Cultural concepts of distress and psychiatricdisorders: literature review and researchrecommendations for global mentalhealth epidemiologyBrandon A Kohrt,1* Andrew Rasmussen,2 Bonnie N Kaiser,3 Emily E Haroz,4 Sujen M Maharjan,5

Byamah B Mutamba,6 Joop TVM de Jong7 and Devon E Hinton8

1Duke Global Health Institute, Department of Psychiatry and Behavioral Sciences, Durham, NC, USA, 2Department of Psychology,Fordham University, New York, USA, 3Department of Anthropology, Department of Epidemiology, Emory University, Atlanta, GA,USA, 4Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA,5Department of Psychology, Tribhuvan University, Kirtipur, Nepal, 6Butabika National Referral Mental and Teaching Hospital,Kampala, Uganda, 7AISSR, University of Amsterdam, The Netherlands and 8Massachusetts General Hospital and Harvard MedicalSchool, Boston, MA, USA

*Corresponding author. Duke Global Health Institute, Trent Hall #213, 310 Trent Drive, Duke University, Durham, NC 27710, USA.E-mail: brandon.kohrt@duke.edu

Accepted 4 October 2013

Background Burgeoning global mental health endeavors have renewed debatesabout cultural applicability of psychiatric categories. This study’s goalis to review strengths and limitations of literature comparing psychia-tric categories with cultural concepts of distress (CCD) such as culturalsyndromes, culture-bound syndromes, and idioms of distress.

Methods The Systematic Assessment of Quality in Observational Research(SAQOR) was adapted based on cultural psychiatry principles todevelop a Cultural Psychiatry Epidemiology version (SAQOR-CPE),which was used to rate quality of quantitative studies comparingCCD and psychiatric categories. A meta-analysis was performed foreach psychiatric category.

Results Forty-five studies met inclusion criteria, with 18 782 unique partici-pants. Primary objectives of the studies included comparing CCDand psychiatric disorders (51%), assessing risk factors for CCD(18%) and instrument validation (16%). Only 27% of studies metSAQOR-CPE criteria for medium quality, with the remainder low orvery low quality. Only 29% of studies employed representative sam-ples, 53% used validated outcome measures, 44% included functionassessments and 44% controlled for confounding. Meta-analyses foranxiety, depression, PTSD and somatization revealed high hetero-geneity (I2475%). Only general psychological distress had low het-erogeneity (I2

¼ 8%) with a summary effect odds ratio of 5.39 (95%CI 4.71-6.17). Associations between CCD and psychiatric disorderswere influenced by methodological issues, such as validation de-signs (b¼ 16.27, 95%CI 12.75-19.79) and use of CCD multi-itemchecklists (b¼ 6.10, 95%CI 1.89-10.31). Higher quality studiesdemonstrated weaker associations of CCD and psychiatric disorders.

Conclusions Cultural concepts of distress are not inherently unamenable toepidemiological study. However, poor study quality impedes

Published by Oxford University Press on behalf of the International Epidemiological Association

� The Author 2013; all rights reserved.

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conceptual advancement and service application. With improvedstudy design and reporting using guidelines such as the SAQOR-CPE, CCD research can enhance detection of mental healthproblems, reduce cultural biases in diagnostic criteria and increasecultural salience of intervention trial outcomes.

Keywords Culture, developing countries, epidemiologic methods, global mentalhealth, mental disorders, meta-analysis

IntroductionIn 1904 Emile Kraepelin initiated the field of compara-tive psychiatry (vergleichende Psychiatrie) through in-vestigation of dementia praecox in Java, and he laterdocumented psychiatric presentations among NativeAmericans, African Americans and Latin Americans.1

A century later, active debate continues regarding therole of culture in mental disorders and the cross-cultural applicability of biomedical psychiatric diag-noses.2 Methodological limitations in cross-culturalpsychiatric epidemiology have been cited as a primaryreason why cultural differences have not translated intore-evaluating psychiatric concepts and treatment prac-tices.3,4 For example, cultural differences in schizophre-nia outcomes, which have been identified in threesuccessive studies,5–10 have done little to alter concep-tualizations or treatment of the disorder, and this is inpart due to methodological problems in the cross-na-tional studies.3,11–13 These studies, along with WorldHealth Organization (WHO) World Mental HealthSurveys,14 are typified by application of Western cultur-ally developed biomedical psychiatric diagnoses thatlack inclusion of cultural concepts of distress (CCD).To date there have not been large-scale cross-nationalglobal mental health epidemiology studies incorporat-ing CCD. To address this gap in the research, a review ofthe literature on CCD was undertaken to examine thetypes of studies conducted, the methodologicalapproaches and the association of CCD with psychiatricdisorders. The goal is to identify best practices in cross-cultural psychiatric epidemiology to improve researchon CCD and encourage application to mental healthservices.

The term ‘cultural concept of distress’ is a new add-ition to the Diagnostic and Statistical Manual ofMental Disorders (DSM) series with the publicationof DSM-5: ‘Cultural Concepts of Distress refers to waysthat cultural groups experience, understand, and com-municate suffering, behavioral problems, or troublingthoughts and emotions’.15 The term is a recent ad-vance in the history of attempts to categorize psycho-logical distress with demonstrable cultural influencethat lacks one-to-one unity with biomedical psychi-atric diagnoses (see Box 1 for exemplar CCD.) Theattempt to label CCD dates back to Pow Meng Yap’sresearch in Hong Kong in the 1950–60s.16 Yap em-ployed the term ‘culture-bound depersonalization

syndrome’ to describe koro, a ‘state of acute anxietywith partial depersonalization’ associated with fear ofthe penis retracting into the body. The term ‘culture-bound syndrome’ has been used in cross-culturalpsychiatry since and was included in the DSM-IV.17

However, the term culture-bound syndrome has beenassociated with numerous limitations: findings of simi-lar patterns of distress in disparate cultural settings,lack of cohesive symptom presentation characterizinga syndrome, and wide diversity in aetiological attribu-tions, vulnerability groups and symptoms that influ-ence cultural labels.18–22 Moreover, the combinationof medical anthropology research, which documentsthe social construction of psychiatric disorders,23

with innovations in gene-by-environment and socialneuroscience research, which illustrate that cultureand biology are not neatly divisible categories,24–28

demonstrates that all psychological distress is culturebound. To acknowledge this, the DSM-5 includes textthat ‘all forms of distress are locally shaped, includingthe DSM disorders’.15 Due to dissatisfaction with theterm culture-bound syndrome, researchers have pro-posed other labels such as ‘idioms of distress’, ‘popularcategory of distress’, ‘cultural syndrome’ and ‘explana-tory model’.29–33 The term ‘cultural concept of distress’is an attempt to aggregate these different conceptswithout implying cultural exclusivity.

There has been a tension in cultural psychiatryabout comparing CCD with psychiatric disorders.Because CCD often incorporate culturally salientaetiological models, vulnerability expectations, wide-ranging associated symptoms and a mixture of layand local professional attributions systems, compari-son with psychiatric diagnoses has been criticized asforcing homogeneity onto CCD and losing key aspectsof aetiology and vulnerability that are not incorpo-rated in most psychiatric diagnoses.20,21,34 However,there is a growing body of epidemiology literaturecomparing CCD with psychiatric disorders for a var-iety of goals, such as validating psychiatric disordersagainst CCD, identifying vulnerable groups based onCCD status and identifying forms of distress and im-pairment not captured by psychiatric disorders.

The goal of this review is to explore the methodo-logical approaches of these epidemiological studies ofCCD and psychiatric disorders, to identify limitationsin the approaches and best practices for future work.We sought to develop specific criteria for evaluating

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Box 1. Examples of Cultural Concepts of Distress (CCD)

Nervios-related conditions—In the Americas, nervios (nerves)-related conditions among Latino popula-tions are the most commonly described CCD.126 Nervios starts with ‘a persistent idea that ‘is stuck to one’smind’ (‘idea pegada a la mente’), and these ‘particular idea[s] . . . invade the mind and accumulate . . .Affected individuals think so much about the ideas that the ideas ‘get stuck’ to the brain’.94 AmongMexicans with nervios, 40% endorsed having an idea stuck to their mind. In nervios, feelings of humiliationlead to the slow deterioration of one’s mind, nerves and spirit and ‘may even cause death, if adequate help isnot timely received’.127 The spectrum of nervios follows a gradient of behavioural control.80 One end of thespectrum begins with socially acceptable nervousness: ser una persona nerviosa (being a nervous person).Padecer de los nervios (suffering from nerves) is more serious. Ataques de nervios (attacks of nerves) havegreater severity and are characterized by social stressors triggering loss of behavioural control, dissociation,violent acts toward oneself or others, anger and somatic distress.128 Severe nerve illness can lead to loco(madness). Nervios (nerves), padecer de nervios (suffering from nerves) and ataques de nervios (nerveattacks) have been studied in clinical samples in large-scale Latino representative community studies inPuerto Rico and the USA.70,71 Ataques de nervios overlap with some symptoms of panic attacks and panicdisorder. However, they are distinct from panic attacks because of the centrality of interpersonal disputes intriggering episodes, dissociative features and an experience of relief among some individuals after anataque.80,132 These nervios-related conditions are associated with unexplained neurological complaints, phys-ical health problems and functional impairment independent of association with psychiatric disorders.Dhat—Dhat syndrome has been studied in South Asia and is rooted in Ayurvedic traditions about bodilyproduction of semen as representing an end-product of energy demanding metabolism: 40 meals create 1 dropof blood, 40 drops of blood create 1 drop of semen.43 Dhat is recognized by a whitish discharge in urineassumed to be semen. Although sexually transmitted infections may be a source of such discharge, dhatsufferers do not appear to have greater frequency of STIs.69 Dhat sufferers do appear to have high rates ofpsychosexual dysfunction including premature ejaculation and erectile dysfunction: 42% of men with dhathad premature ejaculation in one study in India.64 Young males appear to be the most frequent demographicgroup presenting with dhat. Dhat has corollaries in Chinese medicine and European and American historywith accounts of weakness, physical illness and mental illness related to the loss of semen.43,77

Koro—Koro was one of the first cultural concepts discussed in transcultural psychiatry literature.16 Koroepidemics have been reported in South Asia, and case reports have been reported throughout the world. Fearof the penis retracting into the body among men and retraction of breasts among women is a centralfeature. The majority of reported cases are among men.Brain fag—Brain fag has been studied for a half-century in Western Africa. The condition is characterizedby distress from thinking too much, with students being a vulnerable population.86 The experience includesheadaches and an experience of a worm crawling in the head. This is similar to the Nigerian culturalconcept of distress, ode ori:84 the disorder ode ori (hunter in the head) affects the brain under the anteriorfontanelle where the iye (senses) control mental functions through okun (strings) that project throughoutthe body and provide direct linkages among the brain, eyes, ears and heart.Khyal attacks and ‘wind’-related illnesses—The substance qi, (cf chi, chi’i, khı, khii, rlung, khyal) isassociated with wind flow and wind balance. Wind-related illnesses are commonly described in East Asianpopulations including Tibetans, Cambodians, Vietnamese, Chinese and Mongolians.73,77,78,129,130 Shenjingshuairuo (neurological weakness, neurasthenia), studied by Kleinman in the 1970s and 80s, is associatedwith weakness, fatigue and social distress mediated by an alteration in qi.77 Yadargaa, a nervous fatiguedescribed in Mongolia, is similarly viewed as an alteration in khii flow and balance.78 In the VietnameseCCD ‘hit by wind’, shifts in ambient temperature, especially gusts of cold air, are associated with a range ofphysical complaints, traumatic memories, thinking too much, epilepsy and stroke.73 Similarly, in China,nerve weakness is associated with a fear of cold because it worsens nerve weakness.77 Among Cambodians,the wind-like substance khyal can be experienced as an attack associated with palpitations, asphyxia anddizziness.130 Khyal attacks can lead to rupture of blood vessels in the neck and spinning of the brain.Kufungisisa—The experience of thinking too much (Shona: kufungisisa) is associated with general psy-chological distress and common mental disorders in Zimbabwe. Thinking too much is considered both asymptom of distress and a cause of other physical and psychological health problems: thinking too muchcan cause pain and feelings of physical pressure on the heart.54

Hwa-Byung—Heat and fire are important elements in East Asian ethnopsychology. The condition hwa-byung(fire illness resulting from chronic accumulated anger) in Korea occurs when haan (a mixture of sorrow,regret, hatred, revenge and perseverance) builds up to create a pushing sensation in the chest, resulting inthe inability to appropriately control one’s anger.85 Hwa-byung affects middle-aged women in Korea who haveexperienced years of interpersonal conflict, typically in the context of an abusive marital relationship.

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epidemiological studies based on cultural psychiatryprinciples. With the expansion of global mentalhealth research and scaling up of services,35–38 it isan ideal time to evaluate if and how CCD can beincorporated into community and clinical epidemi-ology to reduce suffering. Our review is divided intothe following sections: identification of studies com-paring CCD and psychiatric disorders; description ofstudy objectives and methods including ranking epi-demiological quality of these studies; examining sum-mary effect sizes and sources of heterogeneity whencomparing CCD and psychiatric disorders; and con-cluding with recommendations for incorporatingCCD in global mental health research and services.

MethodsInformational sourcesTo identify literature on CCD we searched MEDLINE/PubMed, applying the following keywords: ‘culture-bound’ or ‘culture bound’ or ‘idiom of distress’ or‘idioms of distress’. To assure inclusion of popularlystudied CCD, we combined the above search with asearch of CCD listed in the DSM-5 glossary: ‘nervios’or ‘dhat’ or ‘khyal’ or ‘kufungisisa’ or ‘maladi moun’ or‘shenjing shuairou’ or ‘susto’ or ‘taijin kyofusho’). Welimited psychiatric outcomes to common mental dis-orders (operationalized here as depression, anxiety-related conditions including posttraumatic stress dis-order (PTSD) and panic disorder, and somatization-related conditions) because of their significant burdenof disease, the breadth of research on CCD andcommon mental disorders, and feasibility of assessingcommon mental disorders through self-report. In con-trast, psychosis-related conditions have shown poor re-liability and low detection through self-reportcross-culturally.39,40 In our preliminary searches forsubstance use disorders, eating disorders and develop-mental disorders, we identified a limited number ofstudies precluding synthesis of findings. Thepsychiatric disorder search terms thus included the fol-lowing: ‘depression’ or ‘depression, postpartum’ or‘PTSD’ or ‘stress disorders, post-traumatic’ or ‘fatiguesyndrome, chronic’ or ‘fatigue’ or ‘anxiety disorders’ or‘anxiety’ or ‘panic disorder’ or ‘panic attack’ or ‘soma-toform disorders’ or ‘somatic complaints’. Searcheswere limited to English-language peer-reviewed jour-nal publications. In addition, reference sections of pre-vious reviews on culture-bound syndromes weresearched,41–48 and reference sections of articles identi-fied in the search were used to locate additionalarticles. The initial searches was performed inNovember 2012 and repeated for new references inMarch 2013 and September 2013.

