CC BY
18
Mustafaeva Shahlo1, Regan Shercliffe1, Mustafaev Farhad2
!Luther College, University of Regina, 2Fergana State University, Uzbekistan
MEASURING AND DEFINING DEPRESSION IN THE UZBEK POPULATION: TRANSLATING AND EXTENDING THE CENTER FOR EPIDEMIOLOGICAL
STUDIES DEPRESSION SCALE
Summary
Although words describing depression may not exist across all cultures, the symptoms of depression do. This study details the process of developing and evaluating a depression-screening tool for an Uzbek population. Moreover, this study also included open-ended questions to identify the terms and phrases Uzbek people use for depression and what symptoms they associated with it. 190 Uzbek students participated in the assessment of the psychometric properties of the original version of the CES-D and an experimental Uzbek version of the CES-D. The Uzbek CES-D showed a good reliability and content validity as a depression screening tool.
Keywords: depression, Uzbek, culture, Center for Epidemiologic Studies Depression Scale (CES-D), assessment.
Measuring and Defining Depression in Uzbek Population: Translating and Extending the Center for Epidemiological Studies Depression Scale
1.1 Introduction
In recent years, the prevalence of depressive symptoms and related problems has been a major focus for epidemiological research. Research in Western cultures, i.e North America and Western Europe, is facilitated by the availability and development of self-report depressive symptom measures and diagnostic instruments such as standardized interviews (Lin, 1989). However, research on depression in Asian cultures, and in particular Central Asian cultures, has been very limited and is mostly dependent upon direct translations of these Western depression instruments. The use of translated depression measures in Asian cultures is an understandable starting point. However, there is mounting evidence to suggest these instruments do not capture some of the symptoms experienced by Asian cultures as these measures of depression are based on the Western understanding and definition of depression. Therefore, the use of these measures in non-Westernized cultures may introduce significant limitations in understanding the prevalence and impact of depression in other cultures.
1.1.1 Current Cross-Cultural Challenges
1.1.1.1 Universal Definition of Depression
Current methods of cross-cultural research on depression are problematic for several reasons. Achieving a universal operational definition that is valid across cultural boundaries constitutes a major challenge (Noh, Avison, & Kaspar, 1992). Relatively little attention has been directed to ethnocultural variations in the experience of depression. The Western perspective (for the purpose of this paper "Western" refers to North America and Western Europe) conceptualizes depression as existing within a relatively strict set of biological (e.g. disruptions with appetite, fatigue) and psychological (thoughts of useless, feeling "down and depressed") parameters. Western society relies almost primarily on the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV;
APA, 1994) to define mental illness and in the case of depression the DSM-IV situates human problems within the physiology of the brain which then determines the psychology of the individual. Even though many human problems brought to the attention of mental health practitioners arise in the context of patterns of familial interactions, cultural settings, and wider social spheres, the first line of treatment often involves the prescription of psychotropic medications to alter brain chemistry.
The majority of research on depression in Asian cultures has focused on Chinese, Japanese and Korean populations and to a lesser extent South Asian populations (Shahlo can you reference the studies here that you reference later in the paper on these specific populations) According to Kleinman and Kleinman (1985), the existence of depressive disorder in these Asian cultures is often expressed in terms of cultural metaphors and syndromes, as adapted to local ideas and understanding of human health and physiology. This accounts for the fact that patients of East Asian decent often present with many somatic complaints and there is a denial of the affective components of distress in favour of more socially acceptable somatic symptoms (Bhugra, 2004). Somatization may very well be a cultural equivalent of depression in non-Western cultures.
One interesting consequence of the cultural inhibition of emotional expression seems to be an actual lack of vocabulary that specifically refers to depressive feelings. For example, Chinese and Japanese languages do not have a word that is equivalent to "depression" in Western cultures (Yoo, 2001). In sharp contrast, Western cultures have used the word "depression" and related terms to describe a diversity of dejected states for over 2000 years (Jackson, 1986).
