“The sun has set even though it is morning”: Experiences and explanations of perinatal depression in an urban township,Cape Town

Local idioms of distress

In order to discover local idioms of distress, the following question was asked:

The [EPDS] questions we just asked you mentioned things like blaming yourself, being anxious or worried or stressed, feeling scared, having difficulty sleeping, being sad, or feeling like harming yourself. [Depending on the symptoms the participant had identified.] What word or words would you use to describe the feelings I have just mentioned?

Some idioms of distress were similar to the symptoms identified by the participants (see following section), but others were distinct. The most common idioms correlated with the most common descriptions of symptoms, particularly in the sample of depressed women, including stress (i-stress/unxungu phalo), thinking too much (ucingakakhulu), being sad or unhappy (ukudakumba), and being scared (ukoyika). This may relate to the fact that there is no specific word in Xhosa for ‘depression,’ and thus identification of the illness may be linked more directly with the symptoms experienced.

In the interviews, i-stress was both a word used to describe the illness (e.g., “You end up with stress and sickness,” Pregnant Woman (PW) 15), and a nonpathological reaction to socioeconomic factors that may have induced the “stress/depression,” such as economic and social insecurity, particularly related to an unwanted pregnancy and a lack of support.

Being sad or unhappy and thinking too much were also direct descriptions of the impact/effect of depression. Thus, when asked to name the word(s) one would use for depression, the most accessible word (idiom) in this context might be one describing or expressing the feelings or meanings related to the unnamed illness or distress.

Along with these direct answers to the above questions, other idioms were also identified. Two women used the depiction of the sun setting on them when describing their depression: “It is bad; you feel the sun has set even though it’s morning. You don’t feel like yourself even when you are walking” (Mother [M] 3). Another said, “It is bad; even the sun you will see it has set. I don’t know how I would compare it. When I had these thoughts, they’d tell me the sun has set. I would just not sleep” (PW 8). These descriptions are a localised means of expressing distress (Nichter, 2010), emphasising that this illness, represented as darkness, is constantly present for these women: the sun has set and it is dark, “even though it is morning.”

A nondepressed woman (ND) brought many idioms into her description of depression, saying: “It’s when your brain is, is cramped . . . It’s not focused on who I’m talking to, the brain is busy, it’s under suffocation, and everything can just blow up right now” (ND 3).

Other less commonly mentioned idioms included suppression of the brain, the brain is tired, heart palpitations, mental disturbance, having pain, and you are like the weather. These all demonstrate a ‘reaching out’ for meaning amongst the women through developing an ‘everyday rhetoric,’ using symbols or language (Hollan, 2004) that may not directly identify the illness but do indicate the suffering involved.

On the whole, idioms and symptoms identified by depressed and nondepressed women and health workers were similar, but some differences should be noted. The depressed women specifically identified idioms of thinking too much, being unhappy/sad, the brain being tired, being scared, and having pain, while only the health workers mentioned (once for each example): fatigue/burnout, mental disturbance, and being crazy/possessed by witchcraft. These differences may demonstrate the distinction between the presentation and appearance of depression to the health workers, combined with a possible lack of understanding of the illness, and the actual ‘feeling’ and experience of it among the depressed women. This underscores the importance of understanding the idioms experienced by the depressed women in order to include them in interventions and inform health workers of these experiences. In the case of this research, the idioms have been included in the development of the counselling intervention manual for the RCT through various means such as: the use of the words identified by the women to describe depression; the use of experiences described by the women as vignettes for examples of problem solving; and the inclusion of a response to the needs identified by the women using theoretical approaches such as ‘problem solving’ and cognitive restructuring or ‘healthy thinking’ (Rahman, 2007). The idioms were also included in a local adaptation and validation of the primary outcome measure for the RCT, the Hamilton Rating Scale for Depression (Hamilton, 1960).

Symptoms of depression

The analysis identified 14 categories of symptoms and descriptions of depression from the participants’ interviews. These are summarised in Table 1. In order to provide a global comparison, Table 1 also displays all of the key DSM-5 and ICD-10 symptoms required for classification of an episode of major depression. All nine DSM-5 requirements (labelled 1–9) and all 10 ICD-10 requirements (labelled 1–3 and a–g) were mentioned by the women, through differing descriptions.

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Table 1.

