Tehran University of Medical Sciences, Tehran, Iran
Mental Health Unit, Ministry of Health and Medical Education, Tehran, Iran
Shahid Beheshti University of Medical Sciences, Tehran, Iran
Epidemiology and Biostatistics Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
Correspondence: Dr A. A. Noorbala, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, South Kargar Avenue, Tehran, Iran. E-mail: noorbala{at}irrcs.org
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To determine the mental health status of a population sample aged 15 years and over.
Method Through random cluster sampling, 35 014 individuals were selected and evaluated using the 28-item version of the General Health Questionnaire. A complementary semi-structured clinical interview was also undertaken to detect learning disability (mental retardation), epilepsy and psychosis.
Results About a fifth of the people in the study (25.9% of the women and 14.9% of the men) were detected as likely cases. The prevalence of mental disorders was 21.3% in rural areas and 20.9% in urban areas. Depression and anxiety symptoms were more prevalent than somatisation and social dysfunction. The interview of families by general practitioners revealed that the rates of learning disability, epilepsy and psychosis were 1.4%, 1.2% and 0.6%, respectively. Prevalence increased with age and was higher in the married, widowed, divorced, unemployed and retired people.
Conclusions Prevalence rates are comparable with international studies. There is a wide regional difference in the country, and women are at greater risk.
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INTRODUCTION |
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METHOD |
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Sample
Cluster sampling was conducted, with each cluster comprising eight
households. The choice of cluster size was based on the daily performance
capacity of the data collection group. The statistical framework was based on
the household lists available from every health department in the provinces.
The ratio of sample size to the total number of households was taken as 1:1000
(13 478 households through 1681 clusters). In total, 35 014 persons (22 564
from urban areas and 12 450 from rural areas) in the age group 15 years and
above were studied.
Measures
The 28-item General Health Questionnaire (GHQ28) was used as a
screening tool for the detection of mental disorders. This questionnaire was
developed by Goldberg & Hillier
(1979) for screening for
somatic symptoms, anxiety and insomnia, social dysfunction and severe
depression. A review of studies on the validation of the GHQ28 in
different countries demonstrates its high validity and reliability as a
screening tool of mental disorders in the community. This questionnaire was
translated into the official language of Iran (Persian), which is
comprehensible to almost every Iranian, and its validity and reliability were
approved in an independent study (Noorbala
et al, 1999). The best cutoff point, determined using the
conventional scoring method and the minimum overall misclassification rate,
was 6: that is, those scoring 6 and above were designated as possible cases of
mental disorder. Sensitivity, specificity and overall misclassification rate
for a GHQ28 cut-off score of 6 were 84.7%, 93.8% and 8.2%,
respectively. The reliability of the GHQ28 was assessed on a sample of
90 participants retested 1 week after the initial referral. The estimated
intraclass correlation between the testretest scores was 0.85
(Noorbala et al,
1999). To detect psychosis, epilepsy and learning disability
(mental retardation), a simple semi-structured clinical
interview with its limited validity and reliability was used.
Collection of data
This survey was implemented as a part of the National Health Survey in
Iran. In each province, specially trained general practitioners from the
provincial health centres visited the selected households and completed the
GHQ28 for the age group 15 years and above. Detection of cases of
psychosis, epilepsy and learning disability was based on semi-structured
clinical interviews by the general practitioners, and on available medical and
paramedical records.
Statistical methods
Data relating to the survey were analysed using the Statistical Package for
the Social Sciences, version 8.0 for Windows. Logistic regression modelling
was used to determine the factors that affect mental disorders. Mental
disorders were considered as dependent variables and gender, age, education,
occupation and marital status were considered as independent variables. Using
the logistic regression model, the odds ratios, their level of significance
and standard deviation were calculated. Backward logistic regression
(Pe=0.15 and Pr=0.2) was also used
(Hosmer & Lemshow,
1989).
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RESULTS |
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According to the clinical interviews by general practitioners of household members, 1.4% had evident learning disability, 1.2% had epilepsy and 0.6% had psychotic disorders. It also shows that 21% of the sample experienced depressive symptoms, 20.8% anxiety symptoms, 17.9% somatic symptoms and 14.2% social dysfunction symptoms.
