Prozac NationsHow does mental illness differ cross-culturally? An interview with Lawrence Kirmayer
Ever have the nagging feeling that our celebrity-driven, sound bite society is making us into a stupid, cynical, shallow people? Well, look to Oliver James, author of a May 2000 article in The Ecologist titled "Consuming Misery: Across the World, the Richer a Nation Gets, the More Unhappy Its People Become."
As a critic of consumer culture, I did a double take when I saw that headline--evidence at last! In his book Britain on the Couch, James purports that our way of wealth lowers our levels of serotonin--which he calls the happiness brain chemical--thereby making us depressed. James is far from alone in equating advanced capitalism with mental illness. Here in the United States, a growing movement of therapist-activists battles "affluenza," defined as a debilitating mental state caused by having too much money. While much of the affluenza literature makes a certain kind of sense, all it takes is a cross-cultural perspective to see the problem with arguing that affluence causes depression--namely, it's not true.
All of this is a roundabout way of introducing Lawrence Kirmayer. Dr. Kirmayer is a highly respected cultural psychiatrist at McGill University in Quebec. Unlike the affluenza crowd, Kirmayer has done a great deal of research on the mental health of aboriginal peoples, immigrants, and refugees. He points out that although our capitalist ways may be emotionally hazardous, it's unlikely that we are more depressed than poorer cultures. The only way to know for sure is to study those cultures, and research is generally lacking.
Stay Free! talked to Kirmayer by phone in July 2003 about cross-culture mental illness more broadly. We found him to be a very nice man. --Carrie McLaren
STAY FREE!: What mental problems are the most similar across cultures?
KIRMAYER: At one pole you have organic disorders that are very similar across cultures, like Alzheimer's disease or epilepsy, and perhaps schizophrenia and bipolar disorder. And at the other end you have what used to be called hysteria--dissociative disorders and so on. That said, there are differences cross-culturally even for something like schizophrenia. For example, people with schizophrenia appear to do better in nonurbanized, nonindustrialized countries.
STAY FREE!: Why is that?
KIRMAYER: It's not really clear, but it's probably in part because urban environments are not good for people vulnerable to schizophrenia.
STAY FREE!: Is that unique to schizophrenia or is that the case for mental illness in general?
KIRMAYER: Well, different illnesses don't respond precisely the same way to environmental and social factors. There are probably distinctive processes that underlie schizophrenia. The impact of noisy environments, for example, has been shown to contribute to relapse. One theory why people with schizophrenia do better in some countries has to do with family support and social integration. Someone who hallucinates is going to have a hard time working in a very technological society, but in a rural agrarian society they may still be able to do something useful for the family and community.
STAY FREE!: Do the symptoms of schizophrenia vary in different cultures?
KIRMAYER: Well, there have been studies that have shown differences in the frequency of various symptoms. For example, symptoms of catatonia--people becoming immobile--are more prevalent in some developing countries than they are in the West. Certain bodily symptoms are also more prevalent in some places. In many parts of the world, people with hallucinations may understand their experience in terms of religious systems--they may see themselves as being possessed, or talking to God. You get that in the West too, but you also have common technological interpretations--they think there is a radio transmitter in their tooth and so on.
STAY FREE!: I've read that TV stations get a lot of phone calls from people with schizophrenia and manic depression telling them to stop broadcasting.
KIRMAYER: Yeah, that's a common symptom of psychosis. People will go through this process of trying to figure out, "What could possibly explain this strange feeling that I'm having?" Most of the explanations sanctioned by medicine are basically that you have a "chemical imbalance" and that is very deflating. In another society, you might be told that you have had a significant religious experience, and even though you might still need to get some help, there might be something to valorize what's gone on for you. That tradeoff is harder in a very scientistic culture. Of course, even in our culture, where people are very secular and talk about things in scientific terms, there are still a lot of moral ideas about the person and about self-control.
STAY FREE!: People say, "Get over it!"
STAY FREE!: If someone has symptoms that we associate with depression in the U.S., how might that problem differ in other cultures?
KIRMAYER: There are two sets of issues. There is the issue of what is actually going on for people and the issue of how they understand it. These issues don't necessarily have to match up perfectly, but they interact. People interpret what's going on differently based on their cultural background. In the case of something like depression, how you interpret symptoms influences how things unfold. If you decide these feelings of exhaustion are a sign of depression, then that diagnosis suggests that you have certain other problems. That becomes part of a feedback loop--your thoughts chase each other in circles, and that in itself can intensify depression. Even though we can distinguish between what goes on physiologically and socially, the two levels interact. Once you understand that, you can find something that looks like depression everywhere in the world. In most places, the physical symptoms are the most important part of depression: fatigue, difficulty concentrating, muscular, and skeletal aches and pains and so on. In Japan, a lot of middle-aged women complain of shoulder pain, which is unusual in North America. The name for it is futeishuso which means "nonspecific complaint." Some of those people may actually have depression, but nobody's asked them, "Do you feel sad or low? Do you feel hopeless?"