Symptoms of depression listed by frequency of mention, compared to DSM-5 and ICD-10 symptoms

Symptoms of depression described	Depressed women	Health workers	Nondepressed Women	Total	DSM-5 symptom*	ICD-10 symptom*
Withdrawal & not wanting to talk	9	7	5	21	(2) Markedly diminished interest or pleasure in all, or almost all, activities.	(2) Loss of interest and enjoyment.
					(6) Fatigue or loss of energy nearly every day.	(3) Reduced energy, increased fatiguability, and diminished activity.
Crying or sadness	7	3	3	13	(1) Depressed mood most of the day, nearly every day (e.g., feels sad, empty, hopeless).	(1) Depressed mood.
						(2) Loss of interest and enjoyment.
Poor concentration	6	3	4	13	(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day.	(a) Reduced concentration and attention.
					(5) Psychomotor agitation or retardation nearly every day.
Thinking too much	6	1	2	9	(7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). [The sense of worthlessness or guilt associated with a major depressive episode may include unrealistic negative evaluations of one’s worth or guilty preoccupations or ruminations over minor past failings.]
Fear & anxiety**	5	0	1	6
Stress**	4	3	4	11
Sleep problems	4	1	0	5	(4) Insomnia or hypersomnia nearly every day.	(f) Disturbed sleep.
Headaches & body pain**	4	0	2	6
Don’t care	3	4	0	7	(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.	(2) Loss of interest and enjoyment.
Suicidal thoughts	2	1	1	4	(9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.	(e) Ideas or acts of self-harm or suicide.
Loss of appetite	2	1	0	3	(3) Significant weight loss when not dieting or weight gain.	(g) Diminished appetite.
Anger**	2	6	2	10
Hopelessness	1	0	0	1	(1) Depressed mood most of the day, nearly every day (e.g., feels sad, empty, hopeless).	(1) Depressed mood.
					(7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).	(c) Ideas of guilt and unworthiness.
						(d) Bleak and pessimistic views of the future.
						(b) Reduced self-esteem and self-confidence.
Self-blame/guilt	0	0	2	2	(7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).	(c) Ideas of guilt and unworthiness.

One consideration relating to this descriptive study is that the depressed women were diagnosed using an international diagnostic system, meaning that the symptoms they described had already been identified by the scale. However, the top four symptoms the non-depressed women used to describe depression also align with the principle requirements for the ICD10 and DSM-5 scales to diagnose depression. All other symptoms mentioned by the depressed women were also mentioned by nondepressed women and health workers, and one additional symptom, self blame or guilt, was only mentioned by nondepressed women. This demonstrates, with respect to this particular sample, that both women diagnosed and those not diagnosed using the scales identified symptoms that align with the international scales for depression.

Symptoms were retrieved from quotations such as the following, which typify experiences of depressed women like this mother, and demonstrate the complex nature and symptomology of depression:

They are angry, and when they talk about their problems they cry. Some lose weight when they are stressed. Some gain weight; you will find that they are not happy but they still gain weight. Some lose appetite. When they are with people they are always thinking. (M 60)

One midwife described her experience of the withdrawal of a depressed woman as follows:

After delivery, the patient wasn’t talking to anybody . . . just quiet and staring, as if she is just looking at you—not turning the eyes. Just open her eyes like this. So that is when someone is depressed. (Midwife [MW] 3)

These quotations demonstrate that the women are aware that their behaviour is different when they have these feelings; it is not healthy or ‘normal’ to withdraw, ignore children’s needs, or feel worthless or hopeless in this community. Withdrawal as a result of their feelings has a major impact on their immediate day-to-day interactions. This extends to caring for children’s healthy development, as well as job-seeking behaviour, which has implications for them and their children’s educational, social, and economic development.

Crying or sadness was the other most common symptom mentioned by the participants. This was identified through statements such as: “I feel sad and down, I am not who I used to be” (M 57), “I am thinking and crying” (PW 15), and “I was sad, all the time crying” (PW 8). A nondepressed mother said that her friend who had depression “was always crying, and I would say ‘friend, don’t cry . . . I understand that your heart is hurting . . . It is hurting a lot by small things that are not supposed to make you cry’” (ND 3). These examples too demonstrate the identifiable abnormal patterns of behaviour such as being affected by small things and not being who you used to be.

Rochat and colleagues found in their study of women in rural KwaZulu-Natal that feelings of “sadness” were also the most frequently reported symptoms when describing depression (Rochat et al., 2011). These women also presented with disturbance of mood, loss of interest, suicidal ideation, and concentration difficulties (Rochat et al., 2011), as in the current study.

