6

Mental Health Problems

For many years mental illnesses were thought to be rare in Africa, or at least less severe or of milder consequence compared with other countries, particularly in the more industrialized parts of the world. This belief has gradually been replaced by growing evidence, supported by epidemiologic studies, that such illnesses are at least as frequent in Africa as in the developed world, if not more so. In addition, a number of studies have shown that, as in other societies, there are indeed gender differences in the rate and the course of many mental disorders in African societies.

The Aim of this chapter is to provide a review of the current state of knowledge about women and psychiatric disorders in African countries, underlining the similarities and differences between the two sexes in the rate, phenomenology, course, and outcome of these disorders. With respect to the rates of occurrence, it is their similarity in the two sexes that is remarkable: as Table 6-1 indicates, the only psychiatric disorders that appear to impose a disproportionate and, in this instance, unique burden on Sub-Saharan females are those associated with pregnancy and the puerperium. The similarities and differences will also be compared with the picture in non-African societies, particularly the societies where most epidemiological investigations have been carried out.

MENTAL HEALTH AND MENTAL ILLNESS IN AFRICA: GENERAL ISSUES

The belief that mental disorders were generally less common and less severe in Africa than in other regions arose primarily from the expectation that a rural traditional life, lived in harmony with nature, could only lead to mental health, without psychological stress and suffering. This belief was also supported by some superficial observations regarding the mentally ill in these settings. For instance, in most African countries, few people with mental illness find their way into the European-inspired health system. The majority of people with psychological problems customarily remain with their families and are eventually treated by traditional healers. Those who do come to health clinics and hospitals tend to be brought by law enforcement agencies and have been violent and destructive; there is a greater chance that they will be male. Since many observations concerning the rate of occurrence of mental disorders are based on institutional statistics, it has been easy to sustain the assumption that the smaller number of females admitted to specialized psychiatric hospitals and clinics reflect a true difference in prevalence rates between the sexes, with females at lower risk.

It was also thought that women were essentially dependent, and thus by definition more likely to be kept in the community. The very process of getting an excited person to the hospital is also resource-intensive and expensive,



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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa 6 Mental Health Problems For many years mental illnesses were thought to be rare in Africa, or at least less severe or of milder consequence compared with other countries, particularly in the more industrialized parts of the world. This belief has gradually been replaced by growing evidence, supported by epidemiologic studies, that such illnesses are at least as frequent in Africa as in the developed world, if not more so. In addition, a number of studies have shown that, as in other societies, there are indeed gender differences in the rate and the course of many mental disorders in African societies. The Aim of this chapter is to provide a review of the current state of knowledge about women and psychiatric disorders in African countries, underlining the similarities and differences between the two sexes in the rate, phenomenology, course, and outcome of these disorders. With respect to the rates of occurrence, it is their similarity in the two sexes that is remarkable: as Table 6-1 indicates, the only psychiatric disorders that appear to impose a disproportionate and, in this instance, unique burden on Sub-Saharan females are those associated with pregnancy and the puerperium. The similarities and differences will also be compared with the picture in non-African societies, particularly the societies where most epidemiological investigations have been carried out. MENTAL HEALTH AND MENTAL ILLNESS IN AFRICA: GENERAL ISSUES The belief that mental disorders were generally less common and less severe in Africa than in other regions arose primarily from the expectation that a rural traditional life, lived in harmony with nature, could only lead to mental health, without psychological stress and suffering. This belief was also supported by some superficial observations regarding the mentally ill in these settings. For instance, in most African countries, few people with mental illness find their way into the European-inspired health system. The majority of people with psychological problems customarily remain with their families and are eventually treated by traditional healers. Those who do come to health clinics and hospitals tend to be brought by law enforcement agencies and have been violent and destructive; there is a greater chance that they will be male. Since many observations concerning the rate of occurrence of mental disorders are based on institutional statistics, it has been easy to sustain the assumption that the smaller number of females admitted to specialized psychiatric hospitals and clinics reflect a true difference in prevalence rates between the sexes, with females at lower risk. It was also thought that women were essentially dependent, and thus by definition more likely to be kept in the community. The very process of getting an excited person to the hospital is also resource-intensive and expensive,

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 6-1 Mental Health Problems in Sub-Saharan Africa: Gender-Related Burden Problem Exclusive to Females Greater for Females than for Males Burdens for Females and Males Comparable, but of Particular Significance for Females Psychological disorders associated with pregnancy and the puerperium X     NOTE: Significance is defined here as having impact on health that, for any reason—biological, reproductive, sociocultural, or economic —is different in its implications for females than for males. so that such effort is more likely to be made for men, who generally have a higher socioeconomic status. For all these reasons it was —and still is—true that more men than women are admitted to mental hospitals in Africa, as demonstrated by a number of epidemiological investigations providing data about the percentage of male and female users of psychiatric in- and outpatient services (Ihezue, 1982; Khandelwal and Workneh, 1988; Levin et al., 1981; Orley, 1972). The preponderance of excited patients admitted to mental hospitals for social control purposes was also a factor that led to the erroneous conclusion that the depressive disorders were rare in Africa. Misdiagnosis of weakness and multiple somatic complaints as only somatic, rather than in any way psychological, was another factor, especially in the tumultuous context of busy outpatient departments that allow just a few minutes for each patient and only a limited number of treatment responses. With better understanding of the nature of many mental disorders, and with the growing number of epidemiologic studies in community samples or among general health clinic clients, it became clear that most mental disorders are, in reality, frequent in Africa. A better understanding of changing rural lifestyles further helped to dispel the notion that African populations are free of stress and that their culture somehow protects them from the pressures that normally affect others. Despite this wider awareness, until recently many European and American observers held on to the notion that stressful situations have different, generally milder, consequences among African women than among women elsewhere. Some have believed that African mothers are relatively immune to grief that comes with the death of a child; apparent helplessness in the face of such events has been mistaken for coolness, rather than anguish. It is clear that the stresses on Sub-Saharan women as they go through life are intense, even in the most traditional societies. In the many parts of the region where disruption, famine, war, and forced migration prevail, the pressures are all the greater (Toole and Waldman, 1990). The customs and expectations of women's roles, although variable among African societies, can also lead to stress on women, even where there is no disaster or disruption of family and social ties. In some societies, a young woman will move to her husband's home after her marriage and break many of the ties with her natal family. A "bride price" is often paid to her family, which can mean that if she wishes to return, even for a good reason such as maltreatment, her family will be reluctant to take her back because they would be obliged to return the wealth they had been paid for her. If she bears no children, this too is reason to withhold installments on the price that may have been held back pending proof of fecundity; this puts her at a disadvantage with both her husband's family and her natal family. The great value placed on a woman as a bearer of children should mean that the menopause might be a time of great stress. Yet this can also become a time of caring for grandchildren, although this may depend, at least in the virilocal marriage situation that is normative in much of Africa, on her having borne sons. Even for women who have not borne children, their childless state can be somewhat attenuated by living in a polygamous household and having access to other wives' grandchildren or to a husband's brother's grandchildren. At the same time, living in a polygamous household may be still another source of strain: the frequent jealousy of co-wives can lead them to deliberately harm one other. Although not conducted in Africa, a recent, well-designed epidemiologic study carried out in a sample of women in Dubai, one of the seven Arab Emirates, confirmed that polygamous marriages are psychologically stressful (Ghubash et al., 1992). In this study, the overall prevalence of any