In their ethnographic work with Chinese patients, Kleinman and Kleinman (1985) showed that the condition of "neurasthenia" in Chinese culture and the condition of "depression" in Western cultures correlate highly. Neurasthenia is described by the Chinese as shenjing shuairuo, literally translated to mean nerve weakness, and characterised by fatigue or weakness, sleep disturbance, poor concentration, poor memory, and pain associated with muscle tension (Yen, Robins, & Lin, 2000). This concept indicates a traditional epistemology of disease causation on the basis of a disharmony in vital organs and imbalance of qi, the vital energy believed to be responsible for health and disease in traditional Chinese medicine (Bhugra, 2004). Yen and colleguas (2000) point out that researchers who have re-diagnosed patients with neurasthenia according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) criteria showed that 40 to 90 % of patients met criteria for Major Depression. This indicates that depression, or more generally speaking, disruption in mood that effects functioning, is present in Chinese culture but takes forms that are different from those emphasised in the Western cultures that tend to rely on the DSM system of classification (Ryder, Yang, & Heini, 2002).
Indeed, culture can significantly influence the experience and communication of depressive symptoms. In some cultures these can be experienced or expressed in somatic terms, in others, a more symbolic expression is prevalent. Bhugra (2004) reports that depression in Korea and India is expressed either symbolically or physically and the physical terms are neither bodily nor emotional. According to Bhugra (2004), elderly Koreans express dysphoria in holistic symptoms e.g., "melancholy has been absorbed into my body". They are not somatising but speaking metaphorically using emotional expressions which is consistent with Korean traditional medicine wherein each bodily
organ has a symbolic function. For example, the lungs are related to worry, sorrow, and low spirit; the liver to anger; the kidneys to fear (Bhugra & Mastrogiani, 2004). Furthermore, research with cultures in the Indian subcontinent (Bhugra, 1996, 2001) found that symptoms of depression are identified as "feelings of heat" and "sinking heart". Researchers, therefore, have established that each culture has its own emotional lexicon that encodes unique cultural and moral values. Each culture has its own idioms of distress, although these idioms may not have been anticipated by the Western diagnostic systems (Manson, 1995).
1.1.1.2 Translated Measures
Depression self-report measures are commonly used in research to estimate depression in the population being studied, as indicators of treatment success or failure and in numerous other research capacities. Clinicians use self report measures of depression as a regular part of clinical practice. The assessment instruments that researchers and clinicians rely upon are developed in the context of a Western understanding of mental illness, primarily DSM constructs, and as such may not be entirely valid for use in other cultures. In short research suggests that the using depression screening measures based on DSM diagnostic criteria for depression with Asian populations results in an incomplete understanding (Noh et al., 1992). Although depression screening instruments have been validated and extensively studied in Western countries, their translation and use in other cultures is not nearly as simple as it might appear. Symptom terms often sound awkward or incomprehensible when translated, even if the wording is semantically correct (Yeung et al., 2002). Although terms that address biologically-based symptoms can be more easily translated and understood across cultures, subjective psychological aspects of depression are much more influenced by culture and language and vary across cultures (Ghubash, Daradkeh, Naseri, Bloushi, & Daheri, 2000). The application of these instruments to people whose cultural traits differ from the population on which they were initially developed and standardized could lead to misleading research and erroneous conclusions (Kazarian & Evans, 1998).
The validity of cross-cultural studies investigating the experience of depression is dependent upon the use of an appropriate study design which includes the use of culturally adapted instruments. And yet, in recent decades, the study of depression across different cultural and ethnic groups has been conducted with self-reports (e.g. CES-D, Beck Depression Inventory), interviewer rating scales (e.g. Hamilton Depression Scale, Structured Clinical Interview for DSM-IV) (Marsella, Hirschfelf, & Katz, 1987), and non-clinical family, attitude, and social cognition scales that are based on symptom criteria that are reflective of the Western experience. The resulting conclusions may be irrelevant or misleading (Marsella, 2003).
