Depression in Nepalese Women Tradition, Changing Roles, and Public Health Policy DANA

CROWLEY

JACK

and MARK VAN OMMEREN

estimates that by the year 2020, de­ pression will become the second-leading cause of the global disease burden. Women in both high-income and low-income countries experience depression at a rate almost double the rate of men;l currently, depression constitutes wo­ men's leading cause of disability in the world. In Nepal and most low-income countries, almost no attention has been focused on women's depression, even though the World Health Organization ranks depression as the most important women's health problem in the world overall (Cabral and Astbury 2000; http://www.who.int/mental_health.org).This chapter reports on research con­ ducted on gender and depression in Nepal in 2001. 2 THE WORLD

HEALTH

ORGANIZATION

1. Women experience higher lifetime prevalence rates of major depression than men at a ratio of

approximately two to one in twelve general population studies carried out in a range of countries, in­ cluding Hong Kong, Taiwan, Korea, Germany, France, Puerto Rico, the United States, and Canada. See Piccinelli and Homen 1997. 2. This research was carried out by Dana Jack and was supported by a Fulbright Scholar grant to Nepal in January-July 2001. The research could not have been undertaken without the help of the fol­ lowing: Dr. Bhogendra Sharma of CVICT, Kathmandu, introduced me to the two participating psychi­ atrists, Dr. Nirakar Man Shrestha and Dr. Vidaya D. Sharma, and was supportive in every step of the process. Dr. Sharma and Dr. Shrestha both arranged the demanding schedules at their respective out­ patient clinics--Tribhuvan University Teaching Hospital and Patan Mental Hospital-to accommo­ date the interviews for depressed patients. Our conversations about depression were essential to understanding its specific manifestation in Nepal. The Nepalese interviewers, Pooja Sharma, Shiva Dhakal, Archana Rai, Rushmi Joshi, Birbahadur Lama, and Jyoti Shrestha, interviewed with respect and empathy. My deep gratitude also goes to the women and men who willingly told the stories of their

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Women's Depression in Nepal: The Social Context Nepal is an attractive country with a rich culture, warm people, and strong, coher­ ent communities with a wealth of social resources. However, the status and treat­ ment of many Nepalese women are causes of serious concern. Women's depression must first be put into the context of social issues affecting all women in Nepal. Women's overall health picture is very poor as reflected in their lower life ex­ pectancy than men's (53.7 versus 55.2 years, respectively), partly owing to experi­ encing one of the highest maternal mortality rates in the world (515 per 100,000 live births) (Nepal National Planning Commission, His Majesty's Government of Nepal, and UNICEF 1996,3) and a high incidence of suicide. 3 Women's poor health is influenced by social factors such as extreme poverty (an estimated US$210 annu­ ally), low levels of girls' education, literacy (female 23 percent compared to males 57 percent), heavy work burdens, and early marriages (in 1993, about 60 percent of marriages occurred before age 18). 4 Women are primarily involved in agriculture, comprising 65.7 percent of the agricultural labor force and contributing 60 percent of the agricultural production. Yet women control only 6.4 percent of total land­ holdings. Trafficking of girls and women, estimated for the year 1999 to affect ap­ proximately 5,000 to 7,000 females between the ages of 10 and 20, carries disastrous consequences for victims' physical and mental health (Forum for Women, Law, and Development 1999,6-7,17-20).5 Nepal has a patriarchal system that is reflected through legal discrimination

depression and offered their perspectives on their distress. We hope their interviews provide the basis for deeper understanding of the difficult problem of depression and can help others. 3. There are no official rates of suicide in Nepal, primarily because of social taboos, fear of legal complications, lack of medical care, and complicated reporting requirements. Dr. Nirakar Man Shrestha, director of Patan Mental Hospital, says that "suicide is always underreported and underre­ porting has been reported to occur to the extent of a third or to a fourth of the real occurrences" (per­ sonal communication, June 2001). Rates by gender are not reported, but violence against women is widespread and known to result, in most cases, in mental anguish and stress, and in some cases suicide. See SAATHI 1997. SAATHI (which means "friend" in Nepali) is a nongovernmental organization (NGO) working to prevent violence against women and girls, formed in 1992 in Nepal. 4. The level of absolute poverty is very high, at 45 percent of the population. Unofficial estimates describe the situation more gravely and calculate the ratio at 60-70 percent (Nepal Human Develop­ ment Report 1998, 5). See esp. 3 (poverty), 113 (education), and 123-24 (literacy rates).

