Attitudes toward depression among a sample of Muslim adolescents in

Int J Adolesc Med Health 2011;23(3):293–301 © 2011 by Walter de Gruyter • Berlin • Boston. DOI 10.1515/IJAMH.2011.058

Attitudes toward depression among a sample of Muslim adolescents in the Midwestern United States

Zubeir Haroun1, Ali Bokhari1,2, Monika Marko-Holguin1, Kelsey Blomeke1,3, Ajay Goenka1,a, Joshua Fogel4 and Benjamin W. Van Voorhees1,5,* 1

Section of General Internal Medicine, The University of Chicago, Chicago, IL, USA 2 The Chicago Medical School at Rosalind University of Medicine and Science, Chicago, IL, USA 3 The Divinity School, The University of Chicago, Chicago, IL, USA 4 Department of Finance and Business Management, Brooklyn College of the City University of New York, Brooklyn, NY, USA 5 Section of Child and Adolescent Psychiatry, Department of Psychiatry, The University of Chicago, Chicago, IL, USA

Abstract Background: Little is known about how Muslim youth in non-Muslim countries perceive depression and its treatment and prevention. Objective: We investigated the barriers and suggest treatment models for depressive disorders in Muslim adolescents and young adults residing in the United States. Methods: We conducted a thorough literature review to identify previous study on the beliefs of American Muslim adolescents about depression and its treatment. We identified the gaps and developed a survey to ascertain this information from American Muslim adolescents. Results: The survey was administered to a convenience sample of 125 Muslim subjects (60.0% males) aged 14–21 years. The sample was ethnically diverse with Pakistani (44.8%) encompassing the majority of the sample. Most responders believed that recitation from the Koran relieves mental distress. Multiple linear regression analysis revealed that those who reported strong emotional support from parents or a greater acceptance of taking depression medication prescribed from a physician were more likely to accept a physician’s diagnosis, whereas believing in prayer to heal depression was associated with a lower likelihood of the same. Youth were accepting of Internet and preventive approaches. a

Independent study student. *Corresponding author: Benjamin W. Van Voorhees, MD, MPH, The University of Chicago, Section of General Internal Medicine, 5841 S. Maryland Ave., MC 2007, Chicago, IL 60637, USA Phone: +1-773-702-3835, Fax: +1-773-834-2238, E-mail: [email protected] Submitted October 5, 2010. Revised December 3, 2010. Accepted December 17, 2010.

Conclusion: Planning of culturally sensitive mental health services is useful to accommodate the needs of Muslim youth served by primary care physicians and mental health practitioners in the United States. Muslim adolescents tend to be more traditional with family, social, and religious values. This value system plays an important role in their likelihood of seeking and accepting professional help for depression. Keywords: adolescents; depressive disorder; Internet; intervention; Muslim; prevention.

Introduction Depression in everyday life is an experience that reaches across cultures and time. It can range from mild dejection to profound despair. Depression becomes an illness when individuals cannot rid themselves of a state of deep sadness that paralyzes them (1). Depression in adolescents is a major public health problem. By the age of 18 years, approximately 20% of American adolescents experience a depressive episode (2). Depression in youth is associated with poor social functioning, poor school performance, and increased risk for drug and alcohol use, as well as a higher risk of nicotine dependence (3). Depression is strongly associated with increased risk of suicide, which is the third leading cause of death among adolescents aged between 15 and 24 years (4). Although there are efficacious treatments currently available for adolescent depression (5, 6), data show that few youth in need receive care (7) and care received lacks the efficacy found in clinical trials (8). Although the prevalence of depression is similar among ethnic groups, differences exist in both diagnosis and treatment rates (9). Ethnic minorities are less likely to receive depression treatment (10–12), less likely to use mental health services (1, 13), and could have longer delays before initiating depression treatment than whites (14, 15). Although stigma can affect a person’s willingness to seek care or to accept and adhere to treatment for depression (16), research on ethnic variations concerning this issue is limited (15). Religious beliefs have been found to significantly impact mental health and help-seeking behavior in both Asian (17) and Orthodox Jewish (18) communities (19), as found in several meta-analysis studies and systematic reviews (13). There is a growing body of evidence on religiously based beliefs and practices in different groups, which can complement or conflict with those of orthodox medicine and psychiatry (20–22). These beliefs and practices include: 1) depression could be believed to be impossible in the truly religious individual, and thus denied if it occurs; 2) some religious sources could state that