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa psychiatric disorder, assessed on the basis of the PSE Index of Definition/CATEGO system (a computerized method for determining "caseness"), was about 23 percent; women who were living in polygamous marriages were more than twice as likely to be psychiatric cases as women in monogamous marriages. Another recent study, carried out in a sample of 116 Yoruba adolescents in Nigeria (69 males and 47 females) with a mean age of 17.8, investigated the psychological adjustment of the two groups in relation to their type of birth family (Oyefeso and Adegoke, 1992). Male adolescents from monogamous families seemed to be better adjusted psychologically than those from polygamous families, while no such difference seemed to exist in the levels of psychological adjustment of female adolescents. These findings suggest that: (1) sex-role prescription can influence psychological adjustment of adolescents in Yoruba societies, and (2) female children may enjoy a more protective upbringing in polygamous families than their male counterparts experience. Added to these stresses on women is the nature and size of their workload. The various household duties of cleaning, cooking, and washing must be performed along with the agricultural work, which men traditionally leave to women, except perhaps for occasional heavy digging and clearing. When men go off to the cities to find work, women are left to carry the whole burden of family life. Their burden may be lightened a little by presents or occasional cash brought back from the city by the emigrés, but this would not seem to be the norm. It is not surprising, therefore, to see that mental illness is frequent in Africa, and may not be less so among women. Many of the precursors are there—in the frequent severe life events and difficulties they face—even in contexts where social support may be available. In a study of young women living in an urban environment in Zimbabwe, added stresses were reported, including marital disharmony associated with violence and the threat of AIDS. In such situations the women found themselves powerless, removed as they were from their traditional support systems (Broadhead and Abas, 1993). GENDER DIFFERENCES IN THE RATE, COURSE, AND OUTCOMES OF MENTAL DISORDERS: GLOBAL ISSUES The gender difference in the rate, course, and outcomes of various mental disorders across the world has attracted the attention of researchers and clinicians. It is appropriate to briefly discuss this global issue before examining the African situation in more detail. Several well-conducted epidemiologic studies from outside Africa have indeed shown that there are remarkable differences in the rates of occurrence of various mental disorders between the two sexes, with females generally showing higher incidence and prevalence rates compared with males. This result has been confirmed in a number of reviews (Dohrenwend and Dohrenwend, 1969, 1974; Goldman and Ravid, 1980; Gove and Tudor, 1973; Weissman and Klerman, 1977). In the most recent review of 11 major epidemiologic studies based on direct assessment by standardized research interviews and generally carried out through a two-stage procedure, Goldberg and Huxley (1992) found an overall one-month prevalence rate in random samples of the general population for any psychiatric disorder (excluding cognitive impairment, substance use, and antisocial personality) of 12.1 percent among males, compared with 20.2 percent among females. In the only study conducted in Africa among the 11 considered, however, the prevalence rate was approximately the same among males and females. Despite the consistency of this finding of gender differences in most parts of the world, with that single African "exception," Jenkins (1985) has demonstrated that if samples of males and females are chosen in order to be completely comparable in social adjustment, the sex difference disappears, or is greatly reduced. In addition, some major surveys have not supported the general finding of a sex difference in prevalence rates. For instance, in the Epidemiologic Catchment Area (ECA) Program study for the United States, a large survey carried out in five American sites in an overall sample of over 18,000 people, more men than women reported some kind of psychiatric disorder over their lifetime (36 percent versus 30 percent). Nevertheless, men and women did not differ in the proportions of those with an active disorder in the year immediately prior to the survey, when there was a 20 percent prevalence rate in both sexes (Robins and Regier, 1991). According to the authors, one of the more noteworthy results of the ECA is that it brought into question the overall excess of mental disorder among women compared with men that had been reported in many earlier surveys. This discordance is resolved by disaggregating interactions of gender according to disorder, as noted over two

