Culture, Medicine, and Psychiatry

, Volume 38, Issue 3, pp 448–472 | Cite as

Reflechi twòp—Thinking Too Much: Description of a Cultural Syndrome in Haiti’s Central Plateau

  • Bonnie N. Kaiser
  • Kristen E. McLean
  • Brandon A. Kohrt
  • Ashley K. Hagaman
  • Bradley H. Wagenaar
  • Nayla M. Khoury
  • Hunter M. Keys
Original Paper


A rich Haitian ethnopsychology has been described, detailing concepts of personhood, explanatory models of illness, and links between mind and body. However, little research has engaged explicitly with mental illness, and that which does focuses on the Kreyòl term fou (madness), a term that psychiatrists associate with schizophrenia and other psychoses. More work is needed to characterize potential forms of mild-to-moderate mental illness. Idioms of distress provide a promising avenue for exploring common mental disorders. Working in Haiti’s Central Plateau, we aimed to identify idioms of distress that represent cultural syndromes. We used ethnographic and epidemiologic methods to explore the idiom of distress reflechi twòp (thinking too much). This syndrome is characterized by troubled rumination at the intersection of sadness, severe mental disorder, suicide, and social and structural hardship. Persons with “thinking too much” have greater scores on the Beck Depression Inventory and Beck Anxiety Inventory. “Thinking too much” is associated with 8 times greater odds of suicidal ideation. Untreated “thinking too much” is sometimes perceived to lead to psychosis. Recognizing and understanding “thinking too much” may allow early clinical recognition and interventions to reduce long-term psychosocial suffering in Haiti’s Central Plateau.


Depression Anxiety Idioms of distress Ethnopsychology Mental health Haiti Suicide 



We gratefully acknowledge the contributions of field research assistants Beker Vincent, Jerome Wilkenson, Desir Fitzner, Wilfrid Jean, Adner Louis, Anel Lavard, and Alexis Ronel. We are grateful to Cate Oswald and her colleagues at Partners in Health/Zanmi Lasante for their collaboration. This work was supported by Emory University’s Global Health Institute Multidisciplinary Team Field Scholars and Global Field Experience Awards. The first author is supported by Graduate Research Fellowship grant 0234618 and Doctoral Dissertation Research Improvement Grant BCS-1260270 from the National Science Foundation. Portions of this paper were presented in the Charles Hughes Memorial Fellowship Lecture of the Society for the Study of Psychiatry and Culture, New York, 2012. We thank Craig Hadley for reviewing an earlier version of this manuscript.

Supplementary material

11013_2014_9380_MOESM1_ESM.doc (64 kb)
Supplementary material 1 (DOC 64 kb)


  1. Abas, Melanie A., Jeremy Broadhead, Priscilla Mbape, and Gertrude Khumalo-Sakatukwa 1994 Defeating depression in the developing world: a Zimbabwean model. The British Journal of Psychiatry 164(3):293-296.CrossRefGoogle Scholar
  2. Abbo, Catherine, Elialilia Okello, Solvig Ekblad, Paul Waako, and Seggane Musisi 2008 Lay concepts of psychosis in Busoga, Eastern Uganda: A pilot study. World Cultural Psychiatry Research Review 3(3):132-145.Google Scholar
  3. Abramowitz, S. A. 2010 Trauma and Humanitarian Translation in Liberia: The Tale of Open Mole. Culture, Medicine, and Psychiatry 34(2):353–379.CrossRefGoogle Scholar
  4. Ali, M. K., C. Rabadan-Diehl, J. Flanigan, C. Blanchard, K. M. Narayan, and M. Engelgau 2013 Systems and capacity to address noncommunicable diseases in low- and middle-income countries. Sci Transl Med 5:181-184.CrossRefGoogle Scholar
