The fact that cultural aspects of mental disorders are more explicitly acknowledged in DSM-5 shows that they are increasingly at the front of mind in psychiatry as whole.

The symposium Cultural Differences in the Treatment of Bipolar Disorder, chaired by Professor Andrés Heerlein was therefore an excellent insight into the influence of culture on the detection and management of bipolar I disorder.

Hidden danger

The session started with eloquent perspective on the treatment of bipolar in Arab cultures from Professor Tarek Okasha, an Egyptian psychiatrist whose scope also covered Saudi Arabia (where 70% of psychiatrists are Egyptian).

The first challenge that clinicians face in Arab cultures face is a long delay in patient identification – in fact, one third of patients are diagnosed over 10 years after the initial onset of symptoms.

Breaking barriers

This delay of diagnosis is likely due to:

• Symptom tolerance
• Assimilation in the social network
• Preference for family support over professional support
• Religious attribution

For example, in the depressive phase, symptoms may be attributed to laziness, a weak personality, a lack of faith, or as a redemptive punishment from God. During the manic phase, symptoms can be attributed to possession by Djenee or evil spirits, or to a religious fervour.

Even when symptoms are recognised as a problem, effective treatment still may not be forthcoming, as in Prof Oshaka’s experience, approximately 70% of the time, traditional healers are sought before psychiatric help.

Casting a wide net

The strength of the social network in traditional Arabic societies can be a vital safety net in reducing the impact of bipolar symptoms on a patient and helping them maintain a relatively normal life. However, Prof Oshaka observed that this ‘cushioning’ of symptoms and the protective cocoon of family can make it difficult to identify these patients and to properly quantify their symptoms.

Play it again Sam

Prof Oshaka’s insights into the specific challenges and effects of Arabic culture on bipolar diagnosis and treatment were wonderfully supported by two case studies of patients in Casablanca, Morocco, presented by Professor Driss Moussaoui.

A vicious circle

Prof Moussaoui’s first study looked at 80 women in Casablanca who had been hospitalised with mania. In 14% of the cases, the woman’s family were aware that they were making their living from prostitution, while another 14% of the families were unsure how the woman was supporting themselves.

For a conservative country such as Morocco, up to 28% of female bipolar patients earning their living through prostitution is remarkably high. Prof Moussaoui posited that the conservative nature of Morocco may actually be the cause of this high percentage, as if a young bipolar patient shows or acts on hypersexuality during a manic phase then they will likely be rejected by their family and be forced to turn to prostitution to support themselves.

Losing rhythm

Prof Moussaoui’s next study examined the impact of Ramadan, the Muslim period of fasting and reflection, on bipolar patients. He found that relapse rates during this period of 33-42%, a shockingly high rate.

This increased rate is likely due to changes in social rhythm, and the reduction in average sleep time from 9.3 to 7.3 hours during Ramadan.

Prof Moussaoui therefore advises his bipolar patients not to fast, pointing to the provision in the Koran for ill people to skip the fasting (and he reiterates to his patients that they are ill in the eyes of God).

Different strokes

It can be easy to paint our patient pictures in broad brushstrokes. But Prof Okasha’s and Prof Moussaoui’s presentations showed the importance of taking the social and cultural life of a patient into consideration when we diagnose or treat our patients.

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