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Women and mental health in India: An overview

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Abstract

Gender is a critical determinant of mental health and mental illness. The patterns of psychological distress and psychiatric disorder among women are different from those seen among men. Women have a higher mean level of internalizing disorders while men show a higher mean level of externalizing disorders. Gender differences occur particularly in the rates of common mental disorders wherein women predominate. Differences between genders have been reported in the age of onset of symptoms, clinical features, frequency of psychotic symptoms, course, social adjustment, and long-term outcome of severe mental disorders. Women who abuse alcohol or drugs are more likely to attribute their drinking to a traumatic event or a stressor and are more likely to have been sexually or physically abused than other women. Girls from nuclear families and women married at a very young age are at a higher risk for attempted suicide and self-harm. Social factors and gender specific factors determine the prevalence and course of mental disorders in female sufferers. Low attendance in hospital settings is partly explained by the lack of availability of resources for women. Around two-thirds of married women in India were victims of domestic violence. Concerted efforts at social, political, economic, and legal levels can bring change in the lives of Indian women and contribute to the improvement of the mental health of these women.
Indian J Psychiatry 57 (Supplement 2), July 2015 S205
Alpha bias is seen in psychodynamic theories and therapies
where according to Freudian viewpoint, male anatomy and
masculinity is the most desired and cherished goal and
female anatomy and femininity are seen as a deviation. In
contrast, the cognitive theories, behavioral theories, and
humanistic‑existential theories have beta bias.[1] Alpha bias
could be rooted more in the social conditioning and power
structure in the societies.
Gender roles have been culturally prescribed through
the prehistoric cultures to the more civilized societies.
In hunter‑gatherer societies, women were generally the
gatherers of plant foods, small animal foods, fish, and learned
to use dairy products while men hunted meat from large
animals. In more recent history, the gender roles of women
have changed greatly. Traditionally, middle‑class women
INTRODUCTION
Women and men are different not only in their obvious
physical attributes, but also in their psychological makeup.
There are actual differences in the way women’s and
men’s brains are structured and “wired” and in the way
they process information and react to events and stimuli.
Women and men differ in the way they communicate,
deal in relationships, express their feelings, and react to
stress. Thus, the gender differences are based in physical,
physiological, and psychological attributes. There are
psychological theories that present a gender sensitive
viewpoint called as alpha bias, and there are others that are
gender neutral representing beta bias. Alpha bias proposes
that men and women are different and opposite, and in
beta bias differences between men and women are ignored.
REVIEW ARTICLE
Women and mental health in India: An overview
Savita Malhotra, Ruchita Shah
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Address for correspondence: Dr. Savita Malhotra,
Department of Psychiatry, Post Graduate Institute of Medical
Education and Research, Chandigarh ‑ 160 012, India.
E‑mail: savita.pgi@gmail.com
Access this article online
Website:
www.indianjpsychiatry.org
Quick Response Code
DOI:
10.4103/0019‑5545.161479
Gender is a critical determinant of mental health and mental illness. The patterns of psychological distress and psychiatric
disorder among women are different from those seen among men. Women have a higher mean level of internalizing
disorders while men show a higher mean level of externalizing disorders. Gender differences occur particularly in the
rates of common mental disorders wherein women predominate. Differences between genders have been reported in the
age of onset of symptoms, clinical features, frequency of psychotic symptoms, course, social adjustment, and long‑term
outcome of severe mental disorders. Women who abuse alcohol or drugs are more likely to attribute their drinking to
a traumatic event or a stressor and are more likely to have been sexually or physically abused than other women. Girls
from nuclear families and women married at a very young age are at a higher risk for attempted suicide and self‑harm.
Social factors and gender specic factors determine the prevalence and course of mental disorders in female sufferers.
Low attendance in hospital settings is partly explained by the lack of availability of resources for women. Around
two‑thirds of married women in India were victims of domestic violence. Concerted efforts at social, political, economic,
and legal levels can bring change in the lives of Indian women and contribute to the improvement of the mental health
of these women.
