Knowledge of psychiatric terms and concepts among Kenyan youth: Analysis of focus group discussions

Abstract

Psychiatric disorders and symptoms are common worldwide. However, cultural differences in symptom manifestation and knowledge of psychiatric terms and concepts represent a challenge to accurate clinical assessment. Our previous youth surveys revealed higher rates of psychotic experiences in Kenya compared to several other countries, suggesting culture may influence psychosis risk assessment survey results. The goal of the present investigation is to evaluate understanding of general mental health related terms and concepts and specific items from the Structured Interview for Psychosis-Risk Symptoms (SIPS), a commonly used psychosis risk assessment instrument. Six focus groups were conducted in Nairobi, Kenya and surrounding areas with young adults from the community, university and secondary school students, and mental health professionals. Analysis of the information obtained from participants indicated that adolescents and young adults in Kenya were aware of mental illness in their communities, but had very limited knowledge of the meaning of specific psychiatric disorders and symptoms. Many believed that the cause of mental illness was spiritual in nature. These results suggest that in order to obtain accurate reported rates of psychiatric symptoms, assessment of Kenyan adolescents and young adults requires elaboration of assessment questions and use of simplified terms.

Keywords

Adolescents Africa focus groups Kenya mental illness young adults

Introduction

Several cross-national studies have indicated that mental disorders are highly prevalent worldwide (Demyttenaere et al., 2004; Weissman, Bland, Canino, Faravelli, et al., 1996; Weissman et al., 1997; Weissman et al., 1994; Weissman, Bland, Canino, Greenwald, et al., 1996; WHO, 2000), accounting for approximately 14% of the global burden of disease (Prince et al., 2007). The lifetime prevalence of mental disorders has been reported to vary widely across cultures (Demyttenaere et al., 2004; WHO, 2000), with prevalence rates over 40% in some countries, including the United States (Kessler et al., 2005; Robins & Regier, 1991; WHO, 2000). Due to the differing validity of survey results, cross-cultural comparisons of psychiatric symptoms are limited. Many commonly used psychiatric instruments may be less accurate when used in countries other than where they were developed. Epidemiological results may be affected because concepts and phrases used to describe mental syndromes are not culturally sensitive or because the absence of a tradition of anonymous public surveys leads to reluctance to disclose emotional or behavioral problems (Carta, Coppo, Carpiniello, & Mounkuoro, 1997; Kaaya et al., 2002; WHO, 2000; Youngmann, Zilber, & Workneh, 2008). A lack of knowledge of specific psychiatric conditions in many lay populations (Angermeyer & Matschinger, 1999) can also influence psychiatric assessment. This may be exaggerated in low-income countries lacking mental health education.

Little is known about the understanding of psychiatric terms and concepts in sub-Saharan African countries. Due to scarce mental health care funding and a paucity of mental health workers in African countries (Jacob et al., 2007), many Africans may be unfamiliar with psychiatric terms and concepts. In Africa, beliefs in the supernatural causation of mental illness are widely held (Adewuya & Makanjuola, 2008; Ayonrinde, Gureje, & Lawal, 2004; Gureje, Lasebikan, Ephraim-Oluwanuga, Olley, & Kola, 2005; Shibre et al., 2001), especially among rural dwellers (Adewuya & Makanjuola, 2008; Angermeyer & Matschinger, 1999; Khan & Hasanah, 1996). Studies exploring cultural manifestations of illness have revealed that descriptions of psychiatric symptoms can vary extensively between societies (Idemudia, 2004). For example, some studies show that depressed individuals in sub-Saharan Africa present with somatic symptoms more often than depressed individuals in the West (Ebigbo, 1982; Regier et al., 1988; Tomlinson, Swartz, Kruger, & Gureje, 2007). Feelings of guilt, low self-esteem, as well as severe retardation and associated suicidal behavior, may be less prevalent in Africa than in the West (Odejide, Oyewunmi, & Ohaeri, 1989; Otote & Ohaeri, 2000). Due to unreliable data collection, however, rates of suicidal behaviors and certain psychiatric symptoms in Africa may be underestimated (Adinkrah, 2011; Mugisha, Knizek, Kinyanda, & Hjelmeland, 2011). Nevertheless, relatively high lifetime rates of suicidal behaviors have been reported in sub-Saharan Africa countries (Kinyanda, Kizza, Levin, Ndyanabangi, & Abbo, 2011; Omigbodun, Dogra, Esan, & Adedokun, 2008; Uwakwe, Oladeji, & Gureje, 2012; van Pletzen, Stein, Seedat, Williams, & Myer, 2012). Psychotic disorders may have unique symptomatology in some native African populations, including culturally bound positive symptoms (Ensink, Robertson, Ben-Arie, Hodson, & Tredoux, 1998; Maslowski, Jansen van Rensburg, & Mthoko, 1998; Ndetei & Vadher, 1984a), irritability (Ensink et al., 1998), increased hallucinations (Ndetei & Vadher, 1984b) and somatization (Mosotho, Louw, & Calitz, 2011). Other studies, however, have reported cross-cultural similarity in psychotic disorders (Taleb, Rouillon, Petitjean, & Gorwood, 1996).

