Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review
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《英国医生杂志》
1 Royal London Hospital (St Clement's), London E3 4LL, 2 WHO Collaborating Centre for Mental Health, Institute of Psychiatry, London SE5 8AF
Correspondence to: I Mirza, Larkswood Centre, Thorpe Coombe Hospital, London E17 3HP ilyasmirza@blueyonder.co.uk
Abstract
We found 20 studies that directly addressed the questions of the review: 19 were cross sectional epidemiological surveys, and one was a case-control study.w1-w20 Seventeen gave prevalence estimates (n = 9170), while 11 discussed associated risk factors. We did not find any prospective study of the natural course of the disorder or a rigorously controlled study of any interventions. We found little qualitative work. Sample sizes ranged from 113 to 2620 in prevalence studies (mean 539.41, median 298).
Methods of included studies
Table 1 shows the methodological quality of the studies. Only three of the 11 prevalence studies published in local journals gave adequate details of methods. Because of this, it is difficult to comment on possible biases. Even when basic data were provided it is questionable how representative the study sample was of the population.7 Diagnoses in all the studies were made by either a psychiatrist or a trained worker using a validated instrument, and thus seem to be of reasonably good quality.
Table 1 Checklist for quality of studies included in systematic review of evidence on prevalence, aetiology, treatment, and prevention of anxiety and depressive disorders in Pakistan
Most of the studies discussed the generalisability of their findings but did not interpret any null findings. In the discussions, national comparisons were rarely made with findings of other national research groups; comparisons were usually with studies in other countries.
Prevalence of anxiety and depressive disorders
Table 2 lists the prevalence of anxiety and depressive disorders estimated in the studies. The overall mean prevalence in men and women in the six studies of random community samples (n = 2658) was 33.62%, with the point prevalence varying from 28.8% to 66% for women (overall mean 45.5%) and from 10% to 33% for men (overall mean 21.7%). Women aged 15-49 were studied in a paper with 28.8% prevalence, while young men with a mean age of 18 participated in a study reporting 33% prevalence. Only one study reported adjusted prevalence with 95% confidence intervals.
Table 2 Details of studies included in systematic review with prevalence estimates of anxiety and depressive disorders
For those presenting to traditional or faith healers (n = 511), the prevalence of anxiety and depressive disorders among men varied from 2.65% to 27%, and among women from 11.5 % to 52%.
Three studies looked at total psychiatric morbidity in primary care (n = 774). One described women in a rural area, with a prevalence of 50%, while another described 18% prevalence for men and 42.2% for women in an urban area. The third study, with a prevalence of 38.4%, did not specify participants' sex.
Of those presenting to psychiatric outpatients (n = 2430), the prevalence varied between 32% and 66.3%. There were two studies on psychiatric inpatients, one reported a prevalence of depressive illness of 37% (n = 2620), while the other reported 19.1% (n = 177).
Associated social, psychological, and biological factors
Table 3 shows the various factors found to be associated with anxiety and depressive disorders. Sociodemographic factors associated with increased prevalence of anxiety and depressive disorders were female sex, middle age, and low level of education. Loss of husband (being widowed, separated, or divorced), increasing duration of marriage, and being a housewife were also positively associated. Women living in joint households with more than 12 members also showed a positive association; in contrast, one study reported a positive association for women living in unitary households. One study showed a positive significant association for relational problems with in-laws for women compared with other social problems. Chronic difficulties with housing, finances, and health were significantly associated with anxiety and depressive disorders. Absence of a confiding relationship was a significant factor in one study, as were lack of autonomy and arguments with husbands and in-laws in another. A disturbing event in the family was not significantly associated (P = 0.08).
Table 3 Factors associated with risk of anxiety and depressive disorders in studies included in systematic review
Factors perceived by women to be associated with mental distress were low family income, marital disputes, too many children, and verbal abuse by in-laws. Studies that incorporated income found financial difficulties to be a significant factor, except for one study, in which the finding was just non-significant (P = 0.06).
What is the evidence for effectiveness of treatment or prevention in this population?
We could not find any prospective study of the natural course of the disorder or any rigorous controlled study addressing effectiveness of treatment and prevention. We found only one randomised controlled trial in mental health, regarding the ability of schoolchildren to detect mental disorders after having been given health education.8
Discussion
In our systematic review we found that socioeconomic adversity and relationship problems were major risk factors for anxiety and depressive disorders in Pakistan, whereas supportive family and friends may protect against development of these disorders.
