Women, poverty and common mental disorders in four restructuring societies
Introduction
Common mental disorders (CMD) was a term coined by Goldberg and Huxley (1992, pp. 7–8) to describe “disorders which are commonly encountered in community settings, and whose occurrence signals a breakdown in normal functioning”. CMD, also referred to as non-psychotic mental disorders or neurotic disorders, manifest with a mixture of somatic, anxiety and depressive symptoms. CMD are the third most frequent causes of morbidity in adults (prevalence rates) worldwide (World Health Organization, 1995). They are an important cause of disability and pose a significant public health problem (Ormel et al., 1994). The recent WHO report “Investing in Health Research and Development” predicts that depression will be the single most important cause of disability by the year 2020 in the developing world (World Health Organization, 1995). The warning of a mounting crisis of unmet needs for the countless millions with such disorders have been building up over the past 20 years. Evidence of a high prevalence of CMD has been generated from a range of settings in low and middle income countries such as rural Lesotho, primary health clinics in Santiago and the urban general practices of India (Shamasundar, 1986, Hollifield et al., 1990, Araya et al. 1994). These studies reveal prevalence figures of CMD exceeding 30% in community samples and approaching 50% in primary care samples.
The WHO Multinational study of the prevalence, nature and determinants of CMD in general medical care settings was conducted in 14 countries (Ustun et al., 1995b). The startling finding of this study was that, despite the use of standardized methods in all centres, there were enormous variations in most variables. Indeed, the only similarities across centres were the general observations of the ubiquity of CMD, the comorbidity of anxiety and depression, and the association of CMD and disability even after adjustment for physical disease severity. On the other hand, specific variables showed substantial variations; thus the prevalence rates of CMD ranged from 7 to 52% of primary care attenders; physician recognition of CMD varied from 5% to nearly 60% and the association of key variables such as gender, physical ill-health and education with CMD were in opposite directions in different centres. These findings demonstrate the need for locally relevant studies with locally validated methodologies whose aim is to identify local needs and inform local health services (Patel and Winston, 1994).
Female gender, social, economic and interpersonal factors remain the most consistently demonstrated risk factors for CMD in industrialised societies. There is growing evidence of an association between socioeconomic deprivation as represented by unemployment (Warr, 1987, Bartley, 1994, Gunnell et al., 1995), low income (Eaton and Ritter, 1988, Power et al. 1991) and lower social class (Brown and Harris, 1978, Meltzer et al. 1995), with suicide rates (Platt and Kreitman, 1990) and psychological disorder. There is consistent evidence of an association between economic deprivation as measured by social class, income and employment, in developed countries and CMD (e.g. Bartley, 1994). A recent household survey from the United Kingdom demonstrated a strong association between CMD and low household income and not saving from income (Weich et al., 1997). Similarly, many studies from these settings have demonstrated a greater risk for women to suffer CMD (Jenkins, 1985).
Most epidemiological studies of CMD in low-income countries have concentrated on prevalence rate estimations, rarely examining the role of risk factors. The aim of this paper is to bring together data collected by the authors in five separate studies conducted in four low and middle income countries in different stages of economic development to examine two hypotheses: first, that female gender is associated with CMD and, second, that poverty is associated with CMD. The rationale for these hypotheses was that these risk factors had been demonstrated in some studies from industrialised societies. If similar associations were demonstrated in low and middle income countries, the implications would be of great importance since they would reflect not only the universal nature of these risk factors, but also have a bearing on the impact of the dramatic economic changes in these countries on the increased morbidity of CMD. These studies were conducted by the authors in their own countries, using methodologies that were sensitive and valid for the local setting. Thus, this paper is not based on a multinational study in the traditional sense of having its emphasis on uniformity. Instead, this is a model of what the authors propose as locally sensitive research whose findings can be collated to examine themes arising out of diverse cultural settings.
Section snippets
Method
The overall methodology of the 5 studies is summarised in Table 1. Brief information on key aspects of the methodology are described below. Details for each study can be obtained from the original publication describing the studies as referenced.
Sociodemographic data and prevalence of CMD
These are summarised in Table 2.
Association of socio-demographic variables with CMD
Table 3, Table 4 show that there is a consistent association between CMD and female gender, older age and lower education. While there is a trend for those who were previously married (i.e. widowed, separated/divorced) and those who were unemployed, this was not consistent after adjustment for age and sex.
Association of economic indicators with CMD
For the four studies where income data was elicited, the samples were categorized on the basis of income tertiles (Table 5, Table 6). Using the lowest income
Discussion
The aim of this paper was to collate data from 5 data-sets elicited in 4 countries which are currently in the midst of radical economic reforms, to examine the associations between female gender and economic indicators with common mental disorders. In contrast to the stress laid on uniformity in multi-national study designs, all 5 studies collated in this paper were conducted independently. All the authors of the studies described in this paper were resident in the areas of their study and this
Acknowledgements
The study in Harare was funded by the International Development Research Centre (Canada); in Goa by the Wellcome Trust (UK); in Olinda by FACEPE and CNPq (Brazil); in Santiago by Fondo Nacional de Ciencia y Tecnologı́a (FONDECYT, Chile) and in Pelotas by CAPES (Ministry of Health, Brazil). All authors are indebted to the numerous individuals and researchers who participated in each of the studies and are acknowledged in detail in the main publications referenced for each study.
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