Chapter 22:  Mental Health and the Abuse of Alcohol and Controlled Substances

Unipolar Depression

In the GBD 1996, unipolar depression, which differs from bipolar depressive disorder in that it presents with recurring depressive episodes without any manic episodes, unlike bipolar disorder, which has both manic and depressive episodes, was estimated to be the leading cause of the nonfatal disease burden in the world in 1990, accounting for 10.7 percent of total YLD. It was the fourth leading cause of total disease burden, accounting for 3.7 percent of total DALYs (Murray and Lopez 1997b). In the GBD 2000 study, unipolar depression remains the leading cause of YLD, accounting for 11.9 percent of total YLD, and also remains the fourth leading cause of total disease burden, accounting for 4.4 percent of total DALYs (Mathers et al. 2002). In Butajira, Ethiopia, a demographic study site for the University of Addis Ababa and the ministry of health of Ethiopia, it was found that, using the DALY method, depression contributed 7 percent to the total disease burden (Abdulahi, Mariam, and Kebede 2001).¹

Panic Disorder

In the GBD 1996, panic disorder was estimated to be the 27th leading cause of the nonfatal burden of disease in the world (Murray and Lopez 1996). In the GBD 2000 the estimated burden of panic disorder increased slightly, accounting for 1.2 percent of the total YLD. One of the data sources used for this estimate was a study carried out in Lesotho, which found an estimate of a one-month prevalence of 3.7 percent for males and 15.3 percent for females in a population age 19 to 93 years. This prevalence was substantially higher than that found in other regions of the world (Mathers et al. 2002).

Bipolar Disorder

Bipolar disorder is a chronic disease with periods of depression and elevated mood and with remissions and relapses between them. In the 1990 GBD, it was estimated to be the seventh leading cause of the nonfatal burden of disease, accounting for 3 percent of the total YLD (Murray and Lopez 1996). In the GBD 2000, bipolar disorder accounts for 2.5 percent of total YLD (Mathers et al. 2002).

Schizophrenia

The seventh leading cause of YLD at the global level, schizophrenia accounts for 2.8 percent of total global YLD in the GBD 2000 study, up from 10th place (2.6 percent of YLD) in 1990 (Mathers et al. 2002; Murray and Lopez 1996). In an Ethiopian Burden of Disease study, 4 percent of the total disease burden was due to schizophrenia (Abdulahi, Mariam, and Kebede 2001). Sartorius and colleagues (1986) estimate an incidence rate for schizophrenia of 10 cases per 10,000 people. Mathers and colleagues (2002) estimate the incidence rate for Sub-Saharan Africa at 0.2 for males and 0.3 for females per 1,000 people, age-adjusted to between 0.4 and 0.53 percent. In a large semi-urban and rural population study in Ethiopia the prevalence of schizophrenia was found to be 4.7 per 1,000 people (Kebede et al. 2003).

Posttraumatic Stress Disorder

In the GBD 1990, PTSD was estimated to account for 0.4 percent of the total YLD, about the same percentage as schizophrenia (Murray and Lopez 1996). In the GBD 2000, PTSD has increased to 0.6 percent of total YLD (Mathers et al. 2002).

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder was estimated to be the 11th cause of the nonfatal burden of disease in the world, accounting for 2.2 percent of total YLD in 1990 (Murray and Lopez 1996). In the GBD 2000, obsessive-compulsive disorder now accounts for 2.5 percent of total YLD (Mathers et al. 2002).

Data Specific to Sub-Saharan Africa

Although data specific to Sub-Saharan Africa are more difficult to find, the number of epidemiological mental health studies being carried out in the last decade has increased. This is due to an increase in the number of African universities that are training psychiatrists, an increase in the number of African psychiatrists who have been trained in research methods and who are practicing in Africa, an increase in the number of African universities partnering with Western and northern universities, as well as an increasing number of African institutions participating in multi-site studies led by WHO or by U.S. research institutes. There is also a wealth of information coming out of South Africa, which had a much stronger research culture but was closed off to the rest of Africa in the apartheid years.

