Abstract
Background:
Depression is a global crisis and a major concern in mental health interventions, particularly in low- and middle-income countries (LMICs), where it significantly impacts disability, quality of life, and economic stability. These chronic stressors have been used to argue for scaling up the detection and treatment of depression as a public health and development priority.
Aim:
This study aimed to explore illness narratives of depression among patients’ and to gain insights into multifaceted suffering, its impact on persons’ lives, and help seeking. This study is part the broader study which examined global mental health, biopolitics, and depression in Ethiopia, conducted in hospice setting to explore the conception of depression in Bahirdar city, Northern Ethiopia, among patients and health care providers. In this study, we focus on patients’ accounts of depression.
Method:
We employed an ethnography method using in-depth interviews, fieldnotes, and observation to collect the data. A thematic analysis was used to analyze the data. Drawing from cross-cultural and critical psychiatry perspectives, we situate depression within its cultural-eco social framework.
Results:
The study revealed that patients’ experiences and conception of depression are deeply intertwined with Ethiopia’s sociocultural, economic, and spiritual context. Depression was often described as a state of being ‘impaired in life’, reflecting the complex interplay of individual struggles and societal pressures. Integrating quotes from patients, we demonstrated in this analysis the ways in which biographically specific challenges, societal pressures, and mental well-being are understood by study participants in accordance with Ethiopian cultural and religious norms.
Conclusion:
The study suggests moving beyond narrow interpretative frameworks in GMH praxis to understand and address the complex dimensions of depression in Ethiopia and similar contexts. The study advocates for a cultural-ecosocial approach to depression, emphasizing the need for mental health interventions that consider the broader social and cultural factors contributing to mental distress.
Keywords
Introduction
Presently, around 1 billion people worldwide live with a mental disorder, with 81% reported residing in low-income and middle-income countries (LMICs; Hermman et al., 2022). According to the World Health Organization (WHO), major depression disorder (MDD) is reported as the single largest contributor to loss of healthy life, and this contribution has apparently further increased during the COVID-19 pandemic (Santomauro et al., 2021; World Health Organization [WHO], 2017; Xiong et al., 2020). The COVID-19 pandemic has exacerbated this issue, having led to increased poverty, socio-economic instability, and a surge in mental health issues (Holmes et al., 2020).
Depression, affecting over 350 million people worldwide and has emerged as a significant contributor to years lived with disability, and is particularly prevalent in LMICs (Chisholm et al., 2016; DALYs, GBD, and HALE Collaborators, 2018; Thornicroft et al., 2017) . Individuals in LMICs face a constellation of chronic stressors like conflict, poverty, and violence, exacerbating mental health challenges (Chisholm et al., 2016; Lund et al., 2011), perpetuating structural violence (Farmer et al., 2006), and social suffering (Kleinman, 1988). To address this, there has been an increased global focus on expanding mental health care and services, particularly in LMICs. Efforts led by the Movement for Global Mental Health (MGMH) and the World Health Organization (WHO) have aimed to extend mental health services to LMICs (Collins et al., 2011; Patel, et al., 2011).
While this growing focus in addressing mental health needs in LMICs has a laudable aim, predominant biomedical models have tended to prioritize pharmaceutical interventions (Applbaum, 2015; Ecks, 2021; Mills, 2014a, 2014b). Thus, the WHO, as the primary advocate of GMH, stated 20 years ago at the outset of its GMH campaigns that ‘distress has a physical basis in the brain . . . can affect everyone, everywhere [and] can be treated effectively’ (WHO, 2001, p. x). More recently, the WHO (2012) stated,
Depression is a disorder that can be reliably diagnosed and treated in primary care. For common mental disorders such as depression managed in primary care settings, the key interventions include antidepressant drugs and psychotherapy. Treating depression in primary care is feasible, affordable, and cost-effective (p. 7).
Consequently, it is in this language that mental health has been proposed to become a ‘reality’ for all (Patel et al., 2011, p. 90). The biomedical perspective often tends to reduce mental health issues to biological malfunctions, disregarding broader social influences (Krieger, 2011). Most significantly, as Krieger (2011) has explained, a fundamental postulate of biomedicine is that ‘the parts’ explain ‘the whole’, which is both an ‘ontological and epistemological’ stance because it ‘makes claims about both how the world works and how it can be known’ (p. 136). This approach has been harshly criticized for sidelining the societal, political, and cultural contexts shaping mental health, including depression in the GMH praxis specially in its earlier days from 2007 to 2014 (Ecks, 2021; Kirmayer & Pederson, 2014; Mills, 2014a, 2014b). But the social matters deeply. Overreliance on biomedical interventions or clinical solutions may divert attention from the most important social and cultural factors underlying mental distress at the root of suffering.
