Our objectives are to determine whether the 4DSQ is valuable for Turkish-speaking patients living in Belgium who face language barriers-meaning they are not fluent in Dutch or French-and have psychological complaints, and to provide better support within the primary healthcare system for general practitioners (GPs).

We will use individual semi-structured interviews with GPs who applied the Turkish 4DSQ to diagnose only Turkish-speaking patients with mental health issues.

In Belgium, psychological complaints are common in general practice. Patients present with a wide spectrum of issues, ranging from mild symptoms to severe mental illnesses. According to a study conducted in Flanders in 2024, approximately 22% of the adult general population in Flanders meet the criteria for a mental disorder. This is more than the 15% estimated twenty years ago. As a general practitioner (GP), you understand your patient's background, have a trusted relationship, and serve as a key point of contact.

Clinicians employ a diverse range of models and treatments for patients presenting with mental health concerns. This variation in practice raises important questions about the provision of optimal care. In 1994, Dutch researchers developed a mental health assessment approach specifically designed for use in primary care. This approach involves a multidimensional assessment where patients' symptoms are reported and scored across four key areas: distress, depression, anxiety, and physical symptoms. The assessment is conducted using the Four-Dimensional Symptom Ques- tionnaire (4DSQ) before or between consultations. The resulting score profile across these dimensions helps inform clinical decision-making during the consultation. In a thesis which

completed by a family doctor at KU Leuven University in Belgium between 2014 and 2016, the 4DSQ was identified as a valuable resource for general practitioners in primary care in Belgium.

In medical and psychological care, a language barrier can lead to misunderstandings, incorrect diagnoses, and limited access to appropriate care. Therefore, translations must be not only linguistically accurate but also aligned with how people in a particular community discuss and understand mental health.

The 4DSQ has been translated into multiple languages and is used worldwide in primary care and psychological diagnostics. Currently, it is available on the EMGO website in 17 different languages: Some of them are Dutch, English, French, German, Czech, Greek, Polish, Romanian, Russian, Serbian, Turkish, Urdu (the official national language of Pakistan).

For the two versions, the cutoff scores had to be adjusted to match the Dutch version. Specifically:

In the English version, the cutoff for the highly elevated anxiety score needed to be lowered by one point. In the Polish version, the cutoff for the normal distress score had to be lowered by one point.

A significant Turkish population lives in Belgium. Given varying estimates, it's reasonable to infer that the Turkish community, including both immigrants and their descendants, comprises between 200,000 and 500,000 individuals in Belgium. According to recent studies in Belgium, Turks are among the ethnic groups with the highest antidepressant use.

The 4DSQ was translated into Turkish with the help of a team of general practitioners from Marmara University, Istanbul, and a Dutch-Turkish psychiatrist in the Netherlands. Two separate studies were conducted, and the test was adapted to the culture of the Turkish community. However, how frequently it is used in Turkey or Belgium remains unknown.

Study Aim

The aim of this study is to determine whether the Turkish version of the Four-Dimensional Symptom Questionnaire (4DSQ) is a valuable tool for assessing psychological complaints in Turkish-speaking patients living in Belgium who face language barriers-that is, those who are not proficient in Dutch or French. The goal is to explore whether the use of the 4DSQ in this population can contribute to more accurate clinical evaluations and improve support within the primary healthcare system.

This approach is expected to help minimize the medicalization of psychological symptoms and reduce unnecessary-or potentially harmful-overtreatment with antidepressant medications. Moreover, the use of the 4DSQ may promote broader diagnostic conversations during consultations by incorporating symptom dimensions frequently described by patients themselves, such as distress or stress, even in the absence of a formal depression diagnosis.

Research Question

Does the use of the Turkish version of the 4DSQ in primary care consultations improve the diagnostic accuracy, communication, and treatment quality for Turkish-speaking patients with psychological complaints who face language barriers in Belgium?

Expectations

This study is expected to yield several important outcomes for both patients and healthcare providers, particularly within the context of culturally and linguistically diverse primary care:

1. Improved Clinical Understanding by General Practitioners

   It is anticipated that Belgian GPs will gain a deeper and more structured understanding of the psychological symptoms experienced by Turkish-speaking patients. The 4DSQ enables standardized assessment of distress, depression, anxiety, and somatization, reducing diagnostic errors caused by language barriers.

2. Enhanced Doctor-Patient Communication The culturally adapted and linguistically accessible self-report nature of the 4DSQ may improve communication, especially when verbal interaction is limited. Patients may feel more understood and empowered to express their symptoms, potentially leading to more open and honest disclosure.

3. Potential Changes in Diagnostic and Treatment Pathways Better symptom profiles obtained through the 4DSQ may lead to more targeted treatments, such as increased psychosocial referrals and decreased unnecessary use of antidepressants, thus reducing the medicalization of stress-related complaints.

4. Increased Satisfaction Among Patients and Providers Higher satisfaction is anticipated from both patients and GPs. Patients may feel more acknowledged and taken seriously, while GPs may experience more confidence in clinical decision-making due to the availability of a validated screening tool.

5. Support for Culturally Competent Care in Primary Practice Findings may support the broader use of culturally adapted screening tools in routine care, potentially serving as a model for other minority groups and enhancing equitable access to mental healthcare.

Inclusion Criteria:

• We will include GPs who don't speak Turkish.

Patients must:

• be 18 years or older
• be fluent in Turkish, not in Dutch or French

Exclusion Criteria:

• Patients with severe psychiatric disorders requiring specialized care