Acta psychiatr. scand. 1985:71:417-426

Key words: Psychiatric morbidity; outpatients; transcultoral psychiatry; general hospital psy- chiatry; Ethiopia.

Psychiatric morbidity and psychosocial background in an outpatient population of a general hospital in western Ethiopia

L. Jacobsson Department of Psychiatry, University of UmeA, Sweden

ABSTRACT - The psychiatric morbidity in 465 outpatients seen at a general hospital in western Ethiopia was found to be 18 %. The great majority of cases had neurotic conditions often with a somatic shading, only six were psychotic. A few were themselves aware that they were suffering from men- tal disorders. There was no tendency for the mental disorders to be correlated to somatic disorders. The psychiatric morbidity rate seemed increased in women, in younger patients and in patients with higher educational level and income.

Received July 25,1984; accepted for publication September 24, 1984

It is apparent that mental disturbances do not receive proper recognition in the medical sys- tem of clinics and hospitals operating in de- veloping countries. For example, cases of men- tal disturbances are seldom mentioned in re- ports to the Public Health Department from rural clinics in the Wollega province of western Ethiopia. There are also very few, if any, psy- chiatric cases in reports on the diagnostic panorama from various general hospitals in Ethiopia.

Giel et al. (l), however, found a psychiatric morbidity of 18 % in 200 medical outpatients in one of the general hospitals in Addis Abeba. Dormar et al. (2) found a psychiatric morbidity of 16.2 % in a Police Hospital and 6.8 % in a rural general hospital outpatient clientele, and Giel & van Luijk (3) found a psychiatric mor- bidity of 19 % in a health center clientele in a small rural Ethiopian town.

In order to contribute to the epidemiology

of mental disorders in Ethiopia, and to pro- vide evidence of the psychiatric work done in a general hospital, a survey was made of the outpatient population of a general hospital in western Ethiopia. The data could also con- tribute to the discussion on how to improve psychiatric service in this context, as the gen- eral hospital will continue to be the major psychiatric facility in developing countries for many years to come.

The town and the hospital have been de- scribed elsewhere (4).

Methods The investigation was carried out over two periods of two weeks each: 2-15 November 1962, Ethiopian calendar (July 1970: Euro- pean calendar) and 26 April- 7 May 1962, Ethiopian calendar (January 1971: European

27'

418 L. JACOBSSON

calendar). The first period was in the middle of the rainy season and the second during the dry season. During the first period all pa- tients aged 15 years or more who attended because of a new complaint were examined, 229 in all. These patients were also given Hb, ESR and stool tests. During the second period the number of patients increased to more than double, thus only every second patient was sent to the author for investiga- tion, 236 in all. Their socio-economic back- ground was recorded on a special form by one of the nurses. The author then made a detailed examination with regard to earlier and present mental disturbances. A careful somatic examination was also made using the hos- pital's excellent laboratory and X-ray facili- ties to get as close a diagnosis as possible. At the time of the first investigation period the author had had almost 1 year's experience of working at the hospital. Unfortunately, most communication with the patients took place through interpreters. These, however, were well-trained and experienced and co-operation with both them and the nurses was very good.

The patients were classified according to the bodily system to which the complaint was re- lated and according to Kessel's classification of psychiatric morbidity (5).

Only the main complaint or disorder which the author considered to be the major one was registered, although one patient often had several different complaints and disorders. Almost 75 % of the patients, for example, had intestinal parasites which often they did not consider worth treating. The disorders were registered according to the organ involved, for example, malaria was registered under diseases of the blood, pneumonia under respiratory system, headache under nervous system, etc. Special note was made of in- fectious diseases as they are of a particular interest in developing countries.

The psychiatric morbidity according to Kes- sel has been used earlier in the same kind of investigations in Ethiopia by Giel and co- workers (1-3, 6). The patients are classified in four groups according to the following criteria:

I.

11.

111.

IV.