Limitations of study
Our review may be subject to publication and selection bias as we were unable to systematically contact the experts in Pakistan for unpublished material or grey literature.
The coverage of the studies we identified is low. Despite detailed searches, we found that most studies satisfying our inclusion criteria were from the provinces of Punjab and Sindh, the two provinces with the largest population in Pakistan. The epidemiological data were collected from a handful of villages and urban settlements. There was considerable methodological variation in study design and in the instruments used. Thus one is unable to extrapolate these epidemiological findings to the whole of Pakistan.
Comparison with other low income countries
Using stringent criteria, Harding et al reported an overall frequency of anxiety and depression of 13.9% in four developing countries.9 Community studies from Africa have reported prevalences of 24% in rural Uganda and 20%-24% in rural South Africa. Among patients attending primary care, the prevalence varied from 8% to 29%. Patients attending primary care in India showed prevalences between 21% and 57%.1
In relation to risk factors, Abas and Broadhead found a significant association with formal employment, below average income, overcrowding, and certificate of secondary education in urban Zimbabwe.10 In the same study, they also found a significant association with humiliation or entrapment and with death or other loss.11 Bhagwanjee in rural South Africa found a significant association with age (risk increasing with age, to a maximum among people aged 30-39 years), single marital status, unemployment, low income, and low educational level.12 Similar risk factors were found in studies from Pakistan. However, we found that the reported overall rates were higher in Pakistan and higher among rural than urban populations compared with the above studies. The question is whether these differences are an artefact of measurement or are because of specific factors operating in Pakistan.
Possible reasons for our findings
Pakistan's population has been exposed to sociopolitical instability, economic uncertainty, violence, regional conflict, and dislocation for at least the past three decades.13 These are risk factors for psychiatric disorders3 and may help explain the findings of this review.
As in many other countries, women in Pakistan generally have higher rates of illness than men. In a recent study, the main health problems reported by women were mental tension leading to headache and white vaginal discharge leading to body pains and fatigue.14 In another study, most women perceived that financial, interpersonal, and family problems were causative or contributory factors in their ill health. They also linked their health to broader social institutions and cultural norms and expectations regarding women's roles and relationships between family members.15
The need for stronger evidence and improved research capacity
The argument that health will automatically improve with economic growth is not supported by the current evidence. Diseases will not go away without specific investments in health interventions.3 A coherent mental health policy with a strategic implementation plan is essential for countries that wish to enhance their social, economic, and social capital.16
A major obstacle in formulating effective health policy is the lack of robust epidemiological research in Pakistan.17 Our review highlights the absence of survey evidence and data from wider regions of Pakistan with regard to anxiety and depression, and the lack of outcome studies and prevention and treatment trials. The time is right for Pakistan to build on this research effort by increasing investment in research capacity. It would also be helpful to have a national epidemiological survey of mental disorders. Such surveys are useful to assess the needs of the population, document the use of existing services, obtain valid information on prevalence and associated risk factors, and monitor the health of the population and trends.16
Conclusion
Available evidence suggests a major social cause for anxiety and depressive disorders in Pakistan, and an overall prevalence of 34%. This evidence is limited because of methodological problems. Nationally representative psychiatric morbidity surveys and controlled treatment trials are required to inform policy in order to control morbidity from anxiety and depressive disorders.
What is already known on this subject
Anxiety and depressive disorders are associated with considerable economic burden
These disorders represent an emerging public health threat in low income countries
What this study adds
In Pakistan relationship problems, financial difficulties, and low educational level are positively associated with anxiety and depressive disorders, whereas having a supportive relationship is negatively associated
Systematically collected, peer reviewed evidence suggests an overall prevalence of 34% for anxiety and depressive disorders in this population, but this finding must be treated with caution because of methodological limitations
Nationally representative psychiatric morbidity surveys and controlled treatment trials are needed to inform policy in order to control morbidity from anxiety and depressive disorders in Pakistan
Funding: None.
Competing interests: None declared.
Ethical approval: Not required.
References w1-w20 are listed on bmj.com
Contributors: IM proposed the idea, which was further developed by RJ. IM performed the literature search and data extraction. IM and RJ both wrote the paper. IM is guarantor for the study.
References
Institute of Medicine. Neurological, psychiatric, and developmental disorders: meeting the challenge in the developing world. Washington, DC: National Academy Press, 2001. (http://books.nap.edu/catalog/10111.html)
Murray C, Lopez A. The global burden of diseases: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Boston: Harvard School of Public Health, WHO and World Bank, 1996.