5. Rescued victims face violence, intimidation, STDs, AIDS, and abandonment from families and society.

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against women in many areas: property inheritance rights, citizenship rights, em­ ployment, business, and contractual rights as well as laws affecting marriage, di­ vorce, adoption, abortion, and rape. Domestic violence is a widespread problem in Nepal, and the linkage between violence against women and depression is well es­ 'tablished by studies in many cultures. 6 In the midst of these obstacles, Nepal's women are experiencing new possibili­ ties resulting from an increased focus on gender equity and a heightening social awareness of women's rights. Opportunities for women exist in higher education and in government leadership for literacy training within their villages. 7 Yet the un­ settled political situation resulting from the murder of King Birendra and the royal family in 2001 and the government response to the Maoist insurgency have diverted attention from Nepal's beginning efforts toward women's empowerment. Mental health in Nepal is a largely neglected area and faces numerous barriers to improvement, including social stigma, inadequate resources such as personnel and health facilities, and a virtual absence of formal mental health services in iso­ lated rural areas where the vast majority of the population lives. Most of Nepal's people depend on traditional ways of understanding and treating mental problems, primarily turning to traditional healers. Long-standing cultural practices and even some laws discriminate against those individuals with mental problems. For exam­ ple, the husbands of women who are considered "mad" (the local slang for mentally troubled, which includes severe depression) can take a new wife (5angroula 200). 8 Very little is known about women's mental health in Nepal, particularly regard­ ing their subjective experiences and perspectives on what is causing their distress. 50

6. See, for example, Cabral and Astbury 2000. Regarding Nepal, a 1997 SAATHI study found that violence "cut[s] across women and girls of all class, caste, age and ethnicitywith 9S percent ofrespon­ dents attesting first hand knowledge of violence against women and girls incidents. In 77 percent of the cases the perpetrators were reported to be members of the family.... In the case of domestic violence, nearly 58% reported it as being a daily occurrence" (ii). 7. Nepal's government requires that at least S percent of the total number of candidates contesting any election in the country be women and has reserved three seats for women in the National Assem­ bly, out of a total of sixty seats. The amendment of the Local Self-Government Act with 20 percent reservation for women is another special measure adopted by the government to increase women's participation in local government, which has resulted in some forty thousand women participating in local governments. SAATHI (1997): 5. 8. See also Forum for Women, Law, and Development 1999, which states that the law allows a man to marry a second wife if a woman becomes "physically disabled, does not produce children or if the children do not survive after 10 years of marriage, of if she becomes blind or otherwise disabled" (39).

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far, all published studies of women's depression have been conducted with nonvali­ dated questionnaires, offering data that do not present a clear picture of social fac­ tors related to depression in women. We sought to complement these quantitative studies by listening to women's own perspectives on their depression with the goal of helping foster interventions focused on women's realities.

