BIOMEDICAL AND CULTURAL EXPLANATORY MODELS OF WOMEN'S MENTAL DISTRESS IN SOUTH ASIA, WITH PARTICULAR FOCUS ON PAKISTAN: A SCOPING REVIEW

Abstract

Background: In South Asia, women's mental distress is understood in a range of systems of meaning, some of which are conflicting and some of which are complementary. Psycho-medical and/or psycho-pathological discourses along with explanations of local origin, such as stress, family relations, jinn or spirit possession, black magic, nazar, curses, and religious idioms and other locally meaningful explanations, coexist. Such explanatory models are important as they influence who is approached initially, if there is any delay in seeking medical help, and whether the various treatment systems are pursued one after another or simultaneously. The aim of this study is to identify, map and critically compare biomedical and cultural explanatory models of women's mental distress in South Asian contexts, especially in Pakistan and to explore their implications for help-seeking and pathways to care. Methods: This was done using a JBI-informed scoping-review framework in all the eight SAARC countries: Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka following PRISMA-ScR. Twenty-six empirical evidence reports have been identified and included from Pakistan, India, Bangladesh, Nepal and Sri Lanka, the lack of mapped evidence from Afghanistan, Bhutan and Maldives is not an exclusion but a geographical research gap. Data charting distinguished source-documented psychiatric diagnosis, validated screening results and reproductive status and diagnosed reproductive/endocrine disorders from cultural attributions. Biological factors were included for individual cases/samples if they were explicitly mentioned in the original source. Results: There is evidence of explanatory pluralism and evidence in the biology and the reproductive evidence base is reduced, but clinically significant. Psychiatric evidence was source-documented psychiatric presentations where psychosis or serious mental illness was part of the pathway studies and women-specific reproductive evidence was clinically diagnosed PCOS with depression/anxiety screening in Islamabad and postpartum or perinatal depressive morbidity in India, Bangladesh and Sri Lanka. In the Islamabad PCOS study, the prevalence of depression and anxiety were 17.6% and 20.3% respectively in the women with clinically diagnosed PCOS and defined by HADS. The prevalence of PPD at 4 week and 24 week postpartum was 29.2% and 18.0% respectively in the Sri Lankan postpartum cohort using the validated EPDS cutoff. South Asian context studies included were not directly measuring reproductive hormone levels and so, in absence of hormone measurements or clinically documented hormone levels, no a priori assumptions were made about hormones or endocrine mechanisms and women. Conclusion: The difference between biomedical and cultural is not just ‘clinically relevant’ or not. A more useful model is to distinguish between biomedical-first, spiritual/traditional-first and informal/family-first and plural/parallel pathways. In some studies, supernatural/ spiritual attribution was associated with a longer or more complex route to formal care, but in some situations, a person's faith or the traditional healers served as a buffer between the tribal and the biomedicine.