Data collectionTo extract relevant data, all studies identified throughsearches were read and evaluated for inclusion by the

first author. Inclusion criteria comprised Englishlanguage, prevalence data for a psychiatric category,prevalence data for a CCD, odds ratios with 95%confidence intervals for association of CCD and psy-chiatric category or data presented in a mannerenabling construction of a two-by-two comparisonof psychiatric classification and CCD. Exclusion cri-teria were case studies and articles lacking originalquantitative data. Extracted data included worldregion, country, study population (including currentcountry of residence for refugee and immigrant popu-lations), researcher label for CCD (e.g. idiom of dis-tress, culture-bound syndrome, cultural syndrome,cultural somatic symptom), language of term,English translation of term, research objective of thestudy, sample size, sample description, sample origin(clinical, community or school), age group of sample,representative vs convenience or other sample, inclu-sion and description of control or comparison group,symptom/syndrome description, assessment methodfor CCD (self-labelling with single-item term, label-ling based on a multi-item self-report instrumentscore, labelling by healthcare provider including trad-itional healers and clinical providers, labelling fromkey informant in community), symptom severityassessment, type of symptoms (subjective self-report,externally observable or mixed), CCD prevalence (life-time, current or unclear), age of onset, duration ofcurrent episode, psychiatric diagnostic instrument,administration format of psychiatric instrument (e.g.clinician administered, researcher administered, self-report), validation of instrument in study population,assessment of functioning and impairment, aetiology/perceived cause of CCD, vulnerability factors and riskgroup for CCD, protective factors against CCD, inclu-sion of follow-up assessment, percentage lost tofollow-up, reasons lost to follow-up, current or priortreatment status, description of study treatment,assessment of psychiatric comorbidities, assessmentof biological comorbidities and potential confounds.

Quality assessmentTo assess quality, we chose the Systematic Assessmentof Quality in Observational Research (SAQOR), whichhas been developed for assessing quality in observa-tional studies49 and has been used to rate globalmental health research conducted across cultural set-tings.50 SAQOR includes six domains: Sample, Control/Comparison Group, Quality of Exposure/OutcomeMeasurements, Follow-Up, Distorting Influences andReporting Data. Each domain contains multiple cri-teria. For this study, the results section describes modi-fication of SAQOR to develop a version for CulturalPsychiatry Epidemiology (SAQOR-CPE).

Meta-analysesOdds ratios were extracted or calculated from quanti-tative studies to determine the likelihood of a specificpsychiatric category given the presence of a specific

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CCD. Two-by-two tables were constructed for allquantitative papers that included data for categoricaloutcomes of CCD (yes vs no) and psychiatric cate-gories (yes vs no). If studies only included meanscores on symptom scales without providing informa-tion on categorical cut-offs, these studies were notincluded in the meta-analysis. In the two-by-twotables, CCD were considered the independent variableand psychiatric categories were considered the de-pendent variable.

Odds ratios (OR), 95% confidence intervals, sensitiv-ity, specificity, positive predictive value (PPV) andnegative predictive value (NPV) were calculated forall studies in the meta-analysis. If a study containedan empty field in the two-by-two table, then individ-ual study outcomes (OR, sensitivity, specificity, PPVand NPV) were not calculated; however, the partici-pants were included in the meta-analysis summarycalculations. Sensitivity was calculated as the propor-tion of persons positive for both the CCD and thepsychiatric category, among all persons with CCD.Specificity was calculated as the proportion of personsnegative for the CCD and negative for the psychiatriccategory, among all persons negative for the CCD.Positive predictive value was calculated as the propor-tion of participants positive for both the CCD andpsychiatric category, among all participants positivefor the psychiatric category. Negative predictivevalue was calculated as the proportion of participantsnegative for both the CCD and the psychiatric cat-egory, among all persons negative for the psychiatriccategory.

Heterogeneity for summary effect sizes was calcu-lated with the Q statistic. The statistic was calculatedby summing the squared deviations of each study’seffect estimated from the overall effect estimate;each study was weighted by its inverse variance.51

I2 is another measure of heterogeneity calculated bydividing the difference of the Q statistic and its de-grees of freedom by the Q statistic and multiplyingthis by 100.51 Low values (e.g. <25%) suggest lowheterogeneity whereas I2 475% suggests high hetero-geneity with study characteristics and methods influ-encing the associations.

Generalized estimating equations (GEE) were usedto assess the influence of study design on effect sizes.GEE is one method that can account for the clusteringof multiple comparisons within a single study.52 Theodds ratio for each study was used as the dependentvariable. Independent variables included world region(Americas, Africa, Asia), researcher label (‘culture-bound . . .’, ‘idiom . . .’, ‘popular . . .’, other ‘. . . syn-drome’ and other label), study objective (compareCCD and psychiatric disorder, instrument validationstudy, assessment of risk factors for psychological dis-tress, and other), sample size (<100, 100–499 and5500 participants) recruitment site (clinical, commu-nity or school-based settings), representativeness ofsample (representative sample vs all other recruitment

forms), CCD type (four groups were created based ongreatest number of participants: nervios-related stu-dies, 10 820 participants; dhat studies, 863 partici-pants; hwa-byung studies, 3087 participants; and allother cultural concepts of distress, 4012 participants),CCD-self report (participant endorsed CCD vs studiesin which the CCD was attributed to the participant bythe researcher, a clinician, or a key informant), as-sessment method for CCD [categorized into fourgroups: (i) self-report single item binary categoricalendorsement (e.g. yes vs no for ‘Have you ever hadan ataque de nervios?’); (ii) self-report multi-symptom instrument score (e.g. mean scale above acut-off for number of symptoms to meet criteria as aproxy for ataques de nervios, such as symptoms ofblinding, fainting and paralysis with symptoms begin-ning after a troubling experience53); (iii) clinical diag-nosis (e.g. clinician making a diagnosis of dhat orhwa-byung based on specific clinical guidelines); or(iv) other third party labelling (e.g. binary categoricallabel of CCD provided by someone other than partici-pant or clinician; this was usually done by key in-formants in the community or parents)], prevalenceof CCD (lifetime, current/point or unclear), psychiatriccategories (classified in five groups: general psycho-logical distress, all anxiety disorders, mood disorders,somatoform disorders and other disorders), control-ling for comorbidity (control through inclusion/exclu-sion criteria or through statistical analysis vs nocontrol for comorbidity) and SAQOR-CPE overallranking score (very low quality, low quality,medium quality, or high quality). Only analyseswith OR outcomes were entered into the GEE. Thisled to inclusion of 79 comparisons drawn from 26studies because some studies had multiplecomparisons.

ResultsStudy characteristicsThrough the search terms, 211 citations were identi-fied; 12 studies were added from reviews and refer-ences lists. Of the total of 223 studies evaluated,4553–97 included quantitative data on both culturalconcepts of distress and psychiatric categories (seeFigure 1). Ten studies were conducted in Africa, 18in the Americas and 17 in Asia (see Table 1a, b, c).The most common CCD were nervios-related condi-tions, comprising 30% of studies. Nine studies (20%)included children, and the remainder only had adultparticipants. Studies with participants under 18 yearsof age were predominantly nervios-related conditions,as well as dhat among adolescent boys. Sixteen (35%)of the studies used the label ‘culture-bound’; ninestudies (20%) used ‘idiom of distress’; and 23 studieshad comparison of CCD with psychiatric disorders asa primary objective. For eight studies, the primarygoal was to evaluate association with a risk factor

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or vulnerable group. Seven studies had instrumentadaptation and validation as the primary goal.

Quality ratings: SAQOR-CPEWe reviewed the studies to identify types of datacommonly reported, and we drew upon broader CCDliterature to consider key aspects of CCD relevant toquantitative studies that could influence or confoundassociations between CCD and psychiatric disorder.These issues were incorporated into the SystematicAssessment of Quality in Observational Research(SAQOR)98 to develop a modified version forCultural Psychiatry Epidemiology (CPE): theSAQOR-CPE. Table 2 lists the seven categories andtheir criteria. Table 3 includes the quality scoring forindividual studies in the review. Below we describeeach category and criterion.

SampleThe Sample category and each of its original five cri-teria were retained.

Representative refers to studies that can be generalizedto a population of interest. Cultural PsychiatryEpidemiology (CPE) studies should use the same epi-demiological principles as standard health studies. Itis especially crucial that CPE studies have a clear def-inition of the cultural group of interest to which find-ings can be applied. For example, ataque de nerviosfindings from Puerto Rico may not be generalizable toGuatemalans, Cubans or Bolivians in their homecountries or after immigration. An exemplar study isthe investigation of ataques de nervios in the NationalLatino and Asian American Study, in which outcomesare presented separately for Puerto Ricans, Cubans,Mexicans and other Latinos, revealing group differ-ences.71 Less than one-third of the studies (29%) inthis review used culturally appropriate representativesampling.

Source refers to how cases are identified. Authorsshould clearly state if self-labelling, clinician diagnosisor other key informant identification was used toenroll a participant as either CCD or non-CCD. If anindividual other than the participant assigned thelabel, then the degree of concordance between theexternal label and the self-label should be reported.A study to validate a postpartum depression measurein the Democratic Republic of Congo provides a goodexample of this: of 91 women identified with a CCDby key informants, only 41 (45%) self-endorsed theCCD label; of 42 women identified by key informantsas not having the CCD, only 20 (48%) self-endorsednot having the CCD.56 This illustrates that using keyinformants in this setting to identify cases and makegeneralizations is no better than randomly assigning agroup of women to CCD vs not-CCD status. In all, 44studies reported CCD source.

Method refers to the process of recruiting partici-pants. In cross-cultural research, recruitment methodmay bias prevalence rates and association with riskfactors. For example, if key informants are used,they may be less likely to identify high-status individ-uals in the community who have CCD. Stigma maylead to CCD non-disclosure despite experiencing suf-fering. A study of Darfuri refugees in Chad usedUnited Nations High Commissioner for Refugees(UNHCR) registration to randomly select participants;because caseness (ie CCD status) was not a criteria inthe sampling frame, potential participants wereapproached without prior knowledge of CCD status,thus reducing potential bias in endorsement.93 A totalof 43 studies provided some information on recruit-ment methods.

Sample size and power calculation: studies need to beadequately powered to detect differences betweengroups in exposures, psychiatric disorders or otherfactors. Prior studies done with similar populationscan be used to estimate prevalence of a CCD. If

211 unique records iden�fied through database searching

12 addi�onal records iden�fied

other sources

223 full text ar�cles assessed for

eligibility

45 ar�cles included in quan�ta�ve synthesis

178 ar�cles excluded(only qualita�ve data; no comparison of CCD

and psychiatric label; no CCD; no original data; no psychiatric category; single case

study; beliefs-model only)

Figure 1 PRISMA diagram showing selection of studies for inclusion in systematic review of cultural concepts of distress(CCD) and psychiatric disorders

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Ad

ult

:3

0p

sych

iatr

icp

ati

ents

Ch

ild

:2

34

stu

den

tsage

11

-20

years

Ch

ild

:1

66

war-

aff

ecte

dyo

uth

inin

tern

al

dis

pla

cem

ent

cam

pin

no

rth

ern

Ugan

da

Ass

ess

me

nt

me

tho

dS

elf-

rep

ort

mu

lti-

sym

pto

min

ven

tory

Sin

gle

-ite

mk

eyin

form

an

tan

dse

lf-r

epo

rt

Tra

dit

ion

al

hea

ler

Sel

f-re

po

rtm

ult

i-sy

mp

tom

inve

nto

ryS

ingle

-ite

mk

eyin

form

an

t,p

are

nt

an

dse

lf-r

epo

rt

Pre

va

len

ceU

ncl

ear

Un

clea

rC

urr

ent

Un

clea

rU

ncl

ear

Co

mp

ari

son

gro

up

Un

clea

r—n

oin

form

ati

on

regard

ing

part

icip

an

tsw

ith

ou

th

ozu

no

rm

ajn

un

,o

nly

mea

nsc

ale

sco

res

Yes

—sa

mp

lein

clu

ded

key

-in

form

an

tn

ega-

tive

case

san

dw

om

enn

ot

end

ors

ing

syn

dro

me

No

—all

pati

ents

had

od

eo

rila

bel

sU

ncl

ear—

no

info

rma-

tio

no

fp

art

icip

an

tsw

ith

no

bra

infa

g,

on

lym

ean

BF

SS

sco

res

pro

vid

ed

Yes

—sa

mp

lein

clu

ded

KI-

neg

ati

ve,

pare

nt-

rep

ort

neg

ati

ve,

an

dse

lf-r

epo

rtn

egati

veca

ses

Psy

chia

tric

cate

go

rie

sD

epre

ssio

n,

PT

SD

Dep

ress

ion

,p

ost

-p

art

um

dep

ress

ion

All

majo

rp

sych

iatr

icca

tego

ries

An

xie

tyA

nx

iety

,d

epre

ssio

n,

con

du

ctp

rob

lem

s

Inst

rum

en

ts,

va

lid

ati

on

BS

I,P

CL

-C,

no

tva

lid

ate

dE

PD

S,

HS

CL

,n

ot

vali

date

dP

SE

,n

ova

lid

ati

on

info

rmati

on

pro

vid

edB

FS

S,

ST

AI

vali

date

din

Nig

eria

AP

AI,

loca

lly

dev

elo

ped

scale

Fu

nct

ion

ing

WH

O-D

AS

Lo

cal

syn

dro

mes

No

tre

po

rted

Pee

rre

lati

on

ship

sN

ot

rep

ort

ed

(co

nti

nu

ed)

CULTURAL CONCEPTS OF DISTRESS AND PSYCHIATRIC DISORDERS 7

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

Dow

nloaded from

Ta

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1a

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Re

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20

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Ab

as

19

97

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Pa

tel

19

95

88

Pa

tel

19

97

89

Co

un

try

Ugan

da

Ugan

da

Zim

bab

we

Zim

bab

we

Zim

bab

we

Cu

ltu

ral

con

cep

to

fd

istr

ess

Sp

irit

po

sses

sio

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o’k

wek

yaw

a(l

oca

ld

epre

ssio

nsy

nd

rom

e)K

usu

wis

ia(d

eep

sad

nes

s);

ku

fun

gis

isa

(th

ink

ing

too

mu

ch)

