9th Greek Australian Legal and Medical Conference
Rhodes, Greece 2003

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CULTURAL DIFFERENCES IN DEPRESSION AND ANXIETY: A COMPARISON OF GREEK-BORN AND ANGLO-AUSTRALIAN COMMUNITIES IN MELBOURNE

Miss Litza A. Kiropoulos and Mr Steven Klimidis.
Department of Psychiatry, The University of Melbourne;
Centre for International Mental Health, School of Population Health,
The University of Melbourne; and
Victorian Transcultural Psychiatry Unit, Level 2, Bolte Wing,
St. Vincent's Hospital Campus,
14 Nicholson St, Fitzroy, Victoria, 3065, Australia.

(This speech is based upon a PhD thesis produced by the first author under the supervision of the second.)

Today I will be speaking about the research I have undertaken for my PhD in the Department of Psychiatry at the University of Melbourne. The aim of my research was to examine cultural differences in depression and anxiety between the Greek-born and Anglo-Australian communities in Melbourne and what may underlie these differences.

Mental illness is now considered to be one of the most important health concerns affecting communities around the world. In an examination and comparison of the impact of 107 major diseases, taking mortality and disability into account, the Global Burden of Diseases study found that mental disorders ranked as high as cardiovascular and respiratory diseases, surpassing all cancers combined and even HIV infection (Murray & Lopez, 1996). Disability caused by major depression was found to be equivalent to that caused by blindness or paraplegia. With regard to years lived with disability, depressive disorders as a single diagnostic category were the leading cause of disability worldwide (Murray & Lopez, 1996).

In addition to these global findings and predictions for the burden of mental disorders, epidemiological and cross-national studies have also displayed that there are differences in the level, prevalence rates and manifestation of mental disorders across cultures (Kringlen, Torgersen & Cramer, 2001; Sartorius, Jablensky, Gulbinat & Ernberg, 1980; Ustun & Sartorius, 1995; Weissman et al., 1996). Some cultural groups displaying higher rates and levels, and variations in the manifestation of mental illness. For example, rates of depression and anxiety have been suggested to vary cross-culturally with differences noted in the rates and in the manifestation of depression and anxiety in Greek samples. Epidemiological and smaller community based studies have indicated that the current and lifetime prevalence rates of depression ranged from 6.2% - 68.8% and rates of anxiety ranged from 6.7%-18.6% for Greek-born samples. These rates seem to be higher than some other cultural groups. However, this research has primarily focused on Greek-born people living in Greece and not Greek-born immigrants.

Australia boasts a multi-cultural society and Melbourne is home to over 62,000 Greek-born immigrants and has the largest Greek-born population outside of Greece. To date, and consistent with the epidemiological and community based studies undertaken, the small amount of cross-cultural research undertaken indicates that members of the Greek-born community in Australia, particularly women, experience higher levels of psychiatric morbidity when compared with many of the other birthplace groups including the Anglo-Australian people. According to the 1996 Australian National Health Survey data, Greek-born people were reported to be "more unhappy with their lives" and as having higher use of psychotropic medicines compared to other members of other birthplace groups including the Anglo-Australians (Castles, 1989; Stuart, Klimidis & Minas, 1998). So, why are there differences in rates and in the presentation of mental illness, specifically depression and anxiety, between the Greek-born population and other cultural groups in Australia?

As yet, there has been no comprehensive investigation into the factors contributing to the rate of psychiatric morbidity in the Greek-born community, particularly one that takes into account an interpersonal, cognitive and personality perspective. How might cultural differences in the experience and presentation (i.e., expression and patterning) of psychiatric disorders emerge? Are there particular, already known, psychosocial mechanisms that can account for such differences? My research aimed to contribute to the understanding of cultural differences specifically in depressive and anxiety illness symptom reporting and presentation in Greek-born and Anglo-Australian individuals by examining what mechanisms might underlie these differences.

My research examined a variety of psychosocial factors, but I will be discussing only a number of these today. These included stress, trait negative affectivity, illness concern, impression management, self-focused attention, and stigma.

Stress was defined as the generic term that pertains to the psychological impact of a "stressor" on the human organism and a "stressor" refers to a specific condition or a set of conditions that threatens the wellbeing of a person. Hence, stress, as measured in the current study, relates to the stressful negative life events that an individual has experienced in the last 6 months.