Depression

There have been at least three geographically localized but well-conducted epidemiological surveys of depression in Sub-Saharan Africa. Hollifield and colleagues (1990) used a two-stage approach in a rural village in Lesotho and found a prevalence of depression of 9 percent when alcohol abuse was corrected for, assuming that alcohol use preceded depressive disorder. The researchers noted that 19 percent of subjects with panic and depressive disorder had comorbid alcohol use. Rumble and colleagues (1996) note a similar high prevalence of depression in people in a rural South African village, in a study that screened for symptoms using an adapted version of the Self Report Questionnaire–25-item version (SRQ-25) and the Present State Examination (PSE) as a second-stage instrument.

The weighted prevalence for unipolar depressive disorder using the CATEGO (a computerized classification system) was 18 percent. More than half of the psychiatric morbidity detected was attributed to depressive disorders. In a homestead survey in two villages in Uganda, where the Luganda version of the PSE was used, Orley, Blitt, and Wing (1979) found that 14.3 percent of males and 22.6 percent of females among adults age 18 to 65 met criteria for depressive disorder using the CATEGO classification system. Estimated prevalence of depression in women in Harare, Zimbabwe, was reported to be 30 percent (Abas and Broadhead 1994) and the incidence rate of depression in the same population was estimated at 18 percent (Broadhead and Abas 1994). The incidence rate of major depression was found to be 15.6 percent in a rural general practice of South Africa (Strauss et al. 1995) and 15.5 percent in Rwanda five years after the genocide of April 1994 (Bolton, Neugebauer, and Ndogoni 2002).

Common Mental Disorders

Common mental disorders is a term used to discuss both anxiety and depression when they occur in the primary health care setting, often presenting with medically unexplained physical symptoms as well as the symptoms of depression, and anxiety (Patel et al. 1995). People with CMDs are frequent attenders at general primary health care clinics and medical and surgical inpatient beds, because they are specifically seeking help for their disorder, because they have a coexisting physical illness, or because they are somatizing their mental disorder. CMDs are significant contributors to the workload in general health clinics.

Schizophrenia

Schizophrenia is found in all countries and cultures and has a lifetime prevalence of between 7 and 9 per 1,000 people (Jablensky et al. 1992). The point prevalence varies between about 2 and 5 per 1,000. Collaborative studies by the WHO have shown that the prevalence of schizophrenia, when assessed in comparable ways, is similar in different countries (Jablensky et al. 1992). Although much rarer than depression and anxiety, it too forms a significant contribution to the overall public health burden because of the chronicity, deterioration, and extreme social disability in a significant proportion of sufferers. The outcome of schizophrenia is more favorable in developing countries than in the West, but the reasons are not yet clear (IOM 2001; Jablensky et al. 1992; Leff et al. 1992; Sartorius et al. 1986).

Jablensky recently reviewed the epidemiology of schizophrenia (IOM 2001) and concluded that there have been few systematic surveys of psychoses in Africa, although there are plenty of service-based clinical studies. An exception is a recent, well-designed community survey in an area of Ethiopia with a population of 100,000 in the age range 15 to 49 years. He concluded that the reported point prevalence of schizophrenia in most areas of the developing world where epidemiological surveys have been conducted is comparable with that in the developed world. Taking into account such factors as the higher mortality among people with serious mental disorders and incomplete ascertainment of a proportion of cases, it is likely that the reported rates are underestimates of the true prevalence of the disorder.

Posttraumatic Stress Disorder

Forty-one percent of all deaths in the WHO Sub-Saharan Africa region are from intentional injuries, the highest rates being for males age 15 to 29 years (56 percent) and 30 to 34 years (53 percent). The Sub-Saharan Africa region has the highest rates of death due to war-related injuries in the world, with a rate of 22 percent of all war-related injuries and 32 per 100,000 people (WHO 2002b). Estimates for psychosocial and mental disorders resulting from conflicts were 15.5 percent in Rwanda five years after the genocide (Bolton 2001b; Bolton, Neugebauer, and Ndogoni 2002). Studies carried out in Africa and other parts of the world indicate rates of 20 to 60 percent for depression, anxiety symptoms, and PTSD among children and women (de Jong 2002; Mollica et al. 1998; Mollica et al. 1999).