Women's Depression in Global Context Gender affects the material and symbolic positions people occupy in societies as well as the daily experiences that condition their lives. Women's inequality affects their exposure to risks, for example, to sexual and physical violence and also affects their power to manage their own lives, to cope with such risks, and, thus, to influ­ ence their own health. The common consensus is that depression results from interacting biological, psychological, and social factors. However, the influence of social factors tends to be ignored in research, clinical practice, and public mental health policy. Overwhelm­ ing evidence points to the significance of social factors in the onset of women's de­ pression; such factors include their greater exposure to poverty, domestic violence, negative life events, chronic difficulties, lower education, and heavier workloads than men. 9 These social factors are translated into depression through emotional experiences of humiliation, hopelessness, entrapment, lack of control, feelings of inferiority, and loss of self. Factors that can protect women from depression are hav­ ing the ability to experience some control when confronted with severe events, which requires having access to some resources, and having support from a close re­ lationship. Poverty is a recognized risk factor in the pathway into depression for women, especially when combined with negative life events, ongoing difficulties, and the lack of a confiding relationship and support. 10

9. In a study in four countries undergoing economic restructuring, strong associations among fe­ male sex, low education, and poverty with common mental disorders was found in Goa, India; Harare, Zimbabwe; Santiago, Chile; and Pelotas and Olinda, Brazil, revealing how gender inequality is linked to economic inequality and rising income disparity. See Patel et al. 1999. See also Cabral and Astbury. 10. Social theories of women's depression emphasize the interaction of life events; vulnerability factors, including parental loss before the age of seventeen, particularly the loss of one's mother before age eleven; the presence at home of three or more children younger than fourteen; a poor, nonconfid­ ing marriage; and the lack of full- or part-time employment. See Brown and Harris 1978.

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Silencing the Self, Relationships, and Women's Depression Research around the world finds that in most instances, the severe events provoking women's depression involve a core relationship. Women, as a group, place a higher degree of importance on the quality of their personal relationships, and the quality of such relationships centrally affects women's sense of self, self-esteem, and self­ regard. The importance that women place on their relationships with husbands and partners, combined with women's inequality, leads them to avoid conflict and sup­ press anger in order to preserve those relationships. Inequality leads to a form of self-censorship that Dana Jack has metaphorically called «silencing the self" (1991). A woman's economic dependence on a man who may leave her for many reasons­ she fails to produce a son, she becomes "mad"-increases her fear of abandonment and her self-silencing. Silencing the self, in turn, is hypothesized to contribute to a fall in self-esteem and feelings of a loss of self, inner division, and depression. Trying to keep relationships by pleasing others, or at least by complying with their wishes, a woman experiences a hidden self that is resentful, angry, and, likely, increasingly hopeless. Yet her anger cannot be expressed for fear of retribution or abandonment. Silencing the self fits with how women internalize subordination; muting one's voice and anger works to reinforce subordination. Being female coincides with hav­ ing a lower rank in society; as the UNDP's 1995 Human Development Report ob­ served, "No society treats its women as well as its men:' In Nepal, as in many cultures, girls are likely to internalize this social fact from birth on, and it influences their self-perception. Social inequality becomes part of one's felt worth and sense of standing in the world. For example, the restrictions on women's physical move­ ment, self-expression, and sexuality are internalized and work as a form of self­ inhibition and self-surveillance. They restrict women's imagination about their already limited choices; many women berate themselves or feel anxiety if they think they have «stepped over the line" of acceptable behavior. Submissive, dependent, and nonassertive behaviors are still considered desirable feminine traits by many so­ cieties, including Nepal. Trained in girls and expected of women, such behaviors are also found to be associated with depression (Allan and Gilbert 1997). The Silencing the Self Scale (STSS) was designed to measure self-silencing and internalized subordination as it manifests in interpersonal behaviors, specifically self-sacrifice, self-silencing, pleasing, and seeing oneself through others' eyes. It also assesses a person's endorsement of presenting an outwardly compliant self in rela­ tionships while feeling inwardly angry and asks respondents to describe the stan­

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dards they use to judge themselves and feel they fail to live up to.ll The STSS corre­ lates with women's depression across studies in numerous countries, including India, Hong Kong, Greece, Puerto Rico, Canada, England, and in various ethnic groups within the United States. The Depression Study: Goals and Description This exploratory study of gender and depression in Nepal was designed to examine what women seeking help at outpatient clinics identify as the sources of their de­ pression, their symptoms, help-seeking patterns, and how social factors affect their depression. The study included comparison samples of men in order to examine gender differences with respect to these critical issues of depression.