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DISCUSSION |
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Comparing the results with Western studies, the prevalence rate obtained in this survey is higher than rates in surveys conducted by Hoeper et al (1979), Hodiamont et al (1987) and Fones et al (1998), but lower than those obtained by Kessler et al (1994) and Lee et al (1990). It is approximately similar to prevalence rates found by Stansfeld & Marmot (1992) and Roca et al (1999). The findings further show that the maximum rates of positive responses to questions on the GHQ28 were for headache, distress, insomnia, sorrow and disappointment, confirming findings of other studies conducted in Iran. Anxiety and depressive symptoms were common, which is comparable with results of similar surveys in Iran and in other studies reported by Kaplan & Sadock (2000).
Gender distribution
The study found higher prevalence rates of mental disorder in women than in
men (25.9% v. 14.9%), compatible with results of other surveys in
Iran and those conducted in other countries. Gender and marital roles can be
considered as possible explanations for the higher rates. The majority of
women are bound to their social roles as housewives; even when women work
outside the home, they still have the burden of housework. Hence, the latter
group should be more subject to strains and stress; however, our research
showed that working only within the home has a more serious impact on
psychiatric morbidity. The fact that women in Iran are more at risk of mental
disorders than is the case in Western cultures may be due to the robust effect
of biological factors or to social inconveniences experienced more by women
than by men. However, the type of such social problems may differ between
cultures. The study demonstrates higher rates in rural populations than in
city dwellers (21.3% v. 20.9%), but the difference is not
statistically significant.
Age distribution
The study revealed a significant correlation between age and the occurrence
of mental disorders. Prevalence rates increase with age, supporting the
results of Lee et al
(1990) and Hodiamont et
al (1987). This may be
explained by reduction in physical vigour and the greater vulnerability of
older people to stress as well as mental and physical diseases. This finding
is not compatible with those of similar surveys conducted in Iran showing
higher rates in people aged up to 45 years compared with those aged 45 and
above (Noorbala et al,
2001).
Stress
This study supports the results of earlier studies showing higher rates of
mental disorders among illiterate and semi-literate groups. Sociocultural
constraints in such groups posing limits to their coping styles in the face of
stress may be considered as one of the main factors. Confirming the results of
other epidemiological studies in Iran
(Noorbala et al,
1998), our surveys findings demonstrate higher prevalence
rates of mental disorder among the married: these may be due to economic and
social stress factors such as financial matters, family management and child
care. The studys findings of higher rates of mental disorder among
housewives and unemployed men also reported by Hodiamont et al
(1987), Stansfeld & Marmot
(1992), Murthy & Burns
(1992), Bahar et al
(1992) and Noorbala et
al (1998) may be
explained as the overall outcome of insufficient income, the stress of
unemployment, limited social relations and monotonous lifestyle. There is also
a possibility that mental disorders have contributed to unemployment.
Implications for health care
Our finding that about a fifth of the population surveyed in the age group
15 years and above suffers from mental disorders suggests that 1012
million persons in Iran require mental health care. Taking into consideration
the present number of Iranian psychiatrists (735) and the present number of
Iranian mental hospital beds (7850; Yasamy
et al, 2001), the need to provide appropriate staff and
facilities to render mental health care is more evident than ever.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Many thanks to Professor Goldberg for providing the original GHQ28 manual and related literature. Our appreciation goes to Dr Hosein Malekafzaly, Deputy Minister of Health and Medical Education, Research Affairs; Dr Ali Akbar Sayyari, Deputy Minister of Health and Medical Education, Health Affairs; Dr Zavaran; Dr Gouya; and the late Dr Shahmohammadi. We also thank our colleagues Dr Seyedreza Majdzadeh, Dr Seyed Mehdi Sadathashemi, Dr Masoud Karimlu, Dr Hamid Yaghoubi, Reza Mohammad Salehi and many others for their support, efforts and patience.
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Received for publication April 23, 2003. Revision received July 15, 2003. Accepted for publication July 31, 2003.