Alcohol Abuse

Adult per capita alcohol consumption is generally estimated by dividing the sum of alcohol production and imports less alcohol exports by the adult population age 15 years and older (WHO 1999b). In countries where the production is mainly home brews and spirits, thus not taxable, as in most of Sub-Saharan Africa, it becomes extremely difficult to get an accurate estimate of consumption. It is now widely accepted that the proportion of the population drinking excessively is closely related to the average consumption of that population (WHO 1999b). The increase in road traffic accidents, liver cirrhosis, and pancreatic disease as alcohol consumption increases further validates this premise.

The WHO estimates a sharp increase in per capita consumption of alcohol in Sub-Saharan Africa. Five of the 13 countries with the world's highest increase in alcohol consumption from 1970–72 to 1994–96 are in Sub-Saharan Africa. Lesotho ranked 1st, with a 1,817 percent increase; Nigeria, 5th, with a 196 percent increase; Rwanda, 10th, with a 129 percent increase; Burkina Faso, 12th, and Sudan, 13th, with 116 percent and 108 percent increases, respectively (WHO 1999b). Drinking is greater among males than females and greater among the uneducated than the formally educated. In the Seychelles, male drinkers consume eight times as much alcohol as females; among black South Africans, more than twice the men drink more regularly than women; and in Zambia, four times as many men as women drink weekly. A pattern of men drinking more frequently and to the point of intoxication is prevalent across Sub-Saharan Africa (WHO 1999b).

A worrying trend is that of consumption of alcohol by children (WHO 1999b). In Namibia, 20 percent of schoolchildren and 75 percent of young people not in school abuse alcohol on weekends. In Zimbabwe, 31 percent of those age 14 years and under report using alcohol. In Lesotho, 8.8 percent of children between the ages of 10 and 14 years and 4 percent of those between 5 and 9 years currently use alcohol.

Suicide

Suicide is an important cause of mortality in Sub-Saharan Africa. Studies have mainly been carried out in Nigeria, South Africa, and Zambia. In South Africa from 1984 to 1986 up to 0.37 percent of all admissions to hospitals (Okulate 2001) and 1.3 percent of all national mortality were suicide attempts (Flisher and Parry 1994). Parasuicide (attempted suicide) rates are much higher. In a study of 10,984 patients seen in a hospital in Durban, 17.7 percent were referred to the Department of Psychiatry because of parasuicide (Schlebusch 1985). In Nairobi, Kenya, suicide was the fourth most common cause of death due to injuries, making up 12 percent of all injury-related deaths (Muniu et al. 1994).

In a study of high school students in Addis Ababa in 1989 and 1990, Kebede and Ketsela (1993) found 14.3 percent reporting having attempted suicide. Kebede and Alem (1999) found a lifetime prevalence of 0.9 percent in Addis Ababa, and Alem et al. (1999) found a lifetime prevalence of 3.2 percent in Butajira, Ethiopia. Suicides generally occur between the ages of 13 and 50 years and peak at 20 to 29 years (WHO 1999a). Most studies reported that females generally have a higher frequency of suicide than males. Most of the suicide and parasuicide is associated with depression or alcohol abuse, or both. Dong and Simon (2001) found an increase of 320 percent in organophosphate poisoning in urban Zimbabwe for the period 1995 to 2000. Breetzke (1988) reported that in South Africa, suicide was more frequent among the white population (14 per 100,000) than among those of mixed race (3 per 100,000) and blacks (0.7 per 100,000). A study of accidental and violent death in Tanzania in women age 16 to 45 found that suicide is as common in that country as it is in the United Kingdom (CDC 2000; Setel et al. 2000). Table 22.3 summarizes some of the studies of suicide carried out in Sub-Saharan Africa.

