Literature review of Cultural concepts of distress and psychiatric disorders

Literature review of Cultural concepts of distress and psychiatric disorders

Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology

Brandon A Kohrt1,*, Andrew Rasmussen2, Bonnie N Kaiser3, Emily E Haroz4,Sujen M Maharjan5, Byamah B Mutamba6, Joop TVM de Jong7 and Devon E Hinton8

+Author Affiliations

  1. 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 Medical School, Boston, MA, USA
  2. *Corresponding author. Duke Global Health Institute, Trent Hall #213, 310 Trent Drive, Duke University, Durham, NC 27710, USA. E-mail:
  • Accepted October 4, 2013.


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

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

Results Forty-five studies met inclusion criteria, with 18 782 unique participants. Primary objectives of the studies included comparing CCD and psychiatric disorders (51%), assessing risk factors for CCD (18%) and instrument validation (16%). Only 27% of studies met SAQOR-CPE criteria for medium quality, with the remainder low or very low quality. Only 29% of studies employed representative samples, 53% used validated outcome measures, 44% included function assessments and 44% controlled for confounding. Meta-analyses for anxiety, depression, PTSD and somatization revealed high heterogeneity (I2 > 75%). Only general psychological distress had low heterogeneity (I2 = 8%) with a summary effect odds ratio of 5.39 (95% CI 4.71-6.17). Associations between CCD and psychiatric disorders were influenced by methodological issues, such as validation designs (β = 16.27, 95%CI 12.75-19.79) and use of CCD multi-item checklists (β = 6.10, 95%CI 1.89-10.31). Higher quality studies demonstrated weaker associations of CCD and psychiatric disorders.

Conclusions Cultural concepts of distress are not inherently unamenable to epidemiological study. However, poor study quality impedes conceptual advancement and service application. With improved study design and reporting using guidelines such as the SAQOR-CPE, CCD research can enhance detection of mental health problems, reduce cultural biases in diagnostic criteria and increase cultural salience of intervention trial outcomes.

Our paper has been published in Int. J. Epidemiol. (2013)doi: 10.1093/ije/dyt227, First published online: December 23, 2013.
Thanks to Brandon Kohrt for giving me an opportunity to collaborate with him and rest of the team on it. 

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