Trait negative affectivity (TNA) has been suggested to be identical to other dispositional constructs such as neuroticism, trait anxiety, pessimism and general maladjustment. TNA reflects pervasive individual differences in negative mood and self-concept (Watson & Clark, 1984). Individuals with high TNA experience consistently higher levels of distress and dissatisfaction over time and across different situations. High TNA subjects are also more introspective and tend to dwell on their failures and shortcomings. They tend to be negativistic, focusing on the negative aspects of themselves and others.

Illness concern refers to the tendency to which people are focused and/or pre-occupied with illness and its seriousness. Hence, the current study examined whether Greek-born people display higher levels of illness concern and whether illness concern is associated with and is a predictor of depression and anxiety.

Impression management represents one traditional view of responding to a questionnaire: that some subjects purposefully tailor their answers to create the most positive or negative social image (Edwards, 1970; Paulhus, 1984, 1986). It has been suggested that such individuals may misrepresent themselves only to avoid social disapproval; that this tendency will vary according to situational demands; and that this may obscure the validity of the respondent's self-reports (Crowne, 1979; Paulhus, 1991).

Self-focused attention (SFA) has been defined as an awareness of self ­referent, internally generated information. In particular, the degree and nature of attention to the self have been cited as a potentially important factor in mediating certain dysfunctional processes in depression such as negative internal attributions, negative thinking, recalling negative events, exacerbated negative affect, poor self-esteem and feeling sad; in the maintenance and exacerbation of depression; it has also been associated with state and trait anxiety and in pain experience.

Stigma has been characterised as an attribute that is socially defined as "deeply discrediting" (Goffman, 1963). Stigma can be defined as a two-part sequence. First, there must be a "mark" or a "deviation from a prototype or a norm" (Jones, Farina, Markus, Miller and Scott, 1984). Then, to be stigmatising, a mark must link the bearer to unwanted, usually undesirable attributes that publicly discredit him or her. For example, if a person is hospitalised for mental illness and is then assumed to be dangerous, incompetent, or untrustworthy, the person may be seen as being stigmatised.

Mental illness, especially if chronic, is regarded historically, at best, as undesirable and, at worst, as requiring that afflicted persons be shunned, locked away, and on rare occasions put to death. Stigma had origins in Ancient Greece and in Greek culture; madness and mental illness are themes of shame, loss of face, and humiliation. The notion of pollution, that the madman is polluted and can also pollute, is interwoven with the sense of shame (Dodds, 1951; Simon, 1978). These were important aspects of ancient Greek culture and has been suggested to continue to be so in Greek culture today (Blum & Blum, 1970; Littlewood, 1998).

In view of the literature, the stigma of having a psychiatric illness has been shown to affect the individual's social capacities, functions and identity; their interpretation and disclosure of their illness and associated symptoms; and the individuals' and their families' help-seeking behaviour. Cross-cultural studies have also displayed that the cultural environment and beliefs influence a person's and a community's view and level of stigmatisation of mental illness.

My research examined whether stress, trait negative affectivity, illness concern, impression management, self-focused attention, and stigma underlie depression and anxiety in a Greek-born population. To the best of my knowledge, no study has examined the relationship or association between these variables and depression and anxiety in a Greek-born immigrant population.

What were my findings?

Greek-born people had higher depression scores compared to the Anglo-Australian group. Greek-born people reported more Beck depression symptoms than the Anglo-Australian people. Twenty percent of the Greek-born people were included in the moderate to severe categories compared to only 5 % of the Anglo-Australian people. Greek-born people had higher anxiety scores compared to the Anglo-Australian group. Greek-born people reported more state anxiety symptoms than the Anglo-Australian people. Of the Greek-born people, 44.3% were found to be in the moderate to severe categories compared to 17.1% of the Anglo-Australians.

Greek-born people had higher stress, TNA, illness concern, SFA, stigma scores associated with psychological symptoms scores than the Anglo-Australian people. However, Greek-born and Anglo-Australian people did not differ on IM scores.

Why are there higher levels of depression and anxiety in the Greek-born people compared to the Anglo-Australian people?

