Physical pain, heart-related sensations and repetitive negative thoughts are among the most commonly reported symptoms of depression in South Asian communities, yet none of them are included in the diagnostic criteria used to screen for depression in the UK, according to new research led by the University of Surrey.
Published in British Journal of Psychiatrya systematic scoping review examined decades of research across the United Kingdom, Canada, the United States, and Australia. They found that South Asian diaspora populations experience depression differently than the majority white population and with symptoms listed in ICD-11, the international classification system that is the basis for widely used screening tools such as the Patient Health Questionnaire-9 (PHQ-9).
This review is part of the NIHR-funded PAPER study (Prescribing Antidepressants in Primary Care: Ethnic Inequalities in Treatment), investigating symptoms and treatment of depression in South Asian populations in the UK.
Among the key findings of this review, physical pain, including headaches, body aches, and neck pain, was reported in as many studies as anhedonia (complete loss of interest in previously enjoyed activities), one of the two main symptoms that clinicians are trained to look out for. Sleep disorders were similarly prevalent. Neither physical pain nor heart-related symptoms are captured by ICD-11 diagnostic criteria.
In multiple studies, participants used heart-related words to describe depression. Punjabi, Urdu, and Hindi speakers used expressions that fell somewhere between metaphor and physical sensation, such as “sinking heart” and “dead heart.”
Many participants reported these heart-related experiences as felt physically, describing sensations of pressure, squeezing, and shortness of breath.
The review also found that repetitive negative thinking (described by participants as spinning their thoughts or replaying events “movie-like”) was widely reported across qualitative and quantitative studies. Although this symptom is not listed in the ICD-11 diagnostic criteria for depression, it may be related to trauma, such as trauma from migration or intergenerational experiences.
Dr Rose Rickford, lead author of the review from the Department of Psychology at the University of Surrey, said:
“When someone visits their GP with a headache, persistent pain, or heart-related sensations, depression may not be the first consideration. However, our research shows that these are among the symptoms of depression commonly reported in South Asian communities. The screening tools used in primary care don’t ask about them, which means some patients may fall into the gap between what they’re experiencing and what the system is designed to detect.
South Asian groups make up the largest ethnic minority population in the UK. Previous research has found that Pakistani women living in the UK consult their GP more often than white women, but are less likely to receive treatment for depression. The authors of this review argue that differences in the presentation of depression and the limitations of screening tools built on criteria that may not reflect these differences may contribute to this treatment disparity.
Dr Lydia Poole, senior author and principal investigator of the PAPER Study from Queen Mary University of London, said:
“Accurate diagnosis depends on asking the right questions. If the tools we use in primary care are built on a narrow set of symptoms, we risk systematically under-serving patients whose experience of depression does not fit that template. This review strengthens the case for culturally informed clinical practice and training to help general practitioners recognize how depression presents.”
This review recommends that general practitioners assessing patients in South Asia consider physical symptoms other than ICD-11, especially physical pain, as potential indicators of depression. It also requires training of clinicians in culturally specific presentations and diagnosis based on cultural humility rather than strict adherence to standardized criteria.
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Reference magazines:
Rickford, R. others. (2026) Understanding the heterogeneity of depressive symptoms among ethnic minorities in South Asia: A systematic scoping review. British Journal of Psychiatry. DOI:10.1192/bjp.2026.10539. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/ Understanding-depression-symptom-heterogeneity-in-south-asian-minority-groups-systematic-scoping-review/5EDDE3C95D9F31191775DB3256D47F9C
