Expressions of psychological distress in Sierra Leone: implications for community-based prevention and response

Abstract

Background Over recent decades there has been considerable mental health research in Sierra Leone but little on local conceptualisations of mental health conditions. Understanding these is crucial both for identifying the experienced needs of the population and utilising relevant community-based resources to address them. This study took a grounded approach to identify the ways in which adults in Sierra Leone express psychological distress. Methods Rapid ethnographic methods deployed included 75 case study interviews with community members, 12 key informant (KI) pile sorts and 55 KI interviews. Thematic analysis of data was supported by frequency analysis and multi-dimensional scaling. Results Thirty signs of distress were identified. The only consistent ‘syndrome’ identified with respect to these was a general concept of crase, which referred to psychosis-related presentation but also a wide range of other signs of distress. We did not find consensus on locally defined concepts for mild-moderate forms of mental disorder: people use multiple overlapping signs and terms indicating psychological distress. Conclusions Analysis supports calls to view mental health problems as a ‘continuum of distress’ rather than as discrete categories. This framing is coherent with opportunities for prevention and response in Sierra Leone which do not focus primarily on formal healthcare service providers but rather involve a range of community-based actors. It also enables attention to be paid to the identification of milder signs of distress with a view to early response and prevention of more severe mental health problems.

Understanding perceptions of recovery from psychological distress in Sierra Leone through qualitative comparative analysis

“…Thirty signs of distress (listed in Appendix 1, Supplementary Information) were identified (Horn et al, 2020). For the purpose of this paper, the most frequent six signs of distress were analysed.…”

“…This means that continuing with constructive activity requires considerable motivation, especially when the income generated is small. A failure to continue with these activities (work, study, farming, business) was identified as a common sign of psychological distress in another phase of this project (Horn et al, 2020), which suggests that a person's engagement in work and other forms of constructive activity is not seen purely as a reflection of the economic situation in the country, but rather as an indicator of the individual's emotional wellbeing. In the same study, withdrawing from people ('stays indoors or isolates self; disconnects from people, stops going to public gatherings including mosque or church') was also identified as a key sign of psychological distress.…”

“…Data were collected in the context of a wider study of idioms of distress (Horn et al, 2020). The analysis in this paper draws on 75 case study interviews.…”

The development of a contextually appropriate measure of psychological distress in Sierra Leone

“…The study described here does not follow this pattern; instead it aims to measure ‘signs of distress’ without drawing any conclusions about clinical significance, or trying to equate experiences of distress with clinical diagnoses such as depression, anxiety of post-traumatic stress disorder. This decision is partly made as a result of the first phase of data collection, from which no clear ‘syndromes’ or local disorders emerged [ 22 ]. However, it is also heavily influenced by the recent Lancet Commission on Global Mental Health [ 42 ], which recognises that ‘the binary approach to the diagnosis of mental disorders—although useful for health professionals—does not adequately reflect the dimensional nature of mental health or the experience of people affected’ (p4).…”

“…The 30 signs of distress to be included in the tool were identified in an earlier qualitative phase of work which has been described elsewhere [ 22 ]. It was based on the ‘rapid ethnographic’ approach developed by Bolton and colleagues [ 15 , 18 ] and included freelisting, key informant interviews and pile sorts.…”