  5. Avotri, Joyce, and Vivienne Walters 1999 “You just look at our work and see if you have any freedom on earth’’: Ghanaian women’s accounts of their work and their health. Social Science & Medicine 48(9):1123-1133.CrossRefGoogle Scholar
  6. Bass, Judith, Bhava Poudyal, Wietse Tol, Laura Murray, Maya Nadison, and Paul Bolton 2012 A controlled trial of problem-solving counseling for war-affected adults in Aceh, Indonesia. Social Psychiatry and Psychiatric Epidemiology 47:279-291.CrossRefGoogle Scholar
  7. Beck, Judith 2011 Cognitive Behavior Therapy: Basics and Beyond. New York: The Guilford Press.Google Scholar
  8. Betancourt, Theresa S., Julia E. Rubin-Smith, William R. Beardslee, Sara N. Stulac, Ildephonse Fayida, and Steven Safren 2011 Understanding locally, culturally, and contextually relevant mental health problems among Rwandan children and adolescents affected by HIV/AIDS. AIDS Care 23(4):401-412.CrossRefGoogle Scholar
  9. Bolton, Paul 2001 Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard. Journal of Nervous and Mental Disease 189:238-242.CrossRefGoogle Scholar
  10. Bolton, Paul, Pamela J. Surkan, Amber Gray, and Martine Desmousseaux 2012 The mental health and psychosocial effects of organized violence: A qualitative study in northern Haiti. Transcultural Psychiatry 49(3-4):590-612.CrossRefGoogle Scholar
  11. Bolton, Paul, and Alice M. Tang 2002 An alternative approach to cross-cultural function assessment. Social Psychiatry and Psychiatric Epidemiology 37(11):537-543.CrossRefGoogle Scholar
  12. Brodwin, Paul 1996 Medicine and Morality in Haiti: The contest for healing power. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  13. Brown, Alex, Ushma Scales, Warwick Beever, Bernadette Rickards, Kevin Rowley, and Kerin O’Dea 2012 Exploring the expression of depression and distress in aboriginal men in central Australia: a qualitative study. BMC Psychiatry 12(1):97.CrossRefGoogle Scholar
  14. Collins, Pamela, Vikram Patel, Sarah Joestl, Dana March, Thomas R. Insel, and Abdallah Daar 2011 Grand challenges in global mental health. Nature 475(7354):27-30.CrossRefGoogle Scholar
  15. Coreil, Jeannine, Deborah Barnes-Josiah, Antoine Augustin, and Michel Cayemittes 1996 Arrested pregnancy syndrome in Haiti: Findings from a national survey. Medical Anthropology Quarterly 10(3):424-436.CrossRefGoogle Scholar
  16. D’Avanzo, Carolyn, and Sasha Barab 1998 Depression and anxiety among Cambodian refugee women in France and the United States. Issues in Mental Health Nursing 19(6):541-556.CrossRefGoogle Scholar
  17. Deshauer, D., D. Moher, D. Fergusson, E. Moher, M. Sampson, and J. Grimshaw 2008 Selective serotonin reuptake inhibitors for unipolar depression: A systematic review of classic long-term randomized controlled trials. Canadian Medical Association Journal 178(10):1293-1301.CrossRefGoogle Scholar
  18. Desrosiers, Astrid, and Sheila St Fleurose 2002 Treating Haitian patients: Key cultural aspects. American Journal of Psychotherapy 56(4):508-521.Google Scholar
  19. W. C. Knowler, S. E. Fowler, R. F. Hamman, C. A. Christophi, H. J. Hoffman, A.T. Brenneman, J. O. Brown-Friday, R. Goldberg, E. Venditti, and D. M. Nathan 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 374(9702):1677-1686.CrossRefGoogle Scholar
  20. Eberhardt, Nancy 2006 Imagining the Course of Life: Self-Transformation in a Shan Buddhist Community. Honolulu: University of Hawai’i Press.Google Scholar