There have been recent strong calls in GMH for a paradigm shift toward a social approach (see, Bayetti et al., 2023; Bemme et al., 2024; Burgess et al., 2020) and medical pluralism (Bracken et al., 2016; Orr & Bindi, 2017; Ventriglio et al., 2016). With such a shift, mental health and mental illness and their related interventions should be considered in the framework of social contexts where patients live and in relation to the factors they face daily. Expanding upon these ongoing calls, this study explored patients’ accounts of depression in Ethiopia through a cultural-ecosocial lens (Gómez-Carrillo & Kirmayer, 2023), which is part of a broader study into global mental health, biopolitics, and depression in Ethiopia. This cultural-eco-social lens emphasizes that understanding and responding to depression are deeply rooted within local cultural models and interpretive systems (Kirmayer, 2019; Kirmayer & Gómez-Carrillo, 2019).
Therefore, the study explored and presented narratives of illness from Ethiopian patients experiencing depression. It is also crucial to note that while the analysis presented here explores depression as a state of being ‘impaired in life’, in accordance with terminology attributed by participants to their state of being, we do not intend to diminish the significance of symptoms in clinical diagnosis. Instead, this study advocates for a closer examination of patients’ ‘life worlds’ (Kirmayer, 2019; Kirmayer & Gómez-Carrillo, 2019). This research situates patients within the social milieu of their distress and emphasize the unique experiences of individuals facing suffering.
Methods
Study setting
The research took place at two tertiary healthcare facilities situated in Bahir Dar, the capital city of the Amhara regional state, Northwestern Ethiopia. The city has a population of approximately 2 million people. Specifically, the study was carried out at Felege Hiwot Referral Hospital and TibebeGhion Specialized Hospital, both of which have played pivotal roles in global mental health initiatives. Notably, they have been actively involved in the implementation of the Mental Health Gap Action Programme (mhGAP) since 2008. The study was enriched by the extensive 15-year networking and work experience of the first author as a university lecturer and public health researcher in the research setting. These long-standing connections not only fostered trust and rapport with participants but also enhanced the study team’s comprehension of the local sociocultural context. However, it is crucial to note the challenging context in which this research was conducted. The Amhara region has been significantly affected by an ongoing conflict since November 2020. At the time of writing, the Amhara regional state is under a state of emergency, with significant social upheaval that has likely had repercussions on the mental well-being of its residents.
Research design
The study employed an exploratory qualitative research design, utilizing a critical ethnographic inquiry method (Murchison, 2010; O’Reilly, 2012). Our objective was to investiexplore the perceptions of depressive disorder and the sociocultural influences on its meaning and management among patients diagnosed with depression in Bahirdar City, Northern Ethiopia. In doing so, our aim was to gain insight into the complex interplay between cultural factors, healthcare infrastructure, and the experiences of those at the forefront of depression management. The first author conducted semi-structured interviews with mental health professionals in the focus hospitals. Employing ethnographic methods, including conversations and semi-structured interviews with mental health professionals in Bahirdar City, the study sought to uncover the unique aspects of how depression is conceptualized and responded to within the context of living in a specific cultural environment. Through this comprehensive exploration, we aimed to contribute to a more nuanced understanding of depression and the socio-cultural challenges associated with managing it within the distinct cultural context of Ethiopia.
Theoretical framework: Cultural-ecosocial approach
The ecosocial view of mind, brain, and culture is concerned with shifting research and clinical practice from the emphasis on neurobiological processes that is currently dominant in North American psychiatry toward existential, social, and cultural predicaments as a central focus of clinical concern (Gómez-Carrillo et al., 2023b; Gómez-Carrillo & Kirmayer, 2023; Kirmayer, 2019). Applied to global mental health, an ecosocial approach calls attention to the complex interplay between psychiatric disorders, health determinants, and illness experience, and their social and cultural embeddedness. The ecosocial approach is person-centered and insists that patients’ distress be understood not simply as brain-based but part of ecosocial networks that consist of interacting symptoms, cultural meanings, and social expectations and responses (Kirmayer, 2019; Kirmayer et al., 2017). On this view, the environment in turn presents itself as structured affordances for action and perception to which individuals respond based on their social position, social norms, expectations, and aspirations (Kirmayer, 2019). In other words, this is an approach that acknowledges human beings grow up and develop within a society and specific cultures and their upbringing and learnt interactions define their behaviors that in turn affect brain structures, leading in some instances to dysfunction (Kirmayer & Gómez-Carrillo, 2019; Ventriglio et al., 2016). The main source of the argument here is that social determinants play a major role – perhaps constituting the most significant influence – in mental health.
