Mackin et al (Reference Mackin, Targum and Kalali2006) make a laudable attempt to evaluate cultural differences in the perception of psychiatric symptoms. Unfortunately, aspects of their methodology make it difficult to draw definitive conclusions. I will leave it for the statisticians to decide whether the sample sizes for the English and Indian groups (n=20 and 24 respectively) are large enough to allow the findings to be generalised. Given the authors’ concerns about the influence of confounding variables on the findings, however, the disparity between the size of these groups and that of the American clinicians (n=82) is striking. A demographic breakdown of the various groups might have been useful in allaying these concerns.

A further source of potential bias is introduced by asking the participants to complete rating scales for only two patients of a single nationality. There is a risk that cultural differences between nationalities might influence attitudes as to what can be considered ‘normal’ behaviour for people of other nationalities. Certainly, an English psychiatrist whose expectations of a ‘typical’ American have been shaped by stereotyped media images might not be expected to register certain aspects of the patients’ behaviour as pathological on the Young Mania Rating Scale. The threshold for recognition of manic symptoms might well have been different had they been asked to rate their own compatriots. More revealing conclusions could perhaps have been drawn had all participants been asked to complete rating scales for patients of a variety of nationalities, including their own.

The authors make a compelling argument about the potential consequences of cultural differences in the recognition of symptoms of mental illness, and have provided a useful starting point for future discussion and research. Unfortunately, they fall short of proving these differences exist with their preliminary data.