Attitudes Toward Depression in Arab-American Muslims: A Pilot Study

Attitudes Toward Depression in Arab-American Muslims:

A Pilot Study

Shady S. Shebak, MDa,*; Ahmad M. Elkhatib, DOb; Henda Albiatty, MPHc; Taj Elsayed, MDd; Heba Sobh, PharmDe; M. Baqir Mohie El Deen, MPPf,g; and Mohammad Ghaziuddin, MDa

Arab-American Muslims have a unique pattern of acculturation that is different from that of other religious and ethnic groups, including Arab-American Christians. Unlike Christians who follow patterns consistent with the theory of acculturation, for Muslims, integration is not necessarily associated with better mental health.1 While there is a rich tradition of familial ties in Islam, competing forces of modernity and secularization diminish the importance of traditional values espoused within the Arab and Muslim culture.2 For Muslims living in Western countries, the process of acculturation adds another strain. Studies on the relationship between acculturation and health in this population have yielded conflicting results. For example, Aprahamian et al3 found that the relationship between acculturation and mental health within the Arab-American population was not significant, while Jadalla and Lee4 suggested that acculturation was an important factor, especially for mental health. Better mental health outcomes were associated with those who were attracted to American culture, and better physical health was associated with bicultural identification.4

Furthermore, in some Arab and Muslim countries, supernatural beliefs about health and illness are widely prevalent, and this is particularly true of mental illness. Some of these beliefs include that mental illness is due to possession by spirits or Jinn, is a result of personal shortcomings, or is due to the evil eye or black magic.5,6 However, beyond anecdotal reports, very little systematic study has been done on the relationship between religious and cultural beliefs and mental health in Arab-Muslim Americans. In this pilot study, based on a similar study conducted in Riyadh, Saudi Arabia,6 we tried to determine how religious and cultural beliefs influence the attitudes of Arab-American Muslims toward depression, the most common mental health disorder.

METHODS

The study was conducted at the Islamic Center of America, Dearborn, Michigan, as part of the Movement for Outreach, Volunteerism, and Education (MOVE) psychoeducation seminars. MOVE is a nonprofit organization that hosts mental health psychoeducational events, with a focus on culturally appropriate mental health advocacy, currently directed toward Arab Americans living in southeast Michigan, which is home to a sizeable Arab-American population. From October 2017 to October 2018, a mental health topic was discussed every month and advertised to the Islamic Center of America’s congregation via social media and in collaboration with the mosque’s youth group. At each psychoeducational session, mental health professionals including psychiatrists and social workers were present to provide appropriate referrals for participants seeking mental health services.

A modified version of the Depression Awareness Questionnaire (DAQ)6 was handed out to participants who attended the psychoeducational seminars at the Islamic Center of America. The DAQ contains items adapted from the 9-item Patient Health Questionnaire,7 which is used by primary care physicians to screen patients for depression. Additional questions were added to assess how religion influenced mental health. Some of the questions included "Do you think that if you are near to God you are safe from depression?" and "Do you think that black magic or the evil eye can cause depression?" Each question had 3 possible responses: yes, no, and I do not know. Upon arrival, participants received the DAQ along with a written consent form. They were instructed to fill out the DAQ and return both forms prior to the topic discussion of the evening. The respondents were Arab-American Muslims over the age of 18 years. The seminar series lasted for 1 year, but participants were only allowed to fill out the survey once at the first seminar they attended. For reasons of confidentiality and cultural sensitivity, exact dates of birth and age were not asked. All respondents had to be able to read and understand English. The study was reviewed and approved by the Michigan State University Institutional Review Board.

• Mental health treatment of an increasingly diverse society requires health care providers to be aware of and sensitive to cultural and religious differences.
• Arab-Muslim Americans place high importance on both cultural and religious traditions.
• Mental health advocacy within the Arab-Muslim American community should take culture and religion into account and find ways to use these factors positively and in congruence with current evidence-based practice.