Sp

irit

ual

illn

ess:

chi-

van

hu

,m

ud

zim

u,

mam

hep

o,

zvis

hri

Men

tal

pro

ble

ms

Te

rmin

olo

gy

Ind

igen

ou

sex

pre

ssio

ns

of

psy

cho

logic

al

dis

tres

s

Lo

cal

syn

dro

me

Ex

pla

nato

rym

od

elS

pir

itu

al

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dig

eno

us

con

cep

to

fp

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oso

cial

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tres

s

Re

sea

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ob

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Vali

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SD

Inst

rum

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Ass

ess

pre

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of

dep

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ng

loca

lin

stru

men

ts

Ass

ess

pre

vale

nce

of

com

mo

nm

enta

ld

iso

rder

san

del

icit

exp

lan

ato

rym

od

els

Eva

luate

freq

uen

cyo

fsp

irit

ual

mo

del

so

fil

lnes

san

dass

oci

-ati

on

wit

hm

enta

ld

iso

rder

s

Eva

luate

rela

tio

nsh

ipb

etw

een

stru

ctu

red

psy

chia

tric

dia

gn

osi

san

dp

rim

ary

care

(tra

dit

ion

al

an

db

iom

edic

al)

pro

vid

erid

enti

fica

tio

n

Re

cru

itm

en

tC

om

mu

nit

yC

om

mu

nit

yC

om

mu

nit

yC

lin

ical

Cli

nic

al

Sa

mp

leC

hil

d:

50

4w

ar-

aff

ecte

dyo

uth

inN

ort

her

nU

gan

da

Ad

ult

:6

7ad

ult

sid

enti

-fi

edb

yk

eyin

form

-an

tsan

dse

lfas

suff

erin

gfr

om

syn

dro

me

Ad

ult

:1

72

wo

men

fro

mto

wn

ship

sA

du

lt:

30

2p

rim

ary

care

att

end

ees

Ad

ult

:3

02

pri

mary

care

att

end

ees

Ass

ess

me

nt

me

tho

dS

elf-

rep

ort

mu

lti-

sym

p-

tom

inve

nto

ryS

ingle

-ite

mk

eyin

-fo

rman

tan

dse

lf-

rep

ort

Sin

gle

-ite

mse

lf-r

epo

rtC

lin

icia

nan

dse

lf-r

epo

rtm

ult

i-sy

mp

tom

rati

ngs

Cli

nic

ian

att

rib

uti

on

(pri

mary

care

an

dtr

ad

itio

nal

hea

ler)

Pre

va

len

ceU

ncl

ear

Un

clea

rC

urr

ent

Cu

rren

tC

urr

ent

Co

mp

ari

son

gro

up

Un

clea

r—

on

lyS

PS

mea

nsc

ore

sp

rovi

ded

Yes

—k

eyin

form

an

tan

dse

lf-r

ati

ng

po

siti

vean

dn

egati

veca

ses

No

—ex

pla

nato

rym

od

els

no

tass

esse

dam

on

gP

SE

neg

ati

vep

art

icip

an

ts

Yes

—h

alf

of

sam

ple

did

no

ten

do

rse

spir

itu

al

aet

iolo

gy

Yes

—p

art

icip

an

tsn

ot

class

ifie

db

yp

rim

ary

care

wo

rker

or

hea

ler

as

havi

ng

am

enta

lp

rob

lem

Psy

chia

tric

cate

go

rie

sD

epre

ssio

n,

PT

SD

Dep

ress

ion

Psy

cho

logic

al

dis

tres

sG

ener

al

psy

cho

logic

al

dis

tres

sG

ener

al

psy

cho

logic

al

dis

tres

s

Inst

rum

en

ts,

va

lid

ati

on

HS

CL

,P

DS

,S

PS

,C

AP

Sn

ot

vali

date

dL

ay

inte

rvie

ww

ith

DS

M-I

VM

DD

cri-

teri

a,

not

vali

date

d

PS

E,

SS

MD

has

vali

dati

on

psy

cho

met

rics

CIS

R,

SS

Q,

SR

Q,

tran

s-cu

ltu

ral

equ

ivale

nce

info

rmati

on

pro

vid

ed

SS

Q,

CIS

Rtr

an

scu

ltu

ral

equ

ivale

nce

info

rmati

on

pro

vid

ed

Fu

nct

ion

ing

Lo

cal

scale

Lo

cal

scale

No

tre

po

rted

No

tre

po

rted

WH

OQ

uali

tyo

fL

ife

(co

nti

nu

ed)

8 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

Dow

nloaded from

Ta

ble

1b

Stu

die

sco

nd

uct

edin

the

Am

eric

as,

mee

tin

gin

clu

sio

ncr

iter

iafo

rco

mp

ari

son

of

cult

ura

lco

nce

pts

of

dis

tres

san

dp

sych

iatr

icca

tego

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Re

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Sa

lga

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de

Sn

yd

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20

00

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de

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Co

un

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Mex

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an

dU

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Cu

ltu

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con

cep

to

fd

istr

ess

Ner

vio

s(n

erve

s)L

lak

i(g

rief

),su

sto

(fri

gh

t),

pie

nsa

-mie

ntu

wan

(wo

rryi

ng

mem

ori

es),

tuta

lp

ien

sam

ien

tuw

an

(ex

cess

of

wo

rryi

ng

mem

ori

es)

Ata

qu

ed

en

ervi

os

(att

ack

of

ner

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Ata

qu

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(att

ack

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ves)

Ata

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(att

ack

of

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ves)

Te

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y-in

terp

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dsy

nd

rom

eC

ult

ure

-bo

un

dtr

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ma-

rela

ted

dis

ord

ers;

loca

lid

iom

so

fd

istr

ess

Po

pu

lar

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go

ryo

fd

istr

ess

Cu

ltu

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syn

dro

me

Cu

ltu

ral

idio

mo

fd

istr

ess

Re

sea

rch

ob

ject

ive

Pre

vale

nce

,co

mo

rbid

ity

wit

hm

oo

dan

dan

x-

iety

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ord

ers,

an

dass

oci

ate

dsy

mp

tom

s

Map

ind

igen

ou

sco

nst

ruct

ion

of

emo

tio

ns

inre

spo

nse

top

oli

tica

lvi

ole

nce

Ass

oci

ati

on

wit

hd

isas-

ter

an

dso

cial

chara

cter

isti

cs

Pre

vale

nce

an

dp

sych

i-atr

icco

rrel

ate

sam

on

gch

ild

ren

Ass

oci

ati

on

bet

wee

nata

-q

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an

dso

mati

cco

mp

lain

tsam

on

gP

uer

toR

ican

you

th

Re

cru

itm

en

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om

mu

nit

y,re

pre

sen

tati

veC

om

mu

nit

y,o

nly

per

son

sw

ith

hig

hG

HQ

an

dH

SC

Lsc

ore

s

Co

mm

un

ity,

rep

rese

nta

tive

Cli

nic

al

an

dco

mm

u-

nit

y,re

pre

sen

tati

veC

om

mu

nit

y,re

pre

sen

tati

ve

Sa

mp

leA

du

lt:

94

2co

mm

un

ity

resi

den

tsA

du

lt:

14

4sc

reen

edfr

om

com

mu

nit

yA

du

lt:

91

2co

mm

un

ity

sam

ple

Ch

ild

:1

89

2co

mm

un

ity

an

d7

61

clin

ical

Ch

ild

:1

13

8co

mm

un

ity

sam

ple

Ass

ess

me

nt

me

tho

dS

ingle

-ite

mse

lf-r

epo

rt(n

ervi

os

ever

vsn

ever

)

Sin

gle

-ite

mse

lf-r

epo

rt(i

dio

ms

curr

entl

yye

svs

no

)

Sin

gle

-ite

mse

lf-r

epo

rt(a

taq

ue

de

ner

vio

sev

ervs

nev

er)

Sin

gle

-ite

mp

are

nt

an

dse

lf-r

epo

rt(a

taq

ue

de

ner

vio

sev

ervs

nev

er)

Sin

gle

-ite

mp

are

nt

an

dse

lf-r

epo

rt(a

taq

ue

de

ner

vio

sev

ervs

nev

er)

Pre

va

len

ceL

ifet

ime

Po

int

pre

vale

nce

Lif

etim

eL

ifet

ime

Lif

etim

e

Co

mp

ari

son

gro

up

Yes

—ad

ult

sn

ot

end

ors

ing

ner

vio

sY

es—

part

icip

an

tsd

enyi

ng

frig

ht

idio

ms

Yes

—p

art

icip

an

tsd

eny-

ing

ata

qu

ed

en

ervi

os

epis

od

es

Yes

—p

art

icip

an

tsd

eny-

ing

ata

qu

ed

en

ervi

os

epis

od

es

Yes

—p

art

icip

an

tsw

ith

ou

tp

are

nt

or

self

-re

po

rto

fata

qu

ed

en

ervi

os

Psy

chia

tric

cate

go

rie

sA

nx

iety

,d

epre

ssio

nA

nx

iety

,d

epre

ssio

n,

PT

SD

All

majo

rp

sych

iatr

icca

tego

ries

All

majo

rp

sych

iatr

icca

tego

ries

So

mati

cco

mp

lain

ts(h

ead

ach

e)

Inst

rum

en

ts,

va

lid

ati

on

CID

I,va

lid

ate

din

Sp

an

ish

GH

Qan

dH

SC

Ln

ot

vali

date

dfo

rth

isp

op

ula

tio

n

DIS

,va

lid

ate

dP

uer

toR

ican

vers

ion

DIS

C,

vali

date

dP

uer

toR

ican

vers

ion

DIS

C,

vali

date

dP

uer

toR

ican

vers

ion

Fu

nct

ion

ing

No

tre

po

rted

No

tre

po

rted

DIS

GA

SA

sses

sed

‘lim

ited

act

ivit

ies’

(co

nti

nu

ed)

CULTURAL CONCEPTS OF DISTRESS AND PSYCHIATRIC DISORDERS 9

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

Dow

nloaded from

Ta

ble

1b

Co

nti

nu

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Re

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Gu

arn

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Co

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AU

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US

AU

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US

A

Cu

ltu

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to

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Ata

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ack

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Ata

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Ata

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Te

rmin

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Cu

ltu

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ysa

nct

ion

edex

pre

ssio

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fd

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ess

Cu

ltu

re-b

ou

nd

syn

dro

me

Po

pu

lar

syn

dro

me

Cu

ltu

ral

idio

ms

of

dis

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s

Re

sea

rch

ob

ject

ive

Eva

luate

ata

qu

ed

en

ervi

os

as

mark

ero

fso

cial

an

dp

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icvu

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ab

ilit

y

Eva

luate

the

ass

oci

ati

on

of

un

exp

lain

edn

euro

-lo

gic

al

sym

pto

ms

wit

hata

qu

es

Det

erm

ine

pre

vale

nce

of

ata

qu

e-re

late

dsy

mp

-to

ms

acr

oss

cult

ura

lgro

up

s

Eva

luate

ph

eno

men

o-

logic

al

dif

fere

nce

sam

on

gata

qu

e,p

an

icatt

ack

san

dp

an

icd

iso

rder

To

evalu

ate

ass

oci

ati

on

am

on

gP

TS

D,

dis

-so

ciati

on

an

dcu

ltu

ral

idio

ms

of

dis

tres

s

Re

cru

itm

en

tC

om

mu

nit

y,re

pre

sen

tati

veC

lin

ical

Sch

oo

lC

lin

ical

Cli

nic

al

Sa

mp

leA

du

lt:

25

54

Lati

no

Am

eric

an

sA

du

lt:

95

His

pan

icp

ati

ents

an

d3

2E

uro

pea

nA

mer

ican

pati

ents

Ad

ult

:3

42

un

iver

sity

stu

den

ts(2

00

Cau

casi

an

,5

8A

fric

an

Am

eric

an

,5

0H

isp

an

ic)

Ad

ult

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0H

isp

an

icp

ati

ents

pre

sen

tin

gto

an

xie

tyd

iso

rder

scl

inic

wit

hse

lf-r

epo

rto

fata

qu

ed

en

ervi

os

Ad

ult

:2

30

Lati

na

ou

tpati

ents

Ass

ess

me

nt

me

tho

dS

ingle

-ite

mse

lf-r

epo

rt(a

taq

ue

de

ner

vio

sev

ervs

nev

er)

Sel

f-re

po

rtm

ult

i-sy

mp

tom

inve

nto

ryS

elf-

rep

ort

mu

lti-

sym

p-

tom

inve

nto

ryS

elf-

rep

ort

mu

lti-

sym

p-

tom

inve

nto

ryS

ingle

-ite

mse

lf-r

epo

rt

Pre

va

len

ceL

ifet

ime

No

tre

po

rted

No

tre

po

rted

No

tre

po

rted

Lif

etim

e

Co

mp

ari

son

gro

up

Yes

—p

art

icip

an

tsd

eny-

ing

ata

qu

ed

en

ervi

os

Yes

—p

ati

ents

no

tm

eeti

ng

crit

eria

for

ata

qu

eb

ase

do

nm

ult

i-it

emch

eck

list

Yes

—p

art

icip

an

tssc

or-

ing

bel

ow

cuto

ffo

nata

qu

ed

en

ervi

os

chec

kli

st

Yes

—all

pati

ents

self

-re

po

rted

ata

qu

ed

en

ervi

os,

bu

to

nly

32

met

8-s

ymp

tom

crit

eria

Yes

—p

ati

ents

no

ten

do

rsin

gata

qu

ed

en

ervi

os

Psy

chia

tric

cate

go

rie

sA

llm

ajo

rp

sych

iatr

icca

tego

ries

An

xie

ty,

pan

ic,

dep

ress

ion

,u

nex

pla

ined

neu

ro-

logic

al

com

pla

ints

Pan

icP

an

icP

TS

D

Inst

rum

en

ts,

va

lid

ati

on

CID

I,va

lid

ate

dfo

rp

op

ula

tio

nP

RIM

E-M

D,

Ata

qu

ech

eck

list

,C

IDI

vali

date

dP

AQ

-R,

no

vali

dati

on

rep

ort

edS

CID

,va

lid

ate

dS

CID

,va

lid

ate

d

Fu

nct

ion

ing

CID

IN

ot

rep

ort

edN

ot

rep

ort

edN

ot

rep

ort

edN

ot

rep

ort

ed

(co

nti

nu

ed)