Psychiatric Disorders among Children

Not many data are available on the burden of mental disorders among children. This is mainly because of the lack of validated testing instruments sensitive to the context of Sub-Saharan Africa; the lack of specialized personnel, such as child psychiatrists and child psychologists, able to carry out the assessments; and limited resources. Schier, Yecunnoamlack, and Tegegne (1989) found that 6.8 percent of 1,078 children treated on pediatric wards in Ethiopia had a neuropsychiatric disorder. A study carried out in Kenya found that one-third of the children referred to a psychological assessment center had emotional disorders as the cause for their learning difficulties (Dhadphale and Ibrahim 1984).

Malnutrition

Malnutrition is prevalent in Sub-Saharan Africa; from 20 to 50 percent of all children under five years are severely malnourished. The World Health Report 2002 estimates that 32 percent and 31 percent of children in WHO AFR D (characterized by high child and high adult mortality) and AFR E (characterized by high child and very high adult mortality), respectively, are two standard deviations below the weight for age.² Malnutrition is associated with mild to moderate mental retardation. Micronutrient deficiencies have also been found to be a major risk factor. These include iodine and zinc, with rates of 37 percent in AFR D and 62 percent in AFR E not consuming the recommended dietary intake. Iodine deficiency is the single most prevalent cause of mental retardation and brain damage, 25 percent of the global burden of iodine-related deficiency disorders are contributed by AFR E (WHO 2002a). Iron deficiency is prevalent in the region with hemoglobin levels of 10.6 for both AFR D and AFR E. A growing body of evidence indicates that iron deficiency anemia in early childhood is associated with reduced intelligence in mid-childhood (WHO 2002a). A study carried out in South Africa found that permanent intellectual stunting results from chronic malnutrition of infants up to four years of age (Booyens, Luitingh, and van Rensburg 1977).

Genetic Vulnerability

There is strong evidence that genetic vulnerability is an important part of the cause of schizophrenia; a person's risk of developing the disorder increases steeply with the degree of genetic relatedness (IOM 2001). Few risk factors have been specifically identified or validated in developing countries, although obstetric complications and early brain injury due to neuroinfection, toxic effects, other trauma, or maternal malnutrition during gestation are likely to be involved in a greater proportion of cases of adult schizophrenia in the developing world than in the developed world.

Incidence and prevalence studies from developing countries suggest a clustering of onset of schizophrenia in early adulthood, similar to that observed in developed countries, although it tends to occur at an earlier age in developing countries. The onset tends to be earlier in males than in females. An important difference between developing and developed countries is that in the majority of developed countries males have a higher morbidity than females, whereas in some developing countries this dominance is attenuated or inverted. Given that in many developing countries, women have higher mortality than men, this finding suggests that if adjustment for mortality could be made, the risk for schizophrenia for women in developing countries would be even higher. Causes of such a higher risk of schizophrenia among women in developing countries may involve both biological and psychosocial factors and requires further research.

Life Events

Life events that lead to the threat of loss or to actual loss, such as the death of a family member, marital separation, maternal deprivation, or loss of employment, have been shown to cluster before the onset of depressive episodes and to influence the course of depression in both developed and developing countries. Beck (1986) has described a cognitive triad that may contribute to the onset or reoccurrence of depressive episodes by increasing the risk of exposure to stressful life events: negative self view, negative interpretation of experience, and negative view of the future. Rates of depression increase in a variety of vulnerable groups, including refugees, neglected ethnic minority groups, and those exposed to war trauma (Baingana et al. 2004; Baingana, Bannon, and Thomas 2005; Barton and Mutiti 1998; de Jong 2002; Green et al. 2003; Mollica et al. 1998). Depression is also postulated to be high in Sub-Saharan Africa, resulting from the prevalent violence against women and HIV/AIDS (Baingana, Thomas, and Comblain, 2005; Bouta, Frerks, and Bannon 2004).