World Health Organization. Macroeconomics and health: investing in health for economic development. Geneva: WHO, 2001 (http://www3.who.int/whosis/menu.cfm?path=whosis,cmh&language=english).
Desjarlis R, Eisenberg L, Good B, Kleinman A. World mental health: problems and priorities in low-income countries. Oxford: Oxford University Press, 1995.
Population Division, Department of Economic and Social Affairs, United Nations Secretariat. U.N. The world at six billion (ESA/P/WP.154). Part 2—Table 5-8. New York: UN, 1999: 12-22. (www.un.org/esa/population/publications/sixbillion/sixbilpart2.pdf)
Greenhalgh T. How to read a paper: the basics of evidence based medicine. London: BMJ Publishing Group, 1999.
Mirza I. Common mental disorders in urban v rural Pakistan. Br J Psychiatry 2001;178: 475-6.
Rahman A, Mubbashar M, Gater R, Goldberg D. Randomised trial of impact of school mental-health programme in rural Rawalpindi, Pakistan. Lancet 1998;352: 1022-5.
Harding TW, de Arango MV, Baltazar J, Climent CE, Ibrahim HH, Ladrido-Ignacio L, et al. Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries. Psychol Med 1980;10: 231-41.
Abas M, Broadhead J. Depression and anxiety among women in an urban setting in Zimbabwe. Psychol Med 1997;27: 59-71.
Broadhead J, Abas M. Life events, difficulties and depression among women in an urban setting in Zimbabwe. Psychol Med 1998;28: 29-38.
Bhagwanjee A, Parekh A, Paruk Z, Petersen I, Subedar H. Prevalence of minor psychiatric disorders in an African rural community in South Africa. Psychol Med 1998;28: 1137-47.
Mehmood S. Pakistan: political roots and development 1947-1999. Oxford: Oxford University Press, 2000.
Winkvist A, Akhtar H. Images of health and health care options among low income women in Punjab, Pakistan. Soc Sci Med 1997;45: 1483-91.
Tareen E. The perception of social support and the experience of depression in Pakistani women . Colchester: University of Essex, 2000.
Jenkins R. Making psychiatric epidemiology useful: the contribution of epidemiology to government policy. Acta Psychiatr Scand 2001;103: 2-14.
Baig L. Why epidemiological research in Pakistan? J Pak Med Assn 2001;51: 206.(Ilyas Mirza, specialist r)
Correspondence to: I Mirza, Larkswood Centre, Thorpe Coombe Hospital, London E17 3HP ilyasmirza@blueyonder.co.uk
Abstract
We found 20 studies that directly addressed the questions of the review: 19 were cross sectional epidemiological surveys, and one was a case-control study.w1-w20 Seventeen gave prevalence estimates (n = 9170), while 11 discussed associated risk factors. We did not find any prospective study of the natural course of the disorder or a rigorously controlled study of any interventions. We found little qualitative work. Sample sizes ranged from 113 to 2620 in prevalence studies (mean 539.41, median 298).
Methods of included studies
Table 1 shows the methodological quality of the studies. Only three of the 11 prevalence studies published in local journals gave adequate details of methods. Because of this, it is difficult to comment on possible biases. Even when basic data were provided it is questionable how representative the study sample was of the population.7 Diagnoses in all the studies were made by either a psychiatrist or a trained worker using a validated instrument, and thus seem to be of reasonably good quality.
Table 1 Checklist for quality of studies included in systematic review of evidence on prevalence, aetiology, treatment, and prevention of anxiety and depressive disorders in Pakistan
Most of the studies discussed the generalisability of their findings but did not interpret any null findings. In the discussions, national comparisons were rarely made with findings of other national research groups; comparisons were usually with studies in other countries.
Prevalence of anxiety and depressive disorders
Table 2 lists the prevalence of anxiety and depressive disorders estimated in the studies. The overall mean prevalence in men and women in the six studies of random community samples (n = 2658) was 33.62%, with the point prevalence varying from 28.8% to 66% for women (overall mean 45.5%) and from 10% to 33% for men (overall mean 21.7%). Women aged 15-49 were studied in a paper with 28.8% prevalence, while young men with a mean age of 18 participated in a study reporting 33% prevalence. Only one study reported adjusted prevalence with 95% confidence intervals.
Table 2 Details of studies included in systematic review with prevalence estimates of anxiety and depressive disorders
For those presenting to traditional or faith healers (n = 511), the prevalence of anxiety and depressive disorders among men varied from 2.65% to 27%, and among women from 11.5 % to 52%.