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa decades ago by Dohrenwend and Dohrenwend (1969). There is generally an excess of alcohol and substance abuse and antisocial personality among males, while there is an excess of depressive and neurotic disorders among females. From a variety of clinical and epidemiological studies, gender emerges strongly and consistently as a major risk factor for depression, with women outnumbering men, on average, by a 2:1 ratio (Goodwin and Blehar, 1993). A major review by Nolen-Hoeksema (1987) found a mean female-to-male ratio across all clinic-based studies of treated cases of depression of 1.95:1 in the United States and 2.39:1 outside the United States; these gender differences were statistically significant. Moreover, considering data from 12 studies that provided only summary data on all affective disorders, used idiosyncratic criteria for diagnoses, or were based on small samples, the mean female-to-male ratio was 1.5:1 (< 01). Three of these studies were carried out in African countries (Kenya, Nigeria, and Zimbabwe). On the whole, from epidemiologic studies carried out in a variety of countries and sociocultural settings throughout the world, it appears that there are significant gender differences in the rate of selected mental disorders when these are sorted by type, with an excess of males for some disorders and an excess of females for others. In addition, several clinical and follow-up studies have also shown gender differences in age of onset, course, and outcomes of various mental disorders. To take two major examples, it has been shown repeatedly that, on average, schizophrenia starts five years earlier in men than in women (Warner and de Girolamo, 1995), and that it has a milder course and a better outcome among females. In contrast, depression seems to have a more severe course in females than in men, and females appear to be at higher risk of relapse (Brown, 1991). THE EPIDEMIOLOGIC EVIDENCE IN AFRICA Data concerning psychological symptoms and psychiatric disorders in Africa are not abundant. Epidemiologic studies are few, and most have been carried out on people presenting at health clinics, so that they suffer from all the usual problems associated with biases leading to clinic attendance. Although many studies do segregate data from males and females, they do not customarily provide data broken down by age. Very few studies look beyond simple ''head-counting" for a selected number of diagnoses. A number of mental health problems are mentioned in this chapter in passing, because although they represent a significant cause of morbidity and burden, they do not differentially affect women; indeed, in some cases women may be relatively spared. Problems such as depression, anxiety, schizophrenia, and puerperal illness, which do affect women differentially, are addressed in more detail. When samples for studies are drawn in some relatively unselected way from within a total community, these will be referred to as "community-based," and the results should be understood to reflect the rates of disorder expected within the population as a whole. Where studies have been done on individuals attending a clinic (even a general outpatient clinic), they are referred to as "clinic-based," and their results should not be viewed as generalizable to community samples because a variety of factors differentially affect help-seeking behavior in males and females. Two comprehensive reviews that focus on the extent of mental health problems in Africa today are important—German (1987) and Odejide and colleagues (1989). The first author emphasizes that while early estimates of the prevalence of psychiatric disorder in black Africa were universally low, primarily because they were mainly hospital-based, more recent studies that have sampled diverse populations suggest a burden of psychiatric morbidity in black Africa not dissimilar to that found in more developed countries. Some of the studies reviewed suggest that rates in Africa may be even higher than in developed countries. Similar conclusions were reached by the authors of the second review. Unfortunately, neither of these reviews discussed the gender issue in any detail. Nevertheless, they provide a crucial starting point by underlining the magnitude of mental health problems among Africans and pointing to the need for a closer examination of this important topic. GENDER DIFFERENCES IN AFRICA FOR ALL PSYCHOLOGICAL DISORDERS The study carried out in Nigeria by Leighton and coworkers (1963a) was the seminar psychiatric investigation for the African continent, as well as for cross-cultural psychiatry. This extensive investigation was carried out in the late 1950s and early 1960s, and it was aimed at estimating the prevalence of psychiatric disorders among the

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Yoruba people in the western region of Nigeria. The sampling methods were sound, with scientifically acceptable applicability or generalization of the observations. Findings from the Stirling County study, a major community-based epidemiologic investigation carried out in rural Canada (Leighton et al., 1963b), provided the main comparative data. In general, the Yoruba group seemed to have more symptoms but fewer cases of clearly evident psychiatric disorder. While in the Stirling County study the prevalence of psychiatric disorder, especially psychoneurotic symptoms, was considerably greater among women than men (65 versus 47 percent), in the Yoruba sample this pattern was reversed, although the sex difference was small (42 percent among males and 39 percent among females). The Yoruba group also showed a higher prevalence of psychiatric symptoms based primarily on organic disorder than the Stirling County population, a finding that was compatible with the greater amount of severe endemic disease and malnutrition in the Nigerian population. Another seminal community survey was carried out by Orley in the early 1970s (Orley and Wing, 1979) in two Ugandan villages, and its results were compared with those obtained in a survey conducted with the same methodology in a working-class area in southeast London (Camberwell) among 237 women. The brief form of the ninth edition of the Present State Examination was used, translated into the Luganda language, and all the interviews in the Ugandan villages were conducted in that language. The data were analyzed using the PSE Index of Definition/CATEGO system. The three major psychiatric illnesses detected were depression, hypomania, and anxiety states, and higher rates were found for all three diagnoses in the Ugandan villages. The highest rates were for depression—the Ugandan rates were twice as high as those in Camberwell, both at threshold and for more definite cases. There was no significant difference in the overall rate of disorders between the two sexes in the Ugandan sample; combining all cases at threshold level and above, according to the Index of Definition, 27 percent of the women and 24 percent of the men had psychiatric disorders. For comparison, 11 percent of the women surveyed in the London sample were cases at threshold level and above. The PSE mean total scores were not significantly different between the two sexes in the Ugandan sample (male, 5.22; female, 5.71). A number of other community surveys of various sample sizes and employing methodologies with different degrees of sophistication have been carried out in other African countries, including Sudan (Baasher, 1961; Rahim and Cederblad, 1989) and Senegal (Beiser et al., 1972; Diop et al., 1982). The Senegal studies did not break down psychiatric morbidity rates by gender, and thus will not be discussed further. In Sudan, Baasher (1961) surveyed the inhabitants of a village with 1,860 residents. A team including a psychiatrist visited all households and interviewed family members in order to pick up any cases of mental disorders. (The short report on the study does not specify how many people were actually interviewed.) The author found an overall prevalence rate for most common psychiatric disorders of 6.3 percent; females outnumbered males almost 4:1. The author points out that this result was the opposite of that found in a Khartoum clinic studied, where the ratio of males to females was 3:1. Two explanations were advanced to account for the excess of females in rates of psychiatric disorders within the general population: (1) the absence of husbands for 38 percent of married women; and (2) a high infant mortality rate (up to 116/1,000), which was expected to have a significant psychological impact on females' mental status. In the later study in Sudan, Rahim and Cederblad (1989) randomly selected 204 subjects between the ages of 22 and 35 from a newly urbanized part of Khartoum. Subjects were assessed using the Self-Reporting Questionnaire, the Eysenck Personality Inventory, and a Sudanese rating scale of anxiety and depression. A psychiatric interview and a medical examination were also administered. It was found that 40.3 percent of the subjects had at least one psychiatric symptom; 16.6 percent received clinical diagnoses according to DSM-III. The most common diagnoses were neurotic and endogenous depressive illness (8.4 percent) and generalized anxiety (3.4 percent). Alcohol abuse was very rare (0.4 percent). No gender differences in the rates of the disorders assessed were encountered. AFFECTIVE AND NEUROTIC DISORDERS Despite the contention of some researchers in the past that depression, and particularly guilt, were uncommon in African populations (Carothers, 1953), subsequent investigations contradict such conclusions and reveal a remarkable rate of depressive disorders and symptoms in the samples surveyed. In the 1963 studies by Leighton and colleagues (1963a,b) cited above, depressive symptoms were four times more common in their Nigerian series