1.1.1.3 Regional Differences
Furthermore, there are regional differences within larger cultural groups that should be taken into account. Despite the growing interest in mental health in Asian cultures, most research has taken place in East Asia (Leong, Okazaki, & Tak, 2003). Rarely, if ever, have studies examined mental health, particularly depression, in Central Asia (i.e., Uzbekistan, Kazakhstan, Kirgizstan, Turkmenistan, and Tajikistan). Asian cultures may share similar aetiology concerning depression, but patterns and manifestations of depression can vary owing to the differing characteristics of cultural traditions and institutions (Chen, Chan, Bond, & Steward, 2006). Some aspects of mental health
concerns in larger Asian cultures such as in China or Japan may be applicable to other Asian populations, but others may not be. Each population deserves to be considered in its own right and Uzbekistan is a relevant example. For many years clinicians and researchers believed that depression was seen only in industrialized countries and it did not exist in pre-industrialized countries such as Uzbekistan (Leff, 1988). Their assumption was that the term "depression" did not exist in many languages, and therefore the disease itself did not exist in those communities. However interviews with neurologists, psychologists, and psychiatrists working in Uzbekistan reveal that the prevalence of depression in the Uzbek populace is increasing but adequate data describing the status of Uzbeks' physical and mental health and their health needs are not available at present, nor has a data system been developed to allow systematic monitoring of the population (Ilkhamov & Jakubovski, 2001). Efforts to assess the mental health of Uzbeks, taking into consideration the unique cultural context of their lives, have rarely been made.
1.1.1.4 The Uzbek Culture
Uzbek culture is complex and has been shaped and influenced by many cultures including Persian, Arabian, Turkish, Russian, and increasingly Western culture. In general, Uzbeks are perhaps culturally most closely-related to other Persian and Turkic peoples of Central Asia (Dickens, 1990). After the Turks of Turkey, the Uzbeks are the largest ethnic group of Turkic people in the world and they were the third largest ethnic group of the former Soviet Union when it collapsed in 1991 (Gall, 1998). But in some respects, Uzbeks do also have a broadly Asian character. They value collective welfare over individual achievement; rules of propriety do not allow the expression of extreme emotions; patience and self-control are considered desirable behaviors (Mee, 2001). Uzbeks maintain a strong sense of duty to the elderly and to the community, thus children are taught that openly approaching an adult is wrong and that they should be quiet and composed even if they are upset or angry (Gall, 1998). As a result of such cultural differences, Uzbeks conceptualize and manifest emotional problems very differently than do people of Western cultures. This cultural inhibition of emotional expression could possibly result in a somatic expression of mood disorder.
As Uzbek societies are collectivistic the burden of mental illness falls not only upon the individual, but upon the entire family. This can have a catastrophic effect on family life and family standing in the community. Accordingly, families would rather hide mental illness or, if necessary, communicate it in terms of a socially acceptable physical illness (Bhui, Bhugra, Goldberg, Dunn, & Desai, 2001). Consequently, individuals are reluctant to seek help outside the family, including mental health professionals (McCollaum & Lester, 1997; Pyon, 1993, as cited in Kim, 2002).
We could find no research addressing depression among Uzbeks but as noted above it would appear that the rates of depression have increased sharply in recent years for several reasons including ecological neglect (e.g. Aral sea) (Crighton, Elliot, Meer, Small, & Upshur, 2003), increased substance abuse, economic hardship, and increasing incidence of family conflict (Mee, 2001). The challenges of an increasingly urban and global society may also bring an increase in psychiatric disorders of all types (Mendels & Amsterdam, 1980) as societies face rapid change, cultural disintegration and collapse of traditional structures (Marsella, 2003).
Given the increasing challenges to the mental health of Uzbeks we believe that it is a useful endeavour to develop a reliable, valid, and culturally sensitive depression scale appropriate to the Uzbek population. Therefore the purpose of this study was twofold: 1) to translate into Uzbek a widely used measure of depression (Center for Epidemiological Studies Depression Scale [CES-D], Radloff, 1977) and 2) add culturally relevant items to the CES-D to increase the validity of the measure in an Uzbek population. Furthermore, we hope this research will add to the growing literature on cross cultural expression of mental illness. This literature is important for practitioners who work with people from different cultural backgrounds as it details the heterogeneity and similarities that exist between cultures which in turn informs practice.
1.2 Method
1.2.1 Instruments
The CES-D is a self-report depression scale that is used as a preliminary screening tool. Depression symptoms are categorized into four degrees of severity according to the frequency of these symptoms in the previous week. The survey is composed of 20 items and strongly emphasizes the cognitive, affective, somatic, and interpersonal components of depression (Kim, 2002). Four items in the scale are worded in the positive direction, to assess positive affect and to break up the tendency to answer all questions in the same direction. The 20 items are scored from 0 (rarely/none of the time) to 3 (most of the time). A total score is calculated by adding the ratings for all items, and the total score ranges from 0 to 60 with the higher score reflecting a higher level of distress (Radloff, 1977).