Patients complaining of explicit psycho- logical problems such as being nervous, depressed, having feelings of anxiety, etc. Patients complaining of somatic symptoms not adequately explained after physical ex- amination and laboratory tests as somatic disorders, for example, burning sensations in the body, abdominal feelings of cramp and discomfort, shortness of breath, diz- ziness, etc. Patients with indisputable somatic dis- orders but in one way or another abnor- mal psychic reactions to these. Personality disorders with no direct rela- tion to the current disease.

This original model was modified so that Group I also included patients whose com- plaints the author considered mainly mental, but who were themselves unaware of the rela- tion between somatic and mental disturbances. Patients belonging to these four groups (I-IV) are here defined as displaying Psychiatric Mor- bidity.

Socio-economic background 188 of the 465 patients were from Nakamte town and most of the others lived within 50 km of Nakamte.

Fig. I. Wollega province.

PSYCHIATRIC MORBIDITY IN WESTERN ETHIOPIA 419

Table 1 Age and sex distribution and psychiatric morbidity (PM)

Males Females Total Age range N PM % N PM % N PM %

~~ ~~~~~~ ~

15-29 118 22.9 109 26.6 227 24.7 30-49 82 11.0 86 17.4 168 14.3

50 47 6.4 23 8.7 70 7.1

Total 247 15.8 21 8 21.1 465 18.3

Table 2 Ethnic group and psychiatric morbidity (PM)

Males Females Total Tribe N PM 70 N PM % N PM %

Galla 191 15.2 162 16.8 353 15.9 Amhara 37 16.2 45 33.3 82 25.6 Others:

Tigrae, Gurage, Arab 19 21.1 11 36.4 30 26.7

Total 247 15.8 218 21.1 465 18.3

Table 3 Religion and psychiatric morbidity (PM)

~ ~~

Religion

~ ~~~~~

Males Females Total N PM % N PM % N PM %

Christian: Coptic Orthodox 203 13.3 178 20.2 381 16.5 Evangelic 26 38.5 15 26.7 41 34.1 Roman Catholic 1

Muslim 13 15.4 25 20.0 38 18.4 Animists, others 4 25.0 - - 4 25.0

- 1 - - -

Total 247 15.8 218 21.1 465 18.3

Age and sex distribution is shown in Table 1. These data are only approximate because most people only knew their age to within 5 years. Relatively more men than women attended the clinic. The ratio of medwomen at OPD was 1:13 compared with that in Wollega pro- vince 0:92 (7). The age group 15-29 years was overrepresented in relation t o the total population of Wollega. The ethnic distribu- tion is shown in Table 2. The Gallas make up the majority while the Amharas are a rather large minority consisting of people who have moved in from other parts of

Ethiopia. These people are mainly officials. The Tigraes are usually well-educated people in government service working as teachers, etc. The Gurages and the Arabs are usually traders.

Most of the patients stated that they were Coptic Christians (Table 3). Evangelical Chris- tians made up a relatively small group con- sidering that there is a rather large Evangelical church in the town and that the hospital was run by the Evangelical mission. There were few “animists” as, among other things, the traditional Galla religion has a low status compared to the Coptic confession, which

420 L. JACOBSSON

Table 4 Civil status and psychiatric morbidity (PM)

Males Females Total Status N PM % N PM % N PM %

Single 78 21.8 29 48.3 107 30.0 Married 161 12.4 168 15.5 329 14.0 Divorced 6 - 11 36.4 17 23.5 Widowed 2 100.0 10 20.0 12 33.3

Total 247 15.8 218 21.1 465 18.3

Table 5 Education and psychiatric morbidity (PM)

Education Males Females Total N PM % N PM % N PM %

None 113 6.2 178 17.4 291 13.1 Elementary school

grade 1-6 64 10.9 24 37.5 88 18.2 Sec. school - high

school grade 7-12 53 43.4 11 36.4 64 42.2 Religous school -

Arab school 17 11.8 5 40.0 22 18.2

Total 247 15.8 218 21.1 465 18.3

Table 6 Profession and psychiatric morbidity (PM)

Total

Farmers, cultivators 183 Housewives 90 Students 31 Teachers, higher officials and technicians 29 Lesser office employees, police, drivers, etc. 67 Daily workers, servants, bar girls, tedj-sellers, etc. 65

Psychiatric morbidity

%

8.7 27.8 35.5 31.0 7.5

29.2

Total 465 18.3

dominates. Many reported that they belonged to the Coptic church whilst in practice they were still animists.

