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Table of Contents
PERSPECTIVE/VIEWPOINT
Year : 2019  |  Volume : 1  |  Issue : 1  |  Page : 43-46

Examining the “Social” in social psychiatry: The changing profile of context in the era of globalization and epidemiological transitions, with a special focus on Sub-Saharan Africa


1 Department of Psychiatry, WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Substance Abuse, University of Ibadan, Ibadan, Nigeria; Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
2 Department of Psychiatry, Old Age Unit, University of Ibadan, Ibadan, Nigeria

Date of Submission17-Jun-2019
Date of Decision01-Jul-2019
Date of Acceptance08-Jul-2019
Date of Web Publication27-Sep-2019

Correspondence Address:
Prof. Oye Gureje
Department of Psychiatry, WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Substance Abuse, University of Ibadan, Ibadan, Nigeria

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WSP.WSP_5_19

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  Abstract 


Interest in seeking to understand psychopathology in social and cultural contexts has gone through phases. There was a time when the traditional social context in which Africans lived was mystified and exoticized by the West as simple and unsophisticated. While a more liberalized understanding of the diversity of social organizations is now common, a more complex social configuration is nevertheless emerging on the continent. The countries in sub-Saharan Africa are undergoing rapid transitions characterized by epidemiological shifts, urbanization, and a reorganization of family structure. Each of these transitions is, in turn, affected by the pervasive influence of globalization and the prominent impact of information technology, including social media. In this context, the traditional defining features of “social” networks and sociocultural norms and rituals are changing. These changes bring tensions which have consequences for the mental health of populations and how the people who experience mental illness are related to and cared for. Changes that produce lonely elderly in the villages and disaffiliated youths in urban slums challenge us to re-think how we conceptualize the emerging social networks and social interactions and grasp the nexus of syndemics that often develop in those contexts.

Keywords: Comparative psychiatry, cultural diversity, cultural psychopathology, social economic transitions


How to cite this article:
Gureje O, Ojagbemi A. Examining the “Social” in social psychiatry: The changing profile of context in the era of globalization and epidemiological transitions, with a special focus on Sub-Saharan Africa. World Soc Psychiatry 2019;1:43-6

How to cite this URL:
Gureje O, Ojagbemi A. Examining the “Social” in social psychiatry: The changing profile of context in the era of globalization and epidemiological transitions, with a special focus on Sub-Saharan Africa. World Soc Psychiatry [serial online] 2019 [cited 2019 Nov 21];1:43-6. Available from: http://www.worldsocpsychiatry.org/text.asp?2019/1/1/43/267971




  Introduction Top


Psychopathology is embedded in the social and cultural contexts in which it is experienced, and understanding these contexts is important for defining the boundaries of what is normative from those that signify illness.[1] This is partly because the interpretation of behaviors as either socially acceptable or maladaptive is based on standards that are set through social and cultural norms. Social and cultural views affect help-seeking and determine to what extent a given intervention proffered for a mental health condition by the specialist is seen as credible and likely to be efficacious.[2] Interest in understanding the social context of psychopathology is therefore of great importance and has become increasingly salient to the practice of psychiatry in a globalizing world.[3]

The understanding of psychopathology in the context of culture has evolved through phases and information derived from many years of work in the field has been important in propelling hypotheses around the possible protective effect of social capital against mental health conditions.[4] In the earlier phases in history, psychopathology was understood and defined based on norms in Western European and North American cultures.[5] Deviations from those norms often led to gross misinterpretations of their import, and when attempts were made to make provisions for their occurrence, a raft of “culture-bound” syndromes were described in international classificatory systems.[6]

Examples of such misinterpretations abound in the literature. A common manifestation of this was the tendency for the traditional social context in which Africans lived to be mystified and exoticized.[7] Early literature describing psychopathology in Africans contained clinical case descriptions that paid scant attention to social and cultural norms of the people, neglected differences in language and modes of expression of distress and made inferences based on this lack of appreciation of diversity.[8] As a result, the views that some conditions such as depression and obsessive–compulsive spectrum disorders were not common and that their absence was due to some poorly developed brain structures in the African were canvassed by prominent opinion leaders in the psychiatry at the time.[9] Furthermore, the notion that African patients were often lacking in the required sophistication to express their distress in clear psychological language and were therefore prone to expressing such distress in somatic presentations was common.[7] These early ideas have had a longstanding effect on the practice of psychiatry globally leading to, for example, the concept of European psychologization of depression versus somatization in African or non-European populations.[10] To this day and despite evidence to the contrary,[11] this notion remains strongly influential in the field of cultural and social psychiatry.


  Better Understanding of Cultural Diversity in the Era of Comparative Psychiatry Top


Starting with the pioneering comparative cross-national epidemiological studies of psychiatric disorders in West Africans by Lambo et al.[12] and through later and large cross-national comparative studies in primary care settings and the community, important information about similarities and nuances in the expression of distress and social disability across cultures have continued to emerge.[13] Such studies have been supplemented by the results of those conducted among migrant groups in Europe and America.[14]

From these studies, we now know that minor variations in expression and rates of disorders are likely attributable to cultural and environmental factors, including those relating to lifestyles. Thus, while it is plausible to speculate that social and emotional integration of people are better guaranteed in “collectivist” societies[15],[16] that existed and still exists in much of Africa, it is also clear that persons living in more disadvantaged settings across the world, especially in much of sub-Saharan Africa, may be at greater risk of many types of psychiatric disorders.[17] For example and contrary to some of the old literature on the occurrence of depression in Africa, in a series of studies by our group,[18],[19],[20],[21] we found some of the highest global prevalence and incidence rates of late-life depression in Nigeria.

