Joanne Corrigall

Poverty and common mental disorders in low and middle income countries: a systematic review.

In spite of high levels of poverty in low and middle income countries (LMIC), and the high burden posed by common mental disorders (CMD), it is only in the last two decades that research has emerged that empirically addresses the relationship between poverty and CMD in these countries. We conducted a systematic review of the epidemiological literature in LMIC, with the aim of examining this relationship. Of 115 studies that were reviewed, most reported positive associations between a range of poverty indicators and CMD. In community-based studies, 73% and 79% of studies reported positive associations between a variety of poverty measures and CMD, 19% and 15% reported null associations and 8% and 6% reported negative associations, using bivariate and multivariate analyses respectively. However, closer examination of specific poverty dimensions revealed a complex picture, in which there was substantial variation between these dimensions. While variables such as education, food insecurity, housing, social class, socio-economic status and financial stress exhibit a relatively consistent and strong association with CMD, others such as income, employment and particularly consumption are more equivocal. There are several measurement and population factors that may explain variation in the strength of the relationship between poverty and CMD. By presenting a systematic review of the literature, this paper attempts to shift the debate from questions about whether poverty is associated with CMD in LMIC, to questions about which particular dimensions of poverty carry the strongest (or weakest) association. The relatively consistent association between CMD and a variety of poverty dimensions in LMIC serves to strengthen the case for the inclusion of mental health on the agenda of development agencies and in international targets such as the millenium development goals.

Intermittent Explosive Disorder in South Africa: Prevalence, Correlates, and the Role of Traumatic Exposures

Background: The epidemiology of DSM-IV intermittent explosive disorder (IED) is not well characterized in developing country settings. In South Africa, given the high rates of violence and trauma, there is particular interest in traumatic exposures as potential risk factors for IED. Methods: We examined the prevalence and predictors of IED in a nationally representative sample of 4,351 South African adults. IED and other diagnoses based on DSM-IV criteria were assessed using the World Health Organization Composite International Diagnostic Interview (CIDI). A 28-item scale was constructed to measure exposure to traumatic events. Results: Overall, 2.0% of participants (95% CI: 0–4.9%) fulfilled criteria for the narrow definition of IED, and 9.5% (95% CI: 6.6–12.3%) fulfilled criteria for the broad definition of IED. Individuals with IED experienced high rates of comorbid anxiety, mood and substance use disorders compared to non-IED participants. In multivariate analysis, a diagnosis of IED was associated with Caucasian and mixed-race ethnicity, psychiatric comorbidity and exposure to multiple traumatic events. Conclusion: These data suggest a relatively high prevalence of IED in South Africa. By reducing violence and trauma, and by providing appropriate psychological support to trauma survivors, we may be able to reduce rates of IED.

Experience of mental disorder in the context of basic service reforms: The impact on caregiving environments in South Africa

Abstract The integration of mental health services into primary health care and the shift towards community- and family-based care for chronic mental disorders has been associated with increased burden on households. At the same time, research investigating the impact of policies of cost recovery for basic services such as water and electricity has also indicated an increased burden on households. This study aimed to investigate the impact of these basic service reforms on households caring for a family member with a chronic mental disorder in Cape Town, South Africa. The findings indicate that factors associated with service reforms may increase the stress and burden experienced by households and in turn impact on the primary environment in which care is received.

Piloting a trauma surveillance tool for primary healthcare emergency centres

OBJECTIVE We aimed to pilot a trauma surveillance tool for use in a primary healthcare emergency centre to provide a risk profile of injury patterns in Elsies River, Cape Town. METHODS Healthcare workers completed a one-page questionnaire capturing demographic and injury data from trauma patients presenting to the emergency unit of the Elsies River Community Health Centre over a period of 10 days. RESULTS Trauma cases comprised about one-fifth of the total headcount during the study period. Most injuries took place before midnight. Approximately 47% of the trauma patients were suspected of being under the influence of alcohol with 87% of these cases caused by interpersonal violence; 28% were males between the ages of 19 and 35 years old, suspected of being under the influence of alcohol and presenting with injuries due to violence. CONCLUSION Injury surveillance at primary healthcare emergency centres provides an additional perspective on the injury burden compared with population-level mortality statistics, but the quality of data collection is limited by resource constraints. We recommend that the current trauma register be revised to separate trauma and medical headcounts and enable better resource planning at a facility and subdistrict level. Information gathered must be linked to health and safety interventions aimed at reducing the trauma burden within communities.