  21. Ekers, David, David Richards, and Simon Gilbody 2008 A meta-analysis of randomized trials of behavioural treatment of depression. Psychological Medicine 38:611-623.CrossRefGoogle Scholar
  22. Farmer, Paul 1988 Bad blood, spoiled milk: Bodily fluids as moral barometers in rural Haiti. American Ethnologist 15(1):62-83.CrossRefGoogle Scholar
  23. Fenton, Steve, and Azra Sadiq-Sangster 1996 Culture, relativism and the expression of mental distress: South Asian women in Britain. Sociology of health & illness 18(1):66-85.CrossRefGoogle Scholar
  24. Frye, Barbara 1991 Cultural themes in health-care decision making among Cambodian refugee women. Journal of community health nursing 8(1):33-44.CrossRefGoogle Scholar
  25. Frye, Barbara, and Carolyn D’Avanzo 1994 Cultural themes in family stress and violence among Cambodian refugee women in the inner city. Advances in Nursing Science 16(3):64-77.CrossRefGoogle Scholar
  26. Frye, Barbara, and Deborah McGill 1993 Cambodian refugee adolescents: Cultural factors and mental health nursing. Journal of Child and Adolescent Psychiatric Nursing 6(4):24-31.CrossRefGoogle Scholar
  27. Goodman, Janice 2004 Coping with trauma and hardship among unaccompanied refugee youths from Sudan. Qualitative Health Research 14(9):1177-1196.CrossRefGoogle Scholar
  28. Hagaman, Ashley, Bradley Wagenaar, Kristen McLean, Bonnie Kaiser, Kate Winskell, and Brandon Kohrt 2013 Suicide in rural Haiti: Differences in clinical and lay community perceptions of prevalence, etiology, and religious implications. Social Science & Medicine 83:61-69.CrossRefGoogle Scholar
  29. Harms, Sheila, Ruth Kizza, Joshua Sebunnya, and Susan Jack 2009 Conceptions of mental health among Ugandan youth orphaned by AIDS. African Journal of AIDS Research 8(1):7-16.CrossRefGoogle Scholar
  30. Hinton, Devon, Dara Chhean, Vuth Pich, Steven Safren, Stefan G. Hofmann, and Mark H. Pollack 2005 A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees withtreatment-resistant PTSD and panic attacks: a cross-over design. Journal of Traumatic Stress 18(6):617-629.CrossRefGoogle Scholar
  31. Hinton, Devon E., and Roberto Lewis-Fernández 2010 Idioms of distress among trauma survivors: Subtypes and clinical utility. Culture, Medicine, and Psychiatry 34(2):209-218.CrossRefGoogle Scholar
  32. Hinton, Devon E., Vuth Pich, Luana Marques, Angela Nickerson, and Mark H. Pollack 2010 Khyâl Attacks: A Key Idiom of Distress Among Traumatized Cambodia Refugees. Culture, Medicine, and Psychiatry 34(2):244-278.CrossRefGoogle Scholar
  33. Hinton, Devon, Alexander Hinton, Kok-Thay Eng, and Sophearith Choung 2012 PTSD and Key Somatic Complaints and Cultural Syndromes among Rural Cambodians: The Results of a Needs Assessment Survey. Medical Anthropology Quarterly 26(3):383-407.CrossRefGoogle Scholar
  34. Hinton, Devon, and Susan Hinton 2002 Panic disorder, somatization, and the new cross-cultural psychiatry: The seven bodies of a medical anthropology of panic. Culture, Medicine and Psychiatry 26:155-178.CrossRefGoogle Scholar
  35. Hinton, Devon, Stefan G. Hofmann, Roger Pitman, Mark H. Pollack, and David H. Barlow 2008 The panic attack-posttraumatic stress disorder model: applicability to orthostatic panic among Cambodian refugees. Cognitive Behavior Therapy 37(2):101-116.CrossRefGoogle Scholar