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa than among the population of Stirling County, Canada. In the Orley and Wing (1979) study, also cited above, there were approximately twice as many cases of depression in their Ugandan series as in the female sample from a London inner-suburb. In a later review of this topic, Jegede (1979) also noted a considerable frequency of depression among Africans and stressed the common somatic presentation of this disorder. It has already been noted that most epidemiologic investigations carried out in community samples in various sites, predominantly in industrialized countries, have found a remarkable difference in rates of depressive disorders between males and females. Bebbington (1988, p. 8) has stated, "Perhaps, the most consistent finding in psychiatric epidemiology is that women suffer from depression more frequently than men." The situation in Africa appears to be more complicated. For instance, the Nigeria study referred to above (Leighton et al., 1963a) found no significant difference between the reports by men and women of depressive symptoms, although formal clinical diagnoses were not made. While one analysis of the Ugandan data showed a significant excess of women with depressive disorders, however, this was largely accounted for by the exclusion from that analysis of subjects over 65 years of age: four of the eight men over age 65 in the group had a depressive disorder, but none of the seven women did. Adding the four men to the "depressed" sample served to narrow the gender gap, although the predominance of depressive symptoms among women persisted. Beyond the results obtained in these two studies, we lack population-based data, which might help clarify the issue, although there is an accumulation of data gathered through clinic-based investigations. Unfortunately, the clinic-based results cannot be generalized to total populations because of the potential biases inherent in presenting samples, which can be extreme between the two sexes in any clinical setting. For instance, a study was conducted in Ghana among all patients showing depressive symptoms who contacted a psychiatric impatient or outpatient service over a period of several weeks. These patients were then evaluated using the WHO Schedule for the Assessment of Depressive Disorders (SADD) (Majodina and Johnson, 1983), and two-thirds of the study population showing depressive symptoms were females. Yet in a similar study conducted at the outpatient psychiatric clinic of a hospital in Addis Ababa over a period of three years, a slight excess of males over females (27 versus 25) was encountered (Keegstra, 1986). Another—and crucial—issue is the relationship between life events and depression. An investigation carried out in Kenya using methodology comparable to that used in studies in Britain (Brown and Harris, 1978) found that the group identified as depressed had experienced more life events in the 12 months preceding the onset of depression than the controls in that same period (Ndetei and Vadher, 1984; Vadher and Ndetei, 1981). These results are similar to those obtained by researchers in Western settings and underscore the centrality of this issue to any future study that purports to unravel the determinants of depression in African settings. As for manic disorder, one relatively large study looked at all patients presenting over a two-year period at the two psychiatric units of a teaching hospital in Nigeria who met the Research Diagnostic Criteria for manic disorder (Makanjuola, 1985). Out of a total of 104 patients diagnosed, 61 were males and 43 were females. Although there was an excess of females in the group diagnosed with bipolar disorder compared with the groups with recurrent unipolar manic disorder or with a single manic episode, the difference was not statistically significant. Conversion hysteria and anxiety and panic disorders have also been studied in African settings, providing institutional statistics about the differential sex prevalence among psychiatric patients treated for these disorders and the various aspects of their phenomenology, determinants, and course (Awaritefe, 1988; Benjamin et al., 1975). Because these studies suffer from the service bias noted earlier, they are not discussed in detail here. And, despite the great problems that many African countries face as a result of natural and man-made disasters, there have been no studies that systematically set out to assess the extent, course, and outcome of post-traumatic stress and related disorders among African populations. In sum, there is ample scope for community-based epidemiologic investigations of different African populations—conducted with comparable designs and methodologies, with samples of sufficient size and rigor of selection —to provide a better understanding of the full spectrum of disorders addressed above.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa SCHIZOPHRENIA Incidence The only study carried out in Africa focusing on the incidence of schizophrenia was part of the WHO Study on the Determinants of Outcome of Severe Mental Disorders (the "Outcome Study"; see Jablensky et al., 1992), which included a site at Ibadan, Nigeria. Unfortunately, the Ibadan portion, in common with 4 other sites out of the total of 13 participating in the Outcome Study, was unable to achieve adequate coverage of the "helping agencies" that were likely to serve as the first contact for psychotic patients. This aspect of the study methodology had been considered essential to grasping the ''true" incidence rates of all new schizophrenia cases, independent of any possible service bias. Because of this incomplete coverage in the five sites that included Ibadan, incidence rates were expected to be, and indeed proved, lower than rates in the sites with complete coverage. In any event, the final report of the WHO study does not mention the specific rates for those five sites, and it is therefore impossible to discuss gender differences in the incidence of this disorder in the African population in even a tentative way. Although the study has provided a wealth of additional data about many aspects of premorbid adaptation, antecedents, and initial symptomatology of subjects with a diagnosis of schizophrenia, these data are disaggregated by gender in only a very limited fashion, and therefore preclude even speculation about these aspects of the disorder as they might apply differently to males and females in the Nigerian site. Nevertheless, an interesting result was obtained from the site that is worth mentioning. In studying the subgroup of patients worldwide (n = 386) with acute-onset schizophrenia, the investigators found that stressful life events had preceded onset of the disorder in a substantial proportion of cases, about 65 percent of the total (Day et al., 1987). While in six of nine sites, event rates per person were similar both to each other and to rates recorded in London by Brown and Harris (1978), rates were lower in the Nigerian and Indian centers, and the rate was the lowest of all in the African site. Despite the possibility advanced by the authors that the rate was artificially low because of methodological limitations of the study, it is still the case that the Nigerian site reported more very acute onsets of schizophrenia than sites in developed countries, and many of these did not appear to have been related to stressful life events. This distinctive pattern remains to be investigated. Prevalence In a recent review on the epidemiology of schizophrenia (Warner and de Girolamo, 1995), three African prevalence studies were retrieved that had been carried out in Botswana, Ghana, and Sudan. In the first study, the authors ascertained an age-corrected, one-year prevalence rate among individuals aged 15 years or older living in 6 villages in a remote area of Botswana (Ben-Tovim and Cushnie, 1986); all cases were diagnosed by two experienced psychiatrists according to ICD-9 criteria. The age-adjusted prevalence rate found was 5.3 per 1,000 population. Unfortunately, the two authors did not provide any information about the gender distribution of the cases identified. In the Ghana study in a relatively urbanized suburb of Accra, the authors found an age-adjusted point prevalence rate of 1.1 per 1,000 population (Sikanerty and Eaton, 1984). In this study, as well as in two other previous investigations mentioned by these authors, a male-to-female ratio greater than 1.5:1 was encountered. As noted in the original report of the study, the male-to-female ratio for other disorders (for example, depression and neurosis) showed an excess of females, but the magnitude of this excess is not specified. Nonetheless, there again appear to be variations in gender ratios that depend on the nature of the disorder under study. In the third study, carried out in Sudan and mentioned earlier in this chapter, Baasher (1961) found a point prevalence rate (without age correction) of 6.9 per 1,000 population in a sample of 1,860 inhabitants of a Sudanese village. Again, no data on gender ratios were provided.