When patients describe distress differently, clinicians may need to ask different questions
Commonly used depression screening tools may fail to identify some South Asian patients experiencing depression because they do not capture several symptoms that are frequently reported within these communities, according to a new review published in The British Journal of Psychiatry. The findings raise questions about whether existing diagnostic approaches adequately reflect the diverse ways depression can present across different cultural groups.
Led by researchers from the University of Surrey, the systematic scoping review examined decades of research conducted in Australia, the United Kingdom, Canada, and the United States. The study focused on South Asian diaspora populations and found that experiences of depression often differed from both White majority populations and the symptom profiles reflected in the ICD-11, the international classification system underpinning screening tools such as the Patient Health Questionnaire-9 (PHQ-9).
The review forms part of the PAPER Study (Prescribing Antidepressants in Primary Care: Ethnic Inequalities in Treatment), an initiative investigating depression symptoms and treatment experiences among South Asian populations. Researchers sought to better understand whether current diagnostic frameworks adequately capture culturally diverse presentations of depression.
Among the most significant findings was the prominence of physical pain as a feature of depression. Symptoms including headaches, body aches and neck pain were reported as frequently as anhedonia, one of the two core symptoms clinicians are trained to assess when screening for depression. Sleep disturbances were also commonly reported. However, neither physical pain nor heart-related symptoms are included within ICD-11 diagnostic criteria for depressive disorders.
Researchers found that many participants described their experiences of depression using language centred on the heart. Across multiple studies, Punjabi, Urdu and Hindi speakers used terms such as "sinking heart" and "dead heart". These descriptions appeared to occupy a space between metaphorical language and physical sensation, reflecting culturally specific ways of expressing emotional distress.
Some participants described these heart-related experiences as tangible physical sensations, including squeezing, pressure and breathlessness. According to the review's authors, these symptoms may not immediately be recognised as potential indicators of depression within conventional diagnostic frameworks.
The study also identified repetitive negative thinking as a common feature of depression among South Asian populations. Participants frequently described thoughts that repeatedly cycled through their minds or experiences that replayed "like a film". Although widely reported across both qualitative and quantitative studies, this symptom is not included in ICD-11 diagnostic criteria for depression. Researchers noted that these thought patterns may be related to personal trauma, migration experiences and intergenerational influences.
"If someone walks into their GP surgery with headaches, persistent pain, or sensations relating to the heart, depression may not be the first thing considered. But our review shows these are among the commonly reported symptoms of depression in South Asian communities. The screening tools used in primary care don't ask about them, and that means some patients could be falling through the gap between what they experience and what the system is designed to detect," Dr Rose Rickford, Research Fellow in Qualitative Methods, said.
The findings may have implications for addressing disparities in mental health diagnosis and treatment. Previous research cited by the authors found that Pakistani women in the UK consult general practitioners more frequently than White counterparts yet are less likely to receive treatment for depression. The researchers suggest that differences in symptom presentation, combined with the limitations of existing screening tools, may contribute to this treatment gap.
The authors argue that diagnostic systems developed around a narrow symptom profile may overlook clinically significant experiences of depression when those experiences are expressed differently across cultural groups. As a result, some patients may be less likely to receive timely assessment, diagnosis and treatment.
"Accurate diagnosis depends on asking the right questions. If the tools we use in primary care are built on a narrow set of symptoms, they risk systematically under-serving patients whose experience of depression doesn't fit that template. This review strengthens the case for culturally informed clinical practice and for training that equips GPs to recognise the full range of ways depression can present," Dr Lydia Poole, senior author and principal investigator of the PAPER Study from Queen Mary University of London, said.
The review recommends that clinicians assessing South Asian patients consider non-ICD-11 somatic symptoms, particularly physical pain, as possible indicators of depression. It also calls for greater awareness of culturally specific symptom presentations and for diagnostic approaches informed by cultural humility rather than strict reliance on standardised criteria alone.
For clinicians working in primary care and mental health settings, the findings highlight the importance of exploring a broader range of symptoms when assessing patients from diverse cultural backgrounds. The authors suggest that a more culturally informed approach to depression screening may help improve recognition of mental health conditions and reduce inequities in diagnosis and treatment.