WHO’s Sick? The WHO and cross-cultural mental health surveys

As a student of clinical psychology I think it is important to have an understanding of what mental illness and wellness looks like in my own country as well as in other societies. Cross cultural research on mental health disorders should reflect local definitions and beliefs about illness and wellness. The World Health Organization’s (WHO) Composite International Diagnostic Interview (CIDI) attempts to demonstrate the prevalence of DSM IV disorders, measure their severity and assess what percentage of individuals with disorders access treatment across 28 countries. At the time findings were published in 2004, 16 countries had completed participation in the CIDI. Six of these countries were defined as “developing.” 

While the WMH-CIDI study does begin to fill an important gap in scientific knowledge about cross-cultural mental health and illness, there are several methodological issues with the study that the authors do not explore. The published article provides little discussion about the possible complications involved in imposing DSM IV definitions of mental disorders on countries as varied as Lebanon and Nigeria. The DSM IV is the U.S. bible for mental health disorders. Hot debate surrounds several of the diagnostic categories in the DSM IV. Its use has been exported to countries around the world over the last three decades. In addition to these issues, key disorders like schizophrenia, almost universally recognized to exist across cultures, are not included in the WMH-CIDI study.

One of the main findings the researchers point to is the correlation between severity of mental health disorders and likelihood of accessing any kind of mental health intervention. The basic idea is the more sever the disorder the more likely someone will access some kind of mental health intervention. What the authors’ fail to explore is what groups of symptoms, or disorders, individuals believe cause the most impairment in different settings. A social phobia may be considered particularly debilitating in a cosmopolitan US setting. As a result, individuals in the US might be more likely to seek treatment. In a different society or culture the local discourse surrounding the aggregate of symptoms associated with social phobia may be different. As a result, individuals who technically meet criteria may understand their symptoms to be less debilitating or not meriting professional intervention.

The WMH-CIDI also does not provide any explanation for how “developed” and “developing” countries are defined. Data collection took place between 2001 and 2003. At that time, Beijing and Shanghai were categorized as developing, but Spain was defined as a developed country. It is important to provide basic information about how populations are defined and grouped. Clearly projected economic growth was not the main factor used to define “developing” and “developed” countries, or Beijing and Shanghai would fall into the “developed” category.

While I do think that there is value in conducting cross-cultural epidemiological studies on mental health, as a field we need to make sure to include universally recognized disorders like schizophrenia. If we then impose US diagnostic definitions like those in the DSM-IV-R, it is important to first make sure that such disorders and definitions have local meaning and salience.

. (2004). Prevalence, Severity, and Unmet Need for Treatment of Mental Disorders in the World Health Organization World Mental Health Surveys JAMA: The Journal of the American Medical Association, 291 (21), 2581-2590 DOI: 10.1001/jama.291.21.2581