In Kenya, our group Africa Mental Health Foundation (AMHF) has previously conducted surveys of psychosis-risk symptoms among adolescents and young adults in the community (Mamah et al., 2011) as well as of psychotic experiences in students from primary/secondary schools (Mamah et al., 2013) and universities (Ndetei et al., 2013). Our results indicated higher symptom endorsement rates in Kenya than in other countries using identical assessment instruments (Fresan, Apiquián, Ulloa, & Nicolini, 2007; Gale, Wells, McGee, & Browne, 2011; Nuevo et al., 2010; Ochoa et al., 2008). While these findings may suggest higher symptom prevalence rates in Kenya, the discrepancy may also be a result of variation in the comprehension of survey items across countries. The current study evaluates knowledge of psychiatric terms and concepts in Kenya, using focus groups comprised of young adults from the community, university and secondary school students as well as mental health professionals. In focus groups, the dynamic nature of the questions asked by the moderator, as well as the group process, produce a level of insight that is rarely derived from “unidirectional” information collection devices such as observation, surveys, and less interactional interview techniques (Morgan, 1993). Listening to others’ verbalized experiences can stimulate memories, ideas, and experiences in participants. A potential weakness of focus groups however, is that participants may not express their personal opinion in order to conform to a popular opinion or acquiesce to another participant (Morgan, 1993).

In our focus groups, we also explored knowledge of general mental health topics and comprehension of selected questions on the SIPS questionnaire (McGlashan, Walsh, & Woods, 2010). This questionnaire was used in our previous studies in Kenya in order to assess risk factors for the development of psychotic disorders. In addition to adolescent and young adult focus groups, we also included a focus group consisting of mental health professionals, in order to obtain an additional perspective on knowledge of mental health terms and concepts among young adults in Kenya.

Methods

This study was a collaborative effort between the Department of Psychiatry at Washington University Medical School and the Africa Mental Health Foundation in Nairobi, Kenya (AMHF). The protocol was approved by the Kenyan Medical Research Institute, as well as the Kenyan of Ministry of Education, Science and Technology, and Washington University’s Institutional Review Board.

Participants

Six focus groups were conducted in order to evaluate knowledge of mental health terms and concepts among Kenyan young adults. Five focus groups consisted of young adults from the community, or students from universities or secondary schools in Kibera (a slum neighborhood six miles from Nairobi) or the city of Nairobi. One focus group consisted of Nairobi-based mental health professionals. Students were randomly chosen in consultation with the schools’ leadership, in order to ensure that the focus group participants were representative of the schools’ demographic population. An informed consent statement was read to participants and signed by a “witness” (research assistant) to ensure anonymity.

Participants who had completed secondary school but were not attending tertiary institutions are referred to as “community males” and “community females” respectively in the Results section. The first focus group was comprised of six male community young adults between the ages of 18 and 21, and the second focus group was comprised of nine female community young adults between the ages of 18 and 22. These participants were randomly recruited from Kibera by community health workers. The third focus group consisted of two male and four female students, between 18 and 21 years old, from the University of Nairobi and Strathmore University in Nairobi. University students were majoring in engineering, information technology, or business. The fourth focus group was comprised of 11 male students, 14–18 years of age, in the ninth to 12th grades at Olympic Secondary School in Kibera. The participants in the fifth focus group were eight female peers from the same school and grades of study. The final group consisted of six female mental health professionals working in the Nairobi area, including two psychiatrists, one psychiatric nurse, one psychologist, and two community mental health support workers. At the time of our study, no male mental health professionals were available to participate in our focus groups.

Focus group discussions

Focus group discussions involving university students and mental health professionals were held in AMHF research conference rooms. Secondary school student focus group discussions were held in student classrooms. All focus groups were conducted in English. At the beginning of each focus group discussion session, the moderator (LBC) described the focus group study and encouraged participants to contribute. The moderator asked questions on specific topics involving mental health disorders, symptoms, and incidence, as well as participant understanding of specific questions on the SIPS. The principal investigator of the present study (DM) also assisted in facilitating the discussions and provided clarification when needed. Focus group discussions lasted approximately 60 minutes. All focus group discussions were audio-recorded for transcription, and detailed notes were taken (CWS and AM). Nonverbal participant expressions were recorded.

Analysis

The transcribed audiotapes and recorded notes were coded manually and analyzed (DM). Themes were identified, and quotes from group interactions were listed for each theme. Themes that represented the most salient ideas were reported. Outliers that did not emerge as common group ideas, yet seemed important, were also recorded. The thematic content and data categorization were subsequently verified for quality control and agreement by the other authors.

Results

Themes are presented beginning with those involving knowledge of general mental health topics, followed by those related to comprehension of selected questions or terms on the SIPS questionnaire.

The meaning of mental illness

Community males and females and secondary school males indicated that they understood the term “mental illness” as: “doesn’t reason the way a normal personal reasons,” “there is trouble with operations,” “mind not working well,” or “tends to act weirdly.” One secondary school female stated it was something that “affects your grades.”

In both the male and female community groups, several participants remarked that mental illness was common in Kenya. A community female added that it occurs “especially in the slum area”; another stated that it occurs in “about 1% of every household.” At least four community males personally knew of someone who had mental illness. Four secondary school males knew of a relative or a friend with a mental illness. Three university students knew of someone in their age group with a mental illness.

