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Anxiety and Depression in Women in India

Dr. Pratap Sharan
Medical Officer, Mental Health: Evidence and Research, Department of Mental Health and Substance Dependence, World Health Organization.

Dr. Sachin Rai
Resident, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Address for Correspondence:
Mental Health: Evidence and Research
Department of Mental Health and Substance Dependence
World Health Organization
CH-1211, Geneva, Switzerland
E-mail: sharanp@who.int
Phone 41 22 7912646
Fax 41 22 7914160

Introduction:

Anxiety and depressive disorders are among the most common psychiatric disorders in the community. Both disorders are more common in women according to literature available from developed countries (Fichter et al, 1996). In this report we will evaluate whether such a trend is also seen in India, and if it is, what could be the possible factors behind it.

Before evaluating prevalence figures for a given disorder, it may be necessary to establish that the referents for the disorder are similar to the prototype across cultures as it was widely believed earlier that depression was less common in non- western cultures. In an Indian sample comprising nearly equally of men and women, Gupta et al (1991), found that sadness of mood, anxiety or tension, joylessness, lack of energy, social functioning, irritability, loss of ability to concentrate and lack of appetite were the most common symptoms reported. Additionally, 81% subjects had somatic symptoms, 36% had feelings of guilt, 47% had suicidal ideas and 2%-5% have depressive delusions. Chaturvedi et al (1985) examined negative symptoms in depression. Most common negative symptoms reported were inability to enjoy recreational activities/interests, anhedonia, and inability to enjoy sex or form friendships, and lack of physical energy. These studies suggest that the depressive syndrome described in India is similar to that described in ICD-10 and DSM-IV. However, as in other developing countries, somatic symptoms are more common and cognitive symptoms less common in Indian samples in comparison to those in developed countries (Bhattacharya and Vyas, 1969;Gada, 1982).

Prevalence of anxiety and depression in Indian women:

In a meta-analysis of 13 general population epidemiological surveys that covered a total of 6550 families with 33572 persons and used common methodological parameters (face to face interviews with each subject, coverage of all age groups, availability of separate prevalence reports for rural and urban sector and for males and females) done in the period between 1967 and 1995 in India, Reddy and Chandrasekar (1998) found that anxiety and depressive disorders were significantly more common in women. The prevalence per thousand population in males and females were as follows: manic depressive psychosis - depressed 5.6:12.3 (p<.01), neurotic depression 1.2:5.2 (p<.01), anxiety neurosis 3.2:8.4 (p<0.01), phobic neurosis 2.4:6.0 (p<0.01) and obsessive compulsive neurosis 1.7:4.6 (p<0.01).

Perhaps the most robust study regarding prevalence of a broad group of psychiatric disorders in a community sample in India till date was carried out by Premarajan et al (1993). They employed a two stage method for data collection. The Indian Psychiatric Survey Schedule (Kapur and Carstairs, 1974) was used for screening subjects and Present State Examination-9 (World Health Organization, 1974) was applied to establish diagnosis in those who screened positive. The point prevalence of depressive neurosis, anxiety neurosis and manic depressive psychosis - depression as per the ICD - 9 (World Health Organization, 1978) was reported to be 6.2%, 2.9% and 3.6%, respectively. Given the differences in methodology and diagnostic systems, the prevalence of depressive disorders in Indian women appear to be similar to that in women in developed countries like the United States of America and Germany (Fichter et al 1996). It would appear that anxiety is less common in India in comparison to the United States of America. But this is a mere artefact of Classificatory Systems used for diagnosing psychiatric disorders. Indian studies had employed ICD -8 (World Health Organization, 1974) or ICD -9 (World Health Organization, 1978), both of which have a hierarchical structure that rules out anxiety disorders in the presence of depressive disorders. The US studies employed the DSM - III (American Psychiatric Association, 1980) and the DSM - III - R (American Psychiatric Association, 1987), which have done away with hierarchical arrangements and allow for co-morbid occurrence of anxiety and depressive disorders. Creed et al (1999) compared depressive and anxiety disorders in sibling pairs of ethnic Indians in UK and those in India. Both in UK and India, the sibling pairs had equivalent prevalence of depression and anxiety though women in India reported the presence of significantly more stressors (42% of the sibs in India versus 30% of the sibs in UK) and more severe stressors (death of a relative, financial problems, and illness in relatives of the sibs in India versus unemployment and financial problems of the sibs in UK). It is likely that the greater prevalence of stressors was balanced by greater social support available to women in India. A WHO study on epidemiology that is currently in progress across 10 centres in India will provide general population prevalence estimates obtained through the application of similar methodology and diagnostic systems as in the developed countries.