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Course and Outcome Insofar as the course and outcome of schizophrenia are concerned, it has been consistently demonstrated, especially in the two major WHO multicentric studies (WHO, 1979; Jablensky et al., 1992), that schizophrenia has a significantly better course and outcome among patients living in developing countries than in those living in developed countries.1 The International Pilot Study of Schizophrenia (IPSS) (WHO, 1979), in which the African site of Ibadan (Nigeria) took part, included two follow-ups of the patients enrolled in the study at intervals of two and five years. A major finding was that the onset, symptomatology, and help-seeking behavior of people diagnosed with schizophrenia differed in significant ways across settings. Onset of schizophrenia was much more likely to be acute than insidious in developing countries; catatonia was more common in the two sites of Ibadan and Agra (India) than elsewhere; and, to repeat, the course and outcome of schizophrenia were significantly better in the developing than in the developed countries studied. Among all nine sites in the study, patients in Ibadan had the best prognosis of all. In the Outcome Study mentioned at the beginning of this section, there were surprisingly few gender-related differences in course and outcome when data from centers in developed and developing countries were aggregated. When centers in developed and developing countries were taken separately, however, some suggestion of gender differences appeared. As shown in Table 6-2, females in the Ibadan site outnumbered males in the group with the best course (that is, single psychotic episode followed by complete remission; 60.5 percent versus 43.6 percent), while there was a relative predominance of males with poor course (two or more psychotic episodes with incomplete remissions between most of them; 16.4 percent versus 2.3 percent). This was consistent with the result found for all developing countries considered together. Although the authors provided a distribution of selected course variables by gender (including percentage of time spent in psychotic episodes, in complete remission, on antipsychotic medication, in hospital treatment, and percentage of time of unimpaired social functioning), the results of this in-depth analysis are not available for individual study sites, so it is impossible to take a closer look at the gender differences in the African center alone. Still, in the overall study, female subjects tended to have more favorable outcomes than male subjects, and the data from the Nigerian center do not appear to contradict this general trend. TABLE 6-2 Pattern of Course of Schizophrenia by Gender in the Ibadan Center, Outcome Study (percentage distribution) Pattern of Course Males (n = 55) Females (n = 43) Single psychotic episode followed by complete remission 43.6 60.5 Single psychotic episode followed by incomplete remission 5.5 2.3 Single psychotic episode followed by one or more nonpsychotic episodes, with complete remissions between all or most of the episodes 5.5 4.7 Single psychotic episode followed by one or more nonpsychotic episodes, with incomplete remissions between all or most of the episodes — 2.3 Two or more psychotic episodes with complete remissions between all or most of the episodes 25.5 25.6 Two or more psychotic episodes with incomplete remissions between all or most of the episodes 16.4 2.3 Continuous psychotic illness (no remission); psychotic symptoms present most of the time     Continuous nonpsychotic illness (no remission); psychotic symptoms may be present for some time, but nonpsychotic symptoms predominant throughout — — Information inadequate for rating the pattern of course 1.8 — SOURCE: Data taken from Jablensky et al., 1992.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa PSYCHOLOGICAL DISORDERS IN GENERAL MEDICAL SETTINGS As stated above, most epidemiologic studies in Africa have been conducted in primary care or general medical settings, generally surveying consecutive patients attending the clinic(s) participating in the study. While such approaches are more feasible than community-based surveys, which often require large investments of research staff and funds, they have substantial limitations, as noted earlier. Table 6-3 lists the principal studies carried out in general medical settings in African countries, with a breakdown of their characteristics and the rates of disorders found among males and females. Three studies (Abiodun et al., 1993; Binitie, 1981; Jegede et al., 1990) that did not provide separate rates of disorders for males and females have been included nonetheless, because they provide some textual comments on differential rates of disorders in the two sexes. It can be seen that in three of the studies listed in Table 6-3, females showed higher rates of psychiatric disorders than males. The study by Abiodun (1993) also found a statistically significant excess of psychiatric morbidity among females compared with males, although it did not provide the actual numbers. In one study, the rate was exactly the same for the two sexes; in another three studies —in the police force hospital, mentioned in the paper by Giel and Van Luijk (1969); in the study by Binitie (1981); and in the WHO multisite study (Sartorius et al., 1993)—males outnumbered females. Jegede and colleagues (1990) did not provide differential rates by sex, but reported approximately similar PSE scores for males (9.73, SD ± 62.7) and females (11.34, SD ± 8.44), without any significant difference. While the results reported by Giel and Van Luijk (1969) and by Binitie may be explained by the settings where the studies were carried out (in the former case, a clinic attached to a special hospital for police personnel and their families; in the latter, an overall sample with males greatly outnumbering females), the findings of the WHO multisite study are of particular interest and deserve a more in-depth discussion. The WHO multisite study was designed to investigate the form, frequency, course, and outcome of psychological problems seen in primary health care settings in 15 sites around the world (Sartorius et al., 1993). The research employed a two-stage sampling design in which the 12-item General Health Questionnaire (GHQ-12) was administered to 26,422 persons aged 18 to 65 years who were consulting health care services. Of these, 5,604 were selected for detailed examination using standardized instruments and were followed up at three months and one year to provide information on course and outcome; here we will only refer to the results of the initial examination. The study included an African site, again located in Ibadan (Nigeria). In this site, the study was conducted in the general outpatient department (GOPD) of the University College Hospital (UCH), a tertiary hospital with specialist clinics in many areas of medicine. These specialized clinics serve no defined catchment area and receive referrals not only from Ibadan, but also from hospitals throughout the southwestern area of Nigeria. Unlike the specialist clinics of hospitals, which usually require physician referral, the GOPD is a walk-in clinic, and many patients come on a self-referral basis. Thus, the GOPD tends to draw its patients from the entire city of Ibadan. Of 1,433 patients approached for screening, 1,431 (99.9 percent) took part, with only two refusals. Of the 524 patients eligible for the second-stage interview, 435 (83 percent) completed it. Consistent with patterns in epidemiologic studies in so many primary care settings, more women than men were screened and interviewed; the same pattern appeared in most of the other centers in the overall study. The mean age of the sample was about 33 years. More than a quarter of the participants were in their late teens and early twenties, about another quarter were aged 45 or more, with the remainder between 25 and 44 years. This pattern of age distribution closely approximated those in Bangalore and Ankara, two other developing-country centers, and was generally different from centers in Europe and North America, where subjects tended to be older. Only 34.7 percent of the subjects were judged by clinic doctors to have any mild to severe physical disorders, and 11.8 percent were rated by the clinic doctors as having mild or moderate psychological problems. None was thought to have severe psychological problems. Table 6-4 shows the diagnostic breakdown by gender of the patients actually interviewed; the percentage of the various diagnoses of the total sample; and the estimated prevalences, adequately weighted to reflect the percentage of individuals with a given disorder among consecutive presenters at the health center. On the whole, well-defined ICD-10 disorders had a weighted prevalence of 10.4 percent in this population. Major depression had the highest prevalence (4.2 percent). Alcohol dependence and neurasthenia were present in 0.4 percent and 1.1

