Standard depression screening could be missing key symptoms in South Asian patients, review finds

Published in The British Journal of Psychiatry, the systematic scoping review examined studies spanning decades of research across the UK, Canada, the USA and Australia. It found that South Asian diaspora populations experience depression in ways that differ from both White majority populations and from the symptoms listed in the ICD-11 – the international classification system that underpins widely used screening tools such as the Patient Health Questionnaire-9 (PHQ-9). 

The review is part of the NIHR-funded PAPER Study (Prescribing Antidepressants in Primary care: Ethnic inequalities in treatment), which is investigating symptoms and treatment of depression among South Asian populations in the UK. 

Among the review’s key findings, physical pain – including headaches, body aches and neck pain – was reported in as many studies as anhedonia (a total loss of interest in previously enjoyed activities), one of the two cardinal symptoms clinicians are trained to look for. Sleep disturbances were equally prevalent. Neither physical pain nor heart-related symptoms are captured by ICD-11 diagnostic criteria. 

Across multiple studies, participants described their depression using language relating to the heart. Punjabi, Urdu and Hindi speakers used phrases such as “sinking heart” and “dead heart” – expressions that sit between metaphor and physical sensation.  

A number of participants reported these heart-related experiences as physically felt, describing sensations of squeezing, pressure and breathlessness. 

The review also found that repetitive negative thinking – described by participants as thoughts going around and around, or replaying events “like a film” – was widely reported across qualitative and quantitative studies. This symptom is not listed in ICD-11 diagnostic criteria for depression, though it may be linked to trauma, including the trauma of migration and intergenerational experience. 

South Asian groups are the largest ethnic minority population in the UK. Previous research has found that Pakistani women in the UK consult their GP more frequently than White counterparts but are less likely to receive treatment for depression. The review’s authors argue that differences in how depression presents – and the limitations of screening tools built on criteria that may not reflect those differences – could be contributing to this treatment gap. 

The review recommends that GPs assessing South Asian patients consider non-ICD-11 somatic symptoms, particularly physical pain, as potential indicators of depression. It also calls for clinician training in culturally specific presentations and for diagnosis informed by cultural humility rather than rigid adherence to standardised criteria. 

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Notes to editors 

• The full paper is available at: https://doi.org/10.1192/bjp.2026.10539 
• The research was funded by the National Institute for Health and Care Research (NIHR), grant number 155654.