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Studies on affective disorders in rural Ethiopia
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

Affective disorders are poorly defined and studied in sub-Saharan Africa despite their substantial public health impact.

Objectives

Overall objective: To describe the epidemiology of selected affective disorders in rural Ethiopia.

Specific objectives

1. To describe the validity and utility of the concept of minor depressive disorder (mD).

2. To describe the manifestation, prevalence and the short-term clinical and functional course and outcome of bipolar disorder.

Subjects and methods

Population: Zay community residents (age ≥16), and residents of Butajira (ages 15-49), in Southern Ethiopia.

Study design: Population-based cross-sectional and longitudinal studies

Case identification: For the identification of cases with bipolar disorder, a two stage process was employed. An initial screen used key informants and interview with the Composite International Diagnostic Interview (CIDI) to identify cases with probable bipolar disorder. A second confirmatory diagnostic assessment stage employed the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). For the identification of cases with mD, data from the CIDI was used.

Follow-up: 312 cases with bipolar disorder from Butajira were followed up for a mean of 2.5 years (ranging 1-4 years) through monthly clinical assessments and annual symptom and functional ratings.

Results

The CIDI was administered to 1714 adults among the Zay and to 68, 378 adults among the Butajira residents. The prevalence of mD among the Zay and Butajira was 20.5% and 2.2% respectively. Up to 80% of cases with mD had used services for their symptoms, while a third to a half of cases had thought about self harm. Up to a sixth of cases had attempted suicide. Age, marital status, education and somatic symptoms were independently associated with mD.

The prevalence of bipolar disorder among the Zay was 1.8%. During a 2.5-year follow-up of 312 cases with bipolar disorder from Butajira, 65.9% relapsed (47.8% manic, 44.3% depressive and 7.7% mixed episodes) while 31.1% experienced persistent illness. Female gender predicted depressive relapse whereas male gender predicted manic relapse. Only being on psychotropic medication predicted remission (OR=3.42; 95% CI=1.82, 6.45). Disability was much worse among bipolar patients than in the general population and was predicted by symptom se3verity.

Conclusions

This is the largest study on mD and bipolar disorder in Africa. mD appears to have potential clinical utility in this setting given its association with service use and risk. The identified risk factors for mD also suggest potential aetiological continuity with major depression. The relatively high prevalence of bipolar disorder among the Zay may be related to genetic predisposition perhaps mediated through a founder effect, but other factors need exploring. In relation to the outcome of bipolar disorder, this study indicates that, contrary to previous assumptions, the course of bipolar disorder is characterised by both manic and depressive relapses in a relatively proportionate fashion. Bipolar disorder also leads to significant levels of disability. This is the only prospective outcome study of bipolar disorder in Africa where cases were monitored systematically at short assessment intervals. Therefore, findings are likely to be more robust than previous reports.

Place, publisher, year, edition, pages
Umeå: Umeå University , 2010. , 79 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1381
Keyword [en]
bipolar disorder, depressive disorder, affective disorder, mood disorder, prevalence, outcome, cross-sectional study, prospective study, longitudinal study, isolated population, Ethiopia, Africa, developing countries
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
URN: urn:nbn:se:umu:diva-37813ISBN: 978-91-7459-103-3 (print)OAI: oai:DiVA.org:umu-37813DiVA: diva2:370159
Public defence
2010-12-08, Sal A, våning 0, Psykiatriska kliniken, Umeå, 14:05 (English)
Opponent
Supervisors
Available from: 2010-11-18 Created: 2010-11-15 Last updated: 2010-11-18Bibliographically approved
List of papers
1. Validity of the concept of minor depression in a developing country setting
Open this publication in new window or tab >>Validity of the concept of minor depression in a developing country setting
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2008 (English)In: Journal of Nervous and Mental Disease, ISSN 0022-3018, E-ISSN 1539-736X, Vol. 196, no 1, 22-28 p.Article in journal (Refereed) Published
Abstract [en]

