Why Cambodians Never Get 'Depressed'

People in Cambodia experience what we Americans call depression. But there's no direct translation for the word "depression" in the Cambodian Khmer language. Instead, people may say thelea tdeuk ceut, which literally means "the water in my heart has fallen."

Anxious or depressed Haitians, on the other hand, may use the phrase reflechi twop, which means "thinking too much." And in parts of Nepal and India, people use the English word "tension."

Mental distress is a universal condition. The World Health Organization has made global access to mental health care one of its key goals.

But just as words for depression and anxiety get lost in translation, so can treatments.

Simply setting up mental health clinics identical to the ones we have here in the U.S. isn't necessarily going to help anyone, says Dr. Devon Hinton, a psychiatrist at Harvard Medical School, who works with Southeast Asian populations in the U.S. and abroad.

Culture affects how people understand and express mental disorders. So psychiatrists around the world are working to figure out what these differences are and develop treatments that work for each culture.

Take for instance khyal attacks, or "wind attacks." Cambodians who suffer from anxiety disorders often experience the quick onset of heart palpitations, blurry vision and shortness of breath. Like panic attacks, khyal attacks can happen without warning.

"This is thought to indicate there's a surge of blood in their limbs and body," Hinton says. "And sometimes people feel like they could die from this."

For Cambodians who survived the genocidal Khmer Rouge regime in the 1970s, khyal attacks often occur with flashbacks to traumatic events, bouts of dizziness and trouble sleeping. "There are many terms [in the Khmer language] that suggest that anxiety is like dizziness," Hinton says. "Patients will say 'I'm spinning in the heart.' "

Hinton says he plays off such metaphors when talking to patients about treatment. When a patient suffers from depression and tells Hinton, "The water in my heart has fallen," Hinton may suggest an antidepressant that will "increase the water in the heart, so it will be like the rice fields after a storm.

"We also talk a lot about treatment in terms of Buddhist metaphors," Hinton continues. "We'll say 'If the mind is like the sky, these problems are like clouds, which will pass.'

"The key is understanding patients, and making sure they feel understood."

American psychiatrists working in Nepal learned that lesson the hard way, says Dr. Brandon Kohrt of the Duke Global Health Institute.

"When we first studied PTSD [post-traumatic stress disorder] treatment in Nepal, we realized the way that [foreign] social workers had translated PTSD was stigmatizing," Kohrt says. Counselors would often use the phrase maanasik aaghaat or "brain shock" to describe the condition.

But in Nepal, India and Pakistan, people distinguish between the physical brain — or dimaag — and what they refer to as the mann, or "heart-mind."

"If the brain is damaged, they feel it's permanent: There's no chance for recovery," Kohrt says. "But if the heart is distressed, that emotional distress can be fixed."

People in rural Nepal weren't showing up to PTSD treatment, Kohrt found, because they were confused by the terms used to describe it. "It was this sort of Eureka moment," Kohrt says, when he realized why attendance was so bad.

"A lot of effort needs to go into engaging the patient," says psychologist Arpita Anand, who works with the nonprofit mental health organization Sangath in Goa, India.

Some of her patients know quite a bit about depression, Anand says, while others aren't familiar with it at all. Many of them start out by describing the physical symptoms of their depression or anxiety rather than their emotional distress, she says.

"One woman, for example, who started seeing me three months ago, said she had lost her appetite," Anand explains. "And she talked about her fatigue and sleep difficulties."

But doctors couldn't find any particular reason for these complaints. "After talking with her, it became clear that she was suffering from depression," Anand says. "So then a lot of my effort was to help her recognize that her physical and mental conditions are actually connected."

When working with a new community, counselors and researchers like Kohrt and Hinton often have patients map out their emotions on a drawing of the human body. They tell a patient to describe exactly where and how they feel each symptom of depression or anxiety.

"You've got to figure out what the core signs are for different people," Hinton says. "Ultimately, it's just a matter of being an interested listener."