Poverty

A large body of evidence demonstrates the association between poverty and CMD. For example, a meta-analysis of five cross-sectional surveys carried out in Brazil, Chile, India, and Zimbabwe of people who sought treatment in primary care and the community, examining the economic risk factors for CMD, found a consistent and significant relation between low-income countries and risk for CMD. Similarly, a population-based study from Indonesia revealed that people with less education and fewer material possessions than others in their community were more likely to suffer from depression (Friedman 2004). It appears that both absolute and relative poverty are important in the genesis of depression (Friedman 2004).

Voices of the Poor, a three-volume publication of the World Bank that reports the findings from global focus group discussions with more than 60,000 poor people, notes feelings of worthlessness, hopelessness, and anxiety, as well as lack of planning for the future, as expressions of the state of being poor. These are some of the core symptoms of depression.

Gender

Both community and primary care–based studies indicate that women are often affected disproportionately by depression in both developing and developed countries (Abas and Broadhead 1997; Bean and Moller 2002; Broadhead and Abas 1994; Patel et al. 1999; Ustun et al. 2004). The multiple roles assumed by women, including the bearing and rearing of children, responsibility for the home, caring for both healthy and ill relatives, growing food, and earning income, can lead to increased exposure to life events, social adversity, and other environmental factors. Women in both developed and developing countries also encounter difficulties in relation to their social position, aspirations, social support networks, and domestic problems, which may include physical or sexual abuse.

Postpartum depression has been identified in both developed and developing countries. The greatest risk for postpartum depression is within the first 30 days of childbirth, and the condition can persist for up to two years. Certain practices in some developing countries, such as isolation of recent mothers from family and the new infant, are disruptive to the initial mother-infant relationship and eliminate the benefits of positive social supports. These practices have been identified as possible contributing factors to the onset of postpartum depression. In a study carried out in Zimbabwe, a brief screening questionnaire proved effective in identifying women in the eighth month of pregnancy who were at higher risk of postpartum depression (Nhiwatiwa, Patel, and Acuda 1998). Such a tool may be useful in devising preventive measures aimed at implementing interventions shortly after childbirth for previously identified high-risk individuals.

Violence against women, including sexual abuse of children, is linked to mental disorders of these women (Mulugeta, Kassaye, and Berhan 1998). A study carried out in Ethiopia found that in 5 percent of female high school students, completed rape had occurred and another 10 percent suffered attempted rape. Social isolation (33 percent), fear and phobia (19 percent), hopelessness (22 percent), and suicide attempts (6 percent) were the psychological sequelae. Rates of 21.1 percent have been found for domestic violence among patients presenting at a general practitioner's office (Marais et al. 1999).

Depression resulting from violence against women is postulated to be high in Sub-Saharan Africa (Marais et al. 1999). Rates of PTSD for those with a history of domestic violence were 35.3 percent versus 2.6 percent for those without such a history; rates of depression were 48.2 percent versus 11.4 percent; rates of suicide attempt were 19.0 percent versus 5.8 percent; and rates of substance abuse were 9.4 percent versus 4.7 percent. Those with major depression were also more likely to have attempted suicide and more likely to have unexplained physical symptoms and to make more visits to the general practitioner. Those with depression were also more likely to have comorbid PTSD (Marais et al. 1999).

In Butajira, Ethiopia, more than 3,000 women were systematically selected for a domestic violence study using instruments developed by the WHO (Yegomawork et al. 2003). This study showed that 59 percent of women suffered from sexual violence, and 49 percent suffered physical violence in their lifetime. Within the 12 months prior to the survey, 29 percent and 44 percent, respectively, had experienced physical and sexual violence. Very often, intimate partners are responsible for the violence. Women who suffered domestic violence reported increased lifetime mental health problems more often than those who did not suffer these adverse life events. The etiology of suicide is linked to a woman's history of sexual abuse and domestic violence; alcohol abuse; stressful life events, such as unwanted pregnancy or school-related pressures; as well as mental disorders, including depression and schizophrenia. An inverse relation has been found between suicide and education, older age, higher social class, and other indicators of well-being. Table 22.3 summarizes some of the studies carried out on suicide in Sub-Saharan Africa.

