The influence of stigma on depression, overall psychological distress, and somatization among female Turkish migrants

Abstract

Background

Even though some studies suggest that in Mediterranean and non-western cultures more somatic and less psychological symptoms are reported, this so-called ‘somatization’ hypothesis has been challenged. Reviews show that somatic symptoms are a core component of depressive episodes regardless of cultural background. The expression of symptoms might be related to the psychosocial, social and cultural context surrounding the patient rather than ‘ethnicity’ or related constructs. Also, stigma associated with mental disorders can affect patients'symptom presentation.

Methods

The interrelationships of perceived stigmatization (Explanatory Model Interview Catalogue - Stigma Scale), depression (Beck Depression Index II), overall psychological distress (Symptom Checklist-90-R), and somatic symptoms (The screening for SOMATOFORM SYMPTOMS II) was assessed in a sample of female patients with Turkish descent with a diagnosis of depression (N = 63).

Results

Depression, overall psychological distress, and somatic symptoms were positively and significantly related. Stigma was positively related to depression and overall psychological distress. There was no significant relationship between stigma and somatic symptoms, neither among the severely depressed group (N = 39), nor among the less depressed group (N = 24).

Conclusion

The positive relationships between stigma, depression, and overall psychological distress indicate that patients who are more depressed and who have higher levels of overall psychological distress experience their condition as more stigmatizing. Since somatic symptoms and stigma were not related (neither positively, nor negatively), it appears that depressive symptoms and other symptoms of psychological distress affect concerns about stigmatizing attitudes in a way that somatic symptoms do not. This result challenges common assumption of the ‘somatization’hypothesis, i.e. that depression is ‘somatized’because of concern about stigmatizing attitudes.

Introduction

Cultural differences in the presentation of psychological and somatic symptoms in psychiatric disorders have been a topic under research. Even though some studies suggest that in Mediterranean and non-western cultures more somatic and less psychological symptoms are reported [2,4,5,6,7,14,20], this so-called ‘somatization’hypothesis has been challenged in the literature. A study of the World Health Organization (WHO) about somatic symptoms shows that somatic symptoms are a core component of depressive episodes regardless of cultural background [19]. In line with this finding, a review about cultural variations in the clinical presentation of depression shows that, contrary to the claim that Mediterranean and non-Westerners are prone to ‘somatize’ their distress, somatization is ubiquitous, and somatic symptoms serve as cultural idioms of distress in many ethnocultural groups [8]. Although somatic and psychological symptoms appear to coexist and patients are likely to express both, they may express more of one type of symptom, somatic or psychological, over the other [16]. The expression of symptoms may be related to the psychosocial, social and cultural context surrounding the patient [7,9]. There are several possible reasons for expressing somatic over psychological symptoms.

The above mentioned WHO study conducted at 15 primary care centers in 14 countries showed that a somatic presentation was more common at centers where patients lacked an ongoing relationship with a primary care physician than at centers where most patients had a personal physician [19]. Also, the frequency of somatic symptoms of depression may also vary depending on how somatization is defined. For example, definitions for somatization can include the presentation of a specific somatic symptom, the association between depression and medically unexplained symptoms, or a denial of psychological distress and substitution of psychological distress with somatic symptoms [19]. Furthermore, each person has his or her own specific explanatory model that affects the illness expectations [13], which in turn influence the ways that individuals perceive and evaluate the symptoms. Another hypothesis is that individuals who report physical symptoms are generally more likely to be accepted as ill. Therefore, some patients might reject psychological dimensions as a threat to the legitimacy of suffering [11]. Also, there might be secondary gains from expressing somatic symptoms, such as extra care and sympathy from friends, relatives, and doctors [16]. However, professional's prejudices about the frequency of somatization in different cultural or ‘ethnic’ groups may promote neglect of somatic concerns and contribute to stigmatization of migrants from certain countries.

Stigma related to chronic health conditions such as mental illness is a global phenomenon with a severe impact on the life of affected individuals, their families, and on the effectiveness of prevention and intervention [21]. Stigma associated with mental illness can affect patients’ symptom presentation and helpseeking behavior. When mental illness-related stigma within a culture is strong, patients may present their symptoms as more somatic in an effort to avoid stigmatization [6,16,22]. Kirmayer (2006) discussed how mental illness stigma may also play a role in illness denial. A patient's concern about stigmatizing attitudes or experience of discriminatory behavior can influence their expression of symptoms [16].

A mixed methods study of psychiatric patients in South India using the Explanatory Model Interview Catalogue (EMIC) [23] showed that participants with a greater concern about stigma tended to present a more somatic balance of symptoms [16]. In the narrative part of the interview, participants who expressed symptoms somatically emphasized their personal concerns about stigma. For example, one participant voiced a concern about stigma which caused her to keep knowledge of her mental illness a secret in order to arrange her daughter's marriage without problems. This example illustrates how anticipated stigmatization can be associated with a subsequent change in behavior. In another mixed methods study with psychiatric patients from South India using the EMIC, stigmatization was associated with greater prominence of depressive symptoms but lesser prominence of somatic symptoms. The narratives of these patients revealed that depressive symptoms affect the perceived social status of those who suffer from them in ways that somatic symptoms do not. The social meaning of somatic symptoms was described as less distressing because they closely approximate experiences that everyone has from time to time. Additionally, depressive symptoms may be considered to be private or even socially disadvantageous.

Few studies have investigated the interrelationships of stigma and the severity of psychological and somatic symptoms. In a sample of female patients with Turkish descent with a diagnosis of depression, we analyzed the interrelationship of stigma, depression, overall psychological distress, and somatic symptoms. It was hypothesized that [1] depression, overall psychological distress and somatic symptoms are positively related, [2] stigma is positively related to depression and overall psychological distress. Due to the conflicting results in the literature, no hypothesis was made concerning the relation of stigma and somatic symptoms.