افسردگی پس از آسیب تروماتیک مغز: چشم انداز فرهنگی روانی زیستی

There are several challenges in diagnosing and treating mental illness amongst South Asians. Often times, formulating a patient's case presentation cannot adequately be accomplished strictly using a biopsychosocial model. The cultural components play an imperative role in explaining certain psychiatric symptoms and can guide treatment. With the growing population of immigrants coming to the United States, many of which require treatment for mental illness, it is essential that clinicians be cognizant in incorporating cultural perspectives when treating such patients. The authors describe the case of a 24-year old South Asian male who suffered an exacerbation of a depressive syndrome after a traumatic brain injury. Using a biopsychosocial cultural approach, this case highlights how South Asian cultural values can contribute to and incite psychiatric symptoms while simultaneously providing protective drivers for treatment outcomes.

Mental illness amongst South Asians in the United States (US) can be challenging to assess and treat due to several factors: the negative social attitudes towards mental illness, somatically focused symptom presentation, lack of empathy and understanding of mental illness among family members or care providers, and avoidance of mental health services by patients and family. Because of the negative stigma that is associated with mental illness, South Asians are less likely to disclose their emotional symptoms and thus have difficulty receiving treatment. Additionally, family members may underestimate the nature and/or severity of illness in their loved ones and discourage psychiatric treatment as a result. Non-South Asian clinicians may find it challenging to distinguish such cultural factors from biopsychosocial factors. In general it is important for clinicians to be aware how culture contributes to mental illness itself. Culture can be defined as attitudes, values and beliefs and behaviors shared by a people but also includes culture related experiences related to being an ethnic minority (Hwang et al., 2008). As outlined in a paper by Hwang et al. (2008), culture affects the “prevalence of mental illness, issues with diagnosis and assessment, etiology and course of disease, phenomenology and how distress can be expressed, certain coping styles and help seeking behaviors, as well as issues with treatment interventions” (Hwang et al., 2008). South Asian values can be considered allocentric, or group-oriented (Tavkar et al., 2008). Imbibed within this culture are beliefs that sacrifices should be made by individuals for the better good of the family (Tavkar et al., 2008 and Segal, 1998). There can be considered a sense of collectivism within the South Asian cultural system in which there is a practice of giving priority to the group as a whole rather than to the individual. Often there are expectations of younger generations to excel in education and develop lucrative careers. If these expectations are not met, a sense of shame upon the family may develop. In a study conducted by Bhattacharya and Schoppelrey (2004), two entities in the Asian culture that steered parental expectations were the responsibility of children in enhancing family pride as well as education which would enable advancement through the social class and the caste systems (Bhattacharya and Schoppelrey, 2004). This may predispose South Asians to certain risk factors in the development of psychopathology. Often younger South Asians, particularly students, are placed under immense pressure to excel academically, and often develop mood disorders leading to suicidal thoughts and behaviors. When parental expectations are not met, one feels guilty and ashamed. The individual's family often compounds the individual's shame with their own sense of shame and anger. The failure of an individual subsequently represents a failure of the entire family. This can lead to cognitive representations which predispose to depressive symptoms (Wong et al., 2014). Parents may also exert control over their children which impacts the nature of both maternal and paternal bonding. A study conducted by Singh et al. (2012) revealed that Indian college students who experienced affectionless parental control and neglect had higher rates of hopelessness and suicidal ideation (Singh et al., 2012). Asian Indians may often explain psychological distress as a violation of some moral or religious principle or spirit possessions. Physical and mental deficits are thought to be God's will or past karma. These factors may add to the delay in seeking professional help (Tavkar et al., 2008 and Conrad and Pacquiao, 2005). While the above factors may influence the development of certain psychiatric disorders, one could argue that this collectivism and belief in moral and religious principles might also protect the South Asian patient from the sequelae of severe mental illness, namely suicide. All of the above points should be considered when discussing potential precipitants for symptom presentation within South Asians with mental illness. This warrants an accurate and comprehensive approach to psychiatric diagnoses and ultimately treatment. A biopsychosocial perspective may often be inadequate in accounting for all aspects of a patient's illness. Cultural contributions are essential in comprehensively understanding such patients and can provide for more rigorous treatment approaches. The biopsychosocial model has been described as a scientific model created to include aspects absent in the biomedical model (Engel, 1980). As Engel describes in his paper, the biopsychosocially oriented physician should pay attention to not only biological factors but also psychosocial factors that are both protective and increase the risk for destabilizing a person's emotional homeostasis (Engel, 1980). Excluding the cultural components from this model however, can leave out vital components of a patient's psychiatric presentation, particularly when it comes to both diagnosis and treatment. Proponents of the cultural formulation model, as described by Lewis-Fernandez and Diaz (2002) stress the importance of assessing cultural values as they can play a significant role in an individual's psychiatric symptomatology and can highlight help seeking preferences. These proponents also argue that this can be even more important when physicians and patients are from different cultural backgrounds as an understanding of patients’ cultural values can guide treatment (Lewis-Fernandez and Diaz, 2002 and Mezzich et al., 2009). The authors of this article report the case of a young South Asian male living in the US who developed exacerbation of a major depression after a traumatic brain injury. His story illustrates aspects of cultural and social conflicts that need examination in order to comprehensively understand his symptomatology. His presentation reflects on how cultural factors can be both a hindrance in mental health treatment yet simultaneously protective to adverse events that would otherwise arise from severe mental illness. An example of this is suicide. As the numbers of immigrant populations requiring mental health services continue to rise, it is imperative for clinicians to incorporate a cultural mindset when formulating, diagnosing and treating these patients.