Following this, within the cultural-ecosocial approach, mental disorders are not isolated occurrences but are deeply embedded within specific social and structural contexts (Gómez-Carrillo & Kirmayer, 2023). Culture and society shape the symptoms, course, and outcome of mental disorders (Jarvis & Kirmayer, 2021). Understanding mental disorders within a social-ecological perspective urges recognizing that causal processes leading to mental health issues are rooted in the intricate interactions within the body-person-environment system.
At the heart of this approach is the understanding that conditions of mental illness must be seen as engaging fundamental human processes – processes that constitute an intricate mélange of culture, biology, and psyche, including self, emotion, cognition, gender, identity, and meaning (Gómez-Carrillo et al., 2023; Jenkins, 2015; Jenkins & Kozelka, 2017; Kirmayer, 2019). This requires researchers within this approach to grant primacy in their exploration and analysis to emic perspectives.
Integral to this engagement in studying depression in context in the space of global mental health is a commitment to understand and describe depression distributed along qualitatively defined continua, rather than being defined by discrete and distinct categories (Canguilhem, 1989). Hence, this notion further acknowledges that an individual person, living in a particular historical and cultural context, with a particular set of life circumstances, and a particular set of beliefs and coping strategies, may come to experience distress. Yet, to consider that distress as an illness and set a standardized treatment, cultural and contextual understanding of that distress is required. Positioning research within this approach invites attention to people’s experiences of ‘depression’ without seeking universal answers or universal solutions that deny the experiences of people across different social, cultural, or relational contexts.
Data collection and analysis
Data were generated through a variety of ethnographic techniques. Although in-depth interviews constituted the primary data collection method, the first author also generated field notes stemming from casual discussions and observations within the study hospital environments. These casual discussions and observations provided valuable supplementary data, offering insights into the everyday dynamics, practices, and interactions within the hospital environment. Field notes served to enrich the data by capturing contextual nuances that might have otherwise been overlooked.
We conducted twenty in-depth interviews from June 2022 to July 2023 (female = 16, male = 4)) with individuals diagnosed with major depressive disorder. All in-depth interviews took place at a healthcare facility and were conducted in Amharic, the official language of Ethiopia. The interviews were administered by the first author who is a native Amharic speaker. Participants were asked about their illness, what they thought of depression, how they perceived of and defined it, and how they coped with it, causes, and care pathways. The interview guides were open-ended based on Kleinman’s (1980) illness narratives, covering symptoms, causes, effects, treatment, and health-seeking behaviors. The interview questions were developed in alignment with the research questions and evolved as the study progressed and spanned a duration of 30 to 75 min (see Supplemental Material).
Data collection and analysis occurred simultaneously (Murchison, 2010; O’Reilly, 2012). Initially, we conducted open coding to identify key words, phrases, and themes. Then, we categorized interviews into conceptual domains (O’Reilly, 2012). Thematic analysis involved three fundamental stages to identify and advance understanding of key conceptual domains. Firstly, there was data preparation: in this initial phase, the raw data were gathered, organized, and prepared for analysis. Recordings were transcribed verbatim in Amharic, and the analysis was conducted in Amharic. After completing the analysis, the narrative was translated back into English with Amharic concepts and their English translations to enhance clarity (see, Limenih et al., in press). Quality was ensured by comparing transcripts with audiotapes. Analysis was led and primarily conducted by the first author, who has bilingual proficiency in English and Amharic (native).
In this initial stage, the first author reviewed and revisited the transcripts, generating preliminary codes using Open Code. In the second stage, she familiarized herself with the data by both listening to the audio recordings and re-reading the transcripts. This involved pattern recognition and coding segments of data and grouping them into meaningful categories. During this phase, analytical ideas that emerged during data familiarization informed the re-review of the preliminary codes. This iterative process involved refining the codes, selecting those most pertinent to our research questions, and making sense of the data based on patients’ explanatory models and in dialogue with the rest of the author team. The third stage was theme development and an in-depth analysis to ensure that the combined codes harmonized well with the collected data and remained aligned with the study’s objectives. During the second and third phases, the first author discussed emerging themes and refined them through dialogue with her co-authors. Special attention was given to local (Amharic) terms. When necessary, we have included Amharic words and their English translations into our findings. Through analyzing patient narrative accounts, we aimed to contribute to a more nuanced understanding of depression and its socio-cultural shaping in this particular context.