Weiss, Longhurst, and Mazure (1999), studying risk for depression in American women, found that child sexual abuse is associated with adult-onset depression in both men and women. A study of the patient profile of a clinic for child abuse and neglect in South Africa found that females made up 80 percent of the patients and that sexual abuse (90 percent) was the most common presenting complaint (de Villiers and Prentice 1996). The majority of the patients were young, 55 percent being below 10 years of age and 7 percent below 3 years. Behavior problems were recorded in 73 percent of cases, the commonest being school problems (21 percent), masturbation (19 percent), clingy behavior (12 percent), and withdrawal or depression (11.5 percent).

Similar findings were reported by Berard and Boermeester (1999). This study also found that more sexually abused patients received a diagnosis of depression than was expected, and they also scored higher on depression-rating scales. Logistic regression showed that the presence of suicidal symptoms and alcohol use were independently associated with sexual abuse. The authors concluded that "the associations of sexual abuse with suicidal symptoms, alcohol use, and troubled family circumstances, in the context of high unemployment, poverty, and gang-related violence, indicate a strong correspondence between adverse social conditions and psychological symptoms" (Berard and Boermeester 1999, 975).

HIV/AIDS

The psychiatric sequelae of HIV/AIDS are numerous and have etiologies that involve neurobiological and psychosocial factors. These include depression, anxiety disorders, manic symptoms, and atypical psychosis. Neuropsychiatric abnormalities were present in 41 percent of patients who tested positive for HIV-1 in Zaire (Perriens et al. 1992), and depression was found to be higher in symptomatic seropositive individuals than in matched seronegative individuals in the WHO Neuropsychiatric AIDS study (Maj et al. 1994). Kwalombota (2002), in a study carried out in Lusaka, Zambia, on the effect of pregnancy in HIV-infected women, found 85 percent to have major depressive episodes with suicidal thoughts. Those who knew their HIV status before becoming pregnant did not show severe depressive episodes, but those who found out while pregnant were liable to develop major depressive illness.

In Zaire, Boivin et al. (1995) studied the impact of a mother's HIV-positive status on the well-being of her children. The researchers found that "maternal HIV infection compromises the labor-intensive provision of care in the African milieu and undermines global cognitive development in even uninfected children" (p. 13).

Some research has been carried out in Sub-Saharan Africa on the links between HIV/AIDS and mental and neurological disorders. Although much of the research was done in the developed world, the data can provide information on the gaps in knowledge and the possible consequences of being HIV positive in Sub-Saharan Africa. Table 22.4 summarizes several of the studies on HIV/AIDS in Sub-Saharan Africa.

Poverty

Psychiatric and neurological disorders impose a significant burden in developed and developing countries. In the West, considerable evidence links poverty and mental and neurological illness. For example, the national psychiatric morbidity surveys of 1993–94 in Great Britain showed that people with any form of mental disorder had an average income of only 46.5 percent of the average income for the general population. In countries where there are no social security payments, as is the case in many developing countries, this situation is greatly aggravated. In addition to this effect of poverty on the individual, the economy experiences a loss because of lost production from people with mental and neurological illnesses being unable to work, either in the short, medium, or long term, and reduced productivity from people being ill while at work.

There are also socioeconomic costs to families, including the cost of supporting the dependents of people with mental and neurological illnesses. Long-term consequences include unemployment, crime, and violence in young people whose childhood problems (for example, depression, conduct disorder, dyslexia, and other special educational needs) were not properly addressed in childhood.