Participants Data for the study were collected from women and men attending outpatient clinics at two government-supported hospitals in Kathmandu. When diagnosed with unipolar major depression by Nepali psychiatrists, patients were informed of the study after their first appointment. Those individuals consenting to be interviewed were seen immediately. The consecutive sample, interviewed between April and June 2001, consisted of thirty-four women and sixty-two men. The larger number of men than women seeking help may reflect Nepalese society, where families are more willing to spend money and time on male members and where males are more free to seek help themselves. Women ranged in age from 18 to 68, with a mean age of 37; men's ages ranged from 15 to 73, with mean of 30. Fifty-seven percent of women were illiterate, whereas 11 percent of men were illiterate; 15 percent of women and 14 percent of men were literate through nonformal education; 3 percent of women and 16 per­ cent of men had attended college. These educational patterns reflect Nepal's wider practice of schooling boys more often and longer than girls. Seventy-six percent of women and 66 percent of men were married; 15 percent ofwoDlen and 34 percent ofDlen were unmarried. Women's age at marriage ranged from 10 to 25, with the mean age of 16.3 similar to what is reported for Nepalese women in general. Men's age of marriage ranged from 13 to 32, with a mean age of 11. The STSS is published in Silencing the Self Women and Depression (Jack 1991). The psycho­ lTIetrics and scale construction study are reported in Jack and Dill 1992.

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21.2. Only unmarried women had no children; all married men had children. Fifty­ three percent of women and 57 percent of men lived in joint families; women lived with a mean of 6.2 of family members, men with a mean of 7.7 of family members. Only 12 percent ofwomen earned money through employment, whereas 56 percent of men were wage earners. Seventy-six percent of women and 66 percent of men de­ scribed their income as low relative to other Nepalese.

Measures A semistructured interview inquired into each person's perspective on the causes of their psychological distress and into known factors that affect women's depression. Questions about physical and emotional symptoms and help-seeking patterns were also asked. The interview was translated into Nepali, reviewed by the participating psychiatrists, pilot tested, and revised before use in the study. Trained Nepalese in­ terviewers conducted the interviews with each patient; the interview lasted approx­ imately one hour. A measure of depression, Section E ofthe Composite International Diagnostic In­ terview-2.1 (hereafter referred to as the CIDI). The CIDI has been developed for international use and served to develop a picture of depressive symptoms in Nepal as compared to other countries. The CIDI has been translated into Nepali and uti­ lized in a study of Nepalese-speaking Bhutanese refugees (van Ommeren et al. 2001). Questions from this measure were asked verbally by trained Nepalese inter­ viewers. The CIDI was scored for point prevalence of DSM IV (The Diagnostic and Statistical Manual, Version 4, American Psychiatric Association) major depression, that is, how many people were experiencing the symptoms of major depression within the past two weeks. The Silencing the SelfScale (Jack and Dill 1992). The STSS is a thirty-one-item self-report measure that assesses cognitive schemas about how one "should" inter­ act in order to develop and ITIaintain interpersonal relationships. Respondents rate their agreement or disagreement with items on a five-point Likert scale. STSS items reflect the four subscales that make up the construct of self-silencing. Higher STSS scores indicate a greater degree of self-silencing. The STSS was translated and adapted to Nepalese culture with the use of the Translation Monitoring ForITI (van Ommeren et aL 2001). After translation and blinded back-translation, the STSS was then tested with four focus groups with women, both literate and illiterate, to ITIake sure the instrument was clearly worded

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and relevant to women's lives. It was then tested-retested with the group of master's students to establish reliability and basic scale psychometrics for Nepal. STSS test­ retest reliability for women was .92 (p < .001); for men it was .54 (p < .005). Scale alpha for the women was. 79; for men it was .69. Convergent validity was established by predicted correlation with OSM IV major depression as measured by the CIOI: women (N = 39) .56, p < .001; men (N = 56), .28, p. < .05. The semistructured interview, the CIOI, Section E, and selected items repre­ senting the four subscales of the STSS (nos. 2-9, IS, 16, 19,25,29, and 31) were ad­ ministered to the hospital outpatients who participated in this study. Results