Three secondary school males and several secondary school females indicated they felt “madness” could occur at any age. Two secondary school males and one secondary school female stated that when mental illness occurs in teenagers, it is caused by drugs. One secondary school male added that “spirits” could also cause mental illness, and another stated that physical trauma or accident could also be a cause.

Terms to describe mental illness

Community males and females suggested that many people (for example, many rural dwellers) would not understand the term “mentally impaired” or “mental illness.” Several community males recommended substituting these terms with “mentally challenged” or “mentally disturbed.” While participants acknowledged that most community members would understand the word “mad,” it was felt that this term is inappropriately stigmatizing. The local slang word Chizi was brought up as a term used to describe those that are mentally impaired. Chizi Fresh referred to those who recently became mentally ill.

Symptoms of mental illness

When community young adults and secondary school students were asked to describe mental illness, they mainly described disorganized or bizarre behaviors. Some examples were: “sometimes he walks around naked outside,” “sings to himself at night,” “eats garbage,” “won’t speak to anyone, just do actions with their hands,” “see things that are not there,” “they don’t recognize people they know,” “dress in a funny way,” and “some can run after you.” One community male stated: “the way the person behaves at home changes; he starts ignoring responsibilities.” Another indicated that the mentally impaired often buy drugs and alcohol to use all night. One mental health professional stated, “depending on the young adults, the ones in urban or rural areas, maybe some of them will associate it with drugs. They will talk about people who behave in a funny way.”

Knowledge of specific mental disorders and terms

Community males indicated that young adults in the community would not know the name of the specific mental disorder that they or a relative had; they would simply describe the behavior. All community males agreed with this presumption. When community or university young adults were asked to label specific mental disorders, the responses included: “mad,” “insane,” “mentally handicapped,” “abnormal,” and “psychotic.” The term “psychotic,” however, was understood to mean “abnormalities with loss of memory” by one community male. The only secondary school male that gave an example of a name of a mental disorder used the term “lame,” which he described as someone who can’t see or talk.

Mental health professionals indicated that they felt there is little knowledge of the terms for mental disorders among community young adults, even if they themselves had mental disorders. One professional stated, “My experience is that if they had a mental illness or went to a [mental] hospital, when you ask what their illness was, they don’t know.”

Schizophrenia

Among community males, no one had heard this word. Among community females, none except one participant indicated having heard of the word “schizophrenia.” She described it as “the most common mental disorder, and its main cause is stress, drugs and even shock.” In the university group, only one student knew of the word, and stated, “I believe they are people with multiple personalities, so when they were another personality, they don’t remember what they did.” No secondary school males indicated that they had ever heard of the word “schizophrenia” or the word “psychotic.”

Hallucinations

Among community females, one student indicated she did not know what this meant. Another stated, “It is something that you think is there but it is not there.” Four university students indicated they had heard of this word. One of these students stated, “[hallucinations] are stimulants, and if you take it in your body, your behavior changes.” Another said, “I think [hallucinations] mostly happen in the minds of those affected by drugs and alcohol.”

Depression

Three community males made statements that suggested they understood this term. For example, one remarked, “Someone is under much stress, and can’t think, can’t do anything. He is ‘down.’ He has a feeling that has put him down before, and he keeps remembering and feeling that he can’t get out of it.” Two young adults (one community male, and one university young adult) stated that the term depression required additional clarification in order to be understood by the average community young adults. Five university students indicated that depression was “prolonged stress,” one stating, “[depression is] when people start to not act in a normal way because of what they’ve experienced and they have really been stressed about it for a long time and they really don’t know how to solve it.” None of the secondary school males were able to respond when asked for the meaning of “depression.” Several, however, correctly understood the word “sad.”

Emotionally flat

“Emotionally flat” is a term that refers to the inability to experience the range of emotions, from happiness to sadness, and often manifests as blunted affect. One community male student indicated that this term would be understood as meaning emotionally “down” or “sad.” Two community females perhaps correctly understood the term, describing it as “you have no feelings” and “doesn’t feel anything like emotions.” However, another community female thought it to mean “doesn’t know what is happening to him/her.” Among university students, one did not understand this term. Five others thought it meant that someone does not have emotions, has only few emotions, or has no emotional expression. There were no comments from secondary school males when asked to explain the meaning of “emotionally flat.” Mental health professionals generally agreed that terms such as “mood” or “feelings” are better understood than “emotions” by most community young adults. The local Swahili word Umoboeka, which means “low mood,” is generally understood in the community.

Spiritual beliefs

Several community females stated that they believed in “genies” (pronounced Jin). Two community females stated that they had personally experienced or witnessed another person experience being possessed. One community female described people possessed by a genie as: “They really have some extra energy. They can even talk in tongues that you do not know. I could talk in a voice that’s not mine, and even in another language that I’m not familiar with.” Two community females stated that there are some verses of the Bible or Koran you must say to get rid of a genie. One community female elaborated that the genie would then speak through the possessed individuals, and “for example, ask for a white chicken to be slaughtered, or ask for cow’s blood” before deciding to leave the possessed individual.

