minority individual and vice versa.

  • o   Religion and cultural beliefs, rather than ethnicity on its own, need to be carefully considered. Wang et al. (1997) compared the suicide rate of three groups in Inner Mongolia and reported that the Han have the most tolerant views toward suicide and were found also to have the highest suicide rate. The Hui follow Islam, which condemns suicide, and were found to have the lowest suicide rate. The Meng expect to suffer in life and are thus not prone to suicide, though as they move to the cities and become more educated, they tend to adopt Han cultural values so that their suicide rate is now moderately high.

  • o   Attempted suicide is another story. According to the WHO/EURO Multicentre Study on Parasuicide, there was little difference in suicide intent across nine European regions of various religions and cultures (Hjelmeland et al., 2000). On the other hand, as reported by Bhugra (1999), Asian women in London had higher rates of attempted suicide than white women, while the rates among black groups was lower than expected. Many of these studies take ethnicity as the variable. Perhaps, however, as Yuen et al. suggest, cultural affiliation rather than ethnicity is a risk factor for attempted suicide – Native American adolescents surveyed in Hawaii had significantly higher rates of suicide attempts than other adolescents in Hawaii and the rates were determined by cultural affiliation rather than ethnicity (Yuen et al., 2000).


  • o   Are the seemingly modest rates of homelessness among the CALDB misleading? See (Australian Federation of Homelessness Organisations (AFHO), 2001; Better Health Centre, 1999)

  • o   What mental health issues face CALBD homeless men (Buhrich, Teeson, & Hodder, 1998)? Is there a correlation between the vulnerabilities of certain groups e.g. ethnic, refugee and asylum seekers, to develop mental disorders and then be extruded from their families or frightened of deportation? What about homeless women?

Refugees and asylum seekers

  • o   Medical Ethics and Human Rights. BMA Publication, 2001. Torture, asylum seekers, medical ethics unrelated to asylum seekers (British Medical Association, 2000). See review of this book at and comments on the contents at

  • o   See recent NSW Health data. NSW settled 9,400 refugees in the three years 1999 to 2001. Over one third of these were from countries of the former Yugoslavia, with Iraq (23.6%), Afghanistan (9.2%) and Sudan (7.7%) being the next most common countries of origin. The Longitudinal Survey of Immigrants to Australia (Vanden-Heuvel and Wooden, 1999) showed that, compared with other migrants, humanitarian entrants were more likely to rate their own health as less than good, and to have visited health care providers in the previous four weeks. A relatively greater proportion of humanitarian entrants suffered from a minor mental health disorder. Available at

  • o   STARTTS is a state-wide service and is committed to extending access to specialised torture and trauma rehabilitation services. For an account of the history of STARTTS, see Reid (1990). See STARTTS counselling and therapy services at . Towards a systematic approach for the treatment rehabilitation of torture and trauma survivors in exile (Jorge Aroche and Mariano Coelho), available at

  • o   Social work with refugee survivors of torture and trauma (Robin Bowles), available at

  • o    A useful report of a STARTTS / Refugee Health Service consultation with the Arabic speaking community is available at

  • o   Anxiety, depression and PTSD (Silove et al., 1997)

  • o   See Silove’s proposed model of torture and related abuses as challenging five core adaptive systems subserving the functions of ‘safety,’ ‘attachment,’ ‘justice,’ ‘identity-role,’ and ‘existential-meaning’ (Silove, 1999).

  • o   Counselling survivors of torture and trauma (Cunningham, Silove, & Storm, 1990).

  • o   You should explore whether refugee trauma really subsides naturally over time. Read a recently published population-based study of the long-term effects of trauma in Vietnamese refugees resettled in Sydney, Australia (Steel et al., 2002). Mean time since the most severe traumatic event was 14.8 years and 7% of participants had mental disorders defined by ICD-10 and the culturally-sensitive measure, respectively. Trauma exposure was the most important predictor of mental health status.

  • o   You can read about the role of torture in generating post-traumatic stress disorder (PTSD) symptoms. See a recent study (Silove et al., 2002) that comparing the impact of torture with that of other traumas suffered by a war-affected sample of Tamils living in Australia. Tamils exposed to torture returned statistically higher PTSD scores than other war trauma survivors after controlling for overall levels of trauma exposure.

  • o   Risks of retraumatisation of asylum seekers in Australia (Silove, McIntosh, & Becker, 1993), mental health professionals and social and ethical responsibility (Silove et al., 1996) and detention of asylum seekers (Silove, 2002; Silove, Steel, & Mollica, 2001; Silove, Steel, & Watters, 2000).