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 6-3 Prevalence of Psychiatric Disorders among Subjects Attending General Health Care Clinics, Selected African Countries     Sample (N)           Author and Year Country F M (M + F) Assessment Method Diagnostic System Overall Prevalence Rate Males with any Disorder (%) Females with any Disorder (%) Abiodun et al. (1993) Nigeria     (272) PSE ICD-9 21 — — Binitie (1981) Nigeria     (1,654) Clinical assessment ? 05 — — Giel and Van Luijk (1969) Ethiopia (general hospital) 100 90   Clinical assessment ? — 16 21 Giel and Van Luijk (1969) Ethiopia (provincial hospital) 576 246   Clinical assessment ? — 07 07 Giel and Van Luijk (1969) Ethiopia (health center) 234 146   Clinical assessment ? — 15 27 Giel and Van Luijk (1969) Ethiopia (police force hospital) 287 209   Clinical assessment ? — 18 14 Jegede et al. (1990) Nigeria 41 62   PSE ICD-9 40 — — Ndetei and Muhangi (1979) Kenya     (103) Clinical assessment ? — 19 22 Ustün and Sartorius (1995) Nigeria 97 172   CIDI ICD-10 — 19 07

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 6-4 Prevalence of Current ICD-10 Psychological Disorders by Gender, Ibadan Site, WHO Multicentre Collaborative Study Category Number of Male Patients Interviewed Estimated Prevalence in Males (%) Number of Female Patients Interviewed Estimated Prevalence in Females (%) Alcohol dependence 2 1.5 0 0.0 Harmful use of alcohol 3 3.0 0 0.0 Current depression 8 5.3 15 3.8 Dysthymia 4 1.8 4 1.1 Agoraphobia 0 0.0 1 0.2 Panic disorder 2 1.5 2 0.3 Generalized anxiety disorder 7 4.9 8 2.2 Somatization disorder 1 0.5 2 0.3 Neurasthenia 5 3.4 1 0.2 One mental disorder (from the above) 17 13.3 21 5.6 Two or more mental disorders (from the above) 9 5.8 7 1.6 All patients 97 100.0 172 100.0 NOTE: Information is weighted to reflect baseline prevalence rates among consecutive attenders. SOURCE: Ustü and Sartorius, 1995. percent of the health clinic population, respectively. Generalized anxiety was present in 2.9 percent of the sample, and panic disorder and agoraphobia had a weighted prevalence of 0.7 percent and 0.1 percent respectively. The weighted prevalence rate for all psychiatric disorders mentioned above is much lower than the weighted rate of 27.8 percent reported from an earlier study conducted in a primary care clinic in Ibadan, and in which identical instruments for case detection were used (Gureje et al., 1992). A number of factors may be responsible for this discrepancy. First, in the earlier study, the reported rate had included the diagnostic category of "undifferentiated somatoform disorder," with a prevalence of 10.8 percent. Second, the subjects of the earlier study were older and had received considerably less formal education than those in the later study; 6.7 percent of the later sample had four years or less of education, compared with up to 38 percent of the sample of the earlier study with no formal education. Disorders that were considerably more common in the earlier sample, such as generalized anxiety disorder, were associated with increasing age and with less education. A third factor that may explain the different rates between the two studies is the idiosyncracies of the two settings themselves. The earlier study was conducted in a setting where the patient population on any given day included a substantial number of patients being followed up for ongoing treatment of an existing condition. The later study was conducted in a setting where the population of patients was always dominated by those seeking care for acute disorders; follow-ups were few because most patients in need of further care had been referred to other clinics in the hospital, so that only a few patients would have been ill for a sufficiently long period at the time of the study to meet the criterion of duration of illness. Thus, for example, only a few patients would meet the criterion of six months of illness that would make them eligible for an ICD-10 diagnosis of generalized anxiety disorder (WHO, 1993). The gender differences in rates of disorders found in the later study are of particular interest, for they show an unusual preponderance of males over females: 13.3 percent of males had one mental disorder compared with 5.6 percent of the females, a statistically significant difference (X2 = 4.41; P < 03). An additional 5.8 percent of males had two or more mental disorders compared with 1.6 percent of females, a difference in rates that was not statistically significant. Except for agoraphobia, for which the number of cases was so small that it precluded any meaningful conclusion, there was no disorder among those investigated with a higher rate for females than for males. Alcohol dependence and harmful use of alcohol were exclusively male disorders in this setting.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Beyond these studies of the rates of disorders among users of health clinics, other investigations carried out in similar settings have focused on other indicators of ill-health. For instance, the prevalence and pattern of psychotropic drug use were investigated in an urban walk-in clinic in Nigeria during the course of a two-stage epidemiological survey (Gureje and Obikoya, 1991). A total of 14.9 percent of the patients were using psychotropic drugs, with almost all the users taking anxiolytics. At odds with the results of many studies carried out in developed countries, which consistently show an excess of females taking psychotropic drugs, there was no significant gender difference in the prevalence of drug use. Almost half of the users had been on the drug in question for over 12 months. Increasing age was associated with psychotropic drug use in females, while being married had a similar association in males. Although an increasing score on the GHQ-12 was associated with drug use, over two-thirds of patients with DSM-IIIR disorders identified during the second-stage interview were not taking any psychotropic drug. PSYCHOLOGICAL DISORDERS IN PREGNANCY AND THE PUERPERIUM A number of studies have looked at the frequency, form, and determinants of psychological disorders found among African women during pregnancy and the puerperium. The great importance that reproductive life plays for African women living in traditional societies has already been noted, and the fulfillment of female roles linked to reproduction is regarded as an essential step in any woman's life. For These reasons, it is reasonable to predict a substantial rate of psychological problems associated with this central component of female life. In addition, the mortality rate associated with pregnancy in Africa, the highest in the world according to WHO data, makes pregnancy a particularly stressful event for the many African women living in traditional settings, which are not always well-equipped with maternal health facilities. Cox (1979) conducted one of the most extensive investigations around this topic. He surveyed 263 pregnant women in Uganda and compared them with 89 nonpregnant, nonpuerperal women through administration of a semistructured psychiatric questionnaire. Pregnant women showed increased frequency of psychiatric morbidity compared with the control group, and separated women were at particular risk. The author found no association between antenatal psychiatric morbidity and age, number of children, number of co-wives, or duration of pregnancy. This study supported findings previously reported by Assael and colleagues (1972), who had found an association between psychiatric morbidity and marital separation; in their sample, 24 percent of pregnant Baganda women showed conspicuous psychiatric morbidity. In another careful investigation, 240 pregnant women consecutively attending an antenatal clinic in Nigeria over a period of eight weeks were assessed by a two-stage procedure, using the 30-item General Health Questionnaire (GHQ-30) and the Present State Examination schedule (PSE) (Abiodun, 1993). Overall prevalence of psychiatric disorder was 12.5 percent, with anxiety states and neurotic depression the most common diagnoses. Prevalence of psychiatric morbidity was found to be significantly associated with younger age (under 24 years), being primigravid, having been married for less than one year, having an unsupportive husband, and a previous history of induced abortion. Other investigations have confirmed a substantial rate of psychological disturbances among pregnant African women (Cheetham et al., 1981; Jinadu and Daramola, 1990), at least equalling the prevalence range encountered among women in developed countries (Cox, 1983). In many of the mothers surveyed, psychiatric symptoms (particularly anxiety) present during pregnancy tended to remit after childbirth, suggesting at least some concerns about the birth event itself. Nevertheless, a substantial proportion of mothers continue to exhibit depressive symptoms during the puerperium (Cox, 1983). The question of whether this interferes with the quality of childcare has simply not been addressed. Apart from these studies related to pregnancy, which of necessity must have women as their subjects, there is one further study of an urban community sample of 200 young women (average age, 32 years) from Zimbabwe. Both life events and difficulties and mental state (in those who passed a screening interview) were assessed for the previous 12 months. Thirty percent had suffered a major depression (average duration, 5 months) in the period, often related to severe life events. One-fifth of these had attempted suicide or had previously considered it. Many had been markedly disabled by their condition, leading to reduced family income and child neglect (Broadhead