Key words: Common mental disorder, disorder, domestic violence, mental health, substance abuse, suicide, women
How to cite this article: Malhotra S, Shah R. Women and
mental health in India: An overview. Indian J Psychiatry
2015;57:205-11.
ABSTRACT
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Malhotra and Shah: Women and mental health in India: An overview
Indian J Psychiatry 57 (Supplement 2), July 2015
S206
are typically involved in domestic tasks emphasizing child
care. For poorer women, economic necessity compels them
to seek employment outside the home. The occupations
that are available to them are; however, lower in pay than
those available to men leading to exploitation. Gradually,
there has been a change in the availability of employment
to more respectable office jobs where more education
is demanded. Thus, although, larger sections of women
from all socioeconomic classes are employed outside the
home; this neither relieves them from their domestic duties
nor does this change their social position significantly.
For centuries, the differences between men and women
have been socially defined and distorted through a lens
of sexism in which men assumed superiority over women
and maintained it through domination. This has led to
underestimating the role a woman plays in the dyad of
human existence.
It is necessary to understand and accept that women and
men differ in biological attributes, needs, and vulnerabilities.
MENTAL HEALTH AND MENTAL DISORDERS
Mental health is a term used to describe either a level
of cognitive or emotional well‑being or an absence of a
mental disorder. From perspectives of the discipline of
positive psychology or holism, mental health may include
an individual’s ability to enjoy life and procure a balance
between life activities and efforts to achieve psychological
resilience. On the other hand, a mental disorder or mental
illness is an involuntary psychological or behavioral
pattern that occurs in an individual and is thought to cause
distress or disability that is not expected as part of normal
development or culture.
Gender is a critical determinant of mental health and mental
illness. The morbidity associated with mental illness has
received substantially more attention than the gender specific
determinants and mechanisms that promote and protect
mental health and foster resilience to stress and adversity.[2]
Analysis of mental health indices and data reveals that the
patterns of psychiatric disorder and psychological distress
among women are different from those seen among
men. Symptoms of depression, anxiety, and unspecified
psychological distress are 2–3 times more common among
women than among men; whereas addictions, substance
use disorders and psychopathic personality disorders are
more common among men. The World Health Organization
report[2] lays out these facts effectively. It has further
been suggested that observed gender differences in the
prevalence rates originate from women and men’s different
average standings on latent internalizing and externalizing
liability dimensions with women having a higher mean level
of internalizing while men showing a higher mean level of
externalizing.[3]
WOMEN’S MENTAL HEALTH: THE
FACTS (WORLD HEALTH ORGANIZATION
REPORT, 2001)[2]
• Depressive disorders account for close to 41.9% of
the disability from neuropsychiatric disorders among
womencomparedto29.3%amongmen
• Leading mental health problems of the elderly are
depression, organic brain syndromes, and dementias.
A majority are women
• An estimated 80% of 50 million people affected by
violent conflicts, civil wars, disasters, and displacement
are women and children
• Lifetime prevalence rate of violence against women
rangesfrom16%to50%
• Atleast one infive women suffersrape or attempted
rape in their lifetime.
COMMON MENTAL DISORDERS
Gender differences occur particularly in the rates of
common mental disorders (CMDs)‑depression, anxiety,
and somatic complaints wherein women predominate.