STAY FREE!: Because there's a stigma attached?
KIRMAYER: Partly, yes, and partly because the notion of depression has not been so salient in Japanese psychiatry. Notions of anxiety disorders have been much more common. Psychiatrists don't see people with anxiety and depression, anyway--doctors of internal medicine deal with those patients. Psychiatrists only deal with the most severe disorders, schizophrenia and so forth. Until about five years ago or so there were no SSRI medications in Japan. Eli Lilly didn't even try to introduce Prozac in Japan initially because they thought there would be no market. Finally another pharmaceutical company did try, and now the idea of depression has taken off.
STAY FREE!: How does the notion that depression is a biological condition affect the course of the illness? Are people in the West better or worse off for it?
KIRMAYER: It depends. There's a Japanese psychiatrist, Yutako Ono, who used to tell people, "Depression is like pneumonia, so you have to take your medicine to make it go away." The implication is that it's not chronic. You can certainly promote an image of a mental disorder that is curable even if it is biological.
STAY FREE!: But here it seems that the biological notion implies permanence.
KIRMAYER: Well, but that kind of determinism is not necessarily tied to biology. In American folk psychology, there are notions of character, which imply that someone is or is not a particular way. In the U.S. over the past few years, there has been a huge swing away from the idea that people are molded by their social environment. Instead, there's the assumption that everything is determined by one's constitution. Sometimes it's rooted in genetics, sometimes something's wrong with the brain. The whole biological turn in psychiatry was really in excess of any specific evidence, but I think that it fits well with conservative politics in the U.S. right now.
STAY FREE!: I've heard that people in more affluent nations are more often treated for mental illnesses like depression than people in nations of low or moderate wealth. So does this mean that there is more mental illness in affluent places or is it just a consequence of poor people not having access to mental health care?
KIRMAYER: I think it's mostly the latter, though in many cases we don't know because there aren't enough epidemiological studies. If you want to make a generalization, then it's probably safe to say that poor countries have more mental-health problems, but by saying "poor" nowadays, you often mean societies where there is a huge level of conflict and violence. So it's not simply poverty--you can have a small, well-integrated rural society where people don't have a lot of material goods but they have excellent mental health.
STAY FREE!: Do people in different cultures commit suicide for different reasons?
KIRMAYER: Yes. Of course, the overriding reason, which is common across cultures, is overwhelming hopelessness and the desire to escape suffering. But there are also socially sanctioned reasons that can valorize suicide; in traditional Japan, suicide was a way of maintaining honor. To some extent, this is still a factor. People who have financial reversals will commit suicide not just to escape the problem but to make a gesture that acknowledges responsibility and hence restores honor in some way. Some of that's been exaggerated. There's been a stock image of the Inuit [the indigenous peoples of the arctic formerly called the Eskimo] as having a tradition of altruistic suicide in which older people sacrifice themselves for younger people. Granted, there were situations in which a whole family was starving and an elder would volunteer to be left behind. But that's a kind of self-sacrifice that people from many cultures could understand if they were facing similarly desperate circumstance so I'm not sure that should be viewed as suicide.
STAY FREE!: Has any interesting work been done on social stereotypes? Like the idea that Eastern European Jews are more neurotic?
KIRMAYER: The cultural historian Sandor Gilman has written a lot about the stereotype of the neurotic Jew. For the most part, it's not true--everybody's neurotic. But we have different styles of expression. Woody Allen isn't more neurotic than other people, but he has made a career out of talking about his anxieties. Spalding Gray is equally expressive of his self-doubt and anxiety but with a different cultural flavor. You find huge variations in how open people are about expressing things--these aren't just stereotypes, they are real cultural differences. But even though there are, for instance, certain Asian cultures where people don't express things verbally in the way some Mediterranean or North American groups would, it doesn't mean they aren't experiencing those things. Of course, within each social group you find enormous variation, and it's easy to overestimate the importance of any cultural trait.
STAY FREE!: Scholars who study "subjective well-being" argue that Latin Americans and North Americans are happier than Asians. Is there any truth to this?
KIRMAYER: Well, this relates to what I was saying: how people narrate their own experience will be influenced by culture. Happiness is a particular cultural value. In North America, it is important to indicate your success by exclaiming your happiness. In many other cultural contexts, however, people don't view the point of life as being happy; they may view it as being productive, as being honorable, as being a contributing member to society or to a family. I think the idea that we should be happy is a particularly American value. It fits very well with consumer capitalism, where the route to happiness is the consumption of products. It's certainly possible that the strategies someone uses to pursue well-being (such as through economic productivity) have built into them inevitable unhappiness, but we're not really encouraged to question our value system.