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa and Abase, 1993). These prevalence rates are comparable to those obtained in developed countries for socially disadvantaged women, and they indicate that African women are not spared from high rates of depression, given poor social conditions. CONCLUSIONS Table 6-5 presents a picture of the ages at which mental health problems occur in Sub-Saharan African females; the picture must be considered approximate because of the almost total lack of data for most disorders concerning age at onset. The table suggests that adolescence and early adulthood are life span stages of risk for depression, schizophrenia, and psychological morbidity associated with pregnancy and the puerperium, a finding consistent with those for females in the developed world. Considerations of age aside, the limited data available seem to point to two conclusions: (1) the magnitude of psychiatric morbidity in Africa is substantial and comparable to that found in developed countries; and (2) African women, despite their substantial burdens in various settings, do not seem to show the excess in rates of defined psychological disorders compared with males that have been recorded for women in developed countries. As Table 6-1 indicates, the only psychiatric disorders that appear to impose a disproportionate and, in this instance, unique burden on Sub-Saharan females are those associated with pregnancy and the puerperium. Even in the case of depression, for which there is the greatest evidence of an excess among females in most studies throughout the rest of the world, the African picture seems to be quite different, with males showing a comparable, or even a higher, rate of depressive disorders compared with females. It should be stressed that this conclusion is supported mainly by community-based studies. It is also true that the large majority of studies assessing the actual number of people in treatment at psychiatric facilities in Africa consistently shows an excess of males to females; this excess is certainly caused by differences in help-seeking behavior between the two sexes. It is difficult to explain this finding, bearing in mind that African women have to face substantial problems, adversities, and burdens. A clarification of this issue is surely a research priority for researchers and clinicians active in African countries. It may also provide valuable clues to a better understanding of the complex interplay of risk factors, protective factors, coping styles, and interpersonal relationships that is at the origin of many psychological disorders and strongly affects the course and the outcome of many others. It has been postulated that the low figures reported for certain disorders (including mental disorders) among women in Africa are the result of the underutilization of health services by women. While data for the mental health field do indicate that women are less inclined to be referred and admitted to inpatient facilities, the data obtained for general medical outpatients in the very thorough WHO study cited above (Ustün and Sartorius, 1995) indicate higher utilization by women than by men. Nor were these women attending primarily because they were bringing their children to the clinic. It thus seems likely that the data from the WHO study indicating higher rates of psychiatric disorder in men than women attending the clinic are not an artifact. TABLE 6-5 Ages of Occurrence of Mental Health Problems in Sub-Saharan African Females In Utero Infancy/ Early Childhood (birth through age 4) Childhood (ages 15–14) Adolescence (ages 15–19) Adulthood (ages 20–44) Postmenopause (age 45+)       Depression Depression         Schizophrenia Schizophrenia         Psychological morbidity associated with pregnancy and the puerperium Psychological morbidity associated with pregnancy and the puerperium  

