"My Heart Die in Me": Idioms of Distress and the Development of a Screening Tool for Mental Suffering in Southeast Liberia.

The integration of culturally salient idioms of distress into mental healthcare delivery is essential for effective screening, diagnosis, and treatment. This study systematically explored idioms, explanatory models, and conceptualizations in Maryland County, Liberia to develop a culturally-resonant screening tool for mental distress. We employed a sequential mixed-methods process of: (1) free-lists and semi-structured interviews (n = 20); patient chart reviews (n = 315); (2) pile-sort exercises, (n = 31); and (3) confirmatory focus group discussions (FGDs); (n = 3) from June to December 2017. Free-lists identified 64 idioms of distress, 36 of which were eliminated because they were poorly understood, stigmatizing, irrelevant, or redundant. The remaining 28 terms were used in pile-sort exercises to visualize the interrelatedness of idioms. Confirmatory FDGs occurred before and after the pile-sort exercise to explain findings. Four categories of idioms resulted, the most substantial of which included terms related to the heart and to the brain/mind. The final screening tool took into account 11 idioms and 6 physical symptoms extracted from patient chart reviews. This study provides the framework for culturally resonant mental healthcare by cataloguing language around mental distress and designing an emic screening tool for validation in a clinical setting.

Psychometric properties of two mental health screening tools in southeast Liberia: The Liberian Distress Screener and Patient Health Questionnaire.

Evidence suggests that locally developed and/or adapted screening tools for mental ill-health can have higher validity than directly translated tools developed in other settings. We administered the locally developed Liberian Distress Screener (LDS) and the Liberian-adapted Patient Health Questionnaire-9 (PHQ-9L) to a random sample of 142 outpatients at a regional hospital in Maryland County, Liberia. In the LDS, seven items demonstrated poor model fit and were excluded, resulting in an 11-item screener (LDS-11). Exploratory factor analysis of the 11-item screener (LDS-11) showed a single latent variable construct with significant factor loadings. Cronbach's alpha revealed good internal consistency (α = 0.81). Rasch analyses showed that "brain hot" and "heart fall down" were the most difficult idioms of distress to endorse while "things playing on the mind" was the easiest. All LDS-11 elements were associated with elevated function impairment, with "things playing on the mind," "worry too much," "head is hurting," and "heart cut/beat fast" achieving statistical significance. One item in the PHQ-9L demonstrated poor model fit and was excluded from psychometric analyses. The resultant eight-item PHQ demonstrated internal consistency (α = 0.76) and Rasch analysis revealed that "moving/talking too slowly/fast" was the most difficult item to endorse, while "not happy when doing things" was the easiest. Twelve items were significantly associated with functional impairment. Exploratory analyses reveal items that demonstrate ease and appropriateness of use for assessing mental distress in this population. Implementation research is needed to incorporate idioms of distress and screeners into Liberia's mental healthcare system.