Three studies looked at total psychiatric morbidity in primary care (n = 774). One described women in a rural area, with a prevalence of 50%, while another described 18% prevalence for men and 42.2% for women in an urban area. The third study, with a prevalence of 38.4%, did not specify participants' sex.
Of those presenting to psychiatric outpatients (n = 2430), the prevalence varied between 32% and 66.3%. There were two studies on psychiatric inpatients, one reported a prevalence of depressive illness of 37% (n = 2620), while the other reported 19.1% (n = 177).
Associated social, psychological, and biological factors
Table 3 shows the various factors found to be associated with anxiety and depressive disorders. Sociodemographic factors associated with increased prevalence of anxiety and depressive disorders were female sex, middle age, and low level of education. Loss of husband (being widowed, separated, or divorced), increasing duration of marriage, and being a housewife were also positively associated. Women living in joint households with more than 12 members also showed a positive association; in contrast, one study reported a positive association for women living in unitary households. One study showed a positive significant association for relational problems with in-laws for women compared with other social problems. Chronic difficulties with housing, finances, and health were significantly associated with anxiety and depressive disorders. Absence of a confiding relationship was a significant factor in one study, as were lack of autonomy and arguments with husbands and in-laws in another. A disturbing event in the family was not significantly associated (P = 0.08).
Table 3 Factors associated with risk of anxiety and depressive disorders in studies included in systematic review
Factors perceived by women to be associated with mental distress were low family income, marital disputes, too many children, and verbal abuse by in-laws. Studies that incorporated income found financial difficulties to be a significant factor, except for one study, in which the finding was just non-significant (P = 0.06).
What is the evidence for effectiveness of treatment or prevention in this population?
We could not find any prospective study of the natural course of the disorder or any rigorous controlled study addressing effectiveness of treatment and prevention. We found only one randomised controlled trial in mental health, regarding the ability of schoolchildren to detect mental disorders after having been given health education.8
Discussion
In our systematic review we found that socioeconomic adversity and relationship problems were major risk factors for anxiety and depressive disorders in Pakistan, whereas supportive family and friends may protect against development of these disorders.
Limitations of study
Our review may be subject to publication and selection bias as we were unable to systematically contact the experts in Pakistan for unpublished material or grey literature.
The coverage of the studies we identified is low. Despite detailed searches, we found that most studies satisfying our inclusion criteria were from the provinces of Punjab and Sindh, the two provinces with the largest population in Pakistan. The epidemiological data were collected from a handful of villages and urban settlements. There was considerable methodological variation in study design and in the instruments used. Thus one is unable to extrapolate these epidemiological findings to the whole of Pakistan.
Comparison with other low income countries
Using stringent criteria, Harding et al reported an overall frequency of anxiety and depression of 13.9% in four developing countries.9 Community studies from Africa have reported prevalences of 24% in rural Uganda and 20%-24% in rural South Africa. Among patients attending primary care, the prevalence varied from 8% to 29%. Patients attending primary care in India showed prevalences between 21% and 57%.1
In relation to risk factors, Abas and Broadhead found a significant association with formal employment, below average income, overcrowding, and certificate of secondary education in urban Zimbabwe.10 In the same study, they also found a significant association with humiliation or entrapment and with death or other loss.11 Bhagwanjee in rural South Africa found a significant association with age (risk increasing with age, to a maximum among people aged 30-39 years), single marital status, unemployment, low income, and low educational level.12 Similar risk factors were found in studies from Pakistan. However, we found that the reported overall rates were higher in Pakistan and higher among rural than urban populations compared with the above studies. The question is whether these differences are an artefact of measurement or are because of specific factors operating in Pakistan.
Possible reasons for our findings
Pakistan's population has been exposed to sociopolitical instability, economic uncertainty, violence, regional conflict, and dislocation for at least the past three decades.13 These are risk factors for psychiatric disorders3 and may help explain the findings of this review.