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Insofar as the course and outcome of psychological disorders are concerned, in the case of schizophrenia the most important data come from the WHO Outcome Study and point to a better course and outcome for females than for males with a diagnosis of schizophrenia in Africa (and in developing countries in general). These data are also consistent with those obtained in follow-up studies in developed countries. Important additional data on the course and outcome of less severe disorders will be provided by the follow-up of the patients enrolled in the WHO study on psychological disorders in general medical settings (Ustün and Sartorius, 1995). With regard to reproductive life, some studies seem to show that the Rousseauesque belief that African women have a stress-free, "natural" pregnancy is not substantiated. For a variety of reasons—including the high-risk of physical morbidity and mortality associated with pregnancy in African countries, the anxiety associated with it, and the extremely high value assigned to the fulfillment of a mother's role—pregnancy seems to be a particularly high-risk situation for psychological morbidity, and therefore deserves special efforts in scientific investigations and the refinement of effective preventive and treatment methods. RESEARCH NEEDS The following general recommendations for future studies and research to be carried out in the African continent are proposed. There is a need to further investigate why women in Africa have the same, or perhaps fewer, psychiatric disorders, including depression, than men in Africa. It is still unclear whether this is the result of African mean suffering from an excess of the disorder when compared with men in the developed world, or whether African women are somehow protected from mental disorders more than their counterparts in developed countries. The existing studies seem to indicate that both men and women, and particularly men, suffer from more psychiatric disorder in Africa than in the more developed world. Nevertheless, there are few studies, and more should be done to explore this important issue. These studies should employ reliable methodologies that enable comparisons to be made with findings obtained in other countries. The experience of several researchers has shown that it is indeed possible to carry out careful investigations in African countries using the same methodology employed in developed nations, adapted for local situations and the specificities of African cultures. For this purpose, collaborative, cooperative, or coordinated studies offer a valuable tool, as demonstrated by several WHO multicenter studies, which have included at least one African center as well as other centers from developing countries (for example, IPSS, Outcome Study, the study on psychological problems in general health care settings, and the study of the neuropsychiatric manifestations of AIDS). It is well known that life events and expressed emotion are important in the genesis and maintenance of depression, as well as schizophrenia. Because depression is known to be a significant cause of disability worldwide and occurs frequently in African women, it is necessary to better clarify how depression interacts with these factors in African populations, and to what extent these variables are responsible for sex differences in the rate, course, and outcome of psychiatric disorders. Another area that merits special efforts is related to post-traumatic stress disorders and related disorders. Natural disasters, social disruption, famine, war, and forced migration are not uncommon in many African countries, and it would be important to assess the magnitude of stress-related psychiatric disorders among the affected communities and to investigate the determinants and the variables affecting the onset, the course, and the outcome of these disorders. This is also an area that warrants special efforts in order to define effective methods of prevention and treatment, to be disseminated among various levels of health workers. Finally, the possible effects of puerperal depression on the health of the babies born to these mothers deserve investigation. In situations where infant mortality rates are already high, any added factors may tip the balance of an infant's health adversely, and thus may have an important effect on the mortality rates and the genesis of sporadic cases of infant malnutrition.

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