One university student suggested that as people become more educated, these beliefs are fading away. Another student disagreed with this, stating that these beliefs remain prominent in Kenya. One university student stated, “I’ve seen people being possessed. There was this person who used to take apart his necktie; when we asked [we were] told it was witchcraft and [he was] being possessed.” Another university student thought spiritual possession was associated with people from the coasts, stating that ghosts are often found in the water. Three secondary school males described genies as “invisible things which may enter a person and make him do strange things like make him fight, bite, scratch.” Two secondary school males stated that they didn’t believe in genies. They then stated that “believing” in genies makes it possible for the genies to come after you, suggesting that they did indeed acknowledge the existence of genies.

Several mental health professionals indicated that it is important to focus on the description of symptoms to be evaluated, since multiple spiritual and cultural beliefs exist. One professional stated that including the term “illness” when evaluating presence of a mental disorder or symptom may lead to false negative results, depending on the patient’s beliefs. Using the term “problem,” therefore, may yield more valid data.

Talking to a professional about mental illness

Two secondary school females stated that teachers or counselors could be approached to talk about mental health symptoms. Seven secondary school females stated they would be comfortable talking to someone they did not know personally about their mental illness. The female students added that whether a counselor, teacher, or other adult could be approached depended on their perceived trustworthiness. This was true whether the topic concerned family, school, or mental health problems. Four secondary school females expressed relief at being able to discuss such problems in the focus group, and felt they lacked trustworthy confidants in their lives. Two secondary school females stated they wouldn’t feel comfortable talking about mental illness in their families.

Understanding specific SIPS assessment questions

“Do you feel like the TV or radio is communicating directly with you?”

The question was seemingly misunderstood by community males. The question was taken literally, rather than as implying psychotic phenomena. For example, one community male stated that “most of the mentally ill persons like to relate to the TV or radio; they might be dancing to a tune or moving their arms.” Four university females stated that having felt this way is normal. A community female stated that “when you listen to the person [on TV] and you are undergoing the same situation, you imagine that they are talking to you because you are going through the same situation.” Most mental health professionals agreed that this statement is likely to be misunderstood by community young adults. Remarks made by professionals included: “You have to put it in context,” “there should be something to guide you before asking the question directly,” and “I suggest you put this in very simple language.”

“Do you feel your (mind/ears/eyes) is playing tricks on you?”

This experience was considered to be normal by several male community young adults and university students, and thus was not understood as a psychotic-like experience. Explanations given included, “you are born-again [Christian] and you don’t want to steal, but your mind is telling you to go for it,” “[your mind] tells you it wants something, but you can’t get it,” and “your mind is trying to tell you its not as bad as you know it is.” Three university students stated that in order to uncover a psychotic-like state, the question needed to be further elaborated or alternatively phrased.

Some community females stated that ear or eye tricks were not necessarily pathological. Mental health professionals all agreed that these questions would be very confusing to community young adults. One mental health professional stated that she herself did not understand the meaning of the question.

“Do you feel that what has happened to you now has happened before (déjà vu)”?

Five community females indicated that this was a normal event; one did not. Several community females understood déjà vu to mean “imagination.” One university student believed this was a normal phenomenon; another stated it was confusing and further explanation was required. Three secondary school males stated that this was normal.

“Do you feel/think people may be intending to harm you?”

This question was aimed at uncovering persecutory ideation in respondents. One community male felt this type of feeling could be normal. A university student suggested that differentiating between physical or emotional harm would help clarify the question. Two mental health professionals commented on this question. One indicated that this question would yield nonspecific results, stating, “I think that an immediate answer to that would be yes.” Another professional indicated that in the case of a positive response, it would be necessary to ask a follow-up question to determine the reasons for the interviewee’s beliefs.

“Do you feel you have been chosen by God for a special role?”

One community male felt this could be normal. Others in this focus group did not provide direct responses to this question.

“Do you feel that you can predict the future?”

Mental health professionals generally indicated that there would be a lot of false positive responses to this question by community young adults. It was stated that if not qualified further, normal beliefs, such as predicting for example the outcome of a local election, would easily lead to a positive response. One professional recommended phrasing the question as “Do you have special powers to predict?”

The term “first-degree relatives”

Understanding of the term “first-degree relatives” was also explored as it is used in the SIPS (McGlashan et al., 2010) and other psychiatric instruments to evaluate mental illness in close relatives of interviewees. Community males stated the use of this term would not be understood in most Kenyan communities. A community female defined a first-degree relative as “a person who is very closely related to you like first cousin, brother… even grandmother.” Two community females suggested that “close relatives” was a more appropriate term, although it would not include people that one did not spend significant time with since childhood, even if they were blood relatives. A community female suggested using “first family”; other participants agreed. None of the secondary school males understood the term. One secondary school male suggested the term “home-ground” as an alternative word, but two others disagreed with this, stating that the term included cousins, close friends, and neighbors.

Discussion

Evaluation of responses in our focus groups provided several important insights, including that mental illness appears to be perceived as relatively common by Kenyan adolescents and young adults. Most participants described disorganized or bizarre symptoms (such as eating garbage, walking naked outside, and making bizarre gestures) as characteristic of mental illness. Symptoms that commonly occur in depression or anxiety were not mentioned as symptoms of mental illness. This may suggest that in Kenya, simply inquiring about a personal or family history of “mental illness” may limit positive responses on psychiatric assessments, since depression or anxiety related conditions are not commonly thought of as a mental disorder.