The finding that Greek-born immigrants residing in Melbourne have higher levels of current depressive and anxiety illness than their Anglo-Australian counterparts is consistent with the limited amount of previous research on Greek-born immigrants residing in different countries (Bilanakis, Madianos & Liakos, 1995; Forrest & Ross, 1984; Lofvander & Papastavrou, 1993; Lyketsos, Blackburn & Mouzaki, 1979). The higher levels found in the current study (i.e., 20% of the Greek-born sample currently being moderately to severely depressed) is also within the range of some figures found for current and estimated prevalence of depression and anxiety disorders obtained for the general, inpatient and outpatient populations previously in Greece. The higher the level of current anxiety, even when controlling for SES and age, and the greater the tendency or Greek-born people to score in the more severe category of the anxiety measure is consistent with previous findings suggesting high levels of neurotic symptom reporting and that anxiety disorders are the most common disorders in the Greek population (Lyketsos, Blackburn & Mouzaki, 1979; Mavreas et al., 1995; Mavreas & Bebbington, 1988).

How can these higher levels of depressive and anxiety illness and in the higher number of depressive and anxiety symptoms be explained? The most plausible account is in psychological and socio-cultural terms. The majority of the Greek-born people were married with children and were at the stage were most of their children have left home or getting married. Given that the Greek culture was more collectivistic than the Anglo-Celtic culture and that the central unit in this culture is the family, most of the Greek-born people were not working fulltime and were at a new "stage" of their lives where the central family unit has been broken or is in the process of doing so. Any changes to this central family unit may also bring associated worries or stress to the Greek-born parents which may be contributing to the higher levels of depression and anxiety and to depressive and anxiety symptom reporting evidenced in the current sample. Greek-born immigrants at this stage of their life may also be reminiscing about the "motherland" and reflecting on the sense of loss and separation created by living in a foreign land and as well as to problems of adjustment to a foreign culture i.e., not being able to speak English and to family problems (Mavreas & Bebbington, 1988).

In addition to these socio-cultural explanations, psychological mechanisms (and the association between these mechanisms and cultural variables) seemed to be contributing to the higher levels of depression and anxiety in the Greek-born people. For example, culture may be modifying the effects of psychological mechanisms such as TNA which in turn may lead to higher levels of anxiety. Norms and values such as "philotimo" and child rearing practices such as over protectiveness are culturally determined and may give rise to different sets of cognitions such as a sense of insecurity which may in turn give rise to different emotional disorders such as anxiety in the Greeks.

Hence, the second major aim of my research was to examine whether psycho-social mechanisms such as stress, TNA, illness concern, IM, SFA, stigma and measures of "Greekness" and birthplace contributed to the levels of depression and anxiety in the Greek-born and Anglo-Australian people. In summary, results of the analyses displayed that birthplace and measures of Greekness such as "philotimo" were found to be unique predictors of the depression and anxiety measures when examining all variables concurrently for both the Greek- and Anglo-Australian samples. This finding lends support to Greek culture underlying depression and anxiety. In addition, stress, IM, illness concern, SFA, stigma and also including SES, gender and age were all unique common predictors of depression and anxiety in both the Greek-born and Anglo-Australian groups. However, results indicated that these psychosocial mechanisms may be operating differently in members of the two groups and this requires further examination. The findings indicate that perhaps the influence of certain psychosocial mechanisms along with the cultural environment contributed to the higher levels of depression and anxiety in the Greek-born people compared to the Anglo-Australian people.

Collecting together the observations from this work the two cultural groups showed differences in their psychological symptoms and these differences to a large extent can be attributed to underlying mechanisms that serve to augment or diminish symptom reporting. To summarize these mechanisms included TNA, IM, illness concern, SFA, stigma associated with psychological phenomena as well as integral variables such as stress, SES, age and gender.

Therefore, a reflection on the literature examining psychopathology across cultures suggests that perhaps the literature has underestimated the variability and comprehensiveness in differences by attributing them superficially to "cultural" differences. Different presentation of psychopathology across cultures may be better understood by the degree to which processes underlying symptom reporting, such as those studied in my research, may be salient and culturally determined and there is a great need for cross-cultural replication of these differences found.

