Major depression is a serious and often disabling
psychiatric disorder, with a higher prevalence in women than men.
Common symptoms of this disorder include sadness, loss of
interest in activities that were previously pleasurable to the
individual. These patients
may also feel discouraged, defeated, helpless, hopeless, and have
difficulty carrying out day-to-day activities.
Disturbance in appetite, sleep cycle, motor, energy level,
libido, concentration, memory and thinking are common.
The symptom may finally end tragically with suicide, as it does
in 15 - 30% of patients
with major depression(4). In general, while
women tend to attempt suicide more often, men complete the act at
a greater rate. It has been
proposed that the difference is attributed to the method of suicide,
e.g. pill overdose vs. gun shot to the head.
In 1987, Brown and Harris(1) conducted studies on the
relationship between life stress to
the onset of depression in United Kingdom.
Their findings indicate that six experiences were important
predictors of depression in their patient populations.
These experiences which involve loss included 1. death, 2.
separation, 3. loss of employment, 4. loss of material possessions, 5.
loss of physical health and 6. loss of cherished ideas. These losses
combined with sense of commitment to what is lost has been associated
One can readily appreciate that many Afghan refugees
have experienced all of the six losses described by Brown and Harris,
and much more. In fact, the
two decades of war has caused Afghans to become one of the most
traumatized people in the world, physically and mentally.
It is beyond the scope of this article to discuss the condition
of Afghans within the native country, or to discuss the inarticulate
disbelief of what humans are capable of doing to one another.
In a study conducted by Lipson and Omidian(2) in
1992-93, which was based on a telephone survey, community meetings and a
196-family survey in the San Francisco Bay Area, it was noted that 48%
of Afghan families lost members and 25% had a family member who had been
imprisoned and/or tortured. Separation from environment appeared to be a
stress factor, although 61% reported “mostly satisfied” and 12%
“mostly disappointed” when asked about satisfaction with life in
United States. Problems relating to employment was reported in 42% of
this population. 58% reported loss of property as a source of stress.
Illness in family as a current family stressor was reported in 38%.
And finally loss of status and culture as a source of stressor
was reported in 48 and 70% respectively.
Symptoms of the above mentioned stressors were
described as sleep disturbances, memory problems, headaches, constant
worry, flashbacks of bad memories, depression, dizziness, and anger.
These symptoms may fulfill the criteria for axis I of Diagnostic
and Statistical Manual of Mental Disorder (DSM) IV for Major Depressive
Disorder although Adjustment Disorder with Depressed Mood,
Somatization Disorder and Posttraumatic Stress Disorder may also
be present among these patients. However,
the above study did not evaluate the severity, duration and combination
of symptoms during a single time interval.
Further work is needed to determine these factors and make a more
accurate assessment of depression among this Afghan population.
It is worth reiterating that the above study was
conducted in 1992-93 and geographically is confined to San Francisco Bay
Area. Although a high
concentration of Afghans in the Bay Area may support such research in
Western Hemisphere, it may not reflect the status of Afghan refugees in
other regions of the United States, or for that matter, the world.
Northern California has a relatively temperate weather, compared
to, for example, Minneapolis, where the climate is drastically different
from the native Afghanistan. Also,
families that are in Northern California may form a social network in
the area, where as such support may be impossible, if not difficult, for
families living in South Dakota or Iowa due to distance. On the other
hand some Afghans prefer to be isolated from the large Afghan
communities for variety of personal reasons.
A similar study conducted on 404 Southeast Asian
refugees seen at a Minneapolis (MN) community clinic by Kroll et al (3)
reports three-quarters of patients met DSM-III criteria for major
depressive episode. Interestingly
somatization was a common form of expressing distress in this patient
population. Many would come
in for their pain, and only later spoke of their sadness, losses, and
anger. Although numerous differences exist between the Southeast
Asian refugees and the Afghan refugees, notably language and culture,
there are parallels that can be drawn between the two groups. Many Afghans may recall a relative who complained of
variety of bodily pain, who later was diagnosed with no specific
etiology due to lack of physical evidence.
This contributes to further frustration of these patients and
dissatisfaction with western medicine.
Treatment of depression will largely depend on the
exact diagnosis, patients preferences and type of medical insurance the
patient has. Patients with
major depression are often treated with drugs.
It should be remembered that these drugs, e.g. Prozac and Zoloft,
will not work overnight, rather a lag time of three to four weeks maybe
seen before a true mood-elevating effect is seen. On the other hand,
patients with mild depressions or depression secondary
to environmental “stress” or interpersonal conflicts are best
treated with counseling or psychotherapy.
What are the major manifestations of depression?
Signs and symptoms of this disorder include depressed mood, inability to
experience pleasure, appetite disturbance, sleep disturbance,
psychomotor disturbance, fatigue or loss of energy, feelings of
worthlessness or excessive inappropriate guilt, diminished ability to
concentrate or indecisiveness and recurrent thoughts of death or
suicidal ideation for a period of at least two weeks. Not all of the
above symptoms are necessarily present at one time.
It should be noted that depression may also be secondary to other
physical problems, e.g. hypothyroidism.
Major depression is a serious medical problem.
Physical and mental manifestation of this disorder is not only
debilitating to the individual, but it can negatively affect the loved
ones around the depressed individual. Since this disorder is usually
treatable, it is important for patients with this disorder to seek
professional help. Recent Afghan refugees who are depressed may not be
able to voice their problems due to language barrier and lack of
knowledge about the subject or may not know that they have a problem.
Thus it is important for Afghans to recognize symptoms of this
problem and to seek help for the family member who is suffering from
this treatable disorder.
1. Brown GW, Bifulco A, Harris TO: Life events, vulnerability, and onset of depression: some refinements. Br J Psychiatry 1987; 150:30-42.
2. Lipson J, and Omidian PA: Health among San Francisco Bay Area Afghans: A Community Assessment. The Afghanistan Studies Journal, Volume 4 1993; 71-86.
3. Kroll J, Habenicht M, Mackenzie T: Depression and Posttraumatic Stress Disorder in Southeast Asian Refugees. American Journal of Psychiatry 146:12, December 1989.
4. Gold PW, Goodwin FK, Chrousos GP: Clinical and biochemical manifestation of depression, part II: relation to neurobiology of stress. New England Journal of Medicine 319(6):348-535, 1988a.