The word stress, as a symptom, was examined carefully for its meaning in the different transcripts. It appears that this is used as a word to denote worry, generally about concrete life stressors that the women are facing, but it also represents an affective state, indicating anxiety or discomfort. Thus stress is simultaneously a reflection of the hardships and adversities in the women’s lives and a symptom of depression.

The symptom thinking too much was usually mentioned concurrently with stress by participants. These two phrases were also the most frequent idioms used by the women for depression and were identified as causes, thus forming the core rhetoric of the illness. Thinking too much/excessive rumination about the problem causing depression naturally leads to stress as a symptom of depression, which then encourages further rumination, forming a self-perpetuating cycle. This can be seen in the following examples:

I would say depression is a stress more than others or bigger, maybe thinking too much, it’s made by something you have, or problems, then you think about that thing . . . I could have it in the stress that I have with problems. I am sitting thinking about them. (PW 4)

Another woman said:

It’s someone who is stressed to the point that the stress is too much. Thinking too much, and when she is thinking, it’s like she is going to go mad, and lose control. For example, when she thinks, she can even scream thinking about committing suicide. (M 60)

Lastly, one woman explained:

I would say it’s someone who thinks and does not have anyone to talk to and ends up doing things they are not supposed to and ends up with stress and sickness because of thinking because of that thing you can’t talk about. (PW 15)

Interestingly, the phrase thinking too much (“kufungisisa”) was also identified as both a cause and a symptom of depression by the Shona people in Zimbabwe (Abas & Broadhead, 1997; Patel et al., 1995). Similar descriptions have been documented of “were ironu” in Nigeria (Odejide, Olatawura, Sanda, & Oyenye, 1977) and “nervios” in Mexico (Salgado de Snyder, de Jesus Diaz-Perez, & Ojeda, 2000). The English description for thinking too much is ‘rumination,’ which is commonly included in assessments of depression or anxiety (Nolen-Hoeksema, 2000).

One mother said that she knew she was depressed because she thinks until her “brain is tired” (M 75). This links with the other most commonly mentioned theme in the women’s narratives of depression: poor concentration or confusion. Participants described this as follows: “[Depressed women] don’t talk straight or whatever they talk about they forget it” (ND 2), “There are times I even forget—I don’t know what is happening” (PW 20), and,

[Depression is] when the brain is tired . . . They send you to do something but you are unable to do that thing because you are thinking and forgetful, and then after 10 to 15 minutes you realize what you were sent to do. (PW 30)

Another local feature of depression was that of not caring, which links to the symptom of withdrawal from activities. Lack of motivation to take care of oneself affects the mother and her whole household, as expressed through these comments: “It’s difficult to wash, even to clean the house. It’s difficult to do anything” (M 75), and “You don’t look after yourself, you don’t care about yourself” (PW 22).

The implications of not caring and withdrawal on the baby’s health and wellbeing were demonstrated by a mother who had struggled to accept her baby initially, but had become more “interested in him” and loved him more by the time of the interview:

In the beginning it [being stressed] was affecting me. I had days that I was tired of him, and had a feeling of giving him up for adoption. But I did not have the courage to do it. If something comes up I can’t go, I am stuck, I don’t have money to go there. Had to stay with the baby, so having regrets about him. I didn’t care about him, getting annoyed with him. If he cried I ignore him, it still happens but I don’t want to make that a habit. I continue with what I am doing and finish it, and then I will give him my attention . . . I did not want him really. (M 60)

All the symptoms the women experience have consequences for their daily functioning and attention to infant growth, nutrition, and emotional development. Withdrawal, poor concentration, stress, and ‘not caring’ all have the potential to negatively affect the care of infants, and in turn may affect emotional bonding, psychological development, and physical health of the infant, as illustrated by several studies from LMICs (Cooper et al., 2009; Patel et al., 2003; Rahman et al., 2004).

The above symptoms and experiences were compared with the international diagnostic criteria of the DSM-5 and ICD-10 scales. The comparison revealed that the principle requirements for a diagnosis of depression in both nosological systems were met by the descriptions and idioms of the women. These requirements on both scales are: depressed mood, loss of interest and enjoyment/pleasure, and reduced energy leading to increased fatiguability and diminished activity (American Psychiatric Association, 2013; WHO, 2010).