10 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

by guest on Decem

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Dow

nloaded from

Ta

ble

1b

Co

nti

nu

ed

Re

fere

nce

Lie

bo

wit

z1

99

46

4,

Sa

lma

n1

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87

7C

ap

lan

20

10

61

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ina

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08

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lca

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ra2

01

25

5C

asp

i1

99

86

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Co

un

try

US

AU

nS

AU

SA

US

AU

SA

Cu

ltu

ral

con

cep

to

fd

istr

ess

Ata

qu

ed

en

ervi

os

(att

ack

of

ner

ves)

Co

raje

(rage)

,n

ervi

os

(ner

ves)

,su

sto

(fri

gh

t)

Ner

vio

s(n

erve

s)P

ad

ecer

de

ner

vio

s(s

tate

of

suff

erin

gfr

om

ner

ves)

Beb

atc

het

(dee

pw

orr

y-in

gsa

dn

ess)

,ch

ku

|t

(lo

stm

ind

)

Te

rmin

olo

gy

Po

pu

lar

illn

ess

cate

go

ryId

iom

so

fd

istr

ess

Cu

ltu

re-b

ou

nd

syn

dro

me

Cu

ltu

re-b

ou

nd

syn

dro

me

Cu

ltu

rall

yd

efin

edsy

mp

tom

s

Re

sea

rch

ob

ject

ive

Rel

ati

on

ship

bet

wee

nata

qu

esan

dco

mo

rbid

psy

chia

tric

dis

ord

ers

Det

ecti

on

of

dis

tres

sam

on

gL

ati

no

sn

ot

mee

tin

gcr

iter

iafo

rd

epre

ssio

n

Co

mp

are

per

form

an

ceo

nA

do

lesc

ent

Ner

vio

sS

cale

bet

wee

nL

ati

no

san

dn

on

-Lati

no

s

Ass

oci

ati

on

wit

hacc

ult

ur-

ati

on

bey

on

dva

lue

of

trad

itio

nal

mea

sure

so

fan

xie

tyse

nsi

tivi

ty

Ass

oci

ati

on

of

chil

dlo

ssw

ith

men

tal

hea

lth

an

dfu

nct

ion

imp

air

men

t

Re

cru

itm

en

tC

lin

ical

Cli

nic

al

Sch

oo

lS

cho

ol

Co

mm

un

ity

Sa

mp

leA

du

lt:

15

6H

isp

an

icp

ati

ents

pre

sen

tin

gto

an

xie

tyd

iso

rder

scl

inic

Ad

ult

:5

2p

ati

ents

inp

sych

iatr

yO

PD

Ch

ild

:5

34

mid

dle

sch

oo

lst

ud

ents

(30

7L

ati

no

,2

27

No

n-L

ati

no

)

Ad

ult

:8

2m

oth

ers

of

Mex

ican

ori

gin

Ad

ult

s:1

61

pare

nts

Ass

ess

me

nt

me

tho

dS

ingle

-ite

mse

lf-r

epo

rtS

ingle

-ite

mse

lf-r

epo

rtS

elf-

rep

ort

mu

lti-

sym

pto

min

ven

tory

Sin

gle

-ite

mse

lf-r

epo

rtS

ingle

-ite

mse

lf-r

epo

rt

Pre

va

len

ceL

ifet

ime

Past

mo

nth

Un

clea

rL

ifet

ime

Past

wee

k

Co

mp

ari

son

gro

up

Yes

–p

ati

ents

wh

od

idn

ot

end

ors

eat

aqu

ede

ner

vios

Yes

–p

ati

ents

wit

han

dw

ith

ou

tse

lf-l

ab

eled

sym

pto

ms

Un

clea

r–

part

icip

an

tsw

ith

no

sym

pto

ms,

on

lym

ean

sco

res

pro

vid

ed

Yes

–m

oth

ers

wh

od

idn

ot

have

pad

ecer

de

ner

vio

sY

es–

Pare

nts

wit

ho

ut

Beb

atc

het

or

chk

u|t

Psy

chia

tric

cate

go

rie

sA

nx

iety

,p

an

ic,

dep

ress

ion

Dep

ress

ion

An

xie

ty,

dep

ress

ion

,an

ger

Psy

cho

logic

al

dis

tres

sP

TS

D

Inst

rum

en

ts,

va

lid

ati

on

Cli

nic

ian

dia

gn

osi

sP

HQ

-9,

vali

date

dB

YI-

An

xie

ty,

BY

I-D

epre

ssio

n,

BY

I-A

nger

,E

ngli

shla

ngu

age

vali

dati

on

s

BS

I,S

pan

ish

BS

Iva

lid

ati

on

Harv

ard

Tra

um

aQ

ues

tio

nn

air

e,va

lid

ati

on

no

tre

po

rted

Fu

nct

ion

ing

No

tre

po

rted

PH

Q-9

fun

ctio

nq

ues

tio

nS

cho

ol

fun

ctio

nin

gad

just

men

tN

ot

rep

ort

edS

elec

tfu

nct

ion

ing

item

s

(co

nti

nu

ed)

CULTURAL CONCEPTS OF DISTRESS AND PSYCHIATRIC DISORDERS 11

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

Dow

nloaded from

Ta

ble

1b

Co

nti

nu

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Re

fere

nce

Hin

ton

20

03

73

Hin

ton

20

11

13

3D

’Ava

nz

o1

99

86

6

Co

un

try

US

AU

SA

US

Aan

dE

uro

pe

Cu

ltu

ral

con

cep

to

fd

istr

ess

Tru

ng

gio

(hit

by

win

d)

Wo

rry

att

ack

sK

ho

uch

eran

g(t

hin

kin

gto

om

uch

)

Te

rmin

olo

gy

Cu

ltu

ral

syn

dro

me

No

ne

Cu

ltu

re-b

ou

nd

syn

dro

me

Re

sea

rch

ob

ject

ive

Ph

enom

enolo

gic

all

ych

ara

cter

ize

‘hit

by

the

win

d’.

Det

erm

ine

role

of

cult

ura

lm

od

elo

fw

orr

yin

PT

SD

seve

rity

Eva

luate

freq

uen

cyo

fd

epre

ssio

n,

an

xie

tyan

dC

BS

bet

wee

nU

SA

an

dF

ran

cefo

rC

am

bo

dia

nre

fugee

s

Re

cru

itm

en

tC

lin

ical

Cli

nic

al

Co

mm

un

ity

Sa

mp

leA

du

lt:

60

Vie

tnam

ese

pati

ents

wit

hP

TS

DA

du

lt:

13

0C

am

bo

dia

np

ati

ents

(94

wit

hP

TS

D,

36

wit

ho

ut

PT

SD

)A

du

lt:

15

5C

am

bo

dia

nw

om

enin

Fra

nce

an

dU

SA

Ass

ess

me

nt

me

tho

dS

ingle

-ite

mse

lf-r

epo

rtS

elf-

rep

ort

mu

lti-

sym

pto

min

ven

tory

Un

clea

r

Pre

va

len

ceP

rio

rm

on

thP

rio

rm

on

thU

ncl

ear

Co

mp

ari

son

gro

up

Yes

—p

ati

ents

wit

hP

TS

Dan

dw

ith

ou

tp

an

icY

es—

pati

ents

wit

ho

ut

PT

SD

Un

clea

r

Psy

chia

tric

cate

go

rie

sP

an

ic,

PT

SD

PT

SD

Dep

ress

ion

an

dan

xie

ty

Inst

rum

en

ts,

va

lid

ati

on

Cli

nic

al

inte

rvie

ww

ith

DS

M-I

VP

CL

-CH

SC

L,

vali

date

din

Kh

mer

Fu

nct

ion

ing

In-d

epth

inte

rvie

ws

No

tre

po

rted

No

tre

po

rted

12 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

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nloaded from

Ta

ble

1c

Stu

die

sco

nd

uct

edin

Asi

a,

mee

tin

gin

clu

sio

ncr

iter

iafo

rco

mp

ari

son

of

cult

ura

lco

nce

pts

of

dis

tres

san

dp

sych

iatr

icca

tego

ries

Re

fere

nce

Hin

ton

20

12

74

Kle

inm

an

19

82

77

Bh

ati

a1

99

15

9C

ha

dd

a1

99

06

4C

ha

dd

a1

99

56

3

Co

un

try

Cam

bo

dia

Ch

ina

an

dT

aiw

an

Ind

iaIn

dia

Ind

ia

Cu

ltu

ral

con

cep

to

fd

istr

ess

Cam

bo

dia

nso

mati

csy

nd

rom

es,

kh

yal

att

ack

s(w

ind

att

ack

s),

thin

kin

gto

om

uch

Sh

enji

ng

shu

air

uo

(neu

rast

hen

ia,

neu

rolo

gic

al

wea

kn

ess)

Dh

at

(sem

enlo

ssin

uri

ne)

Dh

at

(sem

enlo

ssin

uri

ne)

Dh

at

(sem

enlo

ssin

uri

ne)

Te

rmin

olo

gy

Cu

ltu

ral

syn

dro

me

an

dcu

ltu

rall

yem

ph

asi

zed

som

ati

cco

mp

lain

ts

Bio

cult

ura

lly

patt

ern

edil

lnes

s;so

mati

zati

on

Cu

ltu

re-b

ou

nd

sex

neu

rosi

sC

ult

ure

-bo

un

dse

xn

euro

sis

Cu

ltu

re-b

ou

nd

neu

roti

cd

iso

rder

Re

sea

rch

ob

ject

ive

Nee

ds

ass

essm

ent

of

trau

ma-a

ffec

ted

po

pu

lati

on

usi

ng

cult

ura

lly-

sen

siti

vein

stru

men

t

Rel

ati

on

of

som

ati

za-

tio

n,

dep

ress

ion

,an

dn

eura

sth

enia

wit

hcu

ltu

ral

con

tex

t

Psy

chia

tric

dia

gn

osi

s,p

rese

nti

ng

sym

pto

ms

an

dtr

eatm

ent

re-

spo

nse

am

on

gth

ose

wit

hD

hat

Psy

chia

tric

an

dS

TI

dia

gn

ose

sam

on

gp

erso

ns

wit

hD

hat

Illn

ess

beh

avi

ou

ram

on

gp

erso

ns

wit

hD

hat

Re

cru

itm

en

tC

om

mu

nit

yC

lin

ical

Cli

nic

al

Cli

nic

al

Cli

nic

al

Sa

mp

leA

du

lt:

13

9ad

ult

sid

enti

-fi

edb

yh

um

an

righ

tsgro

up

Ad

ult

:1

00

Ch

ines

ean

d5

1T

aiw

an

ese

pa-

tien

tsd

iagn

ose

dw

ith

neu

rast

hen

ia

Ad

ult

:1

14

men

pre

-se

nti

ng

top

sych

iatr

yO

PD

wit

hp

sych

ose

x-

ual

com

pla

ints

Ad

ult

:5

2m

ense

lf-p

re-

sen

tin

gto

psy

chia

try

OP

Dw

ith

pass

age

of

dh

at

inu

rin

e

Ad

ult

:1

00

pati

ents

pre

sen

tin

gto

psy

chia

try

OP

D

Ass

ess

me

nt

me

tho

dS

elf-

rep

ort

mu

lti-

sym

pto

min

ven

tory

Cli

nic

ian

Cli

nic

ian

Sin

gle

-ite

mse

lf-r

epo

rtS

ingle

-ite

mse

lf-r

epo

rt

Pre

va

len

ceU

ncl

ear

Lif

etim

eC

urr

ent

Cu

rren

tC

urr

ent

Co

mp

ari

son

gro

up

Un

clea

r—o

nly

SP

Sm

ean

sco

res

pro

vid

edN

o—

all

pati

ents

had

neu

rast

hen

iad

iagn

ose

s

Yes

—m

enw

ith

sex

ual

com

pla

ints

wit

ho

ut

dh

at

No

—all

pati

ents

re-

po

rted

dh

at

Yes

—d

enia

lo

fd

hat

com

pla

int

Psy

chia

tric

cate

go

rie

sP

TS

DA

nx

iety

,d

epre

ssio

n,

som

ati

zati

on

,ch

ron

icp

ain

Dep

ress

ion

An

xie

ty,

dep

ress

ion

An

xie

ty(G

AD

,p

an

ic,

OC

D),

dep

ress

ion

,so

mato

form

dis

ord

ers

Inst

rum

en

ts,

va

lid

ati

on

HT

Q,

PC

L-C

,C

SS

I;P

CL

-Ccl

inic

all

yva

lid

ate

din

Kh

mer

Cli

nic

ian

dia

gn

ose

sH

AM

-DC

lin

ical

inte

rvie

wC

lin

ical

inte

rvie

ww

ith

DS

M-I

II-R

crit

eria

Fu

nct

ion

ing

Per

ceiv

edli

mit

ati

on

sre

late

dto

hea

lth

statu

sC

lin

ical

inte

rvie

wN

ot

rep

ort

edN

ot

rep

ort

edN

ot

rep

ort

ed

(co

nti

nu

ed)

CULTURAL CONCEPTS OF DISTRESS AND PSYCHIATRIC DISORDERS 13

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

Dow

nloaded from

Ta

ble

1c

Co

nti

nu

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Re

fere

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Dh

iva

k2

00

76

7G

au

tha

m2

00

86

9P

erm

e2

00

59

1S

ing

h1

98

59

6B

ha

tia

19

99

58

Co

un

try

Ind

iaIn

dia

Ind

iaIn

dia

Ind

ia

Cu

ltu

ral

con

cep

to

fd

istr

ess

Dh

at

(sem

enlo

ssin

uri

ne)

Dh

at

(sem

enlo

ssin

uri

ne)

Dh

at

(sem

enlo

ssin

uri

ne)

Dh

at

(sem

enlo

ssin

uri

ne)

Dh

at

(sem

enlo

ssin

uri

ne)

,k

oro

(gen

ital

retr

act

ion

)