The correlation of total depression symptoms on the CIOI, Section E, with STSS scores were as follows: females (N = 34), .23 (p > .05); males (N = 62), .48, (p > .001), The correlation of the STSS and the CIOI in the male participants requires a follow-up examination of the meanings Nepalese men attach to scale items; that study is now under way. The four focus groups with women established the useful­ ness of the scale to capture their experience in relationships; similar focus groups are currently being conducted with men. Qualitative Analysis ofInterviews

Responding to the question, «"What brought you to the clinic?" patients overwhelm­ ingly listed physical symptoms, including persistent headaches, weakness, and bod­ ily pain. Their expression of symptoms through physical distress corresponds to symptom expression found in many societies in which physical complaints serve as the idiom for depression. 12 "When identifying what they think is causing their symptoms, both women (70 percent) and men (50 percent) most frequently describe problems in their relation­ ships.13 Women are much more likely to point to problematic relationships with their spouse (40.1 percent of women, 18 percent of men) and with in-laws (women 35.3 percent, men 0 percent). In these relationships, women describe financial de­ 12. See Kleinman and Good 1986. 13. Written interviews were typed and imported into Ethnograph software> which allows system­ atic analysis of themes. Five students were trained to code interviews; the following analysis results from the codings.

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. pendence, social roles that require them to serve men and in-laws, and, for many, early marriages or widowhood that bring severe difficulties. Men describe tension around the roles they are expected to play within the family, particularly in provid­ ing economic support, or feeling disapproval from family members, or being dis­ tressed by family members' nonconforming behavior. As each sex describes their relational problems, women's narratives powerfully

reflect the impact of their inequality on their lives and on their depression. For ex­

ample, among the thirty-four women coming to the clinics, the following situations

were reported as precipitating their psychological distress: rape at age twelve, being

regularly beaten by husbands or in-laws, living as a daughter-in-law in an oppressive

joint family with a heavy work burden and no freedoms, being widowed with low

status and no emotional support, living separately from husbands who send money

sporadically, living with husbands who take second wives or threaten to do so, and

health problems. Each of these situations is affected by women's unequal legal sta­

tus, lack of economic independence, early marriages, lack of education, male child

preference and its corollary of girl children as liabilities to parents, and lack of social

resources to support women who wish to leave abusive relationships.

The violent structure of married relationships that affects many of these

women's mental health appears in the following representative examples from

women's narratives:

#1812-55 (age thirty-five, three children, illiterate, married at fifteen): "My hus­

band is the main cause of my illness.... When I got out [of the hospital] my hus­

band beat me as I was unable to do house chores, and my husband never loved me. 1

have three children, and he still beats me when he is drunk:'

#1812-558 (age thirty-seven, three children, nonformalliteracy, married at sev­

enteen): "My older son is very troublesome.... [H]e beats me and has no respect

for me. I have been suffering from this disease for years. When I had the sickness I

was beaten by my sister and father; my husband also beats me."

#2728-057 (age twenty-seven, two children, illiterate, married at sixteen): «There is no peace at home, only fighting with my husband. He drinks all the time. Whenever he is drunk he beats me. He even kicks me out of the house at midnight. He had sexual relationships with other women, and he had [an] STD. Because of him I also got [an] STD. 1 don't trust my husband. If 1 ask him not to drink he beats me.» #5238 (age twenty-three, one child, high school education, married at twenty­

