|Year : 2019 | Volume
| 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
Oye Gureje1, Akin Ojagbemi2
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 Submission||17-Jun-2019|
|Date of Decision||01-Jul-2019|
|Date of Acceptance||08-Jul-2019|
|Date of Web Publication||27-Sep-2019|
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
Source of Support: None, Conflict of Interest: None
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 2020 Jul 6];1:43-6. Available from: http://www.worldsocpsychiatry.org/text.asp?2019/1/1/43/267971
| Introduction|| |
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. 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. 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.
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. In the earlier phases in history, psychopathology was understood and defined based on norms in Western European and North American cultures. 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.
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. 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. 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. 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. 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. To this day and despite evidence to the contrary, this notion remains strongly influential in the field of cultural and social psychiatry.
| Better Understanding of Cultural Diversity in the Era of Comparative Psychiatry|| |
Starting with the pioneering comparative cross-national epidemiological studies of psychiatric disorders in West Africans by Lambo et al. 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. Such studies have been supplemented by the results of those conducted among migrant groups in Europe and America.
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, 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. 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,,,, 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, 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 and a specific set of guidelines for considering culture in International Classification of Diseases-11.
| Context and Psychopathology in African Societies Undergoing Transitions|| |
Countries in sub-Saharan Africa are undergoing rapid transitions characterized by epidemiological shifts, urbanization, and a reorganization of family structure. 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,,,, armed conflicts, general insecurity, and the effect of climate change are leading to forced migration, especially of the young and physically able., Youth migration is thus occurring faster than ever before,, 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., 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. 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 and other migration processes 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|| |
Social networks are the systems of social relationships in which an individual is embedded. The social network is also seen to be influenced by culture, politics, and economic factors. 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. Social networks also have functional characteristics by increasing the social support resources available to the individual. 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.,
Poverty and material deprivation are widespread in sub-Saharan Africa, and good health-care services are unavailable to many people. 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. 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., 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|| |
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Moleiro C. Culture and psychopathology: New perspectives on research, practice, and clinical training in a globalized world. Front Psychiatry 2018;9:366.
Kirmayer LJ. Mindfulness in cultural context. Transcult Psychiatry 2015;52:447-69.
Kirmayer LJ, Ryder AG. Culture and psychopathology. Curr Opin Psychol 2016;8:143-8.
Schwarzbach M, Luppa M, Forstmeier S, König HH, Riedel-Heller SG. Social relations and depression in late life – A systematic review. Int J Geriatr Psychiatry 2014;29:1-21.
Lucas RH, Barrett RJ. Interpreting culture and psychopathology: Primitivist themes in cross-cultural debate. Cult Med Psychiatry 1995;19:287-326.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th
ed. Arlington, VA: American Psychiatric Publishing; 2013.
Gureje O. Psychiatry in Africa: The myths, the exotic, and the realities. South Afr Psychiatry Rev 2007;10:11-4.
Tooth G. Studies in Mental Illness in the Gold Coast. London: HMSO; 1950.
Carothers JC. A study of mental derangement in Africans, and an attempt to explain its peculiarities, more especially in relation to the African attitude of life. Psychiatry 1948;11:47-86.
Ryder AG, Yang J, Zhu X, Yao S, Yi J, Heine SJ, et al.
The cultural shaping of depression: Somatic symptoms in China, psychological symptoms in North America? J Abnorm Psychol 2008;117:300-13.
Gureje O, Simon GE, Ustun TB, Goldberg DP. Somatization in cross-cultural perspective: A World Health Organization study in primary care. Am J Psychiatry 1997;154:989-95.
Leighton AH, Lambo TA, Hughes CC, Leighton DC, Murphy JM, Macklin DB, et al.
Psychiatric disorder in West Africa. Am J Psychiatry 1963;120:521-7.
World Health Organization. Report of the International Pilot Study of Schizophrenia. Chichester: World Health Organization; 1973.
Tanaka-Matsumi J, Draguns JG. Culture and psychopathology. In: Berry JW, Segall M, Kagitcibasi C, editors. Handbook of Cross-Cultural Psychology. Boston MA: Allyn & Bacon; 1997. p. 449-91.
Fokkema T, De Jong Gierveld J, Dykstra PA. Cross-national differences in older adult loneliness. J Psychol 2012;146:201-28.
Dykstra PA. Older adult loneliness: Myths and realities. Eur J Ageing 2009;6:91-100.
Thoits PA. Sociological approaches to mental illness. In: Scheid TL, Brown TN, editors. A Handbook for the Study of Mental Health Social Contexts, Theories, and Systems. Cambridge, England: Cambridge University Press; 2012. p. 106-24.