Te

rmin

olo

gy

Cu

ltu

re-b

ou

nd

syn

dro

me

Cu

ltu

re-b

ou

nd

syn

dro

me

Cu

ltu

re-b

ou

nd

syn

dro

me

Co

mm

on

lyre

cogn

ized

clin

ical

enti

tyin

def

ined

cult

ure

Cu

ltu

re-b

ou

nd

syn

dro

me

Re

sea

rch

ob

ject

ive

Pre

vale

nce

of

dep

ress

ion

am

on

gp

erso

ns

wit

hd

hat

Male

sex

ual

hea

lth

con

cern

sev

alu

ate

dfr

om

bio

med

ical,

an

thro

po

logic

al

an

dp

sych

iatr

icfr

am

ewo

rks

Co

mp

are

dh

at

an

dn

on

-dh

at

pati

ents

on

illn

ess

bel

iefs

an

dso

mati

zati

on

Am

on

gm

ale

sw

ith

po

ten

cyd

iso

rder

s,ass

ess

cult

ura

lil

lnes

san

dp

sych

iatr

icd

iso

rder

s

So

cio

dem

ogra

ph

ics

an

dp

sych

iatr

icco

mo

rbid

-it

yam

on

gp

erso

ns

wit

hC

BS

Re

cru

itm

en

tC

lin

ical

Cli

nic

al

Cli

nic

al

Cli

nic

al

Cli

nic

al

Sa

mp

leA

du

lt:

30

pati

ents

pre

sen

tin

gto

psy

chia

try

OP

Dw

ith

com

pla

int

of

sem

enlo

ssin

uri

ne

Ad

ult

:3

66

men

pre

sen

tin

gto

OP

Ds

wit

hse

xu

al/

gen

ital

com

pla

ints

Ad

ult

:6

1p

ati

ents

pre

sen

tin

gto

OP

Dw

ith

ou

tm

oo

do

ran

xie

tyd

iso

rder

s

Ad

ult

:5

0co

nse

cuti

vep

ati

ents

inp

sych

iatr

yO

PD

wit

hse

xu

al

dys

fun

ctio

nco

mp

lain

t

Ad

ult

:6

0ad

ult

sp

rese

nti

ng

top

sych

iatr

yO

PD

wit

hp

sych

ose

xu

al

com

pla

ints

Ass

ess

me

nt

me

tho

dC

lin

icia

nS

ingle

-ite

mse

lf-r

epo

rtC

lin

icia

nC

lin

icia

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ingle

-ite

mse

lf-r

epo

rt

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va

len

ceC

urr

ent

Cu

rren

tU

ncl

ear

Cu

rren

tU

ncl

ear

Co

mp

ari

son

gro

up

No

—all

pati

ents

dia

gn

ose

dw

ith

dh

at

Yes

—d

hat

neg

ati

vem

enin

clu

ded

Yes

—p

art

icip

an

tsn

ot

mee

tin

gcl

inic

al

cri-

teri

afo

rd

hat

Yes

—p

ati

ents

no

tcl

in-

icall

yd

iagn

ose

dw

ith

dh

at

Yes

—p

ati

ents

wit

ho

ut

dh

at

or

ko

ro

Psy

chia

tric

cate

go

rie

sD

epre

ssio

nP

sych

olo

gic

al

dis

tres

sS

om

ati

zati

on

,fa

tigu

eA

nx

iety

,d

epre

ssio

n,

fati

gu

e,p

sych

oti

cd

epre

ssio

n

An

xie

ty,

dep

ress

ion

Inst

rum

en

ts,

va

lid

ati

on

HA

M-D

GH

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vali

dati

on

info

r-m

ati

on

no

tp

rovi

ded

SS

I,C

FS

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lid

ati

on

no

tre

po

rted

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lid

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tre

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nic

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inte

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ing

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tre

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rted

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tre

po

rted

No

tre

po

rted

No

tre

po

rted

No

tre

po

rted

(co

nti

nu

ed)

14 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

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ow

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ldo

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scale

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no

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CULTURAL CONCEPTS OF DISTRESS AND PSYCHIATRIC DISORDERS 15

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

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Re

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tom

inve

nto

ry

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va

len

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mp

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son

gro

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—p

ati

ents

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an

dlo

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ore

so

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KS

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nto

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es—

pati

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on

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tric

cate

go

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al

an

xie

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mati

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rum

en

ts,

va

lid

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gn

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hald

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eIn

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gn

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ican

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tal

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ord

ers;

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DS

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din

bu

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erali

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xie

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iso

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esti

on

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epre

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ati

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le);

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op

kin

sS

ymp

tom

Ch

eck

list

;H

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arv

ard

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um

aQ

ues

tio

nn

air

e;K

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eyIn

form

an

t;M

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ajo

rD

epre

ssiv

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iso

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LA

AS

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ati

on

al

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no

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an

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eric

an

Stu

dy;

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sess

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mp

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er);

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tpati

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Dep

art

men

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esti

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au

mati

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esti

on

nair

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nt

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luati

on

of

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tal

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ord

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PS

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han

Vie

tnam

ese

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chia

tric

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le;

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cial

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xie

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iso

rder

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tru

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esti

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nto

ry;

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S,

Taij

inK

yofu

Sh

o.

16 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

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nloaded from

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ple

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ent

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ay

be

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the

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ind

ivid

uals

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hom

the

re-

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from

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ich

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tsare

sele

cted

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from

ap

ool

of

elig

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earl

yd

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ted

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cted

from

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)

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est

ud

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ns

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bec

au

seof

self

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elli

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bei

ng

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ya

clin

icia

nor

bei

ng

lab

elle

db

yso

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oth

erk

eyin

-fo

rman

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oth

er-

an

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port

ed.

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rly

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gro

up

tow

hic

hgen

erali

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on

sco

uld

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dra

wn

(e.g

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pa-

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for

CC

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clea

rly

def

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gro

up

of

self

-en

dors

ing

idio

mor

clin

icia

n-/

key

info

rman

t-as-

sign

edcr

iter

ia;

dif

fere

nce

sb

etw

een

self

-an

doth

er-

lab

elli

ng

shou

ldb

ere

port

ed;

No¼

sele

ctor

bia

sed

gro

up

not

gen

erali

zab

leb

eyon

dre

searc

hst

ud

y(e

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CC

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ase

don

rese

arc

hcr

iter

iaon

ly,

such

as

nu

mb

erof

som

atic

com

pla

ints

,b

ut

not

gen

erali

z-ab

leto

ap

pli

cati

on

of

CC

Dou

tsid

est

ud

yco

nte

xts

)

Me

tho

dT

he

met

hod

of

part

icip

an

tre

cru

itm

ent/

sele

ctio

nm

ust

be

giv

enR

ecru

itm

ent

pro

cess

esin

clin

ical

or

com

mu

nit

yse

ttin

gs

shou

ldb

ere

port

edb

ecau

sep

ub

lic

vsp

riva

tese

ttin

gs

may

imp

act

on

end

ors

emen

tof

CC

D.

Pote

nti

al

bia

ses

rela

ted

tost

igm

ati

zin

gasp

ects

of

CC

Dsh

ou

ldb

eco

n-

sid

ered

inre

cru

itm

ent

met

hod

.F

or

key

info

rman

t-id

enti

fied

part

icip

an

ts,

pote

nti

al

bia

ses

shou

ldb

ead

-d

ress

edsu

chas

not

wan

tin

gto

lab

elin

div

idu

als

inp

osi

tion

sof

pow

eras

suff

erin

gfr

om

CC

D,

esp

ecia

lly

ifk

eyin

form

an

tsare

kn

ow

nto

the

com

mu

nit

y

Yes¼

met

hod

of

recr

uit

men

tre

port

ed,

pote

nti

al

bia

ses

inC

CD

end

ors

emen

tfr

om

recr

uit

men

tm

eth

od

shou

ldb

ed

iscu

ssed

;n

um

ber

of

per

son

sap

pro

ach

edan

dn

um

ber

con

sen

tin

gor

refu

sin

gsh

ou

ldb

ein

clu

ded

;N

o¼

recr

uit

men

tm

eth

od

not

des

crib

edor

no

ack

now

led

gem

ent

of

recr

uit

men

tap

pro

ach

an

dC

CD

end

ors

emen

tb

ias

Siz

eT

he

au

thors

shou

ldd

escr

ibe

how

the

sam

ple

size

was

det

erm

ined

an

dad

equ

acy

of

sam

ple

size

toad

dre

ssre

searc

hq

ues

tion

Sam

ple

size

sid

eall

ysh

ou

ldb

eb

ase

don

pow

erca

lcu

la-

tion

sw

ith

pre

vale

nce

esti

mate

s.F

or

com

mon

lyre

-se

arc

hed

CC

Dsu

chas

ner

vios-

rela

ted

con

dit

ion

s,d

hat

an

dh

wa-b

yun

g,

pre

vale

nce

esti

mate

sin

clin

ical

an

dco

mm

un

ity

sett

ings

are

ava

ilab

le.

For

nove

lC

CD

stu

-d

ies,

key

info

rman

tsan

dp

rim

ary

care

clin

icia

ns

cou

ldb

eu

sed

togro

ssly

esti

mate

pre

vale

nce

inord

erto

de-

term

ine

ifC

CD

are

rare

or

com

mon

inth

eta

rget

gro

up

Yes¼

pow

erca

lcu

lati

on

for

sam

ple

size

incl

ud

edor

eth

nogra

ph

icp

reva

len

cees

tim

ate

base

don

key

in-

form

an

ts;

No¼

no

rati

on

ale

giv

enfo

rsa

mp

lesi

ze

Incl

usi

on

/e

xcl

usi

on

crit

eri

a

All

incl

usi

on

an

dex

clu

sion

crit

eria

shou

ldb

eex

pli

citl

yd

escr

ibed

un

am

big

uou

sly

an

dap

pli

edeq

uall

yto

all

gro

up

s

Incl

usi

on

/ex

clu

sion

crit

eria

shou

ldb

ead

dre

ssed

inth

ree

dom

ain

s:cu

ltu

ral

gro

up

,C

CD

an

dp

sych

iatr

icd

isord

er.

IfC

CD

are

bei

ng

inve

stig

ate

din

ap

art

icu

lar

gro

up

,th

enth

ecu

ltu

ral

incl

usi

on

/ex

clu

sion

shou

ldb

ecl

ear,

e.g.

self

-lab

elli

ng,

pri

mary

lan

gu

age,

loca

tion

of

resi

-d

ence

.F

or

CC

D,

incl

usi

on

an

dex

clu

sion

crit

eria

shou

ldre

fer

tose

lf-e

nd

ors

emen

t,cu

rren

tor

pri

or

epis

od

es,

du

rati

on

of

CC

Dre

qu

ired

for

incl

usi

on

an

dco

morb

idit

yw

ith

oth

erC

CD

.F

or

psy

chia

tric

dis

ord

ers,

clea

rin

clu

-si

on

an

dex

clu

sion

crit

eria

esp

ecia

lly

regard

ing

sub

-st

ance

use

dis

ord

ers,

psy

choti

cd

isord

ers

an

dco

gn

itiv

ed

isord

ers

shou

ldb

ed

escr

ibed

Yes¼

def

ined

crit

eria

,e.

g.

incl

usi

on

age,

spok

enla

n-

gu

age,

eth

nic

ity

etc.

CC

Dcu

rren

tvs

ever

,d

ura

tion

,et

c.E

xcl

usi

on

of

psy

chosi

s,co

gn

itiv

eim

pair

men

t,su

bst

an

cem

isu

se;

No¼

un

kn

ow

ncr

iter

iafo

rcu

l-tu

ral

gro

up

incl

usi

on

,u

nk

now

np

sych

iatr

icor

ph

ysic

al

com

orb

idit

y,u

nk

now

np

rior

epis

od

esof

CC

D

(co

nti

nu

ed)

CULTURAL CONCEPTS OF DISTRESS AND PSYCHIATRIC DISORDERS 17

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

Dow

nloaded from

Ta

ble

2C

on

tin

ued

SA

QO

Ro

rig

ina

lD

esc

rip

tio

nC

ult

ura

lP

sych

iatr

yE

pid

em

iolo

gy

(CP

E)

mo

dif

ica

tio

ns

SA

QO

R-C

PE

mo

dif

ied

eva

lua

tio

n

CO

NT

RO

L/C

OM

PA

RIS

ON

GR

OU

P

Incl

usi

on

Un

less

itis

ad

escr

ipti

vest

ud

yor

case

rep

ort

/se

ries

,co

ntr

ol

gro

up

mu

stb

ein

clu

ded

To

dra

wco

ncl

usi

on

sab

ou

tass

oci

ati

on

of

CC

Dw

ith

psy

-ch

iatr

icd

isord

ers,

ph

ysic

al

hea

lth

pro

ble

ms,

trau

mati

cex

posu

res,

soci

oec

on

om

icvu

lner

ab

ilit

yet

c.,

itis

cru

cial

toh

ave

aco

ntr

ol

gro

up

wh

ich

does

not

end

ors

eth

eC

CD

.T

hen

com

par

ison

sca

nb

em

ad

ere

gard

ing

gre

ate

ror

less

erli

kel

ihood

am

on

gth

ose

wit

hC

CD

Yes¼

rep

rese

nta

tive

com

mu

nit

ysa

mp

lew

ith

per

son

sn

ot

end

ors

ing

CC

Dor

clin

ical

or

com

mu

nit

ysa

mp

lew

ith

matc

hed

part

icip

an

tsn

ot

end

ors

ing

CC

D;

No¼

lack

of

com

par

ison

gro

up

Ide

nti

fia

ble

Isth

ere

acl

ear

dis

tin

ctio

nb

etw

een

the

gro

up

sin

the

stu

dy?

Are

the

sam

eva

riab

les

con

-si

der

edin

the

con

trol

gro

up

as

inth

eex

pose

dgro

up

(s)?

Con

trol/

com

pari

son

gro

up

ssh

ou

ldb

ecl

earl

yd

isti

n-

gu

ish

edb

ase

don

CC

Dst

atu

s.L

ifet

ime

CC

Dex

per

ien

ceis

gen

erall

yst

raig

htf

orw

ard

.H

ow

ever

,w

hen

on

lycu

r-re

nt

CC

Dare

ass

esse

d,

con

trols

may

incl

ud

ep

art

ici-

pan

tsw

ith

rece

nt

CC

Dep

isod

esth

atco

ncl

ud

edb

efore

the

stu

dy

targ

etp

erio

d

Yes¼

con

trol

of

con

fou

nd

ssu

chas

oth

erd

isord

ers

inca

ses

an

dco

ntr

ols

;cl

ear

dis

tin

ctio

nb

etw

een

life

-ti

me

or

curr

ent

CC

D;

No¼

com

par

ison

gro

up

sw

her

eco

nfo

un

ds

or

pri

or

CC

Dare

not

con

troll

ed

So

urc

eC

on

trol

gro

up

shou

ldb

ed

raw

nfr

om

the

sam

ep

op

ula

tion

as

the

exp

ose

dgro

up

(s)

Th

eso

urc

efo

rco

ntr

ols

inth

eco

mm

un

ity

or

clin

icsh

ou

ldco

me

from

com

para

ble

pop

ula

tion

sb

ase

don

cult

ura

l/et

hn

ic/l

ingu

isti

cgro

up

,h

ealt

hst

atu

s,age,

resi

den

ceet

c.R

ecru

itm

ent

stra

tegie

ssh

ou

ldb

eth

esa

me

for

con

trols

tom

inim

ize

imp

act

of

recr

uit

men

tm

eth

od

of

bia

sin

gen

dors

emen

t

Yes¼

case

san

dco

ntr

ols

dra

wn

from

com

par

ab

leso

cial

gro

up

san

dsi

mil

ar

con

tex

t(e

.g.

com

mu

nit

yor

clin

ic),

usi

ng

the

sam

ere

cru

itm

ent

met

hod

;N

o¼

lack

of

rep

ort

ing

ab

ou

tco

ntr

ol

sou

rce

or

dif

-fe

ren

ces

inso

urc

eth

atin

crea

seri

skof

bia

s

Ma

tch

ed

or

ran

do

miz

eF

or

matc

hed

stu

die

s,m

atc

hin

gcr

iter

iaare

giv

en.