Civil status is shown in Table 4. According to official statistics (7) 55 % of the total pop- ulation is single, 30 % married, 4.1 % widowed and only 1.5 % divorced. (The number of sin- gle persons is slightly higher than the number of people under 20 years of age). The fre- quency of divorce is high and it is not un-

common for a person to have been married two or three times. In a survey of a rural village near Nakamte (8) 31 % of all those who had ever been married had also been divorced one or more times.

The level of education is shown in Table 5. More than 60 % were illiterate, which is a low figure compared with the figures for the pro- vince as a whole where 94 % of the popula- tion over 10 years of age is illiterate. As well

PSYCHIATRIC MORBIDITY IN WESTERN ETHIOPIA 421

Table 7 Categories of disorders and psychiatric morbidity

Total No. Infectious Psychiatric Diagnosis of patients disorders morbidity

1. Mental, psychoneurotic personality disorders 24 - 24 2. Blood and lymphatic system 26 25 - 3. Nervous system 16 2 5 4. Eyes 13 6 5 5. Ears 9 6 -

1 6. Circulatory system 6 7. Respiratory system 56 46 3 8. Gastro-intestinal system 123 41 36 9. Genito-urinary system 85 35 6

10. Skin and cellular tissue 36 24 - 11. Bones and organs of movement 20 2 2 12. Endocrine systsm 4

5 13. Ill-defined 15 - 14. General infections: typhoid, smallpox, etc. 8 8 - 15. “Fighting cases” 8 16. Accidents 9 17. “Transferral cases” 7

-

- -

- - - -

3 -

Total 465 192 85

as government and mission schools are the schools belonging to the Coptic Church where the priests and depteras give some education that consists mainly of memorizing texts from the Bible and holy scripts, usually in Ghees, the old church language which is often not understood even by the priests. The pupils might learn to read some Amharic but there is usually no instruction in writing.

Professional status is shown in Table 6. Farmers make up the single dominant group but there is a large group of students and middle-class people, policemen and various office workers. Among the women there is a rather large group of bar girls who are often also prostitutes.

General morbidity (Modified International Classification) Table 7 shows the different categories of dis- orders. A majority of patients suffered from respiratory, gastro-intestinal and genito-urinary diseases and many of these are due to infec- tious agents. The majority of patients with genito-urinary tract disorders are women.

During the rainy season there are more cases of malaria, typhus and other infectious dis- eases. One case of smallpox was admitted dur- ing the dry season. 42 % of all cases were due to infectious agents. Anaemia is prevalent in spite of the high iron-intake. Anaemia limits recommended by WHO adjusted for altitude, viz., 13.9 g% for males and 12.8 g% for fe- males (9), revealed that 57 % of the males and 64 % of the females had Hb values below the limit. 36 % of the total number of patients had an ESR above 20 mm and 50 % had an ESR below 10 mm. Intestinal parasites were examined by direct microscopy. Only 27 % had negative stool tests. 14 % of the patients were admitted to the hospital, only six patients with psychiatric morbidity (PM) were admitted. There was no difference in the admission rate between the two seasonal groups. Two of the patients died, one of a perforated ulcer and one of heart failure.