Poor Physical Health

Poor mental and neurological health is a risk factor for many physical health problems, and emotional distress makes people more vulnerable to physical illness. Various studies carried out in the West show that depression increases the risk of heart disease fourfold (Lett et al. 2004; Nemeroff, Musselman, and Evans 1998; Zellweger et al. 2004), even though it controlled for other risk factors such as smoking (Hippisley-Cox, Fielding, and Pringle 1998). Lack of control at work is also associated with increased risk of cardiovascular disease (Marmot et al. 1997). Sustained stress or trauma increases susceptibility to viral infection and physical illness by damaging the immune system (Marmot et al. 1997; Stewart-Brown 1998). Poor mental health in mothers is a major risk factor not only for their own physical ill health but also for impaired physical, cognitive, and emotional development of children and child mortality from infectious diseases (Rutter and Quinton 1984).

Comorbidity

Comorbidity (the coexistence of two or more disorders) has been found to be common among patients suffering from depression. It typically involves a combination of general physical and mental disorders or neurological and mental disorders. In one study of patients attending primary care, of nearly 21 percent of patients with clinically significant depressive symptoms, only 1.2 percent cited depression as the reason for their visit to the physician (Broadhead and Abas 1994). Comorbidity of physical and mental illness has been found to increase with age.

Substance abuse is a frequent comorbid condition with depression. Studies in both developed and developing countries point to substance abuse as both a cause and effect of depression linked to both genetic and environmental factors. Depression has been shown to be a major factor contributing to relapse in women abusing alcohol and drugs. Identifying substance abuse in patients presenting with depressive illness is an important component of management of the illness. Depression is also a common concomitant of HIV/AIDS (Ciesla and Roberts 2001; Morrison et al. 2002) and is associated with decreased compliance with medications (Turner et al. 2003), increased risk-taking behavior, putting others at risk for infection, and faster progression of the course of the illness evidenced by a rapid fall in the CD4 cell counts (Baingana, Thomas, and Comblain 2005; Evans et al. 2002).

Patients with epilepsy often present with psychological or psychotic symptoms. Sixty percent of 230 patients with epilepsy who were referred to the neurology clinic of Muhimbili Medical Center, Tanzania, had a psychological disturbance warranting intervention; 81 percent had a minor neurotic disorder, but 19 percent had schizophreni-form psychosis (Matuja 1990). Other disturbances were agoraphobia and severe depression. Over 80 percent of patients with a major disturbance had epilepsy and a brain lesion; 77 percent of patients with a minor disturbance had evidence of an organic brain lesion. Organic brain lesion and psychological disturbance were overwhelmingly associated with social disadvantage.

In a study of 478 Zambian patients on a given day, all of whom were examined for goiter, 34.4 percent of all adult females and 23.2 percent of all adult males were found to have goiter (Rwegellera and Mambwe 1977). Goiter was found in 57.6 percent of females with affective illness and 77 percent of males with paranoid psychosis. Bademosi and colleagues (1976) found that 38 percent of patients with infective endocarditis had neuropsychiatric symptoms. For 75 percent of these, the neuropsychiatric symptoms were the presenting feature.

Depression

Effective treatment strategies exist for depression in the form of pharmacological agents, cognitive behavioral therapy, and psychosocial treatments. Although treatment interventions may not cure all forms of depression, a large number of efficacious and low-cost treatments are available. Despite the availability of these interventions, many people in Africa remain undiagnosed and untreated. It is difficult to estimate the actual treatment gap (all those with a clinically diagnosed mental disorder who are not on treatment) because epidemiological data of diagnosed mental disorders in the community or of those who are on treatment are limited. The scant data available are often unreliable. Andrews, Henderson, and Wayne-Hall (2001), studying utilization of the Australian mental health services, found that only about 30 percent of those with a diagnosed mental disorder used the services.