None of the study participants could name a mental disorder. General terms such as “madness” appeared to be the extent of their knowledge. Inquiring about family history of schizophrenia or bipolar disorder, therefore, is unlikely to be informative. Our studies suggested that “schizophrenia” and related terms such as “hallucinations” and “psychosis” are unknown or poorly understood by the majority of the population. A similar lack of knowledge of schizophrenia has also been reported among Nigerian university students (Furnham & Igboaka, 2007). Although some discussants may have vaguely understood terms such as “depression,” our studies suggest that the majority of those surveyed in the general population are likely to misunderstand these terms in assessments. It is therefore necessary to be highly descriptive when describing the symptoms being investigated. Assessing the severity of depressive symptoms will require more generalized terms such as “sadness” or “stress,” with the duration of symptoms and concomitant symptoms specified. Similarly, specific psychotic symptoms require further elaboration in order to be accurately understood.

Belief in spiritual causes of psychiatric presentations was highly prevalent among Kenyan adolescents and young adults. This result is consistent with previous studies of African populations (Adewuya & Makanjuola, 2008; Ayonrinde et al., 2004; Gureje et al., 2005; Shibre et al., 2001). These beliefs, which typically involve possession by an evil force, were also held by some young adults attending higher educational institutions, as reported in previous research (Adewuya & Makanjuola, 2008). Some knowledge of causal factors, however, was noted, as several young adults mentioned the effect of drugs on symptoms (Kabir, Iliyasu, Abubakar, & Aliyu, 2004). Misunderstanding the cause of psychopathology can delay professional intervention, worsening disorder prognosis (Marshall et al., 2005). This indicates a need for greater mental health education concerning the causes, diagnosis, and treatment of mental illness.

Focus group discussions on SIPS assessment items suggested that some of the thoughts described in the questions were not considered pathological. This encouraged endorsement by some healthy individuals. The SIPS phrase “do you feel like the TV or radio is communicating directly with you?” was intended to identify a delusion of reference, but was understood to be normal by several focus group participants. This suggests that a rewording of the text would be necessary to successfully identify psychopathology in our target population. In a recent survey of Kenyan college students using the Composite International Diagnostic Interview (CIDI Screen; Ndetei et al., 2012), a similar delusion of reference item was phrased as, “believing that some strange force was trying to communicate directly with you by sending special signs or signals that you could understand but that no one else could understand.” The resulting lifetime prevalence rate of 6.4% was among the least prevalent of the psychotic symptoms assessed, suggesting that this form of questioning does not lead to overendorsement. Elaborating on the content of this screening question appears necessary in order for it to be qualified as pathological.

There have been several other phrases used to attempt to uncover subtle psychotic or psychotic-risk symptoms. Some of these are used in the SIPS. These phrases focus on determining if interviewees have experienced mind, visual, or auditory “tricks,” involving misperceptions that feel out of the ordinary (Kumra, 2000). Young adults in our focus group, however, did not appear to comprehend the term “tricks” in evaluating perceptual abnormalities. A previous Kenyan study using the abbreviated psychosis-risk questionnaire (PRIME-Screen) also excluded the item on “mind tricks,” as this was deemed incomprehensible to local young adults by the Kenyan researchers (Mamah et al., 2011). It is unclear if this reflects cultural differences in understanding of this term, since the understanding of these terms in other countries has not been extensively investigated. Similarly, déjà vu experiences were found to be normal by focus group participants. High rates of déjà vu experiences have been reported in nonclinical populations (Adachi et al., 2006), suggesting that they are not necessarily pathological. We also found limited evidence that questions aimed at evaluating persecutory and grandiose experiences in the SIPS may need rewording in order to be properly understood in Kenya. Prevalence of persecutory delusions has been found to be extremely high (over 90%) in studies where this is evaluated using phrases such as “have you ever felt as if some people are not what they seem to be?” (Barragan, Laurens, Navarro, & Obiols, 2011; Yung et al., 2009). Our previous study of Kenyan college students employed the phrase “did you ever believe that there was an unjust plot going on to harm you or to have people follow you that your family and friends did not believe was true?” and resulted in a prevalence rate of 5.5% among students surveyed (Ndetei et al., 2012). Thus, including a qualifier assessing a third person’s perception may increase the specificity of our assessment tool in identifying pathology. Similarly, questions aimed at identifying grandiose delusions may lead to overestimated prevalence rates, as thoughts probed in the questions can be misinterpreted as normal. In our previous study evaluating psychotic-risk symptoms in Kenyan adolescents and young adults using the PRIME-Screen, grandiose symptoms were the most prevalent of all the symptoms (Mamah et al., 2011). This may suggest that the given item question may be nonspecific, and may identify behaviors that may be normal and relatively common among young adults (Harrop & Trower, 2001).

In summary, our results suggest that Kenyan adolescents and young adults are aware of mental illness in their community, have a limited vocabulary of specific psychiatric disorders and symptoms, and have significant spiritual beliefs about psychiatric conditions. Results from our studies suggest that evaluation of psychiatric symptoms in Kenyan adolescents and young adults often will require an elaborate description of symptoms and using simplified terminology.

