Managing Depression Among Ethnic Communities: A Qualitative Study

Analysis

Iterative thematic analysis was conducted following Mays and Pope’s²⁵ and Pope’s²⁶ framework for qualitative research and analysis in health care. We developed concepts from the data, rather than using preconceived theoretical frameworks. Three authors (R.K., J.F. and D.N.) read transcripts and analyzed them independently to identify themes and categories. Results were compared and discrepancies discussed with the wider group, and concepts were further refined. Additional thematic categories were added as the analysis developed. Transparency in analysis and reporting was achieved by providing extensive verbatim quotes and independent assessments of transcripts and themes.²⁷

Understanding and Negotiating the Problem of Depression

The physicians believed that patients from refugee communities often had difficulty with Western biopsychiatric concepts of depression. Sadness, worry, and stress were more commonly used terms, but reaching an agreed-upon understanding between doctor and patient about the nature of symptoms being experienced and what should or could be done was a challenge:

I think most people understand sadness…but in some cultures, they don’t understand [depression] as a condition that requires treatment (Physician 9).

Agreement about the phenomenon being discussed was approached tangentially, in a slow process that required sensitivity:

So to broach issues around mental health you need more euphemisms: worry, maybe sadness, stress, anxiety; you need to tiptoe…tread more softly, softly…because I think it [depression] is not a concept that they’d really relate to (Physician 11).

The physicians described these patients as reluctant to view their condition as an individual issue, as something happening to them. Focusing on community and contextual factors, such as family, work, financial, and housing issues, was seen as more acceptable. The physicians avoided the term depression during these discussions:

[P]eople are not really happy to discuss depression in terms of, like, it’s a personal change that has happened in me…you are more likely to keep the discussion going about family, work, or housing or money, stuff like that (Physician 1).

The physicians believed these patients saw the physician’s role as addressing physical problems, not knowing or accepting that a physician could also help with emotional distress:

[T]hey see you as a “treater” primarily of physical problems, that is the model they have inside their head, so why would they…tell the doctor about all this sort of stuff, because what can they [the doctor] do…in fact they don’t realize that telling is the part of the cure, (laughs)…a large part (Physician 5).

Perceptions of power and authority were seen as presenting difficulties in allowing the sort of dialogue needed to negotiate the problem:

I have a sense that…there’s a bit of the doctor-is-God type of view, that if the doctor says this is what ought to happen …[there is] perhaps a reluctance...to question my diagnosis or management…and so the management might not always be optimal (Physician 33).

The physicians thus saw the process of dialog, exchange, and negotiation as an important element of the work of depression care.

Managing the Depression

Refugee and settlement experiences loomed large. Prolonged experience of violence, together with the associated social isolation, language barriers, disconnectedness, unemployment, and family disintegration, were seen as common underlying causes of depression. The larger contextual framework of suffering for some physicians blurred boundaries between emotional distress and clinical depression:

I suspect there are a whole lot of people out there, because of awful trauma in their lives, awful events, (who) have times of deep sorrow, which is really what depression is, and sometimes people are quite desperate about it all (Physician 44).

Isolation compounded the effects of past trauma. Patients would worry about the safety of family who remained in the patient’s country of origin:

The other issue…is just lack of social supports within the community particularly their family…the family is split… some are in (the) country of origin and some are here, and all of the complications to their lives and stress that that creates… (Physician 5).

This contextual framing meant that the physician understood the condition being managed not only in terms of the individual patient’s life, but as a problem at a community level:

I think that there’s a challenge…they haven’t got the supports around them… how do you support that community to form new links that replace the older links or, ah…, or reinforce the older ones but in a different way (Physician 9).

The physicians felt a need to do something for individual patients. Faced with the impossibility of addressing structural issues, to work around the barriers posed by complexities of communication via interpreters, their main recourse was to prescribe an antidepressant medication:

I just think that a doctor sitting there deciding what to do for this patient, if their communication is greatly impaired because of language barriers, they want to do something, so they are more likely to use medication, so I think that’s just an accepted reality. …I don’t think it is a good thing, but it is how we try and manage in a multicultural society (Physician 5).

