title: Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology.
abstract: BACKGROUND
  Burgeoning global mental health endeavors have renewed debates about cultural applicability of psychiatric categories. This study's goal is to review strengths and limitations of literature comparing psychiatric categories with cultural concepts of distress (CCD) such as cultural syndromes, culture-bound syndromes, and idioms of distress.
  
  
  METHODS
  The Systematic Assessment of Quality in Observational Research (SAQOR) was adapted based on cultural psychiatry principles to develop a Cultural Psychiatry Epidemiology version (SAQOR-CPE), which was used to rate quality of quantitative studies comparing CCD and psychiatric categories. A meta-analysis was performed for each psychiatric category.
  
  
  RESULTS
  Forty-five studies met inclusion criteria, with 18 782 unique participants. Primary objectives of the studies included comparing CCD and psychiatric disorders (51%), assessing risk factors for CCD (18%) and instrument validation (16%). Only 27% of studies met SAQOR-CPE criteria for medium quality, with the remainder low or very low quality. Only 29% of studies employed representative samples, 53% used validated outcome measures, 44% included function assessments and 44% controlled for confounding. Meta-analyses for anxiety, depression, PTSD and somatization revealed high heterogeneity (I(2) > 75%). Only general psychological distress had low heterogeneity (I(2) = 8%) with a summary effect odds ratio of 5.39 (95% CI 4.71-6.17). Associations between CCD and psychiatric disorders were influenced by methodological issues, such as validation designs (β = 16.27, 95%CI 12.75-19.79) and use of CCD multi-item checklists (β = 6.10, 95%CI 1.89-10.31). Higher quality studies demonstrated weaker associations of CCD and psychiatric disorders.
  
  
  CONCLUSIONS
  Cultural concepts of distress are not inherently unamenable to epidemiological study. However, poor study quality impedes conceptual advancement and service application. With improved study design and reporting using guidelines such as the SAQOR-CPE, CCD research can enhance detection of mental health problems, reduce cultural biases in diagnostic criteria and increase cultural salience of intervention trial outcomes.
authors.affiliation: Duke Global Health Institute, Department of Psychiatry and Behavioral Sciences, Durham, NC, USA, Department of Psychology, Fordham University, New York, USA, Department of Anthropology, Department of Epidemiology, Emory University, Atlanta, GA, USA, Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA, Department of Psychology, Tribhuvan University, Kirtipur, Nepal, Butabika National Referral Mental and Teaching Hospital, Kampala, Uganda, AISSR, University of Amsterdam, The Netherlands and Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
authors.forename: Brandon A
authors.initials: BA
authors.lastname: Kohrt
authors.forename: Andrew
authors.initials: A
authors.lastname: Rasmussen
authors.forename: Bonnie N
authors.initials: BN
authors.lastname: Kaiser
authors.forename: Emily E
authors.initials: EE
authors.lastname: Haroz
authors.forename: Sujen M
authors.initials: SM
authors.lastname: Maharjan
authors.forename: Byamah B
authors.initials: BB
authors.lastname: Mutamba
authors.forename: Joop T V M
authors.initials: JT
authors.lastname: de Jong
authors.forename: Devon E
authors.initials: DE
authors.lastname: Hinton
mesh_terms: D001008:Anxiety Disorders / Q000208:ethnology; D003469:Culture; D004812:Epidemiologic Methods; D014943:Global Health / Q000208:ethnology; D006801:Humans; D001523:Mental Disorders / Q000208:ethnology*; D008603:Mental Health / Q000208:ethnology*
keywords: Culture; developing countries; epidemiologic methods; global mental health; mental disorders; meta-analysis