Evidence for validity of the diagnostic construct of minor depressive disorder comes primarily from reports on subthreshold depressive states rather than minor depressive disorder per se. We report on the prevalence, impact, and sociodemographic correlates of minor depressive disorder in a developing country setting as further validation of this diagnostic construct. Diagnostic assessment of 1714 adults of an island population in Ethiopia was carried out using the Composite International Diagnostic Interview. The lifetime prevalence of minor depressive disorder was 20.5% (95% confidence interval 18.6, 22.5%). One-third of cases had sought help and expressed suicidal ideation. Being divorced/widowed, middle-aged, and having somatic pain were independently associated with having minor depressive disorder. Only being divorced/widowed was a shared risk factor for both minor depressive disorder and bereavement. Minor depressive disorder seems to be a useful and valid diagnostic construct with particular clinical significance in this and, possibly, similar developing country settings.

Keyword
Depression, prevalence, risk factor, developing country, Ethiopia
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:umu:diva-37804 (URN)10.1097/NMD.0b013e31815fa4d4 (DOI)18195638 (PubMedID)
Available from: 2010-11-15 Created: 2010-11-15 Last updated: 2017-12-12Bibliographically approved
2. Utility of the concept of minor depressive disorder: evidence from a large rural community sample in a developing country setting
Open this publication in new window or tab >>Utility of the concept of minor depressive disorder: evidence from a large rural community sample in a developing country setting
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2007 (English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 104, no 1-3, 111-118 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Evidence on the utility of the minor depressive disorder diagnostic construct in rural communities and developing countries is scarce. AIM: To assess the utility and validity of definitive minor depressive disorder in Ethiopia by determining its impact and sociodemographic correlates.

METHODS: Assessment of 68,378 adults, aged 15-49 years, living in a largely rural district in Ethiopia using the Composite International Diagnostic Interview.

RESULTS: The lifetime prevalence of minor depressive disorder was 2.2% (95% CI=2.1%, 2.3%). Age, marital status, education and unemployment independently predicted minor depressive disorder. Over 80% of cases used health services, 55.1% experienced persistent thoughts of death and 14.6% attempted suicide.

LIMITATION: Findings are based on lifetime estimates.

CONCLUSIONS: Minor depressive disorder is an important public health problem in rural Ethiopia, as shown by the associated high health service use and risk behaviour. Sociodemographic correlates suggest aetiological continuity with major depression. Thus our findings extend the clinical and public health utility of this diagnostic construct to rural community and developing country settings.

Keyword
Depression; Prevalence; Epidemiology; Developing country
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:umu:diva-37805 (URN)10.1016/j.jad.2007.03.008 (DOI)17448542 (PubMedID)
Available from: 2010-11-15 Created: 2010-11-15 Last updated: 2017-12-12Bibliographically approved
3. Bipolar disorder among an isolated island community in Ethiopia
Open this publication in new window or tab >>Bipolar disorder among an isolated island community in Ethiopia
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2004 (English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 80, no 1, 1-10 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Psychiatric data on population groups of geographic and social isolates are rare, but can potentially give insights into factors of aetiological importance. The Zeway islanders have lived in geographic and cultural isolation for over three centuries.

AIM: To determine the prevalence of major psychiatric disorders among the adult population of Zeway islands.

METHODS: A three stage screening design that included the use of structured interview instruments (CIDI and SCAN), key informants, and clinical assessment by psychiatrists was employed for case identification.

RESULTS: Prevalence of bipolar disorders among the adult population (n = 1691) was 1.83% (n = 31) with 66% of the cases originating from one of the islands that constitutes only 17.33% of the study population. Only one subject was identified with schizophrenia.

CONCLUSIONS: A pattern of differential prevalence for bipolar disorders and schizophrenia appears to exist in this isolated population, which also seems shared by other isolated population groups. The high prevalence of bipolar disorders with clustering of cases on one island may represent an environmental or genetic factor of etiologic relevance that deserves further exploration.