Unipolar depression, which is predicted to be the second
leadingcause of globaldisabilityburdenby2020, is twice
as common in women. Furthermore, the lifetime risk of
anxiety disorders (e.g., generalized anxiety disorder) is
2–3 times higher in females as compared to males.[4]
Moreover, depression is not only the most common women’s
mental health problem, but may be more persistent in
women than men.[5] Although depressive symptoms in
men and women have generally been found to be similar
overall, women are more likely to present with atypical or
“reverse vegetative” symptoms such as increased appetite
and weight gain. In case of anxiety disorders, females have
greater severity of symptoms, have more often comorbid
depression and complicated course.[4]
Asacrosstheworld,studiesinIndiahaveshownthatCMD
such as depression and anxiety are strongly associated to
female gender besides poverty. Both community‑based
studies and studies of treatment seekers indicate that
women are, on average, 2–3 times, at greater risk to be
affected by CMD.[6] In light of this convincing evidence
that CMD are more common in women, the next most
intriguing question is what makes females apparently more
vulnerable. Hormonal factors related to the reproductive
cycle may play a role in women’s increased vulnerability
to depression.[7] Another answer may be that the factors
independentlyassociatedwiththeriskforCMDarefactors
indicative of gender disadvantage. These factors include
excessive partner alcohol use, sexual, and physical violence
by the husband, being widowed or separated, having
low autonomy in decision making, and having low levels
of support from one’s family.[8‑10] Furthermore, stressful
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life events are closely associated with the occurrence of
depressioninvulnerableindividuals.Duringtheirlifetimes,
females are faced with various life stressors including
childbirth and maternal roles, caring and nurturing the
old and sick of the family. In addition, women are less
empowered due to lesser opportunities of education and
respectable employment. Moreover, even those who are
financially secure fear to cross social lines and therefore too
are apparently vulnerable.
SEVERE MENTAL ILLNESS
Although severe mental disorders such as schizophrenia
and bipolar disorders are less prevalent than CMD, the
chronic course and associated disability make these
disorders severe. In addition, the stigma associated with
these illnesses has a major impact not only on the sufferer
but also on the families. Also, the families are burdened
with the care of these patients for almost their entire
lives in a great number of cases. Needless to say, the
emotional and financial strain on the caregivers may be
overwhelming.
There are no marked gender differences in the rates of
severe mental disorders like schizophrenia and bipolar
disorder that affect <2% of the population.[11] Gender
differences have been reported, however, in the age of
onset of symptoms, clinical features, frequency of psychotic
symptoms, course of these disorders, social adjustment,
and long‑term outcome. The clinical features of bipolar
disorder differ between men and women; women have
more frequent episodes of depression, more commonly
have “rapid cycling” and a seasonal pattern of mood
disturbances.[12]Largecross‑culturalstudiesinschizophrenia
have shown that “female gender” is associated with a better
course and outcome of schizophrenia in the developing
countries. Furthermore, females have a later age of onset of
schizophrenia as compared to that in males.
Although female gender is associated with a favorable
outcome, social consequences such as abandonment by
marital families, homelessness, vulnerability to sexual abuse,
and exposure to HIV; and other infections contribute to the
difficulties of rehabilitation of women. The prevalence rates
for sexual and physical abuse of women with severe mental
illnesses are twice those observed in the general population
of women. In India, the absence of any clear policies for the
welfare of severely ill women, and the social stigma further
compounds the problem.[6] Stigma has been reported to
be more toward ill women than men and also, women
caregivers become the target of stigma.[13,14]
Suicide
Studies of suicide and deliberate self‑harm have revealed a
universally common trend of more female attempters and
more male completers of suicide. However, in contrast to
the data from many other countries, except China, which
records the highest female suicide rate, women outnumber
men in completed suicides in India, although the gap
between them is narrow.[15] Biswas et al.[16] found that
girls from nuclear families and women married at a very
young age to be at a higher risk for attempted suicide and
self‑harm. The suicide rate by age for India reveals that the
suicide rates peak for both men and women between the
age18and29while in the age group 10–17, theratefor
the female exceeded the male figure.
In his seminal studies, Emile Durkheim had vividly
demonstrated over a century ago, that sociocultural
factors are significant determinants of suicide behavior
and perhaps these impact men and women differently.