For

ran

dom

ized

stu

die

s,ra

nd

om

iza-

tion

met

hod

isd

escr

ibed

To

iden

tify

key

featu

res

that

dis

tin

gu

ish

per

son

sw

ith

CC

Dfr

om

those

wh

od

on

ot

end

ors

eth

eC

CD

,m

atc

hin

gan

doth

erst

rate

gie

sm

ay

be

use

d.

Ifu

sed

,th

em

atc

hin

gcr

iter

iaan

dan

aly

tic

pro

cess

shou

ldb

ed

escr

ibed

ind

etail

.M

atc

hin

gcr

iter

iash

ou

ldb

ere

le-

van

tto

the

CC

D

Yes¼

matc

hin

gcr

iter

ia(e

.g.

pro

pen

sity

score

matc

h-

ing

or

sele

ctio

np

roce

ss);

No¼

no

matc

hin

gor

ran

dom

izati

on

pro

ced

ure

use

dor

des

crib

ed

Sta

tist

ica

lco

ntr

ol

Gro

up

sse

lect

edfo

rco

mp

ari

son

are

as

sim

ilar

as

poss

ible

inall

chara

cter

isti

csex

cep

tfo

rth

eir

exp

osu

rest

atu

s

Sta

tist

ical

an

alys

essh

ou

ldco

ntr

ol

for

as

man

yp

ote

nti

al

con

fou

nd

sas

poss

ible

,w

ith

spec

ial

att

enti

on

toco

n-

fou

nd

sth

atco

uld

infl

uen

ceC

CD

end

ors

emen

t,su

chas

year

sin

an

ewco

un

try

for

imm

igra

nts

an

dre

fugee

s,la

ngu

age

pro

fici

ency

,et

hn

icgro

up

an

dre

gio

nof

resi

den

ce

Yes¼

con

trol

for

con

fou

nd

sor

oth

ercr

iter

iaw

hen

com

par

ing

bet

wee

ngro

up

s;N

o¼

biv

ari

ate

com

par

i-so

ns

that

do

not

incl

ud

ep

ote

nti

al

con

fou

nd

s

CU

LT

UR

AL

CO

NC

EP

TS

OF

DIS

TR

ES

S(C

CD

)

CC

Dca

teg

ori

cal

Not

ap

pli

cab

leP

art

icip

an

tssh

ou

ldb

ecl

ass

ifia

ble

as

CC

Dan

dn

on

-CC

Dgro

up

sb

ase

don

curr

ent

or

life

tim

ep

reva

len

ce,

clin

-ic

ian

dia

gn

ose

sor

key

info

rman

top

inio

ns.

Res

earc

her

-d

efin

edcr

iter

ia(e

.g.

sym

pto

mcu

toff

score

s)alo

ne

are

insu

ffic

ien

tto

cap

ture

cult

ura

lly

sign

ific

an

tim

pli

ca-

tion

sof

CC

Dst

atu

s

Yes¼

self

-rep

ort

for

(cu

rren

tor

life

tim

e)C

CD

end

ors

edor

den

ied

;N

o¼

un

ab

leto

ass

ess

from

data

wh

eth

erp

erso

ns

end

ors

eC

CD

or

den

y(o

nly

pro

xie

su

sed

)

CC

Dp

reva

len

ceN

ot

ap

pli

cab

leC

CD

class

ific

ati

on

tim

ep

erio

dsh

ou

ldb

ecl

earl

yd

efin

ed.

Isli

feti

me

or

curr

ent

pre

vale

nce

use

d?

Ifcu

rren

tp

reva

len

ce,

then

wh

at

isth

eti

me

per

iod

:1

wee

k,

2w

eek

s,1

mon

thet

c.?

Yes¼

life

tim

eor

curr

ent

pre

vale

nce

isre

port

ed,

an

dp

erio

dof

curr

ent

pre

vale

nce

issp

ecif

ied

;N

o¼

un

clea

rp

reva

len

cere

port

ing

(co

nti

nu

ed)

18 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

Dow

nloaded from

Ta

ble

2C

on

tin

ued

SA

QO

Ro

rig

ina

lD

esc

rip

tio

nC

ult

ura

lP

sych

iatr

yE

pid

em

iolo

gy

(CP

E)

mo

dif

ica

tio

ns

SA

QO

R-C

PE

mo

dif

ied

eva

lua

tio

n

CC

Dla

be

lty

pe

Not

ap

pli

cab

leT

he

typ

eof

CC

Dsh

ou

ldb

ed

escr

ibed

wit

hq

uali

tati

vein

form

ati

on

,as

wel

las

qu

an

tita

tive

info

rmati

on

ifp

oss

ible

.F

or

exam

ple

,is

CC

Datt

rib

uti

on

base

don

sin

gle

ob

ject

ive

or

sub

ject

ive

sym

pto

ms,

or

co-o

ccu

r-ri

ng

sym

pto

ms,

cert

ain

typ

esof

exp

osu

res

an

dp

re-

sum

edca

use

sor

spec

ific

vuln

erab

ilit

ygro

up

s?L

ab

els

such

as

sym

pto

m-b

ase

dC

CD

,sy

nd

rom

e-b

ase

dC

CD

,aet

iolo

gy-

base

dC

CD

or

mix

edm

ay

be

ap

pli

cab

lein

som

est

ud

ies.

Wh

enp

oss

ible

,if

aC

CD

isb

ase

don

ap

resu

med

exp

osu

re,

the

typ

ean

dti

min

gof

the

ex-

posu

resh

ou

ldb

ere

port

ed

Yes¼

qu

ali

tati

veor

qu

an

tita

tive

info

rmati

on

isp

ro-

vid

edb

ase

don

how

CC

Dis

class

ifie

d,

e.g.

sym

p-

tom

,sy

nd

rom

e,aet

iolo

gy

or

mix

ed;

No¼

un

clea

rw

hy

part

icip

an

tsen

dors

eC

CD

lab

el

CC

Dse

ve

rity

Not

ap

pli

cab

leS

ever

ity

info

rmati

on

shou

ldb

ep

rovi

ded

,e.

g.

freq

uen

cyof

att

ack

sor

epis

od

es,

nu

mb

erof

sym

pto

ms,

inte

nsi

tyof

epis

od

esor

sym

pto

ms,

or

deg

ree

of

imp

air

men

tass

o-

ciate

dw

ith

CC

D.

Sev

erit

yin

form

ati

on

all

ow

sfo

rco

mp

aris

on

sof

mil

dly

or

seve

rely

aff

ecte

din

div

idu

als

an

dth

eass

oci

ati

on

wit

hoth

erva

riab

les.

Yes¼

seve

rity

ass

esse

dth

rou

gh

freq

uen

cy,

seve

rity

,n

um

ber

of

ass

oci

ate

dsy

mp

tom

sor

fun

ctio

nin

g;

No¼

un

clea

rh

ow

seve

re;

un

clea

rass

oci

ati

on

wit

him

pair

men

t

CC

Dco

urs

eN

ot

ap

pli

cab

leIn

form

ati

on

regard

ing

CC

Dco

urs

ep

reve

nts

spu

riou

sas-

soci

ati

on

sor

mis

inte

rpre

tati

on

of

fin

din

gs

of

psy

chi-

atr

icass

oci

ati

on

s.C

CD

age

of

on

set,

du

rati

on

of

most

rece

nt

epis

od

ean

dp

rese

nce

of

epis

od

icor

chro

nic

sym

pto

ms

shou

ldb

ein

clu

ded

.In

form

ati

on

regard

ing

tim

ing

of

psy

chia

tric

sym

pto

ms

shou

ldb

ein

clu

ded

tod

eter

min

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het

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Dp

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,co

-occ

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dep

end

ent

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psy

chia

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ord

ers

Yes¼

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of

on

set,

du

rati

on

of

epis

od

e,n

um

ber

of

epis

od

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dti

min

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ith

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dia

gn

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s;N

o¼

Un

clea

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her

curr

ent

or

pri

or

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od

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det

ecte

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rd

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chro

nic

vsep

isod

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e

ME

AS

UR

EM

EN

TQ

UA

LIT

Y

Ex

po

sure

How

did

the

au

thors

asc

erta

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atth

eca

ses/

exp

ose

dgro

up

had

ind

eed

bee

nex

pose

dto

the

vari

ab

leof

inte

rest

?

Most

CC

Ds

are

ass

oci

ate

dw

ith

ap

resu

med

stre

ssfu

lex

-p

osu

re,

inth

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chro

nic

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form

ati

on

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mp

ora

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on

ship

of

the

CC

Dto

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exp

osu

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Ex

posu

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shou

ldb

ere

cord

edam

on

gb

oth

CC

Dan

dn

on

-CC

Dp

art

icip

an

ts.

Yes¼

info

rmati

on

isp

rovi

ded

regard

ing

chro

nic

or

epis

od

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posu

res

pre

sum

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oci

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wit

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;N

o¼

no

info

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on

on

exp

osu

res

rep

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ed

Ou

tco

me

sT

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rly

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stu

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(s);

Incl

inic

al

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die

s,th

eou

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esso

rw

as

bli

nd

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exp

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than

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For

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the

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the

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sych

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an

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port

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Ifth

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108,1

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erm

inat

ion

109

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.

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psy

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ents

vali

date

dfo

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sew

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stu

dy

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ula

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an

dp

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men

ts,

e.g.

on

lyu

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back

tran

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(co

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CULTURAL CONCEPTS OF DISTRESS AND PSYCHIATRIC DISORDERS 19

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ber 24, 2013http://ije.oxfordjournals.org/

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ult

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imp

air

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ith

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FO

LL

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Pa

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lost

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Does

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;N

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Was

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Rea

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Yes¼

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Dch

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Not

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Dat

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Dass

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that

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DIS

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RT

ING

INF

LU

EN

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S

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how

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ies)

inth

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aly

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ou

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es:

did

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nt

as

on

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the

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on

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igh

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incl

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/ex

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-si

on

crit

eria

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atis

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idit

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are

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dp

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Yes¼

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for

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orb

idit

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thro

ugh

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/ex

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/ex

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how

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doth

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part

icip

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tsm

ay

have

bee

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kin

g:

did

they

con

trol

for

them

inth

ean

aly

sis

of

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es?

Tre

atm

ent

(both

bio

med

ical

an

dtr

ad

itio

nal)

wil

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flu

-en

cecu

rren

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D.

Cu

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tor

pri

or

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-ch

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may

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act

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statu

s.T

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statu

sth

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may

con

fou

nd

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oci

ati

on

sb

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een

CC

Dan

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n;

No¼

no

info

rmati

on

pro

vid

edon

curr

ent

or

pri

or

trea

tmen

t

(co

nti

nu

ed)

20 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

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Dan

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pto

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the

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the

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the

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Mis

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For

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Yes¼

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Pre

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Data

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Data

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Yes¼

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Dan

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Dan

dn

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Dp

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CULTURAL CONCEPTS OF DISTRESS AND PSYCHIATRIC DISORDERS 21

by guest on Decem

ber 24, 2013http://ije.oxfordjournals.org/

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22 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

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CULTURAL CONCEPTS OF DISTRESS AND PSYCHIATRIC DISORDERS 23

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CULTURAL CONCEPTS OF DISTRESS AND PSYCHIATRIC DISORDERS 25

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CULTURAL CONCEPTS OF DISTRESS AND PSYCHIATRIC DISORDERS 27

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novel CCD are investigated, primary care workers,traditional healers or other key informants could beused to grossly judge whether a CCD is common orinfrequent. Of note, if multiple sites are used, control-ling for clustering needs to be considered in calcula-tions; local variation in terminology and socialcomposition may affect CCD endorsement. Only onestudy used a power calculation, which was based onestimates of receiving quality care and not based onCCD prevalence.69

Inclusion/exclusion criteria are crucial for any epi-demiological study, to minimize confounds and tohave internally comparable participants. For culturalpsychiatry, three domains of inclusion/exclusion cri-teria are important: (i) cultural group, (ii) psychiatricconditions and (iii) CCD. Defining a cultural groupcould be based on self-labelled ethnicity, linguisticproficiency, years living in particular region or otherculturally salient group identifiers. Common psychi-atric exclusion criteria are substance use disorders,psychotic disorders or cognitive impairment. Onestudy of nervios in Mexico used the CompositeInternational Diagnostic Interview (CIDI) to excludeparticipants with substance use disorders and physicalinjuries that produce nervios.94 A total of 42 studiesreported some form of inclusion/exclusion criteria.

Control/Comparison GroupAll criteria for this category were retained for theSAQOR-CPE.

Inclusion refers to the presence of a comparisongroup. For the majority of research objectives in cul-tural epidemiology studies, a comparison group isneeded to test inferences. For example, rate of depres-sion among persons without a CCD is important todetermine whether a CCD increases depression risk.In a study of a somatic CCD in Nepal, auditory hal-lucinations were reported by one-fifth of CCD suf-ferers; however, the control group reported anequally high prevalence of auditory hallucinations.99

In a validation study of the Hopkins SymptomChecklist (HSCL) in Rwanda, a CCD did not differen-tiate between persons with and without anhedonia,100

thus demonstrating that this CCD was not appropriateto selectively identify persons with that feature ofdepression. A total of 36 studies included non-CCDparticipants.