  36. Hinton, Rachael, and Jaya Earnest 2010 ‘I worry so much I think it will kill me’: Psychosocial health and the links to the conditions of women’s lives in Papua New Guinea. Health Sociology Review 19(1):5-19.CrossRefGoogle Scholar
  37. Hollan, Douglas, and Jane Wellenkamp 1994 Contentment and Suffering: Culture and experience in Toraja. New York: Columbia University Press.Google Scholar
  38. IHSD 2009 Population Totale, Population de 18 Ans et Plus Menages et Densites Estimes en 2009. Port-au-Prince: Institut Haïtien de Statistique et D’ informatique.Google Scholar
  39. Ivers, Louise C., Jean-Gregory Jerome, Kimberly A. Cullen, Wesler Lambert, Francesca Celletti, and Badara Samb 2011 Task-Shifting in HIV Care: A Case Study of Nurse-Centered Community-Based Care in Rural Haiti. PLoS ONE 6(5):e19276.CrossRefGoogle Scholar
  40. James, Erica Caple 2008 Haunting ghosts: Madness, gender, and ensekirite in Haiti in the democratic era. In Postcolonial Disorders. M.-J. DelVecchio Good, S. Hyde, S. Pinto, and B. Good, eds. Pp. 132-156. Berkeley: University of California Press.CrossRefGoogle Scholar
  41. Jayawickreme, Eranda, Nuwan Jayawickreme, and Michelle Goonasekere 2012 Using focus group methodology to adapt measurement scales and explore questions of wellbeing and mental health: the case of Sri Lanka. Intervention 10(2):156-167.CrossRefGoogle Scholar
  42. Jerome, G., and L. C. Ivers 2010 Community health workers in health systems strengthening: a qualitative evaluation from rural Haiti. AIDS 24 Suppl 1:S67-72.CrossRefGoogle Scholar
  43. Kaaya, Sylvia, Jessie Mbwambo, Mary Kay Smith Fawzi, H Van Den Borne, Herman Schaalma, and Melkidezek Leshabari 2010 Understanding women’s experiences of distress during pregnancy in Dar es Salaam, Tanzania. Tanzania Journal of Health Research 12(1):36-46.Google Scholar
  44. Kaiser, Bonnie, Brandon Kohrt, Hunter Keys, Nayla Khoury, and Aimee-Rika Brewster 2013 Strategies for assessing mental health in Haiti: Local instrument development and transcultural translation. Transcultural Psychiatry 15(4):532-558.CrossRefGoogle Scholar
  45. Karasz, Alison 2005 Cultural differences in conceptual models of depression. Social Science & Medicine 60(7):1625-1635.CrossRefGoogle Scholar
  46. Keys, Hunter, Bonnie Kaiser, Brandon Kohrt, Nayla Khoury, and Aimee-Rika Brewster 2012 Idioms of distress, ethnopsychology, and the clinical encounter in Haiti’s Central Plateau. Social Science & Medicine 75(3):555-564.CrossRefGoogle Scholar
  47. Khoury, Nayla, Bonnie Kaiser, Aimee-Rika Brewster, Hunter Keys, and Brandon Kohrt 2012 Explanatory models and mental health treatment: Is Vodou an obstacle to psychiatric treatment in rural Haiti? Culture, Medicine and Psychiatry 36(3):514-534.CrossRefGoogle Scholar
  48. Kiev, Ari 1961 Folk Psychiatry in Haiti. Journal of Nervous and Mental Disease 132(3):260-265.CrossRefGoogle Scholar
  49. Kirmayer, Laurence J., Christopher Fletcher, and Robert Watt 2009 Locating the ecocentric self: Inuit concepts of mental health and illness. In Healing traditions: The mental health of Aboriginal peoples in Canada. L. Kirmayer and G. Valaskakis, eds. Pp. 289-314. Toronto: University of British Columbia Press.Google Scholar
  50. Kohrt, Brandon A., and Ian Harper 2008 Navigating Diagnoses: Understanding Mind–Body Relations, Mental Health, and Stigma in Nepal. Culture, Medicine, and Psychiatry 32(4):462-491.CrossRefGoogle Scholar
  51. Kohrt, Brandon, and Daniel J. Hruschka 2010 Nepali Concepts of Psychological Trauma: The Role of Idioms of Distress, Ethnopsychology and Ethnophysiology in Alleviating Suffering and Preventing Stigma. Culture, Medicine, and Psychiatry 34(2):322-352.CrossRefGoogle Scholar