Ethical considerations
The study was approved by Western University’s Health Sciences Research Ethics Board (HSREB; Ref: 2023-122473-79368) and Amhara Public Health Regional Institute Ethics Board (EPHE) at Bahirdar city to start the recruitment process of the study (IRB ref: NoH/R/T/T/D/07/53). All interviews were conducted after obtaining written informed consent from participants. No identifiers were used while transcribing to maintain the privacy of the participants. Participation in the study was voluntary, and participants knew they could decide at any point to opt out.
Findings and analysis
Participant characteristics
The data consist of in-depth interviews conducted among people diagnosed with depression to explore how people suffering from depression interpret and experience their illness. The interviews were conducted with twenty participants aged 20 to 60 years, of which 4 were men and 16 women. The participants varied in educational level and profession from housewife, a farmer to high school teacher, accountant, pensioner, and university student. The majority, however, were from lower socioeconomic status. Most of female participants were housewives. All the participants had received a diagnosis of depression, but the duration of their illness onset varied, with suspected onset preceding the interview by a range of 1 month to 8 years. All participants first tried traditional healing places, including Holy water (tsebel) before they sought medical help. The severity of their illness was the primary factor that led them to seek psychiatric care. Among the majority of patients (N = 15), a suicide attempt was the main reason for their families took them to hospitals after they had tried other traditional healing centers. Participant characteristics are presented in Table 1.
Participant characteristics for patients’ diagnosis with depression.
Participants’ accounts of depression
The accounts of depression contained diverse explanations for and causes of suffering. These included circumstances or factors exacerbating hardships, extreme poverty, domestic violence, losses, and other severe life events such as witnessing mass killings and violent conflicts. Asked about the root causes of their depression, participants’ accounts identified seven categories or ways in which participants came to recognize their health condition (for detail narrative descriptions below). These included psychocultural, religious/spiritual, and social causes, familial challenges, economic hardships, behavioral disturbances, substance abuse, and unknown causes. Patients primarily attributed depression to psychosocial and spiritual factors, with family issues such as conflicts between spouses, relationships with in-laws, and incidents of domestic violence, witnessing mass killings, violent conflicts, along with financial struggles, being the most frequently mentioned triggers. Difficult life circumstances were commonly perceived to be the overarching cause of the depression.
As such, all participants regarded their health condition as connected to socio-economical concerns rather than merely a medical concern so that economic and familial challenges were explicitly narrated in participants’ accounts. For instance, one female participant stated how raising children alone and dealing with economic hardships affected her mental health:
Raising children on your own, living by yourself can bring about hopelessness. He [her husband] was. . . after we lost him, I didn’t even find anyone to manage my land during the harvesting season. When I rented the land, they didn’t use it properly. That makes me so angry. (P004; 32-year-old female participant)
Several female participants likewise attributed their depression to the pressure of providing for their families and living in extreme poverty. The most frequently discussed manifestation of poverty noted by female participants was its impact on their children, including concerns about fulfilling their basic needs for food and education and worrying about their children’s future. One female and widowed participant stated:
I find myself caught in the act of constant worry and sleepless nights about my children’s fate and their future. I have two children. I’m a single mother since their father passed away two years ago. My days often feel like a relentless battle to ensure that there’s enough food on our table. Most of all, I worry about what could happen if something were to happen to me, as they don’t have anyone else to rely on. This constant struggle weighs heavily on my heart, casting a shadow of sadness —
Many female patients attributed their distress to family-related problems, particularly involving control and violence (abuse) from husbands and family members. For instance, one married woman linked her illness to her husband’s control over their shared assets, including livestock and grains:
He [her husband] often makes me angry, controlled all my possessions, and I felt like a prisoner in my own home. I didn’t have a say on my own property. I thought it was better to die than to live like this, so I tried to end my life. (P006 37-year-old female participant).