Identifiable refers to use of a strategy to clearly dif-ferentiate cases from controls. This is generallystraightforward when lifetime prevalence is assessedthrough self-labelling. However, when assessing cur-rent episodes, there should be a clear time period toidentify cases and controls. For example, if 2-weekprevalence is used, is a control with no lifetime epi-sodes comparable to a control with an episode thatended 3 weeks ago? All but 1 study including a com-parison provided information regarding how the non-CCD group was identified.

Source refers to cases and controls drawn from simi-lar populations. If cases are selected from a psychi-atric clinic and controls are drawn from other medicalclinics, this biases the CCD group to have greaterprevalence of psychiatric conditions. Community rep-resentative samples are ideal to assure the samesource.71,72,79,93,101. Only one study lacked informa-tion on source of control participants.

Matching and randomization may be used in somestudies to optimize similarities between groups. Forexample, if a researcher is trying to identify family-related protective factors against ataque de nervios,then matching based on economic status, educationalstatus and residential region in recruitment or statis-tical techniques such as propensity score matchingwould be helpful. Matching could be used to controlfor issues related to language proficiency55 or years ofresidence in a new country that may confound en-dorsement of a CCD. One study employed a matchingprocess.

Statistical control refers to using multivariable modelsto control for issues that may confound relationshipsbetween CCD and psychiatric disorders such as socio-economic status, other psychiatric comorbidities andstressful exposures. A study of dhat found an associ-ation with psychological distress (General HealthQuestionnaire caseness) when statistically controllingfor age, district of residence and marital status, all ofwhich were independently associated with dhat.69 Inthe multivariable analysis, only psychological casenessand region of residence independently associated withdhat. A total of 22 studies included some form ofmultivariable analysis.

Cultural Concept of DistressCCD is a category added to the SAQOR for culturalpsychiatry studies.

CCD categorical classification refers to the presentationof data on who does and does not endorse a CCD as adichotomous variable, ideally through self-endorse-ment by participants; 27 (60%) of the studiesincluded a categorical response by participants regard-ing whether they did or did not endorse having theCCD. The remainder used either clinically-assignedlabels of a CCD or a proxy measure, such as havingsomatic complaints.

CCD prevalence refers to obtaining data on lifetimeand/or current prevalence: if current prevalence,then the time period should be specified; 10 (22%)studies assessed lifetime prevalence and 19 (41%) as-sessed current CCD, such as in the past 2 weeks orpast month and 17 (37%) were unclear regarding timeframe and whether the time range matched with thetiming of the psychiatric disorder. For example, somestudies did not include assessment period and othersused vague language, such as ‘recent’ episodes.

CCD label type should describe whether the CCD isattributed according to a single symptom, a constella-tion of symptoms, a certain type of exposure or being

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part of a vulnerable group. In many cases, CCD mayreflect a combination of the above. A study inMongolia78 used the Explanatory Model InterviewCatalogue (EMIC)31,32 to collect this information. In astudy of women in Zimbabwe, explanatory models werecollected and revealed that kufungisisa was both asymptom of distress and a cause of health problems.54

A total of 37 studies included information on label type.CCD severity refers to measurement of the frequency,

number of associated symptoms or degree of impair-ment associated with a CCD. For example, two indi-viduals may both endorse lifetime ataques de nerviosbut one individual may have weekly episodes whereasthe other has them every few years. This wouldimpact the association with psychiatric categories; 27studies included severity information.

CCD course refers to the age of onset, duration of epi-sodes, timing of episodes and chronicity of experience,with special attention to overlapping periods with psy-chiatric symptoms. For example, the mean age of onsetof dhat in one study was 21.6 years among men.59

Knowing this could help readers of the study considerpotential psychosocial erectile dysfunction versus age-or diabetes-related dysfunction. Studying onset ofataque de nervios revealed that the episodes typicallypreceded depression and anxiety symptoms,70 whichis helpful information for screening and prevention.Only 14 studies included course information.

Measurement QualityThe Measurement Quality category of the SAQOR in-cludes exposure and outcome measures. An additionalcategory for functioning was based on the CCDliterature.

Exposure is important for CCD because explanatorymodels typically associate certain types of experienceswith invoking CCD. For example, family, financial,health and political stressors are strongly associatedwith jham-jham paresthesia in rural Nepal.79

However, work and academic stressors are not risk fac-tors for jham-jham. This contrasts with brain fag inNigeria, in which academic stress is assumed to beone of the main precipitants.86,102 Orthostatic hypoten-sion is not assumed by the lay American public to be atrigger for PTSD, but Hinton and colleagues have shownthat this sensation mediates post-traumatic psychiatricsequelae among Cambodians.103-106 Therefore, assess-ing dizziness and orthostatic hypotension triggers iscrucial to a culturally salient study of khyal attacks. Atotal of 32 studies included information on exposures.

Psychiatric outcome measures require special attentionin cross-cultural research. If an instrument has notbeen validated in the local context, results are difficultto interpret.107 Lack of association between CCD andthe psychiatric measure may be due to using a non-validated instrument rather than cultural-exclusivityof the distress; 24 studies used instruments validatedfor the cultural group, and some provided psychomet-ric properties for the instrument in that

population.54,61,66,79,92 When instruments have notbeen validated, then significant detail should be pro-vided on how instruments underwent transculturaltranslation to achieve cross-cultural equivalence.108,109

Functional outcome was added as an additional criterionfor measurement quality. Early debates in culture-bound syndrome research raised questions aboutdistinguishing between abnormal behaviours relatedto cultural performance vs abnormal behaviours asso-ciated with impairment in multiple domains of life.110–

112 Bolton and colleagues have developed rapid, feasibleapproaches to create functional impairment meas-ures.113 Their approach makes it easy to assess whetherpersons with CCD are more likely to have impaired rolefulfilment. Other studies in our review used standardfunctioning measures such as the WHO DisabilityAssessment Schedule (WHODAS) and the SheehanDisability Scale. A total of 20 studies reported someform of functioning assessment.

Follow-UpThe Follow-Up category includes percentage lost tofollow-up and reasons lost to follow-up. We addedchange in CCD prevalence. Four studies included afollow-up assessment.

Percentage lost to follow-up is standard reporting forlongitudinal studies. In a Nigerian study, 57% ofpatients with ode ori participated in a 1-year follow-up evaluation.84

Wherever possible,Reasons for loss to follow-up shouldbe elicited and reported to inform interpretation ofresults, highlight potential biases, and help shapefuture longitudinal studies of CCD. In a study ofdhat, follow-up rates were much lower among pa-tients receiving counselling compared with patientsreceiving medication; this suggested that participantswere dissatisfied with psychotherapeutic interventionsand dropped out.59

We added CCD change at follow-up as an additional cri-terion. In the CCD literature we reviewed, a major short-coming was lack of CCD documentation at follow-up. Intreatment studies of dhat and hwa-byung, CCD was notevaluated post treatment.59,114,115 Among Cambodianrefugees with ‘thinking too much,’ 58% of patients inCalifornia received sedatives whereas 20% did inMassachusetts; however, no information was providedregarding which group showed better outcomes.116 Theabsence of information on resolution of CCD duringmental health treatment is a major gap in the existingliterature. In studies in Nigeria and China, CCD did notresolve after psychotropic medication despite improve-ment in psychiatric disorders.77,84 In contrast, studies ofculturally adapted psychotherapy treatments showedimprovement for ataque de nervios among Latinasand khyal attacks among Cambodian refugees.75,106 Astudy with pharmacotherapy showed improvement ofkhyal attacks, ‘thinking a lot’ and several other idiomsamong Cambodian refugees as measured by effectsizes.135 Measuring CCD in longitudinal observational

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and treatment studies is crucial to determine whetherCCD worsen, resolve with or are independent of psychi-atric symptoms trajectories.

Distorting InfluencesDistorting Influences in the original SAQOR focusedon distorting influences related to maternal depres-sion.98 We modified the distorting influences categoryfor factors that commonly confound cultural psych-iatry epidemiology studies.

Psychiatric comorbidities: because of the high rate ofcomorbidity among psychiatric disorders, it is possiblethat associations between CCD and a target psychi-atric disorder are the result of another condition.For example, PTSD and depression are often comor-bid. If CCD have significant associations with PTSD, itmay be that the associations are better explained byassociations with depression. Controlling for comor-bidities through selection criteria and analysis is cru-cial. In a study of social phobia and taijin-kyofu-sho(TKS), a CCD in Japan and Korea, the researchersexcluded persons with major depressive disorders, bi-polar affective disorder, psychosis and substancemisuse to assure that associations between TKS andsocial phobia were not the result of mutual associ-ations with other disorders.65 In a study of a fatigueCCD in Mongolia, yadargaa associated significantlywith a scale for chronic fatigue syndrome in bivariateanalysis. However, when other psychiatric conditionswere entered into the analysis, yadargaa associatedsignificantly with depression but the associationwith chronic fatigue syndrome was no longer signifi-cant.78 A study in Uganda among war-affected youthstands out in the CCD literature because multiple CCDwere addressed in the same population.57 Thisallowed for testing CCD comorbidities in addition topsychiatric comorbidities. Half of the studies includepsychiatric comorbidity information.

Physical health comorbidities also impact associationsbetween CCD and psychiatric diagnoses. Investigatorsof dhat often account for physical comorbidities, es-pecially sexually transmitted infections (STIs), in theiranalyses.59,64,69 Including STIs among both dhat casesand controls revealed that STIs were not associatedwith dhat; instead, psychological distress differed be-tween the groups.69 Controlling for possible physicalpathologies led to the finding in Nepal that a somaticcomplaint of paraesthesia, which was strongly asso-ciated with depression, was not the result of psycho-somatization but a consequence of physical healthproblems, commonly B12 deficiency.79 Six studiesincluded information on physical comorbidities.

Treatment status is a potential confound. If partici-pants are receiving biomedical or traditional treat-ments, this may influence psychiatric disorders, CCDor both. Seven studies included information on treat-ment status. Other confounds include linguistic pro-ficiency differences which may influence endorsementof CCD. One study reported that missing data were

significantly more common among persons with lowEnglish proficiency.55 A total of 22 studies includedother potential confounds.

Reporting of DataIn the Reporting of Data category, the SAQOR re-quires that all studies include information on missingdata.

Missing data were repoted by only one study.55

Clarity and accuracy of data refers to use of confidenceintervals, multivariable analyses, and tables and fig-ures that are easily interpreted. A total of 37 studiespresented data clearly. Other studies inconsistentlyidentified CCD vs non-CCD groups; for example,they did not clarify which participants were includedin analyses or included figures that did not clarifyCCD association with psychiatric measures in quanti-tative comparisons.

Meta-analyses for likelihood of a psychiatricclassification given presence of a culturalconcept of distressMeta-analyses were conducted with psychiatric con-ditions as the outcome (see Table 4 and Figures 2–6).The results should be interpreted as the odds that anindividual has a given psychiatric disorder given en-dorsement of a CCD. For example, among personswho endorse dhat, ataque de nervios, susto or otherCCD, there is an 8-fold greater odds of experiencingbivariate depression compared with persons who donot endorse a CCD. The level of heterogeneity, notsurprisingly, was significant for most of the outcomes:all anxiety disorders (Q¼ 13.75, df¼ 28, P < .05),panic (Q¼ 2.43, df¼ 8, P < .05), PTSD (Q¼ 0.10,df¼ 2, P < .05), depression (Q¼ 6.15, df¼ 19,P < .05), somatoform disorders (Q¼ 0.67, df¼ 6,P < .05), and general anxiety (Q¼ 8.70, df¼ 16,P < .10). Converting Q statistics to I2 to account forsmall numbers of studies, all summary effects hadheterogeneity percentages greater than 75%. Onlygeneral psychological distress had a non-significanttest of heterogeneity, (Q¼ 7.41, df¼ 8, P¼ 0.5), withI2¼ 8% suggesting that associations of general psy-

chological distress with CCD are generally homoge-neous with limited variance attributable to between-study characteristics.

Potential sources of between-study variation inassociation of cultural concepts of distress withpsychiatric categoriesGiven the high heterogeneity among the studies, weused generalized estimating equations (GEE) to deter-mine the association of study design with strength ofodd ratios between CCD and psychiatric categories(see Table 5). We conducted 13 bivariate analyses ofstudy characteristics with strengths of odds ratios be-tween CCD and psychiatric disorders. Variables sig-nificant in bivariate analyses were entered into themultivariable analysis. In the multivariable analysis,

30 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

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CULTURAL CONCEPTS OF DISTRESS AND PSYCHIATRIC DISORDERS 31

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studies conducted in the Americas had greater ORsthan those conducted in Africa or Asia; studieslabelled as ‘culture-bound’ had greater ORs than anyof the other labels; validation studies had ORs 16points greater than studies in which the objectivewas to compare CCD with psychiatric disorders;greater sample sizes were associated with greaterORs; self-report multi-item checklists had 6 pointsgreater ORs than dichotomous categorical self-reportscores, and medium quality SAQOR-CPE rankingswere 7 points below ORs of very low quality studies.

DiscussionWithin the growing body of literature comparing cul-tural concepts of distress (CCD) and psychiatric dis-orders, there is a wide range of quality and

epidemiological rigor. Twelve (27%) of the studieshad medium quality based on the SystematicAssessment of Quality in Observational Research–Cultural Psychiatry Epidemiology (SAQOR-CPE) rank-ing system. The remainder were of low or very lowquality. Studies lack both basic criteria for epidemio-logical reporting (e.g. representative samples, preva-lence parameters, missing data frequency andmanagement, and controlling for potential con-founds) and key aspects of CCD reporting (e.g. differ-entiation among symptoms, syndromes, andaetiological models; operationalization of culturaland ethnic groups to generalize findings; assessmentof confounders; and severity and course of distress).