Keyword
Bipolar; Isolated; Island; Prevalence
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:umu:diva-37807 (URN)10.1016/S0165-0327(02)00345-2 (DOI)15094252 (PubMedID)
Available from: 2010-11-15 Created: 2010-11-15 Last updated: 2017-12-12Bibliographically approved
4. Clinical outcome in bipolar disorder in a community-based follow-up study in Butajira, Ethiopia
Open this publication in new window or tab >>Clinical outcome in bipolar disorder in a community-based follow-up study in Butajira, Ethiopia
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2006 (English)In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 114, no 6, 426-434 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To determine the clinical outcome of bipolar disorder in a developing country setup.

Method: After assessing 68 378 individuals, aged 15–49 years, in a double-sampling design in a rural community in Ethiopia, 312 patients with bipolar disorder were prospectively monitored with symptom rating scales and clinically for an average of 2.5 years.

Results: Overall, 65.9% of the cohort experienced a relapse – 47.8% manic, 44.3% depressive and 7.7% mixed episodes – and 31.1% had persistent illness. Female gender predicted depressive relapse, while male gender predicted manic relapse. Being on psychotropic medication was associated with remission.

Conclusion: This large community-based study confirms the relapsing nature of bipolar disorder and a tendency for chronicity. This may be partly because of lack of appropriate interventions in this setting; however, it may also indicate the underlying severity of the disorder irrespective of setting.

Keyword
antipsychotics, bipolar disorder, developing country, remission
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:umu:diva-21747 (URN)10.1111/j.1600-0447.2006.00825.x (DOI)
Available from: 2009-04-20 Created: 2009-04-20 Last updated: 2017-12-13Bibliographically approved
5. Symptomatic and functional outcome of bipolar disorder in Butajira, Ethiopia
Open this publication in new window or tab >>Symptomatic and functional outcome of bipolar disorder in Butajira, Ethiopia
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2006 (English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 90, no 2-3, 239-249 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Limited information is available on the outcome of bipolar disorder in developing countries.

OBJECTIVE: To describe the symptomatic and functional outcome of bipolar disorder.

METHODS: The psychoses and affective disorder modules of the CIDI were used to screen 68,378 individuals by a door-to-door survey of a defined district in Ethiopia. In addition, key informants were used to identify individuals with probable major mental illnesses. SCAN interviews were completed at the second stage to confirm the diagnosis. A total of 315 cases of bipolar disorder were identified, of which 264 (69 recent-onset and 195 prevalent cases) were prospectively followed for a mean of 2.5 (range 1-4) years by baseline and annual clinical assessments using symptom rating scales. Functional dimensions of the SF-36 scale were used to describe functional outcome. Random coefficient analyses were used to evaluate potential correlates of outcome.

RESULTS: The magnitudes of mania and depression symptoms were elevated at baseline but improved with follow-up, although the improvement was less marked for depression. Sociodemographic or clinical variables were not associated with the improvements in symptomatic outcome. Between 35% and 47% of the recent-onset cases had functional role restrictions, while 42-52% of long-standing cases had such restrictions during the follow-up years. Similarly, social and physical functioning deficits were also present in 52-86% and 35-47% of recent-onset and long-standing cases, respectively. The magnitude of depression and mania symptoms was associated with poor functional outcome, while male sex, rural residence and being married were associated with better functional outcome.

CONCLUSION: Although there were improvements in function with follow-up, between one-third and one-half of cases continued to have functional deficits.

Keyword
Bipolar disorder; Outcome; Ethiopia
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:umu:diva-37808 (URN)10.1016/j.jad.2005.11.009 (DOI)16376431 (PubMedID)
Available from: 2010-11-15 Created: 2010-11-15 Last updated: 2017-12-12Bibliographically approved

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