Reducing the burden of injury: an intersectoral preventive approach is needed.

The BoD project is one of some 32 cluster-based multi-departmental cabinet committee work streams typically led by a single provincial government department. Linkages across clusters are difficult to establish, but ostensibly occur at higher levels in sector co-ordinating and top management committees, which report to Cabinet.

The cost of harmful alcohol use in South Africa

BACKGROUND The economic, social and health costs associated with alcohol-related harms are important measures with which to inform alcohol management policies and laws. This analysis builds on previous cost estimates for South Africa. METHODS We reviewed existing international best-practice costing frameworks to provide the costing definitions and dimensions. We sourced data from South African costing literature or, if unavailable, estimated costs using socio-economic and health data from secondary sources. Care was taken to avoid possible causes of cost overestimation, in particular double counting and, as far as possible, second-round effects of alcohol abuse. RESULTS The combined total tangible and intangible costs of alcohol harm to the economy were estimated at 10 - 12% of the 2009 gross domestic product (GDP). The tangible financial cost of harmful alcohol use alone was estimated at R37.9 billion, or 1.6% of the 2009 GDP. DISCUSSION The costs of alcohol-related harms provide a substantial counterbalance to the economic benefits highlighted by the alcohol industry to counter stricter regulation. Curtailing these costs by regulatory and policy interventions contributes directly and indirectly to social well-being and the economy. CONCLUSIONS; Existing frameworks that guide the regulation and distribution of alcohol frequently focus on maximising the contribution of the alcohol sector to the economy, but should also take into account the associated economic, social and health costs. Current interventions do not systematically address the most important causes of harm from alcohol, and need to be informed by reliable evidence of the ongoing costs of alcohol-related harms.

Global trade and mental health.

The consequences of the unprecedented growth of global trade on development and population health are significantly influenced by global trade policies that have delivered millions from poverty, but have constrained the ability of governments to regulate their economies and protect health. While the effects of global trade policy on health have been documented, mental health considerations have been very limited. This analysis explores the impact of global trade policy on a number of socio-structural determinants of mental health including poverty, social inequality, food security, mental health systems, alcohol consumption, access to pharmaceuticals and occupational health. The evidence reviewed makes a strong argument that global trade is likely to have a significant impact on mental health. However, the mental health outcomes of global trade will be influenced by a host of contextual factors and will therefore be heterogeneous. Preliminary recommendations for discussion are considered.

Mental health is integral to public health: A call to scale up evidence-based services and develop mental health research

Despite the difficulty in determining the exact expenditure on mental health services in South Africa, the funds allocated are not commensurate with the proportion of mental illness to the overall disease burden.

Poverty and mental illness: Fact or fiction? A commentary on Das, Do, Friedman, McKenzie & Scott (65:3, 2007, 467–480)

a School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa b Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa c London School of Hygiene & Tropical Medicine, London, UK d Department of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, UK e Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland

Conflict of interest : a tenacious ethical dilemma in public health policy, not only in clinical practice/research

In addition to the ethical practice of individual health professionals, bioethical debate about conflict of interest (CoI) must include the institutional ethics of public policy-making, as failure to establish independence from powerful stakeholder influence may pervert public health goals. All involved in public policy processes are accountable for CoI, including experts, scientists, professionals, industry and government officials. The liquor industry in South Africa is presented as a case study. Generic principles of how to identify, manage and address CoI are discussed. We propose that health professionals and policy makers should avoid partnering with industries that are harmful to health. Regarding institutional CoI, we recommend that there should be effective policies, procedures and processes for governing public-private joint ventures with such industries. These include arms-length funding, maintaining the balance between contesting vested interests, and full disclosure of the identity and affiliations of all participants in structures and reports pertaining to public policy-making.