In an Indian study, the 1‑year incidence of attempted
suicide was 0.8%, and seven of these women (37%) had
baseline CMDs. CMD, exposure to violence, and recent
hunger were the strongest predictors of the incident
attempted suicide cases.[17] A large degree of attempts is
as a response to failures in life, difficulties in interpersonal
relationships, and dowry‑related harassment.[16] The
precipitants for suicide, according to Indian government
statistics, among women compared to men are as follows:
Dowry disputes (2.9% versus 0.2%); love affairs (15.4%
versus 10.9%); illegitimate pregnancies (10.3 versus 8.2);
and quarrels with spouse or parents‑in‑law (10.3% versus
8.2%).ThecommoncausesforsuicideinIndiaaredisturbed
interpersonal relationships followed by psychiatric disorders
and physical illnesses.[15] Spousal violence has been found to
be specifically associated as an independent risk factor for
attempted suicide in women.[18]
Violence and abuse
According to an eye‑opening United Nations report,
around two‑third of married women in India were
victims of domestic violence and one incident of violence
translated into women losing 7 working days in the
country.Furthermore,asmanyas70%ofmarriedwomen
betweentheagesof15and49yearsarevictimsofbeating,
rape or coerced sex.[19] The common forms of violence
against Indian women include female feticide (selective
abortion based on the fetus gender or sex selection of
child), domestic violence, dowry death or harassment,
mental and physical torture, sexual trafficking, and
public humiliation. The reproductive roles of women,
such as their expected role of bearing children, the
consequences of infertility, and the failure to produce a
male child have been linked to wife‑battering and female
suicide.[20,21]
Sexual coercion is a serious and prevalent concern among
female Indian psychiatric patients. Sexual coercion was
reportedby30%ofthe146womeninanIndianstudy.The
most commonly reported experience was sexual intercourse
involving threatened or actual physical force (reported
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S208
by 14% of women), and the most commonly identified
perpetrator was the woman’s husband or intimate
partner(15%),orapersoninapositionofauthorityintheir
community(10%).[22]
The consequences of gender‑based violence are devastating
including life‑long emotional distress, mental health
issues including posttraumatic stress disorder and poor
reproductive health. Common mental health problems
experienced by abused women include depression, anxiety,
posttraumatic stress, insomnia, and alcohol use disorders,
as well as a range of somatic and psychological complaints.
Battered women are much more likely to require psychiatric
treatment and are much more likely to attempt suicide
than nonbattered women.[23] The cross‑sectional data from
a recent study, in India showed an association between
violence and a range of self‑reported gynecological
complaints, low body mass index, depressive disorder, and
attempted suicide.[18] In summary, women are subjected to
an alarming amount of violence in childhood and adulthood,
and the effects of this violence are often profound and
long‑term.
REPRODUCTIVE HEALTH
Mood and behavioral changes have been observed to be
associated with menstrual cycle since ancient times. The
symptoms such as irritability, restlessness, anxiety, tension,
migraine, sleep disturbances, sadness, dysphoria, and
the lack of concentration occur more frequently during
the premenstrual and menstrual phase. A premenstrual
dysphoric disorder consisting of extremely distressing
emotional and behavioral symptoms is closely linked to the
luteal phase of the menstrual cycle.
Mental disturbances frequently occur during late
pregnancy and in the postpartum period. Postpartum
blues is the most common and least severe postpartum
illnessaffectingbetween50%and80%ofnewmothers,[24]
whereas postpartum depression constitutes a major
depressive episode with an onset within 6 weeks
postpartum in a majority of cases. In India, depression
occurs as frequently during late pregnancy and after
delivery as in developed countries, but there are cultural
differences in risk factors. In a study in rural Tamil
Nadu,[25]theincidenceofpostpartumdepressionwas11%.
Lowincome,birthofadaughterwhenasonwasdesired,
relationship difficulties with mother‑in‑law and parents,
adverse life events during pregnancy and lack of physical
help are all risk factors for the onset of postpartum
depression. In addition, the postpartum period carries
the potential for exacerbation of psychiatric symptoms
in women with the preexisting mental illness. Similarly,
a recent systematic review[26] on nonpsychotic common
perinatal disorders (CPMD) among women from low
and middle income countries estimated that about one
in six pregnant women and one in five women who
have recently given birth experience a CPMD. The risk
is highest among the most socially and economically
disadvantaged women. The other important risk factors
include gender‑based factors such as the bias against
female babies; role restrictions regarding housework and
infant care; and excessive unpaid workloads; especially in
multi‑generational households in which a daughter‑in‑law
has little autonomy, and gender‑based violence.[26] Also,
menopause is a time of change for women not only in
their endocrine and reproductive systems, but also their
social and psychological circumstances. It has long been
known that menopause is accompanied by depression
and other mental disturbances.
