The Pervasive Role of Religion/Spirituality in Pakistani Women's Self-Management of Recurrent Depression

Purpose:

           Background:

            Understanding self-management of chronic illness including Major Depressive Disorder (MDD) has become a prominent effort for researchers and clinicals.  Much of the literature on self-management is derived from research focused on Western culture.  Less is known about how people self-manage their MDD in other cultures.  Hence, a qualitative study was designed to understand how women in Pakistan, a South Asian country, self-manage their recurrent MDD.

            There is no nation-wide epidemiological research done yet to determine the prevalence of depression among Pakistani women.  Nonetheless, based regional research depression among Pakistani women appears to be high.  One study conducted in Pakistan also revealed a more than double the prevalence of depression in women compared to men.

            Considering how little is known about Pakistani women’s mental health in general and how they self-manage their MDD in particular, it is timely and imperative to generate  knowledge that enhance understanding of how Pakistani women live their day-to-day lives with recurrent MDD including use of strategies and their effectiveness.

            Religion/spirituality is central in the lives of Pakistanis.  However, the role of religion/spirituality in how Pakistani women deal with recurrent MDD is yet to be empirically explicated.  Currently, little is known about what Pakistani women do to manage their MDD.  A review of literature related to self-management strategies revealed that studies were not conducted from the perspective of self-management.  For example, the study that explored Pakistani women's experiences of depression and coping revealed that women use a variety of coping strategies such as talking to someone, being strong for the children, keeping busy, religious coping, positive self-talking, downward comparing, and using antidepressants.   Though such research study provided some information on coping activities Pakistani women used for their depression, they were not queried from the perspective of self-management and the women were not residing in Pakistan.  

             Purpose:

            A qualitative, descriptive study was conducted to understand the strategies Pakistani women use to self-manage their recurrent MDD including: (i) Pakistani women’s experience of depression, (ii) factors that influence self-management strategies (SMS), and (iii) SMS and their perceived effectiveness. 

Methods:

            Using purposeful sampling, 10 Pakistani women who had had two or more episodes of major depression were recruited through flyers posted in the outpatient psychiatric clinic of a private university hospital and by referrals from psychiatrists to the primary researcher.  Data were collected through semi-structured interviews using an interview guide.  

             The primary investigator, fluent in English and Urdu, translated all the interviews into English and then back translated three randomly selected interviews.  To avoid biased interpretations, two independent bilingual Pakistani colleagues currently residing abroad translated one interview each.

            Content analysis was used to analyze data that aimed at describing Pakistani women's experience of depression, factors influencing strategies, and SMS for their recurrent depression. 

Results:

             Three major themes emerged from the qualitative analysis: a) experience of depression, b) influence of religious/spiritual perspective, within the cultural context, on the selection of strategies, and c) specific religious/spiritual SMS and their perceived effectiveness.  

             The experience of depression was influences by each individual woman’s religion/spirituality. Women viewed their experience of depression through the lens of religion/spirituality which created positive and negative perspectives.  Positive insights were framed as a gift from God and renewed faith in God and Islam.  As a gift from god, depression instilled the understanding and perspective that anyone could have depression and they developed empathy for others. As a renewed faith in God and Islam, they embraced more strongly religious rites and rituals. The negative insights revealed that all women shared their experience of going through depression as painful.  They viewed depression as the worst of all illnesses mainly because of its insidious and hidden course and presentation

             The second theme was the influence of religion/spirituality within the cultural context, on the selection of SMS. Faith in God was the strongest influence on their selection of religious/spiritual strategies for coping with depression believing that God had the power to solve all of their problems and was the source of courage and strength.  

             The third theme was specific religious/spiritual SMS used to manage their depression and their perceived effectiveness. These included having faith in God and ways of connecting with God.  Faith in God was viewed as a source of healing, contentment and ease, source of help, and a sense of hope. The connection to God occurred through performing prayers, reciting the holy Qur’an, talking to God, and performing a Pilgrimage.  Women described that the perceived effectiveness of these strategies changed over time in terms of their usefulness and thus were not constant. 

Conclusion:

             These findings provide valuable insights into the importance of religion/spirituality in how Pakistani women self-manage their depression.  These results constitute evidence that should be the basis for practice when caring for patients from an Islamic culture. Religion and spirituality are the critical lenses through which Islamic women understand their illness and make decisions about how to manage their depression.  Self-management occurs within a cultural context. The norms of the culture influence the options that women have in order to self-manage. Pakistan and many South Asian and Middle Eastern countries are homogenous with respect to religion.  In Western culture, there is more heterogeneity in religious beliefs and spiritual practices. Although these concepts are relevant in Western culture, it is critical for nurses, in order to provide culturally sensitive care, to understand the unique religious and spiritual perspectives that influence how women understand and manage their depression.