  52. Kohrt, Brandon, Daniel J. Hruschka, Holbrook Kohrt, Nova Panebianco, and G Tsagaankhuu 2004 Distribution of distress in post-socialist Mongolia: a cultural epidemiology of yadargaa. Social Science & Medicine 58(3):471-485.CrossRefGoogle Scholar
  53. Kohrt, Brandon, M Jordans, W Tol, R. Speckman, S. Maharjan, C. Worthman, and I Komproe 2008 Comparison of mental health between former child soldiers and children never conscripted by armed groups in Nepal. JAMA 300(6):691-702.CrossRefGoogle Scholar
  54. Kohrt, Brandon, Mark J. D. Jordans, Wietse A. Tol, Nagendra P. Luitel, Sujen M. Maharjan, and Nawaraj Upadhaya 2011 Validation of cross-cultural child mental health and psychosocial research instruments: adapting the Depression Self-Rating Scale and Child PTSD Symptom Scale in Nepal. BMC Psychiatry 11(1):127.CrossRefGoogle Scholar
  55. Le Touze, Dominique, Derrick Silove, and Anthony Zwi 2005 Can there be healing without justice? Lessons from the Commission for Reception, Truth and Reconciliation in East Timor. Intervention 3(3):192-202.Google Scholar
  56. Lecomte, Y., and F. Raphaël, eds. 2010 Santè mentale en Haïti: La pensèe critique en santè mentale. Montreal: Revue Santè Mentale au Quèbec.Google Scholar
  57. Mains, Daniel 2011 Hope is Cut: Youth, unemployment, and the future in urban Ethiopia. Philadelphia: Temple University Press.Google Scholar
  58. Mann, Gillian 2010 ‘Finding a Life’Among Undocumented Congolese Refugee Children in Tanzania. Children & Society 24(4):261-270.CrossRefGoogle Scholar
  59. Mazzeo, John, and Hannah Hoover 2010 Earthquake related sezisman and techniques for psychosocial care giving. In Haitian Studies Association. Providence.Google Scholar
  60. Merkel, Richard 1996 Suicidal Behavior in Vietnamese refugees: Suicide, headaches and the Vietnamese concept of the self, University of Pennsylvania, Philadelphia.Google Scholar
  61. Muecke, Marjorie 1994 Worries and worriers in Thailand. Health care for women international 15(6):503-519.CrossRefGoogle Scholar
  62. Mukherjee, J. S., and F. E. Eustache 2007 Community health workers as a cornerstone for integrating HIV and primary healthcare. AIDS Care 19 Suppl 1:S73-82.CrossRefGoogle Scholar
  63. Murray, L. K., S. Dorsey, P. Bolton, M. J. Jordans, A. Rahman, J. Bass, and H. Verdeli 2011 Building capacity in mental health interventions in low resource countries: an apprenticeship model for training local providers. Int J Ment Health Syst 5(1):30.CrossRefGoogle Scholar
  64. Nepveux, Denise 2009 ‘‘In the Same Soup’’: Marginality, Vulnerability and Belonging in Life Stories of Disabled Ghanaian Women, University of Arizona, Tucson.Google Scholar
  65. Nichter, Mark 1981 Idioms of distress: alternatives in the expression of psychosocial distress: A case study from South India. Culture, Medicine and Psychiatry 5(4):379-408.CrossRefGoogle Scholar
  66. Nolen-Hoeksema, Susan 2000 The Role of Rumination in Depressive Disorders and Mixed Anxiety/Depressive Symptoms. Journal of Abnormal Psychology 109(3):504-511.CrossRefGoogle Scholar
  67. Okello, Elialilia, and Solvig Ekblad 2006 Lay concepts of depression among the Baganda of Uganda: a pilot study. Transcultural Psychiatry 43(2):287-313.CrossRefGoogle Scholar