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the devout individual should not consult a psychotherapist or similar professional because this could lead the person to irreligious ideas and practices; and 3) patients could use a range of religiously endorsed coping strategies and beliefs together with orthodox psychiatric or similar help without consulting professional helpers, for fear of being misunderstood or branded as superstitious (13). Knowledge of these beliefs could be used to improve the quality and outcomes of mental health treatments among groups with religion-based beliefs about mental health (23, 24). Muslim youth living outside of majority Muslim countries can be influenced by a variety of beliefs originating in Islam and their native cultures. Muslims believe that the family is responsible for the greatness or deviance of family members (25). Discussing personal problems with someone outside of the kinship networks brings a deep sense of shame for the discusser (10). Many Muslim families also do not agree with mental health practitioners about mental illness, believing instead that mental illness is a state of arrested or incomplete development of the mind. Many believe mental illness is caused by supernatural forces such as spirit possession, jinni, black magic, or testing by Allah as punishment for one’s sins (11). Additionally, in Muslim countries, an imam takes the role of the mental health counselor, but this role is not recognized in the United States unless the imam has a specialized license or a degree. Owing to high birth rates and continued migration to the United States, Muslim populations are likely to remain a substantial and increasing minority (26, 27). Knowledge about the barriers to mental health treatment that Muslim youth encounter is very limited. Likewise, little is known about Muslim youths’ attitudes and preferences for depression treatment. To better understand the beliefs and attitudes held by Muslim youth towards depression interventions, we administered a survey using a convenience sample of 125 Muslim adolescents at three different mosques in the Midwest of the United States. The questionnaire was designed to assess attitudes of American Muslim adolescents in six key areas related to depression: 1) religious and traditional cultural beliefs; 2) secular beliefs about depression; 3) secular beliefs about social norms and stigma; 4) beliefs and attitudes about the physician and the physician relationship; 5) beliefs about the usage of computer and Internet; and 6) additional miscellaneous beliefs about dealing with depression. In this study, we expect Muslim youth to manifest both traditional religious and cultural beliefs towards depression diagnosis and treatment (Hypothesis 1). Similarly, we also anticipate that Muslim youths’ traditional beliefs would be associated with a lower tendency to accept a physician’s diagnosis and treatment (Hypothesis 2).

Saint Paul) (n=1). The sample included 60% (n=75) males and 40% (n=50) females aged 14–21 years. The sample was ethnically diverse with Pakistani encompassing the majority of the sample (44.80%, n=56), followed by Bangladeshi (32.80%, n=41), and other/not known (22.40%, n=28). The University of Chicago Institutional Review Board approved all protocols.

Method of recruitment A Muslim, non-American-born medical student and a graduate student from the University of Chicago Divinity School who had studied the Muslim faith recruited all the participants in this study. The recruiters obtained official permissions from the mosque officials to allow them contact with adolescent participants in the mosques. As a second step, the recruiters approached the adolescent participants while attending prayers, informed them of the focus of the study, assured them complete confidentiality, and asked them for permission to participate in the study. Finally, the recruiters obtained consent forms from all the adolescent participants (or parents if the adolescents were under 18 years of age) who agreed to complete the survey. Assent from minors was obtained when applicable. Participants were placed in one room in their mosque equidistant from one another, and with their parents present but not next to their adolescents. The survey administrator asked the adolescents to read and complete the survey to the best of their abilities. Once completed, the survey administrator collected the surveys and thanked the adolescents and their parents for participating in the study. No participant incentive was offered for completing the questionnaires.

Survey This paper focuses on the administered survey portion containing 39 attitude/belief items and demographic variables (age, gender, education, employment status, marital status, and parental origin; Table 1). To develop the survey, we first conducted a literature review, which identified 25 relevant publications concerning Muslim attitudes towards mental health interventions. Subsequently, we consulted with healthcare professionals in Pakistan and the United States to identify key thematic areas. Items were constructed to address these thematic areas. As a preliminary step, all possible items were shown to Muslim adolescents who represented the targeted population for the study. Their comments and feedback were used to improve the survey. The 39 items were designed to assess participants’ attitudes and beliefs about a variety of emotional and behavioral health issues or factors. The responses were rated on a 5-point Likert scale (1=strongly disagree, 2=disagree, 3=neither agree nor disagree, 4=agree, and 5=strongly agree). The attitudes/beliefs were categorized into six main domains: 1) religious and traditional cultural beliefs about depression; 2) secular beliefs about depression and depression treatment; 3) secular beliefs about social norms and stigma; 4) beliefs and attitudes about the physician and the physician relationship; 5) beliefs about computer and Internet use as a way of communicating with doctors about one’s depression/sadness; and 6) additional miscellaneous beliefs about dealing with depression. Each domain is described in Table 1.

Outcome measure

Methods Study design and population This study is based on a survey administered to a convenience sample of adolescents (n=125) who attended prayers and social gatherings in three different mosques in Chicago, Streamwood, IL (a suburb of Chicago) (n=2), and Brooklyn Park, MN (a suburb of Minneapolis/

We assessed the likelihood of accepting a doctor ’s diagnosis of depression by recording adolescents’ responses to the statement: “If my doctor told me I had depression/sadness, I would accept it”. The responses were rated on a 5-point Likert type scale (1=strongly disagree, 2=disagree, 3=neither agree nor disagree, 4=agree, and 5=strongly agree), where a higher score indicates a higher probability of accepting a physician’s diagnosis of depression.