The CES-D has adequate psychometric properties and has been studied in various age, gender, geographic, and racial-ethnic subgroups (Kohout et al., 1993; Radloff, 1997; Roberts, 1980; Santor & Coyne, 1997; Sheehan, Fifield, Reisine, & Tenne, 1995, as cited in Cole et al., 2004).
The fundamental strategy in the construction of the instrument for the current study employs a twofold approach. On the one hand, we wanted to maintain the descriptive statements contained in the CES-D as much as possible so that a comparative analysis could be conducted. On the other hand, we hoped to incorporate statements that were more linguistically meaningful and comprehensive in expressing depression to an Uzbek population. We therefore created two adapted versions of the CES-D. The first version is the original CES-D, simply translated into Uzbek by two bilingual professionals. All items were then back-translated into English by a bilingual Uzbek who did not have any familiarity with the CES-D. The reliability of translated items was supported by two college students. They did not have any difficulty understanding the meaning of the items.
Although the items that address somatic symptoms could be easily understood by an Uzbek population, the more subjective, psychological items are much more influenced by language and cultural differences. We therefore created a second version of the CES-D, the "Uzbek CES-D", paying particular attention to the potentially different and uniquely Uzbek ways of expressing depression-related emotions and symptoms. The Uzbek CES-D includes the 20 original items found on the CES-D, which contain some statements that demonstrate semantic equivalence rather than literal translation. For example, "I had trouble keeping my mind on what I was doing" was translated as, "It was difficult to keep my mind on things that I was doing". We added six items to the Uzbek
CES-D after consulting with Uzbek mental health workers. The wording of these additional items reflects common Uzbek expressions of depressed mood and feelings of helplessness. The English translations of these items are as follows:
1) I did not want to do anything but lay down
2) It was hard to breathe
3) My heart was bothering me without any reason
4) I had a constant headache
5) My body felt broken
6) I was tired of my life
Each item in the Uzbek CES-D is scored using a four-point Likert-type scale and is scored and presented in exactly the same manner as the original CES-D. With the addition of the six items the scores can range from 0 to 78, with a higher score indicating a higher frequency of depressive symptoms. A cut-off point has not yet been established for the Uzbek CES-D as the instrument is still at the developmental stage however we are continuing research in this regard.
1.2.2. Participants
The participants for this study were 190 students enrolled at Fergana State University, a regional university within a large metropolitan area in Uzbekistan. We recruited participants randomly from the University's participant pool however students not enrolled in psychology classes were eligible to participate. We wanted to use subjects who had no education regarding depression to help insure that the descriptions given concerning depression would be as reflective as possible of those of the general population given the caveats of using university samples. We randomly selected students either by mail or telephone, explaining the main purpose of the study and asking whether they would be willing to participate. This study was approved by the University of Regina's ethics review board.
1.2.3. Procedure
One group of students (n = 95) was administered the original version of the translated CES-D, and the second group (n = 95) was administered the Uzbek version of the CES-D which included the additional items and the subtle rewording of the questions. In addition to the measures, each questionnaire also included open-ended questions that asked participants to 1) make comments regarding the cultural sensitivity of the instrument, 2) comment on the terms used for depression on the measures 3), provide terms and descriptions they use to express depression and 4) symptoms they associate with depression.
1.3 Statistical Analysis
The reliability of the Uzbek CES-D was assessed on the basis of standardized Cronbach's alpha coefficients and, the items within the scale were examined for consistency, with the desired criteria of item-total correlation being above .30.
1.4 Results
1.4.1 Sample Characteristics
A total of one hundred and ninety students constituted our sample. The age range for the sample of the translated CES-D was 18 to 27 years, with a mean age of 20.32 years (SD = 2.17). For the Uzbek version of CES-D the age range was from 18 to 27 years, with a mean of 21.06 years (SD = 1.86). The majority of the participants in CES-D
group were females (58.9% vs 41.1%). Overrepresentation of females in this group is not a reflection of the gender composition among Uzbeks. However, more males than females completed the Uzbek CES-D group (60% vs 40%).