Reproductive health factors, particularly gynecological
complaints such as vaginal discharge and dyspareunia are
independently associated with the risk for CMD. More
importantly, gynecological symptoms may actually be
somaticequivalentsofCMDinwomeninAsiancultures.[8]
SUBSTANCE USE
Although there are variations between countries, rates
of substance abuse – particularly abuse of alcohol,
tranquillizers, and analgesics – are increasing around the
world.[5] Women are more likely to attribute their drinking
to a traumatic event or a stressor and women who abuse
alcohol or drugs are more likely to have been sexually
or physically abused than other women.[27] Significantly
more major depression and anxiety disorders are found in
females with alcoholism. Thus, the profile of women with
substance use problems differs from that in male abusers.
However, despite increasing rates, services to assist women
are limited.[5]
WOMAN ‑ A LIFE CYCLE OF VULNERABILITIES
As mentioned earlier, in many of the disorders, social
factors and gender specific factors determine the
prevalence and course in female sufferers. In fact, the
numbers are meaningless without considering the
sociocultural factors. Thus, depression, anxiety, somatic
symptoms, and high rates of comorbidities are significantly
related to interconnected and co‑occurring risk factors
such as gender based roles, stressors, and negative life
experiences and events.
Gender determines the differential power and control
that men and women have over the socioeconomic
determinants of their mental health and lives, their
social position, status and treatment in society and their
susceptibility, and exposure to specific mental health
risks. A strong inverse relationship exists between social
position and physical and mental health outcomes. Hence,
the effect of the biological vulnerability is increased by
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the social disadvantages that women have. Pressures
are created by their multiple roles and the unremitting
responsibility of caring of others. In addition, gender
specific risk factors such as gender discrimination and
associated factors of poverty, hunger, malnutrition,
overwork, domestic violence, and sexual abuse combine
to account for women’s poor mental health. There is a
positive relationship between the frequency and severity
of such social factors and the frequency and severity of
mental health problems in women. In addition, severe life
events that cause a sense of loss, inferiority, humiliation
or entrapment can predict depression.
Furthermore, the expectation about what constitutes illness
is gender biased. Thus, the somatic complaints that form
themostprominentpresentationofCMDmaynotbetaken
into account by the care providers. A gender bias more
often than not ensures that the symptoms are taken less
seriously than they are for men. The impact of mental health
problems also shows a gender differential. For example,
whereas women are required to be the primary care givers
if their husbands were mentally ill, it is themselves who still
need to carry on with the role of care giving to the family
despite their problems.
The sociopolitical scene in South‑East Asia including India
in the mildest of terms is bleaker when compared to
the Western world.[6,28] Wrath of dowry practices, a firm
patriarchal family system with the woman having little say,
lesser opportunities for education, and employment add
to the plight of women. Women’s mental health tends to
suffer as they are faced with stressors and are ill‑equipped
to cope with the same.
Furthermore, when a woman becomes mentally ill, services
are sought infrequently and late. Rather she is blamed
for the illness. The mentally ill woman may be socially
ostracized and abandoned by her husband and her own
family. Hence, being a “woman” and being “mentally ill” is
a dual curse. Even though some authors feel that marriage
protects against psychological breakdown, it is not always
true. Several studies show that there is greater distress in
married women as compared to married men. The birth of
a child, abortion or miscarriage, economic stresses, and
major career changes are some of the stressful events in
married life; many of these are gender specific.[29]
The responsibility of care for the mentally ill women is
often left to her own family than to husband or his family.
In a study, of women with schizophrenia and broken
marriages, Thara et al.[13,14] found that the stigma of being
separated/divorced is often felt more acutely by families
and patients than the stigma of having a mental illness.
Feelings of disruption, loss, guilt, frustration, grief, and
fear about the future of their daughter make the caregivers
miserable.