Male participants’ accounts were somewhat distinct from those of the women interviewed. Male participants attributed their illness to feelings of failure despite their hard work, the inability to provide for their families, and unfavorable comparisons with others they believed were leading better lives:
I’m a father with three children, and we make a family of five. Despite my hard work, I’ve struggled to succeed. I’ve tried various ways to improve my life and support my family, but I keep facing one obstacle after another(
With a dominant conception of their depression or stress as a ‘life changing phenomena’ arising from poverty and other social and structural chronic stressors, participants did not report health services could relieve these feelings. As noted earlier with reference to causes, poverty, family conflicts, marriage issues, and job instability or lack of stable employment were cited as contributors to depression, with participants expressing the belief that their circumstances needed to change for their mental well-being to improve. One participant briefly summarized the struggles of a financially challenged individual:
What else can a poor man have besides ‘thinking too much’ (
Often, participants’ accounts of depression contained several explanations, indicating participants did not reduce their condition to a singular cause. A few of the participants presented holistic explanations of depression, combining psychological, social, and other explanations. This reflects the fact that an illness is often an indeterminate process that cannot be represented from a single perspective (Kirmayer & Gómez-Carrillo, 2019; Kleinman, 1988). As an example of the many-sidedness of depression accounts, consider the case of Mrs. Tigist (names of all participants have been changed to pseudonyms to protect confidentiality throughout), a 50-year-old pensioner woman who retired because of depression. Five years earlier she suffered from the death of her husband, and her children forced her to sell their house to have ‘their father’s share’. In the interview, she recounted a significant episode of her life during that period, all having a negative impact on her mood. Within 2 years, this previously energetic and socially active person had been forced to early retirement due to the disability her depression had caused. She gave several explanations to her illness (depression), reflecting on her loss of creativity at work, and social connection. she recalled her life circumstances as follows:
I worked as a textile worker, but after my husband’s sudden death, my sons forced me to sell our house. One of them treated me terribly, and it felt like he had become a devil (
Depression as a state of being ‘impaired in life’
Central to participants’ accounts of depression was the emergence of the concept of ‘impaired life’. This feeling of being ‘impaired in life’ often fueled a sense of despair and hopelessness. Patients portrayed depressive episodes as periods of disruption or stagnation in life’s progression. It also reinforced the belief that individuals were disconnected from life’s possibilities, joys, and aspirations. Take, for instance, Mrs. Yenenesh, a 39-year-old woman who shared her heart-wrenching experience of losing her son in a recent civil conflict in Amhara region. As she reported below, this event profoundly changed her self-perception and outlook on life:
He [her son] accompanied me to the local market. It was on Saturday. Suddenly, armed forces caused chaos, and as we tried to escape, I was attacked, fell to the ground with my son. Bullets flew, but God protected me; the bullet grazed me, but he lost his life. I wish I could die that day. And from then on, I felt that I was like this: I am like a tree. Stuck! I’m not the same Yenenesh I used to be I used to be an active, happy, and inviting my neighbors for holiday celebrations. Now, I don’t want to go on living. I am half living, ‘half dead’.
This sense of being ‘trapped in life’ serves as a reminder of how individuals may undergo profound emotional and psychological distress when confronted with existential frustration. Such circumstances can lead to a profound detachment from life’s intrinsic meaning and purpose. Similarly, one of male patient participants shared and recalled:
I had it all once: a flourishing career as a banker, a loving wife, and a precious son. But destiny took a tragic turn, and I found myself losing everything overnight. My wife vanished in secret, taking our son to Dubai due to her family’s intervention, as they were incredibly rich. Despite my relentless efforts to locate them, including a journey to Dubai, my search was in vain. Upon my return to Ethiopia, I faced the loss of my job as well. It was as though I had surrendered control over my life. I felt utterly useless. Whenever I attempted to articulate this emotion, it was akin to being trapped in an impenetrable darkness, devoid of any light—
Such descriptions captured well what many participants noted: the ways in which depression could create a feeling of being trapped in life’s challenges, leading to existential questioning and a loss of purpose. In the above quote, the participant’s metaphor of ‘being trapped in an impenetrable darkness’ illustrates depression’s overwhelming nature. For this participant and others, this darkness encompasses the emotional and psychological turmoil of depressive episodes, leaving individuals feeling adrift and devoid of hope. As such, as the above narrative accounts of patients indicated, the phenomenon of depressive episodes can often be understood as the sensation of becoming entangled in the intricate web of life itself (Mattingly, 2000). This sense of entrapment also seemed to foster despair, feelings of hopelessness, or a profound sensation of ‘slow death’ (Berlant, 2011), with individuals encountering an assemblage of social and economic crises that are experienced as ‘extraordinary’ (Jenkins, 2015, p. 1). Thus, depressive episodes may be better understood as instances of ‘impaired life’.
Within this context, life becomes intricately interwoven with individuals’ bodily experiences and subjective interpretations (Das & Han, 2016; Ingold et al., 2012; Jenkins, 2015; Kleinman, 1988). The concept of ‘impaired life’ extends beyond conventional notions of depression as a discrete health issue. Instead, depressive episodes are perceived as experiences of being ensnared within life’s intricate web, and the path to healing entails breaking free from this entanglement and reimagining the possibilities that life holds. In other words, it necessitated us to conceptually think and address the experiences of individuals and communities living amid what are variably labeled as ‘slow violence’ (Nixon, 2011) or ‘chronic crisis’ (Vigh, 2008), where everyday existence becomes a persistent source of threat, blurring the boundaries between crisis and non-crisis – when life becomes a struggle writ large.