Making generalizations based on summary effectsfrom meta-analysis is impeded by the high degree ofheterogeneity in all but one of the analyses. The highdegree of heterogeneity is not surprising given the

0.01 1.00 100.00

Coraje (Caplan 2010) [61]

Dhat (Chadda 1995) [63]

Dhat (Bhatia 1999) [58]

Dhat (Bhatia 1991) [59]

Dhat (Singh 1985) [96]

Hwa-byung (Min 2010) [85]

Jham-jham (Kohrt 2005) [79]

Koro (Bhatia 1999) [58]

Nervios (Interian 2005, Hispanic) [53]

Nervios (Interian 2005, European-American) [53]

Nervios (Liebowitz 1994/Salman 1998) [81]

Nervios (Caplan 2010) [61]

Nervios (Salgado de Snyder 2000) [94]

Nervios (Guarnaccia 2005, clinical) [72]

Nervios (Guanaccia 2010) [71]

Nervios (Guarnaccia 2005, community) [72]

Nervios (Guarnaccia 1993) [70]

phiền não tâm thần (Phan 2004, biomedical) [92]

phiền não tâm thần (Phan 2004, naturalist) [92]

Susto (Caplan 2010) [61]

Yadargaa (Kohrt 2004) [78]

DEPRESSION TOTAL EFFECT

Odds Ratio

Figure 2 Meta-analysis with forest plot for odds of having depression given presence of cultural concepts of distress (CCD);n¼ 9032, odds ratio¼ 7.55 (95% confidence interval, 6.69–8.52)

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0.01 1000.00

GENERAL ANXIETY TOTAL EFFECT

Yadargaa (Kohrt 2004) [78]

Nervios (Guarnaccia 2010) [71]

Nervios (Guarnaccia 2005, community) [72]

Nervios (Salgado de Snyder 2000) [94]

Nervios (Guarnaccia 1993) [70]

Nervios (Guarnaccia 2005, clinical) [72]

Nervios (Interian 2005, Hispanic) [53]

Nervios (Interian 2005, European-American) [53]

Nervios (Liebowitz 1994/Salman 1998) [81]

lo âu sợ hãi (Phan 2004, naturalist) [92]lo âu sợ hãi (Phan 2004, biomedical) [92]

Koro (Bhatia 1999) [58]

Jham-jham (Kohrt 2005) [79]

Hwa-byung (Min 2010) [85]

Dhat (Bhatia 1999) [58]

Dhat (Singh 1985) [96]

Dhat (Chadda 1995) [63]

1.0Odds Ratio

Figure 3 Meta-analysis with forest plot for odds of having general anxiety given presence of cultural concepts of distress(CCD); n¼ 8211, odds ratio¼ 5.06 (95% confidence interval, 4.48–5.70)

PTSD TOTAL EFFECT

Worry attacks (Hinton 2011) [75]

Nervios (Guarnaccia 1993) [70]

Fright idioms (Pedersen 2008) [90]

PANIC TOTAL EFFECT

Nervios (Guarnaccia 2005, community) [72]

Nervios (Guarnaccia 1993) [70]

Nervios (Guarnaccia 2005, clinical) [72]

Nervios (Guarnaccia 2010) [71]

Nervios (Lewis-Fernandez 2002) [80]

Nervios (Liebowitz 1994/Salman 1998) [81]

Nervios (Interian 2005, Hispanic) [53]

Nervios (Interian 2005, European-American) …

Nervios (Keough 2009) [76]

PTSDPanic

0.10 1000.001.0Odds Ratio

Figure 4 Meta-analysis with forest plot for odds of having panic attacks/disorder or PTSD given presence of culturalconcepts of distress (CCD); panic attacks/disorder, n¼ 6158, odds ratio¼ 4.48 (95% confidence interval, 3.77–5.32); post-traumatic stress disorder (PTSD), n¼ 1246, odds ratio¼ 10.10 (95% confidence interval, 7.51–13.57)

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wide range of quality and methodological approachesamong the studies. Studies conducted in the Americaswere more likely to show an association of CCD withpsychiatric disorders. This may represent accultur-ation issues among the populations studied becausemost of the participants were immigrants in the USA.Phan and colleagues suggested that CCD werestrongly associated with psychiatric disorders amongVietnamese immigrants in Australia because of accul-turation effects that reframe understandings ofmental health and disorder.92

We were surprised to find that studies in which theresearcher referred to the CCD as ‘culture-bound’ hadstronger associations between the CCD and psychi-atric disorders than all other labels. This was coun-ter-intuitive given that ‘culture-bound’ implies adistinction from psychiatric nosology. However, wefound that labels such as ‘culture-bound’ or ‘idiomsof distress’ were not applied systematically. The sameCCD, e.g. ataques de nervios, was described as a cul-ture-bound syndrome, idiom of distress, and popularcategory by different researchers. Moreover, the

0.10 100.00

Dhat (Gautham 2008) [69]

Jham-jham (Kohrt 2005) [79]

Mental problem (Patel 1997, all clinicians) [89]

Mental problem (Patel 1997, primary care clinicians) [89]

Mental problem (Patel 1997, traditional clinicians) [89]

Nervios (Guarnaccia 2005, community) [72]

Nervios (Guarnaccia 2005, clinical) [72]

Nervios (Alcantara 2012) [55]

Nervios (Guanaccia 2010) [71]

Spiritual problems vs. CISR (Patel 1995) [88]

Spiritual problems vs. SRQ (Patel 1995) [88]

Spiritual problems vs. SSQ (Patel 1995) [88]

Tension (Weaver 2011) [97]

GENERAL PSYCHOLOGICAL DISTRESS TOTAL

1.0Odds Ratio

Figure 5 Meta-analysis with forest plot for odds of having general psychological distress given presence of culturalconcepts of distress (CCD); n¼ 6658, odds ratio¼ 5.39 (95% confidence interval, 4.71–6.17)

0.10 1000.00

Dhat (Chadda 1995) [63]

Nervios (Interian 2005, European-American) [53]

Nervios (Lopez 2011, Puerto Rico) [83]

Nervios (Lopez 2011, United States) [83]

Nervios (Interian 2005, Hispanic) [53]

xáo trộn tâm thần và thế xác (Phan 2004, biomedical) [92]

xáo trộn tâm thần và thế xác (Phan 2004, naturalist) [92]

Yadargaa (Kohrt 2004) [78]

SOMATOFORM DISORDERS TOTAL EFFECT

1.0Odds Ratio

Figure 6 Meta-analysis with forest plot for odds of having somatoform disorders given presence of cultural concepts ofdistress (CCD); n¼ 3268, odds ratio¼ 2.68 (95% confidence interval, 2.18–3.28)

34 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

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category labels for CCD change between studies evenwithin single research teams. Therefore, we do notsuggest that comparing studies based on the labelused is an informative lens and may lead to poten-tially spurious associations.

The finding that validation studies were most likelyto show an association between CCD and psychiatricdisorders is expected, given that in validation studiesresearchers likely try to identify the CCD that aremost similar to a psychiatric category. Furthermore,there is high likelihood of a publication bias in valid-ation studies with negative findings less likely to bepublished (it is rare to read a published negative val-idation study). The same publication bias may nothold for studies comparing CCD and psychiatric dis-orders that have negative findings, as this would stillbe theoretically significant for culture-bound suppos-itions. Multi-item checklists for CCD assessment wereassociated with stronger associations between CCDand psychiatric disorders. This is consistent withchecklists operating more similarly to psychiatricdiagnostic criteria. Studies in which single items areused for CCD endorsement likely enable greater diver-sity of manifestations and framings.

The final noteworthy finding of our review is thatmedium quality studies had weaker associations be-tween CCD and psychiatric disorders than very lowquality studies (no high quality studies were identi-fied in this review). This raises a crucial issue: we donot hypothesize that greater epidemiological rigor willfoster stronger associations between CCD and psychi-atric disorders. The converse is equally likely: morerigorous and culturally appropriate studies (as recog-nized by higher SAQOR-CPE rankings) may representstudies that describe CCD more accurately and thuscapture the uniqueness from psychiatric categories.For example, studies than controlled for psychiatricand physical health comorbidities had weaker associ-ations than those not controlling for comorbidity. Oneof the most important quality issues was better docu-mentation of CCD course and timing in associationwith psychiatric disorders. Future studies that closelydocument course and use longitudinal designs inwell-contextualized community settings will shednew light on the experience and meaning of CCDand their association psychiatric pathological cate-gories. Emulating the work of pioneers in psychiatricepidemiology, such as Alexander Leighton who fol-lowed a rural population in Canada over decades tounderstand life trajectories of mental illness, can helpinform future studies.28,117,118

LimitationsThe objective of this review was to provide an over-view of the quality of epidemiological studies compar-ing CCD and psychiatric disorders. Whereas the issueshighlighted here and the recommendations providedcan be used to strengthen the epidemiological rigor ofCCD studies, we caution against generalizing theT

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36 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

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findings beyond the literature identified here. We lim-ited our initial search of the literature to PubMed/MEDLINE and English-language publications. All ofstudies were coded by the first author; future reviewsshould include multiple coders with inter-rater reli-ability metrics. Future research also should incorpor-ate databases such as PsycInfo, which may includemore rigorous psychological studies, and Web ofScience, which will capture social science and medicalanthropological journals not indexed in PubMed.Inclusion of books and book chapters would also bol-ster the social science representation. Ultimately, tomake broad claims about the association of CCDand psychiatric disorders, access to investigators’ ori-ginal data would be most helpful because many of theshortcomings reported here may reflect what is re-ported rather than what is collected. We hope thatthe adaptation of the SAQOR-CPE can be applied tobroader searches and to the design of future culturalpsychiatric epidemiology studies.

Applications to global mental healthThe DSM-5 and other publications have provided rec-ommendations for the application of CCD to improveclinical care.15,119 CCD also can be applied to improveresearch and public health interventions in globalmental health, with special attention to low resourcesettings:

(i) CCD can be used to enhance screening and de-tection of mental health problems. – The CCDliterature demonstrates an overlap with psychi-atric disorders as well as identification of popu-lations with emotional, behavioral, or cognitiveproblems with significant impairment that maynot be captured by psychiatric diagnoses. Thesingle summary effect with low heterogeneityin our analyses was the comparison of CCDand general psychological distress: personswith any CCD have five-fold greater odds ofhaving general psychological distress than per-sons not endorsing CCD. Furthermore, in orderfor global mental health not to be limited totreating only disorders recognized by Westernbiomedical psychiatry, it will be crucial to con-sider how scaling up services can also addressCCD. CCD feasibly can be incorporated intopsychiatric screeners such as the PHQ-9 throughthe addition of a limited number of questions.Among Latinas, the addition of CCD identifiesdistress not captured by standard PHQ-9 imple-mentation.61 In Zimbabwe, the Shona SymptomQuestionnaire adequately captures commonmental disorders including postpartum distressand has the benefit of including idioms that rep-resent key concerns of both local patient popu-lations and traditional healers.89,120

(ii) CCD are key to assessing treatments and inter-ventions in global mental health. – One of themajor shortcomings of the current literature

was the lack of CCD in treatment studies. Ifinterventions reduce psychiatric symptoms butdo not impact CCD, then individuals will belikely to continue treatment seeking andreport functional impairment. In order forinterventions to be used and sustained theywill need to demonstrate that local concernsand CCD also are improved. Cultural adaptationof psychotherapy is a promising area to addressCCD as well as psychiatric problems. Culturallyadapted CBT has positive outcomes for ataquede nervios and a number of Southeast AsianCCD75,106,121-124 as did treatment withSSRIs.135 Whereas psychotherapy as practicedin hospital settings in India does not appearculturally compelling for treatment ofdhat,59,67,69 clinical trials of SSRIs would beideal because they can improve not only psy-chological distress but also reduce prematureejaculation and other complaints associatedwith dhat.

(iii) CCD can highlight vulnerable populations forpublic health measures and secondary preven-tion initiatives. – Despite variable associationsof CCD with psychiatric disorders, they are con-sistently associated with identifying vulnerablepopulations. CCD are a marker of risk groupsand may indicate a prodrome to psychiatric dis-orders. Public health and non-clinical psychoso-cial interventions should be investigated withCCD-endorsing populations as a possibleavenue of mental health promotion and dis-order prevention.

(iv) Cross-cultural comparison studies of CCD canhelp illuminate biases and limitations in psy-chiatric categories. – One study in our reviewdemonstrated that offense-avoidance symptomsare common among Americans with socialphobia similar to Koreans with TKS.65 Thisdraws attention to therapeutic needs to addressoffense-avoidance in American social phobiapatients, as well as the need to potentiallyadd these to DSM criteria as symptoms of inter-est (current TKS features are limited to ‘cul-ture-related diagnostic issues’ in DSM-5,p.20515). Similarly, cross-cultural comparisonsof ataque de nervios demonstrate that interper-sonal-distress induced anxiety and loss of con-trol are also observable among EuropeanAmericans and are not synonymous withpanic disorder.76 Therefore, the therapeuticneed to address aspects of ataques in non-Latino populations could be considered. Anumber of studies demonstrated that somesymptom requirements in psychiatric disordersmay lead to exclusion of treatment for dis-tressed persons from other cultural groups.For example, requiring that panic attacks beunprovoked would exclude Cambodian patients

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for whom catastrophic cognitions related toorthostatic hypotension and ethnophysiologicalexpectations of khyal trigger attacks.125

Ultimately, cross-national studies that includea range of CCD features as well as psychiatricdiagnoses are needed to reduce cultural bias inpsychiatric nosology and help address unmetneeds in both high-income and low- andmiddle-income settings.

ConclusionsDespite claims that cultural concepts of distress arenot amenable to epidemiological study, our literaturereview demonstrated a range of important contribu-tions of CCD epidemiological studies to detection ofmental health problems, evaluation of interventions,identification of vulnerable groups, and identificationof cultural biases in psychiatric diagnostic criteria. Theliterature, however, suffers from a lack of epidemio-logical rigor and lack of comprehensive data collectionabout key issues in CCD. Tools such as the SAQOR-

CPE are needed to systematically evaluate this litera-ture and establish guidelines for research design andreporting for global mental health studies. Ultimately,combining the strengths of psychiatric epidemiologyand cultural psychiatry will foster equitable, feasible,and effective global mental health services.

FundingThis work was supported by the National Institute ofMental Health [U19 MH095687-01S1, South AsianHub for Advocacy, Research & Education on MentalHealth (SHARE), Principal Investigators: Vikram Pateland Atif Rahman] supplement for continuity of re-search experience during clinical training providedto the first author (BAK). Author BNK is supportedby the National Science Foundation GraduateResearch Fellowship [Grant No. 0234618].

Conflict of interest: None declared.

KEY MESSAGES

� Epidemiology studies of cultural concepts of distress can improve global mental health servicesthrough improved detection of psychological distress, identification of risk groups and assessmentof culturally salient intervention outcomes.

� The literature on cultural concepts of distress and psychiatric disorders is characterized by low epi-demiological rigor (e.g. unclear prevalence reporting, use of non-validated instruments and lack ofcontrol for confounding) and lack of reporting key facets of explanatory models (e.g. aetiologicalattributions, course and severity of distress, and association with impaired functioning).

� Treatment and intervention studies including both psychiatric disorders and cultural concepts ofdistress demonstrate independent changes in these outcomes. Future global mental health interven-tion research should include both psychiatric outcomes and cultural concepts of distress to assurethat culturally salient indicators of distress also resolve in treatment trials.

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