1.4.2 Reliability of the Uzbek CES-D and the CES-D
The standardized Cronbach's alpha coefficient of the Uzbek version of the CES-D (the version with the 6 additional items) was .84 (p < .05) and the item-total correlations range from .20 (for item 7) to .77 (for item 17), with 23 items exceeding .30, the minimum criterion suggested by Kim (2002). The item-total correlation of three items was below the criterion, two of which were items in the somatic subscale, that is, "didn't feel like eating", "felt everything was an effort", and the other item was in the cognitive subscale, that is, "people were unfriendly". When these three items were removed, the standardized alpha improved to .85. Cronbach's alpha for the original CES-D was .77, p < .05.
The overall mean score obtained for the CES-D (without the additional six items) was 21.7 (SD = 6.7). With respect to gender differences the mean score for males was 20.56 (SD = 6.53) and the mean score for females was 22.52 (SD = 6. 88). There were no significant differences between males and females on the translated CES-D, t (93) = -1.39, p = .168. The overall mean score for the Uzbek CES-D (with the additional items) was 25.65 (SD = 9.94). The mean score for males was 23.42 (SD = 7.92) and the mean score for females was 29 (SD = 11.70). Females scored significantly higher than males on the Uzbek CES-D, t (93) = -2.77, p = .007. The overall mean score of the additional six items was 4.3 (SD = 3.5), with females scoring significantly higher than males on the additional items (females M = 5.29, SD = 4.29; malesM = 3.79, SD = 2.90; t (93) = -2.04, p = 0.45).
1.4.3 Open Ended Questions
The open-ended questions generated a series of symptoms and terms associated with depression. In general, participants, both females and males, responded readily to the questions and there were no gender differences observed in the generation of symptom description. Symptoms such as constant headaches, crying with no reason, feeling fearful, inability to sleep, loss of appetite, excessive thinking and excessive worrying (waswasa), feelings of loneliness and sadness, feeling angry, losing one's temper, talking less or not talking to people, boredom, feeling troubled, being tired of life, chest pains, and a feeling of heavy heart were associated with symptoms of depression. Specific terms and expressions that Uzbek participants used to describe depression included: "I am tired of/fed up with my life", "My body feels broken", "People don't understand me", "I want to be alone", "My heart is troubled", "I am tired, I can't do anything", "I am unlucky", "I am fed up/I am bored", "I don't want to talk/listen to anybody", "I feel troubled", "I can't sleep" and "I have headaches".
Moreover, participants mentioned family or home problems, such as financial problems, fights in the family, offending a family member, feelings of guilt, misunderstandings, and being ignored by a family member, as the likely cause of symptoms. Other reported situations that were felt to cause depression were emotionally traumatic events such as losing a close person, divorce, and breaking up with a boyfriend/girlfriend. Figure 1 demonstrates the percentages of people who reported somatic, affective, and behavioral symptoms of depression.
Insert Figure 1 about here
As this figure demonstrates participants who were administered the original version of CES-D reported more somatic symptoms of heavy heart but fewer headache symptoms than participants in the version of CES-D with the additional items. This might be due to the fact that one of the additional items was "I had constant headaches".
1.4.3 Symptomatology
Inspection of the resulting items in the Uzbek version of the CED-S and open-ended questions, demonstrates the culturally distinct concepts and metaphors compared with typical items from psychiatric measures developed and used in Western cultures. Common somatic symptoms of depression regarded by the Uzbek people were also found in other Asian cultures (e.g., Miller et al., 2006, Phan & Silove, 2004). For exampke, cultural expressions such as "waswasa" are mentioned by Sulaiman, Bhugra, and Silva (2001) who conducted research on depression in Dubai. Waswasa is an expression that means "obsession that makes you think too much and be worried about things that usually do not exist" (Sulaiman et al., 2001, p. 207). Another somatic symptom of depression that was often mentioned was "heavy heart" that refers to a feeling of tightness in the chest. A person who is experiencing heavy heart is unable to take a deep breath, leading to a feeling of shortness of breath that makes them sigh repeatedly. It also refers to the feelings of a chest too tightly packed with an excess of unpleasant feelings to accommodate the inspiration of air. A person may feel like crying in order to relieve this feeling, but they often feel unable to do so. The symptom of "heavy heart" was found by Mirdal (1985) in migrant Turkish women.