SERVICE PROVISION AND UTILIZATION
Psychiatric epidemiological data cite a ratio of one woman
for every three men attending public health psychiatric
outpatients’ clinics in urban India. Indian state officials view
this as “under‑utilization” by suffering women, attributing it
to the greater stigma attached to women’s mental illness that
restricts help‑seeking in public health facilities and/or to the
lower importance accorded to women’s health generally.[30]
Gender heightens the discrepancy between prevalence and
utilization. This low attendance is partly explained by the
lack of availability of resources for women in the hospital
settings. The mental hospitals appear to cater primarily
to men in distress, and there is sex‑based discrimination
in the availability of beds. The male:female ratio for the
allotment of beds in government mental hospitals with only
servicewas73%:27%whilethosewithservice,research,and
trainingwas66%:34%.[20]
WHAT NEEDS TO BE DONE?
It is therefore, amply clear that women’s mental health
cannot be considered in isolation from social, political,
and economic issues. A woman’s health must incorporate
mental and physical health across the life cycle and should
reach beyond the narrow perspective of reproductive and
maternal health, which is often the focus of our policies.
In the discussion of the determinants of poor mental health
of women, the focus needs to be shifted from individual
and “lifestyle” risk factors to the recognition of the broader,
social, economic, and legal factors that affect women’s
lives. It is essential to recognize how the sociocultural,
economic, legal, infrastructural, and environmental factors
that affect women’s mental health are configured in the
given community setting.
If the efforts to promote women’s mental health focus
solely on the reduction of individual “lifestyle” risk factors,
they may neglect the very factors that bring that lifestyle
into being. Moreover, if the individual factors are focused
in isolation, ignoring the sociocultural factors, there is an
additional risk of placing the responsibility of change on
the women alone. However, the truth is that largely the
change is beyond their control and lies in the bigger social
change. Inadvertently, the failure to change and improvise
the mental health may be misattributed to the women.
Education, training, and interventions targeting the social
and physical environment are crucial for addressing
women’s mental health. Identification of significant persons
in government departments and other relevant groups in
the community, to obtain and document data indicating
the extent of women’s problems and the burden associated
with women’s mental problems and the development of
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S210
policies to protect and promote women’s mental health are
extremely crucial.
Interventions at various levels aiming at both individual
women and women as a large section of the society are
essential. These should be implemented at primary care
delivery as well on legal and judicial fronts. The primary
care providers must be aware of the major mental
health problems affecting women, routinely enquire
about common mental health problems, provide the
most appropriate intervention and support and provide
education to the community on issues related to the
mental health of women. Women are increasingly joining
the workforce, and there is great potential to intervene at
this level too.
There are many reasons why women are reluctant to report
incidents of assault and abuse to police. These include: A
belief that the incident is a “normal” part of life; feeling
responsible for the violent incident; intimidation by the
partner; fear of reprisal; financial dependence; continuing
love or affection for the partner; inability to respond as a
result of the psychological and emotional trauma arising
from repeated abuse; and intimidation by the whole legal
process. Barriers to an effective criminal justice response
also relate to the attitudes and beliefs of those people
working within the criminal justice system. Taking into
account the above, it is imperative to improve the criminal
justice response to violence against women. The initiative of
Government of India asking citizens to report any incident
of domestic violence that they might have witnessed is
commendable and may go a long way to provide security
to the women.
The more fundamental need is the woman/girl’s education.
Being educated provides awareness of rights and resources,
the capability to fight exploitation and injustice. Education
will also lead to better chances of economic independence,
which is so crucial.
It is essential to develop and adopt strategies that will
improve the social status of women, remove gender
disparities, provide economic and political power, increase
awareness of their rights, and so on. Although much
depends upon the policy makers and planners, but women
must also learn to speak for themselves. Women must act
as social activists to fight against the social evils, which
are responsible for their woes. Women’s anti‑alcohol
movement in Andhra Pradesh where they destroyed
the liquor shops to fight drunkenness of their husbands
is a historical landmark. Similar movements to fight
prostitution, sexual abuse, and domestic violence could be
historical leading steps.
In summary, concerted efforts at social, political, economic,
and legal levels can bring change in the lives of Indian
women and contribute to the improvement of the mental
health of these women.
