Unipolar depression across cultures: A Delphi analysis of the methodological and conceptual issues confronting the cross-cultural study of depression
Melinda Redmond
School of Psychology, Curtin University of Technology, Perth WA
Rosanna Rooney
School of Psychology, Curtin University of Technology, Perth WA
Brian Bishop
School of Psychology, Curtin University of Technology, Perth WA
PP: 113 - 125
Abstract
The objective of the research is to investigate the epistemological and methodological discrepancies involved in the cross-cultural study of unipolar depression. These discrepancies include the methodological design and measurement of depression and culture, and the epistemological variation in researchers as to whether depression is a universal or socially constructed phenomenon.
A Delphi procedure was utilised which enabled a group of eleven culture/depression experts from around the globe to respond to an open-ended questionnaire related to the methodological and epistemological problems confronting the understanding of depression across cultures. Endorsement of these issues and consensus between the Delphi participants to these issues was then assessed by two subsequent questionnaires.
The results indicated that when studying depression across cultures, both universal and social constructionist approaches to depression need to be considered. Quantitative measures of depression should include only the universal aspects of depression so meaningful comparisons can be made across cultures. Quantitative information should be supplemented with qualitative descriptions from research collaborators who can provide an emic perspective of depression. Measuring culture should move beyond the scope of using Hofstede's dimensions which, although measuring some aspects of culture, do not encompass the complexity of cultures.
The impact of globalisation means that our knowledge of cultures needs to be regularly reviewed. Cross-cultural, comparative research of depression is much needed but there are many methodological and epistemological issues that need to be addressed.
Keywords
multicultural mental health, cross-cultural, depression, Delphi technique, cultural research, Hofstede
Article Text
The global burden of depression has been recognised as substantial and increasing (Murray & Lopez, 1996). Cultural differences in depression levels have been reported and cultural psychopathology research has become a significant force in investigating how culture contributes to these epidemiological trends (Berry, Poortinga & Pandey, 1997; Chan, 1995; Ingram, 1990; Lopez & Guarnaccia, 2000; Markus & Kitayama, 2001; Marsella, 1980; Okazaki, 1997; Tseng, 2001). For all these research efforts little clear understanding has been achieved. In this paper we will review some of the problems that have contributed to the current state of confusion. These problems include methodological design issues, measurement problems and epistemological variation in the assumptions of researchers. Rather than follow existing research models, we propose a need to stand back from current research and attempt to refocus on what research questions and methods should be. To this end we report the outcomes of a Delphi panel research program in which the experiences and views of experts in culture and depression were analysed. To our knowledge, this is the first research of its kind to utilise the Delphi procedure to aid in resolving debates about the depression-culture literature and is certainly one of the few studies in cross-cultural psychology generally, to use the Delphi method.
Epidemiological data on depression has not only put depression at the forefront of global health concerns (Greenberg, Stiglin, Finkelstein & Berndt, 1993; Marsella & Kaplan, 2002; Scott & Dickey, 2003) but is also used as rationale for cultural explanations for the variation of depression rates around the globe (Arrindell, Steptoe & Wardle, 2003; Ayuso-Mateos, Vazquez-Barquero, Dowrick et al., 2001). Recently however, the cross-cultural validity of the measures used to assess depression has been questioned with some researchers unconvinced as to whether they are culturally informed (Jenkins, Kleinman & Good, 1991). The findings of the Global Burden of Disease study by the World Health Organization (WHO) (Murray & Lopez, 1996) are arguably the most referred to of the depression epidemiology data (Lopez & Guarnaccia, 2000) yet arguments remain about the quality of the WHO measure and methodological design used to examine depression across cultures. Although these arguments are in part a methodological debate, they are also closely allied with the epistemological stance toward depression as a universal or socially constructed process.
A universal perspective is that depression is culture-general and is concerned with symptom-equivalency and comparability across cultures. Social constructionism explains depression as culture-specific, and only understood within the cultural context in which it occurs. Scepticism concerning the cross-cultural validity of measures, such as those used by WHO, is often formulated from a socially constructed view of depression. Social constructionists argue that since depression is a culture-specific phenomenon, comparability of depression across cultures cannot be guided by a single, quantitative measure. Simply, a quantitative measure lacks meaning in cultures other than those in which it was originally formulated. Universalists affirm that since depression is essentially the same across cultures (Draguns, 1995), a single quantitative method is usually sufficient to convey the experience of depression in diverse cultural centres. Clearly, these epistemological approaches to depression guide research rationale, methodology and conclusions. The fact that the depression-culture field remains divided in their epistemological approach is of significant and practical consequence.
Despite the controversy surrounding the methodological process and the quality of the measurement of depression in gathering epidemiology data, a considerable amount of research has used the cultural differences in depression rates to drive theories about the cultural-causation of depression (Arrindell et al., 2003; Draguns, 1990; Draguns & Tanaka-Matsumi, 2003). Such cultural psychopathology research normally places 'culture' as an antecedent variable to the differences in the rates of depression between cultural centres (Berry, 1976; Greenfield, 2000; Lonner & Adamopoulos, 1997). Given the complexity of culture, measuring it has been a complicated task in cross-cultural research and despite numerous published articles that have used culture as an independent variable, it remains an area of significant debate.
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