As in many other countries, women in Pakistan generally have higher rates of illness than men. In a recent study, the main health problems reported by women were mental tension leading to headache and white vaginal discharge leading to body pains and fatigue.14 In another study, most women perceived that financial, interpersonal, and family problems were causative or contributory factors in their ill health. They also linked their health to broader social institutions and cultural norms and expectations regarding women's roles and relationships between family members.15
The need for stronger evidence and improved research capacity
The argument that health will automatically improve with economic growth is not supported by the current evidence. Diseases will not go away without specific investments in health interventions.3 A coherent mental health policy with a strategic implementation plan is essential for countries that wish to enhance their social, economic, and social capital.16
A major obstacle in formulating effective health policy is the lack of robust epidemiological research in Pakistan.17 Our review highlights the absence of survey evidence and data from wider regions of Pakistan with regard to anxiety and depression, and the lack of outcome studies and prevention and treatment trials. The time is right for Pakistan to build on this research effort by increasing investment in research capacity. It would also be helpful to have a national epidemiological survey of mental disorders. Such surveys are useful to assess the needs of the population, document the use of existing services, obtain valid information on prevalence and associated risk factors, and monitor the health of the population and trends.16
Conclusion
Available evidence suggests a major social cause for anxiety and depressive disorders in Pakistan, and an overall prevalence of 34%. This evidence is limited because of methodological problems. Nationally representative psychiatric morbidity surveys and controlled treatment trials are required to inform policy in order to control morbidity from anxiety and depressive disorders.
What is already known on this subject
Anxiety and depressive disorders are associated with considerable economic burden
These disorders represent an emerging public health threat in low income countries
What this study adds
In Pakistan relationship problems, financial difficulties, and low educational level are positively associated with anxiety and depressive disorders, whereas having a supportive relationship is negatively associated
Systematically collected, peer reviewed evidence suggests an overall prevalence of 34% for anxiety and depressive disorders in this population, but this finding must be treated with caution because of methodological limitations
Nationally representative psychiatric morbidity surveys and controlled treatment trials are needed to inform policy in order to control morbidity from anxiety and depressive disorders in Pakistan
Funding: None.
Competing interests: None declared.
Ethical approval: Not required.
References w1-w20 are listed on bmj.com
Contributors: IM proposed the idea, which was further developed by RJ. IM performed the literature search and data extraction. IM and RJ both wrote the paper. IM is guarantor for the study.
References
Institute of Medicine. Neurological, psychiatric, and developmental disorders: meeting the challenge in the developing world. Washington, DC: National Academy Press, 2001. (http://books.nap.edu/catalog/10111.html)
Murray C, Lopez A. The global burden of diseases: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Boston: Harvard School of Public Health, WHO and World Bank, 1996.
World Health Organization. Macroeconomics and health: investing in health for economic development. Geneva: WHO, 2001 (http://www3.who.int/whosis/menu.cfm?path=whosis,cmh&language=english).
Desjarlis R, Eisenberg L, Good B, Kleinman A. World mental health: problems and priorities in low-income countries. Oxford: Oxford University Press, 1995.
Population Division, Department of Economic and Social Affairs, United Nations Secretariat. U.N. The world at six billion (ESA/P/WP.154). Part 2—Table 5-8. New York: UN, 1999: 12-22. (www.un.org/esa/population/publications/sixbillion/sixbilpart2.pdf)
Greenhalgh T. How to read a paper: the basics of evidence based medicine. London: BMJ Publishing Group, 1999.
Mirza I. Common mental disorders in urban v rural Pakistan. Br J Psychiatry 2001;178: 475-6.
Rahman A, Mubbashar M, Gater R, Goldberg D. Randomised trial of impact of school mental-health programme in rural Rawalpindi, Pakistan. Lancet 1998;352: 1022-5.
Harding TW, de Arango MV, Baltazar J, Climent CE, Ibrahim HH, Ladrido-Ignacio L, et al. Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries. Psychol Med 1980;10: 231-41.
Abas M, Broadhead J. Depression and anxiety among women in an urban setting in Zimbabwe. Psychol Med 1997;27: 59-71.
Broadhead J, Abas M. Life events, difficulties and depression among women in an urban setting in Zimbabwe. Psychol Med 1998;28: 29-38.
Bhagwanjee A, Parekh A, Paruk Z, Petersen I, Subedar H. Prevalence of minor psychiatric disorders in an African rural community in South Africa. Psychol Med 1998;28: 1137-47.
Mehmood S. Pakistan: political roots and development 1947-1999. Oxford: Oxford University Press, 2000.
Winkvist A, Akhtar H. Images of health and health care options among low income women in Punjab, Pakistan. Soc Sci Med 1997;45: 1483-91.
Tareen E. The perception of social support and the experience of depression in Pakistani women . Colchester: University of Essex, 2000.
Jenkins R. Making psychiatric epidemiology useful: the contribution of epidemiology to government policy. Acta Psychiatr Scand 2001;103: 2-14.
Baig L. Why epidemiological research in Pakistan? J Pak Med Assn 2001;51: 206.(Ilyas Mirza, specialist r)