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To review the evidence about the prevalence and determinants of non-psychotic common perinatal mental disorders (CPMDs) in World Bank categorized low- and lower-middle-income countries. Major databases were searched systematically for English-language publications on the prevalence of non-psychotic CPMDs and on their risk factors and determinants. All study designs were included. Thirteen papers covering 17 low- and lower-middle-income countries provided findings for pregnant women, and 34, for women who had just given birth. Data on disorders in the antenatal period were available for 9 (8%) countries, and on disorders in the postnatal period, for 17 (15%). Weighted mean prevalence was 15.6% (95% confidence interval, CI: 15.4-15.9) antenatally and 19.8% (19.5-20.0) postnatally. Risk factors were: socioeconomic disadvantage (odds ratio [OR] range: 2.1-13.2); unintended pregnancy (1.6-8.8); being younger (2.1-5.4); being unmarried (3.4-5.8); lacking intimate partner empathy and support (2.0-9.4); having hostile in-laws (2.1-4.4); experiencing intimate partner violence (2.11-6.75); having insufficient emotional and practical support (2.8-6.1); in some settings, giving birth to a female (1.8-2.6), and having a history of mental health problems (5.1-5.6). Protective factors were: having more education (relative risk: 0.5; P = 0.03); having a permanent job (OR: 0.64; 95% CI: 0.4-1.0); being of the ethnic majority (OR: 0.2; 95% CI: 0.1-0.8) and having a kind, trustworthy intimate partner (OR: 0.52; 95% CI: 0.3-0.9). CPMDs are more prevalent in low- and lower-middle-income countries, particularly among poorer women with gender-based risks or a psychiatric history.
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Epidemiological studies of categorical mental disorders consistently report that gender differences exist in many disorder prevalence rates and that disorders are often comorbid. Can a dimensional multivariate liability model be developed to clarify how gender impacts diverse, comorbid mental disorders? We pursued this possibility in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; N = 43,093). Gender differences in prevalence were systematic such that women showed higher rates of mood and anxiety disorders, and men showed higher rates of antisocial personality and substance use disorders. We next investigated patterns of disorder comorbidity and found that a dimensional internalizing-externalizing liability model fit the data well, where internalizing is characterized by mood and anxiety disorders, and externalizing is characterized by antisocial personality and substance use disorders. This model was gender invariant, indicating that observed gender differences in prevalence rates originate from women and men's different average standings on latent internalizing and externalizing liability dimensions. As hypothesized, women showed a higher mean level of internalizing, while men showed a higher mean level of externalizing. We discuss implications of these findings for understanding gender differences in psychopathology and for classification and intervention.
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There are few population-based studies from low- and middle-income countries that have described the association of socio-economic, gender and health factors with common mental disorders (CMDs) in rural women. Population-based study of currently married rural women in the age group of 15-39 years. The baseline data are from the National Family Health Survey-II conducted in 1998. A follow-up study was conducted 4 years later in 2002-03. The outcome of CMD was assessed using the 12-item General Health Questionnaire (GHQ-12). Due to the hierarchical nature and complex survey design, data were analysed using mixed-effect logistic regression with random intercept model. A total of 5703 women (representing 83.5% of eligible women) completed follow-up. The outcome of CMD was observed in 609 women (10.7%, 95% confidence interval 9.8-11.6). The following factors were independently associated with the outcome of CMD in the final multivariable model: higher age, low education, low standard of living, recent intimate partner violence (IPV), husband's unsatisfactory reaction to dowry, husband's alcohol use and women's own tobacco use. Socio-economic and gender disadvantage factors are independently associated with CMDs in this population of women. Strategies that address structural determinants, for example to promote women's education and reduce their exposure to IPV, may reduce the burden of CMDs in women.
