The globalization of mental illness

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How American ideas of mental illness and treatment may be spreading more mental health problems around the world.

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Last week, the lead coordinator of aid groups in Haiti put out an urgent request for mental health professionals. But he also cautioned that those who come to Haiti must adapt to the culture and the language.

Science writer Ethan Watters would strongly second that motion. He's the author of a new book that concludes that, however well intentioned, the US is exporting its thinking about mental health and may actually spreading mental health problems around the world.

Watters's book, "Crazy Like Us: The Globalization of the American Psyche," examines how America could be contributing to the "symptom pool" of another culture.

Watters argues that there isn't a way to disconnect culture from mental illness, so when America exports its culture along with its mental illnesses, this leads to people in other parts of the world taking on symptoms that may not be related to their illness.

He cites as an example, a form of anorexia diagnosed in Hong Kong in the early '90s, which was a rare disorder that didn't have the characteristics of the American form: The body dysmorphia, the fat phobia, that wasn't related to dieting or weight loss.

But when the press in Hong Kong reported on the illness, it imported the American idea of anorexia, said Watters. "They went to American experts, American diagnostic manuals, to explain to the Hong Kong public what was the strange disease, who was at risk, what did it mean, what were its causes. After 1994, you saw a rise of the disorder, and not only a rise ... but a change in the form of the disorder. Suddenly it looked more like the American diagnosis of anorexia, with all its criteria."

An illness like anorexia could reveal much about a culture, but when the meanings and forces of that culture are drowned out by an American narrative, the opportunity for that learning is lost.

In Sri Lanka after the 2004 tsunami, there was an influx of psychological counselors helping survivors with post traumatic stress disorder, or PTSD. While their intentions were right, their assumptions were wrong, says Watters.

"We went in with this assumption that we knew that PTSD is a universal thing. But anthropologists know that the reactions to trauma actually do differ across cultures. Meanings matter a great deal. What you think of the event, what you predict what your symptoms will be. And it often comes down to really fundamental notions; differences in how you think about the human mind."

Americans, says Watters, believe trauma occurs in an individual's mind; Sri Lankans on the other hand, see the trauma in their social circle. "They'll say it's in my inability to perform my social role, for instance; or it's in the breakages in my social circle. So it's a different sense of where the self resides."

These assumptions extend to how treatment is given. "When we rush into another culture with our American notion of PTSD, we often disconnect the hurt individual from their local conceptions of the self, and also from the local conceptions of how to get better, how to heal."

According to Watters, in Zanzibar, schizophrenia is often linked with notions of spirit possession. While Americans may view this as terribly stigmatizing, in that culture, spirit possession is not used to ostracize the person, but to keep them within the community and provide modes and methods for interacting with the person.

"So our idea that it's better to think of mental illnesses in terms of a biomedical idea, that this will reduce stigma; actually when you study that around the world, it turns out not to be the case. In fact, people who adopt the biomedical notion of mental illness -- as true as it might be -- are also the people who are likely to believe that the ill person is more unpredictable, more dangerous; they want more social distance from that person."

A more obvious attempt at exporting an American notion of mental illness was GlaxoSmithKline's campaign to introduce depression to Japan.

Japan didn't have a category for depression, says Watters. The country's clinical idea of depression was of a very rare and severe illness. Sadness in Japan wasn't something commonly linked to depression. Similarly, suicide in Japan was not necessarily linked to mental illness, but  of "resolve," where it was done for reasons of shame or honor. And while GlaxoSmithKline's introduction of Paxil in Japan did decrease the suicide rate in the country, the rate of depression rose.

"A huge swath of the population that once believed that they were melancholy or sad, now believe that they're mentally ill," said Watters.

GlaxoSmithKline's campaign included advertising, web-based marketing, and lots of money to prominent members of the mental health profession in Japan. To counter the Japanese idea of depression as a severe mental illness, GlaxoSmithKline came up with the phrase that described depression as a "cold of the soul."

"So it's no big deal --  you take a medication for a cold, you should take a medication when you're depressed," said Watters. "And the Japanese really responded to this over time."

Watters says he doesn't have a problem with America sharing quality drugs that could help people deal with mental illness, but he cautions that cultural aspects in other parts of the world should be taken into consideration.

"We should be sharing our knowledge of the mind with the rest of the world, but we have to be careful as we do that not to trample upon local notions of the mind that may themselves be very valuable when it comes to attaining mental health. We cannot stop globalization ... but at least we can hope that the interchange of ideas about how to achieve mental health are not simply West to East, rich to poor; but that actually go both ways."

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