  68. Okello, Elialilia, Victoria Ngo, Gerry Ryan, Seggane Musisi, Dickens Akena, Noeline Nakasujja, and Glenn Wagner 2012 Qualitative study of the influence of antidepressants on the psychological health of patients on antiretroviral therapy in Uganda. African Journal of AIDS Research 11(1):37-44.CrossRefGoogle Scholar
  69. Ormel, J., A. J. Oldehinkel, D. P. Goldberg, P. P. Hodiamont, F. W. Wilmink, and K. Bridges 1995 The structure of common psychiatric symptoms: How many dimensions of neurosis? Psychological Medicine 25(3):521-530.CrossRefGoogle Scholar
  70. Patel, Vikram 2001 Cultural factors and international epidemiology Depression and public health. British medical bulletin 57(1):33-45.CrossRefGoogle Scholar
  71. Patel, Vikram, Ricardo Araya, Sudipto Chatterjee, Daniel Chisholm, Alex Cohen, Mary De Silva, Clemens Hosman, Hugh McGuire, Graciela Rojas, and Mark van Ommeren 2007 Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet 370:991-1005.CrossRefGoogle Scholar
  72. Patel, Vikram, E Simunyu, and F Gwanzura 1995 Kufungisisa (thinking too much): A Shona idiom for non-psychotic mental illness. Central African Journal of Medicine 41(7):209-215.Google Scholar
  73. Pedersen, Duncan, Hanna Kienzler, and Jeffrey Gamarra 2010 Llaki and Ñakary: Idioms of Distress and Suffering Among the Highland Quechua in the Peruvian Andes. Culture, Medicine, and Psychiatry 34(2):279-300.CrossRefGoogle Scholar
  74. Rahman, Atif, Abid Malik, Siham Sikander, Christopher Roberts, and Francis Creed 2008 Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: A cluster-randomised controlled trial. Lancet 372:902-909.CrossRefGoogle Scholar
  75. Rechtman, Richard 2006 Cultural standards, power and subversion in cross-cultural psychotherapy. Transcultural Psychiatry 43(2):169-180.CrossRefGoogle Scholar
  76. Roberts, Bayard, Vicky Norah Odong, John Browne, Kaducu Felix Ocaka, Wenzel Geissler, and Egbert Sondorp 2009 An exploration of social determinants of health amongst internally displaced persons in northern Uganda. Conflict and Health 3(1):10.CrossRefGoogle Scholar
  77. Rubel, Arthur 1964 The epidemiology of a folk illness: Susto in Hispanic America. Ethnology 3:268-283.CrossRefGoogle Scholar
  78. Ryan, Gery W., and H. Russell Bernard 2003 Techniques to Identify Themes. Field Methods 15(1):85-109.CrossRefGoogle Scholar
  79. Saxena, Shekhar, Graham Thornicroft, Martin Knapp, and Harvey Whiteford 2007 Resources for mental health: Scarcity, inequity, and inefficiency. Lancet 370:878-889.CrossRefGoogle Scholar
  80. Schatz, Enid, and Leah Gilbert 2012 “My heart is very painful”: Physical, mental and social wellbeing of older women at the times of HIV/AIDS in rural South Africa. Journal of Aging Studies 26(1):16-25.CrossRefGoogle Scholar
  81. Stepakoff, Shanee, John Hubbard, Maki Katoh, Erika Falk, Jean-Baptiste Mikulu, Potiphar Nkhoma, and Yuvenalis Omagwa 2006 Trauma healing in refugee camps in Guinea: A psychosocial program for Liberian and Sierra Leonean survivors of torture and war. The American Psychologist 61(8):921-932.CrossRefGoogle Scholar
  82. Sterlin, Carlo 2006 Pour une approche interculturelle du concept de santè. Ruptures, revue transdiciplinaire en santè 11(1):112-121.Google Scholar
  83. Stranix-Chibanda, Lynda, Dixon Chibanda, Albert Chingono, Elizabeth Montgomery, Jennifer Wells, Yvonne Maldonado, Tsungai Chipato, and Avinash Shetty 2005 Screening for psychological morbidity in HIV-infected and HIV-uninfected pregnant women using community counselors in Zimbabwe. Journal of the International Association of Physicians in AIDS Care (JIAPAC) 4(4):83-88.CrossRefGoogle Scholar
