title: "Thinking too much": A systematic review of a common idiom of distress.
abstract: Idioms of distress communicate suffering via reference to shared ethnopsychologies, and better understanding of idioms of distress can contribute to effective clinical and public health communication. This systematic review is a qualitative synthesis of "thinking too much" idioms globally, to determine their applicability and variability across cultures. We searched eight databases and retained publications if they included empirical quantitative, qualitative, or mixed-methods research regarding a "thinking too much" idiom and were in English. In total, 138 publications from 1979 to 2014 met inclusion criteria. We examined the descriptive epidemiology, phenomenology, etiology, and course of "thinking too much" idioms and compared them to psychiatric constructs. "Thinking too much" idioms typically reference ruminative, intrusive, and anxious thoughts and result in a range of perceived complications, physical and mental illnesses, or even death. These idioms appear to have variable overlap with common psychiatric constructs, including depression, anxiety, and PTSD. However, "thinking too much" idioms reflect aspects of experience, distress, and social positioning not captured by psychiatric diagnoses and often show wide within-cultural variation, in addition to between-cultural differences. Taken together, these findings suggest that "thinking too much" should not be interpreted as a gloss for psychiatric disorder nor assumed to be a unitary symptom or syndrome within a culture. We suggest five key ways in which engagement with "thinking too much" idioms can improve global mental health research and interventions: it (1) incorporates a key idiom of distress into measurement and screening to improve validity of efforts at identifying those in need of services and tracking treatment outcomes; (2) facilitates exploration of ethnopsychology in order to bolster cultural appropriateness of interventions; (3) strengthens public health communication to encourage engagement in treatment; (4) reduces stigma by enhancing understanding, promoting treatment-seeking, and avoiding unintentionally contributing to stigmatization; and (5) identifies a key locally salient treatment target.
authors.affiliation: Department of Anthropology and Department of Epidemiology, Emory University, 1557 Dickey Drive, Atlanta, GA 30322, USA; Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC 27701, USA. Electronic address: bfullard@gmail.com.
authors.forename: Bonnie N
authors.initials: BN
authors.lastname: Kaiser
authors.affiliation: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Wolfe Street, Baltimore, MD 21205, USA.
authors.forename: Emily E
authors.initials: EE
authors.lastname: Haroz
authors.affiliation: Department of Psychiatry & Behavioral Sciences, Duke Global Health Institute, and Department of Cultural Anthropology, Duke University, 310 Trent Drive, Durham, NC 27710, USA.
authors.forename: Brandon A
authors.initials: BA
authors.lastname: Kohrt
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Broadway, Baltimore, MD 21205, USA.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Bolton
authors.affiliation: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Wolfe Street, Baltimore, MD 21205, USA.
authors.forename: Judith K
authors.initials: JK
authors.lastname: Bass
authors.affiliation: Department of Psychiatry, Massachusetts General Hospital, 15 Parkman Street, WACC 812, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.
authors.forename: Devon E
authors.initials: DE
authors.lastname: Hinton
mesh_terms: D001007:Anxiety / Q000208:ethnology; D003469:Culture; D003863:Depression / Q000208:ethnology; D005008:Ethnopsychology / Q000379:methods*; D006801:Humans; D007802:Language; D008603:Mental Health / Q000208:ethnology*; D013315:Stress, Psychological / Q000523:psychology*; D013850:Thinking
keywords: Anxiety; Cultural concept of distress; Depression; Ethnopsychology; Global mental health; Idiom of distress; PTSD; Transcultural psychiatry