Widely used screening tools like the PHQ-9 (Patient Health Questionnaire 9) were developed in Western clinical contexts and require careful consideration and adaptation before use. In communities where chronic adversity is common, it is important to apply measures in a meaningful way to avoid misreading situational distress as clinical disorder. Local or culturally adapted measures that have been validated and tested should be supported and invested in, with an understanding of their possible benefits and limitations. Using multiple measures or sources of information may also help.

Mental health programs around the world have made significant progress in adapting their delivery to local contexts. But there is a risk if diagnostic and screening instruments are selected that are not properly tested or adapted, or carry untested assumptions that do not hold up. Localizing the work means localizing how we identify, measure, and talk about distress in the first place, as well as using a range of approaches to consider outcomes.

When tools don’t translate

Sean Mayberry of StrongMinds, which has treated 2 million people for depression across East Africa, is direct about the limitations of standard instruments:

Cat Lukach, StrongMinds' chief development officer, frames the broader tension. "There is a constant pull between complying with best practices designed by and for the Global North and trusting what we know actually works,” she says. “We are not a compliance organization. We are innovators, and the communities we serve deserve solutions built for their reality, not borrowed from someone else's."

Others in the Co-Lab echo this skepticism, pointing in particular to the PHQ-9, which was developed in a Western context and geared toward middle- and upper-class populations. This problem goes beyond cultural sensitivity. When a screening tool asks about changes in appetite in a community where people routinely go hungry, it isn't measuring depression. The instrument produces data, but if the questions don't reflect how people in that community actually experience distress, the results will be misleading. When funding decisions, program design, and clinical referrals all flow from those numbers, the consequences of a poorly fitted tool cascade through the entire system. This speaks to the need to use well designed, tested, and adapted measures and to consult with local experts and academics to identify approaches that may work.

Instruments carry hidden cultural assumptions.

Mark Jordans of War Child, who leads research on youth mental health in conflict settings, describes how standard survey instruments embed language and concepts that don't travel. "You could easily find an instrument that measures depression or depressive symptoms, and it will ask a question like, 'How much have you been feeling blue in the last two weeks?' That does not make sense in any other context," he says. His team goes through "a rigorous process of translating, back translating, interviewing, testing, practicing in order to get the language and the terms right. Sometimes even developing new tools specifically for that context."

Ken Carswell of the World Health Organization describes a similar process. WHO advises that "everything is culturally adapted" and that teams work "with local communities, people with lived experience and experts during the development, planning, and adaptation phase to inform the project." Terminology can be a barrier to accurate screening. Carswell notes that "where [a tool] says 'depression' and 'anxiety,’ we would expect that to be changed to the local idiom of distress." If a screening tool asks about "depression" in a community where the concept is understood differently or carries intense stigma, the tool will likely produce unreliable results regardless of how well the program around it is designed. The WHO has a chapter on adaptation that can be used for both programs and tools in its Psychological Intervention Implementation Manual.

Local tools built from local experience

Some organizations are moving beyond adapting existing instruments and developing their own approaches to understanding mental health in context. Gabriela Peixinho of Luta pela Paz, working in Brazil's favelas, found that standard clinical frameworks didn't match how her community experienced or talked about mental health. When her organization first offered mental health services, she recalls, "we didn't have a demand." Through conversations with young people and families, they heard: "This service is not for us. We need to survive. We don't need to have good mental health because it's not possible."

Rather than force a clinical model onto a community that didn't recognize itself in it, Peixinho's team built its own tools. Working with UNICEF, they developed care diaries that help professionals work with young people to identify what affects their mental health and how to respond, grounded in the community's own language and experience. "We understand we need to anchor this methodology to our own community contexts," she says. The lesson extends to measurement: if the frameworks used to identify and understand distress don't reflect how a community actually experiences it, the tools built on top of those frameworks will miss what matters most.

Chiara Servili of the WHO underscores the principle behind this work:

What these organizations are learning, both through trial and error and by drawing on the research that has been conducted on this topic, is that screening tools cannot simply be imported and applied uncritically. Involving local communities and end users in the design of programs and evaluation methods is essential to ensuring they meet local needs, measure outcomes accurately, and avoid causing harm. A young person whose distress is misread by a screening instrument may be referred to the wrong service or missed entirely, while not using measures also risks this outcome. Communities that see their realities ignored by assessment tools may stop engaging with the programs that use them. Both of these highlight the need for a thoughtful and carefully constructed approach to measurement and program design. Building mental health work that actually reaches people starts with making sure the communities are involved throughout the whole process and help ensure the instruments at the foundation of that work reflect how they live, speak, and experience struggle.