Concluding, on a positive note, I believe that in order to address the issue of depression and anxiety in the Greek community of Australia, community education and awareness of depression and anxiety is needed. I believe efforts should be focused on awareness of these disorders in order to decrease the obvious stigma surrounding these conditions and in order to make people of Greek origin who are living in Australia aware that there are various therapeutic strategies available to treat these two conditions. Some pilot work on community education on depression I have been involved with in the Greek community has had an overwhelming positive response and I hope that these community education seminars will be run in the future.

References

Bilanakis, N., Madianos, M. G., & Liakos, A. (1995). Psychiatric morbidity among repatriated Greek migrants in a rural area. European Archives of Psychiatry and Clinical Neuroscience, 245, 36-44.

Blum, R., & Blum, E. (1970). The dangerous hour: The lore and culture of crisis and mystery in rural Greece. London: Chatto and Windus.

Castles, I. (1989). Overseas born Australians 1988: A Statistical Profile. Commonwealth of Australia: Australia Bureau of Statistics (Catalogue No. 4112.0: A. C. T).

Crowne, D. P. (1979). The experimental study of personality. Hillsdale, NJ: Erlbaum.

Dodds, E. R. (1951). The Greeks and the irrational. Berkeley, CA: University of California Press.

Edwards, A. L. (1970). The measurement of personality traits by scales and inventories. New York: Holt-Rinehart-Winston.

Forrest, Q. G. & Ross, M. W. (1984). Predictors of neurosis in migrants: Greek-Italian and male-female differences. The American Journal of Social Psychiatry, 4(2), 52-56.

Goffman, E. (1963). Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice Hall.

Jones, E., Farina, A., Hastorf, A., Markus, H., Miller, D., & Scott, R. (1984). Social stigma: The psychology of marked relationships. New York: Freeman.

Kringlen, E., Torgersen, S., & Cramer, V. (2001). A Norwegian psychiatric epidemiological study. American Journal of Psychiatry, 158 (7), 1091-1098.

Littlewood, R. (1998). Cultural variation in the stigmatisation of mental illness. The Lancet, 352, 1056-1057.

Lofvander, M., & Papastavrou, D. (1993). Cross-cultural psychiatric assessment of Greek and Swedish patients at a Swedish primary health centre. Nordic Journal of Psychiatry, 47, 179-183.

Lyketsos, G. C., Blackburn, I. M., & Mouzaki, D. (1979). Personality variables and dysthymic symptoms: A comparison between Greek and a British sample. Psychological Medicine, 9, 753-758.

Mavreas, V. G., & Bebbington, P. E. (1988). Greeks, British Greek Cypriots and Londoners: A comparison of morbidity. Psychological Medicine, 18 (2), 433-442.

Mavreas, V. G et al., (1986). Results from the Athens centre. In T. B. Ustun & N. Sartorius (Eds.), Mental illness in general health care: An international study (pp. 56-77). Chichester, England: John Wiley & Sons.

Murray, C. J., & Lopez, A. D. (1996). Global Health Statistics: A compendium of incidence, prevalence and mortality estimates for over 200 conditions. Cambridge, MA: Harvard School of Public Health.

Paulhus, D. L. (1984). Two-component models of socially desirable responding. Journal of Personality and Social Psychology, 46, 598-609.

Paulhus, D. L. (1986). Self-deception and impression management in test responses . In A. Angleitner & J. S. Wiggins (Eds.)., Personality assessment via questionnaire (pp. 143-165). New York: Springer-Verlag.

Paulhus, D. L. (1991). Measurement and control of response bias. In J. P. Robinson, P. R. Shaver, & L. S. Wrightsman (Eds.)., Measures of personality and social psychological attitudes (pp. 17-59). San Diego, CA: Academic Press.

Sartorius, N., Jablensky, A., Gulbinat, W., & Ernberg, G. (1980). WHO Collaborative Study: Assessment of depressive disorders. Psychological Medicine, 10, 743-749.

Simon, B. (1978). Mind and madness in Ancient Greece: The classical roots of modern psychiatry. Ithaca, NY: Cornell University Press.

Stuart, G. W., Klimidis, S., & Minas, I. H. (1998). The treated prevalence of mental disorder amongst immigrants and the Australian-born: Community and primary-care rates. International Journal of Social Psych

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Copyright 2003. Greek/Australian International Legal and Medical Conference.
For more information contact Jenny Crofts at jennycrofts@ozemail.com.au