Psychiatric morbidity The figures for “Psychiatric morbidity” are given in Table 7. The majority of psychiatric

422 L. JACOBSSON

Table 8 Categories of psychiatric morbidity

Category of psychiatric morbidity Male Female Total

1. Explicitly psychological-clear psychiatric cases 13 5 18 2. Unexplained physical symptoms 22 35 57 3. Abnormal reaction to physical illness 4 4 8 4. Personality disorders - 2 2

~~ ~

Total 39 46 85

cases, apart from the group of mental dis- eases, was found in the group of gastro- intestinal disturbances where 28 % displayed “Psychiatric morbidity”. The categories of psychiatric morbidity according to Kessel (5) are shown in Table 8.

Group I : Explicitly Psychological comprised those who explicitly complained of being anxious, irritable, etc. or were recognized by the author as clear psychiatric cases. Only eight of the patients realized themselves that they were suffering from more or less ex- plicitly psychic disturbances; four were psy- chotic, two complained of impotence, one student recognized his problem as mainly psychological and one man was exhausted after one day of intense mourning following his mother’s death. In total, six were psy- chotic on admission; one had attempted suicide during a depressive, confusional state caused by a typhus infection, one had a recidivating psychosis with hallucinations, one had a con- fusional postpartum psychosis, one a re- cidivating depressive psychosis and one an unspecific psychosis - confused, attempted to run away, etc. One prisoner was admitted in a psychotic state of hysterical reaction. The other patients in category I were psycho- neurotic cases with symptoms of tension and anxiety; palpitations, nausea, sweating, short- ness of breath, dizziness, sleep disturbances, epigastric burning, “pain all over”, headache, irritable etc.

Group 11: Unexplained Somatic Symptoms comprised psychoneurotic patients with main- ly hypochondriacal reactions: pain and burn- ing in the epigastric region, headache, burn-

ing and moving sensations here and there, pains and feelings of coldness, and a wide variety of symptoms not adequately explained by the findings or from laboratory tests. There were also additional symptoms and signs of tension and anxiety, or records from earlier visits of diffuse complaints or certified psy- chiatric findings.

Group III: Abnormal Reaction to Physical Illness consisted of people who over-reacted to very insignificant disorders. For example, two male students who acted as if their jaws were about to explode when their last molars were erupting. This must be seen against the otherwise stoic tolerance of pain and disaster shown by most of the patients.

Group IV: Personality Disorders comprised two women, one was mentally defective with hysterical symptoms, and attended the clinic frequently, the other displayed an aggressive, restless, impulsive personality.

Table 9 gives a classification of the dis- orders according to the WHO-diagnostic manual (ICD 8, 1965). The great majority of cases can be referred to neurotic distur- bances, often with a somatic shading. The patients who displayed psychiatric morbidity were less often anaemic than the others and there were also fewer cases with a high ESR in this group. There was no difference as re- gards a positive stool test.

Psychiatric morbidity and socio- economic background There was a tendency for women to display

PSYCHIATRIC MORBIDITY IN WESTERN ETHIOPIA 423

Table 9 Diagnosis of psychiatric disorders according to WHO classification

294.20 Psychosis c morbo infectionis 1 294.40 Psychosis in puerperio 1 296.99 Psychosis affectiva NUD 1 300.00 Neurosis angoris incl. reactio angoris 24 300.10 Neurosis hysterica incl. reactio hysterica 8 300.40 Neurosis depressiva 2 300.70 Neurosis hypochondrica incl. reactio hypochondrica 12 300.99 Neurosis NUD 9 301.99 Persona pathologica 2 305.50 “Gastritis” 13 307.99 Causal mental disturbance 6 790.20 Depressio mentis NUD 1 791.99 “Cephalagia” 5

Total 85

PM more than men and the highest frequency is found in the age range 15-29 years in both sexes (Table 1). People belonging to ethnic groups other than the Gallas, tended to dis- play a higher frequency of PM (Table 2). Evangelic Christians displayed a higher fre- quency of psychiatric morbidity than Coptic Christians and Muslims (Table 3). Married people had the lowest frequency of PM, sin- gle and divorced women the highest (Table 4). 20 % of the people married by mutual agree- ment displayed PM compared with 11 % in the group married through elders. The PM rate increases with educational level. 42 % of those with a higher education, secondary school and high school, displayed PM (Ta- ble 5). Farmers and lesser office employees, policemen, drivers, etc. had the lowest fre- quency of PM, while students, housewives and people with a higher educational level had the highest (Table 6) . Within the group of farmers, tenants displayed a higher fre- quency of PM (12 %) than landowners (7 %).