Yet understanding symptoms in the particular traumatic context of these communities meant that expectations of success with medication could be low:

I’d always try it [antidepressants]. But you have to be prepared for the fact that the damage that’s been done is so severe that it will never be quite right again (Physician 44).

Thus although the physicians talked about these patients as experiencing depression, they drew simultaneously on historical, cultural, contextual, and medical understandings of the condition. They had to work with the patient’s own understanding of their symptoms in a process of negotiation.

Working With the Interpreter

Physicians in the study had to use interpreters to work with patients from these communities to explore the painful experiences of trauma, torture, and social isolation. As passive conduits of words and information, interpreters could put this work at risk. Ideally interpreters had to be skilled in working beyond words:

[A] key point is having an interpreter who can convey the importance of emotional empathy…so if you slow the consultation down and speak softly, and use open words, trying to get the patient to emotionally release a bit, so the interpreter needs to be really good at that…you pick up cues from the interpreter about the emotional content of what is being interpreted. So that’s important, so it is not just the words, you can work with interpreters who are just simply doing the words and that can be counterproductive… (Physician 1).

Sometimes interpreters had a direct and important connection to patients:

I sometimes think it is actually their [interpreters’] manner and their demeanor in the consultation which is as much benefit as the questions that I’m feeding them, because in the end the patient is mostly looking at them when they are answering the question, so the response the interpreter has of the nodding and the acknowledgment and the way they ask the questions and the way they receive the answers really are quite critical in…that sort of therapy… (Physician 5).

The relationship between doctor and interpreter thus became an important factor in the therapeutic encounter with a patient:

[T]here is that issue of trusting the interpreter, trusting their professionalism, but also building a rapport, a relationship with the interpreter so that you have that confidence that they’ll be translating what you’re saying and giving you appropriate feedback…. [F]inding the right interpreters can sometimes be the answer (Physician 9).

The physicians were aware that this way of working with interpreters went beyond accepted norms of both medical and interpreting professions, bound by an ideal of interpreter as unengaged in the relationship between doctor and patient.²⁸

Strengths and Limitations

This study involved a small, unrepresentative sample of family physicians. The physicians caring for other cultural groups framed by different historical and contextual influences may report different experiences. It nevertheless provides a case study of depression care by physicians with rich experience of working across cultures. Although patient and interpreter views are reported in detail elsewhere,²⁹ our report highlights the way experienced physicians may engage with cultural difference as an active element of depression care.

We asked the physicians in this study to choose patients to discuss who had achieved a diagnosis of depression at least at some level. In other words these patients had been subsumed within the medicalizing impulse²⁹ of current depression work. The physicians may have been prompted to describe experiences of caring for depression that highlighted the importance of culture rather than seeing it as simply one of many influences. Previous research has shown that cultural difference is invoked in explaining difficulties and problems in the clinical encounter.³⁰ Our study, however, suggests it may also be framed as an opportunity.

Implications for Future Research and Clinical Practice

Our findings highlight the need for more detailed observational research of clinical care for depression across a range of primary care settings and contexts. We do not know whether the family physicians in this study work similarly with patients who are not so obviously different. If they do, it would suggest that they continue to adopt a biomedical understanding of depression, finding it an efficient way to manage the work, while not questioning the underlying construct. Neither do we know whether the physicians similarly approach patients from these communities who are experiencing emotional distress but are not given a diagnosis of depression. It is possible that the physicians support the notion of culturally flexible modes of expression of a range of emotional distress where, at times, the medicalizing notion of depression can usefully be used and others times not.

Our findings suggest a substantial vein of care for depression that would not necessarily be found through conventional studies of medical records, billing records, or patient self-report. Although it is possible that implicit, unspoken frameworks around depression care limit ways in which patients feel they can present symptoms legitimately,³¹ it suggests that depression care by family physicians occupies a unique form, and that grappling with difference is an important element of this work. Future research should better characterize and measure dimensions of this negotiating process as an active element of depression care and explore its relationship to clinical outcomes and physician and patient characteristics.