In a landmark study, Nandi et al (2000) carried out a 20 year follow up of a rural sample that they had first examined in 1972. The diagnoses were made by consensus of two psychiatrists as per the ICD - 8 (World Health Organization, 1974). The authors found that the prevalence of anxiety had increased from 1.1% to 2.2%, while the prevalence of depression had increased from 5.0% to 7.4%. In particular, the authors noted that the reporting of depressive symptoms and feelings of guilt had increased. At both cross-sections women were found to have a greater prevalence of depression and anxiety in comparison to men. Those in the upper classes reported more psychological morbidity. Whether we observe the trend in studies across the decades or we examine the findings of the study by Nandi et al (2000), it is clear that the prevalence of depression is increasing over the years. However, whether the increase is in the true prevalence of depression or an increase in reporting of the same due to greater awareness and lesser stigma attached to common mental disorders is a question that cannot be answered easily.

In another study, Nandi et al (1997) brought out the piquant situation of rural elderly women in India. Seventy percent of them had depression, while 2% has anxiety disorders. High rate of morbidity was seen among the widows. Stressful factors like isolation and low socioeconomic status are closely associated with widowhood. Widowhood has been associated with depression in other studies done in India (Singh et al, 1979).

Possible reasons for higher prevalence of depression and anxiety in women in India:

Nandi et al (1977, 1980) reported that women from an urban background were the worst affected in terms of depression. They observed that officers and Brahmins had similar psychosocial perspectives and followed a rigid, formal, codified value system with a preoccupation of having a secure future. Santhals, on the other hand had less social stratification and were less preoccupied with the future. The authors suggested that the feeling of insecurity led to high stress and neurosis.

Mumford et al (1997) carried out an epidemiological study on anxiety and depression in rural Punjab and Pakistan, a setting that is very similar to the Indian setting. They found that the prevalence rate of anxiety and depression was higher in women and that the rate of these disorders in women increased steadily with age [from 18 to 50 years]. Married women in unitary families had higher levels of emotional distress than those in extended or joint families, whereas single women fared better in unitary families and worse in extended families. Subjects with lower education and lower socio-economic status had greater psychiatric morbidity. For women, practical domestic matters were particularly important.

Discussion:

The fact that depressive disorders are more common in women in comparison with men in India seems to be incontrovertible, despite some discrepancy in the earliest study, in which however, the authors noted the limitations of their estimates. The findings with regard to anxiety is less clear, but this lack of clarity can safely be attributed to the use of hierarchical classificatory systems in the available epidemiological studies as these systems precluded the diagnosis of anxiety in the presence of depressive disorders.

The possible risk factors for higher prevalence of depression and anxiety in women in India include age (Mumford et al, 1997, Nandi et al, 1997), socio-economic status and education {however the findings in this regard are contradictory, see for example Nandi et al (1980) and Mumford et al (1997)}, marriage and widowhood (Mumford et al, 1997, Nandi et al, 1997), and family support (Mumford et al, 1997).

Among psychological issues, Nandi et al (1980) highlighted issues related to future and career in urban/employed women, while Mumford et al (1997) highlighted issues related to practical domestic matters in rural women. The conclusions reflect the preoccupations of the sample that these authors evaluated.

The understanding of gender difference in common mental disorders in India is obviously in an early stage. Biological/genetic influences have not been evaluated and much remains to be done regarding psychosocial determinants. Some of the issues regarding the latter may be unique to the Indian subcontinent, like the complexity of relationships in a joint family and that of a daughter-in-law and mother-in-law. Marriage probably means something very different to Indian women as compared to western women.

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Published: 20 February 2009

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