Discussion As regards statistica1 analysis the author has refrained from testing the statistical signifi- cance of the differences because of the nature of the data, which in his view should be treated more as evidential rather than representative.

The general finding of psychiatric morbidity in 18.3 % of an out-patient population of a general hospital in rural Ethiopia is in close agreement with the findings of Giel and co- workers mentioned earlier. The great major- ity of cases had neurotic conditions, but there were also some psychotic patients.

In a study of the clientele of a Swedish general practitioner using the same method (10) psychiatric morbidity occurred in 35 % of his cases. Only 9.2 % of these patients re- cognized, however, that their problems were mainly due to mental disturbance.

In contrast to the findings of Giel et al. (3) there was a tendency for more women than men to display psychiatric morbidity. This, however, is in line with the findings of, e.g., Shepherd et al. (11) in a London general prac- tice and von Knorring’s cited above. Also as opposed to Giel et al. (3, 12) there was a ten- dency for married people to display a lower frequency of psychiatric morbidity than those who were single or divorced. People married in the traditional way through elders are better off than those married the less traditional way.

The finding that the psychiatric morbidity rate increases with educational level and in- come agrees with the findings of Giel et al. (12) in a rural hospital population, but is not supported by their findings in other out-patient populations (1, 3). There are two main ex- planations for the relationship between socio-

424 L. JACOBSSON

economic background factors and psychiatric morbidity. One is that there is a difference in illness behaviour between different social groups. The more educated and economical- ly better off are more inclined to turn to modern medicine for help when disturbed, whilst the tradition-oriented groups tend to rely on healers of various kinds. This could also explain the higher frequency of psychi- atric morbidity among younger people from ethnic groups other than the original in- habitants, viz. Amharas, Tigrae, etc. who usually are more educated and less traditional in their thinking. The higher frequency among Evangelic Christians who are usually some- what less traditional than the Coptics and the Muslims might also be thus explained.

Another possible interpretation of these differences is that there might be different rates of psychiatric morbidity in different social groups due to the varying degree of stress they are under. The higher frequency of PM among educated, other ethnic groups as compared with the traditional Gallas, among younger people, Evangelic Christians, single and divorced women, and among tenants com- pared with landowners, might well be seen as an effect of the higher degree of alienation and frustration they experience in a still very traditional society.

On the other hand, there are indications that mental illnesses of a psychoneurotic or psycho- somatic nature are equally common, irrespec- tive of the degree of urbanization (3, 6). These questions need to be investigated further in epidemiological surveys involving far more subjects than those undertaken so far.

It is apparent, however, that a great pro- portion of patients with psychiatric disorders do attend the general hospitals in developing countries. This proportion will possibly in- crease due either to a changed illness be- haviour or to the higher degree of frustration experienced in a modern society - probably both. Thus, it is necessary to start planning for more adequate care of this category of patients along the lines that have been dis- cussed in detail by, e.g., Giel & Harding (13) and Swift (14).

Appendix

Reports of some typical psychiatric cases Psychosis NUD. 31-year-old married man with tropical ulcer for many years. Four years ago “not right in mind”, “talking nonsense”, hal- lucinating, trying to run away into the forest, and so on. Now somewhat better but is hear- ing voices again, complaining of insomnia, headache, dizziness.

Depressive syndrome. 38-year-old man, mar- ried, farmer 2nd carpenter, old tbc-pulm., now heafed. Has had the same symptoms before, periodically. Now complaining of pain in all extremities, difficulty in sleeping, stays in bed in the morning, cannot get up and work as usual, feels depressed and sad, apathetic, dizzy, feeling of faintness, shortness of breath.