The most common cultural explanation of somatisation is that it results from the denial and suppression of emotions. Western cultures value individual autonomy and responsibility, and the concept of personal control and experience including powerlessness, helplessness, and detachment are closely related to depressive disorders. Whereas in Asian cultures the loss of personal control does not have the same aversive consequence because they emphasise selfless subordination to family and non-personal control (Marsella, 2003). Collective harmony is valued and wins out over individual psychological wellbeing. In order to maintain group harmony, individuals are not allowed to express extreme emotions. Excessive and overt expressions of one's feelings are viewed not only as a weakness, but as an assault on social harmony. Another important factor leading to somatisation is the cultural stigma attached to mental illness. Because Asian cultures are collectivist the burden of mental illness often falls not only upon the individual, but upon the entire extended family. This can have a catastrophic effect on family life and family standing in the community. Accordingly, families would rather hide mental illness or, if necessary, communicate it in terms of a socially acceptable physical illness (Bhui et al., 2001). Although somatic expressions share similarities with other Asian cultures the emotional expressions and its related variables in a society are show distinctive features. The identification of culturally distinctive features has practical value, paving the way for sensitive clinical inquiry and the effective delivery of therapy for this.
1.5 Discussion
The goal of this study was to compare two versions of the CES-D: the original translated CES-D and an Uzbek version that included additional items as well as changes in some items. We also attempted to gather information on how Uzbek people express
terms associated with depression as well as their views regarding the causes of depression.
The use of the original CES-D in an Uzbek population is generally supported. The content validity of the original scale was examined by comparing the back-translated and original items of the CES-D and the measure demonstrated adequate reliability in our sample. The items of the Uzbek CES-D were slightly changed to make them more culturally sensitive and back-translations seemed to satisfactorily replicate CES-D items. Furthermore the addition of the six items seems to have improved the overall reliability. However, the deletion of three items further improves the reliability of the Uzbek CES-D. From this we can conclude that Uzbek clinicians could use the Uzbek CES-D for screening for depression in the Uzbek population although further research is needed to develop adequate cut scores. Moreover, our results suggest that females were more likely to endorse symptoms of depression than males on the Uzbek CES-D. This finding suggests that either the items we added were more reflective of how an Uzbek female would describe depression (thus the higher score), or it is possible that similar to Western cultures, the prevalence of depression is higher in Uzbek females than males, and the Uzbek CES-D is more sensitive in this regard than the original CES-D.
The results of the descriptive study show a mixture of somatic and psychological symptoms that can also represent anxiety. We found no systematic studies comparing the assessment of depression and anxiety in the Uzbek culture. Thus, further research is needed to address questions such as "Are there distinctive and overlapping features in anxiety and depression among the Uzbek culture? Is the relationship between anxiety and depression similar or different from those found in the Western cultures?" For example research in Western cultures has identified that there is significant comorbidity between depression and anxiety (Morilak & Frazer, 2004).
Several limitations of our study merit mention. First, with the subjects in the sample being university students a generalization of the results of this study to a nonstudent population is limited. Secondly, the utility of these instruments with clinical populations has not been investigated. Administering these instruments to a clinical population would provide more complete results in sensitivity of the CES-D and the Uzbek version of the CES-D. Third, the age range of participants was limited to 27 years old thus limiting the generalizability of our results.
Some clinical limitations in the use of the scale should be noted as well. The Uzbek version of the CES-D needs further psychometric development if the scale is to adequately capture the manifestations of depression among a Central Asian population. The Uzbek CES-D does not yet have established norms or cut-off points for use as a clinical tool. Larger scale validation studies of the Uzbek CES-D are required before it can be applied to clinical settings. Moreover, a more in depth study of somatization in the Uzbek culture would be very important in developing an adequate checklist for depression screening. As our data suggests, while it might be true that Uzbeks express mood disorder in somatic terms, they are also capable of responding to symptomatic questions as well. Thus, more elaborate open-ended probing with a clinical population may yield more accurate symptomatic responses, with the results of our descriptive study suggesting possible future directions. Future analysis of data collected in a larger clinical study would address this question more specifically. Such a study may help suggest
appropriate clinical and community health strategies in identifying and treating depression in Central Asian populations.
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