Relatedly, our findings also highlighted a critical question raised by individuals facing adversity: can medical treatment alone truly benefit them without a fundamental change in their social or economic circumstances? Often, patients linked depression to ‘overthinking’ ( The medicine cannot do anything to me to have fewer thoughts; I will only have fewer thoughts when I can support my children and my family (P-012, 37-year-old male participant)
These narrative accounts of the participant indicated that their strong desire for changes in social and economic circumstances. Additionally, due to the belief that their illness condition or their psychological and emotional states were direct responses to broader social and economic challenges, rather than isolated health conditions that could be addressed solely by medical services, they often tend to discontinue treatment.
Similar findings have been reported in both LMICs and among marginalized groups in high-income settings (see, Roberts et al., 2020, 2022; Torre, 2022). These studies further recommended that addressing the socioeconomic determinants of depression is equally crucial. Similarly, this research adds to the evidence base that decontextualized approaches to mental health treatment make little sense to people whose psychological distress is linked to ongoing adversity such as conflict and extreme poverty (Mills, 2014a, 2014b; Roberts et al., 2022). The implication of this is that we cannot separate the mental from the social. It was evident from participants’ accounts that they were not merely seeking to feel better; they wanted a change in their circumstances. To fully understand their needs, we must recognize that distress often reflects something that is going wrong in a person’s ‘lifeworld’ (Kirmayer, 2019; Kirmayer et al., 2017). Hence, by drawing upon the narratives of patients in this study, the following section centers on the re-conceptualization of depression and proposes a pathway forward for global mental health, placing explicit emphasis on addressing the socioeconomic determinants of psychological suffering – locating depression in the cultural-ecosocial context (Kirmayer, 2019).
Discussion
How we frame and define a mental health problem significantly influences our response to it. Depression is frequently likened colloquially to the ‘common cold’ of psychiatry, emphasizing its prevalence (Busfield, 1996). While standing as a major priority within the GMH movement, it is also framed as an illness akin to any other (Chisholm et al. 2016; Ecks, 2021; Limenih et al., 2023; Mills, 2014a, 2014b). However, the conception of depression varies widely depending on the discipline, perspective, and vested interests (Kirmayer & Pedersen, 2014; Rose, 2019). The medical comprehension of depression spans neurochemical explanations and more psychoanalytic perspectives, including intra-psychological and intersubjective viewpoints that highlight the role of losses and triggering events (Healy, 2004; Moncrieff, 2009, 2018; Whitaker, 2010).
Often, depression is portrayed as a syndrome encompassing emotional, psychomotor, and somatic disturbances (Kendler, 2012; Kendler & Engstrom, 2017; Kirmayer et al., 2017). Informed by this backdrop of diverse perspectives, our analysis aimed to present and situate within biographical and cultural ecosocial contexts the narrative accounts of 20 Ethiopians diagnosed with depression. We now attempt to re-conceptualize depression and propose a route forward for global mental health by placing explicit emphasis on addressing the socioeconomic determinants of psychological suffering.
In LMICs, individuals frequently encounter a complex array of chronic stressors such as conflict, poverty, violence, and displacement, all of which can exacerbate mental health challenges (Chisholm et al., 2016; Lund et al., 2011, 2018). The intertwining of chronic poverty, war, and inequality ensnares millions, leaving them to navigate life’s hardships with a sense of emotional drift. In LMICs, individuals contend with repeated social and economic crises, facing what Jenkins (2015) calls ‘extraordinary conditions’ (p. 1), including chronic poverty, warfare, political violence, domestic abuse, scarcity, and neglect of basic human needs, to name a few. Then, precariousness becomes the common character of expression. As a result, accounts of depression can reflect the social and individual pressures people encounter in their everyday lives. In fact, within the context of the global market promises of the ‘perfect’ and instant life, the flow of ordinary life with its adversities, disappointments, and uncertainty increasingly promotes confusion and discontentment (Berlant, 2011; Monbiot, 2016; Tribe, 2014). Each of these challenges are shaped by social circumstances and adversarial forces (Jenkins, 2015; Lund et al., 2018).