one): "I have family problems with my in-laws and my husband. My husband works

outside Kathmandu and comes home only on holidays. Whenever he comes home,

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my in-laws poison his ears by saying all sorts of things about me. He believes them and starts fighting with me and even beats me. He is talking about [a) second mar­ riage; 1 am always thinking about killing myself, but 1 think of my little daughter." Sixty percent of the women who identified problems in relationship with their husbands reported repeated physical beatings; others described emotional abuse and abandonment. Three additional women described physical beatings by in-laws. Some of the men's narratives provide another view into violence against women within marriages. When the 18 percent of men talked about problems in relation­ ship with their spouse, only two identified such problems as the cause of their psy­ chological distress. The representative excerpts below reveal men's attitudes about male dominance and women's roles in marriage: #2171 (age nineteen, no children, in college, married at eighteen): "My parents found me a girl [wife) who was older than me. She is big and mature, and 1 am smaller and immature.... 1 feel trapped. 1 always regret this marriage." #3188 (age fifty-three, two children, nonformalliteracy, employed, married at seventeen): "I don't share my feelings with my wife because 1 am male, and how can I lower myself in front of a woman? Men are to rule women. Women should be kept under our feet." #3539 (age thirty-one, university education, unemployed, married at twenty­ eight): "I am unemployed but my wife is a lecturer, so 1 feel dominated. Because of my unemployment we usually have fights and arguments.... My wife is employed, and she tries to dominate me." #526-058 (age forty-five, two children, employed, married at twenty): "I do not like to see my wife. When 1 do, 1 automatically want to kill her. [When 1 am angry) 1 run to cut her with a knife." #5781 (age twenty-eight, one son, middle school education, employed, age of

marriage missing): "I can't stand my wife. 1 become irritated whenever 1 see my wife. 1 want to fight with my wife. My friends tease me because my wife works and earns more than 1 do.... 1 feel like my wife tries to dominate me, so 1 beat her." #748-058 (age thirty-two, two children, illiterate, employed, married at six­ teen): "I beat and abuse my wife." Only four men identify violence or its threat as a problem that brought them to seek help. Three of these men had been threatened or beaten by male nonrelatives; one man's step-uncle regularly beat him. When men described violence against their wives, they did not regard it as a problem. Rather, the subject most often came up in response to the question, "What do you do when you get angry?" Numerous researchers in developed and developing countries have identified

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the powerful effect ofviolence on women's depression. The 1997 SAATHI report on violence against girls and women in Nepal found that 95 percent ofrespondents had firsthand knowledge of such violence, with nearly 58 percent reporting domestic vi­ olence to be a daily occurrence. In studies from North America, battered woman are four to five times more likely to require psychiatric treatment and five times more likely to attempt suicide that nonbattered women. 14 Economics. Inadequate income was the second factor most frequently identified by both sexes as the perceived cause of their symptoms. Fifty-six percent of women and 50 percent of men described problems around inadequate income as central to their distress. Only one of the thirty-four women seeking help lived on her own, worked as a salesperson, and had control of the money she earned. Since women's complete financial dependence on others restricts their ability to leave abusive rela­ tionships or take care of children, the overlap of relationship and economic prob­ lems occurs commonly: 79 percent of the time in women's narratives. For example, #2728-057 (age twenty-nine, two children, illiterate, married at seventeen) said: "Two years ago he [my husband] started drinking. At first he used to come home at midnight; sometimes he didn't come home the whole night. I was very worried about him. I couldn't sleep the whole night. He started beating me. We have a small furniture shop. He doesn't work much, so now we don't have enough income. Be­ cause of the tension I became ill." Economic dependency blocks her escape, reduces her choices and sense of control, and contributes to hopelessness. Health. Health problems, other than the symptoms that brought them to the hospital clinics, were described by 35 percent of women; in this group of women, 58 percent described health problems as overlapping with economic and family prob­ lems. For example, #166-058 (age twenty-nine, three children, literate, nonformal education, married at seventeen) says, "I have had a pain in my heart for a long time. Because of my heart problem I cannot work and have become so weak. I have very young children. IfI die from this sickness, what will happen to my children? Because of this problem, I am feeling worse and worse. Since I am not able to contribute to the family work, I feel humiliated. Every member of the family says,