Footnotes

Acknowledgements

The authors would like to thank George W. Couch III for his generous support to this research project. The authors do not have any conflicts of interest to report and declare no financial interests in this study.

Daniel Mamah, MD, MPE, is Assistant Professor in Psychiatry at Washington University Medical School in St Louis, Missouri, where he also received a Master's in Psychiatric Epidemiology. He completed Semmelweis Medical School in Budapest Hungary, following secondary school in Port Harcourt, Nigeria. His research includes epidemiologic studies of psychosis risk in Africa and the US, early intervention, and neuroimaging of psychotic disorders, bipolar disorder and risk states. Dr. Mamah also served on the American Psychiatric Association's task force of the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Catherine W. Striley, PhD, MPE, is Assistant Professor in the Department of Epidemiology at the University of Florida. Her research is concerned with increasing the recognition of psychopathology and addictive behavior and decreasing barriers to services, as well as ethical research conduct and accountability.

David M. Ndetei, MD, PhD, is founding director of the Africa Mental Health Foundation, Nairobi, Kenya, a nongovernmental organization dedicated to research for evidence-based policy, practice in and promotion of mental and neurological health. He is also a professor at the University of Nairobi, and a past Chair of the Department of Psychiatry. Dr. Ndetei has been the principal investigator for the majority of published clinical and community epidemiologic studies on mental health and substance use in Kenya.

Anne W. Mbwayo, PhD, is a research associate at the Africa Mental Health Foundation. She has a Master's of Science in Clinical Psychology from the University of Nairobi, where she received her doctorate degree.

Victoria N. Mutiso, PhD, is a clinical psychologist and a research fellow at the Africa Mental Health Foundation, Nairobi. She is pursuing a Master's degree in Public Health at Moi University in western Kenya, and received a doctorate degree in Clinical Psychology from the University of Nairobi.

Lincoln I. Khasakhala, PhD, is a research associate at the Africa Mental Health Foundation, and received his doctorate in Clinical Psychology at the College of Health Sciences of the University of Nairobi.

Linda B. Cottler, PhD, MPH, is the founding Chair of the Department of Epidemiology at the University of Florida. She has previously served as a professor of epidemiology in the Department of Psychiatry at Washington University in St Louis, where she directed the Epidemiology and Prevention Research Group, the Center for Community Based Research and the Master's of Psychiatric Epidemiology program. Her research has focused on drug and alcohol use and dependence in vulnerable populations like injection drug users, criminal offenders, women and African Americans. She also has developed internationally recognized assessment tools for drug, alcohol, and nicotine use and gambling.

References

Adachi

Takekawa

Akanuma

Ito

Matsubara

Arai

(2006) Déjà vu experiences in patients with schizophrenia. Comprehensive Psychiatry 47(5): 389–393.

Adewuya

A. O.

Makanjuola

R. O.

(2008) Lay beliefs regarding causes of mental illness in Nigeria: Pattern and correlates. Social Psychiatry and Psychiatric Epidemiology 43(4): 336–341.

Adinkrah

(2011) Epidemiologic characteristics of suicidal behavior in contemporary Ghana. Crisis: The Journal of Crisis Intervention and Suicide Prevention 32(1): 31–36.

Angermeyer

M. C.

Matschinger

(1999) Social representations of mental illness among the public. In: Guimón

Fischer

Sartorius

(eds) The image of madness: The public facing mental illness and psychiatric treatment, Basel, Switzerland: Karger, pp. 20–28.

Ayonrinde

Gureje

Lawal

(2004) Psychiatric research in Nigeria: Bridging tradition and modernisation. The British Journal of Psychiatry 184: 536–538.

Barragan

Laurens

K. R.

Navarro

J. B.

Obiols

J. E.

(2011) Psychotic-like experiences and depressive symptoms in a community sample of adolescents. Journal of the Association of European Psychiatrists 26(6): 396–401.

Carta

M. G.

Coppo

Carpiniello

Mounkuoro

P. P.

(1997) Mental disorders and health care seeking in Bandiagara: A community survey in the Dogon Plateau. Social Psychiatry and Psychiatric Epidemiology 32(4): 222–229.

Demyttenaere

Bruffaerts

Posada-Villa

Gasquet

Kovess

Lepine

J. P.

. WHO World Mental Health Survey Consortium (2004) Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. Journal of the American Medical Association (JAMA) 291(21): 2581–2590.

Ebigbo

(1982) Uncertainty in the use of Western diagnostic illness categories for labeling mental illness in Nigeria. Psychopathologie Africaine 18(1): 59–74.

10.

Ensink

Robertson

B. A.

Ben-Arie

Hodson

Tredoux

(1998) Expression of schizophrenia in Black Xhosa-speaking and White English-speaking South Africans. South African Medical Journal 88(7): 883–887.

11.

Fresan

Apiquián

Ulloa

R. E.

Nicolini

(2007) Reliability study of the translation into Spanish of the PRIME Screen Questionnaire for Prodromic Symptoms. Actas Españolas de Psiquiatría 35(6): 368–371.