The emerging fields of cultural neuroscience and the search for novel biological markers of psychiatric disorders[22],[23] have presented evidence on how brain changes before and during psychopathology are determined by culture-specific experiences across the lifespan. All of these studies highlight the need to consider cultural and social variations in the understanding of psychopathology. This need has also been influential in driving recent changes made to the main diagnostic criteria in contemporary psychiatry. Notable is the inclusion of cultural diagnostic formulations in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition[6] and a specific set of guidelines for considering culture in International Classification of Diseases-11.[24]


  Context and Psychopathology in African Societies Undergoing Transitions Top


Countries in sub-Saharan Africa are undergoing rapid transitions characterized by epidemiological shifts, urbanization, and a reorganization of family structure.[25] These transitions have resulted in the emergence of complex social configurations that provides new challenges for the future understanding of social context when considering psychopathology. For example, while the population of older people is growing at a rapid rate in sub-Saharan Africa,[26],[27],[28],[29] armed conflicts, general insecurity, and the effect of climate change are leading to forced migration, especially of the young and physically able.[30],[31] Youth migration is thus occurring faster than ever before,[32],[33] a consequence of which is the continuous depletion of the social networks of older people and an erosion of traditional of extended family systems in sub-Saharan Africa.[15],[16] The “left behind” elderly who are unable to maintain regular contacts with younger family members who might have moved out of the community for socioeconomic reasons may be especially at greater risk of loneliness, lack of social support and psychopathology.

Second, globalization and information technology, including social media, are creating influences that cut through traditional social and cultural boundaries, gender roles, status of the elderly, and sexual expression. These boundaries were hitherto fairly well-defined in sub-Saharan African context.[34] The unique overlap of the listed influences may lead to changes in the way, we interrogate the influence of social and cultural factors on the experience and expression of psychopathology in low- and middle-income countries of sub-Sahara Africa.

The different transitions bring tensions which have consequences for the mental health of populations and how the people who experience mental illness are related to and cared for. Changes brought about by the unique influence of globalization, and social media may, for example, result in novel expressions of psychopathology and changes in the epidemiology of mental health conditions that were hitherto considered to be less common in certain populations, including some in sub-Saharan Africa. For example, the mental health consequences of premigration events[35] and other migration processes[36] are beginning to become well-known in the global literature. Changes that produce lonely elderly in the villages and disaffiliated youths in urban slums challenge us to re-think how we conceptualize the emerging social networks and social interactions and grasp the nexus of syndemics that often develop in those contexts. Given the effect of these transitions, it is likely that the social circumstances of people, especially the elderly, in most parts of sub-Saharan Africa, are changing.


  Traditional and Emerging Social Network Structures in Sub-Saharan Africa Top


Social networks are the systems of social relationships in which an individual is embedded.[37] The social network is also seen to be influenced by culture, politics, and economic factors.[38] In terms of structure, a person's social network may consist of people with whom they regularly interact, the characteristics of such individuals, and the quality of interactions.[4] Social networks also have functional characteristics by increasing the social support resources available to the individual.[39] As people age and experience many losses, their social networks also narrow. This, in turn, reduces the amount of social resources available to cope with the accumulation of stressors in old age.[17],[40]

Poverty and material deprivation are widespread[30] in sub-Saharan Africa, and good health-care services are unavailable to many people.[41] In these circumstances, older persons with limited social network are likely to be at increased risk of mental health conditions. Studies in sub-Saharan Africa are yet to consider emerging typologies of social network structures and how these might relate to prevalence, onset, and course of mental health conditions in the context of rapid transitions in the subregion. Traditional typologies of social network structures in sub-Saharan Africa have also been the focus of only a few studies in the sub-region.[18] Existing studies have not been comprehensive in their approach to social network.

Given the transitions described in this perspective, a challenge for future studies of social network in sub-Saharan Africa is the question of the validity and reliability of available measures.[42],[43] Future research should strive toward attaining the goal of finding the best measurement modalities for social network structures and functions in specific populations and disease contexts. It would seem that the optimal tool for assessing social network structures relevant to mental health conditions in contemporary Africa may yet be unavailable. Such a tool should ideally produce measures that are easy to interpret and are comprehensive enough to assess the traditional and emerging dimensions of social network structures.


  Conclusions Top


Interest in seeking to understand psychopathology in social and cultural context has gone through phases of narrow Eurocentric focus to broad generalizations and an emerging more liberalized understanding of cultural diversity. A more complex social configuration is nevertheless emerging in sub-Saharan Africa due to rapid transitions characterized by epidemiological shifts, urbanization, and a reorganization of family structure. Each of these transitions is affected by the pervasive influence of globalization and the prominent impact of information technology. In this context, previously well-defined boundaries are changing. These changes bring tensions which have consequences for the mental health of populations and how the people who experience mental illness are related to and cared for. They also challenge us to re-think how we conceptualize the emerging social networks and social interactions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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