The results suggest that in this township, amongst Xhosa women, experiences or symptoms of depression are similar to those listed in the DSM-5 and ICD-10 scales, but that women use different words or idioms to describe these symptoms. These findings corroborate those Patel et al., 1995, Broadhead and Abas (1998), who found similarities in the manifestation and expression of depression in Zimbabwe when compared to international criteria. Rochat and colleagues also found that Zulu women in KwaZulu-Natal used “psychological language” to describe symptoms of depression, and they concluded that the standardised diagnostic tools they used were culturally sensitive (Rochat et al., 2011).

Of the 14 symptoms identified by the participants, four are not listed in the main identifying criteria on the DSM-5 or ICD-10 scales. These were: fear and anxiety, stress, headaches and body pain, and anger. However, fear and anxiety and headaches and body pain are mentioned in the “coding procedures” and “associated features” of major depression in the DSM-5 scale (American Psychiatric Association, 2013), and anger is included in other scales commonly used to diagnose depression, such as the Hamilton Rating Scale for Depression (Hamilton, 1960). The above experiences or symptoms have also been frequently shown to have high levels of comorbidity with depression in other international studies (Gorman, 1996), and are associated with a range of other polymorphous expressions of distress and social dysfunction.

Perceived causes of maternal depression

Study participants attributed depression to a number of causes in their community. The most frequent of these were: lack of support, unwanted pregnancy, death of a loved one, poverty and unemployment, thinking too much, coping with a new baby, and stress. It is notable that when women described the causes of depression they were more likely to provide external or tangible explanations for depression as opposed to ‘internalised’ ones, such as biological or genetic aetiologies. The causes identified by the participants are summarised in Table 2.

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Table 2.

Perceived causes of depression

Cause of depression	Depressed women	Health workers	Nondepressed women	Total
Lack of support or partner desertion	8	8	2	18
Unwanted pregnancy	6	6	2	14
Death of a loved one	5	0	1	6
Poverty and unemployment	4	8	2	14
Thinking too much	4	2	1	7
Coping with a new baby	3	3	0	6
Stress	2	6	1	9
Abuse or rape	2	4	2	8
HIV status	1	4	0	5
Witchcraft or beliefs	0	1	0	1
The situation they are in	0	0	2	2

It is clear that there is a great need for support—both emotionally and financially—amongst pregnant women and mothers in this township, many of whom cite lack of support and/or desertion by a partner as the primary cause of their depression. One pregnant woman said that the cause of her depression was “not having someone to tell me what to do so I can get help” (PW 8). This type of explanation was not unexpected, as Fisher et al. (2012) also found difficulties in the intimate partner relationship to be closely associated with perinatal mental health in LMICs (Fisher et al., 2012).

An earlier study in the same township found similar evidence that the strongest predictors of depressed mood in pregnancy were lack of emotional support from women’s partners, relationship violence, a household income below R2,000 (approximately US$200) per month, and young age (Hartley et al., 2011). These findings also corroborate with what Petersen and colleagues found in KwaZulu-Natal, where lack of support was identified as a cause of depression amongst women with HIV (Petersen, Hancock, Bhana, Govender, & PRIME, 2013).

The pregnant women interviewed were recruited at their first antenatal appointment. Many of them had only recently discovered that they were pregnant, and there was a lot of attribution of depression to the cause unwanted or unintended pregnancy. The women’s anxieties around these unwanted pregnancies were related to being unemployed and thus having no money to care for the baby, partners discovering the pregnancy and deserting them, family members rejecting them, and the added burden for some of being HIV positive and having a child to look after. This is consistent with evidence from other resource-constrained countries (Fisher, Cabral de Mello, Izutsu, & Tran, 2011). One woman said her depression was “only caused because I am pregnant” (PW 22). Another mother described the effects of an unwanted pregnancy as an added financial stress and having an impact on caring for other children:

Sometimes I feel like not having the baby. There is nothing I can do. It’s already here. If the baby was not here, there would not be so much stress. But now the problem is this: I have to think about the baby, then my life, what am I going to do... So again I had that dumb brain to let myself get pregnant again . . . For example, I have my first born [but] he is not as important when I have this baby. Most of the time, I am spending my money on the baby. The [first born] in the Eastern Cape, I am not taking care of him ever. Since I gave birth I haven’t sent money at all. (M 40)