12.

Furnham

Igboaka

(2007) Young peoples’ recognition and understanding of schizophrenia: A cross-cultural study of young people from Britain and Nigeria. The International Journal of Social Psychiatry 53(5): 430–446.

13.

Gale

C. K.

Wells

J. E.

McGee

M. A.

Browne

M. A. O.

(2011) A latent class analysis of psychosis-like experiences in the New Zealand Mental Health Survey. Acta Psychiatrica Scandinavica 124(3): 205–213.

14.

Gureje

Lasebikan

V. O.

Ephraim-Oluwanuga

Olley

B. O.

Kola

(2005) Community study of knowledge of and attitude to mental illness in Nigeria. The British Journal of Psychiatry 186: 436–441.

15.

Harrop

Trower

(2001) Why does schizophrenia develop at late adolescence? Clinical Psychology Review 21(2): 241–265.

16.

Idemudia

E. S.

(2004) Mental health and psychotherapy through the eyes of culture: Lessons for African psychotherapy. In: Arlt

Idemudia

E. S.

(eds) The unifying aspects of cultures, Vienna: Austria, pp. 230–232.

17.

Jacob

K. S.

Sharan

Mirza

Garrido-Cumbrera

Seedat

Mari

J. J.

Saxena

(2007) Mental health systems in countries: Where are we now? Lancet 370(9592): 1061–1077.

18.

Kaaya

S. F.

Fawzi

M. C. S.

Mbwambo

J. K.

Lee

Msamanga

G. I.

Fawzi

(2002) Validity of the Hopkins Symptom Checklist-25 amongst HIV-positive pregnant women in Tanzania. Acta Psychiatrica Scandinavica 106(1): 9–19.

19.

Kabir, M., Iliyasu, Z., Abubakar, I. S., & Aliyu, M. H. (2004). Perception and beliefs about mental illness among adults in Karfi village, northern Nigeria. BMC International Health and Human rights, 4(3). doi:10.1186/1472-698X-4-3.

20.

Kessler

R. C.

Demler

Frank

R. G.

Olfson

Pincus

H. A.

Walters

E. E.

Zaslavsky

A. M.

(2005) Prevalence and treatment of mental disorders, 1990 to 2003. The New England Journal of Medicine 352(24): 2515–2523.

21.

Khan

Hasanah

(1996) Belief in supernatural causes of mental illness among Malay patients: Impact on treatment. Acta Psychiatrica Scandinavica 94(4): 229–233.

22.

Kinyanda

Kizza

Levin

Ndyanabangi

Abbo

(2011) Adolescent suicidality as seen in rural northeastern Uganda. Crisis: The Journal of Crisis Intervention and Suicide Prevention, Prevalence and Risk Factors 32(1): 43–51.

23.

Kumra

(2000) The diagnosis and treatment of children and adolescents with schizophrenia: “My mind is playing tricks on me.”. Child and Adolescent Psychiatric Clinics of North America 9(1): 183–199.

24.

Mamah

Mbwayo

Mutiso

Barch

D. M.

Constantino

J. N.

Nsofor

Ndetei

D. M.

(2011) A survey of psychosis risk symptoms in Kenya. Comprehensive Psychiatry 53(5): 516–524.

25.

Mamah

Owoso

Mbwayo

A. W.

Mutiso

V. N.

Muriungi

S. K.

Khasakhala

L. I.

Ndetei

D. M.

(2013) Classes of psychotic experiences in Kenyan children and adolescents. Child Psychiatry and Human Development 44(3): 452–459.

26.

Marshall

Lewis

Lockwood

Drake

Jones

Croudace

(2005) Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: A systematic review. Archives of General Psychiatry 62(9): 975–983.

27.

Maslowski

Jansen van Rensburg

Mthoko

(1998) A polydiagnostic approach to the differences in the symptoms of schizophrenia in different cultural and ethnic populations. Acta Psychiatrica Scandinavica 98(1): 41–46.

28.

McGlashan

T. H.

Walsh

Woods

(2010) The psychosis-risk syndrome: Handbook for diagnosis and follow-up, New York, NY: Oxford University Press.

29.

Morgan

(1993) Successful focus groups: Advancing the state of the art, 1st ed. Newbury Park, CA: Sage.

30.

Mosotho

Louw

Calitz

F. J.

(2011) Schizophrenia among Sesotho speakers in South Africa. African Journal of Psychiatry 14(1): 50–55.

31.

Mugisha

Knizek

B. L.

Kinyanda

Hjelmeland

(2011) Doing qualitative research on suicide in a developing country: Practical and ethical challenges. Crisis: The Journal of Crisis Intervention and Suicide Prevention 32(1): 15–23.

32.

Ndetei

D. M.

Muriungi

Owoso

Mutiso

Mbwayo

Khasakhala

Mamah

(2012) Prevalence and characteristics of psychotic-like experiences in Kenyan young adults. Psychiatry Research 196(2–3): 235–242.

33.

Ndetei

D. M.

Muriungi

S. K.

Owoso

Mutiso

V. N.

Mbwayo

A. W.

Khasakhala,… Mamah

(2013) Prevalence and characteristics of psychotic-like experiences in Kenyan youth. Psychiatry Research 196(2–3): 235–242.

