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.

Dr Rose Rickford, lead author of the review from the School of Psychology at the University of Surrey, said:

“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 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.”

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.

Dr Lydia Poole, senior author and principal investigator of the PAPER Study ffrom 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, 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.”