Pain related to the death of a loved one compounded the lack of support for women, especially in the perinatal period when this was more urgently needed than at other times. Two quotations demonstrate the effect of this loss on the women:

[My friend’s] sister died . . . So [she] was not working and had kids. She was helped by her sister. Her children were fed by her sister, but then her sister died. While she used to be the bread winner. She was never right afterwards. (M 75)

It was not nice and then my brother had died. Then everything was upside down. Nothing was going right . . . It was the first thing to disturb my life. Then my mother died last year December. (PW 8)

There are multiple examples of the effect of poverty and unemployment on mood state in the interviews. One woman said that depression is caused “because a person can need money, or need work, or even food to eat” (ND 5), and another said:

It is caused by not respecting other people and poverty. Having too much load on my shoulders . . . If I could get a job I’d be fine. [It is] the one thing that is discouraging me the most. I am sitting, I don’t have money. (M 60)

Thinking too much, an idiom for depression, was also identified as a cause of depression. Stress, another idiom in turn, was also identified as a cause of depression. This demonstrates the cyclical connection between the descriptions, symptoms, and causes of depression. The participants identified external stressors as the cause of the stress/worry/depression, which brought about the internal stress of thinking too much/depression.

Notably, it was mostly the health workers who attributed depression to stress. This may be related to the fact that they were not experiencing the stress themselves, but were rather interpreting the cause through the multitude of factors that they witnessed women having to cope with on a daily basis. The health workers said that depression “is caused by stress” (CHW 2), “when a person has too much going on” (HIV Counsellor 1), and that depression “is an illness . . . from too much stress. For example around pregnancy, and with regarding being a mother, and worrying about money, and miscarriages etcetera. So stress causes depression” (HIV Counsellor 2). A midwife also related stress and depression thus: “You are stressed and then you think too much and then you get depression and then you don’t see the way things are; you are confused. At that time you are not orientated” (MW 5).

As shown in this discussion, stress (and thinking too much) can be brought about by the presence of extreme stress and daily ‘life stressors’ for these women. Traumatic situations, multiple risk factors, and a lack of support for the pregnant mothers in this township greatly increase the likelihood of depression amongst these women. Causes of depression (or stress) in this respect can be explored using Aneshensel’s ‘Structural origins of mental health disparities’ (Aneshensel, 2009). These origins involve:

Differential exposure to stressors: This is identified in the interviews and literature through poor and crowded living conditions (housing and sanitation), unemployment, poor education, gender-based violence, and high HIV rates.

The risk factors that the women face in this community in South Africa are consistent with many of those identified in international studies, such as low income levels, poverty, partner abuse, low education levels, poor housing and living conditions, poor health care, unwanted pregnancies, and HIV positive status (Brandt, 2009; Coast, Leone, Hirose, & Jones, 2012; Dunkle et al., 2004; Lund, Breen, et al., 2010; Patel et al., 2010; Rochat et al., 2011). The current study provides further evidence to corroborate already documented associations between depression and stressful life events (Aneshensel, 2009; Patel et al., 2010).

In summary, the local descriptions and causes of depression in this township setting appear to be highly interconnected, and they draw attention to the impact of multiple risk factors and social determinants on the mental health of women in the study. The risk factors identified are correspondingly highly conducive to stress, which is the most commonly used phrase to explain depression in the study. A task-shared basic counselling intervention could provide these women with a platform for talking about and reflecting on these feelings. The understanding gained from the analysis of women’s descriptions and experiences of depression provides a clear framework for both psychotherapeutic techniques and terminology to be included in such an intervention to meet local needs.

Limitations of the study

The depressed women who were interviewed were diagnosed using the MINI 6.0 and the EPDS, and thus were likely to have the symptoms of depression identified by the scales. However, we attempted to control for this bias by interviewing women who were not diagnosed as depressed on the same scales, as well as by getting perspectives from health care providers in the area. In addition, the terminology used in the descriptions of symptoms was not the same as that used in the assessment tools, suggesting that the women were describing their own thoughts and feelings and not just repeating the terms in the EPDS or MINI.

The analysis focused specifically on discovering themes related to symptoms and causes of depression, and a distinction was not made between antenatal and postnatal women’s descriptions, or between unintended and unwanted pregnancies. Also, because our focus was on depression, other “persecutory” symptoms that the women may have experienced, may not have been reported, for example, paranoia, phobia, panic states, and anger.