Cultural explanatory models of depression i Uganda

Background: Depressive disorders are among the most frequent psychiatric disorders, accounting for up to 30% of primary care service utilisation in developing countries in general, and Uganda in particular. However, delays in seeking treatment, misdiagnosis and non-specific treatments have compromised appropriate care for people with depression.

The general aim of this thesis is to explore and describe how depressive symptoms are conceptualised and communicated by the Baganda and how this conceptualisation may influence their help-seeking behaviour and processes. The research questions that the studies aimed to answer were: i) How do the Baganda understand, talk about and cope with depression? ii) What is perceived as effective treatment and how severe must symptoms be to warrant treatment? iii) Are the sub-types of depression seen as constituting one illness?

Methods: The thesis consists of four exploratory papers employing qualitative methods of individual interviews and Focus Group Discussions. Paper I reports preliminary results of a pilot study on lay explanations of causes, effects and help-seeking behaviour for depression among the Ganda cultural group. Twenty-nine adults participated in four focus group discussions and four individual interviews. Paper II reports results of an interview study among 25 adults receiving treatment for depression, regarding their personal and social meaning of depression, their beliefs on causes and consequences of depression, and what triggered seeking psychiatric help. Paper III reports results of the study that aimed to explore the Baganda's conceptualization of psychotic depression in terms of illness identity, causes and treatment. Members of the general population participated in 31 individual interviews and 12 focus group discussions. Unlabelled case vignettes based on DSM-IV criteria for psychotic depression were used as stimulants for discussion. Paper IV reports results of a study exploring traditional healers' explanatory model of depression without psychotic features. Interviews were conducted with 22 traditional healers.

Results: Depression without psychotic features was regarded as illness of thoughts. Depression with psychotic features was regarded as a "clan illness" (eByekika), arising from poor relationships between the living and the dead. Both illnesses were perceived as not requiring Western medication but culturally accepted corrective traditional therapies. Patients' illness behaviours, particularly those defined as socially disruptive, were important determinants of entry to psychiatric care. Non-disruptive symptoms were often ignored, misdiagnosed or treated as physical problems by health-care providers.

Concluding remarks: Conceptualisation of depression among the Baganda differs from the Western biomedical model of depression in terms of cause and treatment. Psychiatric help was sought if patients' behaviour became socially disruptive. There are similarities in the conceptualisation of depression between lay people and traditional healers who are the alternative care providers. Implications for clinical practice: It may be important to review the way depression is managed in the Western form of psychiatry when the patients reach mental health services in hospitals. The noted similarity between the alternative care providers and the users of their service has clinical implications for therapeutic approaches such as psychotherapy, where the agreement between the care provider and care receiver is key in a therapeutic relationship. These results have policy, research and training implications.

List of scientific papers

I. Okello ES, Ekblad S. (2006). Lay concepts of depression among the Baganda of Uganda: a pilot study. Transcult Psychiatry. Jun;43(2): 287-313.
https://pubmed.ncbi.nlm.nih.gov/16893877

II. Okello E, Neema S (2006). Explanatory models and help seeking behaviour: pathways to psychiatric care among patients admitted for depression in Mulago hospital, Kampala, Uganda. [Accepted]
https://doi.org/10.1177/1049732306296433

III. Okello E, Musisi S (2006). Depression as a clan illness (eByekika): an indigenous model of psychotic depression among the Baganda of Uganda. World Cultural Psychiatry Research Review. 1(2): 60-73.

IV. Okello E, Ekblad S, Neema S (2006). Beliefs and practices of alternative healers regarding non-psychotic depression: Health policy implications for effective use of scarce health resources in Uganda. [Submitted]