In this complexity, depression seems to become an almost natural way to react to this distress. At the same time, it has become the expression of the situation: the difficulty of living. When ordinary life seems to become too difficult to bear, and it is reacted to with depression, it can suggest serious problems within the society, not primarily, or only within or between, individuals. This understanding requires us to explore depression as a form of life itself (Biehl et al., 2007; Biehl & Petryna, 2013; Das & Han, 2016; Ingold et al., 2012).
On this perspective, the definition of what constitutes depression as a ‘disorder’ poses several challenges. The expression or emotion of depression, for example, is common and is normal, in most day-to-day circumstances. Yet, at some level of severity and impairment, the feeling of depression acquires the level of a ‘disorder’ (Frances, 2013a; Kendler, 2016; Kendler & Engstrom, 2017). Deciding that level or threshold is not a precise science (Frances, 2013a, 2013b; Kendler, 2012), and this imprecision has been the basis of the controversy about whether psychiatric disorders such as depression are normal judgments or reflect ‘real’ disease (Bracken et al., 2016; Jarvis & Kirmayer, 2021). Moreover, if the formation of depression is dynamic and intricate, having a precise definition and a universal construct is almost impossible as there are no ‘well-made ontologies’ (Das, 2015) which could explain this health condition (p.22).
A consistent tension persists between medical and moral perspectives regarding the nature and boundaries of depression (Jarvis & Kirmayer, 2021; Maj, 2023). The literature continuously engages in an ongoing debate concerning the nature of mental disorders and depression (Cole et al., 2008; Kendler, 2016; Maj, 2023; Mulder, 2009; Wakefield, 2008; Wakefield & Horwitz, 2012). Attempts to reach a consensus on the cluster of symptoms justifying a diagnosis of mental illness have been fervently debated. This is evident in the historical and current discussions surrounding successive revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (APA, 2013; British Psychological Society, 2013; Caplan & Cosgrove, 2004; Frances, 2013a; Kendler, 2016; Kendler & Engstrom, 2017; Wakefield & Horwitz, 2012) used by practitioners globally, including Ethiopia, for diagnosing and treating depression due to the categorical nature of the DSM-5 amplifying the disease model.
A recent study conducted in Eastern Africa also found a significant challenge faced by Ethiopian healthcare providers (HCPs) in identifying and conceptualizing depression in Ethiopia. This challenge arises from variations in patients’ symptom presentations, often not aligning with DSM-5 criteria (see Limenih et al., in press). The discrepancy is frequently attributed to the somatic nature of patients’ symptom descriptions and cultural nuances, such as variations in illness narratives. Several HCPs in Ethiopia come across patients whose descriptions of their suffering do not always align precisely with the criteria outlined in the DSM-5.
Consequently, depression may not be considered an illness or a health concern within the society at large. As a result, HCPs acknowledged that while DSM-5 serves as valuable framework or reference, it often did not fully capture the nuanced nature of depression, especially within the Ethiopian cultural context, where religious and cultural interpretations play a dominant role in how ‘depressive like experiences’ are presented and interpreted (Limenih et al., in press). This acknowledgment aligns with the broader understanding of depression as a complex interplay between individual and environmental factors (see, Haroz et al., 2017; Kessler & Bromet, 2013; Kirmayer et al., 2017).
Most importantly, the present analysis sheds light on the multifaceted socio-cultural, economic, and spiritual dimensions shaping individuals’ illness experiences. This research contributes to the evidence base showing that decontextualized approaches to global mental health treatment may not resonate with individuals whose psychological distress is linked to ongoing adversity like conflict and extreme poverty (see, Roberts et al., 2022). The implication of this is that we cannot separate the mental from the social. Participant accounts under the concept of ‘impaired in life’ reveal that they sought not just to feel better, but also desired a change in their circumstances. To fully understand their needs, we must recognize that distress often mirrors something amiss in a person’s ‘lifeworld’ (Kirmayer, 2019).
As a result, to better understand depression and social suffering at large, we propose or suggest a shift in our notion of inquiry and psychiatric research and practice, reasoning from what is wrong with people affected by depression to what happened to them. This view will lead to a broader understanding of mental illness since it requires a recognition of depression as a condition of the whole person in their milieu. We need to conceptualize mental illness (depression) as a human experience in context as such. It is crucial to understand how social determinants affect people and in what ways. Depression is not a brute fact arising from social disadvantage, unemployment, isolation, or even violence itself but it is shaped by the way individuals understand and encode their experience, expectations, and cultural beliefs (Jarvis & Kirmayer, 2021; Limenih et al., 2023; Rose, 2019).