Gureje O, Oladeji B, Abiona T. Incidence and risk factors for late-life depression in the Ibadan study of ageing. Psychol Med 2011;41:1897-906.
Ojagbemi A, Bello T, Gureje O. Gender differential in social and economic predictors of incident major depressive disorder in the Ibadan study of ageing. Soc Psychiatry Psychiatr Epidemiol 2018;53:351-61.
Gureje O, Kola L, Afolabi E. Epidemiology of major depressive disorder in elderly Nigerians in the Ibadan study of ageing: A community-based survey. Lancet 2007;370:957-64.
Ojagbemi A, Abiona T, Luo Z, Gureje O. Symptomatic and functional recovery from major depressive disorder in the Ibadan study of ageing. Am J Geriatr Psychiatry 2018;26:657-66.
Kohrt BA, Worthman CM, Ressler KJ, Mercer KB, Upadhaya N, Koirala S, et al.
Cross-cultural gene- environment interactions in depression, post-traumatic stress disorder, and the cortisol awakening response: FKBP5 polymorphisms and childhood trauma in South Asia. Int Rev Psychiatry 2015;27:180-96.
Kim HS, Sasaki JY. Cultural neuroscience: Biology of the mind in cultural contexts. Annu Rev Psychol 2014;65:487-514.
Gureje O, Lewis-Fernandez R, Hall BJ, Reed GM. Systematic inclusion of culture-related information in ICD-11. World Psychiatry 2019;18:357-8.
United Nations. The International Migration Report 2017. Geneva: United Nations: 2017.
Dotchin CL, Akinyemi RO, Gray WK, Walker RW. Geriatric medicine: Services and training in Africa. Age Ageing 2013;42:124-8.
Dong X, Beck T, Simon MA. The associations of gender, depression and elder mistreatment in a community-dwelling Chinese population: The modifying effect of social support. Arch Gerontol Geriatr 2010;50:202-8.
Axinn WG, Ghimire DJ, Williams NE, Scott KM. Associations between the social organization of communities and psychiatric disorders in rural Asia. Soc Psychiatry Psychiatr Epidemiol 2015;50:1537-45.
Kuscu MK, Dural U, Onen P, Yaşa Y, Yayla M, Basaran G, et al.
The association between individual attachment patterns, the perceived social support, and the psychological well-being of Turkish informal caregivers. Psychooncology 2009;18:927-35.
Ojagbemi A, Bello T, Luo Z, Gureje O. Living conditions, low socioeconomic position, and mortality in the Ibadan study of aging. J Gerontol B Psychol Sci Soc Sci 2017;72:646-55.
Cappuccio FP, Miller MA. Cardiovascular disease and hypertension in sub-Saharan Africa: Burden, risk and interventions. Intern Emerg Med 2016;11:299-305.
Leigh-Hunt N, Bagguley D, Bash K, Turner V, Turnbull S, Valtorta N, et al.
An overview of systematic reviews on the public health consequences of social isolation and loneliness. Public Health 2017;152:157-71.
The Academy of Medical Sciences. Challenges and Priorities of Global Mental Health in the Sustainable Development Goals (SDG) Era. London, United Kingdom: The Academy of Medical Sciences; 2018. p. 24.
Adeleye OA, Aldoory L, Parakoyi DB. Using local culture and gender roles to improve male involvement in maternal health in Southern Nigeria. J Health Commun 2011;16:1122-35.
Hollifield M, Warner TD, Krakow B, Westermeyer J. Mental health effects of stress over the life span of refugees. J Clin Med 2018;7. pii: E25.
Bhugra D, Gupta S, Bhui K, Craig T, Dogra N, Ingleby JD, et al.
WPA guidance on mental health and mental health care in migrants. World Psychiatry 2011;10:2-10.
Berkman LF, Syme SL. Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda county residents. Am J Epidemiol 1979;109:186-204.
Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium. Soc Sci Med 2000;51:843-57.
Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991;32:705-14.
Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psychol Bull 1985;98:310-57.
Uwakwe R, Ibeh CC, Modebe AI, Bo E, Ezeama N, Njelita I, et al.
The epidemiology of dependence in older people in Nigeria: Prevalence, determinants, informal care, and health service utilization. A 10/66 dementia research group cross-sectional survey. J Am Geriatr Soc 2009;57:1620-7.
O'Reilly P. Methodological issues in social support and social network research. Soc Sci Med 1988;26:863-73.
Butts CT. Social network analysis: A methodological introduction. Asian J Soc Psychol 2008;11:13-41.