Haroun et al.: Muslim adolescents in the United States

Table 1

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Independent variables predicting the outcome.

Religious and traditional cultural beliefs about depression Summary Muslims are more likely than other Americans to incorporate spirituality into their dealings with mental illnesses. Many Muslim adolescents even seek blessings and spiritual guidance from their religious leaders before embarking upon a formal consultation with a trained physician. Prayer is understood by some Muslims to be the only type of treatment modality for mental distress and worries. Statements concerning religious and cultural beliefs included: My parents would prefer a Muslim doctor for routine medical care I have good parental support during stressful situations I have close parental supervision at home My depression/sadness would be taken care of by my parents adequately My parents would recommend that I discuss my depression with my doctor My parents would prefer a female doctor for female members of my family Prayer alone can help to treat depression/sadness Being very diligent in prayer could cure depression Evil spirits cause depression Depression/sadness represents a person’s moral weakness Depression/sadness is the outcome of sinful acts committed by a person Recitation of the Holy Koran relieves mental distresses such as depression Secular beliefs about depression and depression treatment Summary Attitudes towards depressive disorders and their treatment are closely linked to beliefs about sin and suffering in many Muslim societies. Some Muslims attribute depressive disorders to some type of separation from the divine or even a possession by evil (28). The beliefs of both patients and of the mental health professionals treating them towards the treatment of mental illnesses all have variable bearing in a patient’s comfort to seek psychiatric consultation. Statements that assess such attitudes included: Depression is inherited; I can’t help it no matter what Biological changes in the brain cause depression/sadness Participating in youth/religious programs is the first thing to do to treat depression Counseling is as effective as medication in treating depression Meeting with a school counselor to talk about my feelings and learning copings skills might help my mood I would prefer to discuss what I can do to treat depression/sadness with my spiritual mentor I can change my depression/sadness by changing my behavior Secular beliefs about social norms Summary Seeking help and openly discussing problems can be uncomfortable for many adolescents, but especially so for those who are influenced by cultural values that view mental illnesses in non-medical terms, such as American Muslim adolescents. Despite having access to healthcare and primary care providers, young American Muslims might be reluctant to seek assistance for depressive disorder because of a perceived stigma. Statements assessing attitudes about depression stigma included: If I had depression, my family would be disappointed in me I would be embarrassed if my friends knew that I was getting professional help for an emotional problem Sometimes I feel like I have to hide my down mood from others Counseling brings too many bad feelings such as anger or sadness The idea of taking medication for depression/sadness scares me The idea of face-to-face counseling for depression/sadness scares me Beliefs and attitudes about the physician and the physician relationship Summary Communication problems and repeated negative experiences caused by cultural misunderstandings could reinforce American Muslim adolescents’ sense of distrust towards their primary care doctors. Medical professionals, including family physicians, have been found to hold stigmatizing attitudes towards people suffering from mental illnesses (28, 29) further hindering help-seeking behavior by American Muslim adolescents. Furthermore, parents often prefer to choose a treatment provider based on the gender of their children and often have their own reservations about therapists. Items we identified to assess such beliefs included: I trust my doctor I feel comfortable talking to doctors about my depression/sadness I find my doctor an empathic listener to my emotional problems I believe that my doctor has adequate cultural competency to address my depression My depression/sadness is difficult to diagnose by my doctor Time is a big limitation in expressing my emotional health issues in the doctor’s clinic My doctor does not follow-up with my depressed/sad mood If my doctor told me I had depression, I would accept that [used as outcome variable] I would accept medicine that my doctor prescribed to treat my depression I shall discuss with my doctor what I can do to prevent myself from developing clinical depression


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(Table 1 continued) Beliefs about computer and Internet use as a way of communicating with doctors about one’s depression/sadness Summary As one of the most valuable learning tools of the 21st century, the Internet has captured the attention of health practitioners and educators using the Internet in interventions, quantitative and qualitative research (30). One advantage that the Internet has been shown to have over the traditional methods of data collection is that of reaching otherwise hard-to-reach populations, such as Muslim adolescents (30). There are no present data assessing Muslim adolescents’ attitudes and beliefs towards an Internet-based depression intervention program. Statements measuring such attitudes and beliefs include: Starting an exercise program with 30 min of aerobic activity for 6 weeks on my own will help treat my depression I would take a health class to learn about feelings and coping skills with other kids in my school/college An Internet-based learning program can help to teach me coping skills The idea of using a computer to inform my doctor about my feelings and daily activities appeals to me

Statistical analysis We calculated descriptive statistics for each of the 38 attitudes and beliefs (not including the 39th items which was the outcome measure), which we grouped in blocks based on the rationales presented above. Linear regression analysis was employed to calculate the likelihood of accepting a doctor ’s diagnosis for depression based on a diverse number of variables. The analysis included three models. Model 1 was a univariate analysis. Model 2 adjusted for age, ethnicity (measured by parental origin), and gender. Model 3 simultaneously adjusted for all items that were significant or approached significance for the outcome (p