The ways that psychological symptoms and disorders are perceived, interpreted, and responded to depend on local contexts shaped by cultural norms, values, and practices (Jarvis & Kirmayer, 2021; Ramstead et al., 2016). Indeed, mental disorders are the product of interactions among physical and social factors that are themselves culturally shaped (Kendler, 2012; Kirmayer, 2019). Most of the problems that people bring to the clinic are deeply rooted in the social contexts of local worlds and personal predicaments (Biehl & Petryna, 2013). There is growing global evidence that mental disorders in populations are strongly socially determined (Lund et al., 2011, 2014, 2018; WHO, 2008). Because mental disorders are so strongly socially determined, the global burden of these disorders is unlikely to be relieved by improved access to mental health treatments alone (though this remains crucial). In the words of the final report of the WHO Commission on the Social Determinants of Health in 2008: ‘Why treat people only to send them back to the conditions that made them sick in the first place?’ (WHO, 2008). As such, if suffering is to be culturally and contextually understood as something shaped by the wider ecologies in which it occurs, so can notions of wellbeing and recovery (Jarvis & Kirmayer, 2021; Kirmayer, 2019; Gómez-Carrillo & Kirmayer, 2023).
Understanding the biosocial dynamics of depression requires moving beyond woolly conceptions of depression in GMH to devise sociopolitical strategies that might reduce the prevalence of both minor and major mental health problems. This way of thinking requires not only a different policy response but also a reappraisal of our entire worldview. For individuals and populations, health is primarily a function of historical, ecological, and sociocultural factors. However, if we see only the individual body or mind as the sole locus of health or diseases, various information about causation and potential solutions are lost (Kirmayer, 2019; Rose, 2019). As we address lives in the contexts of clinical, political, environmental, cultural, and economic crises of our time, improving mental health demands researchers and practitioners accommodate the various factors and pathways of complex health conditions like depression.
Conclusion
While this study engaged with a limited number of participant narrative accounts about depression, it raises pertinent questions with broader relevance to GMH research, practice, and policy, drawing on perspectives from Eastern Africa. The study unveiled a profound narrative of suffering, adversity, and life challenges that intertwine with the lived experiences of patients in Ethiopia. These accounts offer nuanced accounts of how Ethiopians diagnosed with depression explain their conditions of distress, highlighting the concept of ‘impaired life’ influenced by socio-economic, cultural, familial, and spiritual factors. These accounts and their analysis underscores how socio-economic burdens, such as poverty and family conflicts, act as catalysts for depressive episodes, illustrating the intricate relationship between life’s challenges and mental health.
Importantly, participants perceived their mental health struggles as inseparable from broader societal issues, challenging the efficacy of solely medical interventions. Many emphasized the necessity for substantial changes in circumstances to ensure mental well-being. These narratives further promote critical reflections on the conventional biomedical approach to mental health interventions advocated in GMH intervention strategies for addressing depression in the Global South over the past 15 years. This calls for more research and a nuanced approach to consider local contexts and practices when understanding depression. The meanings of illness are strongly influenced by local contexts and social processes (Gómez-Carrillo & Kirmayer, 2023). This further underline exploring cultural and structural barriers, identifying sources of resilience, and analyzing socio-cultural and economic processes as they can play a crucial role in shaping individuals’ comprehension of their illness experience and influencing their responses to symptoms and behaviors.
In other words, by acknowledging depression not merely as an individual affliction but also as a consequence of societal adversities, a compelling case emerges for sociopolitical strategies to address the root causes and help the people who are suffering with depression to re-engage with life. In sum, the narrative accounts in this study depicted a complex human experience deeply embedded in societal contexts that requires rethinking the nature of mental health problems in terms of the environments in which we live, and points toward the need for political and economic change to directly reduce inequality as well.
Footnotes
Acknowledgements
We acknowledged all the research participants and all the research facilitators from Felegehiwot Referral Hospital and TebeGhion specialized Hospitals. This research would not have been possible without your involvement.
Author contributions
L.G: Conceptualization, design, protocol development, data analysis, synthesis, manuscript write-up, manuscript review, and edits. M.A: manuscript review and edits. S. M.J: manuscript review and edits. N.E: manuscript review and edits and supervision. All authors read and approved the final manuscript.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics statement
The study was approved by the Western University Health Sciences Research Ethics Board (HSREB; Ref:2023-122473-79368) and Amhara Public Health Regional Institute Ethics Board (EPHE) at Bahirdar city to start the recruitment process of the study (IRB ref: NoH/R/T/T/D/07/53). The participants provided both verbal and written informed consent during the interviews.