  • o   For a critique of the DSM and an alternative category for refugee mental health, choose from the following readings Eisenbruch (1991; 1992).

  • o   Cultural influences in psychotherapy with refugee survivors of torture and trauma (Morris & Silove, 1992) and in working with Cambodian and Chilean patients (Morris et al., 1993). The influence of culture on psychiatric treatment of the Vietnamese refugee (Phan & Silove, 1997)

  • o   See ‘cultural bereavement’ (Eisenbruch, 1988; Eisenbruch, 1990b; Eisenbruch, 1990c; Eisenbruch, 1990d), which also links to the role of homesickness (Eisenbruch, 1997). There are, too, the global relations between those who resettled in Australia, for example, and their family members and compatriots dispersed in other countries of resettlement as well as in displaced persons and refugee camps and those in the homeland (Eisenbruch, 1994).

Problem gambling

  • o   Problem gambling and Young People (aged 15-25) from CALDB. Gambling among particular cultural and subcultural communities in Australia (Tran & The Ignatius Centre for social policy and research, 1999)


  • o   Mismatch between doctor’s prescribing and patient’s use: why it is CALD patients take more/less than prescribed. Refer to the Tobin report (Tobin et al., 2000) on differential prescription of psychotropic medication

Occupational therapy

  • o   Occupational therapy and mental health (Dillard et al., 1992)


  • Australian Federation of Homelessness Organisations (AFHO) 2001, Annual Report 2000-2001.

  • Bashiri, N. & Spielvogel, A. M. 1999, "Postpartum depression: a cross-cultural perspective", Primary Care Update for OB/GYNS, vol. 6, no. 3, pp. 82-87.

  • Baume, P. J. & Clinton, M. E. 1997, "Social and cultural patterns of suicide in young people in rural Australia", Austrial Journal of Rural Health, vol. 5, no. 3, pp. 115-120.

  • Better Health Centre. Moving forward in men's health.  1999. Sydney, NSW Health Department. Better Health Good Health Care.

  • Ref Type: Serial (Book,Monograph)

  • Bhugra, D., Desai, M., & Baldwin, D. S. 1999, "Attempted suicide in west London, I. Rates across ethnic communities", Psychological Medicine, vol. 29, no. 5, pp. 1125-1130.

  • Boydell, J., Van Os, J., McKenzie, K., Allardyce, J., Goel, R., McCreadie, R. G., & Murray, R. M. 2001, "Incidence of schizophrenia in ethnic minorities in London: ecological study into interactions with environment", BMJ, vol. 323, no. 7325, p. 1336.

  • British Medical Association 2000, The Medical Profession & Human Rights: Handbook for a Changing Agenda Zed Books and British Medical Association.

  • Buhrich, N., Teeson, M., & Hodder, T. 1998, Down and Out in Sydney: A Report into Homelessness, Wesley Mission Publications.

  • Cheetham, R. W., Rzadkowolski, A., & Rataemane, S. 1981, "Psychiatric disorders of the puerperium in South African women of Nguni origin. A pilot study", S Afr.Med J no. 13, pp. 502-506.

  • Coatsworth, J. D., Szapocznik, J., Kurtines, W., & Santisteban, D. A. 1997, "Culturally Competent Psychosocial Interventions with Antisocial Problem Behavior in Hispanic Youth".

  • Cox, J. L., Holden, J. M., & Sagovsky, R. 1987, "Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale [see comments]", Br.J.Psychiatry, vol. 150:782-6, pp. 782-786.

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  • Eisenbruch, M. 1990b, "Cultural bereavement and homesickness," in On the move: The psychology of change and transition, S. Fisher & C. L. Cooper, eds., John Wiley & Sons Ltd, New York, pp. 191-205.

  • Eisenbruch, M. 1990c, "The cultural bereavement interview: A new clinical research approach for refugees.", Psychiatric Clinics of North America, vol. 13, no. 4, pp. 715-735.

  • Eisenbruch, M. 1990d, "The role of cultural bereavement for the health transition in a multicultural society," in Cultural, social and behavioural determinants of health, J. C. Caldwell et al., eds., Australian National University Press, Canberra.

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  • Eisenbruch, M. 1994, "Mental Health and the Cambodian Traditional Healer for Refugees Who Resettled, Were Repatriated or Internally Displaced, and for Those Who Stayed at Home", Collegium Antropologicum, vol. 18, no. 2, pp. 219-230.

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