  84. Thorpe, K. E., L. L. Ogden, and K. Galactionova 2010 Chronic conditions account for rise in Medicare spending from 1987 to 2006. Health Affairs 29(4):718-724.CrossRefGoogle Scholar
  85. Tinkle, M., R. Kimball, E. A. Haozous, G. Shuster, and R. Meize-Grochowski (2013) Dissemination and Implementation Research Funded by the US National Institutes of Health, 2005–2012. Nursing Research and Practice 2013:909606.CrossRefGoogle Scholar
  86. Tricco, A. C., N. M. Ivers, J. M. Grimshaw, D. Moher, L. Turner, J. Galipeau, and et al. 2012 Effectiveness of quality improvement strategies on the management of diabetes: A systematic review and meta-analysis. Lancet 379(9833):2252-2261.CrossRefGoogle Scholar
  87. van Ommeren, Mark, Bhogendra Sharma, Suraj Thapa, Ramesh Makaju, Dinesh Prasain, Rabindra Bhattarai, and Joop de Jong 1999 Preparing instruments for transcultural research: Use of the translation monitoring form with Nepali-speaking Bhutanese refugees. Transcultural Psychiatry 36(3):285-301.CrossRefGoogle Scholar
  88. Ventevogel, P., W. van de Put, H. Faiz, B. van Mierlo, M. Siddiqi, and I. H. Komproe 2012 Improving access to mental health care and psychosocial support within a fragile context: a case study from Afghanistan. PLoS Med 9(5):e1001225.CrossRefGoogle Scholar
  89. VERBI 1989–2010 MAXQDA: Software for Qualitative Data Analysis. Berlin: Sozialforschung GmbH.Google Scholar
  90. Wagenaar, Bradley, Ashley Hagaman, Bonnie Kaiser, Kristen McLean, and Brandon Kohrt 2012 Depression, Suicidal Ideation, and Associated Factors in rural Haiti. BMC Psychiatry 12:149.CrossRefGoogle Scholar
  91. Wagenaar, Bradley, Brandon Kohrt, Ashley Hagaman, Kristen McLean, and Bonnie Kaiser 2013 Determinants of Care Seeking for Mental Health Problems in Rural Haiti: Culture, Cost, or Competency? Psychiatric Services 64:366–372.CrossRefGoogle Scholar
  92. WHO 1991 Training for Mid-level Managers: The EPI Coverage Survey. Geneva: World Health Organization Expanded Programme on Immunization.Google Scholar
  93. WHO 2008a The Global Burden of Disease: 2004 Update. Geneva: World Health Organization.Google Scholar
  94. WHO 2008b Task Shifting: Guidelines and Recommendations. Geneva: World Health Organization.Google Scholar
  95. Yarris, Kristin 2011 The Pain of “Thinking too Much”: Dolor de Cerebro and the Embodiment of Social Hardship among Nicaraguan Women. Ethos 39(2):226-248.CrossRefGoogle Scholar
  96. Zohar, J., and H. G. Westenberg 2000 Anxiety disorders: a review of tricyclic antidepressants and selective serotonin reuptake inhibitors. Acta Psychiatrica Scandinavica Supplementum 403:39-49.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Bonnie N. Kaiser
    • 1
  • Kristen E. McLean
    • 2
  • Brandon A. Kohrt
    • 3
  • Ashley K. Hagaman
    • 4
  • Bradley H. Wagenaar
    • 5
  • Nayla M. Khoury
    • 6
  • Hunter M. Keys
    • 7
  1. 1.Department of Anthropology, Department of EpidemiologyEmory UniversityAtlantaUSA
  2. 2.Department of AnthropologyYale UniversityNew HavenUSA
  3. 3.Department of Psychiatry and Behavioral Sciences, Duke Global Health InstituteDuke UniversityDurhamUSA
  4. 4.School of Human Evolution and Social ChangeArizona State UniversityPhoenixUSA
  5. 5.Department of Epidemiology, School of Public HealthUniversity of WashingtonSeattleUSA
  6. 6.Department of PsychiatryCambridge Health AllianceCambridgeUSA
  7. 7.School of Public Health, School of NursingEmory UniversityAtlantaUSA

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