RESULTS

The study included a total of 75 respondents, of whom 27 were men and 48 were women. Twenty-five (33.3%) respondents said they had depressive symptoms, 14 (18.7%) said they had a low mood nearly every day, 20 (26.7%) had a loss of interest in things that used to make them happy, and 34 (45.3%) reported diminished energy or activity level. Also, 30 (40.0%) participants reported difficulty with concentration, 27 (36.0%) reported a change in appetite, 13 (17.3%) reported low self-esteem, and 17 (22.7%) reported having excessive guilt. With regard to thoughts about wanting to die, only 2 (2.6%) respondents said yes, and 2 (2.6%) reported thoughts about suicide. Furthermore, only 12 (16.0%) respondents had been seen by a psychiatrist.

Regarding beliefs about depression, 33 (44.0%) participants said depression was a hereditary illness, 24 (32.0%) said it was not, and 18 (24.0%) did not know. Also, 64 (85.3%) respondents believed depression was a medical illness requiring medical intervention. Beliefs regarding treatment were as follows: 24 (32.0%) respondents believed antidepressant medications lead to addiction, 36 (48.0%) did not believe this, and 15 (20.0%) did not know. Furthermore, 59 (78.7%) participants believed that patients with depression could get better if they received treatment, 8 (10.6%) did not believe patients would get better with treatment, and 4 (5.3%) did not know As for religious and spiritual causes of depression, 26 (34.7%) participants reported that black magic or the evil eye could cause depression, 36 (48.0%) responded no, and 13 (17.3%) were not sure. Nearness to God was viewed by 28 (37.3%) respondents as a way to stay safe from depression, while 33 (44.0%) did not view nearness to God as related to depression, and 14 (18.7%) were not sure. Table 1 provides a summary of survey responses.

Click figure to enlarge

DISCUSSION

Our study examined the attitudes, beliefs, and knowledge about depression in a group of Arab-American Muslims in Dearborn, Michigan. Of the respondents, 85.3% believed that depression is a medical illness requiring intervention, and 78.7% believed that patients could get better if treated. At the same time, 37.3% believed that being near to God could save someone from depression. Thus, while the participants understood the gravity of depression and the importance of treatment, religion and religious beliefs still played a strong role in their approach to health and disease. A smaller percentage of respondents in our study viewed nearness to God as related to depression, which is in contrast to the study by Alrahili et al6 in Saudi Arabia in which 75% of respondents reported nearness to God as a way of avoiding depression. This finding suggests that Saudi Muslims might more strongly believe in the role of faith and religion in the treatment of mental disorders such as depression. Similarly, 34.7% believed black magic or the evil eye can cause depression. This number was closer to the finding of Alrahili et al6 wherein 57% of respondents believed black magic or the evil eye can cause depression. Again, these findings illustrate that religious views about health and disease are influenced by geographical factors and underscore the importance of cultural sensitivity in providing education and assistance to Arab-American Muslims who come from varied national backgrounds. Only 2 attendees expressed that they have death wishes or have ever thought of ending their lives. In Islam, there are strong religious sanctions against suicide, and in Muslim nations, there is an overall lower rate of suicide.8 From our preliminary study, it is unclear if respondents were ashamed to admit to a history of suicidal thoughts due to religious sanctions against the act itself or if the responses were accurate in this domain. Further study is needed.

It is also important to stress the limitations of our study. First, the size of the sample was rather modest. Second, demographic data were incomplete; for example, birthdate, immigration status, and country of birth were unknown. Third, our study was confined to attendees of the mental health seminars, which were made up of English speakers, mostly young adults, and Shia Muslims of Iraqi and Lebanese descent. Despite this caveat, the study provides useful preliminary data on the religious views of Arab-American Muslims as they relate to mental health. It also sheds light on the prevalence of depressive symptoms in this population and how they are influenced by religion. In addition, the findings are broadly in agreement with those of the Saudi Arabian study by Alrahili et al,6 thus endorsing the role of religion in attitudes toward mental health in Muslim societies.

CONCLUSION

The results of this study show that Arab-American Muslims hold on to their cultural and religious beliefs, and these beliefs should be taken into account when providing patient care or psychoeducation. In future studies, we plan to ask questions and compare results across age, sex, and immigration generation. We would also like to open up our study to non-English speakers and to first-generation immigrants and Sunni-Arab Muslims spanning other Arab nationalities. We plan to expand our questions to determine views regarding honor and shame to better understand the Arab-American Muslim population of southeast Michigan.

Submitted: June 14, 2019; accepted September 9, 2019.

Published online: December 5, 2019.

Potential conflicts of interest: None.

Funding/support: None.

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