Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology
Open accessAbstract
BACKGROUND: Burgeoning global mental health endeavors have renewed debates about cultural applicability of psychiatric categories. This study's goal is to review strengths and limitations of literature comparing psychiatric categories with cultural concepts of distress (CCD) such as cultural syndromes, culture-bound syndromes, and idioms of distress. METHODS: The Systematic Assessment of Quality in Observational Research (SAQOR) was adapted based on cultural psychiatry principles to develop a Cultural Psychiatry Epidemiology version (SAQOR-CPE), which was used to rate quality of quantitative studies comparing CCD and psychiatric categories. A meta-analysis was performed for each psychiatric category. RESULTS: Forty-five studies met inclusion criteria, with 18 782 unique participants. Primary objectives of the studies included comparing CCD and psychiatric disorders (51%), assessing risk factors for CCD (18%) and instrument validation (16%). Only 27% of studies met SAQOR-CPE criteria for medium quality, with the remainder low or very low quality. Only 29% of studies employed representative samples, 53% used validated outcome measures, 44% included function assessments and 44% controlled for confounding. Meta-analyses for anxiety, depression, PTSD and somatization revealed high heterogeneity (I(2) > 75%). Only general psychological distress had low heterogeneity (I(2) = 8%) with a summary effect odds ratio of 5.39 (95% CI 4.71-6.17). Associations between CCD and psychiatric disorders were influenced by methodological issues, such as validation designs (β = 16.27, 95%CI 12.75-19.79) and use of CCD multi-item checklists (β = 6.10, 95%CI 1.89-10.31). Higher quality studies demonstrated weaker associations of CCD and psychiatric disorders. CONCLUSIONS: Cultural concepts of distress are not inherently unamenable to epidemiological study. However, poor study quality impedes conceptual advancement and service application. With improved study design and reporting using guidelines such as the SAQOR-CPE, CCD research can enhance detection of mental health problems, reduce cultural biases in diagnostic criteria and increase cultural salience of intervention trial outcomes.
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There is a paucity of evidence concerning the effectiveness of interventions for specific cultural idioms or concepts of distress.
“Furthermore, there is a paucity of evidence concerning the effectiveness of (a) interventions for specific cultural idioms or concepts of distress [16] and (b) existing supportive cultural practices to manage stress-related conditions, such as yoga for stress management, or cultural mourning practices for bereavement.”
From World Health Organization guidelines for management of acute stress, PTSD, and bereavement: key challenges on the road ahead (2014) · cites this paper as [16]
One of the major shortcomings of the literature on cultural concepts of distress is the failure to include cultural concepts of distress in treatment outcome studies.
“However, one of the major shortcomings of this literature concerned the failure to include cultural concepts of distress in treatment outcome studies [16].”
From World Health Organization guidelines for management of acute stress, PTSD, and bereavement: key challenges on the road ahead (2014) · cites this paper as [16]
A recent meta-analysis found a particularly high level of overlap between locally defined cultural concepts of distress and a diagnosis of PTSD.
“A recent meta-analysis found a particularly high level of overlap between locally defined cultural concepts of distress and a diagnosis of PTSD.”
From World Health Organization guidelines for management of acute stress, PTSD, and bereavement: key challenges on the road ahead (2014) · cites this paper as [16]
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Cultural Adaptation of Scalable Psychological Interventions: A New Conceptual Framework
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“recognized representation of depression both in Uganda and in other places around the world (42-46).”
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- Authors
- Kohrt, B. A., Rasmussen, A., Kaiser, B. N., Haroz, E. E., Maharjan, S. M., Mutamba, B. B., de Jong, J. T., & Hinton, D. E.
- Affiliations
- Johns Hopkins University (US)
- Venue
- International Journal of Epidemiology
- Publisher
- Oxford University Press (OUP)
- Published
- 2013-12-23
- Volume
- 43
- Issue
- 2
- Pages
- 365-406
- ISSN
- 0300-5771 (ISSN-L)
- 1464-3685
- PMC
- PMC3997373
- OpenAlex
- W2143077576
- Cited by
- 355
- References
- 141
- Citations by year
- 2026: 46 · 2025: 33 · 2024: 34 · 2023: 31 · 2022: 44 · 2021: 31 · 2020: 30 · 2019: 25 · 2018: 23 · 2017: 18 · 2016: 12 · 2015: 11 · 2014: 14 · 2012: 2
- FWCI
- 1.62
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- International Journal of Epidemiology (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- UvA-DARE (University of Amsterdam) (publishedVersion)
- UvA-DARE (University of Amsterdam) (submittedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Funders
- National Institute of Mental Health (U19MH095687, T32MH014592)
- Topics
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Social Sciences › Sociology and Political Science › Cultural Competency in Health Care
- Keywords
- cultural concepts of distress, mental illness, cultural syndromes, culture-bound syndromes, idioms of distress, cross-cultural psychiatry, study quality assessment, diagnostic validity, anxiety, depression, post-traumatic stress disorder, somatization
- MeSH terms
- Anxiety Disorders, Mental Disorders, Culture, Epidemiologic Methods, Humans, Mental Health, Global Health
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
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