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Disability and Treatment of Psychiatric and Physical Disorders in South Africa

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Disability and Treatment of Psychiatric and Physical Disorders in South Africa ORIGINAL ARTICLE Disability and Treatment of Psychiatric and Physical Disorders in South Africa Sharain Suliman, MA,* Dan J. Stein, MD, PhD,† Landon Myer, PhD,‡ David R. Williams, PhD,§ and Soraya Seedat, MD, PhD* Africa (World Health Organisation, 2001), however, both public and Abstract: We aimed to compare disability rates associated with physical private health-care systems have appeared to concentrate prevention disorders versus psychiatric disorders and to establish treatment rates of both and intervention efforts on major communicable diseases (The classes of disorder in the South African population. In a nationally repre- Institute of Medicine, 2001). In South Africa, neuropsychiatric sentative survey of 4351 adults, treatment and prevalence rates of a range of disorders rank high in their disability adjusted life year (DALY) physical and psychiatric disorders, and their associated morbidity during the estimates (Bradshaw et al., 2007), and there is a need for a stronger previous 12 months were investigated. Physical illnesses were reported in health sector response to these conditions. 55.2% of the sample, 60.4% of whom received treatment for their disorder. Cost (and burden) of illness studies are relatively lacking in Approximately 10% of the samples show a mental illness with 6.1% having Africa and the rest of the developing world (Hu, 2006). However, received treatment for their disorder. The prevalence of any mental illness findings from community-based studies in the developed world have reported was higher than that reported individually for asthma, cancer, documented significant psychiatric disability (Bijl and Ravelli, diabetes, and peptic ulcer. Mental disorders were consistently reported to be 2000; Kouzis and Eaton, 1997; Ormel et al., 1994), with several more disabling than physical disorders and the degree of disability increased studies finding that respondents with one or more psychiatric disor- as the number of comorbid disorders increased. Depression, in particular, was rated consistently higher across all domains than all physical disorders. der functioned worse than, or comparable to, respondents with a Despite high rates of mental disorders and associated disability in South physical disorder (Kouzis and Eaton, 1997; Ormel et al., 1994; Africa, they are less likely to be treated than physical disorders. ESEMeD/MHEDEA 2000 Investigators, 2004). A dose-response relationship has also been documented (i.e., increasing level of Key Words: Disability, mental health, physical health, South Africa, disability with an increase in the number of psychiatric disorders) treatment. (Alonso et al., 2004). Despite this, a large number of people with (J Nerv Ment Dis 2010;198: 8–15) psychiatric disorders do not receive treatment (Weiner and Hanley, 1989; Eaton, 1994; Rupp, 1995; Wang et al., 2007). Clayer et al. (1998) have suggested that this may be because treatment is sought only when symptoms are deemed to interfere with a person’s ability he Global Burden of Disease (GBD) study determined that the to function adequately. Other possible reasons include fear of Thighest disease burden in 1990 (21.4% of the global total) was in stigmatization, low mental health literacy levels (Jorm et al., 1997), sub-Saharan Africa (Murray and Lopez, 1997), and in 2001 found neglect by healthcare professionals and the lack of resources. that almost half this burden was due to noncommunicable diseases Owing to the scarcity of resources in South Africa and other (Lopez et al., 2006). For example, neuropsychiatric disorders have parts of the developing world, it is necessary that careful decisions been reported to cause 17.6% of all years lost due to disability in are made regarding resource allocation (Landman and Henley, 1999). The negative economic consequences of psychiatric disorders far exceed the direct costs of treatment, thus making this group of *MRC Anxiety and Stress Disorders Unit, Department of Psychiatry, Univer- disorders important to treat (Hu, 2006). As such, data on burden and sity of Stellenbosch, Cape Town, South Africa; †Department of Psychia- try, University of Cape Town, Cape Town, South Africa; ‡Infectious cost, both direct (i.e., treatment costs) and indirect (i.e., impaired Disease Epidemiology Unit, School of Public Health and Family Medicine, functioning in work and social roles, family burden, lost productiv- University of Cape Town, Cape Town, South Africa; and §Department of ity) (Ormel et al., 1994; Spitzer et al., 1995), are important for both Society, Human Development and Health, Harvard School of Public Health, health planners and to inform