Organic psychosis - attempted suicide. 30-year- old married man with four children but as af- flicted by poverty has had to send some of the children to relatives. Has been sad and easily upset for a long time. Now acutely confused, ran away and tried to hang himself in a tree, but his wife was able to cut him down at once. On admission was found to have a typhus in- fection with Weil-Felix pos 1:640, fever, hal- lucinating.

Hysterical reaction in a prisoner. 3 1-year-old married man, farmer from Nakamte area, im- prisoned. Suddenly ill: falling down, breathing deeply, not speaking. On admission, not talk- ing, closed eyes but not unconscious, no fever. No physical signs of disease. Treated with in- jections of chlorpromazine, and vitamins and bedrest. Quite well the day after admission, talking, walking, etc. The actual conflict was not revealed.

Anxiety-tension in a foreign teacher. 37-year- old male Indian teacher with his family in India. Has attended the clinic previously be- cause of difficulty with breathing, feeling of swelling in his throat. Now abdominal dis-

PSYCHIATRIC MORBIDITY IN WESTERN ETHIOPIA 425

comfort, epigastric pain worsened after food, etc.

Hysteric-epileptical fits. 23-year-old married women with symptoms for 4 months, chest pain, shortness of breath, epigastric pain and occasional vomiting, insomnia, headache. Also some kind of fits, “unconscious” for 1-3 h, no real cramps, no passing of urine or stool, about two attacks a month. Anamnestically, most probably hysterical symptoms but epi- lepsy cannot be excluded.

Psychoneurosis. 27-year-old woman, married for 12 years, no children, the only wife of her husband. Troubles for many years with head- ache, back pain, epigastric burning, occasional diarrhoea, pain and itching all over her body, not sleeping well. No physical findings of relevance.

Psychoneurosis. 22-year-old woman, married for about 7 years, no children, shifting pains in the lower abdomen for months and dys- pareuni, somewhat depressed, irregular men- struations. Has attended several timcs before because of vague complaints of the same kind without any physical correlates.

Anxiety-tension in a student. 19-year-old boy, 11th grade student complaining of pain in the legs, shoulders and neck. Feeling of weakness in the mornings, but sleeping well, dizziness, eye tiredness, more troubles when studying.

Transferral case - impotense and tension in a teacher. Male aged 26 years, teacher, Muslim, married. Feelings of coldness in the knees, reaching up to the scrotum and penis which is “shortened”, occasional impotence. Most worried about his impotence. His wife has had difficult deliveries and had a stillbirth 4 months ago which resulted in a vesicovaginal fistula. He has had numerous injections at the local pharmacy, which give tempory relief, but he is soon worse again. Now wants trans- ferral from Mendi, where he lives, to a place with a hospital for his wife.

Impotence. Male, 15 years old, not married,

farmer’s boy from the Gimbi area. Had sex- ual contact for about 1 year with a married woman in the village, but was afraid of her husband. He also got gonorrheoea and was treated for this 3 months ago, still some pain in right testis. Impotent for the last 4 months.

Unwanted unrecognized pregnancy. 18-year- old girl living with her uncle after her father died and her mother married again. Com- plaining of no menstruation for 1 year and now distended abdomen, occasional vomiting. The investigation revealed a pregnancy in the 8th month. She denied in spite of careful ques- tioning that she had had any contact with a man or any knowledge of being pregnant.

Post script The publication of these data collected in 1971 and 1972 has been delayed for many reasons. Perhaps the most important has been the wish to extend the study. As this has become im- possible I have decided to publish the data, although fully aware of the study’s limitations. I think the information will be of some in- terest, both now and in the future, as a docu- ment on the situation as it was and a basis for comparisons with the situation as it develops.

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lage, population, housing and living conditions. Wollega Public Health Department, Nakamte, Ethiopia: Stencil, 1967.

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Address

Lars Jacobsson Dept. of Psychiatry University of UmeA S-901 85 Umea Sweden