34.

Ndetei

D. M.

Vadher

(1984a) Frequency and clinical significance of delusions across cultures. Acta Psychiatrica Scandinavica 70(1): 73–76.

35.

Ndetei

D. M.

Vadher

(1984b) A comparative cross-cultural study of the frequencies of hallucination in schizophrenia. Acta Psychiatrica Scandinavica 70(6): 545–549.

36.

Nuevo

Chatterji

Verdes

Naidoo

Arango

Ayuso-Mateos

J. L.

(2010) The continuum of psychotic symptoms in the general population: A cross-national study. Schizophrenia Bulletin 38(3): 475–485.

37.

Ochoa

Haro

J. M.

Torres

J. V.

Pinto-Meza

Palacín

Bernal

Autonell

(2008) What is the relative importance of self reported psychotic symptoms in epidemiological studies? Results from the ESEMeD-Catalonia Study. Schizophrenia Research 102(1–3): 261–269.

38.

Odejide

A. O.

Oyewunmi

L. K.

Ohaeri

J. U.

(1989) Psychiatry in Africa: An overview. The American Journal of Psychiatry 146(6): 708–716.

39.

Omigbodun

Dogra

Esan

Adedokun

(2008) Prevalence and correlates of suicidal behaviour among adolescents in southwest Nigeria. The International Journal of Social Psychiatry 54(1): 34–46.

40.

Otote

D. I.

Ohaeri

J. U.

(2000) Depressive symptomatology and short-term stability at a Nigerian psychiatric care facility. Psychopathology 33(6): 314–323.

41.

Prince

Patel

Saxena

Maj

Maselko

Phillips

M. R.

Rahman

(2007) No health without mental health. Lancet 370(9590): 859–877.

42.

Regier

D. A.

Hirschfeld

R. M.

Goodwin

F. K.

Burke

J. D.

Jr. Lazar

J. B.

Judd

L. L.

(1988) The NIMH Depression Awareness, Recognition, and Treatment Program: Structure, aims, and scientific basis. The American Journal of Psychiatry 145(11): 1351–1357.

43.

Robins

L. N.

Regier

D. A.

(1991) Psychiatric disorders in America. The Epidemiologic catchment area study, New York, NY: Free Press.

44.

Shibre

Negash

Kullgren

Kebede

Alem

Fekadu

Jacobsson

(2001) Perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia. Social Psychiatry and Psychiatric Epidemiology 36(6): 299–303.

45.

Taleb

Rouillon

Petitjean

Gorwood

(1996) Cross-cultural study of schizophrenia. Psychopathology 29(2): 85–94.

46.

Tomlinson

Swartz

Kruger

L.-M.

Gureje

(2007) Manifestations of affective disturbance in sub-Saharan Africa: Key themes. Journal of Affective Disorders 102(1–3): 191–198.

47.

Uwakwe

Oladeji

B. D.

Gureje

(2012) Traumatic events and suicidal behaviour in the Nigerian Survey of Mental Health and Well-Being. Acta Psychiatrica Scandinavica 126(6): 458–466.

48.

Van Pletzen

Stein

D. J.

Seedat

Williams

D. R.

Myer

(2012) Recall of early non-fatal suicidality in a nationally representative sample of South Africans. Ethnicity & Health 17(1–2): 149–159.

49.

Weissman

M. M.

Bland

R. C.

Canino

G. J.

Faravelli

Greenwald

Hwu

H. G.

Yeh

E. K.

(1996) Cross-national epidemiology of major depression and bipolar disorder. JAMA 276(4): 293–299.

50.

Weissman

M. M.

Bland

R. C.

Canino

G. J.

Faravelli

Greenwald

Hwu

H. G.

Yeh

E. K.

(1997) Cross-national epidemiology of panic disorder. Archives of General Psychiatry 54(4): 305–309.

51.

Weissman

M. M.

Bland

R. C.

Canino

G. J.

Greenwald

Hwu

Lee

C. K.

Wickramaratne

P. J.

(1994) The cross national epidemiology of obsessive compulsive disorder: The Cross National Collaborative Group. The Journal of Clinical Psychiatry 55: 5–10.

52.

Weissman

M. M.

Bland

R. C.

Canino

G. J.

Greenwald

Lee

C. K.

Newman

S. C.

Wickramaratne

P. J.

(1996) The cross-national epidemiology of social phobia: A preliminary report. International Clinical Psychopharmacology 11(3): 9–14.

53.

World Health Organization International Consortium in Psychiatric Epidemiology (WHO) (2000) Cross-national comparisons of the prevalences and correlates of mental disorders. Bulletin of the World Health Organization 78(4): 413–426.

54.

Youngmann

Zilber

Workneh

(2008) Adapting the SRQ for Ethiopian populations: A culturally-sensitive psychiatric screening instrument. Transcultural Psychiatry 45(5): 566–589.

55.

Yung

A. R.

Nelson

Baker

Buckby

J. A.

Baksheev

Cosgrave

E. M.

(2009) Psychotic-like experiences in a community sample of adolescents: Implications for the continuum model of psychosis and prediction of schizophrenia. The Australian and New Zealand Journal of Psychiatry 43(2): 118–128.