health care policy. Boston, MA. Supported by the United States National Institute of Mental Health Given these considerations, the aims of this article were (i) to (R01MH070884), the John D. and Catherine T. MacArthur Foundation, the compare disability associated with physical disorders versus that Pfizer Foundation, the US Public Health Service (R13-MH066849, R01- associated with psychiatric disorders (depression and anxiety disor- MH069864, and R01 DA016558), the Fogarty International Center (FIRCA ders) and (ii) to establish treatment rates of both classes of disorder R01-TW006481), the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical, Inc, GlaxoSmithKline, and Bristol- in South Africa. Myers Squibb. The South Africa Stress and Health study was supported by grant R01-MH059575 from the National Institute of Mental Health and the National Institute of Drug Abuse with supplemental funding from the South African Department of METHODS Health and the University of Michigan. Also, by the Medical Research Council (MRC) of South Africa (to D.J.S. and S.S.). Sample A complete list of WMH publications can be found at: http://www.hcp.med. The South African Stress and Health Study had as a national harvard.edu/wmh/. probability sample of 4351 adult South Africans living in both The South African Stress and Health study was carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative. households and hostel quarters. Hostel quarters were included to Send reprint requests to Sharain Suliman, MA, MRC Unit on Anxiety and Stress maximize coverage of young working age males, but the sample did Disorders, Department of Psychiatry, PO Box 19063, Tygerberg 7505, Cape not include individuals in institutions or in the military. Individuals Town, South Africa. E-mail: [email protected]. of all race and ethnic backgrounds were included in the study. Full Copyright © 2010 by Lippincott Williams & Wilkins ISSN: 0022-3018/10/19801-0008 details of the sampling are provided in previous articles (Williams et DOI: 10.1097/NMD.0b013e3181c81708 al., 2004; Williams et al., 2008). 8 | www.jonmd.com The Journal of Nervous and Mental Disease • Volume 198, Number 1, January 2010 The Journal of Nervous and Mental Disease • Volume 198, Number 1, January 2010 Mental Health and Associated Disability The sample was selected using a 3-stage probability sample Composite International Diagnostic Interview diagnoses of anxiety and design. The first stage involved selecting a stratified probability mood disorders and independent clinical assessment (Haro et al., 2006; sample of primary sampling areas equivalent to counties in the Kessler et al., 2005). United States or the United Kingdom, based on the 2001 South Disability was assessed with the Sheehan Disability Scales African Census of Enumeration Areas (EAs). The EAs were sam- (SDS) (Sheehan et al., 1996). The SDS asked respondents to rate, pled with probabilities proportionate to population size. The second separately, the amount of disability caused by specific physical and stage involved selecting an equal probability sample of housing psychiatric disorders in the domains of work, home management, units within each EA. The third stage involved selecting 1 random social life, and close relationships during 1 month in the past year adult respondent from each sample housing unit. Interviewers se- when the disorder was most severe. Ratings were made usinga0to lected a single adult respondent at random using the Kish procedure 10 visual analogue scale in which response option labels were none for objective respondent selection (Kish, 1949). A total sample of (0), mild (1–3), moderate (4–6), severe (7–9), and very severe (10). 5089 households was selected for South African Stress and Health A global SDS disability score was also created by assigning each Study; of these, 4351 individuals agreed to participate and provided respondent the highest SDS domain score reported across the 4 complete data that are included in this analysis. domains. The SDS scales were administered separately for each of the 10 psychiatric disorders and for 1 physical disorder selected Procedures randomly from among all the physical disorders reported by the All interviews were conducted face-to-face by trained lay respondent as being in existence during the 12 months before interviewers. Interviewers were trained in the administration of the interview (there was a chart embedded in the interview, that allowed interview in centralized group sessions lasting 1 week. The inter- the interviewer to make a random selection given the number of views were conducted in 7 different languages: English, Afrikaans, chronic conditions that the respondent had demonstrated). To correct Zulu, Xhosa, North Sotho, South Sotho, and Tswana. The protocol, bias that may have been introduced by under-selection of comorbid
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