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OBJECTIVE: To review the evidence about the prevalence and determinants of non-psychotic common perinatal mental disorders (CPMDs) in World Bank categorized low- and lower-middle-income countries. METHODS: Major databases were searched systematically for English-language publications on the prevalence of non-psychotic CPMDs and on their risk factors and determinants. All study designs were included. FINDINGS: Thirteen papers covering 17 low- and lower-middle-income countries provided findings for pregnant women, and 34, for women who had just given birth. Data on disorders in the antenatal period were available for 9 (8%) countries, and on disorders in the postnatal period, for 17 (15%). Weighted mean prevalence was 15.6% (95% confidence interval, CI: 15.4-15.9) antenatally and 19.8% (19.5-20.0) postnatally. Risk factors were: socioeconomic disadvantage (odds ratio [OR] range: 2.1-13.2); unintended pregnancy (1.6-8.8); being younger (2.1-5.4); being unmarried (3.4-5.8); lacking intimate partner empathy and support (2.0-9.4); having hostile in-laws (2.1-4.4); experiencing intimate partner violence (2.11-6.75); having insufficient emotional and practical support (2.8-6.1); in some settings, giving birth to a female (1.8-2.6), and having a history of mental health problems (5.1-5.6). Protective factors were: having more education (relative risk: 0.5; P = 0.03); having a permanent job (OR: 0.64; 95% CI: 0.4-1.0); being of the ethnic majority (OR: 0.2; 95% CI: 0.1-0.8) and having a kind, trustworthy intimate partner (OR: 0.52; 95% CI: 0.3-0.9). CONCLUSION: CPMDs are more prevalent in low- and lower-middle-income countries, particularly among poorer women with gender-based risks or a psychiatric history.
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The relationship between partner alcohol use and violence as risk factors for poor mental health in women is unclear. To describe partner-related and other psychosocial risk factors for common mental disorders in women and examine interrelationships between these factors. Data are reported on 821 women aged 18-49 years from a larger population study in north Goa, India. Logistic regression models evaluated the risks for women's common mental disorders and tested for mediation effects in the relationship between partner alcohol use and these disorders. Excessive partner alcohol use increased the risk for common mental disorders two- to threefold. Partner violence and alcohol-related problems each partially mediated the association between partner excessive alcohol use and these mental disorders. Women's own violence-related attitudes were also independently associated with them. Partner alcohol use, partner violence and women's violence-related attitudes must be addressed to prevent and treat common mental disorders in women.
Conference Paper
Research from the west indicates that women living with a psychiatric disorder are particularly vulnerable to sexual coercion and abuse. However, there have been no published reports of sexual abuse among female psychiatric patients in India. This exploratory study sought (1) to determine the prevalence of sexual coercion in a representative sample of female psychiatric patients in India; (2) to identify clinical and sociodemographic correlates of sexual coercion; (3) to clarify the association between sexual coercion and human immunodeficiency virus (HIV)-related risk behavior ; and (4) to determine whether self-report of sexual coercion from these patients was recorded in their medical charts. Consecutive female inpatient admissions (N 146) to a large psychiatric hospital in southern India were assessed using a structured interview and standardized measures. During these structured clinical interviews, sexual coercion was reported by 30% of the 146 women. The most commonly reported experience was sexual intercourse involving threatened or actual physical force (reported by 14% of women), and the most commonly identified perpetrator was the woman's husband or intimate partner (15%), or a person in a position of authority in their community (10%). Women with a history of abuse were more likely to report HIV-related sexual behavior (P < .001). In contrast to the 30% of women who reported sexual coercion during interviews, only 3.5% of the medical records contained this information. Thus, sexual coercion is a serious and prevalent concern among female Indian psychiatric patients, but is rarely reported in medical charts. Increased screening and reporting are indicated, as are sexual abuse prevention and treatment programs.
Article
Background Community-based epidemiological data on post-partum depression from developing countries are scarce. Aims To determine the incidence of and risk factors for developing post-partum depression in a cohort of women living in rural south India. Method We assessed 359 women in the last trimester of pregnancy and 6-12 weeks after delivery for depression and for putative risk factors. Results The incidence of post-partum depression was 11% (95% CI 7.1-14.9). Low income, birth of a daughter when a son was desired, relationship difficulties with mother-in-law and parents, adverse life events during pregnancy and lack of physical help were risk factors for the onset of post-partum depression. Conclusions Depression occurred as frequently during late pregnancy and after delivery as in developed countries, but there were cultural differences in risk factors. These findings have implications for policies regarding maternal and childcare programmes.