Culture, Medicine, and Psychiatry

, Volume 42, Issue 3, pp 684–703 | Cite as

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

  • Katrin FabianEmail author
  • Josiah Fannoh
  • George G. Washington
  • Wilfred B. Geninyan
  • Bethuel Nyachienga
  • Garmai Cyrus
  • Joyce N. Hallowanger
  • Jason Beste
  • Deepa Rao
  • Bradley H. Wagenaar
Original Paper


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.


Idioms of distress Liberia Screening tool development Culture and psychiatry Mental health 



The study was supported by Partners in Health, Liberia. BHW was supported by Grant Number K01MH110599 from the U.S. National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with Ethical Standards

Conflict of interest

The authors report no conflict of interest.

Supplementary material

11013_2018_9581_MOESM1_ESM.pdf (29 kb)
Supplementary material 1 (PDF 28 kb)
11013_2018_9581_MOESM2_ESM.pdf (364 kb)
Supplementary material 2 (PDF 363 kb)
11013_2018_9581_MOESM3_ESM.pdf (30 kb)
Supplementary material 3 (PDF 30 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Katrin Fabian
    • 1
    • 2
    Email author
  • Josiah Fannoh
    • 2
    • 3
  • George G. Washington
    • 3
  • Wilfred B. Geninyan
    • 2
    • 3
  • Bethuel Nyachienga
    • 2
  • Garmai Cyrus
    • 2
  • Joyce N. Hallowanger
    • 4
  • Jason Beste
    • 1
    • 5
    • 6
  • Deepa Rao
    • 1
  • Bradley H. Wagenaar
    • 1
    • 2
    • 7
  1. 1.Department of Global HealthUniversity of WashingtonSeattleUSA
  2. 2.Partners in HealthMonroviaLiberia
  3. 3.Tubman UniversityHarperLiberia
  4. 4.Mental Health ProgramMinistry of HealthHarperLiberia
  5. 5.Brigham and Women’s HospitalBostonUSA
  6. 6.Harvard Medical SchoolBostonUSA
  7. 7.Health Alliance InternationalSeattleUSA

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