Because of their efficacy and cost-effectiveness, antide-pressant medications represent the mainstay of treatment for depression in developed countries. Seventy percent of patients prescribed antidepressants show significant clinical improvement. Antidepressants are also effective as prophy-laxes: treatment has been shown to reduce the relapse rate for recurrent depression from 80 percent over three years to 22 percent. There has been far less research in developing countries, but the limited available evidence shows similar rates of efficacy. Tricyclic antidepressants (TCAs) and the newer selective serotonin reuptake inhibitors (SSRIs) have similar efficacy for moderate depression. The reduced side effects of SSRIs enhance patient compliance. However, the high cost of SSRIs means that they remain out of reach as a first-line treatment in Africa for all but the wealthy. Indeed, simply ensuring an adequate supply of TCAs to the primary care level across Sub-Saharan Africa still represents a major financial challenge for these countries, even though TCAs are relatively cheaper than the SSRIs, even if the latter are now getting off patent protection. The median yearly cost for treating depression in an individual with amitriptyline in Sub-Saharan Africa was estimated at US$30.66 in 2001 and is now estimated to be US$34.38 (WHO 2001, 2005).

Bolton and colleagues (2003) tested the efficacy of group interpersonal psychotherapy in alleviating depression and dysfunction in rural Uganda and found it to be highly efficacious. Mean reduction of depression severity was 17.47 points for intervention groups and 3.55 points for controls. After the intervention, 6.5 percent of the intervention group and 54.7 percent of the control group met the criteria for major depression compared with 86 percent and 94 percent, respectively, before treatment was initiated.

Cognitive behavior therapy, problem-solving therapy, and family-focused therapy have met with success in the treatment of depression. A small number of published reports address the use of psychosocial interventions to treat depression in developing countries. Problem-solving therapy has been suggested as an effective psychosocial treatment, particularly because it seeks to provide the patient with a technique for coping with future problems, thereby potentially preventing a recurrence of depressive symptoms or enabling the patient to deal with them more effectively when they recur. Problem-solving therapy has been conducted effectively by trained community nurses in primary care settings, making the approach particularly attractive for resource-poor settings, where psychiatrists and specially trained general physicians are not available.

Schizophrenia

Evidence suggests that correct early diagnosis and initiation of treatment can have a positive impact on the subsequent course of schizophrenia. Antipsychotic medication is the mainstay of treatment and is indicated for the majority of patients over prolonged periods with no fixed limit to duration. Two classes of pharmacological agents are available. The two offer approximately equal efficacy in controlling the positive symptoms of the disorder but differ considerably in their side effects and tolerability as well as cost. The median yearly cost per person for chlor-promazine for Sub-Saharan Africa was estimated at US$40.88 in 2001 and is now estimated to be US$49.06 (WHO 2001, 2005).

Posttraumatic Stress Disorder

A combination of psychosocial and mental health interventions is recommended for PTSD. Psychosocial interventions include counseling, group support meetings, play activities, art, music, and other expressive art therapies. Mental health interventions include a short course of anxiolytics for acute distress, not to be taken for longer than two weeks. Symptoms that persist beyond the acute phase respond to smaller doses of antide-pressants and antipsychotics. Drug treatment for PTSD is best combined with a psychotherapeutic intervention, such as group therapy, individual therapy, or counseling.

Mental Disorders among Children

The first step in the management of mental disorders among children is making the correct diagnosis. Management is also dependent on a collaboration between the parents or caretaker, the teachers, and the health care provider. Treatment depends on the diagnosis and the underlying causative factors. Antidepres-sants are effective in the management of emotional disorders of children. However, the teacher must be aware of the diagnosis and provide support within the school system. For children with learning difficulties, special needs education teachers play a crucial role in providing education tailored to the needs of the child.

For children with attention–deficit/hyperactivity disorder, Ritalin and other stimulants are not widely used in Sub-Saharan Africa, mainly because of the lack of child psychiatrists and psychologists, necessary for the close supervision required. High activity levels can be managed with behavioral methods, and a special needs education teacher can design a learning program tailored to the attention deficit. A few countries, such as Kenya, South Africa, and Uganda, have developed comprehensive special education teacher-training programs.