The phenomenology and explanatory models of common mental disorder: A study in primary care in Harare, Zimbabwe

ArticleinPsychological Medicine 25(6):1191-9 · December 1995with25 Reads
DOI: 10.1017/S003329170003316X · Source: PubMed
In order to describe the explanatory models and the etic and emic phenomena of common mental disorder in Harare, Zimbabwe, 110 subjects were selected by general nurses in three clinics and by four traditional healers from their current clients. The subjects were interviewed using the Explanatory Model Interview and the Revised Clinical Interview Schedule. Mental disorder most commonly presented with somatic symptoms, but few patients denied that their mind or soul was the source of illness. Spiritual factors were frequently cited as causes of mental illness. Subjects who were selected by traditional healer, reported a greater duration of illness and were more likely to provide a spiritual explanation for their illness. The majority of subjects were classified as 'cases' by the etic criteria of the CISR. Most patients, however, showed a mixture of psychiatric symptoms that did not fall clearly into a single diagnostic group. Patients from a subgroup with a spiritual model of illness were less likely to conform to etic criteria of 'caseness' and they may represent a unique category of psychological distress in Zimbabwe. A wide variety of emic phenomena were elicited that have been incorporated in an indigenous measure of non-psychotic mental disorder. Kufungisisa, or thinking too much, seemed to be the Shona term closest to the Euro-American concept of neurotic illness.
    • "" For example, participants in Indonesia meeting clinical cut-offs for depression (Andajani-Sutjahjo et al., 2007) or with elevated symptoms of depression and anxiety (Bass et al., 2012) were either locally-or self-identified as experiencing " thinking too much " or described their condition as such. Others found that scores on depression and anxiety screeners were significantly higher among those endorsing " thinking too much " (Kaiser et al., 2015; Patel et al., 1995a,b,c). Miller and colleagues (2006) found that in a factor analysis of the locally-developed Afghan Symptom Checklist, " thinking too much " loaded strongly on the same factor as depression symptoms such as feeling hopeless, sad, and irritable . "
    [Show abstract] [Hide abstract] 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.
    Full-text · Article · Oct 2015
    • "Goldberg introduced the term 'common mental disorder' to denote any depressive or anxiety disorder (including PTSD) [34,35]. In Africa, the term 'common mental disorder' has been used, for example in adult populations in Zimbabwe [36,37] and Ethiopia [38]. For children in Africa, the concept of 'common mental disorder' has not been not been widely used, and there has been no research into a single questionnaire to identify children with mental disorder in need of assistance. "
    [Show abstract] [Hide abstract] ABSTRACT: In Sub Saharan Africa, there has been limited research on instruments to identify specific mental disorders in children in conflict-affected settings. This study evaluates the psychometric properties of three self-report scales for child mental disorder in order to inform an emerging child mental health programme in post-conflict Burundi. Trained lay interviewers administered local language versions of three self-report scales, the Depression Self-Rating Scale (DSRS), the Child PSTD Symptom Scale (CPSS) and the Screen for Child Anxiety Related Emotional Disorders (SCARED-41), to a sample of 65 primary school children in Burundi. The test scores were compared with an external 'gold standard' criterion: the outcomes of a comprehensive semistructured clinical psychiatric interview for children according the DSM-IV criteria (the Schedule for Affective Disorders and Schizophrenia for School-Age Children - K-SADS-PL). The DSRS has an area under the curve (AUC) of 0.85 with a confidence interval (c.i.) of 0.73-0.97. With a cut-off point of 19, the sensitivity was 0.64, and the specificity was 0.88. For the CPSS, with a cut-off point of 26, the AUC was 0.78 (c.i.: 0.62-0.95) with a sensitivity of 0.71 and a specificity of 0.83. The AUC for the SCARED-41, with a cut-off point of 44, was 0.69 (c.i.: 0.54-0.84) with a sensitivity of 0.55 and a specificity of 0.90. The DSRS and CPSS showed good utility in detecting depressive disorder and posttraumatic stress disorder in Burundian children, but cut-off points had to be put considerably higher than in western norm populations. The psychometric properties of the SCARED-41 to identify anxiety disorders were less strong. The DSRS and CPSS have acceptable properties, and they could be used in clinical practice as part of a two-stage screening procedure in public mental health programmes in Burundi and in similar cultural and linguistic settings in the African Great Lakes region.
    Full-text · Article · Feb 2014
    • "Incidentally, the findings may not be generalizable in the different socio-cultural circumstances of developing countries; hence the importance of cross cultural perspectives . Evidence from low and middle income countries (LMICs) indicate that adults are more likely to present with somatic symptoms when seeking help even when they are aware of having psychological symp- toms16171819. A strong association between somatoform disorders and anxiety and depression in women (with odds ratio ranging from 2.5 to 3.5) was observed in a systematic review covering studies from eight LMICs[20]. "
    [Show abstract] [Hide abstract] ABSTRACT: To explore association between medically unexplained symptoms in children in Pakistan with emotional difficulties and functional impairments. We conducted a matched three-group case-control study of 186 children aged 8-16years in Lahore, Pakistan. Cases were 62 children with chronic somatic symptoms for which no organic cause was identified after investigations. Two control groups of 62 children with chronic medical paediatric conditions, and 62 healthy children were identified. Cases and controls were matched for gender, age, and school class. Somatisation was measured with the Children's Somatisation Inventory (CSI-24) while anxiety and depression were measured with the Spencer Children's Anxiety Scale and the Short Mood and Feelings Questionnaire respectively. All questionnaires were translated into Urdu. Mean age was 11.7years (SD=2.1). Cases scored significantly higher on somatisation (CSI-24), anxiety and depression than both control groups. Paediatric controls scored significantly higher than healthy controls on all three measures. Two hierarchical linear regression models were used to explore if somatisation predicted depression and anxiety while controlling for several confounders. Somatisation (higher CSI-24 scores) independently and significantly predicted higher anxiety (β=.37, p=.0001) and depression (β=.41, p=.0001) scores. This is the first study to show an association between medically unexplained symptoms and anxiety and depression in Pakistani children. This highlights the importance of screening for emotional difficulties in children presenting with unexplained somatic symptoms in this region.
    Article · Feb 2014
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