Is Global Mental Health Missing the Point? Ethiopian Voices Challenge Western Models

A new study published in the International Journal of Social Psychology finds that people in Ethiopia experience depression not as a medical disorder but as a state that is tied to the social, cultural, economic, and spiritual context around them.

In the research, led by Gojjam Limenih of Western University in London, participants commonly understood difficult life circumstances to be the cause of depression. These factors included extreme poverty, domestic violence, witnessing mass killings, and violent conflict. Many participants in the current research understood depression as a state of being trapped by life’s challenges. Participants also expressed an understanding of depression informed by Ethiopian spiritual beliefs and practices.

These findings call into question the biomedical approach of the global mental health movement (GMH) in treating depression in low and middle income countries. The narrow understanding of the disease model championed by the GMH may be incapable of addressing the complex circumstances that surround depression in places like Ethiopia. The authors and participants in the current study pointedly ask: “can medical treatment alone truly benefit them without a fundamental change in their social or economic circumstances?” In contexts where extreme poverty and violence are part of everyday life, a medical approach seems powerless to address the root causes of depression.

The authors write:

“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.”

The goal of the current work was to investigate how people in Ethiopia understand depression. Additionally, the authors wanted to explore how the Ethiopian context influences the presentation and perception of depression. The current research approaches this question through a cultural-ecosocial perspective. This perspective holds that “culture and society shape the symptoms, course, and outcome of mental disorders.”

This approach views cultural expectations and social positions as determinants of behavior that can alter brain structure and appreciates the interplay between environment and biology in understanding psychological distress. The cultural-ecosocial view rejects universal solutions to problems like depression and insists that proper treatment must be informed by the culture and context around the person that is suffering.

The authors conducted 20 interviews with participants who had a diagnosis of major depressive disorder. The interviews took place within healthcare facilities in Bahirdar City, Northern Ethiopia. The interviews and the subsequent analysis were conducted in Amharic, Ethiopia’s official language. The data and analysis were also informed by field notes based on observations and casual conversations within the hospitals where the interviews were conducted.

First author Gojjam Limenih primarily performed the analysis, as she was bilingual and understood both English and Amharic. The data went through three stages of analysis. First, the interviews were organized and prepared for analysis, including being transcribed verbatim in Amharic. After initial coding for critical key words and concepts, the analysis was translated into English. Second, the data was grouped into meaningful categories based on service users’ understanding of depression in the Ethiopian context. Third, the authors developed themes from the initial codes and patterns in the data.

The participants were between 20 and 60 when the interviews were conducted. Most participants were women (16 of 20) from lower socioeconomic backgrounds. All the participants had been through traditional healing practices before seeking medical help. Most participants (15 of 20) were brought to the hospital after a suicide attempt.

Women’s Experience of Depression

While both men and women often reported experiences of depression as rooted in difficult life circumstances, there were clear differences in their accounts. Many female participants reported distress due to family issues. These issues often revolved around violent and controlling husbands. One female participant reported that her husband “controlled all my possessions.” She went on to add:

“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. “

Raising children in poverty and worrying about their futures also factored heavily into women’s experience of depression. One female participant said “Raising children on your own, living by yourself can bring about hopelessness.” Another reported:

“I find myself caught in the act of constant worry and sleepless nights about my children’s fate and their future … This constant struggle weighs heavily on my heart, casting a shadow of sadness.“

Men’s Experience of Depression

Men most often attributed their feelings of depression to failure in spite of hard work, not being able to adequately provide for their families, and feelings of insecurity when comparing their lives to their more successful peers. One male participant reported:

“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. I wonder why my life isn’t like others’, how some people seem to live well without working hard. This situation makes me both angry and sad.”

Depression as Feeling ‘Stuck’

Many participants related depression to feeling stuck, impaired, and disrupted in their lives. This experience led to feelings of hopelessness and disconnection from the joys of life. One participant reported that after the violent death of her son, she wished she “could die that day. And from then on, I felt that I was like this: I am like a tree. Stuck!”

Another participant reported:

“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. I felt stuck.”

Inadequacy of the Biomedical Model

As most participants viewed depression as arising from social and structural stressors, they were skeptical of medical approaches to treatment. One participant said “If I had money, all my life worries would end. You know, um, [The doctor] can’t provide bread to your home. When your hunger is over, your mind will return to normal.”

Another participant expressed a similar sentiment in reporting that “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.”

The authors acknowledge one limitation to the current research. The limited number of participants means the views expressed are likely only a fraction of how Ethiopians experience and understand depression. Additionally, translating the analysis into English likely loses some of the nuances present in the original Amharic. This research took place entirely in one city in Northern Ethiopia, so generalizability to other populations may be limited.

The authors conclude:

“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.”

Experts have expressed concern over exporting western ideas of mental health to non-western countries. Cross-cultural researchers have emphasized that “Western depression is not a universal condition,” and treating it as such risks misallocating precious resources. Another study found that research in low and middle income countries tends to focus on treating depression rather than preventing it through addressing systematic issues of inequality and injustice. Experts from India have reported that while there is some benefit in the judicious use of psychotropic medications, these drugs are often used “to suppress underlying issues like domestic violence, poverty, hunger, and social suffering.”

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Limenih, G., MacDougall, A., Smith, M. well, & Nouvet, E. (2024). ‘impaired in life’: Analyzing people’s accounts of depression in Ethiopia – implications for a cultural-eco social approach to Global Mental Health. International Journal of Social Psychiatry, 71(1), 78–89. (Link)